In this Chapter
- Pulse Measurement
- Respiration Measurement
- Blood Pressure Measurement
- Blood Pressure Log
- Blood Pressure Measurement (Digital) Procedure
- Blood Pressure Measurement (Digital) Skills Checklist
- Oral Digital or Tympanic Temperature Measurement Skills Checklist
- Radial Pulse & Respiration Count Skills Checklist
- Pulse Oximetry Measurement - RN/LPN only
Vital signs are the traditional signs of life. Vital signs include temperature, pulse, respiration, and blood pressure. It is important to accurately take and record vital signs.
Temperature is the measure of body heat. The body produces heat during such processes as the oxidation of food. Respiration, perspiration, and excretion release body heat. Direct measurement of the temperature indicates if the balance between heat produced and heat lost is being maintained.
An elevated oral temperature above 100.4° F or an axillary (under the arm) temperature of 99° F may be one of the first signs of an infectious disease. Call the parent/guardian to come and take the student home and provide the parent with a Illness Notice.
- Rectal temperatures should never be taken in the schools.
- Glass thermometers are not to be used in the schools.
If an electronic, digital, a tympanic membrane sensor (ear) instrument or temporal scanner is used, follow the instructions accompanying the thermometer.
Always use disposable plastic sheaths with digital thermometers and disposable probe covers with an electronic and tympanic thermometer.
Refer to the Temperature Measurement Skills Checklist for temperature measurement procedure.
Measurement of Pulse
The pulse rate indicates the number of times the heart beats in one minute and is a measure of how well the circulatory system is functioning. When you feel a pulse, you are feeling the pressure of the blood against the artery wall as the heart contracts and then relaxes. The radial pulse is one of the easiest to find. The radial artery is located on the thumb side of the wrist. Use the tip of your first two fingers to take a radial pulse. At around age 2, the rate ranges from 70 to 110 beats/minute. With adolescence, the rate varies between 55 and 90 beats/minute and remains so throughout adulthood. See Radial Pulse and Respiration Count Skills Checklist for the procedure for measuring pulse.
Measurement of Respiration
Respiration is the process of oxygen and carbon dioxide exchange in the lungs. Breathing in once (inspiration) and breathing out once (expiration) makes up one respiration cycle. It is important to be aware that respiratory patterns can change for a variety of reasons. Some reasons are more critical and require immediate attention, such as an asthma attack or the presence of foreign body airway obstruction. A young child may have a respiratory rate of 8 to 26 breaths/minute; an adult may have normal respiration of 12 to 20 breaths/minute. See Radial Pulse and Respiration Count Skills Checklist for the procedure for taking a pulse reading.
Measuring Blood Pressure
Blood pressure (BP) refers to the force of blood against the arterial walls when the heart contracts (systole) and when the heart is at rest (diastole). The standard unit for measuring BP is millimeters of mercury (mm Hg). The measurement indicates the height to which the BP will raise a column of mercury. The systolic pressure is the first reading. Normal systolic pressure readings are from 90 to 140 mm but will vary with age. The diastolic pressure is the second reading. Normal diastolic pressure readings are from 60 to 90 and vary with age. The blood pressure reading is written in a fraction with the systolic reading on the top of the line and the diastolic reading on the bottom under the line. A student’s normal blood pressure range is to be determined by the child’s licensed health care provider.
If a student’s blood pressure is to be taken during the school day, a Medication/Treatment Authorization Form signed by the physician and parent/guardian will be required. The form will list the day(s) of the week, time, parameters, and action to be taken when the blood pressure is outside the parameters. A Blood Pressure (Digital) Skills Checklist will need to be completed unless the procedure is performed by a licensed medical professional as designated in their job description. The parent/guardian shall provide the digital blood pressure monitor. Alert the school RN if a student needs blood pressure monitoring in the school.
Record the blood pressure measurement on the Blood Pressure Log.
Measuring Pulse Oximetry- RN/LPN Only
Pulse oximetry is a noninvasive test that measures the oxygen saturation level of the blood. The pulse oximeter is a small clip-like device that most commonly attaches to a finger. Pulse oximetry can rapidly detect even small changes in oxygen levels. These levels show how efficiently blood is carrying oxygen to the extremities furthest from the heart. The pulse oximeter will be able to tell you oxygen saturation levels and heart rate.