UNIVERSITY OF SOUTHERN MINDANAO

VITAL SIGNS TAKING

Jan Paolo T. Cosmiano, RN

 Topic Outline
• Vital Signs Checking
Temperature
1. Oral
2. Axilla
3. Rectal
4. Tympanic
Pulse Rate
1. Radial Pulse
2. Apical puls
Respiratory Rate
Blood Pressure
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 Intended Learning Outcomes
• Student will demonstrate understanding and execute the
following nursing procedures:
1. Temperature checking
2. Pulse rate monitoring
3. Respiratory rate monitoring
4. Blood Pressure checking

3
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 Purpose
• To determine the change in client status
• To recognize variation of Vital signs from normal and it’s significance
• To help the physician prescribe right treatment
• To help identify specific life threatening conditions
• To detect changes in client health status
• To help in the diagnosis of the disease, the result of treatment and
medication.

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Temperature Checking

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 Definition
• It is the difference between heat produced and heat lost by
the body and is measured through the use of a digital
thermometer. Body temperature readings vary depending
on where on the body a person takes the measurements.
Rectal readings are higher than oral readings, while axilla
readings tend to be lower.

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 Body Temperature
Normal Body Temperature:
Type of Reading 0-2 years 3-10 years 11-65 years Over 65 years

Oral 35.5-37.5℃ 35.5-37.5℃ 36.4-37.6℃ 35.8-36.9℃

95.9-99.5℉ 95.9-99.5℉ 97.6-99.6℉ 96.4-98.5℉

Axilla 34.7-37.3℃ 35.9-36.7℃ 35.2-36.9℃ 35.6-36.3℃

94.5-99.1℉ 96.6-98.0℉ 95.3-98.4℉ 96.0-97.4℉

Rectal 36.6-38℃ 36.6-38℃ 37.0-38.1℃ 36.2-37.3℃

97.9-100.4℉ 97.9-100.4℉ 98.6-100.6℉ 97.1-99.2℉

Tympanic 36.4-38℃ 36.1-37.8℃ 35.9-37.6℃ 35.8-37.5℃

97.5-100.4℉ 97.0-100.0℉ 96.6-99.7℉ 96.4-99.5℉

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 Body Temperature
• Normal body temperature readings will vary within these ranges
depending on the following factors:
• A person’s age and sex
• The time of day, typically being lowest in the early morning and
highest in the late afternoon
• High or low activity levels
• Food and fluid intake
• For females, the stage in their monthly menstrual cycle
• The method of measurement such as oral (mouth), rectal
(bottom), or axilla (armpit) readings
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 Equipment needed
• Digital thermometer
• Cotton balls with Alcohol
• Bathroom tissue or clean towel
• Clean gloves
• Lubricating jelly
• Jotdown notebook
• Pencil or pen

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Temperature Checking- Oral Method

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 Procedure
• Read the chart. Wash hands.
To obtain data; to eliminate the spread of microorganism.

• Determine any previous activity that would interfere with the

accuracy of temperature measurement.
Smoking or oral intake of foods/fluids can cause false
temperature taking.

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 Procedure
• Bring the tray to the bedside and explain the procedure to the
patient.
When the patient understands the procedure to be done, he will
cooperate better.

• Take the thermometer out of its holder. Clean the probe

(pointed end) of the thermometer with cotton balls with
rubbing alcohol in twisting motion up to the stem.

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 Procedure
• Place the thermometer under the patient’s tongue on one
side of his/her mouth and instruct him/her to close his/her
lips.
When the probe rest against the superficial blood vessels under
the tongue and the mouth is closed, a reliable measurement of
the body temperature can be obtained

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 Procedure
• Leave the thermometer in place until the thermometer
signals it is finished.
When it beeps, it signifies that the thermometer can be
removed.

• Remove the thermometer carefully and read the

temperature on the digital display.

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 Procedure
• Clean the stem to the probe (tip) with cotton balls soaked in
rubbing alcohol in twisting motion. Put the thermometer
cover and place the thermometer in its container.
Cleansing from area where there are few organisms minimizes
the spread of organisms to cleaner area. Friction helps to
loosen matter from a surface.

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 Procedure
• Dispose cotton balls in a trash bin.

• Record the temperature in the jot down notebook. Report to

the Clinical Instructor for any unusualities.

• Wash hands and record the temperature on the master lists

sheet and graphic chart.
Accurate documentation allows for comparison of data.

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Temperature Checking- Axillary Method

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 Procedure
• Read the chart. Wash hands
To obtain data; to eliminate the spread of microorganism.

