生命体征测量

Vital Signs Measurement

生命体征是体温、脉搏、呼吸、血压的总称。护理人员通过认真、仔细地观察生命体征，可以了解机体重要脏器功能活动情况，了解疾病的发生、发展及转归，为预防、诊断、治疗及护理提供依据。

Vital signs are the general term for body temperature, pulse, respiration, and blood pressure. By carefully observing vital signs, the caregiver can understand the function activities of important organs, understand the occurrence, development and outcome of the disease, and provide a basis for prevention, diagnosis, treatment and caring.

步骤1：工作准备

Step 1: Preparation

1、环境准备：室内清洁；温湿度适宜；关闭门窗

1. Preparation of environment: The indoor environment shall be clean, with proper temperature and humidity, and the doors and windows shall be closed

2、照护人员准备：着装整洁，仪容大方，七步洗手法洗净双手

2. Preparation of caregiver: The caregiver shall dress neatly with a generous appearance and wash hands with the seven-step hand washing method

3、照护对象准备：照护对象坐于桌前，神志清楚。

3. Preparation of the patient: The patient shall sit at the table, with consciousness.

4、操作用物：治疗盘、血压计、清洁纱布、消毒液棉球、记录单、小方盘（内盛体温计一支）、弯盘（测后体温计）、护士表

4. Materials used in operation: Treatment plate, sphygmomanometer, cleaning gauze, disinfectant cotton ball, record sheets, small square plate (including a thermometer), bent plate (including a post-measurement thermometer) and caring form

步骤2：评估与沟通

Step 2: Assessment and Communication

5、询问30分钟前有无进食冷热饮、有无做过剧烈运动、有无洗过热水澡、有无喝茶吸烟；如有以上情况，应休息30分钟后再测量。

5. Ask the patient if he/she ate hot or cold drinks, exercised strenuously, bathed in hot water, and smoked or drank tea 30 min ago; if so, rest for 30 min before measurement.

6、同照护对象解释测量体温的目的，取得配合；

6. The caregiver shall explain the purpose of body temperature measurement to the patient and obtain cooperation;

步骤3：测量体温

Step 3: Measure Body Temperature

7、协助照护对象解开衣物，有汗应擦干腋下。

7. Assist the patient to untie his/her clothes, and wipe his/her armpits dry in case of sweating.

8、检查体温计，右手持体温计，将水银柱甩至35℃以下。双手配合将体温计水银端放于腋窝处。协助照护对象屈臂过胸夹紧。

8. Check the thermometer, hold the thermometer with your right hand and make the mercury column below 35°C by shaking. Place the mercury end of the thermometer in the armpit with both hands. Assist the patient in clamping the thermometer by flexing the arm over the chest.

9、计时，测量10min。

9. Start timing and measure for 10 min.

10、测量时间到后，取出体温计，用消毒液棉球擦试。

10. When the time is up, take out the thermometer and wipe it with disinfectant cotton ball.

11、右手横拿体温计，慢慢转动，眼睛与水银刻度在同一水平线上，读数，告知测量结果。

11. Hold the thermometer with your right hand and rotate it slowly. Keep eyes level with the mercury scale, read and inform the measurement results.

12、将体温计甩至35℃以下，用75%医用酒精消毒30分钟。整理衣物，洗手，记录。

12. Make the thermometer below 35°C by shaking and disinfect it with 75% medical alcohol for 30 min. Sort clothes, wash hands and make records.

步骤4：测量脉搏

Step 4: Measure Pulse

13、照护人员以食指、中指、无名指的指腹按压在照护对象桡动脉处，数脉搏次数（节律整齐者，测量30秒，乘以2；脉搏异常者应测 1min）。

13. The caregiver presses the pulp of the index finger, middle finger, and ring finger against the radial artery of the patient and counts the pulse rate (for those with regular rhythm, measure for 30 seconds, multiply the pulse rate by 2; for those with abnormal pulse, measure for 1 min).

14、告知照护对象脉搏次数，并记录。

14. Inform the patient of the pulse rate and record.

步骤5：测量呼吸

Step 5: Measure Respiration Rate

15、照护人员将手放在照护对象的诊脉部位似诊脉状，观察照护对象胸部和腹部的起伏，数呼吸次数。

15. The caregiver puts his/her hand on the diagnosis pulse of the patient, observes the fluctuations of the chest and abdomen of the patient, and counts the respiratory rate.

