Vital Signs
Vital Signs
Vital Signs
CG INTERVENTIONS
Monitor VS
Assess skin color and temperature
Remove excess blankets when the client feels warm; provide extra warmth
when the client feels chilled
Provide adequate foods and fluids
Promote rest. To reduce body heat production
Provide good oral hygiene. To prevent herpetic lesions of the mouth
Provide cool, circulating air using a fan to dissipate heat by convection
Provide dry clothing and bed linens
Provide TSB (water is 80-98OF)
Administer antipyretic as ordered.
Methods of Temperature-Taking
1. Oral most accessible and convenient method.
Contraindications
Young children and infants
Patients who are unconscious or disoriented
Who must breath through the mouth
Seizure prone
Patient with N/V
Patients with oral lesions/surgeries
2. Rectal- most accurate measurement of temperature
Contraindications
Patient with diarrhea
Recent rectal or prostatic surgery or injury because it may injure inflamed
tissue
Recent myocardial infarction
Patient post head injury
3. Axillary safest and non-invasive
4. Tympanic thermometer
5. Chemical-dot/ chemical Strip thermometer
II. Pulse It is the wave of blood created by contractions of the left ventricles of
the heart.
FACTORS AFFECTING THE PULSE RATE
1. Age
2. Sex/gender
3. Exercise
4. Fever
5. Medications
6. Hemorrhage
7. Stress
8. Position changes
PULSE SITES
1. Temporal over the temporal bone of the head; superior and lateral to the
eye.
2. Carotid at the lateral aspect of the neck; below the ear lobe.
3. Apical at the left mid-clavicular line, 5th ICS. Use stethoscope.
4. Brachial inner aspect of the upper arm or medially at the antecubital space
5. Radial on the thumb side of the inner aspect of the wrist.
6. Femoral along the side of the inguinal ligament.
7. Posterior tibial at the medial aspect of the ankle, behind the medial
malleolus.
8. Popliteal at the back of the knee.
9. Pedal (dorsalis pedis) at the dorsum of the foot.
4.
5.
6.
7.
8.
9.
Race
Obesity
Sex/gender
Medications
Diurnal variations
Disease process
SYSTOLIC in
mmHg
DIASTOLIC in mmHg
<120
<80
NORMAL BLOOD
PRESSURE
and/o
120-139
CATEGORY
80-89
PREHYPERTENSION
140-159
90-99
STAGE 1 HYPERTENSION
160 or more
100 or more
STAGE 2 HYPERTENSION