North Glasgow University Hospitals NHS Division
Clinical Procedure Manual
Section A – General Procedure Guidelines
1.15
Vital Signs
a)
Body Temperature
Objectives
By the end of this section you should know:
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How to prepare the patient for temperature recording;
How to collect and prepare the equipment;
How to measure and record body temperature at the axilla, aural and rectum;
Range of body temperatures;
Different types of clinical thermometer.
Indications for recording body temperature
Body temperature is measured using a calibrated clinical thermometer or electronic probe. Sites for
recording body temperature include the axilla, rectum and ear. For each patient, the site for temperature
measurement should be consistent. The normal range of body temperature is between 36°C and 37.5°C.
The upper and lower limits for survival are not known exactly but are thought to be in the region of 45°C
and 25°C respectively. Recording of body temperature may be required:
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To establish a baseline reading;
To monitor fluctuations in temperature;
To monitor signs of incompatibility during blood transfusion;
To monitor the temperature of patients being treated for infection;
To monitor the temperature of patients recovering from hypothermia.
Types of Thermometer
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Oral/axillary thermometer – calibrated between 35°C & 43.5°C;
Rectal thermometer – calibrated between 35°C & 43.5°C;
Low reading thermometer – calibrated between 25°C & 40°C;
Disposable thermometer – these have rapid reacting heat sensitive chemicals so that a recording can
be made in 60 seconds;
Electronic thermometers – these have probes, which must be protected by disposable covers before
being placed at the recording site. Some probes are designed for axillary, rectal or aural temperature
recording. (Refer to manufacturer’s instructions)
Procedure
See manufacturer’s instruction for electronic thermometer.
Axilla
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Perform hand hygiene;
Explain procedure to patient;
Dry skin at the axilla by wiping with a tissue;
Shake the thermometer to return the mercury column to 35°C;
North Glasgow University Hospitals NHS Division
Clinical Procedure Manual
Section A – General Procedure Guidelines
1.15
Vital Signs cont.
Procedure cont …
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Clean thermometer by wiping it with an alcohol wipe and allow 30 seconds to dry;
Place the bulb of the thermometer under the patient’s axilla;
Ask patient to hold arm across their chest to hold thermometer in position;
Leave thermometer in position for a minimum of 4 minutes;
Remove thermometer;
Clean thermometer with alcohol wipe in a twisting motion;
Perform hand hygiene;
Record and document temperature. Report abnormalities.
Rectum
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Perform hand hygiene;
Maintain patient’s privacy;
Lie patient on side with knees bent;
Prepare thermometer as for axillary temperature;
Apply a disposable sleeve;
Lubricate the protected end of the thermometer;
Insert the thermometer into the patient’s anus for 2 – 4 cm;
Leave thermometer in position for at least 4 minutes;
Remove thermometer;
Dispose of protective sleeve;
Clean thermometer using an alcohol wipe in a twisting motion;
Perform hand hygiene;
Record and document temperature. Report abnormalities.
REFERENCES:
1. Anon. (2001) Essential skills: a monthly collectable guide to core clinical procedures. Observation
and monitoring. 13. Recording temperature. Nursing Standard 15(38): insert-12.
2. Cronin, K. and Wallis, M. (2000) Temperature taking in the ICU: which route is best? Australian
Critical Care 13(2): 59-64.
3. Jackson, N. (1994) Vital signs. in Perry, A. G. and Potter, P. A. Clinical Nursing Skills and
Techniques St Louis: Mosby. Ch.11 pp 196-239.
4. Mallett, J. and Dougherty, L (2000) Observations. Manual of Clinical Nursing Procedures Oxford:
Blackwell Science. Ch.28 pp 402-432.
