A PRESENTATION BY MS.

FRANCISCA
ACHALIWIE AND MS. MABEL AVANE
VITAL SIGNS
 VITAL SIGNS
DEF.
The signs of life, namely temperature, pulse, and
respiration
Measurement of temperature, pulse, and
respiration. Blood pressure is customarily
included in this category although not strictly a
vital sign.
The rate of values indicating an individual’s
pulse, temperature and respiration.
VS observations provide guide to the patients’
condition and progress
 Reasons for taking vital signs
• To determine changes in the patient’s
condition
• For diagnostic purposes
• To help determine the functions of vital organs
• To act as baseline data for patient
management e.g. vitals are monitored before
and after surgery.
 When to take vital signs

• On admission or first contact with the patient

• When patient condition changes
• Before and after certain medications
• According to orders
• Before and after surgery or certain procedures
• According to institution policy
 Temperature
TEMPERATURE; is the degree of sensible heat
or cold.
BODY TEMPERATURE; is the level of heat
produced and sustained by the body
processes
Body temperature reflects the balance
between the heat produced and heat lost in
the body. It is measured in units termed
degrees.
 Temperature cont’d
Heat is produced in the body through;
Digestion
Exercise
Strong emotions
Hormonal effect
Change in environmental conditions
Diseases
 Body temperature
Heat is lost from the body through;
The skin
The lungs
The kidneys
The bowels
– Temperature is measured in degree Celsius or in
Fahrenheit.
– The instrument used in measuring temperature is the
thermometer.
Clinical Thermometer
Electronic(Digital) Thermometer
 Temperature cont’d
There are 2 kinds of body temperature
Core temperature; temperature of deep
tissues of the body. E.g. the liver. Core
temperature remains relatively constant
Surface temperature; temperature of the
skin, subcutaneous tissues and fat. This
temperature rises and falls in response to the
environment.
 Factors Affecting Body Temperature
Environment: extremes in environmental
temperature can affect body temperature.
Exposure to heat can elevate the temperature
while cold can result in hypothermia.
Exercise: extraneous exercise can increase body
temperature.
Hormones: women hormone level affect body
temperature. Progesterone secretion at the time
of ovulation rises body temperature.
 Factors Affecting Body Temperature
cont’d
Time of the day: body temperature changes
throughout the day. It is at the lowest point
early in the morning and rises As the day
progresses.
Alcohol, drugs medication: alcohol and
recreational drugs can change body
temperature. Also certain medication can alter
body temperature. E.g. antibiotics elevate
temperature while drugs like Tylenol reduces
temperature
 Factors Affecting Body Temperature
cont’d
Stress: stimulate the production of epinephrine and
nor epinephrine that intend increases metabolic
activities and heat production
Illness, disease and trauma
Age: a new born has some difficulties adjusting to
body temperature ( can be slightly high one time
and slightly low the next). An elderly person usually
have low-normal temperature as a result of changes
within (e.g. decrease in the amount of
subcutaneous fat) the body and decrease in physical
activity
 Normal body temperature
Also known as euthermia or normothermia
depends on the place of the body at which
the measurement is made, time of the day
and level of activity. Different part of the
body takes different temperature;
 Oral: 33.2-38⁰c (92-102⁰F)
 Rectal: 34.4-37.8⁰c (98-100⁰F)
 Axillary 35.5-37⁰c (96-99⁰F)
 Tympanic cavity: 35.4-37.8⁰c (96-100⁰F)
 Alteration in body temperature
The main alterations in body temperature are
pyrexia and hypothermia.
PYREXIA
Is a body temperature above normal. Also
termed hyperthermia or fever in lay terms). A
very high fever (41⁰c) is called hyperpyrexia.
There are 4 common types of fever. These are;
Alteration in Body temperature cont’d
 Intermittent fever: temperature alternates at regular
interval between periods of fever and period of
normal or subnormal temperature. E.g. in malaria
 Remittent fever: there is a wide range of temperature
fluctuations (more than 2⁰c (3.6⁰f) above normal over
a period of 24 hours
 Relapsing fever: short febrile periods of few days are
interspersed with 1 or 2 days of normal temperature
 Constant fever: temperature fluctuates minimally, but
always remains above normal
Alteration in Body temperature cont’d
In some instances, there can be elevated temperature
that is not a fever
Heat exhaustion; extreme tiredness (fatigue) as a result
of decrease in blood pressure and blood volume. This
is caused by exposure to excessive heat resulting in
dehydration (loss of body fluids and salts). s/s
include; dizziness, nausea, fainting and moderately
increased temp.
Heat stroke; occurs when the body temperature
becomes dangerously high due to heat exposure and
the body is no linger able to cool itself and start to
overheat. More serious than heat exhaustion. s/s,
headache, confusion, thirst. hyperventilation etc.
Alteration in Body temperature cont’d

