Definitions:

 Vital signs
o These include the temperature, pulse, respiration and blood pressure that
gives indication of the state of health of an individual.
 Temperature
o It is the difference between heat produced and heat lost by the body and
is measured using a thermometer.
 Pulse
o It is the rhythmical throbbing from a wave of blood passing through an
artery as the heart contracts.
o Pulse rate is the number of rhythmical throbbing or heartbeats per minute.
 Respiration
o Is the exchange of oxygen and carbon dioxide between the atmosphere
and body cells and is initiated by the act of breathing.
o One respiration is a cycle of inspiration and expiration.
 Blood pressure
o It is the lateral force exerted by the blood on the arterial walls

Purpose:

The purpose of taking vital signs is to establish a baseline for the healthcare provider as
it represents the state of functioning of the person. The pulse rate is obtain to estimate
the quality of the heart’s action per minute while the respiratory rate is to also obtain to
have an estimate of the patient’s respiratory status. The blood pressure is also
important as it aids in the diagnosis and to observe the changes in a patient’s condition.

Procedures:

A. Temperature (Axilla)
Equipment:

 A tray containing:
o thermometer
o jar of cotton balls in water
o jar with cut tissue paper
o waste receptacle
 Wristwatch with second hand
 Jot down notebook and pen
Procedure
1. Read the Chart.
2. Wash Hands.
3. Determine any previous activity
that would interfere with the
accuracy of temperature
measurement.
4. Bring the equipment needed to the
bedside of the patient and explain
the procedure.
5. Clean the thermometer by using a
alcohol swap in a firm twist motion
from bulb to stem and dry it by
using a dry cotton ball with the
same motion from bulb to stem.
6. Expose arm and shoulder by
removing one sleeve of client’s
gown. Avoid exposing client.
7. Pat the client’s axilla dry with a
towel or tissue then place the
thermometer into the center of the
axilla. Bring the client’s arm down
close to his body and place his
forearm over his chest.
8. Leave the thermometer in place
until signal is heard.
9. Remove the thermometer, Assist
the client to put back the sleeve
then inform the client about his/her
temperature.
10. Clean the thermometer using an
alcohol swab in a twisting motion
from stem to bulb and dry it using a
Rationale
1. To obtain data
2. Deter the spread of
microorganism.
3. Activities done may alter the
accuracy of the body temperature
4. When the client knows what is to
be done, he/she will cooperate
better
5. It would be easier to place the
thermometer in the desired area
6. To promote cleanliness and
hygiene
7. Deepest area of the axilla provides
the most accurate temperature
measurement
8. Allowing sufficient time for the
axillary tissue to meet the
thermometer bulb results in a
reasonably accurate measurement
of body temperature
9. Informing the cline allows her to be
aware of her current temperature
10. To deter the spread of
microorganism
 cotton in the same direction and
the same motion.
11. Write the result in your jot down
notebook.
12. Wash your hand.
13. Write the recorded result on the
patient’s Graphic chart and master
list.
B. Radial Pulse
Equipment:
 Wristwatch with second hand
 Alcohol swab
 Stethoscope
 Jot down notebook
Procedure
1. Have the client rest his arm along
side his body with the wrist
extended and the palm of the hand
downward or place arm on top of
the client’s upper abdomen.
2. Place your first, second, and third
finger along the radial artery and
press gently across the radius and
rest the thumb on the back of the
client’s wrist .
3. Apply enough pressure so that the
client’s pulsating artery can be felt.
4. Using a watch with a second hand
count the number of pulsations felt
in one full minute.
5. If the pulse rate is below or above
the normal range, Repeat the
counting to determine accurately
11. To avoid the occurrence of
forgetting the result.
12. To prohibit the spread of
microorganism.
Rationale
1. This position places the radial
artery on the inner aspect of the
client’s wrist. The nurse’s finger’s
rest conveniently on the artery with
thumb in a position to the outer
aspect of the client’s wrist.
2. The fingertips which are sensitive
to touch will feel the pulsation of
the client’s radial artery. If the
thumb is used to palpate the
client’s pulse, the nurse may fell
her own.
3. Moderate pressure allows the
nurse to feel the superficial artery
expand and contract with each
heartbeat.
4. Sufficient time is necessary to
detect irregularities or other
defects.
5. When the pulse is abnormal,
 the rate and quality. longer counting and palpation are
necessary to identify most .
6. Record the pulse rate on the jot
down notebook. 6. To avoid forgetting the actual
result.
7. Refer any unusual to the clinical
instructor and head nurse
7. To provide proper care
immediately.
8. Record in the client’s char and
master list

9. Write the result in your jot down

notebook.

C. Cardiac pulse
Equipment:

 Wristwatch with second hand

 Jot down notebook
Procedure Rationale
1. Position the client in a supine 1. making the patient comfortable and
position. it lessens the risk for alteration of
beat.