• Determine any previous activity that would interfere with the

accuracy of temperature measurement.
Smoking or oral intake of foods/fluids can cause false
temperature taking.

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 Procedure
• Bring the tray to the bedside and explain the procedure to the
patient.
When the patient understands the procedure to be done, he will
cooperate better.

• Take the thermometer out of its holder. Clean the probe (pointed
end) of the thermometer with cotton balls with rubbing alcohol in
twisting motion up to the stem.

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 Procedure
• Pat the patient’s axilla dry with bathroom tissue or patient’s
clean towel. Place the thermometer into the center of axilla.
Bring the patient’s arm down close to his body and place his
forearm over his chest.
The deepest area of the axilla provides the most accurate
temperature measurement.
• Leave the thermometer in place until the thermometer
signals it is finished.
When it beeps, it signifies that the thermometer can be
removed.
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 Procedure
• Remove the thermometer carefully and read the
temperature on the digital display.
• Clean the stem to the probe (tip) with cotton balls soaked in
rubbing alcohol in twisting motion. Put the thermometer
cover and place the thermometer in its container.
Cleansing from area where there are few organisms minimizes
the spread of organisms to cleaner area. Friction helps to
loosen matter from a surface.
• Dispose cotton balls in a trash bin.
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 Procedure
• Record the temperature in the jot down notebook. Report
to the Clinical Instructor for any unusualities.

• Wash hands and record the temperature on the master lists

sheet and graphic chart.
Accurate documentation allows for comparison of data.

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Temperature Checking- Rectal Method

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 Procedure
• Read the chart. Wash hands and bring the equipment to the
bedside and explain the procedure to the patient (adult) or
significant other’s (infant/child).
To obtain data; to eliminate the spread of microorganism. It
elicits cooperation and understanding of the significant others.

• Place the patient in lateral position/sim’s position.

Proper positioning ensures visualization of the anus.

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 Procedure
• Drape patient exposing only the rectum.
To avoid embarrassment and ease comfort.

• Don gloves.
Working gloves are used to avoid contact with bodily secretions
and to reduce transmission of microorganisms.

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 Procedure
• Take the thermometer out of its holder. Clean the probe
(pointed end) of the thermometer with cotton balls with
rubbing alcohol in twisting motion up to the stem.
70% Isopropyl alcohol eliminates microorganisms.

• Lubricate the end of the probe with small amount of

lubricating jelly.
Lubricant reduces friction and the therapy facilitates the
insertion of the mucus membrane of the anal area.
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 Procedure
• With the dominant hand, hold the thermometer. With the
non-dominant hand, raise the upper buttocks to expose the
anus.
Aids visualization of the anus.
• Instruct the patient to take deep breath. Gently insert the
thermometer into the anus (infant –1.2cm/0.5 inch); (adult –
3.5cm/1.5 inches). If resistance is felt, do not force insertion.
Release buttocks to allow fall in place.
Relaxes anal sphincter.
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 Procedure
• Hold the thermometer in place until it beeps then remove
the thermometer. Read the temperature result on the
display.
When it beeps, it signifies that the thermometer can be
removed.
• Wipe anal area with tissue to remove lubricant or feces and
cover patient. Dispose soiled tissue in the trash bin.
Cleansing from area where there are few organisms minimizes
the spread of organisms to cleaner area. Friction helps to
loosen matter from a surface.
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 Procedure
• Clean the stem to the probe (tip) with cotton balls soaked in
rubbing alcohol in twisting motion. Put the thermometer
cover and place the thermometer in its container.
• Dispose cotton balls in a trash bin.
• Record the temperature in the jot down notebook. Report
to the Clinical Instructor for any unusualities.
Accurate documentation allows for comparison of data.
• Wash hands and record the temperature on the master lists
sheet and graphic chart.
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Temperature Checking- Tympanic Method

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 Procedure
• Read the chart. Wash hands and bring the equipment to the
bedside and explain the procedure to the patient (adult) or
significant other’s (infant/child).
To obtain data; to eliminate the spread of microorganism. It
elicits cooperation and understanding of the significant others.

• Place the patient in lateral position.

Proper positioning ensures visualization of the ear.

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 Procedure
• Don gloves.
Working gloves are used to avoid contact with bodily secretions
and to reduce transmission of microorganisms.

• Take the thermometer out of its holder. Clean the probe

(pointed end) of the thermometer with cotton balls with
rubbing alcohol in twisting motion up to the stem.
70% Isopropyl alcohol eliminates microorganisms.

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 Procedure
• With the dominant hand, hold the thermometer. With the
non-dominant hand, gently tug on the ear pulling it back.
This will help straighten the ear canal and make a clear path
inside the ear to the ear drum.

