Measuring vital signs

Dr. Wafaa Mostafa

Faculty of Nursing

Damietta University

Measuring vital signs

Introduction

Assessing vital signs is a routine part of nursing

care. Vital signs provide important information

about the health condition of the patient. Vital signs

are body temperature, pulse: respiration: and blood

pressure.

Guidelines for assessing vital signs

1- When patient is admitted to health care facility.

2- Before and after surgery.

3- Before and after invasive diagnostic procedures.

4- Before and after medications that could change

patient’s vital signs.

5- When patient general condition changes.

6- When patient complains of specific symptom or

comments on not feeling right or well.

Objective for assessing vital signs

To monitor patient’s condition.

Obtain baseline data for comparing future measurement.

To detect abnormalities involve alteration in body

temperature, pulse , respiration, blood pressure .

To evaluate effect of medication or nursing measures or to

evaluate the response to medication or nursing measures.

Body Temperature

Definition: Body temperature represents the balance between heat

production and heat loss.

The normal range of body temperature varies between 36.4 –

37.5°c

Body temperature can be measured with a mercury-in-glass

thermometer, an electronic thermometer or tympanic thermometer

or temporal artery thermometer.

Body temperature is measured in degrees using either of two

scales, the centigrade scale or the Fahrenheit scale.

Routes of Measuring Body Temperature

Measuring oral temperature by mouth leave the

thermometer 3 minutes & take the reading of

thermometer as it is.

Measuring rectal temperature Through rectum leave the

thermometer 1 minutes & decrease 0.5c from temperature

reading because the rectal area rich with superficial blood

vessels.

Routes of Measuring Body Temperature

Measuring axillary temperature by axilla leave the thermometer 5

minutes & add 0.5c on temperature reading because the axillary

area have a less superficial blood vessels than oral& rectal area.

Measuring Tympanic membrane temperature through auditory

canal ( Ear cavity ) take the reading of thermometer as it is after

seconds from pressing the scan button ( its more accurate and fast )

mainly used for measuring core temperature.

Measuring temporal artery temperature across forehead and just

behind the ear.

Oral: By mouth

Rectally: By rectum

Axillary: Under the arm in the

armpit

Tympanic: In the ear

Types of Thermometers (cont.)

– Glass Thermometers: Mercury rises in a

glass tube until its level matches the

temperature.

Bulb shapes

– Long tip – for oral use.

– Security tip – for oral

and rectal use.

– Rounded tip – for

rectal.

TYPES OF THERMOMETERS

2. Electronic

thermometer

(Digital

thermometer)

– rectal = red

– oral = blue

TYPES OF THERMOMETERS

Temperature

sensitive strip

Tympanic

thermometer

Contra-indications for oral method

1. Unconscious patient & confused patient.

2. Mentally ill patient.

3 .Young child and very old patients.

4. Irritable patients.

5. Patients with persistent cough.

6. Mouth breather patient or tachypneic patient or has

sores in mouth cavity.

Contra-indications for oral method

7. Patients with oral problems or surgery.

8- Facial bone fractures.

9- Patient with nasogastric tube or orogastric tube.

10- If there is no alcohol to wipe the thermometer with it.

11- If the patient loose his teeth, or suffered from

epilepsy, vomiting, nasal pack.

12- Patient on oxygen therapy & mechanical ventilator

Equipment

Thermometer (Mercury in Glass / Electronic / Tympanic / Temporal )

Clean tray.

Dry cotton sponge in a labeled container

Cotton sponge soaked with alcohol in a labeled container.

labeled container or kidney basin for unclean thermometers. Or Paper

bag.

Watch with seconds.

Nursing record & a pen. (Vital signs chart).

Water and soap

Remember 1-Wash hands & Prepare all needed equipment

3 - Explain the procedure to the patient.

4 - Place patient in a comfortable position either sitting or lying.

5 - Take only oral temperature in adult conscious persons.

6 - Make sure that the patient did not eat, drink hot or cold or smoke

just before taking the temperature, it is taken 30 min after.

7 -Clean thermometer with water and soap after use and rinse

thoroughly, dry with cotton sponge and wipe with cotton sponge

soaked with alcohol then store in its container.

Procedure of Measuring Oral Temperature

Action Rationale

1. Gather all needed equipment &

Review medical record for baseline data

and factors that influence vital signs.

Safe the time &effort. Establishes

parameters for client’s normal

measurements

2-Wash hands and apply gloves. To reduce the transmission of

microorganisms.

