Karl Angelo Montano BSN 3B

Denmar Prias
Michael Canton

Vital signs
Definition: Temperature pulse, respiration and blood pressure some indications of
the state of health of an individual. They represent interrelated
physiologic systems of the body.
Purpose: The purpose of recording vital signs is to establish a baseline on
admission to a hospital, clinic, professional office, or other encounter
with a health care provider.
Equipments used:

 Sphygmomanometer
 Stethoscope
 Thermometer

Procedures:

Temperature

- It is the difference between heat produced and heat lost by the body and is
measured through the use of a thermometer
A. Oral method
Equipment used:

- Thermometer
- CB in water
- Jar with cut tissue paper
- Waste receptacle
- Jot down notebook

1. Read the chart

2. Wash hands
3. Determine any previous activity that would interfere with accuracy of
temperature measurement
4. Identify the client and explain the procedure
5. Rinse it by using CB with water in a firm twisting motion from the bulb to the
stem and then dry using same motion using dry CB or clean soft tissues
6. Place disposable protective sheath over probe
7. Grasp top of the probe’s stem. Avoid placing pressure on the ejection button
 8. Place tip of thermometer under the client’s tongue and along the gumline to
the posterior sublingual pocket lateral to center of lower jaw and instruct him
to close his lips tightly
9. Thermometer will signal when a constant temperature registers
10. Remove the thermometer and wipe it at once with dry cb or sof tissue from
stem down to the bulb using firm twisting motion
11. Read measurement on digital display
12. Push ejection button to discard disposable sheath into receptacle and return
probe to storage
13. Inform client of temperature reading
14. Cleanse the thermometer from the stem to the bulb using CB with water, then
dry and return to the container
15. Dispose the used CB and tissue paper in the waste receptacle
16. Record the temperature in the jotdown notebook
17. Wash hands
18. Record the temperature on the masterlist sheet and graphic chart

B. Axillary method
Equipment used:

- Thermometer
- CB in water
- Jar with cut tissue paper
- Waste receptacle
- Jot down notebook

1. Follow steps 1,2,3, and 4 of oral temperature taking

2. Expose arm and shoulder by removing one sleeve of client’s gown. Avoid
exposing chest
3. Rinse it by using CB with water in a firm twisting motion from the bulb to the
stem and then dry using same motion using dry CB or clean soft tissues
4. Pat the client’s axilla dry with a face towel. Place the thermometer or probe
into the center of axilla bring the client’s arm down close to his body and place
his forearm over his chest.
5. Leave the thermometer in place until signal is heard
6. Remove, dry and read measurement on digital display of electronic
thermometer.
7. Inform client of temperature reading
8. Put back the sleeve
9. Cleanse the thermometer from the stem to the bulb using CB with water, then
dry and return to the container
10. Record the temperature in the jot down notebook
11. Wash hands
 12. Record the temperature on the master list sheet and graphic chart
C. Rectal method

Equipment used:

- Thermometer
- CB in water
- Jar with cut tissue paper
- Waste receptacle
- Jot down notebook
- Lubricant
- Working gloves

1. Read the chart

2. Bring the preparation
3. Place client in lateral position
4. Drape client exposing only rectum
5. Don gloves
6. Prepare the thermometer
7. Lubricate tip of rectal thermometer
8. Instruct client to take a deep breath. Gently insert the thermometer
approximately 0.5 to 1 inch
9. Hold the thermometer in place for until the beep sound is heard
10. Remove thermometer and wipe with dry tissue. Discard used tissue in the
receptacle
11. Read measurement on digital display
12. Wipe anal area with tissue and cover client
13. Cleanse the thermometer
14. Remove and dispose gloves
15. Wash hands
16. Record the temperature on the master list sheet and graphic chart

 PULSE
-it is a rhythmical throbbing that results from a wave of blood through an artery
as the heart contracts.

Equipment used: watch with second hand, jot down notebook and pen, alcohol
swab, stethoscope
 A. RADIAL PULSE
1. Explain the procedure.

