* The first step is to gather equipments and check them if
They are functioning well. The rationale of it is for you to
not have trouble while taking the vital signs for your
client and of course to save time and energy.
* Second step is to introduce yourself and ask for the
client’s identity, “Hi my name is Kristine Garcia, I am an
olgc nursing student I am here to take your vital signs.
May I ask for your complete name and age?”
* Third step is to explain to the client of what you are
going to do, why is it necessary and how he or she can
participate. “So you are here for your vital signs taking,
this will last for only few minutes, all I want for you is to
relax so that the result of your vital signs will be correct
and accurate.”
* And next step, perform hand hygiene before touching
the client to avoid passing or contamination of
microorganisms.
* Then position the client appropriately and ask her if she
Is comfortable with her position now.
* Before assessing oral temperature, disinfect first the
Electronic thermometer from its tip down to its stem to
avoid passing microorganisms from one patient to
another.
* Instruct the client to open her mouth and place the tip
of the thermometer on either side of the frenulum.
* Instruct the client to close her mouth and wait the
Appropriate amount of time. Reading is complete as
indicated by tone.
*So the rationale of oral temperature is more accurate
than axillary temperature as oral is more an indication of
body’s temperature.
* When you hear the beep of the thermometer, remove
it from the client’s mouth and wipe the thermometer
with sanitized cotton or tissue from its stem down to its
tip in one direction only so that the microorganisms does
not go back and forth. And look at the result of her temp.
* Obtain the reading and record.
* For assessing the pulse of your client, position the
client’s forearm resting across the thigh or on the table,
with the palm of the hand facing downward or inward.
* Locate the radial pulse by placing two or three middle
Fingertips lightly over the pulse point.
* Palpate and count the pulse in 1 full minute while
noting for rhythm and volume as well.
* After 1 minute, stay your fingertips on the pulse point,
don’t remove it, just remember the beats per minute of
the pulse of your client, with your fingers still on the
client’s wrist it is like you are still taking the pulse of your
client but actually you’re already assessing the respiration.
* Simply and not should be obvious in observing for the
rise and fall of the chest of your client. As maybe your
client will be not comfortable with you looking at her
chest.
* Count the respiratory for 1 minute. An inhalation and an
exhalation counted as one respiration.
* Observe the depth, rhythm and character of
respirations.
*Record the findings on pulse and respiration.
* In assessing the blood pressure, assess for factors
affecting the blood pressure such as activity, stress,
pain, time the client has last smoked or ingestion of
caffeine.
* Determine the client’s previous blood pressure
reading. “Are you aware or do you know what is your
previous blood pressure reading?
* So if she doesn’t know, then perform the palpatory
method. So the rationale of this method is for the
estimation of systolic as you don’t know the previous
BP of the client.
*Wrap the cuff evenly around the upper arm with the
lower border of the cuff 1 inch above the antecubital
fossa. Then locate the brachial artery and ensure that
the center of the bladder is directly over the artery.
* In this method, palpate the brachial pulse with your
fingertips.
* After that, close the valve on the bulb.
* Pump up the cuff until you no longer feel the
brachial pulse.
* Note the pressure on the sphygmomanometer at
which is no longer felt.
*Release the pressure completely in the cuff and wait
1 to 2 minutes before making further assessments.
* After doing the palpatory method then proceed to
the auscultatory method. The rationale of this
method is that it can measure the correct and
accurate measurement of the BP of the patient.
*In this method obtain the stethoscope and cleanse
the earpieces, bell and the diaphragm with antiseptic
wipe or cotton.
* Insert the ear attachments of the stethoscope in
your ears so that they tilt slightly forward.
* Place the bell side of the amplifier of the
stethoscope (as it can hear the low pitches) over the
brachial pulse.
* Hold the diaphragm with any of your fingers except
for the thumb as it has its own pulse.
*Pump up the cuff until the sphygmomanometer
reads 30 mmHg above the estimated systolic of the
brachial pulse.
* Release the valve on the cuff carefully so that the
pressure decreases.
*Note the systolic and diastolic pressure reading at
Korotkoff sound.
* Deflate the cuff rapidly and completely.
* Remove the cuff and place the client in a
comfortable position.
*Inform the client of her vital signs.
* Plot the client’s vital signs on the graphic sheet.
*Determine any abnormal findings that requires
reporting.