Nursing Skill: Vital signs-Measuring Body Temperature (BT)

Preparation
Environment • Ensure good lighting, privacy and warmth
Nurse • Wash hands
Client • Position: sitting or lying
Follow instruction of holding the mercury type
thermometer
Equipment • Thermometer
Alcohol swab
Water-soluble lubricant (for rectal measurements only)
Disposable sheath or cover for using any type of
thermometer
Pen
Vital sign sheet or record form
Clean gloves (optional)
Soft tissue and kidney dish
Hygiene items
Watch with a second hand
Tray
Oral temperature:
Procedure
1. Identify patient using at least two identifiers.
2. Perform hand hygiene.
3. Prepare the thermometer by ensure that the level of mercury column is below
35℃ or below, and covering it with a disposable sheath.
4. Ask patient to open mouth and gently place thermometer probe under tongue in
posterior sublingual pocket lateral to center of lower jaw.
5. Ask patient to hold thermometer probe with lips closed.
6. Leave thermometer probe in place for 2 minutes.
7. Perform hand hygiene.
Rectal temperature:
Procedure
1. Identify patient using at least two identifiers.
2. Perform hand hygiene.
3. Patient’s privacy and draw curtain.
 4. Assist patient to side-lying or Sims position with upper leg flexed. Move aside
bed linen to expose only anal area. Keep patient’s upper body and lower
extremities covered with sheet or blanket.
5. Apply clean gloves. (Optional: Cleanse anal region when feces or secretions
are present. Remove soiled gloves, perform hand hygiene and reapply clean
gloves.)
6. Using a single-use package, squeeze a liberal amount of lubricant on tissue.
Dip tip of probe cover of thermometer into lubricant, covering 2.5 to 3.5 cm for
adult.
7. With non-dominant hand separate patient’s buttocks to expose anus. Ask
patient to breathe slowly and relax.
8. Gently insert thermometer into anus in direction of umbilicus 3.5 cm for adult.
Do not force thermometer.
9. Leave thermometer probe in place for 3 minutes.
10.Wipe probe stem with alcohol swab.
11.Wipe patient’s anal area with soft tissue to remove lubricant of feces. Assist
patient in assuming a comfortable position.
12.Remove and dispose of gloves in appropriate receptacle.
13.Perform hand hygiene.
Axillary temperature:
Procedure
1. Identify patient using at least two identifiers.
2. Perform hand hygiene.
3. Patient’s privacy and draw curtain.
4. Assist patient to supine or sitting position. Move clothing or gown away from
shoulder.
5. Raise patient’s arm. Inspect for skin lesions and excessive perspiration, if
needed, dry axilla or select alternative site. Insert thermometer probe into
center of axilla. Lower arm and place arm across patient’s chest.
6. Leave thermometer probe in place for 10 minutes.
7. Assist patient in assuming comfortable position, replacing linen or gown.
8. Perform hand hygiene.
Nursing Skill: Vital signs-Tympanic membrane temperature
Electronic thermometer
Procedure
1. Identify patient using at least two identifiers.
2. Perform hand hygiene.
3. Assist patient in assuming comfortable position with head turned toward side, away
from the nurse.
4. Insert speculum into ear canal following manufacturer instructions for tympanic
probe positioning.
a. Pull ear pinna backward, up, and out for an adult. For children less than 3
years of age, pull pinna down and back.
b. Fit speculum tip snug in canal, pointing toward the client’s nose.
5. Once positioned, press scan button on handheld unit. Leave speculum in place unit
audible signal indicates completion and patient’s temperature appears on digital
display.
6. Carefully remove speculum from auditory meatus. Push ejection button on handheld
unit to discard speculum cover into appropriate receptacle.
7. If temperature is abnormal or second reading is necessary, replace probe cover and
wait 2 minutes before repeating in same ear, or repeat measurement in other ear.
Consider an alternative temperature site or instrument.
8. Perform hand hygiene.
Evaluation
1. If patient has fever, take temperature approximately 30 minutes after
administering antipyretics and every 4 hours until temperature stabilizes.
2. Record temperature and route on vital sign flow sheet.
3. Initiate measures to lower body temperature:
a. Cool room environment.
b. Reduce external covering on patient’s body to promote heat loss, but
do not induce shivering.
c. Keep clothing and bed linen dry.
d. Limit physical activity and sources of emotional stress.
e. Administer antipyretics as ordered.
f. Increase fluid intake.
