Vital Signs Created by Debbie Johnson RN- 2003
Vital Signs (VS) Temperature ( T) Pulse (P) Respiration (R) Blood Pressure (BP)
Normal Range Temperature Ideal NormalRange Oral Axillary Rectal Tympanic
Glass Thermometer
Steps to taking temperature with glass thermometer Ask if client has had anything to eat drink or smoke in the last 15 minutes Shake down thermometer Place disposable cover over thermometer Insert thermometer under tongue Hold thermometer in place for 3 minutes
Reading a thermometer Hold thermometer to view mercury column
Steps to taking temperature- continued Remove thermometer from mouth Remove disposable cover Read and record temperature Shake down thermometer Report any abnormalities to charge nurse
Normal Pulse Range Adult Birth to 4 weeks weeks to 1 year to 2 years to 6 years years
Normal Respiration Adult Infants and children normally breathe faster than adults Respirations should be quiet, effortless, and regular Both sides of the chest should raise and fall equally
Taking Pulse and Respiration Leave hand in place after taking pulse and count respiration
Steps to taking pulse and respiration Wash hands Identify self and client Explain procedure Provide privacy Find radial pulse and count for one full minute and record- Must be + or – 4 beats of evaluator
Steps to taking pulse and respiration - continued Count respirations for one full minute and record- Must be + or – 2 respirations of evaluator Leave signal light in place Wash hands Report any abnormalities to charge nurse
Normal Blood Pressure Ranges Adults: 120/80 Range: Systolic Diastolic Children and infants have lower blood pressure readings New research has indicated that the above numbers may actually be “Pre- hypertensive”
Steps to taking Blood Pressure Wash hands Identify self and client Explain procedure Provide privacy Clean earpieces and diaphragm with alcohol Expose forearm Palpate brachial pulse
Always Clean Equipment Wipe diaphragm and earpieces with alcohol
Steps to taking Blood Pressure-continued Inflate sphygmomanometer to 30 millimeters of mercury where pulse last felt Deflate cuff slowly Remove cuff Record Bp reading within 4 beats of mercury of evaluator’s reading
Steps to taking Blood Pressure-continued Give client signal light Return equipment to proper storage Wash hands Report any abnormalities to charge nurse
Vital Signs Accuracy is the key! Recheck if necessary Report abnormalities