Measuring Vital Signs

Measuring Vital Signs

Introduction:
Vital signs are the collection of measurements that includes body temperature, pulse,
respiration, and blood pressure. Also, pain is considered as a fifth vital sign and oxygen saturation
is also could be considered the sixth vital sign. Vital signs are obtained as indicators of health
status and disturbed if there is any abnormality in the functions of the body.
Purposes:

 Obtain baseline data about patient’s vital signs for comparing future measurement.
 Detect any abnormalities.
 Evaluate the patient’s response to therapies and patient’s progress.

Body temperature reflects the balance between heat production by the

body and heat loss to the environment.
Body temperature is measured in degrees using either of two scales, the centigrade
(Celsius) scale or the Fahrenheit scale.
Temperature acceptable range 36.5 – 37.2° C
Temperature acceptable average
 Oral/tympanic 37.0° C
 Rectal 37.5° C
 Axillary 36.5° C
The most common sites for measuring body temperature are oral, rectal, axillary,
Types of thermometers:
Traditionally, body temperatures were measured using mercury-in-
glass thermometers. Such thermometers, however, can be hazardous
due to exposure to mercury, which is toxic to humans, and broken glass
should the thermometer crack or break.

Electronic thermometers: It can provide a reading in only

2 to 60 seconds depending on the model. The equipment
consists of a battery- electronic base, a probe, and a probe
cover, which is usually disposable.

Electronic thermometers :Home electronic thermometer)

1. Infrared tympanic thermometers: Infrared thermometers sense body heat
in the form of infrared energy given off by a heat source, which in the ear canal,
is primarily the tympanic membrane. The infrared thermometer makes no
contact with the tympanic membrane.

2. Chemical disposable thermometers: Chemical thermometers have liquid

crystal dots or bars that change in color to indicate temperature. These
thermometers can be used orally, rectally or in the axilla.

Temperature-sensitive tape thermometers: may also be used to obtain a

general indication of body surface temperature. The tape contains liquid crystals
that change color according to temperature. When applied to the skin, usually of
the forehead or abdomen, the
temperature digits on the tape
respond by changing color. This
method is particularly useful at
home and for infants.
 Pacifier thermometers: Are shaped like a baby's
pacifier. They have a display that shows the
temperature. The pacifier is placed in the child's mouth
to measure temperature.

Temporal artery thermometers: The probe is

placed in the middle of the forehead and then drawn
laterally to the hairline.

Measuring Body Temperature

Purposes:
1. Obtain baseline data for comparing future measurements.
2. Screen for alterations in temperature.
3. Evaluate temperature response to therapies.

Equipment:
1. Appropriate thermometer:
a- Electronic thermometer.
b- Tympanic membrane thermometer.
2. Plastic Thermometer sheath or cover
3. Water- soluble lubricant for a rectal temperature, Towel for axillary temperature.
4. Alcohol sponge in iodine bowel (Tissues/ Antiseptic wipes).
5. Disposable gloves.
6. Kidney basin lined with tissue paper or piece of cotton.
8. Pen and vital signs documentation record.

1. Measuring Axillary Temperature

Procedure:
Nursing Action Rationale
1. Perform hand hygiene. - To prevent cross infection.
 Nursing Action Rationale
2. Prepare equipment. - To save time and effort.
3. Put on disposable gloves. - To decrease spread of microorganism
4. Remove thermometer from storage container.
 Wash the thermometer with soap and water.
 Rinse well with running water.
 Put the thermometer in kidney basin lined with
tissue paper.
 Remove the gloves and dispose of them correctly.
 Perform hand hygiene.
 Put on disposable gloves.
 Dry the thermometer from bulb to tip.
 Hold the thermometer between thumb and index
finger at the end opposite the bulb at eye level.
 Check temperature reading on thermometer, if - From cleaner to less clean
reading is not below 35C shake down by holding
thermometer at the end away from bulb between
thumb and forefinger and shake wrist sharply. -To ensure accuracy.
 Wipe the thermometer with alcohol sponge from
bulb to tip and cover it with tissue paper.
 To use a disposable sheath (cover) disinfect the
thermometer with an alcoholic sponge. Insert it into
the disposable sheath opening. - For accurate measurement.
5. Take the thermometer to the patient’s bedside.
6. Explain the procedure to the patient.
7- Close door or apply curtains. - To prevent contamination.
8- Assist the patient to comfortable position and
expose axilla.
9. Dry the axilla with tissue paper gently.
10. Ask the patient to reach across his chest and grasp
the opposite shoulder, lifting his elbow. -To gain the patient's cooperation and reduce
11. Position the thermometer in the center of the axilla. fear and anxiety.
12. Tell him/her to keep grasping his shoulder and to
lower his/her elbow and hold it against his chest. -To maintain patient's privacy
13. Remove a mercury thermometer after 10 minutes.
14. Holding the thermometer at eye level, rotate slowly
until mercury column is visib1e. Note upper end of
column as the temperature reading. - For accurate measurement.
15. Wash thermometer with soap from tip to bulb, rinse
under running water, dry it from bulb to tip and -To maintain correct placement of the
put it in kidney basin lined with tissue paper, thermometer
remove disposable gloves. - To promote skin contact with the
16. Return the thermometer to storage container. thermometer.
17. Record temperature in vital signs documentation
record. (Date, time, result & abnormalities). - For accurate measurement
18. Discuss findings with patient if possible.
19. Report any abnormalities to the physician.
 Nursing Action Rationale

Contra-indications for axillary method:

Patients with axillary problems and surgery.

