The document outlines the procedures and protocols for assessing vital signs, including blood pressure, temperature, heart rate, respiration rate, and oxygen saturation. It details the methods for accurately measuring these vital signs, the normal and abnormal ranges, and when to notify medical providers. Each client should have specific written protocols regarding these assessments to ensure proper care.

2. INTRODUCTION
You may need to assess vital signs on clients in
your care.
• You need to know how to do this.
• You also need to know if results are abnormal or
should be reported to someone.
• Protocols regarding vital signs should be written
for each client.

3. VITAL SIGNS – how many are there?
’ B
Blood pressure
’ Temperature
’ Heart rate
’ Respiration rate
’ Oxygen saturation (pulse oximetry)

4. BLOOD
PRESSURE

5. TAKING A BLOOD PRESSURE
B
Before
e taking
g a
a blood
d pressure,
, pay
y attention
n to
o the
e size
e and
d
placement
t of
f the
e cuff,
, the
e person’s
s position,
, and
d technique.
.
’ Cuff
f size
e –
– if
f too
o small
l the
e systolic
c pressure
e will
l be
e high.
.
’ Cuff
f placement
t –
– ideally
y above
e the
e elbow
w over
r a
a bare
e arm.
.
o May
y take
e over
r thin
n clothing
g but
t thick
k clothing
g should
d be
e
removed.
. Do
o not
t roll
l up
p the
e sleeve.
.
’ Body
y position
o Crossing
g legs
s or
r sitting
g without
t a
a back
k support
t can
n cause
e
higher
r readings.
.

6. POSITIONING

7. BLOOD PRESSURE DEVICES
B
Blood
d pressure
e cuffs
s that
t take
e the
e
pressure
e in
n the
e upper
r arm
m (over
r the
e
elbow)
) give
e the
e most
t accurate
e results
s
whether
r taken
n on
n an
n automated
d
system
m or
r manually.
.
Wrist
t devices
s are
e often
n used
d on
n
someone
e who
o is
s obese.
. Wrist
t
readings
s are
e often
n falsely
y elevated.
.
Blood
d pressure
e measurements
s on
n the
e
finger
r are
e not
t recommended
das
s the
e
results
s are
e quite
e inaccurate.
.

8. OVER THE ELBOW BLOOD PRESSURE DEVICE
W
With
h automated
d blood
d pressure
e cuffs,
, the
e cuff
f is
s
inflated
d to
o the
e correct
t amount
t and
d automatically
y
gives
s the
e blood
d pressure
e reading.
.
With
h manual
l blood
d pressure
e cuffs,
, inflate
e to
o about
t
180
0 mm
m Hg
g and
d then
n allow
w to
o deflate
e slowly.
.
• Listen
n for
r the
e pulse
e over
r the
e brachial
l artery
y
using
g a
a stethoscope.
.
’ When
n the
e pulse
e is
s first
t heard,
, that
t is
s the
e
systolic
c pressure
e reading.
’ As
s the
e air
r escapes,
, the
e sound
dof
f the
e pulse
e will
l
disappear.
. The
e point
t that
t the
e sound
d disappears
s
is
s the
e diastolic
c pressure
e reading.
.

9. NORMAL
AND
ABNORMAL
BLOOD
PRESSURE
READINGS

10. TEMPERATURE

11. TAKING A TEMPERATURE
’ A person should not smoke, eat, or drink
for at least 10 minutes before taking an
oral temperature as the body temperature
will be altered.
’ Document which part of the body was
used when taking a temperature.
’ Ear and rectal temperatures are one half
to one degree F higher than oral
temperatures.
’ Axillary (armpit) and forehead
temperatures are usually one half to one
degree F lower than oral temperatures.

12. NORMAL AND ABNORMAL TEMPERATURES
Normal 97 to 99 degrees Fahrenheit (fF)
Fever Anything over 100.4 fF
• Notify medical provider if temperature is over 103fF
• Notify medical provider if fever more than 3 consecutive days
• Notify medical provider if fever accompanied by severe sore throat
swelling, vomiting, headache, stiff neck, rash, severe cough or
shortness of breath.
o Individualprotocolsmay differ. Follow the protocolsof your agency.
Hypothermia Temperatures below 95fF

13. HEART
RATE
(pulse)
The pulse is the number
of times the heart beats
per minute

14. TAKING A PULSE
’ Using your first and second fingertips, gently
press down on the artery until you feel the pulse.
Never use your thumb as you will be feeling your
own pulse.
’ The radial pulse is located on the thumb side of
the wrist, where the wrist bends.
’ Count the heartrate for 30 seconds and multiply
by 2 to obtain the pulse which is always recorded
as beats per minute.
’ Note if the pulse is regular or irregular (rhythm).
’ Record the rate and rhythm.

15. NORMAL AND ABNORMAL HEART RATES
Normal 60 to 90 beats per minute (BPM)
Tachycardia Over 100 BPM
• Rate normally increases with exercise, sickness, injury, emotions.
• Seek medical attention if rate is over 130 or very irregular.
• Seek medical attention if accompanied by shortness of breath,
lightheadedness, or chest discomfort.
Bradycardia Abnormally low heart rate
• Heart rates are slower when sleeping.
• Concerning symptoms (report):
oFeeling lightheaded, dizzy, faint
oWeakness, fatigue, confusion
• Seek immediate attention if accompanied by chest pain, trouble
breathing, low blood pressure, or fainting.

16. RESPIRATION
RATE
Respiration rate is the number
of breaths per minute.

17. PROCEDURE
1. Count how many times the chest rises over a minute.
2. To get an accurate reading, do this without the person knowing it is being
done so they don’t change their breathing rate.

18. NORMAL & ABNORMAL BREATHING RATES
Normal 12 TO 20 Breaths per minute
• Rate increases with fever, illness, lung disease
Respiratory
distress
Seek Immediate Medical Attention if:
• Struggling to breath
• Pain with breathing
• Turning blue
• Irregular or very shallow breaths.

19. PULSE
OXIMETRY
Pulse oximetry is a non-
invasive way to monitor
the amount of oxygen in
the blood.

20. FALSE READINGS
’ Low blood pressure
’ Nail polish, artificial nails
’ Hypothermia (vessels constrict)
’ Motion (shivering, seizures, etc.)
’ Dark skin color
’ Dirt on hands
’ Intense light (bright sunlight,
fluorescent lights)

21. BLOOD OXYGEN LEVELS
Pulse Oximeter Reading
95 to 100% Normal blood oxygen levels
91 to 95% “Concerning” blood oxygen levels - monitor
Under 90% Low blood oxygen levels – notify medical provider
80 to 85% Seek Medical attention
x Brain is affected at these levels and below
80% and lower Cyanosis

22. SYMPTOMS OF HYPOXIA
’ Restlessness
’ Headache
’ Confusion
’ Difficulty breathing
’ Rapid heart rate
’ Rapid breathing
’ Anxiety

23. SYMPTOMS OF SEVERE HYPOXIA
’ Slow heartrate
’ Extreme restlessness
’ Blue skin (cyanosis)

24. THANK YOU
JEAN JUSTAD, MD, MEDICAL DIRECTOR, DDP
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