HYPOTHERMIA
Is when body temp. drops below that
required for normal metabolism and
body functions
(1-2⁰c below normal temperature)
 Assessing Body Temperature
Common sites for measuring body temperature
are;
 Oral: should be taken 30 minutes after taking
in cold or hot fluid to ensure that, the temp. of
the food would not affect the temperature of
the mouth
 Rectal: This is the most reliable method
Assessing Body Temperature cont’d
 Axilla: is the preferred site for measuring temp.
in newborns if accessible and safe
 Tympanic membrane or nearby tissue in the ear
canal: is a frequent site for assessing core body
temp. uses electronic tympanic thermometer.
 Temporal artery: temp is taken on the forehead.
Useful for infants and children. Uses chemical or
temporal artery thermometer
 Groin.
 Indications
• Routine part of assessment on admission for
establishing a base-line data
• As per agency policy to monitor any changes
in patient’s condition
• Before, during and after administration of any
drug that affects temperature control function
• When general condition of patient changes
• Before and after any nursing intervention that
affect temperature of the patient
 Contraindications
A. Oral
 Patients who are not able to hold thermometer in
their mouth
 Patients who may bite the thermometer
 Infants and small children
 Surgery/infections in oral cavity
 Trauma to face/mouth
 Patients with history of convulsions
 Patients having chills
 Contraindications cont’d
B. Rectal
 Clients with myocardial infarction
 Clients undergoing rectal surgery
 Patients with hemorrhoids
 Clotting disorders
 Diarrhea and other diseases of the rectum
C. Axilla
 Any surgery/lesion in the axilla
 Requirements
A tray containing the following;
 Clinical thermometer (rectal thermometer if
rectal method)
 Gallipot with cotton swabs
 Gallipot with water for rinsing thermometer
 Receiver for used swabs
 Temperature chart
 A watch with seconds hand or pulsometer
 Pen
 Lubricant in case of rectal method
Pulsometer
 Procedure
1. Ascertain method of taking temperature and explain
procedure to patient and instruct him/her on how to co-
operate
 For oral, ensure that patient had not taken any cold or
hot food and fluids orally or smoked 15-30 minutes
prior to procedure
 For rectal method provide privacy and position patient
in Sim’s position. In young children, position laterally
with knees flexed or prone across the lap
 For axilla method, expose axilla and pat dry with a
towel. Avoid vigorous rubbing
 Procedure cont’d
2. Wash and dry hands
3. Prepare equipment
 If glass thermometer is in disinfectant solution,
transfer it to gallipot with plain water
 Wipe thermometer dry with clean cotton swab
using rotatory method from bulb to the stem
 Shake down the mercury if needed by holding the
thermometer between thumb and forefinger at
the tip of the stem. Shake till mercury is below
35°с (95°F)
 Procedure cont’d
4. Take temperature
a. For oral method
i. Place bulb of thermometer under patient’s
tongue
ii. Instruct patient to close the lips and not the
teeth around thermometer
iii. Leave thermometer in place for 2-3 minutes
 Procedure cont’d
b. For rectal method
i. Don disposable gloves
ii. Apply lubricant on the bulb of thermometer
using cotton ball
iii. With non-dominant hand , expose anus raising
upper buttocks
iv. Instruct patient to breath deeply and insert
thermometer into anus. 3.5-4cm in adults,
2.5cm in a child and 1.5 cm in an infant
v. Hold thermometer in place for 1-2 minutes
 Procedure cont’d
c. For axilla method
i. Place bulb in the centre of axilla
ii. Place arm tightly across chest to hold thermometer
in place
iii. Hold thermometer in place for 2-3 minutes
5. Remove thermometer, wipe using cotton ball from
stem to bulb in a rotatory manner

