TAGUM DOCTORS COLLEGE, INC.

Mahogany St., Rabe Subd., Tagum City

Telefax: (084) 655 – 6971 E-Mail: tdci_007@yahoo.com
Website: TagumDocollege.com

CHECKING THE VITAL SIGNS

Definition: Temperature, pulse, respiration and blood pressure give some indication of the
state of health of an individual. They represent interrelated physiologic systems
of the body.
TEMPERATURE:
Definition: It is the difference between heat produced and heat lost by the body and is measured through the
use of a thermometer.
ROUTE ADVANTAGES DISADVANTAGES
Oral (Normal 98.6 F, 37 C) Easy, fast, Accurate Cannot be used for clients who are
More reflective of core unconscious, confused, prone to seizures,
temperature recovering from oral surgery, or below age
6.
Need to wait 15-20 minutes after eating
Rectal (Normal: 99.5 F, 37.5 C) More reflective of core Cannot be used for client with rectal
temperature bleeding, hemorrhoids, or diarrhea or who
are recovering from rectal surgery.
Contraindicated for cardiac clients
because it may stimulate the vagus nerve
and decrease heart rate.
Not recommended for newborns because
of risk of perforating anus.
Tympanic (Normal: 97.6 F, 37.5 C) Fast Reports of accuracy are conflicting.
Axillary (Normal: 97.6 F, 36.5 C) More reflective of core Measures skin surface, which can be
temperature variable.
Safe, good for children
Forehead (Normal: 94 F, 34.4 C) Safe, good for children and Measures skin surface temperature
newborns
Safe and easy
Temporal Arterial Least accurate method
(Normal: Close to rectal
temperature, 1 F or 0.5 C higher
than an oral temperature and 2 F
or 1 C higher than an axillary
temperature)

Normal Body Temperature:

1. Oral temperature : 36.1-37.2 C or 97-99 F (Ave: 37 C)
2. Rectal Temperature : 36.7-37.8 C or 98-100 F (Ave: 37.5 C)
3. Axillary temperature: 35.6-36.7 C or 96-98 F (Ave: 36.7 C)

Types of thermometer include:

•Electronic digital thermometer. Used for oral, rectal or axillary temperature measurements.
•Tympanic thermometer. Temporal artery thermometer: Measures arterial temperature through infrared
scanning of the temporal artery.
•Disposable paper strips with temperature sensitive dots: Used for oral or skin/surface temperature
measurements.
ORAL METHOD
Contraindications:
1. Infants
2. Unconscious and irrational clients
3. Clients who breath through their mouths
4. Those with disease of the oral cavity or surgery of the nose or mouth
5. Clients who have taken cold or hot foods or fluids
Equipment:
•Tray containing:
1. Thermometer
2. Jar of CB in water
3. Jar with cut tissue paper
 TAGUM DOCTORS COLLEGE, INC.
Mahogany St., Rabe Subd., Tagum City
Telefax: (084) 655 – 6971 E-Mail: tdci_007@yahoo.com
Website: TagumDocollege.com

4. Waste receptacle
•Watch with second hand
•Jot down notebook and pen

Procedure:

Action
1.Read the chart.
2.Wash hands
3.Determine any previous activity that would
interfere with accuracy of temperature
measurement.
4.Bring the tray to the bedside. Identify 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 tissue.
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 gum line to the posterior
sublingual pocket lateral to center of lower jaw and
instruct him to close his lips tightly
9.Thermometer will signal (beep) when a constant
temperature registers.
10.Remove the thermometer and wipe it at once
with dry CB or soft tissue from stem down to the
bulb using a firm twisting motion
11.Read measurement on digital display of
electronic thermometer.
12.Push ejection button to discard disposable
sheath into receptacle and return probe to storage
well.
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 jot down
notebook. Report to the CI or head nurse any
unusualities.
17.Wash hands.
18.Record the temperature on the masterlist sheet
and graphic chart.
Rationale
To obtain data
To deter the spread of microorganisms
Smoking or oral intake of foods/fluids can
cause false temperature reading.
When the client knows what is to be done, he
will cooperate better.
Chemical solutions may irritate mucus
membrane and may have an objectionable
odor or taste. CB or soft tissues will
approximate the surface and twisting helps the
tissue wipe to come in contact with the
thermometer’s entire surface.
When the bulb rests against the superficial
blood vessels under the tongue and the mouth
is closed, a reliable measurement of body
temperature can be obtained.
Allowing sufficient time for the oral tissues to
come in contact with the thermometer results
in a more nearly accurate measurement of
body temperature.
Cleansing from an area where there are few
organisms minimizes the spread of organisms
to cleaner area. Friction helps to loosen matter
from a surface.
Confining contaminated articles helps to
reduce the spread of pathogens.
Accurate documentation allows for
comparison of data.

