Vital Signs

Created by Debbie Johnson RN- 2003

Vital Signs (VS) Temperature ( T) Pulse (P) Respiration (R) Blood Pressure (BP)

Normal Range Temperature Ideal Normal

Range

Oral 98.6 97.6-99.6

Axillary 97.6 96.6-98.6

Rectal 99.6 98.6-100.6

Tympanic 98.6 98.6

Glass Thermometer

Steps to taking temperature with glass thermometer Ask if client has had anything to eat

drink or smoke in the last 15 minutes

Shake down thermometer Place disposable cover over

thermometer Insert thermometer under tongue Hold thermometer in place for 3

minutes

Reading a thermometer

Hold thermometer to view mercury column

Steps to taking temperature- continued Remove thermometer from mouth Remove disposable cover Read and record temperature Shake down thermometer Report any abnormalities to charge

nurse

Normal Pulse Range Adult- 60-100 Birth to 4 weeks- 80-180 4 weeks to 1 year-80-160 1 to 2 years- 80-130 2 to 6 years- 80- 120 6-12 years-70-110

Normal Respiration Adult- 12-20 Infants and children normally

breathe faster than adults Respirations should be quiet,

effortless, and regular Both sides of the chest should

raise and fall equally

Taking Pulse and Respiration

Leave hand in place after taking pulse and count respiration

Steps to taking pulse and respiration Wash hands Identify self and client Explain procedure Provide privacy Find radial pulse and count for one

full minute and record- Must be + or – 4 beats of evaluator

Steps to taking pulse and respiration - continued Count respirations for one full

minute and record- Must be + or – 2 respirations of evaluator

Leave signal light in place Wash hands Report any abnormalities to charge

nurse

Normal Blood Pressure Ranges Adults: 120/80 Range: Systolic- 100-140 Diastolic- 60-90 Children and infants have lower

blood pressure readings New research has indicated that

the above numbers may actually be “Pre-hypertensive”

Total Care Programming 1999 59

P C S

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Reading a Sphygmomanometer

Reading a Reading a SphygmomanometerSphygmomanometer

Total Care Programming 1999 60

P C S

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What are measurements on these gauges?

What are measurements on What are measurements on these gauges?these gauges?

Steps to taking Blood Pressure Wash hands Identify self and client Explain procedure Provide privacy Clean earpieces and diaphragm with

alcohol Expose forearm Palpate brachial pulse

Always Clean Equipment

Wipe diaphragm and earpieces with alcohol

Steps to taking Blood Pressure-continued Inflate sphygmomanometer to 30

millimeters of mercury where pulse last felt

Deflate cuff slowly Remove cuff Record Bp reading within 4 beats

of mercury of evaluator’s reading

Steps to taking Blood Pressure-continued Give client signal light Return equipment to proper

storage Wash hands Report any abnormalities to charge

nurse

Vital Signs

Accuracy is the key!Recheck if necessaryReport abnormalities