6. Read temperature by holding thermometer at eye

level and rotate it till reading is visible and read it
accurately
 Procedure cont’d
7. Shake down the mercury level
8. Record reading on temperature chart
9. Thank patient
10. Leave patient comfortable
11. Disposed off used swabs, clean thermometer,
gallipots and receiver and store appropriately
12. Wash and dry hands
13. Report any abnormality
 Disinfection of Clinical Thermometer
• Use a clean soft tissue or cotton wool each
time the thermometer must be wiped
• Hold tissue/swab at the end of the
thermometer near the fingers
• Wipe down towards the bulb using a rotatory
(twisting) motion
• Clean it with soap or detergent solution again
using twisting motion
 Disinfection of Clinical Thermometer
Cont’d
• Rinse under running cold water
• Immerse it in savlon or hibitane 1% for 20
minutes
• Rinse thermometer with water after
disinfection and before re-use
• Return it to storage receptacle if not needed
for immediate use
 Conversion of Celsius to Fahrenheit
and vice versa
Fahrenheit to Celsius
C=(Fahrenheit temp-32)x 5/9
Example temp= 100⁰f
C=(100-32)x 5/9
=68x5/9
=37.8⁰c
 Conversion cont’d
Celsius to Fahrenheit
F= (Celsius temp x 9/5)+32
Example temp=40⁰c
F=(40x9/5)+32
=72+32
=104⁰f
 Rigor
• A tremor caused by chills
• Rigor is an episode of shaking or exaggerated
shivering which can occur with a high fever. It
is an extreme reflex response which occurs for
a variety of reasons
 Epidemiology

• Rigors are a common accompaniment of high

fever.
• They occur more commonly in children.
• They are less likely to occur in the elderly.
• However, they are a predictor of bacteraemia
and bacterial infection in young and old.
 Presentation
• The sudden attack of severe shaking
accompanied by a feeling of coldness (chills) is
referred to as rigor.
• It is often associated with awarded rise in
body temperature.
• It may be described by patients as
uncontrollable shaking.
• A history of rigor should raise suspicion of
infection particularly bacterial infection.
 What to look out for during rigor
• Symptoms suggestive of local infection
especially RTI, UTI etc.
• Recent surgical procedures
• Any relevant past medical history such as
rheumatic heart diseases.
 Conditions Associated with Rigor

• Malaria
• Pyelonephritis
• Pneumonia
• Prostatitis
• Drug reaction e.g. gentamicin
• Gastroenteritis
• Urinary tract infection
• Tuberculosis
• Pericarditis
• Postoperative infection
 Stages of rigor

The cold stage:

Patient feels cold, there is shivering, pulse is
bounding and temperature begins to rise
Hot stage:
• Hot skin or patient’s skin is dry and warm to
touch, temperature rises rapidly, pulse is
tready, shivering stops
 Sweating stage:

• Temperature drops
• Patient begins to sweat and pulse
improves
• This is as a result of vasodilation.
• This phase is referred to as the flush phase
 Interventions for the stages of rigor

