Measuring and Recording Vital signs

Equipment

Stethoscope
BP apparatus
Watch, oximeter (SpO2)
Thermometer

Procedure
MEASURING AND RECORDING VITAL SIGNS
STEPS RATIONALE
1. Check doctor’s orders if available Identify correct client
How frequent
2. Wash hands Reduce spread of microorganism

4.Prepare and assemble equipment Prepare equipment to perform skill

including disinfecting the stethoscope within a timely manner.
and ensure mercury in thermometer is
reading below 35o
Celsius/ 990 Fahreint
Elicit cooperation
3. Introduce yourself to client and
explain procedure.

MEASURING THE
TEMPERATURE Immobilize thermometer

5. (Mercury) Thermometer. Place

thermometer, with the silver bulb,
under the arm for 5-7mins. Ask client
to place the fingers of the hand on the
opposite shoulder.

6. Remove thermometer, clean, place

at eye level and read were the
mercury has stopped.

OR

7. Hold infra red gun and point to the

forehead to register temperature.

8. Record results on the appropriate

chart.

MEASURING AND RECORDING VITAL SIGNS

STEPS RATIONALE
MEASURING THE PULSE

9. Locate the radial pulse found on Easier to locate

the inside of the wrist closest to the
thumb

10. Use first and second fingertips Thumb has a pulse

(never the thumb) to press firmly but
gently on the wrist (or otherwise)
until you feel a pulse.

11. With an analog clock or watch,

wait until the second hand is on the
12.
12. Begin counting the beats of the
pulse.
13. Count pulse for 60 seconds until
the second-hand returns to the 12
(you may also count for 15 seconds
and multiply by 4 to calculate beats Can miscount heart beats
per minute).
14.When counting, do not watch the
clock continuously, but concentrate
on the beats of the pulse.
 MEASURING RESPIRATION
15. Look at the chest and observe for
rise and fall of the chest. (inhale and
exhale)
16. With an analog clock or watch,
wait until the second hand is on the
12.
17. Count breaths (inhale + exhale =
1 respiration) for one minute.
18.Document respiration rate, noting
any observations (such as wheezing).
To identify pulse for placement of
diaphragm
MEASURING BP
18. Place fingers on the underside of
the elbow to locate pulse (called the
brachial pulse).
19.Wrap and fasten deflated cuff
snugly around the upper arm at least
To ensure air remains in the arm cuff
one inch above where you felt the
to allow BP to be measure.
strong and steady brachial pulse

20 .Insert stethoscope earpieces and
position diaphragm directly over the
brachial pulse
.
21.Turn the knob on the air pump
clockwise to close the valve.
21.Pump air, inflating the arm cuff
until the dial pointer reaches 170.

MEASURING AND RECORDING VITAL SIGNS

STEPS RATIONALE
22. Gently turn the knob on the air
pump counter-clockwise to open the
valve and deflate the cuff.
23. As the dial pointer falls, watch the
number and listen for a thumping
sound.
24. Note the number shown where the
first thump is heard (systolic
pressure). Continue to listen to the
heart beat until it is no longer heard
and observe at the same time note the
location of the mercury as it drops.
The last thumping sound is the Minimise spread of microorganisms
diastolic.
Communicate findings to ensure
25. Remove cuff from client’s arm appropriate medical management is
and leave client in comfortable given.
position.
26. Disinfect blood pressure
equipment and return to storage area.
27. Wash hands
28. Record blood pressure
 STEPS RATIONALE

Measuring SpO2

1. Wash hands Minimise spread of microorganism

2. Place pulse oximeter on the

finger, or earlobe or the toe.

3. Observe two lines of waves

displayed on the screen.
Level of oxygen circulating in the
4. Note the figure to the top of the body ( %)
screen

5. The figure at the bottom is the

pulse/heart beat

6. Record the SpO2

Prepared by
Shanette Brewster