5. Torrance, C. and Semple, M. (1998) Practical procedures for nurses. Recording temperature - 2... no.
6.2. Nursing Times 94(3): insert-27.
6. Torrance, C. and Semple, M. (1998) Practical procedures for nurses. Recording temperature - 1... no.
6.1. Nursing Times 94(2): insert-20.
North Glasgow University Hospitals NHS Division
Clinical Procedure Manual
Section A – General Procedure Guidelines
1.15
Vital Signs cont.
b)
Pulse
Objectives
By the end of this section you should be able to:
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Locate, measure and record the radial pulse;
Locate the major pulse points in the body.
Related information
Normal range varies according to age, with an normal adult pulse rate of 60 – 100 beats per minute.
Sites of major pulse points (see Diagram)
Temporal
Carotid
Brachial
Radial
Femoral
Popliteal
Posterial tibial
Dorsalis pedis
Equipment
Watch with a second hand
Procedure
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Perform hand hygiene;
Explain the procedure to the patient;
Locate radial artery, place second and third fingers along it and press gently;
Count pulse for 60 seconds;
Perform hand hygiene;
Document pulse recording, comparing past recordings and report any irregularities or abnormalities.
REFERENCES:
1. Jackson, N. (1994) Vital signs. in Perry, A. G. and Potter, P. A. Clinical Nursing Skills and
Techniques St Louis: Mosby. Ch.11 pp 196-239.
2. Mallett, J. and Dougherty, L. (2000) Observations. Manual of Clinical Nursing Procedures Oxford:
Blackwell Science. Ch.28 pp 402-432.
North Glasgow University Hospitals NHS Division
Clinical Procedure Manual
Section A – General Procedure Guidelines
1.15
Vital Signs cont.
c)
Respiration
Objectives
By the end of this section you should be able to assess, measure and record the patient’s respiratory rate.
Related information
Rate
Normal respiratory rates vary according to age. The accepted normal range is:
Healthy adults
Adolescents
Children
Infants
14 – 20 per minute
18 – 22 per minute
22 – 28 per minute
30 or more per minute
Depth
The depth of respiration is approximately the same for each person and can be described as normal,
shallow or deep.
Pattern
A normal breathing pattern is effortless, evenly paced, regular and automatic. Abnormal patterns may be
described as:
Dyspnoea
Difficult, laboured breathing. The nostrils are dilated and the chest wall and shoulder girdle are raised
and lowered in an exaggerated fashion.
Cheyne – Stokes
There is a gradual increase in the depth of respiration followed by a gradual decrease and then a period of
no respiration (apnoea). This syndrome is associated with terminal illness.
Kussmaul’s respirations
There is an increased rate and depth of respiration with panting and long grunting expirations. This
syndrome may be associated with lobar pneumonia.
Stertorous respirations
These are noisy respirations caused by excessive secretions in the trachea or bronchi. It may also be a sign
of partial airway obstruction.
Stridor
A harsh, high-pitched noise on inspiration caused by laryngeal obstruction.
Indications for assessing respiration
Respiration is the exchange of oxygen and carbon dioxide between the cells of the body and the
environment through rhythmic expansion and deflation of the lungs. Each respiration consists of an
inhalation, exhalation and the pause which follows. The respiratory rate may be assessed to:
North Glasgow University Hospitals NHS Division
Clinical Procedure Manual
Section A – General Procedure Guidelines
1.15
Vital Signs cont.
Indications for assessing respiration cont …
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Establish a baseline respiratory rate;
Monitor the patient’s condition during and following investigative procedures and treatments (eg.
Aspiration of pleural cavity, pleural biopsy, peritoneal dialysis);
Estimate the degree of dysfunction and the effect of treatment.
Equipment
Watch with a second hand
Procedure
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Ensure patient is relaxed and if possible unaware of the counting process;
Count the respiratory rate and observe the depth and pattern of respiration;
Count the number of respirations for at least 30 seconds;
Document the results and report abnormal findings.
REFERENCES:
1. Cox, C. L. and McGrath, A. (1999) Respiratory assessment in critical care units. Intensive & Critical
Care Nursing 15(4): 226-234.