• Cold stage: reassure patient, cover him/her with

blanket and serve hot or warm drinks
• Hot stage: remove blanket, tepid sponge if
temperature is 38°c and above.
• Serve drinks or fluids, provide ventilation. Serve
prescribed IV fluid and antipyretics
• Sweating Stage: provide proper ventilation, put
patient in light clothing, give bed bath with warm
water or clean sweat.
 General Nursing Intervention for
Clients with Fever
• Expose body to cool air
• Give cold drinks
• Encourage patient to drink a lot of fluids
• Tepid sponge
• Tepid bath
• Use hypothermic blankets
• Serve well balanced diets
• Provide adequate rest and sleep
• Give mouth care to prevent cracks of the lips and coated tongue
• Monitor urine output
• Monitor vital signs
• Assess skin colour
• Remove excess blankets when clients feels warm.
 PULSE
 Pulse is wave of blood created by contraction
of the left ventricle of the heart
 Pulse represents the tactile arterial palpation
of the heart beat
In a healthy person, the pulse reflects the heart
beat. However, in some cardiovascular
conditions, the heart beat and the pulse rate
may differ
 Pulse cont’d
 Peripheral pulse: is located away from the heart.
E.g. in the wrist or foot
 Apical pulse: is the central pulse located at the
apex of the heart.
 Listening area for apical pulse is the 5th left
intercostal space (just below the left nipple) for
adults and the 4th left intercostal space for a
young child or infant
 When checking pulse, take note of the rate,
rhythm and volume.
 Pulse cont’d
 Rate: may be normal fast or slow. An average
rate of a resting adult is 60-100 beats per
minute(bpm).
 Rate faster than 100bpm is tachycardia and rate
lower than 60bpm is bradycardia
 Rhythm: is the pattern of beat and the interval
between the beat, in other wards the regularity
of the pulse beat. In a normal pulse beat, equal
time elapses between beats.
 When the pulsation occurs at different
rate, then the rhythm is irregular. Pulse
with irregular rhythm is referred to as
dysrhythmia or arrhythmia
 Volume: is the force or strength of the
pulse. Pulse that lacks strength can be
described as thready, weak or feeble,
while pulse that feels forceful can be
strong, full or bounding.
 Factors Affecting Pulse Rate
 Age: pulse rate decreases from birth to
adulthood, then increases with advancing
age.
 Sex: women have slightly faster pulse than
men
 Body temperature: pulse increases (7-10) for
each degree of temperature elevation
 Exercise: pulse rate increases with activity.
That is the beats faster to meet the increase
demand for oxygen
Factors Affecting Pulse Rate cont’d
 Medication: some medication (epinephrine)
increases the heart rate while others(digitalis)
decrease it.
 Pain: increases pulse rate
 Pathology: cardiac and respiratory conditions
can alter pulse rate.
 Digestion: increase metabolic rate during
digestion slightly increases pulse rate
 Blood pressure: BP and pulse has an inverse
relationship. Low Bp results in high pulse rate as
the heart attempts to increase blood output
 Sites for Taking Pulse
The pulse may be palpable in any place that
allows an artery to be compressed against a
bone. Sites include;
 Temporal pulse: located in the temple
directly in front of the ear
 Carotid pulse: located at the side of the neck
 Brachial: located on the inside of the upper
arm near the elbow
 Radial: on the lateral wrist
 Sites for Taking Pulse cont’d
 Femoral: on the inner thigh, at the mid-
inguinal point.
 Popliteal: behind the knee. Found by holding
the bent knee.
 Dorsalis pedis(pedal): on top of the foot
 Tibialis posterior(posterior tibial): on the
medial surface of the ankle
 Apical pulse: measures below the heart itself
on the left side of the chest about 8cm to the
left of the sternum.
Sites for Taking Pulse cont’d