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

Equipment: Same as oral method except for the axillary thermometer.

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 TAGUM DOCTORS COLLEGE, INC.
Mahogany St., Rabe Subd., Tagum City
Telefax: (084) 655 – 6971 E-Mail: tdci_007@yahoo.com
Website: TagumDocollege.com

1.Tray containing:
a. thermometer
b. jar of CB in water
c. jar with cut tissue paper
d. waste receptacle
2.Client’s wash cloth
3.Jot down notebook and pen.

Procedure:

ACTION RATIONALE
5.Follow steps 1,2,3 and 4 of oral temperature
taking.
6.Expose arm and shoulder by removing one sleeve
of client’s gown. Avoid exposing chest.
7.Rinse it by using CB with water in a firm twisting Chemical solutions may irritate mucus
motion from the bulb to the stem and then dry membrane and may have an objectionable
using same motion using dry CB or clean soft odor or taste. CB or soft tissue will
tissues. approximate the surface and twisting helps the
tissue wipe to come in contact with the
thermometer’s entire surface.
8.Pat the client’s axilla dry with a face towel. Place The deepest area of the axilla provides the
the thermometer or probe into the center of axilla. most accurate temperature measurement.
Bring the client’s arm down close to his body and
place his forearm over his chest.
9.Leave an electronic thermometer in place until Allowing sufficient time for the axillary tissue
signal is heard. to come in contact with the thermometer bulb
results in a reasonably accurate measurement
of body temperature.
10.Remove, dry and read measurement on digital
display of electronic thermometer. Push ejection
button to discard disposable sheath into receptacle
and return probe to storage well.
11.Inform client of temperature reading.
12.Assist client to put back the sleeve.
13.Follow subsequent steps of cleaning as in oral
method numbers 14 and 15.
14.Record reading and indicate site in the jot down
notebook. Report to the CI/HN any unusualities.
15.Wash hands
16.Record the reading on the master list sheet and
graphic chart.

RECTAL METHOD

Purposes:
1.To obtain the first temperature of newborn to check for rectal patency .
2.To check the core temperature of an adult.

Contraindications:
This method is contraindicated to the following clients:
1.With rectal surgery.

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Mahogany St., Rabe Subd., Tagum City
Telefax: (084) 655 – 6971 E-Mail: tdci_007@yahoo.com
Website: TagumDocollege.com

2.With having diarrhea

3.With having disease of the rectum.
4.With cardiovascular alternation because the thermometer may stimulate the vagus nerve causing bradycardia
or rhythm disorder.
5.With leukemia may traumatize the rectal mucosa causing bleeding.

Equipment: Same as in oral method with the addition of:

1.lubricant
2.working gloves
3.toilet paper(client’s supply)
4.thermometer(client’s supply)