2. Raise client’s gown to expose 2. allows access to client’s chest for

sternum and left side of the chest or proper positioning.
do not expose.
3. Placing a cold diaphragm against
3. Warm the diaphragm of the the skin may startle the client and
stethoscope with your hand before momentarily increase the heart rate
applying it to the client’s chest.
4. This gives the loudest and most
4. Place the diaphragm of the distinctive sound of the heart.
stethoscope over the apex of the
heart located at the 5th intercostal
space, left midclavicular line. Then,
Insert the earpiece in your ears. 5. A full minute count is important for
an accurate assessment. A longer
5. Move the diaphragm to the site of duration helps determine pulse
the loudest beat. Count the beat for rhythm and quality
60 seconds and note their rhythm
and rate. Also evaluate the intensity
of heart sounds.

6. Remove the stethoscope and make
the patient comfortable.
7. Record the result in the jot down
notebook.
8. Refer anything unusual to the
Clinical instructor or Head nurse
9. Record the result on the chart and
TPR master list.
D. Respiration
Equipment:
 Wristwatch with second hand
 Jot down notebook
Procedure
1. While the fingertips are still in place
after taking the pulse rate, observe
the patient’s respiration.
2. Note the rise and fall of the patient’s
chest with each inspiration and
expiration.
3. Count the number of respiration for
one full minute using a wristwatch
with a second hand.
4. If respirations are abnormal, repeat
the previous steps and observe the
characteristics of breathing.
5. Record the respiration rate on the
jot down notebook including the
abnormalities.
6. Refer to the CI for any unusualities.
6. In no instance, is the radial pulse
count greater than the apical pulse
count.
7. To avoid forgetting the accurate
result.
8. Referral of anything unusual in a
client enables the professional
nurse to respond immediately to the
needs or problem of the patient.
Rationale
1. This keeps the patient from
becoming conscious of his/her own
breathing which can alter his/her
usual rate.
2. This is to avoid wrong results of the
respiratory rate. One respiration is
composed of one cycle of
inspiration and expiration.
3. Sufficient time is necessary to
observe the respiratory rate.
4. This is to avoid discrepancies from
the previous respiratory rate.
5. Documentation allows comparison
of data and to have a proof of doing
the procedure.
6. Referral of anything unusual allows
immediate respond to the needs or

7. Record the respiratory rate in the
patient’s chart and TPR master list.
E. Blood pressure
Equipment:
 Stethoscope
 Sphygmomanometer with appropriate size of cuff
 Alcohol swab
 Jot down notebook and pen
Procedure
1. Ask the patient if he/she has not
smoked a cigarette or ingested
beverages containing caffeine
within 30 minutes.
2. Place the patient in a comfortable
position with the forearm supported
and the palm upwards.
3. Position yourself so that the
calibration can be read at an eye
level.
4. Position the cuff in place. It should
be centered over the brachial artery
with the two tubing on the surface of
the arm and the lower edge of the
cuff is at 2.5-5cm above the
antecubital fossa.
5. Wrap the cuff smoothly and snugly
around the arm and the end should
be secured.
6. Use the fingertips to locate a strong
pulsation on the antecubital space.
Then, place the bell or diaphragm
over the pulse.
problem of the patient.
7. Documentation allows comparison
of data from the previously taken
vital signs.
Rationale
1. Nicotin can cause vasoconstriction
in the blood vessels, thus resulting
to an increase blood pressure.
Caffeine is also a stimulant that
increases blood pressure.
2. The position allows accessibility of
the brachial artery and the
stethoscope can rest on it
conveniently.
3. This is to obtain an accurate
reading of the patient’s blood
pressure.
4. The pressure applied directly to the
artery will yield the most accurate
readings.
5. A twisted cuff and wrapping could
produce inaccurate reading. It could
also be uncomfortable for the
patient.
6. Accurate blood pressure is taken
when the stethoscope is directly
placed over the artery.
 7. Inflate the cuff to 30mmHg where 7. This will prevent missing the first
the pulsation disappears. tap sound.

8. Slowly deflate the cuff all the way to 8. The first sound is the systolic blood
zero. Take note of the first and the pressure and the last sound is the
last clear and loud sound. diastolic blood pressure.

9. Remove the cuff and make the 9. This allows patient to relax their arm
patient comfortable. after the constricting pressure.

10. Record the result on the jot down 10. Documentation allows comparison
notebook. of data and to have a proof of doing
the procedure.

11. Report to the CI for any unsualities.
12. Record the blood pressure on the
patient’s chart.
11. Referral of anything unusual allows
immediate respond to the needs or
problem of the patient.
12. Documentation allows comparison
of data from the previously taken
vital signs.

Additional information: Normal Values

Temperature(Axillary 35.6- 36.7⁰C

)
Radial Pulse Male: 70-80 beats per minute
Female: 80-90 beats per minute
Cardiac Rate Male: 70-80 beats per minute
Female: 80-90 beats per minute
Respiratory Rate 16-20 breathes per minute
Blood pressure 110/70-130-90

Sample Documentation:

Date Time Nurses Notes

8/4/20 7:00am Received lying on bed, awake with IVF of D53 NaCl
500 @ 80cc/hr infusing well at Right metacarpal vein
with level of 200cc.
8:00am VS checked and recorded; patient afebrile.
8:10am Health teachings rendered:
1. Encouraged to increase OFI and is provided with
calibrated glass.
 2. Encouraged to have small frequent feeding.
10:00am Bedside care done.
11:30am IVF checked and regulated.