2. Measuring Rectal Temperature:

Nursing Action Rationale
1. Follow the previous Nursing Action from 1 to 6. - Draping to maintain patient privacy.
2. Position the patient on his side with his top leg
flexed and drapes him. Then fold back the bed
linen to expose the anus.
3. Squeeze the lubricant onto tissue paper. - To reduce friction.
4. Lubricate about (4cm) of the thermometer bulb. If
use disposable rectal sheath don't apply lubrication.
5. Lift patient’s upper buttock, instruct the patient to - Avoid perforation of anus or rectum or
take a slow deep breath during insertion and insert breaking the thermometer, ensure accurate
the thermometer about 3.5cm, gently direct reading.
thermometer along the rectum toward the
umbilicus.
6. Hold mercury thermometer in place for 2-3 - To remove any lubricant from anal area.
minutes.
3. Carefully remove the thermometer, wiping it.
Then wipe the patient’s anal area.
Contra-indications for rectal method
Patients with:
1. Heart disease (myocardial infarction) as it stimulates the vagus nerve and causing
bradycardia
2. Anal problems and anal operation.
3. Low platelets count: The rectum is very vascular, and a thermometer could cause
rectal bleeding
3. Measuring Body Temperature using Tympanic Thermometer
 Nursing Action
1. Check medical order or nursing care plan for
frequency of measurement and route. More
frequent temperature measurement may be
appropriate based on nursing judgment.
2. Identify the patient and explain the
procedure.
3. Ensure the electronic or digital thermometer in -To save effort and time.
working condition.
4.Remove thermometer from recharging base
5. Perform hand hygiene & gloving if indicated
6. Assess the patient for significant ear drainage
or a scarred tympanic membrane.
7.Attach disposable probe cover to sensor unit
Rationale
- Assessment and measurement of vital signs
at appropriate intervals provide important
data about the patient’s health status.
-To gain patient cooperation , to decrease
patient anxiety and to maintain patient
humanity
-To decrease spread of microorganism
-These conditions can provide inaccurate
results, discomfort
-To prevent cross infection.

8. Push the "on" button & wait for the "ready" -For proper function
signal of the unit

7. Insert the probe gently into ear canal while -If the probe not inserted correctly , the
gently pulling upward and back ward on the patient's temperature be noted as lower than
pinna of ear , angling the probe toward jaw normal
line "Take care that too deep or too.
force damage ear canal"
8.Activate the thermometer , read it immediately
"within 2 second"
9. Record the result
10. Dispose of the probe cover in the waste -To prevent accidently re-using by another
receptacle by pushing the probe release nurse to another patient.
button or use rim of cover to remove from - To be ready to use at all times.
probe.
11. Perform hand hygiene.
12. Discuss finding with patient if appropriate
 Nursing Action Rationale
13. Report any abnormalities to physician.

1-9-2023

88kg

10:00 37.3OC
AM
Signature
2:00
11:00PM
AM 37.3
36.9OO
R AX Ms. Fatma Ahmed
https://www.youtube.com/watch?v=2j3nH6XmE-k
 Pulse and Respiration
Methods of assessing pulse:

Palpation
Feeling

Auscultation
Hearing by the stethoscope is used for assessing apical pulses.

Doppler ultrasound stethoscope (DUS)

It is used for pulses that are difficult to assess.

Methods of Assessing Respiration:

1. Auscultation: Listening with stethoscope.
2. Observation: Chest raising up and falling.

Assessing Peripheral Pulse and Respiration

Purpose of Assessing Peripheral Pulse and Respiration:

1. Obtain base-line data about the patient’s physical condition.

2. Determine the rate and quality of patient's pulse and respiration.
3. Detect the presence of arrhythmias or inadequate circulation or other changes in the
patient's condition.
4. Detect the presence of respiratory depression or respiratory distress, or other changes in the
patient's condition.
5. Estimate doses of some medication.
Heart rate = Pulse rate
Equipment:
• Watch with a second hand or digital readout.
• Graphic chart and patient's record.
• Pen.
Different sites for assessing the pulse:
 Nursing Action Rationale
1. Perform hand hygiene. - To prevent cross infection.
2. Identify the patient and explain the procedure - To gain patient's cooperation and reduce fear
to the patient. and anxiety.
3. Check the patient’s previous pulse and
respiratory rate recordings.
4. Ascertain the patient's medical diagnosis and
any prior history of arrhythmias or respiratory
problems or difficulties.
5. Assess factors affecting pulse and respiration as
age, exercise, and medications.
6. Assist the patient to a position of comfort and
position the forearm at a 90-degree angle
across the chest.
7. Locate the patient's radial pulse and palpate  Using the thumb is contraindicated because the
with your first 2 or 3 fingers. nurse's thumb has a pulse that could be mistaken
for the patient's pulse.
8. Count pulse using a watch with second hand  To detect any abnormalities in the pulse rhythm.
for one minute.
 To avoid voluntary control of his respiration.
9. Note the rhythm and volume of the patient's
pulse.

10. With fingers still on the wrist count

respiration for one minute by looking at the chest Observe the patient's:
as it rises and falls. ▪ Color,
11. Observe the patient's color, depth of ▪ Depth of respiration,
respiration, presence of nasal flaring, retractions, ▪ Presence of nasal flaring, retractions,
and rhythm of respiration. Also observe the body ▪ Rhythm of respiration.
position he or she assumes to breathe. ▪ Patient's body position he/she or she assumes
12. Perform hand hygiene. to breathe.
13. Record the result

When counting the patient's respiratory

rate, observe for any signs of respiratory
distress that are:
 Use of accessory muscles.
 Cyanosis.
 Retraction of the intercostal muscles.
 Exhalation is usually longer than inhalation.
 Sternum; or nasal flaring.
Document for peripheral
pulse:
1- Rate
2- Rhythm
3- Force
4- Volume

Document for peripheral

respiration:
1- Rate
2- Rhythm
3- Odor
4- Pain
5- Cyanosis
6- Depth
7- Effort
It is important to make sure that the earpieces are facing forward and that they fit well. Otherwise, you
might not be able to hear anything with your stethoscope. If you put them in backwards, you won’t be
able to hear.