Procedure:
ACTION RATIONALE
1.Read the chart To obtain data
2.Bring the preparation to the bedside Elicits the cooperation and understanding of
the significant other
3.Place client in lateral position/Sim’s Position. Proper positioning ensures visualization of
anus.
4.Drape the client exposing only the rectum Avoid embarrassment. Flexing knee relaxes
muscles for ease of insulin.
5.Don gloves Gloves are used to avoid contact with body
secretions and to reduce transmission of
microorganisms
6.Prepare the thermometer
7.Lubricate tip of rectal thermometer or probe to Lubrication reduces friction and the therapy
approximately one inch above the bulb. facilitates the insertion of the thermometer,
this minimizes irritation of the mucous
membrane of the anal canal.
8.With the dominant hand, hold thermometer. With
non dominant hand, separate buttocks to expose anus
Instruct client to take a deep breath. Relaxes the anal sphincter
9.Hold the thermometer in place for until the beep
sound is heard.
10.Remove thermometer and wipe with dry tissue. Immediate ejection of disposable sheath into
Discard used tissue in the receptacle. the receptacle minimizes the spread of
organism.
11.Read measurement on digital display of electronic
thermometer and return probe to storage well
12.Wipe anal area with tissue and cover client. To remove lubricant/feces.
Dispose soiled tissue in the trash can
13.Cleanse thermometer as previously learned.
14.Remove and dispose gloves in trash can
15.Wash hands
16.Record temperature in the jot down notebook
17.Inform CI for any unusuality
18.Record in the chart and TPR master list.

Disposable (Chemical Strip) Thermometer

Procedure:

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 TAGUM DOCTORS COLLEGE, INC.
Mahogany St., Rabe Subd., Tagum City
Telefax: (084) 655 – 6971 E-Mail: tdci_007@yahoo.com
Website: TagumDocollege.com

Action Rationale
1.Follow steps 1,3,4,5,&6 of oral temperature taking
2.Apply tape to appropriate skin area, usually forehead.
3.Observe tape for color changes
4.Record reading and indicate method
5.Wash hands

Tympanic Temperature: Infrared Thermometer – it uses infrared sensors to sense temperature measurements
of the tympanic membrane.

Procedure:
Action Rationale
1.Follow steps 1,2,3,4,5,& 6 of oral temperature taking
2.Position client in Sim’s position.
3.Remove probe from container and attach probe cover to tympanic thermometer unit.
4.Turn client’s head to one side. For an adult, pull pinna upward and back; for a child, pull down and back. Gently
insert probe with firm pressure into ear canal.
5.Remove probe after the reading is displayed on digital unit (usually 2 seconds)
Note; Hospital probe plastic is hard. Don’t discard. Should be placed in a plastic bag provided by the hospital
6.Remove probe cover and replace in storage container.
7.Return tympanic thermometer to storage unit.
8.Record reading and indicate site.
9. Wash hands.

PULSE – It is a rhythmical throbbing that results from a wave of blood passing through an artery as the heart
contracts.

Possible sites for taking the pulse:

1.apical 6. Popliteal
2.radial artery 7. Carotid artery
3.temporal artery 8. Brachial artery
4.dorsalis pedis 9. Posterior tibialis
5.femoral artery

What to note while counting the pulse:

1.rate 3. Tension or compressibility
2.rhythm or regularity 4. Volume

Normal pulse rate per minute:

Newborn
1-1 month------------------- 120-160(ave. 140)
11-12 month ---------------- 100-140(ave. 120)
Toddler ----------------------- 80-120 (ave. 100)
Preschooler ----------------- 75-120 (ave. 100)
Adult
Male ------------------------ 70-80 beats/minute
Female --------------------- 80-90 beats /minute

Purpose: To obtain an estimate of the quality of the heart’s action per minute.

Equipment: a. Watch with second hand c. Alcohol swab

b.Jot down notebook and pen d. stethoscope

RADIAL PULSE

Procedure:
Action Rationale
1.Explain the procedure Gain cooperation and makes client at ease
2.Have the client rest his arm alongside of his body This position places the radial artery on the

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 TAGUM DOCTORS COLLEGE, INC.
Mahogany St., Rabe Subd., Tagum City
Telefax: (084) 655 – 6971 E-Mail: tdci_007@yahoo.com
Website: TagumDocollege.com

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 first, 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 the client’s pulsating
artery can be felt for one full minute.
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.
7.Record pulse rate on the jot down notebook
8.Refer anything unusual to the clinical instructors
and head nurse
9.Record in client’s chart and master list.
inner aspect of the client’s wrist. The nurse’s
fingers rest conveniently on the artery with
thumb in a position to the outer aspect of the
client’s wrist.
The fingertips which are sensitive to touch will
feel the pulsation of the client’s radial artery. If
the thumb is used to palpate the client’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.

