BASIC NURSING - VITAL SIGNS for Nursing students

Observation and Recording of Vital Signs

1. BNS111: BASIC NURSING OBSERVATION AND RECORDING OF VITAL SIGNS

2. LESSON OBJECTIVES At the end of the lesson students should be able to: Explain vital signs Mention the four (4) primary vital signs. Differentiate between the different types of body temperatures. Demonstrate how to taking a patient/clients temperature using the mercury thermometer. Demonstrate how to plot the vital signs

3. VITAL SIGNS Vital signs are physical signs that indicate an individual is alive, such as temperature, pulse, respiration and blood pressure. A baseline set of vital signs serves as a guide to identifying changes in a patient’s/ client’s conditions. Vital signs may reveal sudden changes in a patient/client’s condition in addition to changes that occur progressively overtime.

4. VITAL SIGNS ( cont ) These signs may be observed, measured and monitored to assess an individual’s level of physical functioning. It requires using all the senses - sight, touch, hearing and smell (except taste). SIGHT : - For reading temperature on thermometers, to observe colour, texture of skin, breathlessness.

5. VITAL SIGNS ( cont ) TOUCH : - assessing the skin temperature, feeling of the pulse rates or beats, examination, palpation and percussion. HEARING : - noise in irregular breathing and coughing, auscultation or to listen to the heart sound with stethoscope, when taking blood pressure and apex beats. SMELL : - odour of breath, excreta, body fluids.

6. WHEN TO TAKE VITAL SIGNS According to physician’s order or the institution’s policy or standard of practice During admission. Before and after a surgical or invasive diagnostic procedure. Before and after the administration of drugs or therapy that affects cardiovascular, respiratory and temperature control function When the client’s general physical condition changes When the clients report symptoms of physical distress When assessing the client during home health visit.

7. 1. TEMPERATURE It is the measure of the degree of hotness/coldness of a substance or body which can be measured against a standard scale. The instrument used for the measurement of temperature is the THERMOMETER which works on the principle that substance expand on heating and contract on cooling. Body temperature is controlled by the heat regulating center - hypothalamus situated in the brain.

8. BODY TEMPERATURE Body temperature is the degree of heat maintained by the body or the balance between the heat produced and the heat lost in the body. There are two (2) kinds of body temperature: Core temperature: temperature of the deep tissues of the body such as the abdominal cavity and pelvic cavity and is relatively constant Surface temperature: temperature of the skin, the subcutaneous tissue and fat. It rises and falls in response to the environment

9. SITES FOR RECORDING BODY TEMPERATURE Mouth – oral temperature Axilla – body temperature Rectum – rectal temperature Groin – body temperature Forehead – body temperature (paediatrics) Tympanic membrane/ear

10. thermometer It is an instrument used to measure the temperature of a substance or body, The standard scales most commonly used are the centigrade and the Fahrenheit scales. The fixed points on both scales are the boiling and freezing points of water at normal atmospheric pressure.

11. TYPES OF CLINICAL THERMOMETERS MERCURY DIGITAL INFRARED HAND HELD

12. MERCURY THERMOMETER Mercury is the material most commonly used in thermometers and has several advantages over other substances. i.e. a. It has a high boiling point and a low freezing point. b. Its opaque thus its level can easily be read when it is inside a transparent glass tube. c. It is a good conductor of heat and so rapidly reaches the temperature of the substance under test.

13. MERCURY THERMOMETER The thermometer is made from a piece of capillary glass tubing which ends in an elongated bulb. The bulb is filled with mercury. A protective glass covering, marked with scale, it’s arranged round the capillary tube containing the mercury

14. Converting Temperature from Fahrenheit to Centigrade and Vice Versa From F to C, subtract 32, multiply by 5/9 From C to F, multiply by 9/5 and add 32 E.g. To convert 37°C to °F (37×9/5) + 32 = 98.6°F To convert 98.6°F to °C (98.6 ­ 32) × 5/9 = 37°C

15. THE THERMOMETER The various types of thermometers for special purposes are; Bath thermometers – to take the temperature of patient’s bath water. The scale ranges from 1°C to 65°C (30°F to 150°F). Lotion thermometer – to take the temperature of lotions used in various nursing treatments. Scale ranges from 19°C to 115°C (0°F to 240°F) or -6.6°C to 104°C (20°F to 220°F). Wall thermometer – to take the temperature of the atmosphere especially in the hospital wards. Sometimes alcohol, coloured with a red dye, is used instead of mercury.

