V/s and nursing responsibility

2. TEMPERATURE
PULSE
RESPIRATIONS
BLOOD PRESSURE
VITAL SIGNS MUST BE MEASURED, REPORTED, AND
RECORDED ACCURATELY
IF YOU ARE NOT SURE OF A MEASUREMENT,
RECHECK IT

3. o WHEN A PERSON IS ADMITTED TO A HEALTH CARE
FACILITY
o BEFORE AND AFTER SURGERY
o AFTER SOME NURSING PROCEDURES
o BEFORE MEDICATIONS ARE GIVEN THAT AFFECT THE
RESPIRATORY OR CIRCULATORY SYSTEM
o WHENEVER THE PERSON COMPLAINS OF PAIN,
SHORTNESS OF BREATH, RAPID HEART RATE, OR NOT
FEELING WELL.

4. o ILLNESS
o EMOTIONS – ANGER, FEAR, ANXIETY, PAIN
o EXERCISE AND ACTIVITY
o AGE
o SEX
o ENVIRONMENT - WEATHER
o FOOD AND FLUID INTAKE
o MEDICATIONS
o TIME OF DAY – ↓ IN THE MORNING, ↑ IN THE AFTERNOON/EVENING
o NOISE
A CHANGE IN ONE VITAL SIGN WILL CAUSE A CHANGE IN
THE OTHERS

5. o ANY VITAL SIGN IS CHANGED FROM A PREVIOUS
MEASUREMENT
o VITAL SIGNS ARE ABOVE THE NORMAL RANGE
o VITAL SIGNS ARE BELOW THE NORMAL RANGE

6. MANY AGENCIES HAVE TEMP BOARDS OR TPR BOOKS
RECORD VITAL SIGN MEASUREMENTS AS SOON AS
POSSIBLE
CARRY A SMALL NOTEBOOK IN YOUR POCKET SO YOU
CAN RECORD THEM AS YOU TAKE THEM
ABBREVIATIONS
TEMPERATURE – T
PULSE – P
RESPIRATIONS – R
BLOOD PRESSURE - BP

7. BODY TEMPERATURE IS THE AMOUNT OF HEAT IN THE
BODY
IT IS A BALANCE BETWEEN THE AMOUNT OF HEAT
PRODUCED AND THE AMOUNT OF HEAT LOST
HEAT IS PRODUCED BY :
THE CONTRACTION OF MUSCLES DURING EXERCISE
THE BREAKDOWN OF FOOD DURING DIGESTION
THE ENVIRONMENTAL TEMPERATURE
HEAT IS LOST THROUGH :
URINE FECES
RESPIRATIONS PERSPIRATION

8. BODY TEMPERATURE IS MEASURED IN ONE OF FOUR
AREAS OF THE BODY
THE MOUTH – ORAL
THE RECTUM – RECTAL
THE AXILLA (UNDERARM) – AXILLARY
THE EAR – TYMPANIC
WE NOW ALSO HAVE THE TEMPORAL SITE - FOREHEAD
MOST TEMPERATURES ARE TAKEN ORALLY
RECTAL TEMPERATURES ARE THE MOST ACCURATE
AXILLARY TEMPERATURES ARE THE LEAST ACCURATE

9. SITE NORMAL RANGE
ORAL 98.6 ° 97.6 ° TO
99.6 °
RECTAL 99.6 ° 98.6 ° TO
100.6 °
AXILLARY 97.6 ° 96.6 ° TO
98.6 °
TYMPANIC 98.6 ° 98.6 °
TEMPORAL 98.6° 98.6°

10. A SMALL HOLLOW GLASS TUBE THAT CONTAINS
MERCURY OR A MERCURY-FREE SUBSTANCE IN A BULB
AT ONE END.WHEN HEATED THE MERCURY RISES IN
THE TUBE.
Pear – shaped tip

11. o THE SCALE IS MARKED FROM 94° TO 108°
o THE LONG LINES REPRESENT ONE DEGREE
o THE SHORT LINES REPRESENT TWO TENTHS OF A DEGREE
o ONLY EVERY OTHER DEGREE IS MARKED WITH A NUMBER