• Instruct the patient to take deep breath. Gently insert the

thermometer until the ear canal is fully sealed off.

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Procedure
• Hold the thermometer in place until it beeps then remove
the thermometer. Read the temperature result on the
display.
When it beeps, it signifies that the thermometer can be removed.
• Clean the stem to the probe (tip) with cotton balls soaked in
rubbing alcohol in twisting motion. Put the thermometer
cover and place the thermometer in its container.
Cleansing from area where there are few organisms minimizes
the spread of organisms to cleaner area. Friction helps to loosen
matter from a surface.
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 Procedure
• Dispose cotton balls in a trash bin.
• Record the temperature in the jot down notebook. Report to
the Clinical Instructor for any unusualities.
Accurate documentation allows for comparison of data.
• Wash hands and record the temperature on the master lists
sheet and graphic chart.

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Pulse Rate

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 Definition
• It is the regular beating or throbbing caused in the arteries by each
ventricular contraction.

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 Pulse Rate
Sites where the pulse can be obtained:
• Radial artery
• Facial artery
• Temporal artery
• Dorsalis pedis artery
• Femoral artery
• Popliteal artery
• Carotid
• Apical
• Brachial
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 Pulse Rate
Normal Pulse rate per minute:

Newborn: 120-140 beats per minute

1 year old: 115-130 beats per minute
2 years old: 100-115 beats per minute
7 years old: 85-90 beats per minute
Male: 70-80 beats per minute
Female: 80-90 beats per minute
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 Pulse Rate
What to take note when taking the pulse:
• Rate - the number of heartbeats per minute.
• Rhythm - he rhythmical throbbing of arteries produced by the regular
contractions of the heart, especially as palpated at the wrist or in the
neck
• Tension or compressibility - It corresponds to diastolic blood
pressure. A low tension pulse (pulsus mollis), the vessel is soft or
impalpable between beats. In high tension pulse (pulsus durus),
vessels feel rigid even between pulse beats.
• Volume

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Respiratory Rate

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 Definition
• or the number of breaths per minute, is a clinical sign that
represents ventilation (the movement of air in and out of
the lungs).

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Normal Respiratory rate per minute

Newborn: 30-40 breaths per minute

Children: 20-25 breaths per minute
Adult: 16-20 breaths per minute

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 EQUIPMENT
• Watch with second hand
• Pen and paper
• Stethoscope

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 Procedure
• Have the patient rest his arm alongside his body with wrist
extended and all the palm of the hand downward. Or place
arm on top of the patient’s upper abdomen
This position places the radial artery in the inner aspect of the
patient’s wrist. The nurse’s finger rest conveniently on the
artery with the thumb in opposition on the outer aspect of the
patient’s wrist. Palm down.

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 Procedure
• While the fingertips are still placed after counting the pulse
rate, observe the patient’s respiration.
Counting the respiration while presumably still counting the
pulse keeps the patient from becoming conscious of his
breathing and possibly altering his usual rate.
• Note the rise and fall of the patient’s chest with each
respiration and expiration. This observation can be made
without disturbing the patient’s bedclothes.

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 Procedure
• Using a watch with second hand, count the number of
respirations for one whole minute.
Sufficient time is necessary to observe rate, depth, and other
characteristics.

• If respirations are abnormal in any way, repeat to determine

accurately the rate and the characteristics of the breathing

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 Procedure
• Record the pulse and respiration rate on your jot down note
book and refer to CI any unusualities noted.
Referral of anything unusual in a patient enables the
professional nurse to respond immediately to the needs or
problem of the count.

• Record the result to the chart and TPR master list.

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Obtaining Cardiac rate or Apical pulse

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 Purpose
• If a peripheral pulse is irregular, weak, or extremely rapid,
causing it to be difficult to assess accurately, the apical rate
may be assessed. The apical pulse is also used to assess
newborn, infants, and young children.

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 How to locate Apical pulse
• The apical pulse is best assessed when you are either sitting
or lying down.
• use a series of “landmarks” on your body to identify what’s
called the point of maximal impulse (PMI). These landmarks
include:
• the bony point of your sternum (breastbone)
• the intercostal spaces (the spaces between your rib bones)
• the midclavicular line (an imaginary line moving down your
body starting from the middle of your collarbone)

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 How to locate Apical pulse
• Starting from the bony point of your breastbone, locate the
second space between the ribs. They’ll then move the
fingers down to the fifth space between the ribs and slide
them over to the midclavicular line. The PMI should be
found there.
• Once the PMI has been located, use the stethoscope to
listen to your pulse for a full minute in order to obtain apical
pulse rate. Each “lub-dub” sound counts as one beat.