2. Endacott, R. and Jenks, C. (1997) RCN: continuing education. Respiratory assessment in A&E.
Emergency Nurse 5(4): 31-38.
3. Finesilver, C. (1992) Respiratory assessment. RN 55(2): 22-30.
4. Fritz, D. J. (1997) Fine tune your physical assessment of the lungs and respiratory system. Home
Care Provider 2(6): 299-305.
5. Jackson, N. (1994) Vital signs. in Perry, A. G. and Potter, P. A. Clinical Nursing Skills and
Techniques St Louis: Mosby. Ch.11 pp 196-239.
6. Mallett, J. and Dougherty, L. (2000) Observations. Manual of Clinical Nursing Procedures Oxford:
Blackwell Science. Ch.28 pp 402-432.
7. Marchese, T. W. and Diamond, F. B. (1995) Primary care for women: comprehensive assessment of
the respiratory system. Journal of Nurse-Midwifery 40(2): 150-162.
8. Owen, A. (1998) Respiratory assessment revisited. Nursing 28(4): 48-49.
9. Stevens, S. and Becker, K. L. (1988) How to perform picture-perfect respiratory assessment. Nursing
18(1): 57-63.
10. Torrance, C. and Elley, K. (1997) Practical procedures for nurses. Respiration: technique and
observation - 2... no. 4.2. Nursing Times 93(44): insert-Nov.
11. Torrance, C. and Elley, K. (1997) Practical procedures for nurses. Respiration: technique and
observation - 1... no. 4.1. Nursing Times 93(43): insert-28.
12. Woodrow, P. (2002) Assessing respiratory function in older people. Nursing Older People 14(3): 2728.
North Glasgow University Hospitals NHS Division
Clinical Procedure Manual
Section A – General Procedure Guidelines
1.15
Vital Signs cont.
d)
Apical – radial pulses
Objectives
By the end of this section you should be able to locate, measure and record the apical – radial pulses.
Indications for measuring the apical – radial pulses
The rate at the apex of the heart and the radial pulse rate are counted simultaneously to determine if there
is a deficit in the rate. It may be assessed to estimate the degree of dysfunction and effect of treatment for
patients with:
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Cardiac impairment;
Patients receiving medication to improve cardiac function;
Patients who have vascular disease.
Equipment
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Watch with a seconds hand
Stethoscope
Procedure
N.B.
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2 nurses are required to carry out this procedure
Perform hand hygiene;
Explain the procedure to the patient;
Assist the patient into a comfortable position with access to chest wall;
Clean stethoscope with alcohol wipe, allowing 30 seconds to dry;
Nurse 1 places the stethoscope over the apex of the patient’s heart (at the 5th intercostal space and
12cm to the left of the midline);
Nurse 2 locates the radial pulse;
Ensure the watch is visible to both nurses;
Both nurses count the heart rate simultaneously for 1 minute;
Clean stethoscope with alcohol wipe;
Perform hand hygiene;
Document the results on the patient’s chart and report any abnormal findings.
REFERENCES:
1. Hwu, Y., Coates, V. E., and Lin, F. (2000) A study of the effectiveness of different measuring times
and counting methods of human radial pulse rates. Journal of Clinical Nursing 9(1): 146-152.
2. Jackson, N. (1994) Vital signs. in Perry, A. G. and Potter, P. A. Clinical Nursing Skills and
Techniques St Louis: Mosby. Ch.11 pp 196-239.
3. Jevon, P., Ewens, B., and Lowe, R. (2000) Practical procedures for nurses. Measuring apex and radial
pulse. Nursing Times 96(50): 43-44.
North Glasgow University Hospitals NHS Division
Clinical Procedure Manual
Section A – General Procedure Guidelines
1.15
Vital Signs cont.
e)
Blood Pressure
Objectives
By the end of this section you should know how to:
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Prepare the patient for the procedure;
Collect and prepare the necessary equipment;
Assess, measure and record blood pressure.
