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Procedures

When to Assess

Temperature Assessment

  1. Determine whether the patient has consumed any hot or cold food or fluid or has smoked within the last 30 minutes.
  2. Wash hands.
  3. Don gloves.
  4. Electronic temperature devices are appropriate for all temperature assessments. Follow the manufacturer’s instructions for use of equipment.
  5. Position the patient appropriately:
    • Axillary: Expose axilla.
    • Rectal: Lateral or prone position.
  6. Slide the cover over the temperature probe until it snaps into place.
  7. Insert the covered thermometer probe:
    • Oral:
      • Place probe at the base of the tongue to the right or left of the frenulum.
      • Have patient close lips around the probe.
    • Axillary:
      • Use patting motion to dry axilla with a towel.
      • Place probe in axilla and hold patient’s arm across the chest or to the side to secure the probe.
    • Rectal: Don gloves and lubricate probe; separate buttocks and ask the patient to take a deep breath; insert the probe past the outer rectal sphincter (adult:1.5 inches; young child: about 0.5 inch).
    • Tympanic:
      • Some devices must be turned on and used only after the "ready" signal appears or a "beep" sounds.
      • Insert probe snugly into the external canal of the ear toward the tympanic membrane (straighten the ear canal of the adult by pulling the pinna of the ear up and back and of the child under age 3 years by pulling the pinna down and back).
  8. Listen for the sound indicating that the temperature measurement is complete.
  9. Remove the thermometer and determine the reading. (A reading is provided in 2 to 60 seconds depending on the device used.)
  10. Discard the probe cover.
  11. Replace the temperature unit in its holder to recharge the battery.
  12. Document the temperature and the route by which it was assessed.

Norms

Pulse Assessment

  1. Wash hands.
  2. Place two to three fingertips lightly over a pulse point.
    Never use the thumb because it has a pulse.
    FOR DOPPLER PULSE ASSESSMENT
    • Place a small amount of gel over a pulse point or directly onto the transducer tip.
    • Turn the volume control until static is audible.
    • Slide the transducer tip over the pulse area until "shooshing" is heard.
  3. If the pulse is regular, count for 30 seconds and multiply by 2. If it is irregular, count for 1 minute.
  4. Assess the pulse rhythm and volume.
  5. Document the pulse rate, rhythm, and volume.

Example: Radial pulse full &bounding. Rate 90 with regular rhythm.

NOTE: For more information on pulse evaluation and location of pulse points, see assessment section.

Respirations Assessment

  1. Observe the rise and fall of the chest. Ensure that the patient is resting quietly and is unaware that the respiratory rate is being assessed.
  2. Count respiratory rate for 30 seconds and multiply by 2 if respirations are regular; if they are irregular, count for a full minute.
  3. Observe rhythm and character of respirations.
  4. Document the respiratory rate, depth, rhythm, and character.

Example: RR:16/min, normal depth, unlabored, regular rhythm.

Norms

Respiratory Assessment Vocabulary

RATE

VOLUME

RHYTHM

CHARACTER

Blood Pressure Assessment

  1. Make sure the patient has not smoked or ingested caffeine within 30 minutes prior to measurement.
  2. Position the patient in a comfortable position with the arm slightly flexed and the palm of the hand facing up with the forearm supported at the level of the heart.
  3. Expose the upper arm.
  4. Make sure the bladder of the cuff encircles at least ½ of the arm and that the width of the cuff covers ½ to 2/3 of the upper arm.
  5. Apply the center of the cuff bladder directly over the medial aspect of the arm about 1 inch above the antecubital space. (When applied, the cuff must not constrict circulation. Any slack between the cuff and the arm results in an invalid reading.)
  6. Palpate the brachial artery with your fingertips, close the valve on the pump (turn it clockwise), and inflate the cuff until you feel the pulsation disappear (note the reading on the gauge; this is the palpated systolic pressure).
  7. Insert the tips of the stethoscope into your ears.
  8. Palpate the brachial artery with your fingertips and place the stethoscope gently over the artery.
  9. Close the valve on the pump.
  10. Inflate the cuff to at least 30 mm Hg above the palpated systolic pressure.
  11. Slowly release the pressure in the cuff, noting the:
    • Point at which sound is first heard
    • Point at which sound becomes muffled (not always heard)
    • Point at which sound completely ceases

NOTE: There is controversy regarding which of the last two "points" should be recorded as the diastolic reading. The best method of recording validates all sounds that are heard.

Example:142/96/82 or 142/82, if no muffling of sound is heard

Wait 1 minute before taking further blood pressure measurements in the same arm.