Adjust Stethoscope’s Earpieces.

anything.
 Assessing Apical Pulse
Apical pulse is the result of closure of mitral and tricuspid valves “lub sound” and
the aortic and pulmonic valves “dub sound”. The combination of the two sounds is
counted as one beat.
Purpose:
1- To assess heart rate when the peripheral pulse is weak or irregular or both.
2- To assess heart rate before administering medication such as digitalis.
3- To identify pulse deficit.
Equipment:
- Stethoscope - Tray
- Two iodine bowls - Alcohol sponges or (Antiseptic wipes)
- Watch with a second hand
Nursing Action Rationale
1- Perform hand hygiene - To prevent cross infection.
1- Identify the patient.
3- Explain the procedure -To ensure the right patient and prevent the
4- Examine the patient's previous pulse rate errors
recording.
5- Ascertain the patient's medical diagnosis and - To gain patient’s cooperation.
any prior history of arrhythmias.
6- Assess the factors that could affect the pulse
rate such as: patient’s age, exercise, or - To obtain a database about patient’s
medication. condition and progress.
7- Close the door and windows and apply
curtains. - For accurate measurement
8- Assist the patient to a position of comfort
(lying position or sitting position).
- To maintain patient’s privacy
9- Clean the stethoscope diaphragm and
earpieces with an alcohol sponge before the - To facilitate locating the apical pulse
procedure.
10- Expose the patient’s clothes and locate the - For accurate measurement
apical pulse (For adults between fifth-six ribs
or in the fifth intercostal space, left mid - To prevent cross infection.
clavicle line).
Locate the apical pulse:
- Palpate the angle of Louis (the angle between
the manubrium, the top of the sternum, and - For accurate hearing.
the body of the sternum). It is palpated just
 Nursing Action Rationale
below the suprasternal notch and is felt as a
prominence.
- Slide your index finger just to the left of the
sternum and palpate the second intercostal
space.
« Place your middle or next finger in the third
intercostal space and continue palpating
downward until you locate the fifth
intercostal space.
- Move your index finger laterally along the
fifth intercostal space toward the mid
clavicular line.
11- Warm the diaphragm of the stethoscope first -To prevent frighten of the patient which
by holding it against the palm of your hands may affect the pulse rate.
for 5-10 seconds.
12- Insert the earpieces in your ears with the tips
bent forward toward your nose. -According to the anatomical position of
13- Place the stethoscope over the apex of the external ear canal
patient's heart and count for one minute. - To detect any abnormality in pulse rhythm
14- Note the rhythm rate and force. -For accurate measurement.
15- Perform hand hygiene.
16- Record the results (pulse rate, rhythm). - To prevent cross infection.

Location of the Apical Pulse

Locating of the Apical Pulse

Taking an Apical Pulse

 Counting Apical Pulse Performance Checklist
Student's Name: ……………………………... Academic number: …………………………………………………………………..……
Date: ………/……/…………………………..….. Group #: …………………………………………………………….……………...…..
Type of Evaluation
Re-demonstration Formative OSCE Summative OSCE
( ) ( ) ( )

Steps Grades Student's

Grades
1. Perform hand hygiene 0.5
2. Put on gloves if necessary. 0.5
3. Identify the patient correctly 0.5
4. Explain the procedure. 0.5
5. Put the patient in comfortable position (lying 0.5
or sitting).
6. Assess the factors that could affect the pulse 0.5
rate as: patient’s age, exercise, or medication.
7. Disinfect the earpieces and diaphragm of the 1
stethoscope with sponge with alcohol
8. Place the stethoscope in the ear with earpieces 1
directed forward
9. Expose the patient’s clothes and locate the 6
apical pulse.
10. Warm the diaphragm of the stethoscope and 1
place the stethoscope over the apex of the heart
correctly.
11.Cout the pulse for one minute 2
12. Clean the earpieces and diaphragm of 2
stethoscope.
13.Record the pulse for; 4
a. Patient s name
b. Time
c. Rate
d. Rhythm
e. Force
f. Report for any abnormalities.
Total grade 20
Grade out of 10
Student's Signature: ……………………………………

Clinical Faculty's Signature: ………………………

 Measuring Oxygen Saturation using Pulse Oximetry
Introduction:
Pulse oximetry is a painless, noninvasive method of measuring the saturation of oxygen in a
person's blood. Oxygen saturation is a crucial measure of how well the lungs are working. When
we breathe in air, our lungs transmit oxygen into tiny blood vessels called capillaries.

Purpose:
• To assess the percentage to which hemoglobin is filled with oxygen.
• To monitor supplemental oxygen therapy especially during surgery.

Normal Oxygen Saturation in healthy adults

From 95% to 100%
Equipment
• Pulse oximeter
• Clean gloves if there is a risk of exposure to body fluids.
• Antiseptic wipes

Steps Rationale
Pre-procedure
Verify physician prescription. To maintain patient safety
Wash hands. To prevent transmission of
microorganisms.
Prepare necessary equipment. To conserve time and energy
Identify the patient. To ensure that, correct patient
receives intervention.
Introduce yourself to patient. To build trust.
Explain procedure to the patient. To decrease patient anxiety and
promote co-operation.
Keep patient privacy. To minimize embarrassment
Disinfectant your hands. To reduce the risk of infection
Wear clean gloves (if needed)
Procedure
Turn on the pulse oximeter device and check it is To have adequate measurement.
functioning properly. Check that the sensor is
clean and dry.
Select a site that is intact, warm, dry, and Avoid the factors that impede pulse
adequately perfused for pulse oximetry oximetry measurement.
measurement.
Apply the sensor: To detect any change in oxygen
If using a clip: saturation.
A. Squeeze the ends of the clip to open it.
B. Position on the patient.
C. Release the end of the clip.
 Steps Rationale
If using a wrap:
A. Position the bandage-style sensor
around the hand, foot, or digit such that
the light source and receptor are
aligned.
B. Secure the bandage-style sensor snugly,
but do
not
restrict
blood
flow.