Checking radial pulse

 Assessing the pulse rate
Pulse is commonly assessed by palpation or
auscultation. The middle 3 fingers are used to
palpate pulse at all sites except the apical
pulse (auscultation). It is palpated by
applying moderate pressure with the fingers.
Excessive pressure can obliterate the pulse
and too little pressure may not be able to
detect it
 Purpose
• To establish baseline data
• To check abnormalities in rate, rhythm and
volume
• To monitor any changes in patient’s health
status
• To check the peripheral circulation
 Requirements
• A watch with seconds hand or pulsometer
• Vital signs chart
• pen
 Procedure
It is usually taken while taking temperature, but may be
taken separately
1. Explain procedure to patient and check if patient has
been involved in any activity. If so allow patient to
rest for 10 minutes before checking the pulse
2. a. Select the pulse site
b. Assist patient to a comfortable position. for redial
pulse, keep the arm resting over the chest or on the side
with palms downward. In sitting position, keep the arm
resting over the thigh with palm facing downward
 Procedure cont’d
3. Palpate and check pulse
a. Place tip of 3 fingers other than the thumb lightly
over the pulse site
b. After getting the pulse regularly, count it for a whole
minute looking at the seconds hand of the watch
c. Assess for rate rhythm and volume of pulse
4. Document on vital signs chart
5. Make patient comfortable
6. Wash hands
7. Report any abnormalities detected
 RESPIRATION
Respiration is the act of breathing. It consist of
inspiration and expiration
 Inspiration/inhalation: refers to intake of air into the
lungs(breathing in)
 Expiration/exhalation: Refers to breathing out or
movement of gases from the lungs to the
atmosphere.
 Respiratory rate: is the number of breaths a living
being takes within a certain amount of time. (given in
breaths per minute)
 The respiratory cycle is made of inspiration,
expiration and a pause
 Factors affecting respiration
 Exercise; increases respiration
 Temperature; increase temperature
increases respiration and vice versa
 Stress increases respiration
 Medication (e.g. narcotics) can
decrease respiratory rate.
 Assessing Respiration
Respiration should be assessed when patient is relaxed
or at rest. It is done by counting the number of
breaths per minute, that is counting how many times
the chest rises. The rate, depth, rhythm, quality and
effectiveness of respiration should be assessed.
– Rate (number of times person breaths per minute)
– Rhythm (regularity of the breathing pattern)
– Depth of respiration (describing how weak or
shallow the person breaths)
 Assessing Respiration Cont’d
• Normal rate and depth is called eupnoea.
Abnormal slow respiration is termed
bradypnea while abnormal fast respiration is
tachypnea or polypnea. Apnea is the absence
of breathing
 Terms used in describing respiration
• Tachypnoea/polypnoea (rapid respiration over 24cpm)
• Bradypnoea (slow respiration less than 10cpm)
• Apnoea (total cessation of breath)
• Hyperpnoea (increase in the depth of respiration)
• Orthopnoea (patient can breath only in upright position)
• Anoxia (lack of oxygen in tissue)
• Anoxaemia / hypoxaemia (lack of or low oxygen level in
circulation)
• Stertorous respiration (noisy respirations often termed as
snoring)
• Stridor (harsh, vibrating thrill sound heard during
respiration)
 Terms cont’d
• Wheezing ( high whistling sound heard during
respirations)
• Sighing (very deep inspiration followed by
prolonged expiration)
• Cheyne stokes respiration (consists of series of
respirations that become deeper and noisier until
peak is reached and followed an apnoea)
• Cyanosis (blueness of the skin as a result of lack
of oxygen supply)
• Dyspnoea (difficult breathing)
 Care of patient with dyspnoea
• Reassure patient and encourage him/her
• Ensure adequate ventilation
• Prop up patient in bed
• Give oxygen in cyanotic cases
• Ensure airway patency
• Teach patient deep breathing exercises
• Steam inhalations can be administered
• Feed patient in bits
• Continuous observation of the patient
 Purpose of Taking Respiration
• To assess rate, rhythm and volume of
respiration
• To assess for any change in condition and
health of patient
• To monitor the effectiveness of therapy
related to the respiratory system
 Requirements
• A watch with seconds hand or pulsometer
• Vital signs chart
• pen
 Procedure
1. Ensure that patient is relaxed. Assess other vital signs