  1. Remove the cuff from the patient’s arm.
  2. Document as in step 11, noting the patient’s position during assessment and the extremity in which the pressure was assessed. (Readings can vary markedly with position change and extremity.)

Example: BP—130/76, right arm, supine position.

Norms

Pediatric Adaptation

Electronic equipment such as the Doppler or Dynamap is most accurate for BP assessment in the infant or young child. If no such equipment is available and no sounds are audible through the stethoscope, the palpation method of assessment is used. (It is common to hear sounds down to "0" mm Hg in infants when a standard stethoscope is used.)

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*Covered by Vaccine Injury Compensation Program. For information on how to file a claim call 800-338-2382. Please also visit www.hrsa.gov/osp/vicp. To file a claim for vaccine injury contact: U.S. Court of Federal Claims, 717 Madison Place, N.W., Washington D.C. 20005, 202-219-9657.

This schedule indicates the recommended age groups for routine administration of currently licensed vaccines for person 19 years of age and older. Licensed combination vaccines may be used whenever any components of the combination are indicated and the vaccine's other components are not contraindicated. Providers should consult the manufacturers' package inserts for detailed recommendations.

Report all clinically significant post-vaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on filing a VAERS report are available by calling 800-822-7967 or from the VAERS website at www.vaers.org.

For additional information about the vaccines listed above and contraindications for immunization, visit the National Immunization Program Website at www.cdc.gov/nip/ or call the National Immunization Hotline at 800-232-2522 (English) or 800-232-0233 (Spanish).

  1. Tetanus and diphtheria (Td) ––Adults including pregnant women with uncertain histories of a complete primary vaccination series should receive a primary series of Td. A primary series for adults is 3 doses: the first 2 doses given at least 4 weeks apart and the 3rd dose, 6—12 months after the second. Administer 1 dose if the person had received the primary series and the last vaccination was 10 years ago or longer. Consult MMWR 1991; 40(RR-10):1 21 for administering Td as prophylaxis in wound management. The ACP Task Force on Adult Immunization supports a second option for Td use in adults: a single Td booster at age 50 years for persons who have completed the full pediatric series, including the teenage/young adult booster. Guide for Adult Immunization 3rd ed. ACP 1994:20.
  2. Influenza vaccination ––Medical indications: chronic disorders of the cardiovascular or pulmonary system including asthma; chronic metabolic diseases including diabetes mellitus, renal dysfunction, hemoglobinopathies, or immunosuppression (including immunosuppression caused by medications or by human immunodeficiency virus [HIV]), requiring regular medical follow-up or hospitalization during the preceding year; women who will be in the second or third trimester of pregnancy during the influenza season. Occupational indications: health-care workers. Other indications: residents of nursing homes and other long-term care facilities; persons likely to transmit influenza to persons at high risk (in-home care givers to persons with medical indications, household contacts and out-of-home caregivers of children birth to 23 months of age, or children with asthma or other indicator conditions for influenza vaccination, household members and care givers of elderly and adults with high-risk conditions); and anyone who wishes to be vaccinated. For healthy persons aged 5-49 years without high-risk conditions, either the inactivated vaccine or the intranasally administered influenza vaccine (Flumist) may be given.
    MMWR 2003;52(RR-8):1-36; MMWR 2003;53(RR-13):1-8.
  3. Pneumococcal polysaccharide vaccination ––Medical indications: chronic disorders of the pulmonary system (excluding asthma), cardiovascular diseases, diabetes mellitus, chronic liver diseases including liver disease as a result of alcohol abuse (e.g., cirrhosis), chronic renal failure or nephrotic syndrome, functional or anatomic asplenia (e.g., sickle cell disease of splenectomy), immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection, leukemia, lymphoma, multiple myeloma. Hodgkin disease, generalized malignancy, organ or bone marrow transplantation), chemotherapy with alkylating agents, antimetabolites, or long-term systemic corticosteroids. Geographic/other indications: Alaskan natives and certain American Indian populations. Other indications: residents of nursing homes and other long-term care facilities.
    MMWR 1997;46(RR-8):1-24.
  4. Revaccination with pneumococcal polysaccharide vaccine ––One-time revaccination after 5 years for persons with chronic renal failure or nephrotic syndrome, functional or anatomic asplenia (e.g., sickle cell disease or splenectomy), immunosuppressive conditions (e.g., congenital immunodeficiency. HIV infection, leukemia, lymphoma, multiple myeloma, Hodgkin's disease, generalized malignancy, organ or bone marrow transplantation), chemotherapy with alkylating agents, antimetabolites, or long-term systemic corticosteroids. For persons 65 years and older, one-time revaccination if they were vaccinated 5 or more years previously and were aged less than 65 years at the time of primary vaccination. MMWR 1997; 46(RR-8):1-24.
  5. Hepatitis B vaccination ––Medical indications: hemodialysis patients, patients who receive clotting-factor concentrates. Occupational indications: health-care workers and public-safety workers who have exposure to blood in the workplace, persons in training in schools of medicine, dentistry, nursing, laboratory technology, and other allied health professions. Behavioral indications: injecting drug users, persons with more than one sex partner in the previous 6 months, persons with a recently acquired sexually transmitted disease (STD), all clients in STD clinics, men who have sex with men. Other indications: household contacts and sex partners of persons with chronic HBV infection, clients and staff of institutions for the developmentally disabled, international travelers who will be in countries with high or intermediate prevalence of chronic HBV infection for more than 6 months, inmates of correctional facilities. MMWR 1991;40(RR-13):1-19. (www.cdc.gov/travel/diseases/hbv.htm)
  6. Hepatitis A vaccination ––For the combined HepA-HepB vaccine use 3 doses at 0, 1, 6 months. Medical indications: persons with clotting-factor disorders or chronic liver disease. Behavioral indications: men who have sex with men, users of injecting and noninjecting illegal drugs. Occupational indications: persons working with HAV-infected primates or with HAV in a research laboratory setting. Other indications: persons traveling to or working in countries that have high or intermediate endemicity of hepatitis A.
    MMWR 1999; 48(RR-12):1-37. (www.cdc.gov/travel/diseases.hbv.htm)
  7. Measles, Mumps, Rubella vaccination (MMR) ––Measles component: adults born before 1957 may be considered immune to measles. Adults born in or after 1957 should receive at least one dose of MMR unless they have a medical contraindication, documentation of at least 1 dose or other acceptable evidence of immunity. A 2nd dose of MMR is recommended for adults who:
    • Were recently exposed to measles or in an outbreak setting.
    • Were previously vaccinated with killed measles vaccine
    • Were vaccinated with an unknown vaccine between 1963 and 1967
    • Are students in post-secondary educational institutions
    • Work in health care facilities
    • Plan to travel internationally