Related information
Blood pressure is the force extended by the blood as it flows through the blood vessels. It is arterial blood
pressure which is normally recorded. Blood pressure increases with age, weight gain, stress & anxiety.
Normal range is considered to be from 100/60 to 140/90 mm Hg. The term hypotension is used when the
blood pressure is lower than the normal range. The term hypertension is used when the systolic or
diastolic blood pressure is elevated above the normal range. The correct size of cuff must be used to
ensure accurate recordings.
Indications for recording blood pressure
Blood pressure may be recorded to:
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Aid in the diagnosis of disease;
Aid in the assessment of the cardiovascular system;
Assess the cardiovascular system pre and post operatively.
Equipment
Sphygmomanometer
Stethoscope
Alcohol wipes
N.B.
Increasingly electronic sphygmomanometers are being used to monitor blood pressure. The
nurse should refer to manufacturer’s instructions regarding the use of these machines.
Procedure
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Perform hand hygiene;
Explain the procedure to the patient and gain consent;
Prepare equipment including clean stethoscope with alcohol wipe;
Assist the patient into a comfortable position – usually sitting (unless otherwise specified) with the
patient’s arm resting on a firm surface;
Roll up patient’s sleeve, avoiding restrictive tightly rolled up clothing as this may lead to inaccurate
recordings;
Position the sphygnomamometer at approximately heart height, ensuring the mercury level is at zero;
Apply the blood pressure cuff approximately 3-5cm above where the brachial artery can be palpated;
Connect the cuff tubing to the manometer tubing and close the valve to the inflation ball;
North Glasgow University Hospitals NHS Division
Clinical Procedure Manual
Section A – General Procedure Guidelines
1.15
Vital Signs cont.
Procedure cont …
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Palpate the radial pulse and inflate the cuff until the pulse disappears. Inflate a further 20mmHg.
Release the valve slowly and note when the radial pulse returns. The mercury is read at the top of the
meniscus. Allow all the air to escape from the cuff;
Palpate the brachial pulse;
Place the stethoscope over the brachial pulse site and inflate the cuff 20mmHg above the previous
reading;
Release the valve slowly;
When the first pulse is heard, the level of mercury should be noted – this is the systolic blood
pressure;
Continue to deflate the cuff and the pulse will change to a muffled sound until it finally disappears;
The mercury level should be noted at this point – this is the diastolic pulse;
Completely deflate the cuff and remove it from the patient’s arm;
Clean stethoscope with alcohol wipe;
Perform hand hygiene;
Document blood pressure recordings on the patient’s chart and report any abnormalities.
REFERENCES:
1. Abbott, D., Campbell, N., Carruthers-Czyzewski, P., Chockalingam, A., David, M., Dunkley, G.,
Ellis, E., Fodor, J. G., McKay, D., and Ramsden, V. R. (1994) Guidelines for measurement of blood
pressure, follow-up, and lifestyle counselling. Canadian Journal of Public Health 85(Suppl 2): S29S35.
2. Foster-Fitzpatrick, L., Ortiz, A., Sibilano, H., Marcantonio, R., and Braun, L. T. (1999) Brief report.
The effects of crossed leg on blood pressure measurement. Nursing Research 48(2): 105-108.
3. Jackson, N. (1994) Vital signs. in Perry, A. G. and Potter, P. A. Clinical Nursing Skills and
Techniques St Louis: Mosby. Ch.11 pp 196-239.
4. Mallett, J. and Dougherty, L. (2000) Observations. Manual of Clinical Nursing Procedures Oxford:
Blackwell Science. Ch.28 pp 402-432.
North Glasgow University Hospitals NHS Division
Clinical Procedure Manual
Section A – General Procedure Guidelines
1.15
Vital Signs cont.
f)
Neurological Examination
Objectives
By the end of this section you should be able to:
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Prepare and support the patient for a neurological examination;
Collect and prepare the equipment;
Assess, measure and record level of consciousness and decide if GCS monitoring is required.
