Professional Documents
Culture Documents
It is the manner by which the patients temperature, pulse, respiration and blood pressure are taken
Purposes:
To have the opportunity to observe the general condition of the client
To serve as a guide in meeting the needs of the client
To aid the physician in making his diagnosis and planning the clients care
General Considerations:
Before taking the v/s , be sure the client has rested and placed in a comfortable position
The frequency of taking the v/s depends upon the condition of the client and policy of the agency
Inform the physician or the head nurse for any significant changes in the v/s
Explain the procedure to the client so that he will feel at ease.
Times to Assess Vital signs:
BODY TEMPERATURE
It is the balance between heat loss and heat production from the body
Factors affecting Heat Production:
AVERAGE TEMPERATURE
NEWBORN
1 YEAR
3 YEARS
ORAL:37.2 C
5 YEARS
ORAL: 37.0C
ADULT
ORAL: 37C
AXILLA: 36.4C
RECTAL: 37.6C
TYMPHANIC: 37.7C
ELDERLY
(OVER 70 YEARS OLD)
ORAL: 36.0 C
ROUTES OF TEMPERATURE:
1. ORAL
= Most ACCESSIBLE and CONVENIENT
= Taken in 2-3 minutes
= 15 minutes before taking the oral temp. DO NOT allow the client to take hot or cold foods and
fluids
2. RECTAL
= Most ACCURATE measurement
= Thermometer is inserted 0.5 1.5 inches.
= Taken 1- 2 minutes time
3. AXILLARY
= The most NON INVASIVE and the SAFEST route
= Temp. is taken in 5 10 minutes
PULSE
The wave of blood created by the contraction of the left ventricle of the heart
Regulated by the Autonomic Nervous System
NUMBER
DEFINITION
DESCRIPTION
ABSENT
NO PULSATION
1
2
THREADY
WEAK
NORMAL
EASILY FELT
BOUNDING
STRONGER
PULSATION
AGE
1 YEAR OLD AND BELOW
NORMAL RATES
100 160/MINUTE
1 5 YEARS OLD
100 140/MINUTE
5 13 YEARS OLD
100 120/MINUTE
60 100/MINUTE
Pulse sites:
1. Temporal
2. Carotid
3. Brachial
4. Radial
5. Apical
6. Femoral
7. Popliteal
8. Dorsalis pedis
9. Posterior tibial
NORMAL RATES
40 60/MINUTE
30 50 /MINUTE
12 25/MINUTE
12 20/MINUTE
Systolic
Diastolic
Normal
<120
<80
Pre hypertension
120-139
80 - 89
Hypertension Stage 1
140 - 159
90 - 99
Hypertension Stage 2
160
100
For an adult, place the lower border of the cuff approx. 2.5 cm above the antecubital area.
The lower edge can be closer to the antecubital space of an infant
Insert the ear attachments of the stethoscope in your ears so that they tilt slightly forward.
Rationale: Sounds are heard more clearly when the ear attachments follow the direction of
the ear canal
Ensure that the stethoscope hangs freely from the ears to the diaphragm
Rationale: Rubbing the stethoscope against an object can obliterate the sounds of the blood
within artery
Place the bell shape over the brachial pulse
Rationale: Because the blood pressure is a low frequency sound
Pump up the cuff until the sphygmomanometer registers about 30 mmHg above the point
where the brachial pulse disappeared
Release the valve carefully at the rate of 2-3 mmHg
Deflate the cuff rapidly and completely
Wait 1 to 2 minutes before making further determinations
Repeat the steps once or twice
Remove the cuff from the clients arm
Document and report pertinent data
Report any significant changes in the clients blood pressure to the nurse in charge