Nursing Skill: Vital signs-Measuring Radial and apical pulses (P)
Preparation
Environment • Ensure good lighting, privacy and warmth
Nurse • Wash hands
Client • Position: sitting or lying
Equipment • Watch with second hand or digital display
Alcohol swab
Stethoscope
Procedure
1. Identify patient using at least two identifiers.
2. Perform hand hygiene.
3. Assist patient with assuming a supine or sitting positon.
4. Radial pulse:
a. Place the patient’s forearm straight alongside or across lower chest or upper
abdomen.
b. If sitting, bend patient’s elbow 90 degrees and support lower arm on chair.
c. Place tips of first two or middle three fingers of hand over groove along
radial or thumb side of patient’s inner wrist.
d. Slightly extend or flex wrist with palm down until the nurse note strongest
pulse.
e. Lightly compress pulse against radius, losing the pulse initially, and then
relax pressure so that pulse becomes easily palpable.
f. Determine strength of pulse. Note whether thrust of vessel against fingertips
is bounding (4+); full increased, strong (3+); expected (2+); barely palpable,
diminished (1+); or absent, not palpable (0).
g. After palpating a regular pulse, look at watch second hand and begin to
count rate. Count the first beat after the second hand hits the number on the
dial, count as 1, then, 2.
h. If pulse is regular, count rate for 30 seconds and multiply total by 2.
i. If pulse is irregular, count rate for a full 60 seconds, Assess frequency and
pattern of irregularity.
j. When pulse is irregular, compare radial pulses bilaterally.
5. Radial pulse:
a. Patient’s privacy and draw curtain.
b. Assist patient to supine or sitting position.
c. Locate anatomical landmarks to identify point of maximal impulse (PMI).
d. Place diaphragm of stethoscope in palm of hand for 5 to 10 seconds.
e. Place diaphragm of stethoscope over PMI at fifth intercostal space (ICS), at
left midclavicular line (MCL), and auscultate for normal S1 and S2 heart
sound (hear as “lub-dub”).
f. Hear S1 and S2 with regularity, use second hand of watch and begin to
count rate.
g. Count for a full 1 minute (60 seconds).
h. Replace patient’s gown and return to comfortable position.
i. Perform hand hygiene.
Nursing Skill: Vital signs-Measuring Respiration (R)
Preparation
Environment • Ensure good lighting, privacy and warmth
Nurse • Wash hands
Client • Position: sitting or lying
Equipment • Watch with second hand or digital display
• Alcohol swab
• Pen and vital sign flow sheet
Procedure
1. Identify patient using at least two identifiers.
2. Perform hand hygiene.
3. Determine need to assess patient’s respirations.
4. Patient’s privacy and draw curtain.
5. Be sure that patient’s chest is visible. If necessary, move bed linen or gown.
6. Place patient’s arm in relaxed position across abdomen or lower chest, or place
your hand directly over patient’s upper abdomen.
7. Observe complete respiratory cycle (one inspiration and one expiration).
8. After observing a cycle, look at second hand of watch and begin to count rate.
When sweep hand hits number on dial, begin time frame, counting one with first
full respiratory cycle.
9. If rhythm is regular, count number of respirations in 30 seconds and multiply by 2.
If rhythm is irregular, count for 1 full minute.
10. Note depth of respirations by observing degree of chest wall movement while
counting rate. Assess depth by palpating chest wall excursion or auscultating
posterior thorax after the nurse has counted rate. Describe depth as shallow,
normal, or deep.
11. Note rhythm of ventilator cycle. Normal breathing is regular and uninterrupted.
Do not confuse sighing with abnormal rhythm.
12. Replace bed linen and patient’s gown.
13. Discuss findings with patient.
14. Perform hand hygiene.
Evaluation
1. Compare respiration rate with patient’s previous baseline and usual rate,
rhythm, and depth.
2. Correlate respiratory rate, depth, and rhythm with data obtained from pulse
oximetry and ABG measurements if available.
Nursing Skill: Vital signs-Measuring Blood Pressure (BP)
Preparation
Environment • Ensure good lighting, privacy and warmth
Nurse • Wash hands
Client • Position: sitting or lying
Equipment • Aneroid Sphygmomanometer / Electronic blood pressure
machine
Stethoscope
BP cuff of appropriate size for patient’s extremity
Alcohol swab
Pen and vital sign flow sheet
Hygiene items
Upper or lower extremity
Procedure
1. Identify patient using at least two identifiers.
2. Perform hand hygiene.
3. With patient sitting or lying, position patient’s forearm at heart level with palm
turned up. If sitting, instruct patient to keep feet flat on floor without legs
crossed. If supine, patient should not have legs crossed. If the patient cannot be
placed in the prone position, position patient supine with knee slightly bent.
