Vital signs procedure

Vital Signs Include:

1. Blood Pressure

2. Temperature

3. Pulse (Heart Rate)

4. Respiratory Rate

5. Oxygen Saturation (Pulse Oximetry)

6. Pain (Optional but commonly assessed)

1. BLOOD PRESSURE

Definition:

The force of blood pushing against the artery walls.

Normal Range:

90/60 to 120/80 mmHg

Steps:

1. Ensure patient is relaxed, seated with back support, feet flat, legs uncrossed.

2. Use correct cuff size—cuff should encircle 80% of the upper arm.

3. Place cuff 1 inch above elbow over bare skin (avoid rolling tight sleeves).

4. Locate brachial artery and place stethoscope over it.

5. Inflate cuff to 180 mmHg, then deflate slowly.

6. Listen:

   • First sound = Systolic

   • Disappearance of sound = Diastolic

7. 
   

8. Remove cuff and document result.

Precautions:

• Avoid caffeine, smoking, or activity before taking BP.

• Never use wrist/finger devices unless no alternative.

• Do not use on an arm with IV, cast, or surgery.

Example:

Patient Sunita: BP 138/88 mmHg, sitting, right arm.

2. TEMPERATURE

Definition:

Measurement of internal body heat.

Normal Range:

97°F to 99°F (36.1°C to 37.2°C)

• Fever = >100.4°F (38°C)

• Hypothermia = <95°F (35°C)

  
  

Steps:

1. Ensure patient hasn’t eaten, drunk, or smoked in last 10 minutes.

2. Choose route

   • Oral (under tongue)

   • Axillary (armpit): 0.5°F lower than oral

   • Rectal: 0.5°F higher

3. 
   

4. Place thermometer, wait for beep or time out.

5. Remove and read.

6. Clean and store thermometer.

   
   

Precautions:

• Never force thermometer in mouth or rectum.

• Don’t use broken or old mercury thermometers.

Example:

Patient Ramesh: Temp 101.2°F, oral. Fever medication administered.

3. PULSE (Heart Rate)

Definition:

Number of heartbeats per minute.

Normal Range:

60–90 bpm (beats per minute)

• Tachycardia = >100 bpm

• Bradycardia = <60 bpm

Steps:

1. Locate radial pulse (thumb side of wrist).

2. Use index and middle finger (not thumb).

3. Count for 30 sec × 2 or full 60 sec if irregular.

4. Note rate, rhythm, and strength.

   
   

Precautions:

• Resting rate should be taken, not after exertion.

• Report fast/slow or irregular pulse.

  
  

Example:

Patient Priya: Pulse 110 bpm, regular. Post-exercise.

4. RESPIRATION RATE

Definition:

Number of breaths per minute.

Normal Range:

12–20 breaths/min

Steps:

1. Keep fingers on pulse to avoid alerting patient.

2. Count chest rises for 60 seconds.

3. Observe rhythm and depth.

   
   

Precautions:

• Don’t tell the patient; it may alter breathing.

• Monitor for shallow, irregular, or labored breathing.

Example:

Patient Raj: RR 26/min, rapid breathing noted post-surgery.

5. PULSE OXIMETRY (SpO₂)

Definition:

Non-invasive measurement of oxygen saturation in blood.

Normal Range:

95–100%

• 91–94%: Monitor closely

• Below 90%: Seek medical help

• Below 85%: Brain affected

Steps:

1. Place probe on clean, dry fingertip.

2. Wait till reading stabilizes.

3. Record reading and check for movement or errors.

   
   

Precautions:

• Avoid use over nail polish or cold fingers.

• Remove dirt, avoid bright lighting, minimize patient movement.

Example:

Patient Meera: SpO₂ 88%, oxygen started at 2 L/min.

6. PAIN (Optional but important)

Definition:

Patient’s self-report of discomfort.

Assessment:

• Use numeric scale (0–10)

• Ask about location, quality, duration, and intensity.

Example:

Patient: “Pain is 6/10, sharp, right lower abdomen.”

8. Symptoms to Report Immediately:

• BP >180/120 or <90/60

• Temp >103°F

• Pulse <50 or >130 bpm

• RR <10 or >30/min

• SpO₂ <90%

• Chest pain, confusion, blue lips/skin

Visual Guide & Video Links:

• Pulse Points Image:

• Vital Signs Assessment Video:

  RegisteredNurseRN – Full Vital Signs Check