16、告知患者呼吸次数，并记录。

16. Inform the patient of the respiratory rate and record.

步骤6：测量血压

Step 6: Measure Blood Pressure

17、被测者安坐在桌旁，保持舒适的状态，裸露手臂或仅穿贴身薄衣，避免衣物的挤压。

17. The patient shall sit at the table, keep a comfortable state, with bare arms or wearing thin clothes to avoid squeezing the arm by clothes.

13、将左臂穿入臂带，将臂带一端向外拉同时固定臂带位置。松紧以能塞进1-2个指头为准。空气管位于前臂内侧并与中指在同一条直线上。上臂肘关节内侧向上2-3cm处。

13. Insert the left arm into the armband, pull one end of the armband outward and fix the position of the armband. The tightness shall be based on the ability to insert 1-2 fingers. The air tube is located inside the forearm and in line with the middle finger. Keep it in 2-3 cm above the medial side of the upper arm elbow joint.

14、将下手臂平放在桌上，掌心向上，身体坐直，并使臂带中心与心脏（乳头）处于同一高度。

14. Place the lower arm flat on the table with the palm up, sit upright, and keep the center of the armband at the same height as the heart (nipple).

15、打开血压计开关，血压计会自动测量血压，测后把所测的收缩压/舒张压数值记录下来。

15. Turn on the sphygmomanometer, and the sphygmomanometer will automatically measure the blood pressure. After measurement, record the measured systolic/diastolic blood pressure values.

16、关闭血压计。

16. Turn off the sphygmomanometer.

17、生命体征操作速度限 15min 以内。

17. The vital signs shall be measured within 15 min.

体温测量的注意事项

Precautions for Body Temperature Measurement

1、避免改变体温活动：测量前半小时内要避免剧烈运动、进餐、饮用过冷或过热的水或饮料、洗澡。

1. Avoid activities for changing body temperature: Avoid strenuous exercise, eating, drinking supercold or superheated water or drinks, and taking a bath within 30 min before measurement.

2、腋下测温时需要将腋窝内的汗液擦干，并且保持干燥，使用水银体温计测温时，要用上臂夹紧体温计，时间为10分钟以上。

2. When measuring the temperature under the armpit, it is necessary to wipe the sweat in the armpit dry. If the temperature is measured using a mercury thermometer, the patient shall clamp the thermometer with the upper arm for more than 10 min.

3、甩体温计的操作范围在胸前，注意不要触及周围物品，以防破碎。

3. The thermometer shall be shaken in front of the chest, and be careful not to touch the surrounding objects to prevent breakage.

4、测量过程中告知照护对象如果发生体温计滑落或脱位应保持原体位不动，照护人员应耐心寻找，避免体温针破碎误伤照护对象。

4. The caregiver shall inform the patient needs to keep the thermometer in its original position if the thermometer slips or dislocates during the measurement, and look for it carefully to avoid accidental injury to the patient caused by the broken thermometer needle.

5、一旦发现体温计破碎水银外流，照护人员应立即摘下口罩、手套：用硬纸收集包裹按医疗垃圾处理。

5. Once the thermometer is found to be broken and mercury leaks out, the caregiver shall immediately take off the mask and gloves, collect the package with hard paper and dispose of it as medical waste.

血压测量的注意事项

Precautions for Blood Pressure Measurement

1、测量血压前最好休息15到30分钟，保持情绪稳定，避免做剧烈的运动、抽烟、喝茶等。

1. It is best to rest for 15 - 30 min before measuring blood pressure to maintain emotional stability and avoid strenuous exercise, smoking and drinking tea.

2、测量时要注意测量一侧手臂的位置，要与心脏处于同一个水平位，松紧度要适度。

2. During measurement, pay attention to the position of the arm under measurement, which shall be in the same horizontal position as the heart, and the tightness of the armband shall be proper.

3、测量过程中嘱咐照护对象保持自然姿势。身体不要移动，不要说话。保持安静状态。

3. Instruct the patient to keep a natural posture during the measurement. Do not move his/her body or speak. Keep quiet.