Checking Vital Sign

By:
Rezki Novita Sari
1007101020104

Definition
Check to determine the status of the patients
health or to test the response of the patient
against either physiological or physiology
stress or against medical or nursing therapy

Temperature
Nurse can use:
The electronic chemical
Mercury thermometer

Body temperature can be taken by:

Oral
Axillary
Rectal
Tympanic membrane

Cont..
Normal Ranges For Temperatures
Age

Fahrenheit Values

0-2 month

98,3F-100F

3-47 month

98,3F-100,3F

4-9 years

97,8F-100,1F

10-18 years

97,4F-100,1F

Over 18 years

97,2F-100,1F

Taking an Oral Temperature

Explain the procedure to the patient and wash your hands
Put on gloves
Insert the probe into a disposable probe cover
Position the tip of the probe under the patients tongue on
either side of the frenulum as far as possible.
Instruct the patient to close his lips but not to bite down with
his teeth to avoid breaking the thermometer in his mouth
Leave the probe in place until the maximum temperature appears
on the digital display.
Then remove the probe and note the temperature

Taking a Rectal Temperature

Put on gloves
Squeeze the lubricant onto a facial tissue to prevent
contamination of the lubricant suply.
Insert the probe into a disposable probe cover
Position the patient on his side leg flexed, and drape him to
provide privacy. Then fold back the bed linens to expose his anus
Lift the patients upper buttock and insert the thermometer
about 1 cm for an infant and 3,8 cm for an adult
Gently direct the thermometer along the rectal wall toward the
umbilicus to avoid perforating the anus or rectum and to help
unsure an accurate reading.

Cont
Hold the thermometer in place for the appropriate length of
time to prevent damage to rectal tissues caused by displacement
Carefully remove the thermometer, wiping it if necessary. Then
wipe the patients anal area to remove any feces
Remove your gloves, and wash your hands

Taking an Axillary Temperatur

Position the patient with the axilla exposed
Put on gloves and gently pat the axilla dry with a facial
tissue because moisture conduct heat. Avoid harsh
rubbing, which generates heat
Ask the patient to reach across his chest and grasp the
opposite shoulder, lifting his elbow
Place the thermometer in the axilla
Hold the thermometer in place until the temperature
registers

Taking a Tympanic Mambrane

Temperature

Make sure the lens under the probe is clean and shiny
Examine the patients ears
Stabilized the patients head
Gently pull the ear straight back or up and back
Insert the thermometer until the entire era canal is
scaled

Pulse Rate
Pulse rate is an indirect measurement of cardiac
output obtained by counting the number of
peripheral pulse waves over a pulse point

Cont

Cont

Taking a Pulse Rate

Cleanse hands
Inform client of the site at which you will measure pulse
Rest the persons arm an the over-bed table or on the bed.
Locate the radial pulse in the persons wrist using your
middle two or three fingers
Note the strength and regularity of the pulse.
Look at your watch and wait until the second hands gets to
the 12 or 6 . When the second hand reaches the 12 or
the 6 begin counting the pulse

Respirations
The respirations are evaluated in term of rate, regularity,
and quality or adequacy. Normally, the chest rises on
inspiration, however, the chest of a flail segment patient
would fall on inspiration and rise on exhalation

Cont

Procedure
Count respirations by observing the rise and fall of the
patients chest as he breathes.
Position patients opposite arm across his cheast
Consider one rise and one fall as one respirations
Count respirations for 60 seconds
Observe chest movement for depth of respirations
Observe the patient for use of such accessory muscles
Note the results

Blood Pressure
Blood pressure is one of the vital signs are measured by
using spygmomanometer
Blood pressure depends on the force of ventricular
contractions, arterial wall elasticity, and blood volume and
viscosity

Cont

Procedure
Assist the patient into a sitting or lying position
Assist the patient with rolling up his sleeve so that the
upper arm is exposed
Using alcohol wipes, clean the earpieces
Stand no more than 3 feet away from the manometer
Squeeze the cuff to empty it of any remaining air
Turn the valve on the bulb clockwise to close it, this will
cause the cuff inflate when you pump the bulb
Locate the patients branchial artery in the antecubital
space by placing your fingers at the inner aspect of the
elbow
Place the arrow on the cuff over the branchial ertery

Cont
Place the stetoscope earpleces in your ears
Hold the bulb one hand and feel for the patients radial pulse with
the other hand
Inflate the cuff until you are no longer able to feel the radial pulse,
and then inflate the cuff 30 mm Hg more
Position the manometer at your eye level
Turn the valve on the bulb slightly counterclockwise to allow air to
escape from the cuff slowly
Note the reading on the manometer where the first korotkoff sound
id heard. This is the systolic reading
Continue to deflate the cuff. Note the reading on the manometer
where the last korotkoff. This is the diastolic reading
Note the blood pressure on your notepad

Pain
A basic of brief pain assessment includes the clients
description of the onset, quality, intensity, location, and
duration of the pain
Nurses generally use one of four simple assessment tools
to quantify a clients pain intensity: a numeric scale, a word
scale, and a picture scale. Clients identify how their pain
compares with the choices on the scale

Thank You
Any Question??
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