Set the alarm parameters according to the
authorized healthcare provider’s order and
hospital policy.
Measure the SpO2 and pulse rate.
Evaluate the results measured. Compare the
pulse rate on the pulse oximeter and the
patient’s radial pulse or heart rate monitor.
Clean the probe with an antiseptic wipe.
If using a wrap, reposition the wrap as needed
to protect the patient’s skin integrity.
Post-procedure
Remove gloves if worn and perform hand
hygiene.
Ensure that the bed is in the lowest position and
verify that the patient can identify and reach
the nurse call system.
Evaluate the outcomes. Ensure that the patient’s
pulse oximeter measurement is within the
prescribed parameters. If it is not, contact the
authorized healthcare provider promptly.
Document assessment findings, including
respiratory assessment “if applied”; sensor site
assessment; supplemental oxygen if present;
date, time, and site of SpO2 measurement;
patient and family education if provided; and
patient outcomes in the legal healthcare record.
Set alarms for the acceptable ranges of
oxygen saturation to detect any
abnormal condition.
SpO2 normal range in adult = 95%.
Pulse rate normal range in adult = 60-
100 b/m
If there is no correlation between the
pulses, then reposition the sensor and
check again.
To prevent transmission of
microorganisms.
To prevent skin ulcers.
To prevent transmission of infection.
To ensure patient safety.
To detect any abnormal findings such
as hypoxemia
Document Oxygen Saturation findings
in the legal healthcare record.
 Measuring Blood Pressure
Purpose of blood pressure measurement is to:
• Obtain baseline data
• Detect changes in the patient physical condition that may lead to the development of
hypertension or hypotension
• Aid in diagnosis and treatment
• Estimate dose of medication
• Evaluate patient progress

Equipment:
1. stethoscope
2. two iodine bowls
3. alcohol sponges
4. sphygmomanometer
5. blood pressure cuff of appropriate size
6. pencil or pen _ flow sheet

Procedure:
Nursing Action Rationale
1- Check physicians order for frequency of blood - Provide for patient safety
pressure measurement
2- Introduce yourself to the patient - Demonstrates responsibility and accountability
3- Explain the procedure to patient - Reduce apprehension and promote
cooperation
4- Assess the factors that may affect the blood - For accurate measurement
pressure as: effort, medication, emotion (stress-
anger), and smoking.
5- Raise the height of the bed - Reduce muscular skeletal strain
6- Help the patient to sitting position or one of - To ensure accurate measurement
comfort position and select appropriate arm
for application of cuff (free from surgically
compromised operation as mastectomy ,
fistula and shunt )
7- Keeps the legs uncrossed -For accurate measurement (If the legs are
crossed the systolic pressure will be falsely
elevated)
8- Follow principles of measuring blood pressure:
a- Perform hand hygiene - To prevent cross infection
 Nursing Action Rationale
b- support the patient forearm at the level of the - Ensures collecting accurate data and facilitate
heart with palm of the hand upward locating the brachial artery as diastolic pressure
may increase if the arm not supported
secondary to isometric muscle contractions.
c- Expose the inner aspect of the elbow by - Facilitate application of the blood pressure cuff
removing clothing and optimum sound perception
d- Center the cuff bladder so that the lower edge - places the cuff in the best position for occluding
is about (2,5to5cm)above the inner aspect of the blood flow through the brachial artery
the elbow (above the antecubital fossa)with
the tubes directed anteriorly and downward
e- Keep the tubing free from contact with clothing - Reduces sound distortion
f- Wrap the cuff snugly and uniformly about the -Ensures the application of even pressure during
circumference of the arm (not too tight or not inflation
-too tight cuff compress the artery and too loose
cuff interfere with sound

too loose)
g- Make sure that the mercury manometer is in - Prevent errors when observing the gauge
vertical position and the mercury within the
zero level with the gauge at eye level.
 Nursing Action Rationale
9-Estimating systolic pressure:
a -Palpate the pulse at brachial or radial artery - Palpation allows for the approximate systolic
reading.
b-Tighten the screw valve on the air pump. - Prevent loss of pumped air

C- Inflate the cuff while continuing to palpate the - Provides an estimation of systolic pressure
artery until the pulsation within the artery
stops and note the measurement at that point
(palpatory method)
d- Deflate the cuff and wait 1 minute - Allow the return of normal blood flow through
the arm.
10-Obtaining blood pressure
measurement: -To prevent cross infection
a- Clean the earpieces of the stethoscope and
diaphragm with alcohol sponge.
b-Place the ear pieces of the stethoscope within - Ensures accurate measurement
the ears and position the diaphragm of the
stethoscope lightly over the location of the
brachial artery
c- Pump the cuff bladder to a pressure that is 30 - To prevent undue pressure on the artery
mmHg above the point where the pulse -To avoid auscultatory gap
precisely disappeared
d- Loosen the screw on the valve - Releases air from the cuff bladder
e- Control the release of air at a rate of - Ensures accurate measurement between
approximately 2to3 mmHg per second perception of a sound and noting the numbers
on the gauge
f- Listen for the onset and for the complete -Aids in determining the systolic and diastolic
disappearance of the sound, but if the sound pressures
continues to zero listen to the change in the
sound.
g- Read the manometer gauge
11- Clean the stethoscope and perform hand -To prevent cross infection
hygiene
12- Record the measurement on the graphic sheet - Ensures accurate documentation
or flow sheet as:
Date and time
Measurement site
Position of the patient
Report to physician any abnormalities
)elevated or low blood pressure )
 Measuring blood pressure from the lower extremities:
Nursing Action Rationale
Follow Nursing Action from 1-7 as in measuring
from brachial artery.
- Put the patient in the prone position. If -Provides best access to popliteal artery.
unable to assume prone, put him/her in
supine position with the knee slightly flexed.
Ensures proper cuff positioning.
- Expose the patient's leg and remove any -Proper cuff size is necessary for accurate
constrictive clothing from it. reading. Cuff must be wide and long
- Locate the popliteal artery behind the knee. enough to allow for large girth of the thigh.
- Apply large leg cuff 2.5 cm above the Narrow cuff causes false high reading.
popliteal artery around the posterior aspect
of middle thigh. -Facilitates optimal sound.

- Apply the diaphragm or bell of the

stethoscope directly over the popliteal pulse.