3. Explain procedure to the patient ( be

sure the patient doesn’t have hot or cold

fluids or eat & smoke 30 minute before

taking oral temperature

To gain the patient cooperation &

eliminate the fear

4-Put the patient in

comfortable position either

sitting or lying

Promotes comfort and improves

site access for all measurements

5-Bring clean thermometer

in its container to the patient

6-Hold thermometer parallel

at eye level from the glass

part

7- If mercury level is above 35c

hold the thermometer firm

between the thumb & fore finger

down & shake it down far from

any furniture to keep the level of

mercury to 35c or below 35c

Mercury level should be

below or at 35c to have a

correct reading

8- Ask the patient to

open mouth & place the

bulb under the patient

tongue directed toward

either cheek & close lips

The space below the

tongue contains

superficial blood vessels

that transfer the heat

9- Ask the patient to close

lips over the thermometer &

not the teeth to prevent

breakage.

Mercury is a toxic

substance , might be

swallowed if thermometer

was broken down

10-Count three minute

then remove

thermometer , wipe it

from end to bulb with a

dry cotton sponge in one

direction & read it with

error +/-0.1

Secretion on glass will

interfere with reading

11-Shake the thermometer

down below or at 35c

Mercury is returned back to

its chamber for reuse

12- Put the thermometer

after shake down in a

kidney basin or labeled

container for unclean

thermometer & covered

with dry cotton sponge .

Cover the bulb with cotton

sponge to avoid the

breakage

13- Wash the thermometer

with soap under running

water using a rotating

movement

Soap , running water &

friction helps the removal or

minimizing of

microorganisms

14- Dry the thermometer

with a dry cotton sponge

from bulb to end then

wipe with cotton sponge

soaked with alcohol using

a rotating movement

A moist environment helps

in the growth of

microorganisms .

Alcohol is disinfectant so it

kills some microorganisms

15-Store the thermometer in

its container

The thermometer made of

glass can beak easily &

container keeps the

thermometer safe , clean &

ready for use

16- Clean & replace the

equipment

17-Hand wash after

the procedure

18-Record the

temperature & report

any abnormalities if

any

Axillary Temperature

Repeat Actions 1–7.

8-Give the patient clean

piece of dressing to dry or

clean the axilla or make

hygienic care to axilla if

need

Perspiration on

thermometer will distort

the reading

Make sure axillary skin is

dry.

Removes moisture and

prevents a false low

reading.

9-Place the thermometer in

patient axilla:

-Bulb in notch into the center

of axilla closing on the bulb

-The glass part is directed

toward chest

-The fore arm is crossing

chest and hand resting on

opposite shoulder

10-Leave the thermometer

in its place for at least 5

minutes

11-Wipe the thermometer from

glass part to bulb with dry

cotton sponge in one direction

12-Read temperature with error

+/-0.1 & add 0.5c on reading

Add 0.5c on reading

because the axillary

area contain less

superficial blood

vessels than oral &

rectal method

13-Shake the thermometer

down below or at 35c

Mercury is returned back

to its chamber for reuse

14-Put the thermometer after

shake down in a kidney basin

or labeled container for

unclean thermometer &

cover the bulb with dry cotton

sponge

Cover the bulb with

cotton sponge to

avoid the breakage

15-Wash the thermometer with

soap under running water using a

rotating movement

Soap , running water &

friction helps the removal

or minimizing of

microorganisms

16-Dry the thermometer with a dry

cotton sponge from bulb to end

then wipe with cotton sponge

soaked with alcohol using a

rotating movement

A moist environment

helps in the growth of

microorganisms .

Alcohol is disinfectant so

it kills some

microorganisms

17-Store the thermometer in its

container

The thermometer made of

glass can beak easily &

container keeps the

thermometer safe , clean &

ready for use

18-Clean & replace the equipment

19-Hand wash after the procedure

20-Record the temperature &

report any abnormalities if any

Measuring pulse

The Pulse occurs when the left ventricle of the

heart contracts and sends blood into the arteries.

This process creates a pulse wave that the nurse

can palpate (feel). A person’s heartbeat changes

throughout the day to meet the circulatory

needs of the body.

Purpose or Objective

1 - To monitor the patient condition

2 - To detect any abnormality in characteristics of pulse

3 – To obtain base line data during the patient admission

4 – To detect the presence of arrhythmia or inadequate circulation or

other change in patient condition

5 – To estimate the dose of some medication

Pulse sites

apical Carotid Temporal

Brachial Femoral Radial

POSTERIOR

TIBIAL

Dorsalis Pedis

(Pedal)

Popliteal

HOW TO MEASURE?

