Vital Signs

Preparation

!. Verifies patient's name and

introduce self to patient
#. Informs patient of the procedure
and its importance
$. Assess the health condition of your
patient, site most appropriate in
taking vital signs, and factors that
might alter vitals signs
%. Assembles all the articles and
equipments and brings to bedside
&. Perform hand hygiene
'. Provide for privacy
(. Puts patient in an appropriate
position

Procedure

Temperature

!. Clean the thermometer from bulb

to stem and discard cotton ball
with alcohol
#. Wait for the thermometer to
calibrate
$. Place the thermometer at the site
 most appropriate
%. Wait the appropriate amount of
time
&. Remove the thermometer
'. Clean the thermometer from stem
to bulb
(. Read the temperature
I. Document the temperature in the
client record sheet

Radial Pulse

!. Position the arm with palm facing

up
#. Locate the radial pulse
$. Count the radial pulse for 60
seconds
%. Assess the pulse rhythm and
volume

Respiratory Rate

!. Observe the rise and fall of the

patient's chest by putting a hand
against the patient's chest to feel
the chest movement with
breathing
#. Counts the respiratory rate for 60
seconds. One cycle of inhalation
and exhalation is counted as one
respiration
$. Observes the respiration for depth,
 rhythm, and character of
respiration
%. Document the pulse rate, rhythm
and volume together with the
respiratory rate, depth and rhythm
and character on the client's
record sheet

Blood Pressure

!. Position the client appropriately.

Both feet should be flat on the
floor
#. Position elbow slightly flexed with
palm of hand facing up and the
forearm supported at heart level
$. Expose the upper arm
%. Wraps the deflated cuff evenly
around the upper arm
&. Locate the brachial artery
'. Apply the center of the bladder
directly over the artery with the
lower border of the cuff
approximately 2.5 cm (1 inch)
above the antecubital space
(. If this is the client's initial
examination, perform a preliminary
palpatory determination of systolic
pressure
I. Palpates the brachial artery with
the fingertips
Q. Close the valve on the bulb
!Y. Pump up the cuff until you no
longer feel the brachial pulse. Note
the pressure on the
sphygmomanometer at which
pulse is no longer felt.
!!. Release the pressure completely in
the cuff, and wait 1-2 minutes
before taking further
measurements.
!#. Positions the stethoscope
appropriately
!$. Cleanse the earpieces with
antiseptic wipe
!%. Inserts the ear attachment of the
stethoscope in the ear so that they
tilt slightly forward and that the
stethoscope hangs freely from the
ears to the diaphragm
!&. Place the bell side of the
stethoscope directly over the
brachial pulse
!'. Holds the diaphragm with the
thumb and index fingers
!(. Pump up the cuff until the
sphygmomanometer is 30 mmHg
above the point where the brachial
pulse is disappeared from the
usual BP of the client
!I. Release the valve on the cuff
carefully so that the pressure
decreases at the rate of 2-3 mmHg
per second
!Q. As the pressure falls, identify the
manometer reading at Korotkoff
phases I, IV, and V
#Y. If this is the client's initial
examination, repeat the procedure
on the client's other arm
#!. Document findings on the client's
record sheet

After Care

!. Clean and reassemble materials

before returning
#. Discard receptacle appropriately

Documentation

!. Explain to the client the result of

vital signs taking
#. Record findings on the TPR sheet