12. o BATTERY OPERATED
o HAVE AN ORAL PROBE AND A RECTAL PROBE
o DISPOSABLE PROBE COVER IS PLACED ON THE PROBE
o THE TEMPERATURE REGISTERS IN ABOUT 30 SECONDS

13. USE A DISPOSABLE SHEATH

14. o MEASURES THE TEMPERATURE IN THE TYMPANIC MEMBRANE (EARDRUM)
o FAST AND ACCURATE - 1 TO 3 SECONDS
INFANTS – PULL
THE EAR
STRAIGHT BACK
ADULTS AND
CHILDREN OVER
ONE YEAR –
PULL THE EAR UP
AND BACK

15. GLASS
THERMOMETER
o RINSE WITH COLD WATER
o CHECK THE THERMOMETER
FOR BREAKS AND CHIPS
o SHAKE DOWN THE
THERMOMETER SO THE
MERCURY IS BELOW THE LINES
AND NUMBERS
o PLACE A DISPOSABLE COVER
ON THE THERMOMETER
o PLACE THE THERMOMETER
UNDER THE PERSON’S TONGUE
o LEAVE THE THERMOMETER IN
PLACE FOR 2 – 3 MINUTES
o IF THE PERSON HAS BEEN
EATING, DRINKING, OR
SMOKING, WAIT 15 MINUTES
BEFORE TAKING TEMPERATURE

16. DO NOT TAKE AN ORAL TEMPERATURE ON:
o AN INFANT OR YOUNG CHILD ( UNDER AGE 6)
o AN UNCONSCIOUS PATIENT
o A PATIENT THAT HAS HAD ORAL SURGERY OR AN INJURY TO THE FACE,
NECK, NOSE, OR MOUTH
o A PERSON RECEIVING OXYGEN
o A PATIENT WITH A NASOGASTRIC TUBE IN PLACE
o A PATIENT WHO IS CONFUSED OR RESTLESS
o A PATIENT WHO IS PARALYZED ON ONE SIDE OF THE BODY
o HAS A HISTORY OF SEIZURES
o A PATIENT WHO BREATHES THROUGH THE MOUTH

17. o LUBRICATE THE THERMOMETER BEFORE INSERTING INTO THE RECTUM
o PLACE THE PERSON IN A SIDE-LYING POSITION
o INSERT THE THERMOMETER 1 INCH INTO THE RECTUM
o HOLD THE THERMOMETER IN PLACE FOR 2 MINUTES
o REMOVE THE DISPOSABLE COVER AND READ THE THERMOMETER

18. DO NOT TAKE A RECTAL TEMPERATURE ON:
o A PERSON WHO HAS HAD RECTAL SURGERY OR RECTAL INJURY
o IF THE PERSON HAS DIARRHEA
o IF THE PERSON IS CONFUSED OR AGITATED
o IF THE PERSON HAS HEART DISEASE ( STIMULATES THE VAGUS NERVE
WHICH SLOWS THE HEART RATE )

19. o TAKEN ONLY WHEN NO OTHER SITE CAN
BE USED
o MAKE SURE THE UNDERARM IS CLEAN
AND DRY
o THE ARM IS HELD CLOSE TO THE BODY
o YOU NEED TO HOLD THE THERMOMETER
IN PLACE WHILE THE TEMPERATURE IS
BEING TAKEN
o THE THERMOMETER IS LEFT IN PLACE
FOR 10 MINUTES