- Follow Nursing Action from 12-15 as in

measuring from brachial artery.
Measuring blood pressure from the lower extremities
N.B:
- Don’t re-inflate the cuff to check the systolic pressure; this can cause inaccurate
reading and congestion of the blood in the arm.
- To recheck the blood pressure reading, deflate the cuff and wait 1-2 minutes then
recheck of the measurement.
Document for arterial blood pressure (BP):
1- Result
2- Site
3- Patient's position
 Measuring the Arterial Blood Pressure Performance Checklist
Student's Name: ……………………………... Academic number:
…………………………………………………………………..……
Date: ………/……/…………………………..….. Group #: …………………………………………………………….……………...…..
Type of Evaluation
Re-demonstration Formative OSCE Summative OSCE
( ) ( ) ( )
Steps Grades Student's Grade
1. Perform hand hygiene 1
1. Put on gloves if necessary. 1
2. Identify the patient correctly 1
3. Explain the procedure. 1
5. Follow the principles:
a. Flex the elbow slightly with the palm of the hand facing up and the 0.5
forearm supported at heart level.
b. Expose the upper arm. 0.5
c. Wrap the deflated cuff firm around the upper arm, while rubber 0.5
tubes are anterior and downward.
d. Place the lower border of the cuff appropriately 2.5 cm (1 inch) above 0.5
the antecubital space.
6. Perform palpatory determination of systolic pressure. 0.5
7. Palpate the brachial artery with fingertips. 0.5
8. Close the valve on the pump by turning the screw clockwise.Pump 0.5
the cuff until the radial pulse no longer feel. Note the pressure on the
sphygmomanometer at which pulse is no longer felt.
9. Release the pressure completely in the cuff and wait about 30
seconds. 0.5
10. Disinfect the earpieces of the stethoscope with alcohol sponge. 1
11. Insert the ear pieces of the stethoscope in the ears so that they tilt 0.5
slightly forward.

12. Warm the diaphragm of the stethoscope. 0.5

13. Place the diaphragm of the stethoscope over the brachial pulse. 0.5
14. Pump the cuff until the sphygmomanometer reads 30 mm Hg 1
above the point where the radial pulse disappeared. 0.5
15. Release the valve of the cuff carefully so that the pressure decreases
at the rate gradually and slowly.
16. Keep eyes on the indicator and listen care the heights sound systolic 4
pressure )and for sound disappear( diastolic pressure
17. Deflate the cuff rapidly. 0.5
18. Wipe the stethoscope with alcohol sponge. 1
19. Document in the patient's record sheet:
a. Date and time 0.5
b. The blood pressure reading, site of measurement, and patient's 0.5
position.
c. Signature 0.5
20. Report for any abnormalities 1
TOTAL 20
Grade out of 10
Student’s signature: ………………………………..…………………..

Instructor signature: …………………………….……………………..

 Measuring Vital Signs Performance Checklist
Student's Name: ……………………………... Academic number: ……………………………..……
Date: ………/……/…………………………..….. Group #: ………………………...…
Steps Grade Student's Grade
Measuring Body Temperature (Axillary Route)
1- Perform hand hygiene 0.5
2- Put on disposable gloves. 0.5
3- Wash the thermometer with soap and water 0.5
4- Rinse the thermometer under running water 0.5
5- Put thermometer in kidney basin lined with tissue paper 0.5
6- Remove gloves 0.5
7- Perform hand hygiene 0.5
8- Put on disposable gloves 0.5
9- Identify the patient correctly 0.5
10- Assist the patient to comfortable position 0.5
11- Explain the procedure 1
12-Check mercury to be below 35 OC 1
13- Shake the thermometer if mercury above 35 OC 1
14-Wipe the thermometer from bulb to tip with cotton sponge with alcohol. 1
15- Dry under the axilla with tissue paper or ask the patient to do it if able 1
16-Leave the thermometer for 10 full minutes 2
17- Remove the thermometer 1
18- Wipe the thermometer with tissue cotton sponge from tip to bulb. 1
19-Read the mercury level. 5
20- Wash ,rinse, dry and wipe the thermometer with cotton sponge with 1
alcohol from bulb to tip then return it to the container.
Count the peripheral pulse and respiration
nd rd th
21. Place 2 , 3 , and 4 fingers lightly.(radial artery) 2
22. Square over the pulse point and hand relaxed over patient chest. 2
23. Count for one full minute and note the pulse rate, rhythm and volume. 3
24. Count respirations for one full minute while the hand in the same position 3
Measuring the arterial blood pressure
Follow the principles:
25- Keep the elbow slightly fixed with the palm of the hand facing up and the 0.5
forearm supported at heart level
26- Expose the upper arm. 0.5
27- Wrap the deflated cuff firm around the upper arm, while rubber tubes are 0.5
anterior and downward.
28- Place the lower border of the cuff appropriately 2.5 cm (1 inch) above the 0.5
antecubital space.
29- Perform palpatory determination of systolic pressure. 0.5
30- Palpate the brachial artery with fingertips. 0.5
31- Close the valve on the pump by turning the screw clockwise. 0.5
32- Pump the cuff until the radial pulse no feel. 0.5
33- Note the pressure on the sphygmomanometer at which pulse is no felt 0.5
34- Release the pressure completely in the cuff and wait about 30 seconds. 0.5
 Steps Grade Student's Grade
35- Clean the earpieces of the stethoscope with alcohol sponge. 0.5
36- Warm the diaphragm by rubbing it with the palm of hand. 0.5
37- Insert the ear pieces of the stethoscope in the ears so that they tilt slightly 1
forward 0.5
38- Place the diaphragm of the stethoscope over the brachial pulse. 1
39- Pump the cuff above the point where the radial pulse disappeared (30 1
mmHg) 1
40- Release the valve of the cuff carefully so that the pressure decreases at the 4+4
rate gradually and slowly 1
41- Keep eyes on the indicator. 0.5
42- listen carefully the heights sound (systolic pressure )and for sound disappear
(diastolic pressure)
43- Deflate the cuff rapidly.
44- Wipe the stethoscope with alcohol sponge.
45- Document the:
a. Date and time 1
b. Temperature reading and its route. 1
c. Pulse rate , rhythm, volume, and force 1
d. The respiratory rate, depth, rhythm, pain, effort, sound, odor and presence 2
of cyanosis 2
e. Blood pressure reading, site of measurement, and patient's position 1
f. Report for any abnormalities 1
g. Add clear signature. 1
46- Perform hand hygiene
Total grade 60

Student's Signature: ……………………………………….…..

Clinical Faculty's Signature: ……………………………..

