VITAL SIGNS

VITAL SIGNS

BODY TEMPERATURE
PULSE
RESPIRATION
BLOOD PRESSURE
PAIN
TYPES OF BODY TEMPERATURE
a. CORE TEMPERATURE
b. SURFACE BODY TEMPERATURE

NORMAL ADULT TEMP

1. ORAL
2. AXILLARY
3. RECTAL
4. TYMPANIC
METHODS OF TEMPERATURE-TAKING

ORAL
CONTRAINDICATIONS
YOUNG CHILDREN AN INFANTS
PATIENTS WHO ARE UNCONSCIOUS OR
DISORIENTED
RECTAL
POSITION:
HOLD IN PLACE IN 2 MINUTES
DO NOT FORCE TO INSERT THE THERMOMETER

CONTRAINDICATIONS
PATIENT WITH DIARRHEA
RECENT RECTAL OR PROSTATIC SURGERY
RECENT MYOCARDIAL INFARCTION
AXILLARY
HOLD IT IN PLACE FOR 9 MINUTES
NOTE:
1. USE THE SAME THERMOMETER FOR REPEAT
TEMPERATURE TAKING TO ENSURE MORE
CONSISTENT RESULT
2. STORE CHEMICAL-DOT THERMOMETER IN A
COOL AREA BECAUSE EXPOSURE TO HEAT
ACTIVATES THE DYE DOTS.
REMINDERS:

a rectal temperature is often preferred.

Oral: 37.0 is considered normal.

Rectal: Higher than oral by 0.40C to 0.50C
NURSING INTERVENTIONS IN CLIENTS WITH FEVER
MONITOR V.S
ASSESS SKIN COLOR AND TEMPERATURE
MONITOR WBC, HCT AND OTHER PERTINENT LAB
RECORDS
PROVIDE ADEQUATE FOODS AND FLUIDS.
PROMOTE REST
MONITOR I & O
PROVIDE TSB
PROVIDE DRY CLOTHING AND LINENS
GIVE ANTIPYRETIC AS ORDERED BY MD
PULSE
NORMAL PULSE RATE

1 YEAR 80-140 BEATS/MIN

2 YEARS 80- 130 BEATS/MIN
6 YEARS 75- 120 BEATS/MIN
10 YEARS 60-90 BEATS/MIN
ADULT 60-100 BEATS/MIN
RADIAL PULSE

COUNTING FOR A FULL

MINUTE PROVIDES A MORE
ACCURATE PICTURE OF
IRREGULARITIES.
DOPPLER DEVICE
POSITION THE PROBE ON THE SKIN DIRECTLY
OVER A SELECTED ARTERY
SET THE VOLUME TO THE LOWEST SETTING
CLEAN THE PROBE WITH SOFT CLOTH
SOAKED IN ANTISEPTIC.
RESPIRATION
ASSESSING RESPIRATION
NORMAL 18-20/ MIN IN ADULT
COUNT RESPIRATION FOR 60 SECOND
BLOOD PRESSURE

ADULT 90- 132 SYSTOLIC

60- 85 DIASTOLIC
ELDERLY 140-160 SYSTOLIC
70-90 DIASTOLIC
SITTING OR SUPINE POSITION
POSITION THE ARM AT THE LEVEL OF THE
HEART
USE THE BELL OF THE STETHOSCOPE
CRYING OR ANXIOUS
pediatric cuff for children;
leg cuff for obese people.
The cuff above the antecubital fossa.
A difference of 5 to 10 mmHg between arms is
common.
Systolic pressure in lower extremities is usually
10 mmHg higher than reading in upper extremities