4. Expose extremity fully by removing constricting clothing. Cuff may be placed
over a sleeve of thin clothing as long as stethoscope rests on the skin.
5. Palpate brachial artery (arm) or popliteal artery (leg). With cuff fully deflated,
apply bladder of cuff above artery by centering arrows marked on cuff over
artery.
6. Position manometer gauge vertically at eye level.
7. Palpate brachial or popliteal pulse. Palpate artery distal to cuff with fingertips
of non-dominant hand while inflating cuff rapidly to pressure 30mm Hg above
point at which pulse disappears. Slowly deflate cuff and note point when pulse
reappears. Deflate cuff fully and wait 30 seconds.
8. Place stethoscope earpieces in ears and be sure that sound are clear, not
muffled.
9. Palate artery and place bell or diaphragm chest piece of stethoscope over it. Do
not allow chest piece to touch cuff or clothing.
10. Close valve of pressure bulb clockwise until tight. Quickly inflate cuff to 30
mm Hg above patient’s systolic blood pressure (SBP).
11. Slowly release pressure bulb valve and allow manometer needle to fall at rate
of 2 to 3 mm Hg/sec.
12. Note point on manometer when you hear first clear sound. The sound will
slowly increase in intensity.
13. Continue to deflate cuff gradually, noting point at which sound disappears in
adults. Not pressure to nearest 2 mm Hg. Listen for 20 to 30 mm Hg after last
sound and allow remaining air to escape quickly.
14. Remove cuff from patient’s arm or leg.
15. Help patient return to comfortable position and cover upper arm or leg if
previously clothed.
16. Discuss findings with patient.
17. Clean earpieces and diaphragm of stethoscope with alcohol swab as needed.
Evaluation
1. Compare BP reading with patient’s previous baseline and usual BP for
patient’s age.
2. Record BP and site assessed on vital sign flow sheet.
Nursing Skill: Vital signs-Measuring Automatic Blood Pressure (BP)
Procedure
1. Identify patient using at least two identifiers.
2. Perform hand hygiene.
3. Assess need to measure BP and determine patient’s baseline BP.
4. Determine appropriateness of using electronic BP measurement.
5. Perform hand hygiene. Inspect condition of extremities to determine best site for
cuff placement.
6. Collect and bring appropriate equipment to patient’s bedside. Select appropriate
cuff size for patient extremity and appropriate cuff for machine. Electronic BP
cuff and machine must be matched by manufacturer and are not interchangeable.
7. Assist patient to comfortable position, either lying or sitting. Plug device into
electric outlet and place it near patient, ensuring that connector hose between cuff
and machine reaches.
8. Locate on/off switch and turn on machine to enable device to self-test computer
systems.
9. Remove constricting clothing to ensure proper cuff application.
10.Prepare BP cuff by manually squeezing all the air out of the cuff and connecting it
to connector hose.
11.Wrap flattened cuff snugly around extremity, verifying that only one finger can fit
between cuff and patient’s skin. Make sure that “artery” arrow marked on outside
of cuff is placed correctly.
12.Verify that connector hose between cuff and machine is not kinked. Kinking
prevents proper inflation and deflation of cuff.
13.The first BP measurement pumps cuff to a peak pressure of approximately 180
mm Hg. After this pressure is reached, the machine begins a deflation sequence
that determines the BP. The first reading determines peak pressure inflation for
additional measurements.
14.When deflation is complete, digital display provides most recent values and flash
time in minutes that has elapsed since the measurement occurred.
15.Perform hand hygiene.
Nursing Skill: Vital signs-Measuring Oxygen saturation (Pulse Oximetry)
Preparation
Environment • Ensure good lighting, privacy and warmth
Nurse • Wash hands
Client • Position: sitting or lying
Equipment • Oximetry
Acetone or nail polish remove if needed for fingertip
sensor
Pen, vital sign flow sheet
Procedure
1. Identify patient using at least two identifiers.
2. Perform hand hygiene.
3. When using finger as monitoring site, consider removing any fingernail polish
with acetone or polish remover.
4. The sensors involving finger, toe, or ear, a pulse oximeter contains a photoelectric
sensor with two LEDs of differing wavelengths that measures the SpO2 level.
5. SpO2 level is between 95% and 100%.
6. Perform hand hygiene.