Policy & Procedure
Shiawassee County Medical Care Facility
Approved by Social Services Board
Date: 12/31/99
Revised: 7/13/10
Temperature, Pulse and Respirations
Basic Responsibility: Licensed Nurse and Nursing Assistant
If performed by individuals other than those listed in Basic Responsibility, check all that apply.
Procedure Performed by: CENA LPN RN
Purpose
1. To measure body temperature.
2. To determine the quality and rate of pulse and respirations.
3. To assess change in resident’s condition.
General Resident Rights Guidelines
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If resident is in his/her room, knock on the door, wait for a response and identify yourself.
Identify resident and explain reason for procedure.
Explain benefits of the procedure to the resident.
Explain safety measures of the procedure to the resident.
Explain the adverse effects and/or complications of the procedure to the resident.
Place call light within reach and instruct resident to call for assistance, if needed.
Screen and drape resident for maximum privacy.
Include resident’s family and surrogate health care decision-makers in care planning when
possible.
General Guidelines for Assessment may include, but are not limited to:
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Rate, rhythm, depth and quality of respirations.
Pain or discomfort.
Congestion.
Respiratory distress.
Change in level of consciousness.
Dehydration and fluid balance.
Rate, rhythm and quality of pulse.
Diaphoresis.
Skin moisture and temperature.
Allergies.
General Infection Control Guidelines
1. Observe (standard) universal precautions or other infection control standards as approved
by appropriate facility committee.
2. Wash your hands before and after all procedures. Wear gloves when appropriate.
3. Gather equipment, maintaining sterility and cleanliness.
4. Clean and dry skin well before and after procedure.
5. Apply preventive measures to maintain skin integrity, if necessary.
6. Dispose of disposable equipment appropriately.
7. Thoroughly clean all equipment used and return to appropriate storage area.
8. Dispose of soiled linen appropriately.
Equipment
1. Temporal Artery Thermometer.
2. Sterile probes.
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Policy & Procedure
Procedure
Temporal Artery Thermometer
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Take temporal thermometer to bedside.
Explain Procedure to resident.
Place probe flush on thermometer
With probe flush on the center of the forehead.
Depress red button, keep depressed
Slowly slide probe midline across forehead to the hair line
Lift probe from forehead and touch on the neck just behind the ear lobe.
Release the button
Record temperature
If temperature is unusually high or low, check with another thermometer.
Pulse Measurement
1. Radial pulse:
a. Position resident’s arm at the level of the heart with palm down.
b. Palpate the radial artery.
c. Count pulse rate for 60 seconds; note rhythm.
2. Apical pulse:
a. Drape resident to expose left side of chest.
b. Place stethoscope over the apex of the heart- this should be below the left breast.
c. Count the apical pulse for 60 seconds; note rhythm.
Respirations
1. Place stethoscope on resident’s chest.
2. Count respirations for 60 seconds.
3. Listen for breath sounds, note rhythm and volume of respirations.
4. One respiration includes one inspiration and one expiration.
Possible Related Minimum Data Set Triggers
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Delirium.
ADL function/rehabilitation potential.
Psychosocial well-being.
Nutritional status.
Dehydration and fluid balance.
General Documentation Guidelines
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Date, time (or shift), as appropriate.
Other Documentation May Include:
Date, time, temperature (if other than oral, indicate by circled “A” for axillary and circled “R”
for rectal).
Pulse rate, rhythm (regularity) and quality.
Respiratory rate, rhythm (regularity), depth and amount of effort required.
Signature and title.
General Resident Care Plan Documentation Guidelines
Problem
 Identify the appropriate problem under which to list vital sign measurement as an approach.
 Consider listing possible risks and complications.
Goal
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List MEASURABLE goal(s) to be accomplished.
List target date.
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Policy & Procedure
Approaches
 List responsible discipline for each approach.
 List instructions unique to this resident.
 List necessary monitoring and observation of the resident’s respiratory and cardiac
function.
 List observation for change in measurement.
 List frequency of vital sign measurement.
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