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
2.Position the client on supine and drape him
3.Raise client’s gown to expose sternum and left Allows access to client’s chest for proper
side of chest placement of stethoscope
4.Cleanse earpieces and diaphragm of stethoscope Swabbing action removes dirt. ROH evaporates
using alcohol swab fast and render the parts dry easily.
5.Warm the diaphragm of the stethoscope over Placing a cold diaphragm against the skin may
the apex of the heart, located at the fifth startle the client and momentarily increase the
intercostal space, left midclavicular line. Then, heart rate.
insert the earpieces in your ears.
6.Place the diaphragm of the stethoscope over the This gives the loudest and most distinctive
apex of the heart, located at the fifth intercostal sound of the heart.
space, left midclavicular line. Then, insert the
earpieces in your ears.
7.Move the diaphragm to the site of the loudest In no instance, is the radial pulse count greater
beats. Count the beats for 60 seconds and note than the apical pulse count.
their rhythm and rate. Also evaluate the intensity
(loudness) of heart sounds.
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 Referral of anything unusual in a client enables
the professional nurse to respond immediately
to the needs or problem of the count
11.Record the result on the chart and TPR master
list.

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 TAGUM DOCTORS COLLEGE, INC.
Mahogany St., Rabe Subd., Tagum City
Telefax: (084) 655 – 6971 E-Mail: tdci_007@yahoo.com
Website: TagumDocollege.com

RESPIRATION: It is the exchange of oxygen and carbon dioxide between the atmosphere and body cells and is
initiated by the act of breathing
Normal Rates:
Infants - 30-40/minute
Children - 20-25/minute
Adult - 16-20/minute
Purpose: To obtain the respiratory rate per minute and an estimate of the client’s respiratory status.
Equipment: A watch with second hand
Jot down notebook and pen
Procedure:
Action Rationale
1.While the fingertips are still in place after Counting the respiration while presumably still
counting the pulse rate, observe the client’s counting the pulse keeps the client from
respiration. becoming conscious of his breathing which can
possibly after his usual rate.
2.Note the rise and fall of the client’s chest with A complete cycle of inspiration and expiration
each respiration and expiration. This observation constitutes one act of respiration.
can be made without disturbing the client’s
bedclothes.
3.Using a watch with second hand, count the Sufficient time is necessary to observe rate,
number of respiration for one full minute. depth and other characteristics.
4.If respirations are abnormal, repeat to determine
accurately the rate, the characteristics of the
breathing
5.Record respiration rate on the jot down
notebook in rhythm and depth, if any.
6.Refer to the CI and Head nurse for any
unusualities.
7.Record the result in the clients and the TPR
master list.

BLOOD PRESSURE
- Is the lateral force exerted by the blood on the arterial walls.
Purpose:
- To aid in diagnosis
- To observe changes in a client’s condition
Contraindications for Brachial artery blood pressure measurement:
- Surgery including the breasts, axilla, shoulder, arm or hands.
- Venous access device such as AV shunt and IVF
- Injury or disease to the shoulder, arm or hands such as trauma, burn or application of cast or bandage.
Sites for BP taking:
- Either arm on the antecubital space
- Either leg on the popliteal space
- Dorsalis pedis
Equipment:
- Stethoscope
- Sphygmomanometer with appropriate size of cuff
- Jot down notebook and pen
- Alcohol swab
Normal Ranges:
- Infant - 50/40 – 80/50
- Children - 87/48 - 117/64
- Adult - 110/70 – 130/90

Procedure:
Action Rationale
1.Explain the procedure to the client. Make sure Nicotine cause vasoconstriction in peripheral

