Chapter 7: Vital Signs

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TEMPERATURE

Oral Temperature Technique

  1. Remove the probe from the device and place a probe cover (from the box) on the oral thermometer without touching the cover with your hands
  2. Place the thermometer in the mouth under the tongue in the posterior sublingual pocket (slightly off-centre) and instruct the client to keep mouth closed and not to bite on the thermometer
  3. Remove the thermometer when the device beeps
  4. Note the temperature on the digital display of the device
  5. Discard the probe cover in the garbage (without touching the cover)
  6. Place the probe back into the device

 

Tympanic Temperature Technique

  1. Remove the tympanic thermometer from the casing and place a probe cover (from the box) on the thermometer tip without touching the cover with your hands
  2. Turn the device on
  3. For an adult or older child, gently pull the helix up and back to visualize the ear canal. For an infant or younger child (under 3), gently pull the lobe down
  4. Gently insert the probe into the opening of the ear
  5. Activate the device
  6. Note the temperature on the digital display of the device
  7. Discard the probe cover in the garbage (without touching the cover) and place the device back into the holder

 

Axillary Temperature Technique

  1. Remove the probe from the device and place a probe cover (from the box) on the thermometer without touching the cover with your hands
  2. Ask the client to raise the arm away from his/her body
  3. Place the thermometer in the client’s armpit as high up as possible into the axillae on bare skin, with the point facing behind the client, and ask the client to lower arm
  4. Note the temperature on the digital display of the device
  5. Discard the probe cover in the garbage (without touching the cover) and place the probe back into the device

 

Rectal Temperature Technique

  1. Ensure the client’s privacy and wash your hands and put on gloves
  2. Position the client appropriately
  3. Remove the probe from the device and place a probe cover on it
  4. Lubricate the cover with a water-based lubricant
  5. Gently insert the probe 2–3 cm inside the rectal opening of an adult, or less depending on the size of the client
  6. Note the temperature on the digital display of the device when it beeps
  7. Discard the probe cover in the garbage (without touching the cover) and place the probe back into the device
  8. Remove your gloves and wash your hands

 

PULSE AND RESPIRATION

Radial Pulse Technique

  1. Use the pads of your first three fingers to gently palpate the radial pulse along the radius bone close to the flexor aspect of the wrist
  2. Press down with your fingers until you can best feel the pulsation
  3. Note the rate, rhythm, force, and equality when measuring the radial pulse

 

Carotid Pulse Technique

  1. Ask the client to sit upright
  2. Locate the carotid artery medial to the sternomastoid muscle in the middle third of the neck
  3. Gently palpate the carotid artery one at a time
  4. Note the rate, rhythm, force, and equality when measuring the carotid pulse

 

Apical Pulse Technique

  1. Ask the client to lay flat in a supine position
  2. Physically palpate the intercostal spaces to locate the landmark of the apical pulse
  3. Auscultate the apical pulse
  4. Note the rate and rhythm

 

Brachial Pulse Technique

  1. Palpate the bicep tendon in the area of the antecubital fossa
  2. Move your fingers medial from the tendon and about one inch above the antecubital fossa to locate the pulse
  3. Note the rate and rhythm

 

Respiration Technique

  1. Leave your fingers in place when you are done counting the pulse, and then begin assessing respiration
  2. Observe the rise and fall of the chest or abdomen
  3. Count for 30 seconds if the rhythm is regular or for a full minute if it is irregular
  4. Report respiration as breaths per minute, as well as whether breathing is relaxed, silent, and has a regular rhythm

 

OXYGEN SATURATION

Pulse Oximeter 

  1. Remove client nail polish
  2. Clean oximeter probe with alcohol swab
  3. Clip or tape probe onto a client’s finger
  4. Turn oximeter on
  5. Take radial pulse (30 seconds if regular and one minute if irregular)
  6. Ensure radial pulse is aligned with pulse displayed on the oximeter
  7. Document or report findings

 

BLOOD PRESSURE

Two-step Blood Pressure Technique

  1. Palpate the radial or brachial artery, inflate the blood pressure cuff until the pulse is no longer felt, and then continue to inflate 20–30 mm Hg more:  this is the maximum pressure inflation.
  2. Deflate the cuff quickly.
  3. Now, you can start blood pressure so place the bell of the cleansed stethoscope over the brachial artery using a light touch and complete seal.
  4. Inflate the cuff to the maximum pressure inflation number.
  5. Open the valve slightly.
  6. Deflate the cuff slowly and evenly at about 2 mm Hg per second.
  7. Note the points at which you hear the first appearance of Korotkoff sound (systolic blood pressure), and the point in which the sounds go silent (diastolic blood pressure).

One-step Blood Pressure Technique

  1. Palpate the radial or brachial artery, inflate the blood pressure cuff until the pulse is no longer felt, and then continue to inflate 20–30 mm Hg more.
  2. Place the bell of the cleansed stethoscope over the brachial artery using a light touch, but with an airtight seal.
  3. Open the valve slightly.
  4. Deflate the cuff slowly and evenly at about 2 mm Hg per second.
  5. Note the points at which you hear the first appearance of Korotkoff sound (systolic blood pressure), and the point at which the sounds go silent (diastolic blood pressure).

 

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Introduction to Health Assessment for the Nursing Professional (2024) Copyright © by . is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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