20. THE PULSE IS:
o THE BEAT OF THE HEART FELT AT AN ARTERY AS A WAVE OF BLOOD PASSES
THROUGH THE ARTERY
o A PULSE IS FELT EVERY TIME THE HEART BEATS
o MORE EASILY FELT IN ARTERIES THAT COME CLOSE TO THE SKIN AND CAN
BE GENTLY PRESSED AGAINST A BONE
o THE PULSE SHOULD BE THE SAME IN ALL PULSE SITES ON THE BODY
o THE PULSE IS AN INDICATION OF HOW THE CARDIOVASCULAR SYSTEM IS
MEETING THE BODY’S NEEDS
o THE PULSE RATE IS AFFECTED BY MANY FACTORS – AGE, FEVER,
EXERCISE, FEAR. ANGER, ANXIETY, EXCITEMENT, HEAT, POSITION, AND PAIN.
o MEDICATIONS CAN BE TAKEN THAT EITHER INCREASE OR DECREASE A
PERSON’S PULSE RATE.

22. WE USUALLY COUNT A PULSE FOR 30 SECONDS AND
MULTIPLY THE NUMBER TIMES 2 TO GET THE PULSE
RATE FOR 1 MINUTE
WE NOTE THE RHYTHM (PATTERN)
OF THE HEART BEAT – IF THE HEART
BEAT IS IRREGULAR WE COUNT THE
PULSE FOR A FULL MINUTE
WE ALSO OBSERVE THE FORCE
(STRENGTH) OF THE HEARTBEAT.
DOES THE PULSE FEEL :
STRONG FULL BOUNDING
WEAK THREADY FEEBLE

23. o MOST COMMON SITE USED FOR
TAKING A PULSE
o CAN BE TAKEN WITHOUT
DISTURBING OR EXPOSING THE
PERSON
o PLACE THE FIRST TWO OR THREE
FINGERS OF ONE HAND AGAINST THE
RADIAL ARTERY
o THE RADIAL ARTERY IS ON THE
THUMB SIDE OF THE WRIST
o DO NOT USE YOUR THUMB TO TAKE
A PERSON’S PULSE
o USE GENTLE PRESSURE
o COUNT THE PULSE FOR 30 SECONDS
AND MULTIPLY BY TWO

24. ALWAYS CLEAN THE
EARPIECES OF THE
STETHOSCOPE WITH
ALCOHOL BEFORE AND AFTER
USE
WARM THE DIAPHRAGM IN
YOUR HAND BEFORE
PLACING IT ON THE PERSON
HOLD THE DIAPHRAGM IN
PLACE OVER THE ARTERY
DO NOT LET THE TUBING
STRIKE AGAINST ANYTHING
WHILE THE STETHOSCOPE IS
BEING USED

25. o TAKEN WITH A STETHOSCOPE
o COUNTED BY PLACING THE STETHOSCOPE
OVER THE HEART
o COUNTED FOR ONE FULL MINUTE
o THE HEART BEAT NORMALLY SOUNDS LIKE A
LUB-DUB. EACH LUB-DUB IS COUNTED AS ONE
HEARTBEAT.
o DO NOT COUNT THE LUB AS ONE HEARTBEAT
AND THE DUB AS ANOTHER.
o THE APICAL PULSE IS TAKEN ON PATIENTS
WHO HAVE HEART DISEASE , AN IRREGULAR
PULSE RATE, OR TAKE MEDICATIONS THAT CAN
AFFECT THE HEART.

26. THE APICAL AND RADIAL PULSE RATES SHOULD BE EQUAL
SOMETIMES THE HEART BEAT IS NOT STRONG ENOUGH TO CREATE A PULSE IN
THE RADIAL ARTERY
THIS WOULD CAUSE THE RADIAL PULSE TO BE LESS THAN THE APICAL PULSE
ONE PERSON COUNTS THE APICAL WHILE THE OTHER PERSON COUNTS THE
RADIAL
THE DIFFERENCE IN PULSES IS CALLED THE PULSE DEFICIT

27. NORMAL ADULT PULSE RATE IS – 60 TO 100 BEATS PER MIN.
TACHYCARDIA – HEART RATE OVER 100
BRADYCARDIA – HEART RATE BELOW 60
REPORT ABNORMAL HEART RATES TO THE NURSE
IMMEDIATELY