Name: ________________________________________ Date: ______________________

Activity # 1 Measuring Blood Pressure Worksheet

Procedure
Take a blood pressure reading of the two other group members. To take blood pressure, follow
these steps:

1. Place the blood pressure cuff on the upper arm of the student volunteer “patient” (if clothing is
very thick, you may need to ask them to roll up their sleeve). You want the bottom of the cuff
to be just above their elbow.
2. Place the stethoscope so that it is between the patient’s skin and the blood pressure cuff. You
want to place it just above the elbow, on the inside of the arm―on the inside crook of the arm.
This way, it is placed over the brachial artery.
3. Tighten the cuff around the patient’s arm and stethoscope so that is it snug, but not tight.
4. Make sure the relief valve (the screw knob attached to the bulb of the blood pressure cuff) is
completely closed, and press the bulb several times until the dial on the cuff reads 200.
5. While listening through the stethoscope, slowly turn the relief valve so that some air escapes at a
slow but steady rate. You should not hear any pulse in the stethoscope yet, and you should note
that the needle on the dial is slowly going down.
6. Continue to release air and listen until you first hear a pulse through the stethoscope. Mentally
record the number the needle is on when you first hear the sound. This number is the patient’s
systolic pressure.
7. Continue to release air and listen, this time until the pulse sound goes completely away. The
number that the needle is on when the sound stops is the patient’s diastolic pressure.
8. Record both numbers below. Release any residual air from the cuff, and remove it and the
stethoscope from the patient.
Record Results
Student #1
Name: _______________________________
Name: _______________________________
Systolic Pressure: ______________________
Systolic Pressure: ______________________
Diastolic Pressure: ______________________
Diastolic Pressure: _____________________
Student #2
Activity # 2
Brainstorming: What Does it all Mean?

Answer the following questions based on your ideas and

brainstorming answers with your group members. You will not
lose or gain points based on right or wrong answers. This is based
on your thoughts. Answers will be reviewed in Lesson 2, Blood
Pressure Basics.

1. Why do you think blood pressure readings include two different numbers, the systolic pressure
and the diastolic pressure? What do you think each one might mean?

_____________________________________________________________________

_____________________________________________________________________

______________________________________________________________

2. Compare your blood pressure readings for Student #1 with a group member who also took
Student #1’s blood pressure reading. Are your readings the exact same? If not, what might have
caused them to be different?
_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

3. Is having low blood pressure good or bad? Why? Please explain your thoughts.

__________________________________________________________________

__________________________________________________________________

___________________________________________________________

4. Is having high blood pressure good or bad? Why? Please explain your thoughts.
_____________________________________________________________________________

37 | P a g e
1- A nurse obtained a patient’s pulse and 5- If a patient’s blood pressure is 150/96, his
found the rate to be above normal. The pulse pressure is:
nurse document these findings as: a) 54
a) Tachypnea b) 96
b) Hyperpyrexia c) 150
c) Arrhythmia d) 246
d) Tachycardia
6- A rise of 1OC of temperature will
2- While checking an adult patient's pulse, increase the pulse rate by how many beats
the nurse finds the rate 140 beats/minute, per minute?
the nurse should report and document this a) 10
finding as: b) 6
a) Hyperthermia c) 4
b) Bradycardia d) 5
c) Tachypnea
d) Tachycardia 7. Two nurses are taking an apical-radial
pulse and note a difference in pulse
3- What is the pulse pressure of a patient rate of 8 beats per minute. The nurse
with 140/90 mmHg blood pressure would document this difference as
measurement? which of the following?
a) 40 mmHg a) Pulse deficit
b) 190 mmHg b) Pulse amplitude
c) 50 mmHg c) Ventricular rhythm
d) 230 mmHg d) Heart arrhythmia

4- When measuring blood pressure from 7- An adult blood pressure reading of

the lower limb, which of the following 110/80 mmHg is:
arteries the nurse should use: a) Hypotensive
a) Temporal artery b) Hypertensive
b) Popliteal artery c) Prehypertension
c) Femoral artery d) Normal
d) Brachial artery

38 | P a g e
8- A sudden drop in blood pressure 12- Which of the following pulse sites is
because of positional changes is called: located behind the knee?
a) Hypertension a) Femoral
b) Hypotension b) Popliteal
c) Orthostatic hypotension c) Radial
d) Prehypertension d) Pedal

9- For a BP reading of 140/90 mmHg, 13- Where is the apical pulse located in an
what is the bottom number (92) known adult patient?
as? a) On the left side of the chest at the 5th
a) Systolic intercostal space
b) Mean arterial pressure b) In the left arm above the elbow
c) Brachial c) On the right side of the chest below the
d) Diastolic nipple
d) Directly over the sternum
10- The terms, weak and thready, are
MOST usually associated with which vital 14- Pulse is difficult to feel not palpaple
sign measurement? when only slight pressure is applied
a) Temperature a) Thready pulse
b) Pulse b) Bounding pulse
c) Blood pressure c) Normal pulse
d) Respirations d) Absent pulse

11- What is a sphygmomanometer? 15- Pulse site is used during cardiac

a) A rectal thermometer arrest/shock in adults and to determine
b) A device for measuring blood circulation to the brain:
pressure a) Apical Pulse
c) Pump for administering blood b) Radial Pulse
transfusions c) Carotid Pulse
d) Instrument for collecting spinal fluid d) Temporal Pulse
samples.

True or false
 Blood pressure tends to increase in old age.
(T) (F)

 Blood pressure 140-90 mmHg is considered first stage of hypertension.

(T) (F)

 Normally peripheral pulse rate is the same in adults, children or elderly.

(T) (F)

 Diastolic pressure is the greatest amount of pressure exerted by the blood against the
walls of arteries during maximum ventricular contraction.
(T) (F)

 Pulse deficit is the decrease in pulse rate .

(T) (F)

 Small blood vessels caliber decreases blood pressure.

(T) (F)

39 | P a g e
 Pain Management
Definition of Pain
Pain is “an unpleasant sensory and emotional experience
associated with actual or potential tissue damage.

Types of Pain
Types of Pain may be described in terms of location, duration, intensity and quality.
Location
• Classifications of pain based on location (e.g., head,
back, chest). Location of pain is an important
consideration. For example, after knee surgery, a
patient reports moderately severe chest pain, the
nurse must act immediately to further evaluate and
treat this discomfort.