Measured in beats per minute

Count the waves for 60 seconds

Or, count the waves for 30 seconds -

multiply by 2

NORMS

Pulse norms are 60 - 100 beats per minute

Pulses between 90 - 100 are in a gray area

- high normal

Faster than 100 - tachycardia

Slower than 60 - bradycardia

QUALITY OF PULSE

Rhythm: regular or irregular

Rate: Within the normal limits

Strength: Strong, bounding, thready

Equipment

• Watch with a second hand

• Stethoscope

• Alcohol swab

• Gloves

Assessing The Radial Pulse Rate

ACTION

1. Wash hands.

RATIONALE

1. Reduces transmission of

microorganisms.

2. Inform client of the site (s) at

which you will measure pulse.

2. Encourages participation and

allays anxiety.

3. Flex client’s elbow and place

lower part of arm across chest.

Placing client’s hand over chest

will facilitate later respiratory

assessment

4. Support client’s wrist by

grasping outer aspect with thumb.

4. Stabilizes wrist and allows for

pressure to be exerted.

5. Place your index and middle

finger on inner aspect of client’s

wrist over the radial artery and

apply light but firm pressure until

pulse is palpated

5. Fingertips are sensitive,

facilitating palpation of pulsating

pulse. The nurse may feel her

own pulse if palpating with

thumb.

6. Identify pulse rhythm. Describe

as regular or irregular.

7. Determine pulse volume.

Describe as normal, weak,

strong, or bounding.

Taking an Apical Pulse

Explain procedure to the

client

-An explanation encourages

client cooperation

2- Gather equipment -Gathering equipment provides

for organized approach to task.

3-Wash your hands. -To deters the spread of

microorganisms.

4-Use alcohol swab to

cleanse earpieces and

diaphragm of stethoscope. If

necessary.

-To deters the spread of

microorganisms.

5-Assist client to sitting

position in bed or on a chair,

if possible.

6-Provide privacy and move

gown to expose upper chest

area.

7-Hold diaphragm of stethoscope

against palm of hand for a few

second.

-Hand warmth metal area of

stethoscope, which may be cold

and may startle client.

8-Palpate fifth intercostals

space and move to left

midclavicular line. Place

diaphragm over apex of

heart.

-This is point of maximal

impulse, where heartbeat is

easier to hear.

9-Listen for normal heart

sounds, identified as “lub-

dub”.

-These sounds occur as

blood flows through heart

valves.

10--Use a watch with a second hand, count the heart beat for 30 seconds and multiply this number by two to obtain the rate for 1 minute.

-This assessment indicates adequacy of cardiac function.

11- Assess presence of any irregularity in heart rate and rhythm.

-Provide for privacy. 12-Replace the client’s gown and assist client to comfortable position.

13-Record pulse rate on flow sheet or paper. Report any abnormal finding to the appropriate person.

-To deter the spread of microorganisms.

14-Wash your hands.

Measuring Respiration

Definition: Respiration is the act of breathing air into the

lungs (inhalation) and exhaling air out of the lungs

(exhalation). One inhalation and one exhalation equal one

respiration. This is a complex process that involves the intake

of oxygen and the output of carbon dioxide.

Characteristics of Patient’s Respiration

the nurse should assess the rate, rhythm, and depth

1. Respiratory rate: refers to the number of times that a patient

breathes in 1 minute. Respiratory rate vary with the age. Newborn

breath rapidly 35breath/min, the normal rate for adults varies

from 16-24 breath/min.

2. Respiratory rhythm: refers to regularity of inhalation and

exhalations.

3. Respiratory depth: refers to the movement of the body during

inhalation. Respiratory depth is described in a range from shallow

to deep.

Equipment

Watch with second hand

Pencil or pen

Paper or flow sheet

Rational Action

-Counting the respiration while presumably still counting the pulse helps to keep the client from becoming conscious of own breathing and possible altering usual rate.

1- While your fingertips are still in place after counting the pulse rate, observe the client’s respirations

-A complete cycle of inspiration and expiration constitutes one act of respiration.

2-Note the rise and fall of the client’s chest with each inspiration and expiration.

3- Use a watch with a second hand, count the number of respiration for 30 seconds and multiply this number by two to obtain the client’s respiratory rate for 1 minute.

Rational Action

4- If respirations are abnormal in any way, counts the respiratory rate for a full minute.

5-Record respiratory rate on flow sheet or paper. Report any abnormal finding to the appropriate person.

-To deter the spread of microorganisms.

6-Wash your hands.