Name: Hyacinth B.

Carpilla
Course & year: BSN1-Henderson
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Vital Signs Monitoring
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Definition
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Purpose
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Procedure

Assessing the Body Temperature

1. Prepare the client. Ascertain which method of taking

the temperature is appropriate for the client.
For oral temperature – determine the time the client
last took hot or cold food or fluids or smoked.

For a Rectal Temperature – assist the client to assume a

lateral position (newborn-lateral or prone position;
young child lateral position with knees flexed, or prone
across the lap)
- Provide privacy before folding the bedclothes back
to expose the buttocks

For an Axillary Temperature – expose the client’s axilla.

If the axilla is moist, dry it with a towel using a patting motion.

2. Prepare the equipment.

3. Wash hands

4. Explain the procedure to the client

5. Take the temperature

5.1 For an oral temperature
5.1.1 Place the thermometer or probe at the base of
the tongue to the right or left of the frenulum,
the posterior sublingual pocket.
5.1.2 Ask the client to close the lips, not the teeth,
around the thermometer.
5.1.3 Leave the thermometer in place for 2 minutes. If
an electronic oral thermometer is used, the
client holds the thermometer under the tongue
10-20 seconds or until it completes registering.

5.2 For a rectal temperature

5.2.1 Place some lubricant on a piece of tissue. Then
apply lubricant to the thermometer about 2.5
cm (1 in) above the bulb.
5.2.2 Wear disposable gloves on both hands. With the
no dominant hand, raise the client supper
buttocks to expose the anus.
5.2.3 Ask the client to take a deep breath and insert
thermometer into the anus from 1.5 to 4 cm
(0.5 to1.5 in.) depending on the age and size of
the client. (New born 1.5 cm (0.5 in); Child –
2.5cm (0.9 in); Adult – 3.7cm (1.5 in)
5.2.4 Do not force insertion of the thermometer
5.2.5 Hold the thermometer in place for 2 minutes
(for neonates – 5 minutes)

5.3 For an Axillary Temperature

5.3.1 Place the thermometer on the client’s axilla
5.3.2 Assist the client to place the arm across the
chest to keep the thermometer in place.
5.3.3 Leave the thermometer in place for 9 minutes
(infant and children – 5 minutes)
5.3.4 Remain with the client and hold the
thermometer in place if the client is irrational or
very young.

Assessing the Pulse Rate

6. While waiting for the recommended time in taking the

body temperature, prepare the client for the
 assessment of pulse rate.

7. Select a pulse point. Normally, a radial pulse is taken.

8. Place two or three middle fingertips lightly and squarely

over the pulse point.

9. When obtaining baseline data, count the pulse for a full

minute.

10. Assess the pulse rhythm and volume.

- Pulse rhythm can be assessed by noting pattern of
the intervals between beats.
- Pulse volume can be assessed by noting a normal
pulse that can be felt with a moderate pressure and
the pressure is equal with each beat.

Assessing Respiration

11. While your hands still holding the pulse point, observe
the client’s chest movement (young children-observe
the rise and fall of the abdomen)

12. Count the respiratory rate for 60 seconds.

13. Observe the depth, rhythm and character of

respirations.

Assessing the Blood Pressure

14. After assessing the respiratory rate of the client,

prepare the client for the blood pressure monitoring.

15. Wrap the deflated cuff evenly around the upper arm.

16. Palpate the brachial artery with the fingertips.

17. Insert the ear attachments of the stethoscope in your

ears.

18. Place the diaphragm of the stethoscope over the

brachial pulse.

19. Close the valve on the pump by turning the knob

clockwise.

20. Pump up the cuff.

21. Auscultate the client’s blood pressure.

22. Remove the cuff from the client’s arm.

23. Remove the thermometer and wipe in a rotating
motion toward the bulb.

24. Read the temperature at eye level.

25. Clean and shake down the thermometer and return it

to its container.

26. Make patient comfortable.

27. Do after care of the equipment.

28. Wash hands.

29. Document and report pertinent assessment data.