VITAL SIGNS AND

OTHER ASSESSMENT SURVEYS

PRACTICAL SESSION

OBJECTIVES

At the end of this session, each student should be able to: Identify common pulse sites.

Measure the pulse rate at carotid, brachial, and radial pulse sites.

Identify sites of temperature assessment, and the differences among them.

Change the temperature readings from Celsius to Fahrenheit and vice-versa.

Measure brachial blood pressure using mercury sphygmomanometer.

PULSE SITES

Peripheral pulses can be assessed by palpation.

How To Assess The Peripheral PulsesWith moderate pressure, apply (place) pads of the most distal aspects of the middle three fingers on the peripheral site location.

Note: Apical pulse is usually evaluated by auscultation.

صدغي

سباتعضدي

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فخذي

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Note: Apical pulse is usually evaluated by auscultation.

MEASURING ALERT ADULT CLIENT’S ORAL TEMPERATURE USING MERCURY THERMOMETER

See Accompanying Sheets.

SITES OF TEMPERATURE ASSESSMENT

Site Description Time to attain

Oral

Posterior sublingual pocket (under tongue)

No hot or cold drinks or smoking 20 minutes before to assess for the temperature.

The client must be awake and alert.

Not for small children (bite down)

(Mercury) Leave in place 2-3 minutes.

(Electronic)Leave in place until a sound is heard.

SITES OF TEMPERATURE ASSESSMENT

Site Description Time to attain

Axillary

Bulb in center of axilla

Lower arm position across chest

Not-invasive

Good for children.

Less accurate (no major blood vessels nearby)

(Mercury) Leave in place 5-10 minutes.

(Electronic)Leave in place until a sound is heard.

Measures 0.5 C lower than oral temperature.

SITES OF TEMPERATURE ASSESSMENT

Site Description Time to attain

Rectal

Left-side lying with right leg flexed, insert lubricated bulb

•Adult: 1 to 1.5 inch •Infant: 0.5 inch

Note: 1 inch = 2.54 cm

When unsafe or inaccurate by mouth (unconscious, disoriented or irrational)

Left side lying position – right leg flexedLeft leg straight

(Mercury) Leave in place 2-3 minutes.

(Electronic)Leave in place until a sound is heard.

Measures 0.5 C higher than oral temperature

SITES OF TEMPERATURE ASSESSMENT

Site Description Time to attain

Ear

Close to hypothalamus – sensitive to core temperature changes.

•Adult - Pull pinna up and back •Child – Pull pinna down and back

Rapid measurement

Easy to assess

Cerumen الصمغية األذن إفرازاتimpaction distorts reading

Otitis media األذن التهابcan distort reading المتوسطة

(Electronic)2-3 seconds

CHANGING TEMPERATURE READING

How to change Temperature Reading from Celsius to Fahrenheit:

How to change Temperature Reading from Fahrenheit to Celsius:

MEASURING (BRACHIAL) BLOOD PRESSURE (BP) USING MERCURY SPHYGMOMANOMETER

See Accompanying Sheets.