Vital signs

Measuring Body Temperature (Oral Temperature)

Item 0 1 2 comment

1-Purposes: (at least 3 points are required)

1-Determine the current level of internal body temperature.
2- Evaluate the client's recovery from illness.
3- Determine if measures should be implemented to reduce a
dangerously elevated body temperature.
4- Determine if measures should be implemented to conserve body
heat when the body temperature is dangerously low.
5- Detect the response of a client once heat-producing or heat-
reducing measures have been initiated.
2- Assessment: (at least 3 points are required)
1- Assess patient ability to hold thermometer.
2- Review the trend in previously recorded temperature.
3- Determine if patient has consumed hot or cold substance,
smoking, or chewed gum within past 15-30 minutes.
4- Observe the ability of the patient to breathe adequately through
his nose with his mouth closed.
5- Others
3- Equipment:
1. Oral thermometer (glass).
2. Watch with a second hand or digital readout.
3. Dry cotton.
4. Disposable gloves.
5. Swap.
Glass Thermometer/Mercury Thermometer (Old Method)
4. Wash hands/ Apply disposable gloves/Identify the patient/
Explain procedure /provide privacy.
5. If the patient has recently had hot or cold liquids, chewed
gum, or smoked, wait 15 minutes before taking
an oral temperature.
6. Help patient to comfortable position that provides easy
access to temperature measurement site.
7. Hold end of glass thermometer with fingertips.
8. *Read mercury level while gently rotating thermometer Not Done
at eye level .if mercury is above desired level , grasp tip Done
of thermometer securely and flick wrist downward until
 reading is below 36 .
9. *Clean thermometer by using swab and wipe from bulb Not Done
toward fingertips and dry it in same way. Done
10. Ask patient to open mouth, then place thermometer under
tongue in posterior sublingual pocket and ask patent to hold
it with lips closed, but avoid biting down with the teeth.
11. Leave thermometer for 3 minutes.
12. Remove thermometer from patient mouth and read it at eye
level .Rotate thermometer until scale appears.
13. Clean thermometer after reading by using swab and wipe
from fingertips toward bulb, dry it in same way.
14. Store thermometer in appropriate container.
15. Assure patient about reading.
16. Return equipment’s.
17. Remove disposable gloves /Wash hands.
18. Documentation and reporting any abnormal reading.
Electronic Thermometer
1. Equipment:
1. Electronic thermometer
2. Disposable thermometer probe cover
3. Clean gloves
2. Ensure that the electronic thermometer is charged.
3. Wash hands/ Apply disposable gloves/Identify the patient/
Explain procedure /provide privacy.
4. Help patient to comfortable position that provides easy
access to temperature measurement site.
5. If the patient has recently had hot or cold liquids, chewed
gum, or smoked, wait 15 minutes before taking
an oral temperature.
6. Remove thermometer pack from charging unit. Attach oral
thermometer probe stem (blue tip) to thermometer unit.
Grasp top of probe stem, being careful not to apply
pressure on ejection button.
7. Slide disposable plastic probe cover over thermometer Not Done
probe stem until cover over thermometer probe stem locks Done
in place.
8. Ask patient to open mouth, then place thermometer probe
under tongue in posterior sublingual pocket lateral to center
of lower jaw and ask patent to hold it with lips closed, but
 avoid biting down with the teeth.
9. Leave thermometer probe in place until audible signal
indicates completion and patient temperature appears on
digital display.
10. Note the temperature and then remove thermometer probe
from under patient's tongue.
11. Push ejection button on thermometer probe stem to discard
plastic probe cover into appropriate receptacle
12. Assure patient about reading.
13. Return the thermometer probe stem to storage position of
thermometer unit.
14. Remove disposable gloves /Wash hands.
15. Documentation and reporting any abnormal reading.

Assessing radial pulse :

Item 0 1 2 comment

1-Purposes: (at least 3 points are required)

1. Determine the number of heartbeats occurring per
minute.
2. Gather information about the heart's rhythm, the
pattern of beats, and pauses between them.
3. Evaluate the amplitude, or strength, of the pulse.
4. Assess the heart’s ability to deliver blood to areas of
the body distant from itself, such as fingers.
5. Assess the response of the heart to cardiac
medications, activity, blood volume, gas exchange,
and so on.
6. Others…
2-Assessment: (at least 3 points are required)
1. Assess for factors that influence pulse rate and give
patient 5-10 minutes to rest after activity, and 15
minutes to rest after smoking.
2. Assess for signs and symptoms of altered cardiac
functions e.g. dyspnea, palpitation.
3. Assess for signs and symptoms of peripheral vascular
disease e.g. pale, cool extremities.
 4. Determine patient’s previous baseline pulse rate.
5. Others…
3-Equipment:
Watch with a second hand or digital readout.
4. Identify the patient/ Explain procedure/ Wash
hands/provide privacy.
5. Assist patient to supine or sitting position.
6. Position patient so that his arm is relaxed and supported.
7. *Place tips of first two or middle three fingers of hand Not Done
over groove along radial or thumb side of patient inner Done
wrist. Slightly extend or flex wrist with palm down until
you note stronger pulse. Don't use your thumb to take
patient pulse
8. Lightly compress against patient radius, and then relax
pressure.
9. Determine strength of pulse.
10. Look at watch in second hand and begin to count, if pulse
is regular count rate for 30 second and multiply total by 2,
if irregular count rate for 60 second.
11. *Give accurate reading. Not Done
Done
12. Determine rhythm of pulse.
13. Return patient to comfortable position.
14. Assure patient about result.
15. Return equipment’s.
16. Wash hands.
17. Documentation and reporting abnormal finding.

