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TAKING THE VITAL SIGNS

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:

On admission to a Health care agency


When a client has a change in health status or reports of symptoms
Before and after surgery or invasive procedure
Before and after administration of medication that could affect the respiratory and
cardiovascular systems
Before and after nursing intervention

BODY TEMPERATURE
It is the balance between heat loss and heat production from the body
Factors affecting Heat Production:

Basal metabolic rate


Muscle activity
Thyroxine output
Epinephrine and Norepinephrine
Fever

Factors affecting Heat loss:


Radiation
Conduction
Convection
Evaporation
Factors Affecting Body Temperature
Age
Diurnal variations
Exercise
Hormones
Stress
Environment
Variations in Body Temp. by Age
AGE

AVERAGE TEMPERATURE

NEWBORN
1 YEAR

AXILLA: 36.1 37.7C


ORAL: 37.7C

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

NOT EASILY FELT


STRONGER THAN
THREADY

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

13 YEARS OLD AND ABOVE

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

RESPIRATION -An act of breathing: inhalation and exhalation


Medulla Oblongata - is the primary respiratory center of the body
AGE
1 YEAR OLD AND BELOW

NORMAL RATES
40 60/MINUTE

1-5 YEARS OLD

30 50 /MINUTE

5-13 YEARS OLD


13 YEARS OLD AND ABOVE

12 25/MINUTE
12 20/MINUTE

BLOOD PRESSURE - The pressure exerted by the blood in the arteries


SYSTOLIC PRESSURE
= The pressure resulting from the contraction of the ventricles
DIASTOLIC PRESSURE
= Pressure when the ventricles are at rest
PULSE PRESSURE
= The difference between the systolic and diastolic pressure
Normal = 30 40 mmHg
For 18 years and older (JNC 7th Report)
Description

Systolic

Diastolic

Normal

<120

<80

Pre hypertension

120-139

80 - 89

Hypertension Stage 1

140 - 159

90 - 99

Hypertension Stage 2

160

100

Factors Affecting Blood Pressure


Age
Exercise
Stress
Race
Gender
Medications
Obesity
Diurnal variations
Disease process
Taking the BP:
Make sure that the client has not smoked or ingested caffeine within 30 minutes prior to
measurement
Make sure that the bladder of the cuff encircles at least 2/3 of the arm and the width of the
cuff is appropriate
Position the client in sitting position unless contraindicated
Apply the center of the bladder directly over the medial aspect of the arm
Rationale: The bladder inside the cuff must be directly over the artery to be compressed

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

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