CHECKING THE VITAL SIGNS(VS)

Definition: Clinical measuremants specifically temperature pulse, respiration

and blood pressure that indicate the state ofth patient’s essential
functions.Pain is considered the “ fifth vital sign” in some organizations across
the globe

Temperature Checking (Axillary)

Many hospitals in the Philippines obtain patient’s temperature by the axillary
method. If the axilla has just been washed, obtaining temperature should be
delayed.

Equipment:
1. Tray containing:
a. Thermomete
b. jar of CB in water
c. jar with cut tissue paper d. waste receptacle

2. Jot down notebook and pen

3. Client’s wash cloth or tissue wipes

Procedure

1. Read the chart. To obtain necessary data.

2. Wash hands. To deter the spread of

microorganism.

3. Determine any previous activity Smoking or oral intake of foods/

that would interfere with accuracy of fluids can cause false temperature
temperature measurement. reading.

4. Bring the tray to the bedside and When the patient knows what is to
explain the procedure to the patient. be done, he will cooperate better.

5. Rinse the thermometer by using Chemical solutions may irritate

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.
mucus membrane and may have an
objectionable odor or taste. CB or
soft tissues will approximate the
surface and twisting helps to come in
contact with the thermometer’s entire
surface
7. Expose arm and shoulder by
removing one sleeve of client’s gown.
Avoid exposing chest.

8. Pat the patient’s axilla dry with a
wash cloth or tissue. Place the probe
of the thermometer into the center of
the axilla. Bring the patient’s arm
down close to his body and place his
forearm over his chest.
Moisture in the axilla may alter the
result of the temperature. The
deepest area of the axilla provides
the most accurate temperature
measurement.

Allowing sufficient time for the

9. Leave the thermometer in place axillary tissue to come in contact
until signal or beep is heard or 1-3 with the thermometer bulb results in
minutes of ordinary thermometer. a reasonably accurate measurement
of body temperature.

10. Remove, dry with tissue paper

and read measurement on digital To see the result clearly
display of the thermometer

11. Inform client of temperature Increases involvement and trust of

reading. the client.

12. Assist client in putting back the

sleeve of gown.

13. Cleanse the thermometer from

the stem to bulb using CB with water
twice, then dry with tissue wipe and
return to the container.

14. Dispose the used CB and tissue Confining contaminated articles help
paper in the waste receptacle. to reduce the spread of pathogens.

15. . Record the temperature in the

jotdown notebook. Report to the CI
or headnurse any unusualities.

16. Wash Hands

17. . Record the temperature on the Accurate documentation allows for

TPR masterlist sheet and graphic comparison of data.
chart.
II - PULSE
Definition: It is a rhythmical throbbing that results from a wave of blood
passing through an artery as the heart contracts.
Purpose: To obtain an estimate of the quality of the heart’s action per minute.
Procedure
Action
1. Explain the procedure to the
patient.
2. Have the patient rest his arm
along side of his body with the wrist
extended and the palm of the hand
downward, or place arm on top of
the patient’s upper abdomen with the
palm downward position.
3. Place your first, second and third
fingers along the radial artery and
press gently against the radius; rest
the thumb on the back of the
patient’s wrist.
4. Apply enough pressure so that the
patient’s pulsating artery can be felt
distinctly.
5. Using a watch with a second hand,
count the number of pulsation felt for
one full minute.
6. If the pulse rate is abnormal in
any way, repeat the counting to
determine accurately the rate, the
quality and the volume.
Rationale
To gain cooperation and make client
at ease.
This position places the radial artery
on the inner aspect of the patient’s
wrist. The nurse’s fingers rest
conveniently on the artery with
thumb in a position to the outer
aspect of the patient’s wrist.
The fingertips which are sensitive to
touch will feel the pulsation of the
patient’s radial artery. If the thumb is
used to palpate the patient’s pulse,
the nurse may feel her own pulse.
Moderate pressure allows the nurse
to feel the superficial artery expand
and contract with each heart beat.
Sufficient time is necessary to detect
irregularities or other defects.
When the pulse is abnormal, longer
counting and palpation are
necessary to identify most accurately
the unusual characteristics of the
pulse.
7. Record pulse rate on the jot down
notebook.

8. Refer anything unusual to the

clinical Instructors and/ or head
nurse.

9. Record in client’s graphic chart

and VS master list.

B. CARDIAC RATE OR APICAL PULSE

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 newborns, infants, and young children.

Procedure
Action Rationale

1. Explain the procedure to the Elicits cooperation from the client.

patient and/or significant others.

2. Assist the client on supine position.

Swabbing action removes dirt. ROH
3. Cleanse earpieces and diaphragm evaporates fast and render the parts
of stethoscope using alcohol swab. dry easily

Allows access to patient’s chest for

4. Raise the gown and properly proper placement of stethoscope.
drape the client exposing the
sternum and the left side of chest.

