2. Vita
l
sign
s
Vital signs are indicators of
physiologic functioning, reflects
the health status of a person and
any change may indicate a
change in health. It is include:
2
Temperature (T) Pulse (P)
Respiration (R) Blood pressure
(BP)
3. When to take vital signs?
3
When?
On admission
Care routine
Invasive
procedure
Medication
Blood
transfusion
Nursing
intervention
Change
physical
condition
5. Definition
Body temperature is the difference between the
amount of heat produced by body processes and the
amount of heat lost to the external environment.
5
6.
7.
8. Temperature Conversion
8
1. Celsius to Fahrenheit: To convert Celsius to Fahrenheit,
multiply by 9/5 and add 32:
°F = (°C × 9/5) + 32
2. Fahrenheit to Celsius: To convert Fahrenheit to Celsius,
subtract 32 and multiply by 5/9:
°C = (°F − 32) × 5/9
16. Temperature Conversion
Presentation title 16
1. Celsius to Fahrenheit: To convert Celsius to Fahrenheit,
multiply by 9/5 and add 32:
°F = (°C × 9/5) + 32
2. Fahrenheit to Celsius: To convert Fahrenheit to Celsius,
subtract 32 and multiply by 5/9:
°C = (°F − 32) × 5/9
17. Preparation
Presentation title 17
• Assess patient to determine appropriate method to obtain
body temperature.
• For an oral temperature, obtain reading 15 to 30 minutes
after ingestion of hot or cold food or fluids or smoking.
• Oral route is contraindicated if patient is unable to hold
thermometer properly or if there is a risk that patient may
bite thermometer.
• Rectal thermometer must be held securely in place and never
left unattended.
18. Equipment
18
• Thermometer, appropriate for site to be used.
• Soft tissue or wipe.
• Water-soluble lubricant for rectal temperature measurement.
• No sterile gloves, if appropriate.
• Additional personal protective equipment (PPE), as indicated.
• Electronic record, or a pen, paper or flow sheet.
20. 1. Step: Review medical record for baseline data and factors that
influence vital signs.
2. Step: Explain to the client that vital signs will be assessed.
3. Step: Assess client’s toileting needs and proceed as appropriate.
4. Step: Gather equipment.
5. Step: Provide for privacy.
6. Step: Wash hands and apply gloves.
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21. 21
7. Step: Remove thermometer from storage container and cleanse under cool
water.
8. Step: Use a tissue to dry thermometer from bulb’s end toward fingertips.
9. Step: Read thermometer by locating mercury level. It should read 35.5°C
(96°F).
22. 10. Step: If thermometer is not below normal body temperature reading,
grasp thermometer with thumb and forefinger and shake vigorously by
snapping the wrist in a downward motion to move mercury to a level
below normal.
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23. 23
11. Step: Place thermometer in client’s mouth under the tongue
and along the gum line to the posterior sublingual pocket.
Instruct client to hold lips closed.
Rational: Ensures contact with large blood vessels under the tongue.
Prevents environmental air from coming in contact with the bulb.
24. 24
12. Step: Leave in place as specified by agency policy, usually 3–5
minutes.
13. Step: Remove thermometer and wipe with a tissue away from
fingers toward the bulb’s end.
14. Step: Read at eye level and rotate
slowly until mercury level is visualized.
25. 15. Step: Shake thermometer down, and cleanse glass thermometer with
soapy water, rinse under cold water, and return to storage container.
16. Step: Remove and dispose of gloves in receptacle. Wash hands.
17. Step: Record reading and indicate site as “oral temperature (OT).”
18. Step: Wash hands.
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27. 27
1. Step: Repeat steps 1–7.
2. Step: Remove client’s arm and shoulder from one sleeve of gown. Avoid exposing chest.
3. Step: Make sure axillary skin is dry; if necessary, pat dry.
4. Step: Prepare thermometer.
5. Step: Place thermometer into center of axilla.
Fold client’s upper arm straight down and place
arm across client’s chest.
28. 6. Step: Leave glass thermometer in place as specified by agency policy
(usually 6–8 minutes).
7. Step: Remove and read thermometer.
8. Step: Inform client of temperature reading.
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29. 29
9. Step: Cleanse glass thermometer. Shake thermometer down, and
cleanse glass thermometer with soapy water, rinse under cold
water, and return to storage container.
10. Step: Assist client with replacing gown.
11. Step: Record reading and indicate site as “axillary temperature
(AT).”
12. Step: Wash hands.
31. 31
1. Step: Repeat steps 1–7.
2. Step: Place client in the Sims’ position with upper knee flexed.
Adjust sheet to expose only anal area.
32. 3. Step: Place tissues in easy reach. Apply gloves.
4. Step: Prepare the thermometer.
5. Step: Lubricate tip of rectal thermometer (a rectal thermometer usually
has a red cap).
6. Step: With dominant hand, grasp
thermometer. With other hand,
separate buttocks to expose anus.
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33. 7. Step: Instruct client to take a deep breath. Insert thermometer gently
into anus: 3.5 cm (1.5 inches). If resistance is felt, do not force
insertion.
8. Step: Hold in place for 2 minutes.
9. Step: Wipe secretions off glass thermometer with a tissue. Dispose of
tissue in a receptacle.
10. Step: Read measurement and inform client of temperature reading.
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34. 34
11. Step: While holding glass thermometer in one hand, use other hand
to wipe anal area with tissue to remove lubricant or feces. Dispose
of soiled tissue. Cover client.
12. Step: Cleanse thermometer.
13. Step: Remove and dispose of gloves in receptacle. Wash hands.
14. Step: Record reading and indicate site as “rectal temperature
(RT).”
