VITAL SIGNS

TAKING

Ms. Kristine Uy- Urgena, RN, MN

College of Nursing
Xavier University- Ateneo de Cagayan
NCM 101 RLE
 Procedure Rationale
1. Check the routine policy of To avoid discrepancy from hospital
the hospital. standards and procedures.
2. Identify the client. Ensures correct patient
3. Assess client’s readiness for A change in patient’s condition will
the procedure. necessitate a change in time and route
of taking the vital signs.
4. Explain the procedure to To gain client’s participation
the client.
1. Assist the client to a Ensures comfort and accuracy of vital
comfortable position. signs taking.
Perform handwashing.
Reduce transmission of microorganism
Perform
Handwashing
Deter the spread
of
microorganisms.
TEMPERATURE
1. Grasp the digital thermometer Cleaning the thermometer in prescribed direction
from the container and wipe it with a will help minimize the spread of microorganism.
cotton ball with a firm, twisting
motion form its tip to the stem.

2. Wipe the axilla by gentle patting it Cleaning the area prevents the transmission of
with a dry, soft clean cloth. microorganism.

1. Turn on the thermometer To ensure proper use of thermometer

according to the package
direction.
Cleaning the thermometer in prescribed direction
will help minimize the spread of microorganism.
4. Place it into the center of the Expose axilla for correct thermometer probe
axilla and leave it for few minutes, placement.
then remove after the beep sound.
Thermometer probe needs to stay in place until
signal sounds to ensure accurate reading.

5. Clean the thermometer with Cleaning from a cleaner to a dirtier area

cotton ball with a firm twisting minimizes the spread of microorganisms. Friction
motion from the stem to the tip of will help loosen secretion from surface of the
the thermometer. thermometer.

6. Read the result, return to its This signifies that the thermometer is ready for the
container and record the next use.
temperature on a sheet of paper.
PULSE RATE
7. Position the client comfortably Relaxed position of lower arm and slight flexion of
and place two or three fingertips on wrist promote exposure of artery to palpation
the client’s radial artery and press without restriction.
gently.

8. Rest your thumb on the back of Using the thumb is contraindicated because the
the client’s artery. Count the pulse nurse’s thumb has a pulse that could be mistaken
for one full minute. for the client’s pulse.

Inefficient contraction of heart fails to transmit

pulse wave, interfering with cardiac output,
resulting in irregular pulse. Longer time ensures
accurate count.
Relaxed position of lower arm and slight flexion of
wrist promote exposure of artery to palpation
without restriction.
RESPIRATORY RATE
9. After taking the pulse, do not
remove your fingers on the client’s
wrist and proceed counting the
client’s respiration by observing and
noting the rise and fall of the chest for
one full minute.
A similar position used during pulse assessment
allows respiratory rate assessment to be
inconspicuous.
Patient’s hand or your hand rises and falls during
respiratory cycle.
Rate is accurately determined only after you have
observed a respiratory cycle (one inspiration and
one expiration)
A similar position used during pulse assessment allows respiratory rate
assessment to be inconspicuous.

Patient’s hand or your hand rises and falls during respiratory cycle.
BLOOD PRESSURE (PALPATORY
METHOD)

10. Position the client’s arm at heart
level with the palm turned upward.
Locate the brachial artery in the
antecubital space.
If arm is extended and not supported, patient
performs isometric exercise that increases
diastolic pressure.
Placing arm above level of heart causes false-
low reading 2mmHg for each inch above heart
level.

11. Place the cuff around the Ensures proper cuff application.
client’s bare arm, 1 inch above the
antecubital space.
If arm is extended and
not supported, patient
performs isometric
exercise that increases
diastolic pressure.
12. Make sure that the bladder is Inflating bladder directly over artery ensures that
centered over the brachial artery. proper pressure is applied during inflation.

13. Do palpatory BP reading. Wait 1 The initial estimate tells the nurse the maximal
to 2 minutes before making further pressure to which the sphygmomanometer needs
measurements to be elevated in subsequent determinations. It
also prevents underestimation of the systolic
pressure or overestimation of the diastolic pressure
should an auscultatory gap occur.

A waiting period gives the blood trapped in the

veins time to be released. Otherwise, false high
systolic readings will occur.
BLOOD PRESSURE (AUSCULTATORY
METHOD)
14. Check for the brachial artery. Ensures proper cuff application. Inappropriate site
selection results in poor amplification of sounds,
causing inaccurate readings

15. Clean the earpieces of the To prevent transmission of microorganism.

stethoscope prior to use. Place the Sounds are heard more clearly when the ear
earpieces in your ears and the bell attachments follow the direction of ear canal.
or diaphragm firmly but with slight
pressure where the brachial pulse is Tightening valve prevents air leak during inflation.
noted. Tighten the valve on the air
pump by turning it clockwise.
16. Compress the pump to inflate Rapid inflation ensures accurate measurement
the cuff until the gauge rises to of systolic pressure.
approximately 20-30 mmHg
above the point at which systolic
pressure is anticipated to be
heard.

17. Slowly turn the valve If the rate is faster or slower, an error in
counterclockwise to allow release measurement may occur.
of air at a rate of 2mmHg/second.

18. Note on the manometer the First sound reflects as systolic BP

point at which the first sound is
heard. Record it as the systolic
pressure.
19. Continue to open the valve slowly Fourth sound involves distinct muffling of sounds and is
and listen to a muffling sound. Note an indicator of diastolic pressure in children.
both the sound of muffling and the
point at which the sound disappears. Beginning of fifth sound is indicator of diastolic pressure
Not the point on the manometer when in adults.
the last distinct sound is heard. Record
it as the diastolic pressure.

20. Deflate the cuff totally. Continuous cuff inflation causes arterial occlusion,
resulting in numbness and tingling of patient’s arm.

21. Retake after 1-2 minutes or remove A waiting period gives the blood trapped in the veins
the cuff after. time to be released. Otherwise, false high systolic
readings will occur.
First sound reflects as systolic BP

Beginning of fifth sound is indicator of diastolic pressure in adults.

22. Remove and clean the earpieces, Cuff and Stethoscope can become significantly
the bell or diaphragm with alcohol contaminated; cleaning ensures prevention of spread
swab or cotton balls with alcohol. of microorganisms.

23. Place the client comfortably and Restores comfort and promotes sense of well-being.
wash hands. Reduces transmission of microorganisms.

24. Check if the patient has any Evaluate for change in condition or any alterations in
abnormal vital signs. Consider retaking any vital signs.
if you think that there is any possibility
of inaccuracy. Report any abnormal
findings to the appropriate person.

25. Record the temperature, pulse, Document and report pertinent assessment data
respiratory and blood pressure reading according to agency policy.
on the TPR-BP sheet.
Reference:

Kozier & Erb’s Fundamentals of Nursing: Concepts, Process,

and Practice, 10th edition, pages 503-538

Potter and Perry’s Fundamentals of Nursing, 10th edition,

pages 486-531