Pain may radiate (spread or extend) to other

areas (e.g., low back to legs). Pain may also be
referred (appear to arise in different areas) to other
parts of the body. For example, cardiac pain may be felt in the shoulder or left arm, with or
without chest pain).
Duration
Acute pain Chronic pain
It is mild to severe pain that’s rapid in May be defined as pain that lasts for 6
onset and lasts less than 6 months; it can months or longer, it known as persistent
be intermittent or recurrent as in pain, is prolonged and interferes with
migraine and sinus headaches and functioning.
gallbladder colic.

Intensity
Most practitioners classify intensity of pain by using a standard scale (0 no pain) to 10 (worst
possible pain) scale. Linking the rating to health and functioning scores, pain in the 1 to 3
range is mild pain, a rating of 4 to 6 is moderate pain, and pain reaching 7 to 10 is severe pain
and is associated with the worst outcomes.

40 | P a g e
 Pain assessment the fifth vital sign.
Accurate pain assessment is essential for effective pain management.

Comprehensive Pain Assessment: Patient Interview

Location(s) of pain: Ask the patient to state or point to the area(s) of pain on the body.
Sometimes allowing patients to make marks on a body diagram is helpful in gaining this
information.

Intensity: Ask the patient to rate the severity of the pain using a reliable and valid pain
assessment tool. The most common include the following:

Numeric Rating Scale (NRS): The NRS is most often presented as a horizontal 0-to-10 point
scale, with word of “no pain” at one end of the scale,“ moderate pain” in the middle
of the scale, and “worst possible pain” at the end of the scale.

FACES Pain Rating Scale: The FACES scale consists of six cartoon faces with word
descriptors, ranging from a smiling face on the left for “no pain (or hurt)” to a
frowning face on the right for “worst pain (or hurt).” Patients are asked to choose the
face that best reflects their pain.

Visual Analog Scale (VAS): The VAS is a horizontal (sometimes vertical) 10-cm line with
word at the extremes, such as “no pain” on one end and “pain as bad as it could be”
or “worst possible pain” on the other end. Patients are asked to make a mark on the line
to indicate intensity of pain, and the length of the mark from “no pain” is measured and
recorded in centimeters or millimeters.

-Quality: Ask the patient to describe how the pain feels. Descriptors such as “sharp,”
“shooting,” or “burning” may help identify the presence of neuropathic pain.

-Onset and duration: Ask the patient when the pain started and whether it is constant
or intermittent.
-Aggravating and relieving factors: Ask the patient what makes the pain worse and what
makes it better.
-Effect on Activities of Daily Living:
Knowing how ADLs are affected by pain helps the nurse understand the patient’s perspective
on the pain’s severity. The nurse should ask the patient to describe how the pain has affected
such of the following aspects of life:
• Sleep
• Appetite
• Concentration
• Work

41 | P a g e
• Interpersonal relationships
• Emotional status (mood, irritability, depression, anxiety).

-Other information: The patient’s culture, past pain experiences, and pertinent medical history
such as laboratory tests, and diagnostic studies are considered when establishing a treatment
plan.

Quality
It means asking the patient to describe the pain in his or her own words. For example,
the patient is asked to describe what the pain feels like. If the patient cannot describe the
quality of the pain, words such as burning, aching, throbbing, or stabbing can be
offered.

42 | P a g e
43 | P a g e
 Pain assessment
Purposes:

1- To gather information about a patient's pain experience, including the nature, location,
and intensity of the pain.
2- To develop an effective pain management plan that addresses the patient's unique needs
and preferences.
3- To help healthcare providers identify potential underlying conditions that may require
further evaluation and treatment.

Equipment:
• Hand disinfectant.

• Disposable gloves.

• Appropriate pain assessment tool.

Steps Rationale
Pre-procedure
Review patient’s medical/surgical history and review - To focus your pain assessment and guide
previous tool used to perform patient’s pain safe and effective dosing of pain
assessments. medication and implementation of no
pharmacological pain management
interventions.
Verify physician prescription. - To maintain patient safety
Wash hands. - To prevent transmission of
microorganisms.
Prepare necessary equipment. - To conserve time and energy
Identify the patient. - To ensure that, correct patient receives
intervention.
Introduce yourself to patient. - To build trust.
Explain procedure to the patient. - To decrease patient anxiety and promote
co-operation.
Keep patient privacy. - To minimize embarrassment
Disinfectant your hands.
Wear clean gloves (if needed) - To reduce the risk of infection
Procedure
Assess factors that may influence the patient’s report of To have a baseline of patient data.
pain:
• Orientation to person, time, place, and
situation.
• Age, condition, and ability to understand the
pain tool.
• Vision and hearing.
• Language and culture.
• Cognitive and developmental level.
Assess physical, behavioral, and emotional signs and The patient’s self-report is the gold standard
symptoms of pain at the present time or if pain has for pain assessment. Signs and symptoms
been experienced within the last 24 hours. may reveal the source and nature of pain.