28. ONE RESPIRATION CONSISTS OF ONE INSPIRATION AND
ONE EXPIRATION
o THE CHEST RISES DURING INSPIRATION (BREATHING
IN) AND FALLS DURING EXPIRATION (BREATHING OUT)
o COUNT EACH TIME THE CHEST RISES
o COUNT FOR 30 SECONDS AND MULTIPLY X 2
o DO NOT LET THE PERSON KNOW YOU ARE COUNTING
THEIR RESPIRATIONS
o COUNT AFTER TAKING THE PULSE – KEEP YOUR
FINGERS ON THE PULSE SITE
o NORMAL RESPIRATORY RATE FOR ADULT IS 12 – 20
BREATHS PER MIN.

29. TACHYPNEA – RESPIRATORY RATE OVER 20
BRADYPNEA – RESPIRATORY RATE BELOW 12
DYSPNEA – SHORTNESS OF BREATH – DIFFICULTY IN
BREATHING
APNEA – NO BREATHING
HYPERVENTILATION – FAST AND DEEP RESPIRATIONS
HYPOVENTILATION – SLOW AND SHALLOW
RESPIRATIONS

30. THE MEASUREMENT OF THE AMOUNT OF FORCE THE
BLOOD EXERTS AGAINST THE ARTERY WALLS
o SYSTOLIC PRESSURE – PRESSURE EXERTED WHEN THE
HEART MUSCLE IS CONTRACTING
o DIASTOLIC PRESSURE – PRESSURE EXERTED WHEN THE
HEART MUSCLE IS RELAXING BETWEEN BEATS
BLOOD PRESSURE IS RECORDED AS A FRACTION WITH THE
SYSTOLIC PRESSURE ON TOP AND THE DIASTOLIC PRESSURE
ON THE BOTTOM
SYSTOLIC SYSTOLIC /DIASTOLIC
DIASTOLIC 120/80
BP IS MEASURED IN MM (MILLIMETERS) OF HG (MERCURY)

31. AVERAGE ADULT SYSTOLIC RANGE – 100 TO 140
AVERAGE ADULT DIASTOLIC RANGE – 60 TO 90
HYPERTENSION – MEASUREMENTS ABOVE THE NORMAL
SYSTOLIC OR DIASTOLIC PRESSURES
HYPOTENSION – MEASUREMENTS BELOW THE NORMAL
SYSTOLIC OR DIASTOLIC PRESSURES

32. o AGE – BLOOD PRESSURE INCREASES AS A PERSON GROWS OLDER.
o GENDER – WOMEN USUALLY HAVE LOWER BLOOD PRESSURE THAN MEN
o BLOOD VOLUME – SEVERE BLEEDING LOWERS THE BLOOD PRESSURE
o STRESS – HEART RATE AND BLOOD PRESSURE INCREASE AS PART OF THE
BODY’S RESPONSE TO STRESS
o PAIN – INCREASES BLOOD PRESSURE
o EXERCISE – INCREASES HEART RATE AND BLOOD PRESSURE
o WEIGHT – BLOOD PRESSURE IS HIGHER IN OVERWEIGHT PERSONS
o RACE – BLACK PERSONS GENERALLY HAVE HIGHER BLOOD PRESSURE
THAN WHITE PERSONS DO
o DIET – A HIGH-SODIUM DIET INCREASES THE FLUID VOLUME IN THE BODY
WHICH INCREASES BLOOD PRESSURE
o MEDICATIONS – CAN BE TAKEN TO RAISE OR LOWER BLOOD PRESSURE
o POSITION – BLOOD PRESSURE IS LOWER WHEN LYING DOWN

