PROCEDURE ON VITAL SIGNS TAKING

1. Reads the chart.

- To obtain the necessary information.
2. Washes hands.
- To deter spread of microorganisms
3. Prepares the equipment and brings to the bedside.
- To save time
4. Identify the patient by asking his name and birthday and explain the procedure.
- To validate that you are with the rightd patient and so that when the patient knows what to do,
he will cooperate better
5. Wipes the thermometer from the bulb towards the stem with cotton balls on water.
- Chemical solution may irritate the mucusmembrane. Cotton balls will approximate the surface
and twisting will help to come in contact with the thermometer’s entire surface.
6. Pat the axilla dry using washcloth or tissue paper.
- Moisture in the axilla may alter the result of the temperature
7. Turn the thermometer on.
8. Place the thermometer in axilla directed upward Positions patient’s arm across the chest.
- The deepest area of the axilla provides the most accurate temperature measurement.
9. Leave thermometer in place for 2 to 60 seconds or until a sound (beep) is heard.
- Allowing sufficient time for the axillary tissue to come in contact with the thermometer bulb
provides a more accurate results
10. Remove and wipe the thermometer dry using tissue paper.
- Because the thermometer may
11. Read the temperature reading on the digital display.

12. Record the result in the jotdown notebook. Inform client of the result.

13. Disinfect the thermometer twice using CB with alcohol from the stem to the bulb in a firm
twisting motion.
14. Place fingers on the radial pulse with the arm across the client’s chest with the palm positions
downward.
- Since the fingertips are sensitive to touch, you can feel the pulsation more. If you use you’re
thumb, the nurse may feel her own pulse.
15. With a watch with swift second hand, count the pulse rate for a full minute.
- Sufficient time is necessary to detect irregularities or other defects.
16. With fingers still in place after taking radial pulse, note the rise and fall of patient’s chest upon
respiration.
- By doing this, it keeps the patient conscious of his own breathing which can alter his usual
rate. I need to pretend that I am still counting for PR.
17. Count respiratory rate for one full minute.
- Sufficient time is necessary to observe rate and other characteristics.
18. Record PR and RR and notes for any unusual characteristics in the jot down notebook.

19. Apply the BP cuff on the arm without contraptions.

- Pressure applied directly to the artery will yield most accurate readings.
20. Feel for a strong pulsation on the brachial artery with the use of 2-3 fingerpads.
- Accurate blood pressure reading is possible when the stethoscope is directly over the artery.
21. Pump the bulb ... 30 mmHg above the point where the systolic pressure is last heard or when
PROCEDURE ON VITAL SIGNS TAKING

the pulse disappears.

- This will prevent you from missing the first tap sound as a result of the auscultatory gap.
22. Position the diaphragm or bell of the stethoscope over the pulse site with the earpiece into
the ears.
23. Release the air gradually with the use of the valve of the bulb and take note of the systolic
blood pressure.
- The first sound is the systolic BP and the last sound is the diastolic BP.

24. Continue to release air gradually and listen for the diastolic blood pressure.
25. Remove the cuff and makes patient comfortable.
26. Records result on the jotdown notebook.
27. With the patient on supine position, locates the apical pulse on the left side of the chest and
drapes for privacy.
- Allows access to patient’s chest for proper placement of stethoscope.
28. Warms the diaphragm of the stethoscope with the palm.
- So that patient will not get startled
29. Places the diaphragm of the stethoscope over the PMI.
- This gives the loudest and most distinctive sound of the heart.
30. Counts the beat for one full minute.
- A full minute count is important for an accurate assessment
31. Records result on the jotdown notebook.
32. Ask the patient’s stool and urine output within the shift and record on the jotdown notebook.
33. Reports any unusualities in the VS.to the CI/HN.
34. Graphs/records results on the VS and TPR master list, graphic sheet and patient’s chart.