Baby Abdulhamid, a 2 years old toddler was admitted due to difficulty of breathing. He was cuddled by her mother. There is an evident use of accessory muscle when breathing the oxygen saturation is 80%, with Respiratory rate of 50 breaths per minute, shallow. The temperature is 40 degree Celsius, Pulse rate- 145 beats per min, BP of 70/30 mmHg; with sternal retractions, crackles were appreciated upon auscultation at the upper base of the lungs. The baby’s skin is pale and the lips are cyanotic. The mother claimed that 2 days prior to admission, the baby had fever which was observed as warm to touch, with reddish skin, irritable, with appetite, secretions coming out from the nose.

Is the presence of sternal retractions, use of accessory muscle and presence of crackles normal? Why? Support your answer?

What are the general nursing responsibilities in taking the vital signs of the patient?