2. Have the client rest his arm alongside his body with the wrist extended and the
palm of the hand downward, or place arm on top of the client’s upper abdomen.

3. Place your fist, second and third fingers along the radial artery and press gently
against the radius, rest the thumb on the back of the client’s wrist.

4. Apply enough pressure so that client’s pulsating artery can be felt.

5. Using a watch with a second hand, count the number felt for one full minute.

6. If the pulse rate is abnormal in any way, repeat the counting to determine
accurately the rate.

7. Record pulse rate on the jot down notebook.

8. Refer anything unusual to the clinical instructors and head nurse.

9. Record in the client’s chart and master list.

B. CARDIAC RATE
1. Explain the procedure.

2. Position the client on a supine and drape him.

3. Raise client’s gown and left side of chest.

4. Cleanse earpieces and diaphragm of stethoscope using alcohol swab.

5. Warm the diaphragm of the stethoscope using alcohol swab.

6. Place the diaphragm of the stethoscope over the apex of the heart, located at the
fifth intercostal space, left midclavicular line . Then, insert the earpieces in your ears.

7. Move the diaphragm to the site of the loudest beats. Count the beat S foe 60
seconds and note their rhythm and rate. Also evaluate the intensity of heart slunds.
8. Remove the stethoscope and make the client comfortable.

9. Record the apical pulse on the jot down notebook.

10. Refer anything unusual to the CI or head nurse.

11. Record the result on the chart and TPR master list.
 RESPIRATION
It is the exchange of oxygen and carbon dioxide between the atmosphere and body
cells and is initiated by the act of breathing
.
Eq: watch with second hand and jot down notebook and pen

Procedure :

1. While the fingertips are still in place after counting the pulse rate, observe the
client’s respiration.

2. Note the rise and fall of the client’s chest with each inspiration and expiration. This
observation can be made without disturbing the client’s bedclothes.

3. Using a watch with second hand, count the number of respiration for on full
minute.

4. If respirations are abnormal, repeat to determine accurately the rate, the

characteristics of breathing.

5. Record respiration rate on the jot down notebook including abnormalities in rhythm
and depth.

6. Refer to CI and head nurse for any unusuality .

7. Record the result in the client’s chart and TPR master list.
 BLOOD PRESSURE

-Blood pressure is the lateral force extended by the blood in the arterial wall.

Eq: stethoscope, alcohol swab, jot down notebook and pen, sphygmomanometer
with appropriate size of cuff

Procedure :

1. Explain the procedure to the client. Make sure that the client has not smoked
cigarette or ingested beverages that contains caffeine within 30 minutes.

2. Place the client in a comfortable position with the forearms supported and the
palm
upward.

3. Position yourself so that the calibration of the apparatus can be read at eye level
and no more than 1 feet away.

4. Place the cuff so that the inflatable bag is centered over the brachial artery, so that
the lower edge of cuff is 2.5-5cm above antecubital fossa.

5. Wrap the cuff smoothly around the arm with the end of cuff secure.

6. Use the fingertips to feel a strong pulsation on the antecubital space. Place the
bell
or diaphragm directly over the pulse.

7. Inflate the cuff to 30 mmHg where the pulsation appears.

8. Gradually deflate cuff all the way to zero taking note of the first and last clear, loud
sound.

9. Remove the cuff and make client comfortable.

10. Record the reading on the jot down notebook.

11. Report to the CI and headnurse for any unusualities.

12. Record BP on the VS sheet and BP masterlist.

Nursing Responsibilities:

BEFORE THE PROCEDURE:

-Identifies patient’s chart correctly
- Determines patient’s diagnosis, current condition, medications and treatment.
- Checks out for any special orders
- Assess patient’s readiness

DURING THE PROCEDURE:

- Introduce Self and identifies patient
- Explain the procedure to the patient/relatives
- Place patient in a comfortable position

AFTER THE PROCEDURE

- Document all data in the Graphic Sheet
- Ensure appropriate referral if necessary