such as temperature and pulse prior to counting
respiration
2. Assess for factors that might affect respiration
3. Wait for 5-10 minutes if patient has been active
4. Position patient in sitting or supine position with head
elevated 45-60 degrees
5. After checking for pulse, with the hand still on patient’s
wrist, observe respiration without his awareness. If
checking only respiration, keep your fingers over the
wrist as if checking for pulse and position patient’s hand
over his lower chest or abdomen
 Procedure cont’d
6. Observe one complete respiratory cycle;
inspiration, expiration and a pause (note the
rise and fall of patient’s chest)
7. Assess rate, depth rhythm and character of
respiration
8. Count respiration for one whole minute
9. Wash hands
10. Record findings and report any
abnormalities
Variations in Pulse and Respiration by
Age(average and range)
Age Pulse Respiration
Newborn 130(80-180) 35(30-80)
1year 120(80-140) 30(20-40)
5-8years 100(75-120) 20(15-25)
10years 70(50-90) 19(15-25)
Teen 75(50-90) 18(15-20)
Adult 80(60-100) 16(12-20)
Older adult 70(60-100) 16(15-20)
 BLOOD PRESSURE(BP)
 Is the pressure exerted by circulating blood upon
the walls of the blood vessels
 Is the measure of the pressure exerted by the blood
as it flows through the arteries.
There are 2 BP measures;
1. The systolic(maximum) pressure; is the pressure of
blood as a result of contraction of the ventricles.
2. Diastolic(minimum) pressure; is the pressure when
the ventricles are at rest.
 BP Cont’d
 The difference between the systolic and diastolic
pressure is referred to as the pulse pressure. Normal
pulse pressure is 40mmHg.
 Bp is measured in millimeters of mercury (mmHg)
and recorded in fractions, the systolic pressure over
the diastolic pressure. Average BP of a healthy adult
is 120/80mmHg
 Factors Affecting Blood Pressure
 Age: pressure rises with age peaking at the on
set of puberty, then declined. In the elderly,
there is elevated Bp because of decrease
elasticity of the arteries
 Race; African-Americans (males) have higher BP
than Caucasians.
 Gender: females have low Bp than males at
puberty due to hormonal variations
Factors Affecting Blood Pressure cont’d
 Medication ; e.g. caffeine increases BP
 Disease process: conditions affecting cardiac
output, blood volume, and viscosity affects BP
 Exercise: physical activity increases cardiac output
and hence the BP
 Obesity: can predispose to hypertension
 Stress: stressful situations brings about surge of
hormones which temporarily increase BP (the heart
beats faster and the blood vessels narrow)
 Factors Affecting BP Readings
 Alcohol: increases BP
 Position of the body; sitting, lying, standing
 Activity level: from not moving to extreme exertion
 Sleep or awake: lower when asleep
 Caffeine: increases BP
 Smoking: increases BP
 Temperature: BP tend to increase when the
individual is cold
 White coat hypertension: BP increase in medical
settings
 Assessing Blood Pressure
 BP is measured by using a sphygmomanometer and a
stethoscope.
 The sound heard when the stethoscope is put into
the ears during BP monitoring is Korotkoff’s sounds
or beats
 Bp is mostly measured on the client’ upper arm. It
can however be measured on the thigh when it can
not be measured on either arm.
 Bp above normal is termed hypertension while
below normal is hypotension
 Classification of Blood Pressure
Category Systolic BP Diastolic BP
Hypotension <90 or <60
Normal 90-120 and 60-80
Prehypertension 121-139 or 81-89
Hypertension stage1 140-159 or 90-99
Hypertension stage 2 ≥160 or ≥100
 Purpose
• To determine patient’s blood pressure as a
baseline for comparing future measurements
• To aid in diagnosis
• To aid in the assessment of cardiovascular system
preoperatively and postoperatively, during and
after invasive procedures
• To monitor change in condition of patient
• To assess response to medical therapy
• To determine patient’s hemodynamic status
 Requirements
• Sphygmomanometer
• Blood pressure cuff of appropriate size
• Stethoscope
• Pen
Preparation
 Make sure equipments are intact and
functioning well
 Make sure client has not smoked or ingested
caffeine (causes temporary increase in blood
pressure)
BP Apparatus
 Procedure
• Prior to procedure introduce self and verify
client’s identity
• Gather requirements
• Wash and dry hands and observe appropriate
infection prevention procedures
• Provide privacy
• Place patient in a relaxed reclining or sitting
position with arm at heart level.
• Expose upper arm
 Procedure cont’d

