Nursing Performance Guidelines: Vital Signs

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Nursing Performance Guidelines: Vital Signs (Temperature, Pulse, Respiration, Oxygen Saturation, Blood Pressure)

Practice:

1.Introduces self; name, nursing student & level

2.Determines client's name & use name more than once during interaction.

3.Demonstrates professional deportment and appearance

4.Explains procedure to client, including specific actions/use of equipment

5.Hand Hygiene

6.Determine need to assess vital signs

ORAL TEMPERATURE: (electronic probe measurement)

Remove thermometer pack from charging unit

Attach disposable sheath to probe

Place probe under the tongue in posterior sublingual pocket

Instruct client to close his/her mouth tightly

Leave thermometer in place for appropriate time interval depending on model used

Remove thermometer and discard sheath

Return probe to base unit for storage

Verbalizes temperature reading in degrees Celsius and notices if this is in the normal range for the client's age

RADIAL PULSE:

Places client's forearm across chest if supine, or with elbow bent 90 degrees if sitting, with wrist slightly flexed

Using the pad of the first three fingers, palpates the radial pulse at the flexor aspect of the wrist laterally along the radius bone

Palpates until feels strongest pulsation

If rhythm is regular, counts t number of beats in 30 seconds and multiplies by 2. If rhythm is irregular, count for a full minute. Start count with "zero" for the first pulse felt

Assesses the pulse, including the rate, rhythm, and strength

Verbalizes findings and notices if these are in the normal range

RESPIRATION:

Observes respiratory rate by maintaining position for counting the radial pulse and unobtrusively counting respirations by watching the chest rise and fall or watch chest rise and fall separately

Notes the regularity, rhythm, depth and use of accessory muscles

Counts for a full minute of respiratory cycles (inspiration and expiration) that occur in 30 seconds and multiples by 2, counts for a full minute if abnormality suspected

Verbalizes findings and notices if there are in the normal range

OXYGEN SATURATION:

Select most appropriate site for sensor placement by assessing capillary refill & skin condition. f capillary refill is less than 3 seconds.., choose another site

If a finger is used, remove any nail polish

Attach sensor monitoring site. Turn on oximeter

Correlate oximeter pulse rate to radial pulse. If rates are not the same, readjust the oximeter probe and reassess pulse

Leave probe in place until value is constant and pulse display reaches full strength. Observe and record findings

Remove probe and turn off oximeter

Verbalizes findings and notices if these are in the normal range

BLOOD PRESSURE: 2 STEP METHOD:

Assembles appropriate equipment, including a stethoscope and sphygmomanometer. Matches the appropriate size ff to the person's arm size and shape and not to the person's age.

Positions and supports the client, either sitting or lying, with the bare arm supported at heart level

Palpates the brachial artery

With the cuff deflated, centre it about 2.5cm above the brachial artery and wrap it evenly.

Palpate the brachial or radial artery and inflate the cuff until the artery pulsations disappears, and then to 20-30 mm Hg beyond

Deflate the cuff quickly and completely, then wait 30 seconds before re-inflating

Relocate the patient's brachial artery

Place the bell or diaphragm of the stethoscope over the site of the brachial artery, making a light, but airtight seal

Close the valve and rapidly inflate the cuff to 20-30 mm Hg above the palpated systolic pressure

Deflate the cuff slowly and evenly, about 2mm Hg per heartbeat. Note the points at which you hear the first appearance of sound, the muffling of sound and the final disappearance of sound. Listen 10-20 mm Hg after the last sound, then let cuff deflate rapidly.

Removes cuff, replacing it in proper storing place

Record the BP using even numbers. Record the client's position, arm used, and cuff size if different from the standard adult cuff. Notice if this reading is within the normal range for the client's age.

REPORTING & DOCUMENTATION:

Wash hands

Verbally reports accurate findings for BP, T, P, R, and O2 saturation, and compares to normal, interpreting findings.

Documents vitals signs including date and time using the flow sheet and assessment from provided

Completes an organized and efficient assessment using safe, professional techniques including appropriate positioning and draping of the client, and correct positioning and body mechanics for nurse.