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Definition:
Vital signs or cardinal signs are body temperature, pulse, respirations and blood
pressure fifth is pain.
Times to Assess Vital Signs:
- On admission to a health care agency to obtain baseline data.
- When a client has a change in health status or reports symptoms
- Before and after surgery/invasive procedures
- Before and after administration of medications
- Before and after any intervention that could affect the vital signs
1. Check for the patients chart
- In order to check the condition of the patient and to check the last BP if there is
any.
2. Do handwashing.
3. Prepare the needed materials.
- Stethoscope
- Sphygmomanometer
- Thermometer/Axillary and Digital
- Tissue Paper
- Wet Cotton Balls soaked in an alcohol
- Dry cotton balls
- Receptacle
- Ballpen
- Watch with second hand
- Paper
*Patients Info*
- Name
- Age
- Sex
- Date
- Time
- Chief complaint
- Physician
- Temperature
- Radial Pulse
- Respiratory Rate
- Blood Pressure
4. Check the equipments if they are working properly in order to save time.
- Hold the thermometer in an eye level and check if there is any break, if there is
none clean it with wet cotton balls soaked an alcohol then dry it with the use of
dry cotton balls. Then shake it away from the patient or any object because
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thermometer is very sensitive it could easily break, this is in order to lower the
temperature to at least below 35 Degree Celsius.
- Check also the stethoscope, tap your finger lightly on the diaphragm if you can
hear sound.
- Then check the sphygmomanometer for leaks. Pump up the cuff then deflate in
order to determine if there is any leak.
Go to patients room, knock on the door, greet the patient and introduce yourself and
verify the patients identity by asking his/her complete name. Explain to the client
what you are going to do and why it is necessary and how he/she can cooperate.
Discuss how the result will be used in planning for further care or treatments.
- Also ask for the food, fluid intake as well as the activities done prior to getting the
vital signs because it can elevate the results.
Provide for clients privacy.
Place the client in an appropriate position (lateral or sims position)
Start getting the vital signs.
- First I am going to get the body temperature with the use of an axillary
thermometer. Firstly, get a tissue and pat dry the axillae. Do not rub it because it
can elevate the result. Then place the thermometer appropriately, and then wait
for 8-10 minutes for the result.
- While waiting for the body temperature result, I am going to get the radial pulse.
Palpate and count the pulse for one full minute. Place two or three fingers lightly
and squarely over the pulse point. Do not use the thumb because it has pulse
that could be mistaken for the clients pulse. Assess pulse rate, rhythm and
volume. Bear in mind that when you write the result it must include the units of
measure which is beats per minute or bmp
Auscultate and Count Heartbeats. Use antiseptic wipes to clean the earpieces and
diaphragm of the stethoscope if their cleanliness is doubt. The diaphragm needs to
be cleaned and disinfected if soiled with body substances.
Warm the diaphragm (flat-disc) of the stethoscope by holding it in the palm of the
hand for a moment. The metal of the diaphragm is usually cold and can startle the
client when placed immediately on the chest. Tap your finger lightly on the
diaphragm to be sure it is the active side of the head. Place the diaphragm of the
stethoscope over the apical impulse and listen for the normal S1 and S2 heart
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sound, which is heard as lub-dub. The heartbeat is normally loudest over the
apex of the heart. Each lub-dub is counted as one heartbeat. S1 (lub) occurs when
the atrioventicular valves close after the ventricles have been sufficiently filled. S2
(dub) occurs when the semilunar valves close after the ventricles empty. If you have
difficulty hearing the apical pulse asks the supine client to roll onto his/her left side or
sitting client to lean slightly forward. This positioning moves apex of the heart close
to the chest wall. Count for 1 full minute. A second count provides a more accurate
assessment of an irregular pulse than 1 30 second count. Assess the rhythm and
strength of the heartbeat.
After getting the apical pulse, get also the body temperature with the use of the
digital thermometer. (Note: show the result to your Clinical Instructor before turning it
off).
Assessing Respirations
- Then get the respiratory rate (note: do not mention this because youll get minus
point from your clinical instructor) why? Because, patient can control his/her RR if
youre going to mention it. Unit of measure for RR is cycle per minute or cpm
- Observe or palpate and count the respiratory rate. Clients awareness when
counting the respiration rate could cause the client to purposely alter the respiratory
pattern. If you anticipate this, place a hand against the client chest to feel the chest
movements with breathing or place the clients arm across the chest and observe
the chest movements while supposedly taking the radial pulse. Count for 1 full
minute. An inhalation and an exhalation count as one respiration. Observe the
depth, rhythm and character of respirations. Depth by watching the movement of the
chest. During deep respiration, a large volume of air is exchanged, shallow, small
volume of air is exchanged. Regular or irregular rhythm. Normally, respirations are
evenly spaced. Character of respirations sound they produced and the effort they
require. silent and effortless.
Assessing Blood Pressure
Preparation:
- Make sure that the client has not smoked or ingested caffeine within 30 minutes
prior to measurement. Smoking constricts blood vessels and caffeine increases
the pulse rate. Both of these cause a temporary increase in blood pressure.
- Position the client appropriately. The adult should be sitting unless otherwise
specified. Both feet should be flat on the floor. Legs crossed at the knee result in
elevated systolic and diastolic blood pressure.
- The elbow should be slightly flexed with the palm of the hand facing up and the
forearm supported at heart level. The blood pressure increases when the arm is
below the heart level and decreases when the arm is above the heart level.
- Wrap the deflated cuff evenly around the upper arm. Then locate the brachial artery.
Apply the center of the bladder directly over the artery. The bladder inside the cuff
must be directly over the artery to be compressed if reading is to be accurate.
Approximately 2.5 cm (1 inch) above the antecubital space.
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