16. Clinical thermometer It is used for recording body temperature is made of thin-walled glass tubing with a frame bore. There is a constriction just above the bulb to prevent the mercury from falling as it cools until shaken briskly. Graduated from 35°C to 44°C (95°F to 111.2°F). In health the human body maintains an almost constant temperature between 36.6°C – 37.2°C (98°F - 99°F), the average being 36.9°C (98.4°F).

17. FACTORS THAT AFFECT TEMPERATURE READINGS A person’s age and sex. The time of day, typically being lowest in the early morning and highest in the late afternoon Activity levels (high/ low) Food and fluid intake Females, the stage in their monthly menstrual cycle Method or site of measurement, such as oral (mouth), rectal (bottom), or armpit readings

18. VARIATIONS IN TEMPERATURE Temperature increases following activities like; Mental excitation Taking hot bath Sitting close to fire/radiation When patient is nervous/tensed When patient is exposed to humid atmosphere

19. VARIATIONS IN TEMPERATURE They occur in Disease Conditions: Body temperature decreases in conditions like; Dehydration Vomiting Diarrhoea Haemorrhage Toxaemia/Septicaemia (infection of blood) In shock /collapse

20. VARIATIONS IN TEMPERATURE They occur in Disease Conditions: In diseases, bacterial infection increases the rate of metabolism, causing rise in temperature Body temperature increases in conditions like: All febrile conditions Infectious diseases Metabolic diseases/disorders Abnormalities of the heat regulating centre in the brain .

21. Requirements f or Checking Body Temperature (Mercury Thermometer) A tray containing: 1. Clinical thermometer in a container/ bottle with mild antiseptic e.g. 1-20 savlon in 70% spirit. 2. Gallipot containing clean cotton wool swabs 3. Gallipot containing cold water for rinsing thermometer 4. Receiver for soiled swabs 5. Temperature chart (age, name, date) 6. Pen (blue and red), straight edge/rule N.B – Always make sure thermometer is in a container with cotton wool and mild antiseptic solution.

22. Steps For Checking Axilla Temperature (Using Mercury Thermometer) Explain procedure to patient/client Provide privacy Take the temperature tray to the patient’s/ clients bedside. Make him comfortable ( either by lying or sitting ) Take the thermometer, rinse it in cold water and dry it with a dry cotton swab from the bulb towards to the stem Shake the thermometer until the mercury falls below 35°C Dry the axilla/groin by cleaning with dry cotton wool swab and discard in receiver Insert the thermometer in the axilla/groin making sure the bulb is in-between the skin fold

23. Steps For Checking Axilla Temperature (Mercury Thermometer) Leave the thermometer for at least two-three minutes Removes thermometer, wipe from the stem towards the bulb and take the reading by holding it at the eye level (rotate in between the fingers until the mercury line is clearly visible) Record the reading on the temperature chart and Thank patient/client and leave the patient comfortable Dispose the swabs, clean the thermometer gallipot and receiver and store appropriately Wash hands Report any abnormality

24. Steps for Taking Oral Temperature Explain procedure to patient/client Find out if patient/ client has taken a bath/taken in hot/cold drink/food. Rinse thermometer in cold water and wipe dry Insert bulb of thermometer under patient’s/ client’s tongue and advise him to close lips tight but not to bite the thermometer Leave the thermometer for 2-3 minutes Remove thermometer, wipe from stem to bulb with a dry swab Check the reading at eye level Record the reading on the temperature chart Discard the tray Leave patient/ client comfortable Wash hands and report any abnormalities

25. Factors That Hinder Oral Temperature Taking When patient/client has difficulty in breathing When there is localized disease in the mouth like stomatitis (inflammation of the mouth) When the nose is packed with gauze When the patient/client is liable to fit (epilepsy) When patient/client is unconscious Mentally unstable patients/ clients When patient/ client is delirious In children who are unable or unwilling to cooperate