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How to locate Apical pulse

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 Procedure
• Explain the procedure.

• Position the patient on supine and drape him.

• Raise patient’s gown to expose sternum and left side of the

chest.
Allows access to patient’s chest for proper placement of
stethoscope.

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 Procedure
• Cleanse ear pieces and diaphragm of stethoscope using
alcohol swab.
Swabbing action removes dirt. An alcohol evaporates fast and
renders the parts dry easily.
• Warm the diaphragm of the stethoscope with your hand
before applying it to the patient’s chest.
Placing a cold diaphragm against the skin may startle the
patient and momentarily increase the heart rate.

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Procedure
• Place the diaphragm of the stethoscope over the apex of
the heart, located at the fifth intercostals space, left
midclavicular line then insert the ear pieces in your ears.
This gives the loudest and most distinctive sound of the heart.
• Move the diaphragm to the site of the loudest beats. Count
the beats for 60 seconds and note their rhythm and volume.
Also evaluate the intensity (loudness) of heart sounds.
A full minute count is important for an accurate assessment. A
longer duration helps determine pulse rhythm and quality. In no
instance, is the radial pulse count greater than the apical pulse
count.
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 Procedure
• Remove the stethoscope and make the patient presentable
and comfortable.
• Record the apical pulse on the jot down notebook.
• Refer anything unusual to the CI or Head Nurse.
Referral of anything unusual in a patient enables the
professional nurse to respond immediately to the needs or
problem of the count.
• Record the result on the chart and TPR master list.

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Blood Pressure Taking

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 Definition
• Blood pressure is the force exerted by the blood against the walls of
the artery

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 Purpose
As an aid in diagnosis
As a means of observing changes in patient’s condition.

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 Sites for taking Blood Pressure
• Either arm on the antecubital space.
• Either leg on the popliteal space or dorsalis pedis.

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 Normal Ranges
Infant: 50/40 – 80/50 mmHg
Children: 87/48 – 117/64 mmHg
Adult: 110/70 – 130/90 mmHg

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 Equipment
1. Stethoscope
2. Sphygmomanometer
3. Paper and pencil

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 Procedure
• Place the 1st and 2nd and the 3rd fingers along the radial
artery and press gently against the radius; rest the thumb on
the back of the patient’s wrist.
This position places the brachial artery so that a stethoscope
can rest on it conveniently in the antecubital area. The brachial
artery is superficial in the antecubital space.

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 Procedure
• Place the cuff directly above the patient’s elbow, keeping
the antecubital area free.
A twisted cuff and wrapping could produce unequal pressure
and thus an inaccurate reading.
• Place the stethoscope on the brachial artery on the
antecubital space. Where the pulse was noted.
Accurate blood pressure reading is possible when the
stethoscope is directly over the artery.

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 Procedure
• Use the fingertips to feel for a strong pulsation on the
antecubital space.
• Place the stethoscope on the brachial artery on the
antecubital space. Where the pulse was noted.
Direct placement of the stethoscope over the artery will
produce best possible sound transmission.

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Procedure
• Pump the bulb of manometer until it rises to approximately
30mm above the point where it is anticipated that systolic
pressure should be.
Pressure in the cuff prevents blood from flowing through the
brachial artery. Lack of blood causes a numb sensation in the
patient’s lower arm.
• Using valve on the bulb, release air gradually and note on the
manometer the point at which the first sound is heard; record
this figure as the systolic pressure.
Systolic pressure is that point at which the blood in the brachial
artery. Lack of blood causes a numb sensation in the patient’s lower
arm
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 Procedure
• Continue to release air gradually from the cuff. Note the
reading of the manometer when the last distinct loud sound
is heard with the stethoscope. Record this figure as the
diastolic pressure.
Diastolic pressure in that point at which blood flows freely in
the brachial artery and is equivalent to the amount of pressure
normally exerted on the walls of the arteries when the heart is
at rest.

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After Care of Equipments:

• Roll cuff of sphygmomanometer and place in case

• Wash ear pieces of the bell of the stethoscope with soap
and water and dry.
• Return equipment’s to proper place.

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 References
Manual of Nursing Procedures, 2021, University of Southern
Mindanao, p. 5-19.

Weatherspoon, D. (2020, September). Apical Pulse, An overview.

Retrieved from https://www.healthline.com/health/apical-pulse

Kasper DL, Fauci AS, Hauser SL, Longo DL, Jameson JL, Loscalzo
J. What is blood pressure and how is it measured. Retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK279251/

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