DEMO ON VITAL SIGNS

Definition: Vital signs or cardinal signs are body temperature, pulse, respirations & blood pressure, fifth is pain.

Times to Assess Vital Signs:
- On admission to a health care agency to obtain baseline data.
- When a client has a change in health status or reports symptoms
- Before & after surgery/invasive procedures
- Before & after administration of medications
- Before & after any intervention that could affect the vital signs

1. Check for the patients chart
- In order to check the condition of the patient & to check the last BP if there is any.
2. Do handwashing.

3. Prepare the needed materials.
- Stethoscope
- Sphygmomanometer
- Thermometer/Axillary & Digital
- Tissue Paper
- Wet Cotton Balls soaked in an alcohol
- Dry cotton balls
- Receptacle
- Ballpen
-Watch w/ second hand
- Paper
- Ballpen

*Patients Info*
- Name
-Age
- Sex
- Date
- Time
- Chief complaint
- Physician
- Temperature
- Radial Pulse
- Respiratory Rate
- Blood Pressure

4. Check the equipments if they are working properly in order to save time .

- Hold the thermometer in an eye level & check if there is any breaks, if there is none clean it with a wet cotton balls soaked an alcohol then dry it with the use of dry cotton balls. Then shake it away from the patient or any object because thermometer is very sensitive it could easily break, this is in order to lower the temperature to at least below 35 Degree Celsius.

- Check also the stethoscope, tap your finger lightly on the diaphragm if you can hear sound.

- Then check the sphygmomanometer for leaks. Pump up the cuff then deflate in order to determine if there is any leaks.

5. Go to patients room, knock on the door, greet the patient & introduce yourself & verify the patients identity by asking his/her complete name. Explain to the client what you are going to do & why it is necessary & how he/she can cooperate. Discuss how the result will be used in planning for further care or treatments.

- Also ask for the food, fluid intake as well as the activities done prior to getting the vital signs because it can elevate the results.

6. Provide for clients privacy.

7. Place the client in an appropriate position (lateral or sim’s position)

8. Start getting the vital signs.
- First I am going to get the body temperature w/ the use of an axillary thermometer. Firstly, get a tissue & pat dry the axillae. Do not rub it because it can elevate the result. Then place the thermometer appropriately, and then wait for 8-10 minutes for the result.

- While waiting for the body temperature result, I am going to get the radial pulse. Palpate and count the pulse for one full minute. Place two or three fingers lightly & squarely over the pulse point. Do not use the thumb because it has pulse that could be mistaken for the clients pulse. Assess pulse rate, rhythm & volume. Bear in mind that when you write the result it must include the units of measure which is beats per minute or bmp

Assessing an Apical Pulse
- This is in order to check the discrepancy of the result in the radial pulse. The units of measure is beats per minute or bmp Place client in a comfortable supine position or sitting position. Locate the apical pulse.
Adult (left side of the chest, 3 inches to the left of the sternum & at the 4th, 5th or 6th inter-coastal space)

Child 7-9 years old (4th or 5th inter-coastal space).

4 Years old (left of the mid-clavicular line)
- Auscultate & Count Heartbeats. Use antiseptic wipes to clean the earpieces & diaphragm of the stethoscope if their cleanliness is doubt. – The diaphragm needs to be cleaned & disinfected if soiled w/ body substances.

- Warm the diaphragm (flat-disc) of the stethoscope by holding it in the palm of the hand for a moment. – The metal of the diaphragm is usually cold & can startle the client when placed immediately on the chest. Tap your finger lightly on the diaphragm to be sure it is the active side of the head. Place the diaphragm of the stethoscope over the apical impulse & listen for the normal S1 & S2 heart sounds, which is heard as “lub-dub”. – The heartbeat is normally loudest over the apex of the heart. Each lub-dub is counted as one heartbeat. S1 (lub) occurs when the atrioventicular valves close after the ventricles have been sufficiently filled. S2 (dub) occurs when the semilunar valves close after the ventricles empty. If you have difficulty hearing the apical pulse ask the supine client to roll onto his/her left side or sitting client to lean slightly forward. – This positioning moves apex of the heart close to the chest wall. Count for 1 full minute. – A second count provides a more accurate assessment of an irregular pulse than 1 30 second count. Assess the rhythm & strength of the heartbeat.

After getting the apical pulse, get also the body temperature w/ the use of the digital thermometer. (Note: show the result to your Clinical Instructor before turning it off).