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Mahogany St., Rabe Subd., Tagum City
Telefax: (084) 655 – 6971 E-Mail: tdci_007@yahoo.com
Website: TagumDocollege.com

that client has not smoked cigarette or ingested
beverages that contains caffeine within 30 minutes
2.Place the client in a comfortable position with
the forearm supported and the palm upward
3.Position yourself so that the calibration of the
apparatus can be more than 3 feet away.
4.Place the cuff so that the inflatable bag is
centered over the brachial artery, (lies midway on
the anterior of the brachial artery should be at the
center of the 2 tubing surface of the arm) 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.
Place the bell or diaphragm directly over the pulse
7.Inflate the cuff to 30 mmHg where the pulsation
disappears
8.Gradually deflate cuff all the way to zero taking
note of trhe first and the lkast 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 Head nurse for any
unusualities
12.Record BP on the VS sheet and BP masterlist
and coronary blood vessels, thus increase
blood pressure. Caffeine is a stimulant that
increase blood pressure.
This position places the brachial artery so that
a stethoscope can rest on it conveniently on
the antecubital area.
An accurate reading is obtained when the head
of the mercury 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
Bell chest piece is more sensitive to low-
frequency sound that occurs with pressure
release.
This will prevent you from missing the first tap
sound as a result of the auscultatory gap
(period where no sound is heard)
First sound is the systolic BP and last sound is
diastolic BP.

Pulse pressure – the difference between systolic and diastolic pressures.

e.g. 120/80 BP
Pulse pressure is 40

TAGUM DOCTORS COLLEGE

COLLEGE OF NURSING
PERFORMANCE CHECKLIST
VITAL SIGNS TAKING
Name: ________________________________________ Grade: ______________________
Year: _________________________________________ Date: _______________________
Legend:
5 – Excellent 4 – Very Good 3 – Good 2 – Fair 1 – Poor
Rating
5 4 3 2 1
1.Reads the chart
2.Washes hands.
3.Prepares the equipment and brings to the bedside.
4.Identifies the client and explains the procedure.
5.Wipes the thermometer from the bulb towards the stem with alcohol swab.
6.Pats the axilla dry using washcloth or tissue paper.
7.Turns the thermometer on.

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Mahogany St., Rabe Subd., Tagum City
Telefax: (084) 655 – 6971 E-Mail: tdci_007@yahoo.com
Website: TagumDocollege.com

8.Places the thermometer in axilla directed upward. Positions client arm across
the chest.
9.Leaves thermometer in place for 2 to 60 seconds or until a sound (beep) is
heard.
10.Removes and wipes the thermometer dry using tissue paper.
11.Reads temperature reading on the digital display.
12.Records result in the jot down notebook
13.Disinfects the thermometer twice using CB with alcohol from the stem to the
bulb in a firm twisting motion.
14.Places fingers on the radial pulse of the arm on the client’s chest.
15.With a watch with swift second hand, counts the pulse rate for a full time
16.With fingers still in place after taking radial pulse, notes the rise and fall of
client’s chest upon respiration.
17.Counts respiratory rate for one full minute.
18.Records PR and RR and notes for any unusual characteristics in the jot down
notebook.
19.Applies the BP cuff on the arm without contraptions.
20.Feels for a strong pulsation on the brachial artery with use of 2-3 finger pads.
21.Positions the bell of the stethoscope over the pulse site with the earpiece into
the ears.
22.Pumps the bulb until the pin of the manometer reaches to approximately 20
mmHg above the point where the systolic pressure is noted.
23.Releases the air gradually with the use of the valve of the bulb and takes note
of the systolic blood pressure.
24.Conitnues to release air gradually and listen to diastolic blood pressure.
25.Removes the cuff and makes client comfortable.
26.Records result on the jot down notebook.
27.With the client on supine position, locates the apical pulse on the left side of
the chest and drapes for privacy.
28.Warms the diaphragm of the stethoscope with the palm.
29.Places the diaphragm of the stethoscope over the PMI.
30.Counts the beat for one full minute.
31.Records result on the jot down notebook
32.Asks about client’s stool and urine output within the shift.
33.Reports to the CI/HN for any unusualities in the VS
34.Graphs/records results on the masterlist and client’s chart
35.Maintains body mechanics throughout the performance of procedures
36.Manifests neatness in the performed procedure
37.Ensures safety and comfort.
38.respects client’s rights.
39. Receptive to criticisms.
40.Observes courtesy
41.Shows calmness while performing the procedure.
42.uses of correct English
43.Shows mastery of the procedure

Clinical Instructor’s signature Student’s signature