Vital Signs

Question 1

How do you initiate the procedure?

Answer 1

1. collect equipment: sphyg, stethoscope, ox sat probe, thermometer + covers, watch with second hand, clinell wipes, alcohol handwash
2. introduce self by full name and post
3. identify patient - their name, DOb, first line address/hosp no. - check against records/wristband
4. explain procedure and gain consent - what the task is, what it involves, any complications, and is that okay? - ie will be measuring your ox sats, involves placing a probe on your finger which is painless and will only last a few seconds, that okay?
5. Ask pre assessment questions (see next)
6. ensure patients arm is positioned appropriately and supported

Question 2

What pre-assessment questions should be asked?

Answer 2

1. has the patient, within the last 30 mins: eaten a large meal, had a hot or cold drink, hot bath, smoked a cigarette, undertaken physical exercise or exerted themselves?
2. are they taking any blood pressure lowering tablets?
3. explain that these questions are asked as they can alter the measurements
4. are they wearing a hearing aid or have an ear infection?
5. ask about an arterio-venous fistula in the arm, any operations on the arms, armpits or breasts, any swelling or weakness in the arm?

Question 3

How do you measure a patients temperature?

Answer 3

1. place disposable cover on temp probe
2. gently pull back pinna and insert probe into ear canal
3. activate thermometer and wait
4. observe and note reading
5. dispose of disposable cover

Question 4

How do you measure a patients pulse rate?

Answer 4

1. locate the radial artery
2. palpate radial artery for pulse for 1 min (count for 15 x4, do resp rates for remaining time)
3. note rhythm - reg/irreg?
4. record findings on chart

Question 5

How do you measure a patients respiratory rate?

Answer 5

1. obtain whilst palpating radial artery pulse
2. look at shoulders, clothes shifting, stomach, can put hand on shoulder even
3. record findings

Question 6

How do you measure a patients blood pressure?

Answer 6

1. make sure patients comfortable, support arm at level of heart, check arm for contraindications to taking BP on that arm ie fistula, skin rash etc
2. place cuff 2cm above antecubital fossa
3. palpate radial artery and inflate cuff - estimated systolic=pulse disappear, deflate
4. place stethoscope over brachial artery, inflate cuff - 10-30mmHg above estimated, deflate slowly - systolic=pulse appears, diastolic=pulse disappears
5. remove cuff and record findings

Question 7

How do you measure a patients oxygen saturation?

Answer 7

1. make sure finger is well perfused
2. select finger that doesnt have nail polish or fake nail
3. clip on probe to finger
4. switch on machine
5. observe and record ox sats
6. note whether breathing room air or what oxygen flow/%

Question 8

How do you conclude the procedure?

Answer 8

1. remove all equipment
2. make sure patient is comfortable and doesnt have any questions
3. thank the patient

Question 9

How do you record the findings?

Answer 9

1. temp as a dotted line with arrows at either end to indicate the range
2. cross for temperature
3. write number of resps, AIR and SpO2