Assessing respiration
Item 0 1 2 comment

1-Purposes: (at least 3 points are required)

1. Determine the per minute rate on admission as a
base for comparing future measurements.
2. Monitor the effect of injury, disease, or stress
on the client’s respiratory system.
3. Evaluate the client's response to medications or
treatments that affect the respiratory system.
 4. Others…
2-Assessment: (at least 3 points are required)
1. Assess for signs and symptoms of respiratory
alterations e.g. cyanosis, labored breathing,
adventitious breath sounds.
2. Assess for factors that influence character of
respiration e.g. exercise, smoking, and let him
to rest 5-10 minutes after activity.
3. Determine patient’s previous baseline
respiratory rate.
4. 4- Assess pertinent lab values e.g. ABGs, pulse
oximetry, CBC.
5. Others…
3-Equipment:
1. Watch with a second hand or digital readout.
4. Identify the patient / Wash hands/provide
privacy.
5. Assist patient to a comfortable position,
preferably sitting or lying with the head of bed
elevated 45 -60 degrees.
6. Be sure that patient chest is visible. If
necessary, move bed linen or gown.
7. * Do not inform patient that you will be Not Done
counting his/her respiratory rate done
8. Place patient arm in relaxed position across the
abdomen or lower chest
9. Observe complete respiratory cycle (one
inspiration and one expiration)
10. * After cycle observed, look at watch in Not Done
second hand and begin to count rate. If done
rhythm is regular, count number of
respirations in 30 second and multiply by 2.
If rhythm is irregular count for one full
minute.
11. be alert for stridor, wheezing and expiratory
granting
12. Note the depth of respirations.
13. Observe for respiratory effort(using accessory
muscle)
 14. Note the rhythm of respirations.
15. Replace bed linen and patient's gown
16. Assure patient about reading
17. Return equipment
18. wash hands
19. Documentation and reporting abnormal finding

Measuring Blood Pressure

Item 0 1 2 comment
1.Purposes: (at least 3 points are required)
a. Determine the systolic and diastolic pressure of the
client during admission in order to compare his
current status with normal range.
b. Acquire base line data for compression with
subsequent changes that may occur during the care
of the client.
c. Assist in evaluating the status of the client's blood
volume, cardiac output, and vascular system.
d. Evaluate the client response to changes in his
medical conditions as a result of treatment with
fluids or medications.
2. Equipment:
a. Stethoscope.
b. Sphygmomanometer.
c. Blood pressure cuff of appropriate size. The bladder
should encircle at least 80% of the upper arm.
d. Paper, pencil or pen.
e. Alcohol swap.
3. Assessment : (at least 3 points are required)
a. Determine best site for BP assessment.
b. Determine previous baseline BP from patient’s
record.
c. Assess if patient doing exercise or smoking and let
him to rest for 30 minutes before assessment of BP
d. Assess patient’s risk factors for BP alterations:
history of cardiovascular diseases, renal diseases,
 diabetes….etc
e. Assess the patient for signs and symptoms of blood
pressure alterations, e.g.: headache, nosebleed, pale,
cool skin…etc
4. Wash hands\ Apply Disposable
gloves(optional)\ Identify the patient/ Explain
procedure to patient\ Provide privacy
5. Ask patient not to speak while BP is measured.

6. Assist patient to sitting or lying position with

patient’s forearm, supported if needed at heart
level, with palm turned up. If sitting instruct the
patient to keep the feet flat on the floor without
leg crossed.
7. Expose extremity by removing constricting
clothing.
8. Palpate brachial artery, position cuff 2.5 cm
above site of pulsation. Center bladder of cuff
above the artery.
9. With cuff fully deflated, wrap it evenly and
snugly around upper arm.
10. Position manometer vertically at eye level, no
farther than 1 meter from the observer.
11. * Measuring BP using two –step method: Not Done
Estimating systolic blood pressure using Done
palpation. As you feel the radial pulse (distal
to cuff) with the fingers of non-dominant
hand, inflating the cuff until pulse
disappears. . . Slowly deflate cuff. Read
this pressure on the gauge and add 30 mm
Hg to it. Use this sum as the target
inflation to prevent discomfort from over
inflation.
12. Deflate cuff fully and wait 30 second.

13. Relocate brachial artery and place diaphragm of

stethoscope over it, don’t allow chest piece to
touch cuff or clothing.
14. Close the valve of the pressure bulb clockwise
until tight and quickly inflate the cuff 30mmhg
above the patient’s estimated systolic BP.
15. *Slowly release valve and allow mercury to Not Done
 fall at rate of 2 to 3 mmHg/sec. Done
16. Note point on manometer when first clear sound
is heard.( reflect systolic BP)
17. Continue to deflate cuff gradually.

18. Note point at which sound disappears, note

pressure to nearest 2mmHg.(reflect diastolic
BP)
19. Listen for 20-30 mmHg after sounds disappear.

20. Allow the remaining air to escape quickly,

Deflate cuff rapidly and completely.
21. Remove cuff from patient arm, cover arm.

22. Return patient to comfortable position.

23. Assure patient about reading.

24. Return equipment.

25. Wash hands/remove gloves (if used).

26. Documentation and reporting of abnormal

reading.