26. Steps for Taking Rectal Temperature This route is mostly used in children/infants . A special rectal thermometer with a round bulb labelled ‘for rectal use only’ REQUIREMENTS Vaseline is added to the requirement in the tray STEPS Explain procedure to relative and to the patient and if possible Provide privacy if necessary Let patient empty bowel if necessary Rinse, wipe and shake the thermometer Lubricate the bulb at 2cm above Insert the thermometer 1-2 inches into the rectum for 2-3 minutes

27. Steps for Taking Rectal Temperature ( cont ) Hold it in place if patient is not cooperative Remove thermometer and wipe once from stem to bulb and discard swab Read, shake and record Replace thermometer in a jar of disinfectant The patient is then left comfortable and all equipment removed N.B – Factors which hinder rectal temperature taking ; 1. when a rectal surgery is done 2. when there’s disease of rectum/diarrhoea.

28. Normal and Abnormal Ranges of Temperature Collapse (hypothermia) --- Below 35 °C Subnormal temperature --- 35 °C - 36.2 °C Normal temperature --- 36.2 °C - 37.2 °C Pyrexia --- Above 37.2 °C Low Pyrexia --- 37.2 °C - 38.3 °C Moderate Pyrexia --- 38.3 °C - 39.4 °C High Pyrexia --- 39.4 °C – 40.5 °C Hyperpyrexia --- Over 40.5 °C

29. PYREXIA/ FEVER The normal body temperature is within arrange of 36.2- 37.2 °C (degree Celsius). Pyrexia is an increase in body temperature of an individual above/ beyond the normal range. This increase in temperature is usually considered dangerous, but it is a natural defensive mechanism of the body to fight against infections.

30. Causes of Pyrexia Unrelieved continuous pain Infections caused by micro-organisms Toxic conditions Direct interference with the heat regulatory center Disease caused by parasites Inflammatory process

31. TYPES OF PYREXIA Pyrexia is described according to the time onset and type of termination. The fever may start suddenly or gradually and it can resolve suddenly or gradually. Types: Constant e. Inverse b. Remittent f. Relapsing Intermittent g. Irregular Inverse h. Apyrexia

32. TYPES OF PYREXIA 1. CONSTANT – There is a continuous elevation of body temperature It does not vary more than 1.1 °C within a 24 hours period. The temperature fluctuates minimally but always remains above the normal range. 2. REMITTENT – There are variations of more than 2°C in 24 hours The fever spikes and falls without returning to the normal range.

33. TYPES OF PYREXIA 3. INTERMITTENT (Hectic or swinging) – The body temperature swing from normal or subnormal to moderate or high pyrexia at intervals of one, two, or three days. There is variation of more than 1.1°C between the high and the low temperatures The lowest being normal or below normal. It may involve shivering as the temperature rises and sweating as the temperature falls. 4. INVERSE – The highest temperature is recorded in the morning and the lowest in the evening. Found to be a normal state of affairs in night workers

34. TYPES OF PYREXIA 4. RELAPSING – it is a short febrile period for some few days It is interspersed with periods of normal body temperature (a day or two) 5. IRREGULAR – It does fall into any other clearly defined group May show some of the characteristics of some or all the types of pyrexia. 6. APYRETIC – It is the lack of rise in the body However there are signs and symptoms of fever. The onset of the ever may occur gradually or suddenly

35. TYPES OF PYREXIA 5. APYRETIC – In this case a typical febrile condition may be described, the only characteristic lacking being an elevation of temperature. May occur in typhoid fever. The onset of a fever may occur gradually or suddenly. When it is gradual the temperature may take several days to a week to reach its maximum level whereas, when the onset is sudden, it may reach its higher within an hour or so.

