* The first step is to gather equipments and check them if
They are functioning well for you to not have trouble
while taking the vital signs for your client.
* 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 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. Oral
temperature is more accurate than axillary temperature
as oral is more an indication of body’s temperature.
* Instruct the client to close her mouth and wait the
Appropriate amount of time. Reading is complete as
indicated by tone.
* When you hear the beep of the thermometer, remove
the it from the client’s mouth and wipe the thermometer
with sanitized cotton or tissue for it can be used also by
other patients.
* 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 and squarely 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.
As maybe your client will be not comfortable with you
looking at her chest.
* Simply and not should be obvious in observing for the
rise and fall of the chest of your client.
* 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. “Maam Cynthia, today or this past few days
are you experiencing Stress, pain, anxiety, or any bad ?
And when is the last time you ingest caffeine, like
coffee?”
* 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. 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.
* On the first beat that you will feel after opening the
valve will be the estimated systolic.
* 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 auscultarory method. 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
site.
* 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 at the rate of 2 to 3 mmHg per
second.
*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.