5. Warm the diaphragm of the Placing a cold diaphragm against the

stethoscope with your hand before skin may startle the patient and
applying it to the patient’s chest. momentarily increase the heart rate.

6. Place the diaphragm of the
stethoscope over the apex of the
heart, located at the fifth intercostal
space, left midclavicular line 5th ICS,
LMCL). Then, insert the earpieces in
your ears.
7. 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.
This gives the loudest and most
distinctive sound of the heart.
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.
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 Referral of anything unusual in a

or Head nurse. patient enables the professional
nurse to respond immediately to the
needs or problem of the patient.

11. Record the result on the chart

and VS master list.
III - RESPIRATION

Definition: It is the exchange of oxygen and carbon dioxide between the

atmosphere and body cells and is initiated by the act of breathing.

Purpose: To obtain the respiratory rate per minute and an estimate of the
patient’s respiratory status.

Equipment: a. watch with second hand

b. jot down notebook and pe

Procedure
Action Rationale

1. While the fingertips are still in Counting the respiration while

place after counting the radial pulse presumably still counting the pulse
rate, observe the patient’s keeps the client from becoming
respiration. conscious of his breathing which can
possibly alter his usual rate

2. Note the rise and fall of the

patient’s chest with each inspiration A complete cycle of inspiration and
and expiration. This observation can expiration constitutes one act of
be made without disturbing the respiration.
patient’s bedclothes.

3. Using a watch with second hand, Sufficient time is necessary to

count the number of respiration for observe rate, depth and other
one full minute. characteristics.

4. If respirations are abnormal,

repeat to determine accurately the
rate, the characteristics of the
breathing.

5.Record respiratory rate on the jot

down notebook including
abnormalities in rhythm and depth, if
any.

6. Refer to the CI and/or Headnurse

any abnormalities in rate and/or
rhythm.

7.Record the result in the client’s

graphic chart and the TPR master
list.
IV - BLOOD PRESSURE
Definition:
Blood pressure is the lateral force exerted by the blood on the arterial walls.

Purposes:
1. To aid in diagnosis
2. To observe changes in a patient’s condition

Contraindications for Brachial Artery Blood Pressure Measurement

1. Surgery including the breasts, axilla, shoulder, arm or hands.

2. Venous Access Device such as AV shunt (in patients on hemodialysis) or
IVF in the arm.
3. Injury or disease to the shoulder, arm or hands such as trauma, burn or
application of cast or bandage.

Sites for BP taking:

1. either arm on the antecubital space
2. either leg on the popliteal space
3. dorsalis pedis

Equipment:
1. Stethoscope
2. Sphygmomanometer with appropriate size of cuff
3. Jotdown notebook and pen
4. Alcohol swab

Normal Ranges:

1. Infant - 50/40 – 80/50

2. 2. Children - 87/48 – 117/64
3. 3. Adult - 110/70 – 130/90
Procedure
Action
1. Explain the procedure to the
patient. Make sure that client has not
smoked cigarette or ingested
beverages that contains caffeine
within 30 minutes
2. Place the patient in a comfortable
position with the forearm 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 3
feet away.
4. Place the cuff so that the inflatable
bag is centered and lies midway
over the anterior surface of the
brachial artery, (the surface of the
brachial artery should be at the
center of the 2 tubings of the cuff) so
that the lower edge of cuff is 2.5 – 5
cm. above antecubital fossa.
5. Wrap the cuff smoothly and
snugly around the arm with the end
of the cuff secure
6. Use the fingertips to feel a strong
pulsation on the antecubital space.
7. Inflate the cuff to 30 mmHg where
the pulsation disappears. Place the
diaphragm of the stethoscope
directly over the pulse.
.
Rationale
Nicotine causes vasoconstriction in
peripheral and coronary blood
vessels which may cause increase in
blood pressure. Caffeine is a
stimulant that increases blood
pressure
This position exposes the brachial
artery so that a stethoscope can rest
on it conveniently on the antecubital
area
An accurate reading is obtained
when the manometer column is in
direct vision.
Pressure applied directly to the
artery will yield most accurate
readings.
A twisted cuff and wrapping could
produce inaccurate reading.
Accurate blood pressure reading is
possible when the stethoscope is
directly over the artery.
This will prevent you from missing
the first tap sound as a result of the
auscultatory gap (period where no
sound is heard)
8. Gradually deflate cuff all the way First sound is the systolic BP and
to zero taking note of the first and last sound is diastolic BP.
the last clear, loud sound.

9. Remove the cuff and make patient

comfortable

10. Record the reading on the jot

down notebook.

11. Report any unusualities to the CI

and/or Headnurse.

12. Record BP on the VS sheet and

VS masterlist.

* Pulse pressure – the difference between systolic and diastolic pressures. e.g.
120/ 80 BP Pulse pressure is 40 – may be ordered in patients with Dengue
Hemorrhagic Fever.