36. TERMINATION OF PYREXIA 1.CRISIS It is a sudden or sharp drop of temperature to normal range within 24 hours There is also a steady improvement in the pulse and respiration rates and the general condition of the patient/client 2. LYSIS – It’s gradual drop of temperature to the normal range. Taking three (3) to five (5) days. There is also a steady improvement in the pulse and respiration rates and the general condition of the patient/client

37. TERMINATION OF PYREXIA (CONT) 3. FALSE OR PSEUDO-CRISIS – This may occur during the course of a disease before the crisis. It is a decline of body temperature which is not accompanied by a corresponding improvement in the pulse and respiration rates and the general condition of the patient. The body temperature rises again after a short period. FEVER SPIKE A temperature that rises to fever level rapidly following a normal temperature Returns to normal range within a few hours

38. EFFECTS OF PYREXIA ON THE BODY FEBRILE STATE Febrile/ Feverish: describes as the symptoms accompanying a rise in temperature. SYSTEM ------- SIGN AND SYMPTOMS Respiratory Increase rate of breathing Circulatory Increase pulse rate Alimentary Anorexia, dry mouth and tongue, nausea and vomiting, constipation or diarrhea Excretory Diminished output of highly coloured urine Muscular Malaise, general aches, feeling of weakness Nervous Headache, restless, lack of sleep

39. RIGOR Definition: It is a severe and sudden shivering attack as a result of sudden disturbance of heat-regulating mechanism centre. (hypothalamus) It usually indicates the presence of severe febrile illness. STAGES (3) Cold stage/shivering Hot stage Sweating stage

40. RIGOR ( Cont ) 1. COLD STAGE uncontrollable shivering, skin is cold to touch, face pinch and blue. rapid pulse, thread and rise in body temperature may reach 39.9 to 40°C (103°F to 104°F) and even above. 2. HOT STAGE – patient feels uncomfortable hot follows immediately after the cold stage, the skin is hot and dry, they complain of extreme thirst, headache, restlessness, discomfort temperature continues to rise while pulse is full and bouncing.

41. RIGOR ( Cont ) 3. SWEATING STAGE – Patient begins to sweat profusely, temperature falls and pulse rate improves, discomfort subsides gradually. Care must be taken to prevent chilling and possible collapse of the patient during this stage. Documentation 1. The vital signs should be monitored every 15 minutes and recorded on the Temperature chart 2. Through out all the stages the nurse must observe and record the duration and severity of each stage.

42. Nursing Care For Rigor During shivering stage give hot drinks Cover the body with blanket/hot water bottles During hot stage give cold drinks, cold compresses, apply ice bag to the head to relieve headache. Record temperature every 10-15 minutes Tepid sponge to reduce temperature After rigor, there is a feeling of exhaustion and tiredness. Ensure comfortability Throughout the rigor the vital signs should be taken and recorded in a special chart.

43. TEPID SPONGING It is sponging of a patient using tepid water. The temperature of the tepid water is between 27°C - 37°C and it is done in order to reduce a high body temperature. REQUIREMENTS: A trolley with the following Top shelf Bottom shelf A bowl for the tepid water Two jugs with hot and cold water Bath thermometer Long mackintosh and bed linen Six pieces of cloths/small towel Two large bath towels Temperature tray

44. Steps for Tepid Sponging Explain procedure to patient Screen the bed to provide privacy Bring trolley to bedside Wash your hands Take patient’s temperature, pulse and respiration Protect the bed linen with large mackintosh and bath towel to protect the bed from wetting Prepare the tepid water in the basin, test the water with a bath thermometer/elbow Undress the patient, wash and dry face to refresh him/her. Leave the wet towel on the forehead Place six pieces of towel/flannel into basin of tepid water.

45. Steps for Tepid Sponging Place a wet flannel in each axilla and groin Changes the wet flannel frequently to keep the water tepid Sponges upper arms, trunk, lower limbs and back in strokes leaving small drops of water on the skin Changes water as often as necessary Leaves patient for 15-20 minutes Dress patient up and recheck temperature and chart Thanks and make patient comfortable Washes and dries hands and serves cold drink if necessary Documents procedure and report findings.

46. RGN112/RMD113: BASIC NURSING LESSON 4: OBSERVATION AND RECORDING OF VITAL SIGNS (2 nd Section) 09 MAR 21

47. LESSON OBJECTIVES At the end of the lesson students should be able to: Outline the various sites for checking pulse, respiration and blood pressure. Differentiate between the normal and abnormal values of pulse, respiration and blood pressure Demonstrate how to check a patients/ clients vital signs

48. PULSE Pulse is a wave of expansion felt in an artery whenever a superficial artery passes over a bone. It is a measure of the number of times the heart beats in a minute. The wave of expansion corresponds to left ventricular contraction. It is faster in children and slow in aged. It increases with activity or slow down at rest. The normal pulse is described as full and bounding

