STEPS/PROCEDURE RATIONALE

1 Wash hands.  To reduce the transmission of microorganisms.

Prepare the equipment needed (stethoscope,
2 sphygmomanometer, digital thermometer, watch with  To save time, energy, and effort.
second hand, reminders notebook, red and blue ball pen).
3 Explain the procedure to the patient  To promote cooperation and to reduce anxiety.
Place the tip of the digital thermometer under the armpit of
4  To start getting the temperature of the patient in the Axillary.
the patient.
Wait until a sound is heard indicating the registered
5  Signal indicates final temperature reading.
temperature.
Remove the thermometer and read the result. Record in
6  Accurate documentation by site allows for comparison of data.
the reminder’s notebook.
7 Repeat procedure if temperature is less than 36.5 C
8 Return the digital thermometer in its container.
Assist client to assume a sitting position. Place tips of 2
9 fingers of hand over groove along radial client's inner
wrist.
1 Use a watch with second hand and count the pulsation for
0
one full minute.
While holding the patient's wrist, take note of the

1
1 To ensure that the patient’s breathing is not altered.
breathing.
1
2 Count the breathing for one full minute.
1
3 Place the patient in a relaxed position.
1
4 Expose the upper part of the left arm.
Wrap the cuff snugly and smoothly about one inch above
1
5 the antecubital space, with the center of the rubber
bladder over the brachial artery.
1 Palpate the radial artery with the fingertips and inflate the
6
cuff until the pulsations stop, then deflate.
Place the earpieces of the stethoscope into the ears and
1
7 place the diaphragm of the stethoscope on the medial
antecubital fossa where the brachial artery is felt.
1 Inflate the cuff and listen to the korotkoff's sound and
8
determine the blood pressure.
1 Remove the cuff from the client's arm and fold it neatly
9
and return it to the container.

Vital signs
 VITAL SIGNS GRAPHING AND RECORDING
2 Able to graph temperature correctly using blue/black
0
colored ink pen.
2 Graph initial temperature taken after encircling correct
1
baseline temperature.
2 Able to graph the temperature taken in the appropriate
2
column.
2 Able to graph pulse rate correctly using red colored ink
3
pen.
2 Encircled correct baseline pulse rate for graphing initial
4
pulse taken.
2
5 Able to graph the pulse rate at the appropriate column.
2 Record respiratory rate correctly using blue/black colored
6
ink pen.
2 Use blue/black colored ink pen for blood pressure
7
recording.
2 Blood pressure taken recorded correctly at the proper
8
box.
2
9 TPR sheet filled up completely and correctly.
3
0 Wash hands.