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    Vitals Signs

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    eduard adrian manuel
    This document provides a checklist for assessing vital signs including temperature, pulse, respiration, and blood pressure. The checklist outlines 25 steps for correctly performing each assessment, including necessary equipment, positioning, procedures, and documentation requirements. Key factors to consider for each vital sign like fever, hypothermia, cardiovascular issues, breathing difficulties, and hypertension/hypotension are identified. Proper infection control and explaining the procedure to the client are also emphasized.

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    Vitals Signs

    Uploaded by

    eduard adrian manuel
    75 views8 pages
    This document provides a checklist for assessing vital signs including temperature, pulse, respiration, and blood pressure. The checklist outlines 25 steps for correctly performing each assessment, including necessary equipment, positioning, procedures, and documentation requirements. Key factors to consider for each vital sign like fever, hypothermia, cardiovascular issues, breathing difficulties, and hypertension/hypotension are identified. Proper infection control and explaining the procedure to the client are also emphasized.

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    This document provides a checklist for assessing vital signs including temperature, pulse, respiration, and blood pressure. The checklist outlines 25 steps for correctly performing each assessment, including necessary equipment, positioning, procedures, and documentation requirements. Key factors to consider for each vital sign like fever, hypothermia, cardiovascular issues, breathing difficulties, and hypertension/hypotension are identified. Proper infection control and explaining the procedure to the client are also emphasized.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    75 views8 pages

    Vitals Signs

    Uploaded by

    eduard adrian manuel
    This document provides a checklist for assessing vital signs including temperature, pulse, respiration, and blood pressure. The checklist outlines 25 steps for correctly performing each assessment, including necessary equipment, positioning, procedures, and documentation requirements. Key factors to consider for each vital sign like fever, hypothermia, cardiovascular issues, breathing difficulties, and hypertension/hypotension are identified. Proper infection control and explaining the procedure to the client are also emphasized.

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    © All Rights Reserved
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    of 8

    VITALS SIGNS

    Procedures Checklist
    NAME:_____________________________YEAR & SECTION:____________DATE:___________

    Performed
    Preparation Correctly Incorrectly Not Remarks
    1. 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
    – Dyspnea
    Medications affecting
    respiratory rate.
    D.) Blood Pressure
    – Signs and symptoms of
    hypertension
    – Signs and symptoms of
    hypotension
    – Factors affecting blood
    pressure.
    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
    2. – Sphygmomanometer
    Procedure
    Identify the client properly and
    explain what you are going to
    do, why it is necessary, and
    1. how he can cooperate.
    Wash hand and observe other
    appropriate infection control
    2. procedure
    3. Provide for client privacy.
    Place the client in the
    4. appropriate position
    ASSESSING BODY TEMPERATURE (AXILLARY TEMPERATURE)
    Wipe the armpit with tissue
    paper or ask the client to do it if
    1. able
    Wipe the thermometer from
    bulb to stem with alcoholized
    2. cotton ball.
    Place the thermometer on the
    3. client’s opposite side.
    4. Wait for appropriate amount of
    time. (While waiting for the
    time, the nurse can now assess
    the other vital signs.)
    Remove the thermometer and
    wipe with the tissue if
    5. necessary.
    6. Read the temperature.
    Wipe the thermometer with
    alcoholized cotton ball from
    stem to bulb. Return to
    7. container.
    ASSESSING A PERIPHERAL PULSE (RADIAL PULSE)
    Palpate and count the pulse.
    Place two or three middle
    fingers lightly and squarely
    1. over the pulse point.
    Count for one full minute and
    note the pulse rhythm and
    2. volume.
    ASSESSING RESPIRATION
    Place the client’s arm across the
    chest and observe the chest
    movements while supposedly
    1. taking radial pulse.
    Count the respiratory rate for 1
    full minute. An inhalation and
    an exhalation is counted as one
    respiration. Observe the depth,
    rhythm, and character or
    2. respiration.
    ASSESSING BLOOD PRESSURE
    The elbow should be slightly
    fixed with the palm of the hand
    facing up and the forearm
    1. supported at heart level.
    2. Expose the upper arm
    Wrap the deflated cuff evenly
    around the upper arm. Locate
    the brachial artery. Apply the
    center of the bladder directly
    3. over the artery.
    For an adult, place the lower
    border of the cuff appropriately
    2.5 cm (1 inch) above the
    4. antecubital space.
    5. If this is the client’s initial
    examination, perform a
    preliminary palpatory
    determination of systolic
    pressure.
    Palpate the brachial artery with
    6. fingertips.
    Close the valve on the pump by
    7. turning the knob clockwise.
    Pump the cuff until you no
    longer feel the brachial pulse.
    At that pressure, the blood
    cannot flow through the artery.
    Note the pressure on the
    sphygmomanometer at which
    8. pulse is no longer felt.
    Release the pressure completely
    in the cuff, and wait for one to
    two minutes before making
    9. further measurements.
    Position the stethoscope
    10. appropriately
    Clean the earpieces of the
    11. stethoscope with alcohol.
    Warm the amplifier by rubbing
    12. it with the palm of your hand.
    Insert the ear attachments of the
    stethoscope in your ears so that
    13. they tilt slightly forward.
    Ensure that the stethoscope
    hands freely from the ears to
    14. the diaphragm.
    Place the bell of the amplifier
    of the stethoscope over the
    brachial pulse. Hold the
    diaphragm with thumb and
    15. index finger.
    Auscultate the client’s blood
    16. pressure.
    Pump the cuff until the
    sphygmomanometer reads 30
    mm Hg above the point where
    17. the brachial pulse disappeared.
    Release the valve of the cuff
    carefully so that the pressure
    decreases at the rate of 2-3 mm
    18. Hg per second.
    As the pressure falls, identify
    the mamometer reading at each
    19. of five phases, if possible.
    20. Deflate the cuff rapidly.
    Wait one or two minutes before
    21. making further determinations.
    Repeat the above steps once or
    twice as necessary to confirm
    22. the accuracy of the reading.
    If this is the client initially
    examination, repeat the
    procedure on the client’s other
    23. arm.
    24. Remove the cuff.
    Wipe the cuff with an approved
    25. disinfectant.
    Document in the client’s record
    (TPR Sheet):
    A.) The temperature in the
    client record.
    B.) The pulse rate and rhythm
    C.) The respiratory rate, depth,
    and rhythm
    Report pertinent assessment
    date according to agency
    26. policy.

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