    Mumps component:1 dose of MMR should be adequate for protection. Rubella component: give I dose of MMR to women whose rubella vaccination history is unreliable and counsel women to avoid becoming pregnant for 4 weeks after vaccination. For women of child-bearing age, regardless of birth year, routinely determine rubella immunity and counsel women regarding congenital rubella syndrome. Do not vaccinate pregnant women or those planning to become pregnant in the next 4 weeks. If pregnant and susceptible, vaccinate as early in postpartum period as possible.
    MMWR 1998; 47(RR-8):1-57; MMWR 2001; 50:1117.
  8. Varicella vaccination ––Recommended for all persons who do not have reliable clinical history of varicella infection, or serological evidence of varicella zoster virus (VZV) infection who may be at high risk for exposure or transmission. This includes health-care workers and family contacts of immunocompromised persons, those who live or work in environments where transmission is likely (e.g., teachers of young children, day care employees, and residents and staff members in institutional settings), persons who live or work in environments where VZV transmission can occur (e.g., college students, inmates and staff members of correctional institutions, and military personnel), adolescents and adults living in households with children, women who are not pregnant but who may become pregnant in the future, international travelers who are not immune to infection. Note: Greater than 95% of U.S. born adults are immune to VZV. Do not vaccinate pregnant women or those planning to become pregnant in the next 4 weeks. If pregnant and susceptible, vaccinate as early in postpartum period as possible.
    MMWR 1996; 45(RR-11):1-36; MMWR 1999; 48(RR-6):1-5.
  9. Meningococcal vaccine (quadrivalent polysaccharide for serogroups A,C,Y, and W-135) ––Consider vaccination for persons with medical indications: adults with terminal complement component deficiencies, with anatomic or functional asplenia. Other indications: travelers to countries in which disease is hyperendemic or epidemic ("meningitis belt" of sub-Saharan Africa, Mecca, Saudi Arabia for Hajj). Revaccination at 3-5 years may be indicated for persons at high risk for infection (e.g., persons residing in areas in which disease is epidemic). Counsel college freshmen, especially those who live in dormitories, regarding meningococcal disease and the vaccine so that they can make an educated decision about receiving the vaccination. MMWR 2000; 49(RR-7):1-20.

Note: The AAFP recommends that colleges should take the lead in providing education about meningococcal infection and vaccination and offer it to those who are interested. Physicians need not initiate discussion of the meningococcal quadravalent polysaccharide vaccine as part of routine medical care.