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Vital Signs Procedures Checklist

Vital Signs Procedures Checklist

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Published by: juancristo on Jul 24, 2012
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12/14/2013

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VITAL SIGNS
 Procedure Checklist
Posted by: www.NurseTopic.comNAME:_____________________________YEAR & SECTION:__________________DATE:___________Preparation Performed RemarksCorrectly Incorrectly Not1.
 
Assess:
 
A.) Temperature
 - Clinical signs of fever- Clinical signs of hypothermia-
Client’s readiness for the procedure
 - Site most appropriate for measurement- Factors that may alter core body temperature
B.) Pulse
 - Clinical signs of cardiovascular alteration,other than pulse rate, rhythm, or volume- Factor that may alter pulse rate
C.) Respiration
 - Skin and mucus membrane color- Position assumed for breathing- Signs of cerebral anoxia- Chest movement- Activity tolerance- Chest pain- DyspneaMedications affecting respiratory rate.
D.) Blood Pressure
- Signs and symptoms of hypertension- Signs and symptoms of hypotension- Factors affecting blood pressure.
2.
 
Assemble equipment and Supply:
 - Thermometer- Cotton balls with alcohol or alcohol wipes- Tissue /wipes- Watch with a second hand or indicator.- Stethoscope- Blood pressure cuff of the appropriate size- Sphygmomanometer
Procedure1.
Identify the client properly and explain whatyou are going to do, why it is necessary, andhow he can cooperate.
2.
Wash hand and observe other appropriateinfection control procedure
3.
Provide for client privacy.
4.
Place the client in the appropriate position
ASSESSING BODY TEMPERATURE (AXILLARY TEMPERATURE)1.
Wipe the armpit with tissue paper or ask theclient to do it if able
2.
Wipe the thermometer from bulb to stem withalcoholized cotton ball.
3.
Place the thermometer on the client’s opposite
side.
4.
Wait for appropriate amount of time. (Whilewaiting for the time, the nurse can now assessthe other vital signs.)
5.
Remove the thermometer and wipe with thetissue if necessary.
6.
Read the temperature.
7.
Wipe the thermometer with alcoholised cottonball from stem to bulb. Return to container.
ASSESSING A PERIPHERAL PULSE (RADIAL PULSE)1.
Palpate and count the pulse. Place two or threemiddle fingers lightly and squarely over the
 
pulse point.
2.
Count for one full minute and note the pulserhythm and volume.
ASSESSING RESPIRATION1.
Place the client’s
arm across the chest andobserve the chest movements while supposedlytaking radial pulse.
2.
Count the respiratory rate for 1 full minute. Aninhalation and an exhalation is counted as onerespiration. Observe the depth, rhythm, andcharacter or respiration.
ASSESSING BLOOD PRESSURE1.
The elbow should be slightly fixed with thepalm of the hand facing up and the forearmsupported at heart level.
2.
Expose the upper arm
3.
Wrap the deflated cuff evenly around the upperarm. Locate the brachial artery. Apply thecenter of the bladder directly over the artery.
4.
For an adult, place the lower border of the cuff appropriately 2.5 cm (1 inch) above theantecubital space.
5.
If this is the client’s initial examination,
perform a preliminary palpatory determinationof systolic pressure.
6.
Palpate the brachial artery with fingertips.
7.
Close the valve on the pump by turning theknob clockwise.
8.
Pump the cuff until you no longer feel thebrachial pulse. At that pressure, the bloodcannot flow through the artery. Note thepressure on the sphygmomanometer at whichpulse is no longer felt.
9.
Release the pressure completely in the cuff, andwait for one to two minutes before makingfurther measurements.
10.
Position the stethoscope appropriately
11.
Clean the earpieces of the stethoscope withalcohol.
12.
Warm the amplifier by rubbing it with the palmof your hand.
13.
Insert the ear attachments of the stethoscope inyour ears so that they tilt slightly forward.
14.
Ensure that the stethoscope hands freely fromthe ears to the diaphragm.
15.
Place the bell of the amplifier of thestethoscope over the brachial pulse. Hold thediaphragm with thumb and index finger.
16.
Auscultate the client’s blood pressure.
 
17.
Pump the cuff until the sphygmomanometerreads 30 mm Hg above the point where thebrachial pulse disappeared.
18.
Release the valve of the cuff carefully so thatthe pressure decreases at the rate of 2-3 mm Hgper second.
19.
As the pressure falls, identify the mamometerreading at each of five phases, if possible.
20.
Deflate the cuff rapidly.
21.
Wait one or two minutes before making furtherdeterminations.
22.
Repeat the above steps once or twice asnecessary to confirm the accuracy of thereading.
23.
If this is the client initially examination, repeat
the procedure on the client’s other arm.
 

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