Full

hoist

Standing lifter

VITAL SIGNS

Yenni Ferawati Sitanggang, S.Kp. , BN., RN

August 2012

OBJECTIVES

Describe 5th vital signs

Describe pain as possible 6th vital signs

Discuss the correct techniques of taking vital

signs

State the normal range of vital signs

Discuss the correct techniques to document the

vital signs results

Hypotension Hypertension

Refers to a

systolic blood

pressure less

than 90 mm Hg/

20 – 30 mm Hg

below the client’s

normal systolic

pressure

Refers to a

persistent

systolic pressure

greater than 135

/140 mm Hg and

a diastolic

pressure greater

than 90 mm Hg

Blood Pressure Level (mmHg)

Category Systolic Diastolic

Normal < 120 and < 80

Prehypertension 120-139 or 80-89

High Blood Pressure

Stage 1 Hypertension

140–159 or 90–99

Stage 2 Hypertension

160 or 100

http://www.nhlbi.nih.gov

Oral & Rectal Thermometer

Oral thermometer: Glass

thermometer

Place thermometer in

clients mouth under the

tongue

Instruct the clients to hold

lips closed

Leave in place for 3-5

minutes

Read at eye level

Oral temperature :electronic

thermometer

Place thermometer in clients

mouth under the tongue

Instruct the clients to hold

lips closed

Thermometer will signal

beep when temperature

registers

Read measurement on

digital display

Rectal Thermometer Clean the area

Lubricate the tip of

rectal thermometer

Instruct client to

take a deep breath

Insert the

thermometer gently

Hold for 2 minutes

Wipe secretions off

glass thermometer

Axillary temperature Remove clients arm from

sleeve of gown

Make sure axillary is dry, pat dry if necessary

Place thermometer into center of axilla & ask client to fold his/her arm

Range normal 35.9 – 37.4 C

Read the result on the thermometer

Digital thermometer: few seconds

Glass thermometer:3-5 mins

Tympanic thermometer

Clients in seated

position or Sims

position

Remove probe from

container and attach

probe cover to tympanic

thermometer

Turn client’s head to

one side, Adult: pull

pinna upward and back,

Child: pull pinna down

and back

Insert probe with firm

pressure into ear canal

Temporal thermometer

Un familiar in Indonesia

Measured a temperature with a

infrared reading of temporal artery

blood flow

Usually used for children

Arterial Pulses 1. Place 1st, 2nd &/or 3rd fingers

over radial artery and press

gently. Use thumb to support

wrist> Count pulsation 60

seconds

2. In each arterial pulses, we need

to assess the quality, rate,

rhythm, volume (strength).

3. HR : 60 – 100 x/mins

4. HR <60x/mins: Bradycardia

HR>100x/mins: Bradycardia

Respirations

Observe for one complete respiratory

Place clients hand across abdomen and your hand over clients’ wrist

Start counting (inspiration & expiration as one count)

Observe: depth, rhythm, rate

Observe the chest wall movement

Absence of breathing : Apnea, dyspnea:difficult in breathing

Bradypnea: respiratory rate of 10/fewer

Tachypnea : respiratory rate greater than 24x/mins

Pulse oximetry

Is a machine that

measures the oxygen

saturation of the blood

througha probe clipped to

the fingernails

Range of 95%-100%

Oxygen saturation

Pain

References

Berman, A & Snyder, S. (2012). Kozier & Erb’ Fundamentals in nursing, concept, process and practice (9 th Ed). New Jersey

Daniels, R., Grendell, & Wilkins, F. (2010). Nursing Fundamentals, Caring & clinical decision making (2nd Ed). Delmar

Taylor, C., Lilis, C & LeMone, P. (2008). Fundamental of nursing (2008), The art & science of Nursing care (6 th Ed). Lippincot Williams & Wilkins