Vitals

Question 1

Definition

Answer 1

Obtaining & recording of the vital signs (temperature, pulse, and respiration) accurately and safely, recognizing deviation from normal.

Question 2

Puposes

Answer 2

1. To determine the course of illness, this serves as a guide in meeting the needs of the patient.
2. To afford an opportunity to observe the general condition of the patient.
3. To aid the physician in making diagnosis and planning patient’s care.

Question 3

General Considerations

Answer 3

• Be sure the patient has rested before taking vital signs
• Remember the frequency of taking the TPR depends upon the condition of the patient and the policy of the agency.
• Inform the physician or head nurse promptly for any significant change in the vital signs
• Explain the procedure to the patient so that he/she feels at ease.

Question 4

Temperature Definition

Answer 4

The balance between heat produced and heat loss.

Question 5

Temp Special Considerations

Answer 5

• Stay with the patient while thermometer is in place.
• Provide individual thermometer for each patient.
• Use only rectal thermometer, for rectal temperature.
• When patient has diarrhea, do not take temperature by rectum.
• Using the axillary method, see to it that the axilla is dry and the bulb of the thermometer is within the hollow of the axilla.
• Remember that rectal temperature is taken to check the anal passage/opening of the newborn baby.

Question 6

Axillary Temp Equipment

Answer 6

Digital axillary thermometer
Cotton balls
Paper tissue wipes
Soap solution/Petroleum jelly

Question 7

Temp Step 1

Answer 7

Rinse, dry, turn on, and read the digital thermometer.

Question 8

Temp Step 2 + Rationale

Answer 8

Dry it with a cotton ball or a soft paper tissue from the bulb toward the fingers with a firm twisting motion.

• A cotton ball with the aid of friction helps in drying the thermometer.

Question 9

Temp Step 3 + Rationale

Answer 9

Friction may produce heat thereby resulting to inaccuracy of recording of the body temperature.

Question 10

Temp Step 4

Answer 10

Place the digital thermometer into the axilla with the bulb directed toward the patient’s head, bring the patient’s arm down close to his body and place his forearm over his chests.

Question 11

Temp Step 4 Rationale

Answer 11

When the bulb rests against the superficial blood vessels in the axilla and the skin surfaces are brought together to reduce the amount of air surrounding the bulb a reasonable reliable measurement of body temperature can be obtained.

Question 12

Temp Step 6

Answer 12

Remove the digital thermometer and wipe from the finger tips to the bulb in a firm twisting motion.

Question 13

Temp Step 6 Rationale

Answer 13

Cleansing from an area where there are few organisms to an area where there are numerous organisms minimizes the spread of organisms to cleaner areas.
Friction helps to loosen matter from a surface.

Question 14

Step 7 + Rationale

Answer 14

Read the thermometer and then, wash it with soap and water for waterproof digital thermometer or else wipe it with alcohol swab.

• Washing/alcohol swabs remove organisms.

Question 15

Step 8 + rationale

Answer 15

Dispose the tissue used in wiping the thermometer in a receptacle used for soiled items.

• Confining contaminated articles helps prevent the spread of pathogens.

Question 16

Step 9 + rationale

Answer 16

Return the clean digital thermometer to its container

• Ensure safety of the digital thermometer.