33. THE PROPER NAME FOR A BLOOD PRESSURE CUFF IS
SPHYGMOMANOMETER
MERCURY ANEROID

35. o DO NOT TAKE A BLOOD PRESSURE ON AN ARM WITH AN IV, A CAST, OR A
DIALYSIS SHUNT.
o DO NOT TAKE A BLOOD PRESSURE ON THE SIDE THAT A PERSON HAS HAD
BREAST SURGERY ON.
o MEASURE BLOOD PRESSURE WITH THE PERSON SITTING OR LYING.
o APPLY THE CUFF TO THE BARE UPPER ARM. DO NOT APPLY THE CUFF
OVER CLOTHING.
o MAKE SURE THE CUFF IS SNUG.
o USE A LARGE CUFF IF NECESSARY.
o MAKE SURE THE ROOM IS QUIET.
o IF YOU DO NOT HEAR THE BLOOD PRESSURE, WAIT 30 TO 60 SECONDS
AND TRY AGAIN. IF YOU STILL CAN NOT HEAR IT OR ARE UNSURE OF
YOUR READINGS, HAVE THE NURSE CHECK YOUR MEASUREMENTS.

36. 1. CLEAN THE STETHOSCOPE EARPIECES AND DIAPHRAGM WITH ALCOHOL.
2. LOCATE THE BRACHIAL PULSE. THIS IS WHERE THE STETOSCOPE WILL BE PLACED.
3. WRAP THE CUFF ABOVE THE ELBOW WITH THE ARROW POINTING TO THE BRACHIAL
ARTERY. FASTEN THE CUFF SO IT FITS SNUGLY.
4. PLACE THE DIAPHRAGM OF THE STETHOSCOPE FLAT ON THE PULSE SITE, HOLDING IT
IN PLACE WITH THE INDEX AND MIDDLE FINGERS OF ONE HAND.
5. LOCATE THE RADIAL PULSE.
6. CLOSE THE VALVE ON THE BP CUFF BY TURNING IT TO THE RIGHT (CLOCKWISE).
7. INFLATE THE CUFF UNTIL YOU CAN NO LONGER FEEL THE RADIAL PULSE. ,THEN
INFLATE THE CUFF 30 MM HG BEYOND THIS POINT.
8. DEFLATE THE CUFF SLOWLY BY OPENING THE VALVE SLIGHTLY AND TURNING IT
COUNTERCLOCKWISE (TO THE LEFT) WITH YOUR THUMB AND INDEX FINGER. ALLOW
THE AIR TO ESCAPE SLOWLY WHILE LISTENING FOR A PULSE SOUND.
9. NOTE THE READING AT WHICH YOU HEAR THE FIRST CLEAR, REGULAR PULSE SOUND.
THIS NUMBER IS THE SYSTOLIC PRESSURE.
10. CONTINUE LISTENING UNTIL THE SOUND DISAPPEARS. THIS IS THE DIASTOLIC
PRESSURE. NOTE THIS READING.
11. OPEN THE VALVE COMPLETELY TO DEFLATE THE CUFF. REMOVE THE CUFF FROM THE
PATIENT.

40. MEASURING WEIGHT AND HEIGHT
• Standing, chair, and lift scales are used.
• Measuring weight and height
– The person only wears a gown or pajamas.
– The person voids before being weighed.
– Weigh the person at the same time of day.
– Use the same scale.
– Balance the scale at zero before weighing the
person.

41. PAIN
• Pain means to ache, hurt, or be sore.
• Pain is a warning from the body.
• Pain is personal.
• Types of pain
– Acute pain – felt suddenly from an injury,
disease, trauma, or surgery
– Chronic pain – lasts longer than 6 months. Pain
can be constant or occur on and off.
– Radiating pain – felt at the site of tissue damage
and in nearby areas.
– Phantom pain – felt in a body part that is no
longer there.

42. • Signs and symptoms
– Location – Where is the pain?
– Onset and duration – When did the pain start?
– Intensity – Rate the pain on a scale of 1 to 10, with 10 as
the most severe
– Description – Can you use words to describe the pain?
– Factors causing pain – What were you doing when the pain
started?
– Vital signs – Take the person’s vital signs when they
complain of pain.
– Other signs and symptom
• Body responses - ↑ vital signs, nausea, pale skin,
sweating, vomiting
• Behaviors – crying, groaning, holding affected body
part, irritability, restlessness