49. SITES FOR TAKING PULSE The most convenient point to take the pulse is where the radial artery can be pressed against the radius on the anterior surface of the wrist. The other 2 most common sites are the temporal and facial arteries. Sites : 1. Temporal pulse 2. Facial pulse 3. Carotid pulse 4. Apical pulse 5. Radial (wrist) pulse 6. Groin/femoral pulse 7. Brachial Pulse 8. Popliteal Pulse

50. SITES FOR TAKING PULSE

51. AGE APPROXIMATE RANGE (Beats/minutes) AVERAGE (Beats/minutes) New born 120 – 160 140 1 – 12 months 80 – 140 120 1 – 2 years 80 – 130 110 2 – 6 years 75 - 120 100 6 – 12 years 75 – 110 95 Adolescence 60 – 100 80 Adult 60 - 100 80 Pulse rate is higher in women than men and lower in old age The ratio of pulse beat to respiration rate is usually fairly constant at about 4 : 1

52. CHARACTERISTICS OF PULSE Rate – the rate at which the heart is beating in a minute. Rhythm or regularity – the time interval between each beat which should be the same. It also indicates the pattern of the beat Volume/strength of beat – force of blood passing through the artery. It describes the fullness of the artery Tension – texture of the artery, the vessels should be felt softly under the nurse’s fingers. It should not feel hard/ tortuous.

53. PURPOSE OF TAKING PULSE To establish a baseline data To check abnormalities in the rate, rhythm, volume and tension To determine the number of heart beat per minute To asses response of heart to medications, activity and gas exchange To monitor changes in health status

54. REQUIREMENTS FOR RADIAL PULSE . Watch with second hand/ pulsometer Temperature chart Pen/ruler

55. Steps for Checking Pulse Explain procedure to patient/ client Patient/ client must be comfortable Place the your first three fingers of one hand on the anterior aspect of the patient’s forearm just above the base of the thumb at the bottom Feel the pulsation of the radial artery Use the second hand watch to count for a full minute Record the pulse on the observation chart Make patient comfortable Wash hands Report any abnormality detected.

56. ABNORMAL PULSE RATE TACHYCARDIA: This is the term used to denote a quick action of the heart rate above 100 beats per minute. BRADYCARDIA This is excessively low pulse rate which may be between 40-50 beats/minute DICROTIC PULSE It is a type of pulse where one strong beat is immediately followed by a weaker beat. This is due to the fact that the muscle layer of the walls of the blood vessels has lost its tone.

57. ABNORMAL PULSE RHYTHM ARRHYTHMIA – it is the name given to irregularity in pulse rhythm. SINUS ARRHYTHMIA – Condition in which pulse is rapid during inspiration and slows on expiration. Normally occurs in children and is of little importance IRREGULAR PULSE – this is the pulse where the intervals between the beats are uneven.

58. ABNORMAL PULSE VOLUME THREADY/WEAK PULSE – This is when the pulse rate is rapid, weak and the blood flow is easily stopped by pressure. RUNNING PULSE – This is when the pulse is very rapid with a very poor tension. CORRIGAN’S / WATER HAMMER PULSE – In this condition, the first half of pulse is normal but after reaching the peak, it suddenly collapse under the fingers.

59. RESPIRATION It is the act of breathing It is the process whereby exchange of gases take place in the lungs, between the air and the circulating blood. The respiratory cycle makes up of inspiration, expiration and a pause and is controlled by collection of nerve cells in the medulla oblongata called respiratory centre. The steady rise and fall of the chest wall is the apparent sign of respiration and is what the nurse look for and count and record.

60. CHARACTERISTICS OF RESPIRATION RATE: the number of full respiration in a minute (one inspiration and expiration) DEPTH: is established by observing the movement of the chest. it is the volume of air inhaled and exhaled with each respiration. It is described as normal, deep or shallow RHYTHM: is the regularity of both inspiration, expiration and pause

61. AGE AVERAGE RANGE/MINUTES New born 30 – 35 Early childhood (12 months old ) 25 - 30 Late children (2-5yrs) 20 – 25 Adulthood -male 14 – 18 Adulthood - female 16 - 20

62. Requirements For Checking Respiration A watch with second hand/ pulsometer Pen Temperature, pulse and respiration chart (Observation chart) STEPS After checking pulse with the hand still on patient’s wrist, observe patient’s respiration without his awareness Note the rise and fall of patient’s chest during inspiration and expiration, the rise and fall counts as one cycle.

