Vital signs

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Measuring Vital Signs (Temperature) Oral Method

LEARNING GUIDE FORMEASURING VITAL SIGNS (TEMPERATURE) ORAL METHOD
STEP/TASK CASES cases
Done not comment
completely complete
Getting Ready
1. Wash hands
2. Prepare the equipment
3. Explain the procedures to the child and his parents
4. Check thermometer to see the reading.
5. Clean thermometer
6.Shake down the level of mercury down to below 35 C.
During the Procedure
1. Place the thermometer in the mouth under the tongue.
2. Ask the child to close his lips for 3 minutes
3.Remove thermometer and wipe it from up to down to the bulb.
(from the tip to the bulb)
4. Hold the thermometer at eye level and rotate it slowly until
mercury column is visible
5. Take the reading
After The Procedure
1. Record the temperature
2. Wash thermometer with soap and water
3. Keep equipments in their place
 Measuring Vital Signs (Temperature) Axillary's Method
LEARNING GUIDE FORMEASURING VITAL SIGNS (TEMPERATURE) ORAL METHOD
STEP/TASK CASES cases
Done not comment
completely complete
Getting Ready
1.Wash hands
2.Prepare the equipments
3.Explain the procedures to the child and his parents
4.Check thermometer to see the reading
5. Clean thermometer from tip to the bulb
6. Shake down the level of mercury down to below 35 C.
During the Procedure
1.Rinse and dry Axilla
2.Place Thermometer under arm with tip in center of axilla and
keep it close to skin not clothing
3. Hold child's arm firmly against side for 5 minutes.
4. If The child is older, explain to keep the arm flexed across the
chest and close to side of the body and hold in position.
5. Remove thermometer and wipe it from up down to the bulb.
6.Hold the thermometer at eye level and rotate it slowly until
mercury column is visible
7. Take the reading
After The Procedure
1. Record The temperature
2. Wash thermometer with soap and water.
3. Keep equipments in their place

Measuring Vital Signs (Temperature) Rectal

LEARNING GUIDE FORMEASURING VITAL SIGNS (TEMPERATURE) ORAL METHOD
STEP/TASK CASES cases
Done not comment
completely complete
Getting Ready
1.Wash hands
2.Prepare the equipments
3. Explain the procedures to the child and his parents
4.Check thermometer to see the reading
5.Clean thermometer from tip to the bulb
6. Shake down the level of mercury down to below 35 C.
During the Procedure
1.Rinse and dry the anal area
2.Lubricate the bulb of the rectal thermometer
3. Place child in side-lying or prone position
4. Place infant prone across mother's lap or supine with knee
flexed toward abdomen. Or grasp the infant's ankle firmly, placing
your index finger between the ankle firmly, placing your index
finger between the ankle bones.
5. Insert the lubricated thermometer 2.5 cm in the rectum and
hold it for one minute.
6.Remove the thermometer and wipe with swab from up to down
the bulb
7.Hold the thermometer at eye level and rotate it slowly until
mercury column is visible
8.Take The reading
After The Procedure
1. Record the temperature
2. Wash thermometer with soap and water.
3.Keep equipments in their place

Measuring Vital Signs (Apical Pulse)

LEARNING GUIDE FORMEASURING VITAL SIGNS (TEMPERATURE) ORAL METHOD
STEP/TASK CASES cases
Done not comment
completely complete
Getting Ready
1. Wash hands
2. Prepare the equipments
3.Explain the procedure to the child and his parent
During the Procedure
1. Wipe earpieces and diaphragm with alcohol swab.
2. Expose the chest over the apex of the heart
3. Put the diaphragm between the fourth and the fifth intercostals
spaces just below the nipple.
4. Listen to the heart sound and count for one full minute.
After The Procedure
1. Wipe the earpieces and the diaphragm with alcohol.
2. Record your finding
3.Return used equipment
4.Wash hands

Measuring Vital Signs (Respiratory Rate)

 LEARNING GUIDE FORMEASURING VITAL SIGNS (TEMPERATURE) ORAL METHOD
STEP/TASK CASES cases
Done not comment
completely complete
Getting Ready
1. Wash hands
2. Prepare equipments (watch with sound or clock
During the Procedure
1. Expose the chest
2. Observe abdominal movement in infant and young children
3.Observe thoracic movement in older children
4. Observe a respiratory depth and rhythm
5.Count respiratory rate for one full minute
After The Procedure
1. Record on patent's chart respiration for late, depth, rhythm
2.Report any abnormality
3.Wash hands

Measuring Vital Signs (Blood Pressure)

LEARNING GUIDE FORMEASURING VITAL SIGNS (TEMPERATURE) ORAL METHOD
STEP/TASK CASES cases
Done not comment
completely complete
Getting Ready
1.Wash hands
2.Prepare equipments needed (sphygmomanometer, stethoscope ,
sponge with alcohol)
3. Select the appropriate cuff size
4. Attach the tube from the BP cuff
5. Open the cock
6. Close the valve of bulb
7. Explain procedures to older child or his/her parent.
During the Procedure
1. Allow the child to be in supine position
2. Expose the upper arm
3. Warp the cuff evenly over the upper arm with the lower edgy
about 1.5 cm above the antecubital fossa
4. Position the sphygmomanometer on a level surface at
approximately the level of heart.
5. Palpate the redial artery and inflate the cuff until the palpated
pulse is lost then pump for additional 20 mmHg.
 6. Position the bell of the stethoscope over the area where the
brachial pulse is felt.
7. Place the mercury tip manometer at eye level
8. Slowly deflate the cuff and listen to the sounds. the systolic
reading is the point at which the pulse becomes audible and the
diastolic reading is the point the sound is muffed
9. Deflate the cuff completely to zero and remove it
After The Procedure
1. Record the reading& report for any abnormality.
2.Clean the equipments and return it to their place
3. Wash hands