44 | P a g e
 Steps
Such as:
A. Moaning, crying, whimpering, groaning,
vocalizations.
B. Decreased activity
C. Facial expressions (e.g., grimace, clenched
teeth)
D. Change in usual behavior (e.g., less active,
irritable)
E. Abnormal gait (e.g., shuffling) and posture
(e.g., bent, leaning)
F. Guarding a body part; functional impairment
such as decreased range of motion (ROM)
G. Diaphoresis
H. Depression, hopelessness, anger, fear, social
withdrawal.
Select a pain assessment tool that is based on the
patient’s clinical status, cognitive ability,
developmental level, language, and culture such as
“OPQRST”.
O stands for pain Onset. Ask the patient about the
onset of the pain (e.g., “Was onset of pain sudden,
gradual or part of an ongoing chronic problem?”).
P stands for Provocation and Palliation factors.
(e.g., “What makes your pain better or worse?”)
Q stands for pain Quality. Ask the patient about the
quality of the pain (e.g., “Is your pain sharp or dull,
tingling, or achy?”).
R stands for pain Region/Radiation. Ask the
patient about the location of the pain (e.g., “Where
pain is on the body and whether it radiates (extends)
or moves to any other area? Referred pain can provide
clues to underlying medical causes.
S stands for pain Severity. Ask the patient to describe
the intensity of pain by using an appropriate pain
rating scale (e.g., “What do you rate your pain?”).
T stands for Timing of pain. Ask the patient about the
duration and the frequency of the pain (e.g., “How
long have you had the pain, and how often are you
having the pain?”).
Assess patient's response to previous pharmacological
interventions, especially ability to function (e.g.,
sleeping, eating, and other Activity of Daily Livings).
Determine if any analgesic side effects are likely based
on medication and patient's previous responses (e.g.,
respiratory depression, itching or nausea).
45 | P a g e
Rationale
Nonverbal responses to pain are useful in
assessing pain in patients who are
cognitively impaired or unable to self-
report.
(Note: If the patient is not able to
communicate verbally, a behavioral tool
such as the Checklist of Nonverbal Pain
Indicators (CNPI) may need to be used.)
Using the same tool each time an individual
patient’s pain is assessed enhances
consistency between pain assessments
among members of the healthcare team.
Onset (sudden/gradual)
Is the pain better or worse with:
•Activity. Does walking, standing, lifting,
twisting, reading, etc… have any effect of the
pain?
•Position. Which position causes or relieves
pain? Provide examples to the patient‐‐
sitting, standing, supine, lateral, etc…
Assessing the quality of the pain facilitates
an assessment of the character of the pain.
Locating the pain facilitates an assessment of
the underlying cause of the pain. A diagram
allows the patient to communicate the
location of the pain.
Universal Pain Assessment Scale.
“Attached”
Assessing how long and how often the
patient has been experiencing the pain
facilitates an accurate assessment of
whether the pain is chronic or acute.
Determines the extent to which therapies
have or have not been successful in the past.
 Steps Rationale
Assess the patient for pain relief and effects of If the patient is taking analgesics or pain
treatment. If the patient’s pain is not relieved, follow medication (such as opioids), assess the
up with further assessment and interventions if patient at frequent intervals for respiratory
indicated. depression or other adverse effects of pain
medication.
Post-procedure
Perform hand hygiene. To prevent transmission of infection.
Ensure that the bed is in the lowest position and verify To ensure patient safety.
that the patient can identify and reach the nurse call
system.
Evaluate the outcomes. Did the patient understand To evaluate the effect of pain assessment.
the pain tool? Is the healthcare team using a consistent
pain tool for the patient that is age appropriate and
culturally sensitive?
Document assessment findings, care given, and To follow up the patient case.
outcomes in the legal healthcare record:
• Detailed description of the patient’s pain
assessment
• Tool used for pain assessment.
• Vital signs, including respiration and sedation
level.
• Patient’s ability to perform ADLs.
Provide follow-up evaluations and determine whether To take action.
the patient feels that his or her pain and functional
goals were achieved.

Nursing care of the patient in pain

o Assess the pain location, and ask the patient to rate the pain using a pain scale
o Ask the patient to describe the pain quality and pattern, including any precipitating or
relieving factors
o Monitor vital signs and note subjective responses to pain, such as facial grimacing and
guarding of a body part.
o Provide comfort measures, such as back massage, positioning, linen changes, and oral or
skin care.
o Teach the patient noninvasive techniques to control pain, such as relaxation, guided
imagery, distraction, and cutaneous stimulation.
o Teach the importance of taking prescribed analgesics before the pain becomes severe.
o Instruct the patient on the need for adequate rest periods and sleep.
o Administer pain medication around the clock as prescribed.

46 | P a g e
Accepting patient's Pain:
Nurses should ask patients about their pain and to believe their reports of
discomfort.

Assisting Support People:

Nurses can help Support people by giving them accurate information about the
pain and teaching them about the disease and medications (including warning
signs to report) and nondrug pain-relieving techniques they can help with (e.g.,
massage, application of ice).

Reducing Fear and Anxiety:

By providing accurate information, the nurse can reduce many of the paient’s
fears or anxiety which help in alleviating pain.

Preventing Pain:
involves the provision of measures to treat the pain before it occurs or before it
becomes severe e.g. oral or parenteral analgesic administration to reduce
postoperative pain.

47 | P a g e
48 | P a g e
Case Study of a Patient with Pain

Case#1 Patient Mr. A. is a 29-year old admitted to

emergency department with abdominal pain and a
fever (39.8°C). A vague periumbilical pain awoke him
from sleep 12 hours previously, associated with
anorexia, nausea, and vomiting. The pain then
migrated to the right lower quadrant (RLQ) and was
severe. Physical examination reveals RLQ tenderness,
guarding but not rigidity, and rebound tenderness in
the RLQ. Rovsing sign is positive. The initial diagnosis
was suspected appendicitis.

Please prepare pain assessment report using the assigned scenario; fill your
report only using the available data.

Case#2 A 23 year old patient is admitted with suspected appendicitis. The

patient states he is having pain around the umbilicus that extends into
the lower part of his abdomen. In addition, he says that the pain is worst
on the right lower quadrant. The patient points to his abdomen at a
location which is about a one-third distance between the anterior superior
iliac spine and umbilicus.

Mention the pain assessment using the assigned scenario

Case#2 Mr. Ali Al-Said is a 59-year-old

overweight Egyptian male presented to
the Emergency Unit with chest pain. He
looks pale and is sweating. Please take an
appropriate systematic history matched
to the situation of the mentioned patient
and doing a complete analysis of the
presenting sym

49 | P a g e
45-year-old patient who reports pain in A 35-year-old, male patient with
the foot that moves up along the calf says: testicular cancer is joking and playing
"My right foot feels like it is on fire." The cards with his roommate. When assessed
patient reports that the pain started by the pain management nurse, the
yesterday, and he or she has no prior patient rates his pain as a 7 on a Numeric
history of injury or falls. Which components Rating Scale of 0 to 10. The nurse interpret
of pain assessment has the patient it as
reported? a. Mild pain
a. Aggravating and alleviating b. Moderate pain
factors. c. Severe pain
b. Exacerbation, with associated signs d. No pain
and symptoms
c. Intensity, temporal characteristics, Classifications of pain based on where it is
and functional impact in the body refer to
d. Location, quality, and onset a. Pain duration
b. Pain location
c. Pain intensity
d. Pain aggravating factor

Constant versus intermittent in nature

refer to any item of pain assessment
a. Character
b. Onset
c. Duration
d. Location

50 | P a g e