63. Steps For Checking Respiration Note t he depth and rhythm, and difficulty in breathing, rate and regularity. Note t he position in which the patient breaths better Note t he skin colour Record respiration on the TPR chart Make patient comfortable Report any abnormalities on the nurses notes and inform the nurse incharge .

64. TYPES OF RESPIRATION SIGHING OR AIR HUNGER - This is apparent by long deep inspiration and rapid expiration. It indicates the need for more oxygen STERTOROUS – this is manifested by noise snoring inspiration and puffing out of the cheeks. It is often associated with damage to the brain following an injury It may also occur in obstruction of the airway. STRIDULOUS . - In this case the patient makes a harsh whistling sound due to obstruction of the air passage

65. TYPES OF RESPIRATION WHEEZING – This may occur in patients suffering from asthma and bronchitis as a result of air passing through fluid in the air passage. WHOOPING – It is a long drawn out noisy inspiration occurring after paroxysm of coughing in whooping cough. CHEYNE-STROKES – respiration is irregular characterised by alternate periods of apnoea and hyperventilation.

66. ABNORMAL RESPIRATORY PATTERNS APNOEA – period during which breathing has stopped or ceased. TACHYPNOEA – deep and rapid respiration above 20 cpm DYSPNOEA – laboured and difficult breathing. It is characterized by increased effort to exhale and inhale (with or without pain) ORTHOPNOEA – This term describes the condition in which the patient is unable to breathe easily unless he is in an upright or sitting up position. HYPERPNOEA – inspiration are increased in depth and rate. BRADYPNOEA – rate of breathing is less than 10 cpm

67. BLOOD PRESSURE Blood pressure it is the force required by the heart to pump blood from the ventricles into the arteries. It is the pressure exerted laterally on the walls of blood vessels. It is maintained by the pumping force of the heart in which the circulating blood exerts pressure upon the walls of the blood vessels. The instrument used in measuring the blood pressure is the Sphygmomanometer and measured in millimetres of mercury (mmHg)

68. TYPES OF SPHYGMOMANOMETER ANERIOD MERCURY DIGITAL

69. TYPES OF BLOOD PRESSURE ARTERIAL BLOOD PRESSURE : this is the pressure exerted in the blood as it pulsates through the arteries (blood moves in waves). There are two (2) blood pressures measured in the arteries. Systolic blood pressure Diastolic blood pressure 2. VENOUS BLOOD PRESSURE : It is the pressure that is exerted by the blood as it moves through the veins

70. TYPES OF ARTERIAL BLOOD PRESSURE Systolic blood pressure (contract): it is the pressure of the blood due to contraction of the heart Systolic pressure is the blood pressure greatest at each heart beat The systolic reading is written as the numerator The normal systolic pressure is between 90-140 mmHg b. Diastolic blood pressure (relaxes) : it is the pressure present at all times within the arteries when the heart is resting and occurs after contraction. Diastolic pressure is the lowest blood pressure at each heartbeat The diastolic reading is recorded as the denominator The diastolic pressure remains fairly constant The normal diastolic pressure is between 60-90mmHg.

71. FACTORS THAT MAINTAIN BLOOD PRESSURE Cardiac output : the amount of blood sent into circulation by the heart at each beat. Blood Volume – It is the amount of blood in circulation Rhythm – it is the rate at which the blood is pumped. Peripheral Resistance – the amount of resistance with which the blood is met as it flows through the vascular system depends on mainly the size of the lumen of the arteries and the viscosity of blood.

72. FACTORS THAT MAINTAIN BLOOD PRESSURE (CONT) Viscosity Of Blood – This is the thickness or lightness of the blood in circulation. the thicker the blood – increased pressure the lighter the blood – decreased pressure Elasticity Of The Arterial Wall – it is the pressure in the arteries in its highest point. It permits the arteries to contract during the systolic and relax during the diastolic.