Assessing Respirations
- Then get the respiratory rate (note: do not mention this because you’ll get minus point from your clinical instructor) why? Because, patient can control his/her RR if you’re going to mention it. Unit of measure for RR is cycle per minute or cpm

- Observe or palpate & count the respiratory rate. Client’s awareness when counting the respiration rate could cause the client to purposely alter the respiratory pattern. If you anticipate this, place a hand against the client chest to feel the chest movements w/ breathing or place the client’s arm across the chest & observe the chest movements while supposedly taking the radial pulse. Count for 1 full minute. An inhalation & an exhalation count as one respiration. Observe the depth, rhythm & character of respirations. Depth by watching the movement of the chest. – During deep respiration, a large volume of air is exchanged, shallow, small volume of air is exchanged. Regular or irregular rhythm. – Normally, respirations are evenly spaced. Character of respirations – sound they produced & the effort they require. – silent & effortless.

Assessing Blood Pressure
Preparation:
- Make sure that the client has not smoked or ingested caffeine w/ in 30 minutes prior to measurement. – Smoking constricts blood vessels & caffeine increases the pulse rate. Both of these cause a temporary increase in blood pressure.

- Position the client appropriately. The adult should be sitting unless otherwise specified. Both feet should be flat on the floor. – Legs crossed at the knee result in elevated systolic & diastolic blood pressure.

- The elbow should be slightly flexed w/ the palm of the hand facing up & the forearm supported at heart level. – The blood pressure increases when the arm is below the heart level & decreases when the arm is above the heart level.

- Wrap the deflated cuff evenly around the upper arm. Then locate the brachial artery. Apply the center of the bladder directly over the artery. – The bladder inside the cuff must be directly over the artery to be compressed if reading is to be accurate. Approximately 2.5 cm (1 inch) above the antecubital space.

- If this is the client’s initial examination, perform a preliminary palpatory determination of systolic pressure. – The initial estimate tells the nurse the maximal pressure to which the manometer needs to be elevated in subsequent determination. It also prevents under estimation of the systolic pressure or over estimation of the diastolic pressure should an auscultatory gap occur.

- Palpate the brachial artery c/ the fingertips.
- Close the valve on the bulb.
- Pump up the cuff until you no longer feel the brachial pulse. At that pressure the blood cannot flow throw the artery. Note the pressure on the sphygmomanometer at which pulse is no longer felt. – This gives an estimate of systolic pressure (+30).

- Release the pressure completely in the cuff & wait 1 to 2 minutes before making further measurements. – A waiting period gives the blood trapped in the veins time to be released. Otherwise, false high systolic readings will occur.

- Position the stethoscope appropriately. Cleanse the earpieces w/ antiseptic wipes. Insert the ear attachments of the stethoscope in your ear so they tilt slightly forward. – Sound are heard more clearly when the ear attachments follow the direction of the ear canal.

- Ensure that the stethoscope hangs freely from the ears to the diaphragm. – If the stethoscope tubing rubs against an object, the noise can block the sounds of the blood w/ in the artery.

- Place the bell side of the amplifier to the stethoscope over the brachial pulse site. – Because blood pressure is a low-frequency sound, it is best heard w/ the bell-shaped diaphragm.

- Place the stethoscope directly on the skin, not on clothing over the site. – This is to avoid noise made from rubbing the amplifier against cloth.

- Hold the diaphragm w/ the thumb & index finger.
- Auscultate the client’s blood pressure. Pump up the cuff until the sphygmomanometer reads 30 mmHg above the point where the brachial pulse disappeared.

- Release the valve on the cuff carefully so that the pressure decreases at the rate of 2 to 3 mmHg per second. – If the rate is faster or slower, an error in measurement may occur.

- Deflate the cuff rapidly & completely. Wait 1 to 2 minutes before making further determinations.- This permits blood trapped in the veins to be released.

- Repeat the above steps to confirm the accuracy of the reading especially if it falls outside the normal range. If there is 75mmHg difference between the two readings, additional measurements may be taken & the result averaged.

- If this is the client’s initial examination repeat the procedure on the other arm. There should be no more than 10 mmHg difference between the arms. Arm with higher BP should be used for subsequent examinations.

- Remove the cuff & wipe w/ an approved disinfectant. – Cuffs can become significantly contaminated.

- Document & report pertinent assessment & data.

- Read the result of the axillary thermometer (let your clinical instructor see the result before putting it down.

10. Write the results.
11. Inform the patient of the result because they have the right to know.
12. Do after care.
13. Don’t forget to say thank you to the patient before the leaving the room.

Note: Sequence
1. Body temperature (Axillary thermometer 5. Body Temperature (digital thermometer)
2. Radial Pulse 6. Blood Pressure
3. Respiratory Rate
4. Apical Pulse