Indications for neurological examination
Determining a normal level of consciousness indicates adequate perfusion of blood to the brain. In
patients whose level of consciousness is abnormal this may indicate a primary neurological disease
process or a disease process primarily outwith the neurological system.
Assessing level of consciousness can be carried out in two ways, either by simple assessment or Glasgow
Coma Scale Monitoring. Changes in patient level of consciousness give early indication of patient
deterioration.
Indication for assessing level of consciousness:
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To establish a baseline
To aid in diagnosis/monitor of neurological disease
To aid in the assessment and treatment during the course of a neurological disease
To aid in the detection of life threatening situations and those which need medical intervention.
Equipment
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Pencil torch
Procedure
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Perform hand hygiene;
Collect and prepare the equipment;
Explain procedure to the patient and gain consent and co-operation;
Ensure the patient has privacy;
Observe the patient throughout this activity (see below);
Ensure the patient is left feeling as comfortable as possible;
Dispose of the equipment as per Division policy;
Perform hand hygiene;
Document procedure, monitor after-effects and report abnormal findings immediately.
North Glasgow University Hospitals NHS Division
Clinical Procedure Manual
Section A – General Procedure Guidelines
1.15
Vital Signs cont.
Simple Assessment
Is the patient alert and orientated to time and place?
Is the patient confused?
Does the patient respond to verbal stimuli?
Does the patient respond to painful stimuli?
Does the patient make no response and remain unconscious despite repeated attempts at painful stimuli?
Glasgow Coma Scale
Glasgow Coma Scale should be used for all patients:
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Admitted with suspected or proven head injury;
who on assessing are found to only respond to painful stimuli;
where there is no response.
If patient is unresponsive, or only responding to pain, formal GCS scoring should be started. Coma is
defined as GCS of 8 or below; if GCS is recorded as below 15, medical staff should be informed.
The GCS describes level of consciousness by assessing a patient’s ability to perform three activities:
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eye opening
motor response
verbal response
Eye opening
4
spontaneous
3
voice
2
pain
1
none
Verbal
5
4
3
2
1
orientated
confused
inappropriate word
incomprehensible sound
nil
Motor
6
5
4
3
2
1
obeys
localised
normal flexion
abnormal
extension
nil
If a GCS falls by 2 or more points, inform medical staff.
REFERENCES:
1. Anon. (2000) Essential skills: a monthly collectable guide to core clinical skills. 6. Observation and
monitoring: assessment of level of consciousness. Nursing Standard 15(7): insert-7.
2. Harrahill, M. (1996) Trauma notebook. Glasgow Coma Scale: a quick review. Journal of Emergency
Nursing 22(1): 81-83.
3. LeJeune, G. M. and Howard-Fain, T. (2002) Nursing assessment and management of patients with
head injuries. Dimensions of Critical Care Nursing 21(6): 226-231.
4. Lower, J. (2002) Facing neuro assessment fearlessly. Nursing 32(2): 58-65.
5. Mallett, J and Dougherty, L (2000) Neurological observations. in Manual of Clinical Nursing
Procedures 5th edn. Oxford. Blackwell Science. Ch.26 pp 376-384.
6. O'Hanlon-Nichols, T. (1999) Neurologic assessment. American Journal of Nursing 99(6): 44-50.
7. Shah, S. (1999) Neurological assessment. Nursing Standard 13(22): 49-56.
8. Sullivan, J. (1990) Neurologic assessment. Nursing Clinics of North America 25(4): 795-809.
North Glasgow University Hospitals NHS Division
Clinical Procedure Manual
Section A – General Procedure Guidelines
1.15
Vital Signs cont.
REFERENCES:
9. UKCC (1992) Code of Professional Conduct. United Kingdom Central Council for Nursing,
Midwifery and Health Visiting: London.