73. FACTORS THAT INFLUENCE BLOOD PRESSURE READINGS Exercise Loss of elasticity of vessel wall Age Disease Posture Body weight emotions

74. CHECKING AND RECORDING OF BLOOD PRESSURE Its measured using the instrument sphygmomanometer and a stethoscope Measured in millimetres of mercury, (mmHg).

75. PLACING THE SPHYGMOMANOMETER

76. PROCEDURE- BLOOD PRESSURE Explain procedure to patient, Ensure that the patient is comfortably seated with arm supported and relaxed Empty cuff of air, pressing flat. Special armlets required for obese patient or the young child Place centre of cuff over brachial artery and wrap round arm, tucking in end neatly. Inflate cuff sufficiently to obliterate radial artery brachial artery.

77. PROCEDURE- BLOOD PRESSURE Slowly deflate cuff until pulse becomes just perceptible. Note height of mercury, which at this point is the systolic pressure. Put on stethoscope locating the brachial artery. Watch mercury. Inflate cuff until pulse again disappears and apply stethoscope to

78. CHECKING VITAL SIGNS – TEMPERATURE, PULSE, RESPIRATION, BLOOD PRESSURE (USING THE INDIVIDUAL ELECTRONIC THERMOMETER AND ELECTRONIC SPHYGMOMANOMETER) REQUIREMENTS A tray containing; Electronic or mercury thermometer Gallipot with cotton wool swabs or balls Gallipot with water Receiver for used swabs Sphygmomanometer Stethoscope Watch with second hands (nurse’s watch) or pulsometer Observation chart (vital sign chart) Red, blue pen, ruler and nurse’s note

79. STEPS Explain procedure to patient Presses knob to ensure thermometer and sphygmomanometer are functioning Prepare and send tray to patient’s bedside Make patient comfortable by lying/sitting up in bed, washes and dries hands or use alcohol rub Presses knob again to show reading on the screen, exposes axilla, dries with clean dry cotton wool and discards Cleans the thermometer with a dry cotton wool swab from bulb to stem Inserts thermometer into the axilla between two skin folds

80. STEPS Checks and records pulse and respiration whiles thermometer is in axilla Removes thermometer after beep, reads, records and cleans from stem to the bulb and inserts thermometer back into its container Charts readings of temperature, pulse and respiration Stretches patient’s arm and places sphygmomanometer beside arm at the same level Winds/wounds/wraps cuff around arm above elbow

81. STEPS Inflates cuff by pressing the start knob and wait for reading to appear on the screen Removes cuff and reassemble apparatus Thanks and makes patient comfortable Washes and dries hands, records reading

82. CHECKING VITAL SIGNS – TEMPERATURE, PULSE, RESPIRATION, BLOOD PRESSURE (NON-DIGITAL THERMOMETER) Explain procedure to patient and provide privacy Prepare and send tray to patient’s bedside Make patient comfortable by lying/sitting up in bed, washes and dries hands or use alcohol rub Rinses thermometer in cold water Dries thermometer with cotton wool from bulb towards the stem Shakes thermometer until mercury falls below 35°C Dries axilla with clean cotton wool and discards Inserts thermometer in the axilla between two folds of skin and leaves in position for 2-3 minutes whiles thermometer is in axilla

83. CHECKING VITAL SIGNS – TEMPERATURE, PULSE, RESPIRATION, BLOOD PRESSURE (NON-DIGITAL THERMOMETER) Whiles thermometer is in axilla, check and records pulse Checks and record respiration Removes thermometer and wipes from stem towards the bulbs Checks and records temperature, replaces thermometer in container Washes and dries hands or use alcohol rub Stretches patient’s arm and places sphygmomanometer beside arm at the same level Winds/wounds/wraps cuff around arm above elbow

84. CHECKING VITAL SIGNS – TEMPERATURE, PULSE, RESPIRATION, BLOOD PRESSURE (NON-DIGITAL THERMOMETER) Inflates cuff and palpates radial artery and notes level of mercury at which pulse disappears Wears and places stethoscope on brachial artery Releases pressure slowly and listens to sound with stethoscope Removes cuff and reassemble apparatus Thanks and makes patient comfortable Records reading on vital signs chart and nurses note