• Wrap the deflated cuff evenly around the upper

arm with the center of the bladder over the
brachial artery
• Palpate the brachial artery with fingertips
• Close the valve of the bulb and pump up the cuff
until you no longer feel the brachial pulse (gives
an estimate of the systolic pressure)
• Release pressure on cuff and wait 1-2 minutes
before further measurements
 Procedure cont’d

• Position the stethoscope appropriately

• Place the bell side of the amplifier of the
stethoscope over the brachial pulse site, directly
on the skin and not on clothing
• Hold the diaphragm with the thumb and index
finger.
• Pump up the cuff until the sphygmomanometer
reads 30mmHg above the point where the
brachial pulse disappeared.
 Procedure cont’d

• Release valve on cuff carefully, so that

pressure decreases at a rate of 2-3mmHg per
second until the first korotkoff’s beat or
sound is heard. That is the systolic pressure
• Continue to deflate cuff, note when the
sound begins to muffled and when it
completely disappears
• Wait for 1-2minutes before making further
determinations
 Procedure cont’d

• Repeat the above steps to confirm accuracy of

reading especially if it falls outside the normal
range
• If there is 5mmHg difference between the 2
readings, additional measurement may be taken
• If this is client’s initial examination, repeat
pressure on the other arm. There should be a
difference of not more than 10mmHg between
the arms. The arm with higher pressure should
be used for subsequent assessment.
 Procedure cont’d

• Remove cuff from patient’s arm

• Record blood pressure and if appropriate blood
pressure site
• Compare blood pressure readings with previous
readings
• Make patient comfortable
• Wash and dry hands
• Report any significant change in client’s blood
pressure
 Checking of V/S Using Electronic
Thermometer
1. Explains procedure to patient

2. Press knob to ensure thermometer is functioning and

wash hands
3. Prepare and send tray to patient’s bedside

4. Make patient comfortable by lying or sitting up in

bed
5. Press knob again to show reading on the screen,
expose axilla, dry with clean cotton wool and discard

6. Inserts thermometer into the axilla, between two

skin folds and leave it in place until it beeps
 Checking of V/S Using Electronic
Thermometer Cont’d
7. Whiles thermometer is in the axilla, check and
records pulse and respiration
8. Remove thermometer after beep and read, record,
clean from stem to the bulb and insert
thermometer back into its cover
9. Record readings of temperature, pulse, respiration

10. Stretch patient’s arm and place

sphygmomanometer beside arm at the same level

11. Wound cuff around arm above elbow

 Checking of V/S Using Electronic
Thermometer Cont’d
12.Inflate cuff, palpate radial artery and note level
of mercury at which pulse disappears

13.Wear and place stethoscope on brachial artery

14.Release pressure slowly and listen to sound

with stethoscope
15.Remove cuff and reassemble apparatus

16.Thank patient, wash hands, record reading and

make patient comfortable
Thank You

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