Vital Signs Checklist

Taking the TEMPERATURE
1. Explain the procedure to the patient.
2. Get the thermometer, disinfect from bulb to stem.
3. Read the thermometer if in the level of 35ºC, if not shake the
thermometer until it reaches to 35ºC.
4. Instruct the patient to open mouth and place thermometer
under the patients tongue then instruct patient to closemouth.
Taking the PULSE Rate
1. While waiting for the appropriate time, palpate radial artery
and count pulse for 1 minute in the proper.
Taking the RESPIRATORY Rate
1. Proceed to counting the pulse rate for 1 minute. Observing the
proper technique, 1 hand still holding unto the radial artery.
Record both RR & PR.
Taking the BLOOD PRESSURE
1. Apply the BP cuff with arm hyper extended.
2. Palpate brachial artery with left hand, put the stethoscope unto
the ear with the earpiece the patient
3. Inflate cuff till pulsation disappears and add 30 mmHg
4. Place diaphragm bell of stethoscope over brachial artery
5. Release valve slowly, take systole, then diastole.
6. Remove cuff and record BP.
7. Remove Oral thermometer from the mouth
8. Wipe thermometer from stem to bulb.
9. Read the temperature and record.
10. Disinfect thermometer properly.
 11. Record TRP and Graph properly.
Be familiar first with the Normal Vital Signs by Age:
VARIATIONS IN NORMAL VITAL SIGNS BY AGE

Oral
TemperatureIn Respirations
Degrees Celsius Pulse (Average (Average and Blood Pressure
Age (Fahrenheit) and Ranges) Ranges) (mm Hg)
36.8 (98.2)
Newborns axillary 130 (80 to 180) 35 (30 to 80) 73/55
36.8 (98.2)
1 year axillary 120 (80 to 140) 30 (20 to 40) 90/55
5 to 8 years 37 (98.6) 100 (75 to 120) 20 (15 to 25) 95/57
10 years 37 (98.6) 70 (50 to 90) 19 (15 to 25) 102/62
Teen 37 (98.6) 75 (50 to 90) 18 (15 to 25) 120/80
Adult 37 (98.6) 80 (60 to 100) 16 (12 to 20) 120/80
Older adult Possible
(more than 70 increase
years) 37 (98.6) 70 (60 to 100) 16 (15 to 20) diastolic
VITALS SIGNS
Procedures Checklist
NAME:_____________________________YEAR &
SECTION:____________DATE:___________
 
Performed
Preparation Correctly Incorrectly Not Remarks
1. Assess:
A.) Temperature
– Clinical signs of
fever
– Clinical signs of
hypothermia
– Client’s readiness
for the procedure
 – Site most
appropriate for
measurement
– Factors that may
alter core body
temperature
B.) Pulse
– Clinical signs of
cardiovascular
alteration, other than
pulse rate, rhythm, or
volume
– Factor that may
alter pulse rate
C.) Respiration
– Skin and mucus
membrane color
– Position assumed
for breathing
– Signs of cerebral
anoxia
– Chest movement
– Activity tolerance
– Chest pain
– Dyspnea
Medications affecting
respiratory rate.
D.) Blood Pressure
– Signs and
symptoms of
hypertension
– Signs and
symptoms of
hypotension
– Factors affecting
blood pressure.
2. Assemble equipment
and Supply:
– Thermometer
– Cotton balls with
 alcohol or alcohol
wipes
– Tissue /wipes
– Watch with a
second hand or
indicator.
– Stethoscope
– Blood pressure cuff
of the appropriate
size
–
Sphygmomanometer
Procedure
Identify the client
properly and explain
what you are going to
do, why it is
necessary, and how
1. he can cooperate.
Wash hand and
observe other
appropriate infection
2. control procedure
Provide for client
3. privacy.
Place the client in the
4. appropriate position
ASSESSING BODY TEMPERATURE (AXILLARY TEMPERATURE)
Wipe the armpit with
tissue paper or ask
the client to do it if
1. able
2. Wipe the
thermometer from
bulb to stem with
 alcoholized cotton
ball.
Place the
thermometer on the
3. client’s opposite side.
Wait for appropriate
amount of time.
(While waiting for
the time, the nurse
can now assess the
4. other vital signs.)
Remove the
thermometer and
wipe with the tissue if
5. necessary.
6. Read the temperature.
Wipe the
thermometer with
alcoholized cotton
ball from stem to
bulb. Return to
7. container.
ASSESSING A PERIPHERAL PULSE (RADIAL PULSE)
Palpate and count the
pulse. Place two or
three middle fingers
lightly and squarely
1. over the pulse point.
Count for one full
minute and note the
pulse rhythm and
2. volume.
ASSESSING RESPIRATION
 Place the client’s arm
across the chest and
observe the chest
movements while
supposedly taking
1. radial pulse.
Count the respiratory
rate for 1 full minute.
An inhalation and an
exhalation is counted
as one respiration.
Observe the depth,
rhythm, and character
2. or respiration.
ASSESSING BLOOD PRESSURE
The elbow should be
slightly fixed with the
palm of the hand
facing up and the
forearm supported at
1. heart level.
2. Expose the upper arm
Wrap the deflated
cuff evenly around
the upper arm. Locate
the brachial artery.
Apply the center of
the bladder directly
3. over the artery.
For an adult, place
the lower border of
the cuff appropriately
2.5 cm (1 inch) above
4. the antecubital space.
5. If this is the client’s
 initial examination,
perform a preliminary
palpatory
determination of
systolic pressure.
Palpate the brachial
6. artery with fingertips.
Close the valve on
the pump by turning
7. the knob clockwise.
Pump the cuff until
you no longer feel the
brachial pulse. At that
pressure, the blood
cannot flow through
the artery. Note the
pressure on the
sphygmomanometer
at which pulse is no
8. longer felt.
Release the pressure
completely in the
cuff, and wait for one
to two minutes before
making further
9. measurements.
Position the
stethoscope
10. appropriately
Clean the earpieces
of the stethoscope
11. with alcohol.
Warm the amplifier
by rubbing it with the
12. palm of your hand.
 Insert the ear
attachments of the
stethoscope in your
ears so that they tilt
13. slightly forward.
Ensure that the
stethoscope hands
freely from the ears
14. to the diaphragm.
Place the bell of the
amplifier of the
stethoscope over the
brachial pulse. Hold
the diaphragm with
thumb and index
15. finger.
Auscultate the
client’s blood
16. pressure.
Pump the cuff until
the
sphygmomanometer
reads 30 mm Hg
above the point
where the brachial
17. pulse disappeared.
Release the valve of
the cuff carefully so
that the pressure
decreases at the rate
of 2-3 mm Hg per
18. second.
19. As the pressure falls,
identify the
mamometer reading
at each of five
 phases, if possible.
Deflate the cuff
20. rapidly.
Wait one or two
minutes before
making further
21. determinations.
Repeat the above
steps once or twice as
necessary to confirm
the accuracy of the
22. reading.
If this is the client
initially examination,
repeat the procedure
on the client’s other
23. arm.
24. Remove the cuff.
Wipe the cuff with an
approved
25. disinfectant.
Document in the
client’s record (TPR
Sheet):
A.) The temperature
in the client record.
B.) The pulse rate
and rhythm
C.) The respiratory
rate, depth, and
rhythm
Report pertinent
assessment date
according to agency
26. policy.