10. UKCC (1996) Guidelines for Professional Practice. United Kingdom Central Council for Nursing,
Midwifery and Health Visiting: London.
11. Woodward, S. Practical procedures for nurses. Neurological observations - 2: pupil response... no.
5.2, Nursing Times 93(46):insert 18, 1997.
12. Wooten, C. The trauma top 10. The top 10 ways to detect deteriorating central neurological status,
Journal of Trauma Nursing 3(1): 25-27, 1996.
North Glasgow University Hospitals NHS Division
Clinical Procedure Manual
Section A – General Procedure Guidelines
1.15
Vital Signs cont.
g)
Central Venous Pressure Recordings
Objectives
By the end of this section you should be able to:
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Prepare the patient for a recording of central venous pressure;
Collect and prepare the equipment;
Monitor and record the central venous pressure.
Indications for central venous pressure recording
The CVP recording is the measurement of the pressure of the right atrium of the heart and is measured in
cmH2O. Sixty percent of the circulating blood volume is held within the venous system, the CVP being
the product of blood volume and venous tone. The range of normal is between 3-10 cmH2O. The
frequency of measuring the central venous pressure will be dependent on the patient’s condition.
Equipment
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A central venous catheter, intravenous fluid and associated lines in situ
A venous pressure manometer
A spirit level
Procedure
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Prepare hand hygiene;
Collect and prepare the equipment;
Explain the procedure to the patient and gain consent;
Ensure the patient has privacy;
Assist the patient into the correct position, preferably lying flat;
Position the manometer, which should be on a pole to allow easy reading. Ensure there are no strains
on line or catheter.
Observe the patient throughout this activity;
Assess the baseline. This is level with the patient’s right atrium, where the tip of the catheter is lying.
Assist the medical practitioner as requested. The medical practitioner will note the level at an
imaginary 90° angle between the sternal notch and the midline form the axilla. In some areas, it is the
practice to use the sternal notch as a proxy for this point. With the patient’s consent, this can be
marked on the skin to ensure consistency;
Read the baseline. A spirit level is used to record the level on the manometer gauge that corresponds
to the baseline level, which may be marked on the side of the patient’s chest, to ensure accuracy;
Turn off all other infusions;
Flush the line;
Turn the tap on the three-way stopcock away from the patient and towards the infusion fluid, to allow
the manometer tub to refill with fluid;
North Glasgow University Hospitals NHS Division
Clinical Procedure Manual
Section A – General Procedure Guidelines
1.15
Vital Signs cont.
Procedure cont …
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Turn the tap towards the patient; to establish a free flow of fluid between the manometer and the
catheter. The fluid in the manometer tube will tall to a level that corresponds to the pressure in the
right atrium or superior vena cava. The fluid fluctuates in relation to the patient’s respiration once it
falls to the level for recording;
Read the level of the lower fluctuation on the manometer gauge once the fluid in the tube is
maintaining a steady level with a fluctuation of 0.2 – 1.0 cm.
Subtract the baseline reading figure from this figure to give the measurement of CVP.
Turn the tap on the stopcock back to the correct position.
Ensure the patient is left feeling as comfortable as possible;
Dispose of the equipment as per Division policy;
Perform hand hygiene;
Document the procedure, monitor after-effects and report abnormal findings immediately.
REFERENCES:
1. Mallett, J. and Dougherty, L. (2000) Vascular access devices. in Manual of Clinical Nursing
Procedures. 5th edn. Oxford: Blackwell Science. Ch.44 pp 630-635.
2. Christensen, B. (1992) Hemodynamic monitoring: what it tells you and what it doesn't... part 1.
Journal of Post Anesthesia Nursing 7(5): 330-337.
3. Haynes, S. (1991) Central venous pressure monitoring. Professional Nurse 6(12): 727-729.
4. McDermott, M. (1996) Central venous pressure. Nursing Standard 9(35): Cardiol-30.