Republic of the Philippines

SULTAN KUDARAT STATE UNIVERSITY

ACCESS. E.J.C. Montilla, Tacurong City

College of Health Sciences

PROCEDURES AND RATIONALE
ON VITAL SIGNS TAKING

VITAL SIGNS are defined as the procedure that takes the sign of basic
physiology which includes temperature, pulse, respiration and blood pressure. If
any abnormality occurs in the body, vital signs change immediately.

Purpose:
1. To assess the client’s condition.
2. To determine the baseline values for future comparisons
3. To detect changes and abnormalities in the condition of the client

TEMPERATURE
Definition: Measuring/ monitoring patient’s body temperature using clinical
thermometer.
Types of Methods:
 Axillary
 Tympanic
 Oral route
 Rectal route

Purpose:
a. To determine body temperature.
b. To assist in diagnosis.
c. To evaluate patient’s recovery from illness.
d. To determine if immediate measures should be implemented to reduce
dangerously elevated body temperature or converse body heat when body
temperature is dangerous low.
e. To evaluate patient’s response once heat conserving or heal reducing
measures have been implemented.

PULSE RATE
Definition: Checking presence, rate, rhythm and volume of throbbing of artery.

Purpose:
a. To determine number of heart beats occurring per minute( rate)
b. To gather information about heart rhythm and pattern of beats
c. To evaluate strength of pulse
d. To assess heart's ability to deliver blood to distant areas of the blood viz.
fingers and lower extremities
e. To assess response of heart to cardiac medications, activity, blood volume
and gas exchange
f. To assess vascular status of limbs
RESPIRATION
Definition: Monitoring the involuntary process of inspiration and expiration in a
patient
Purposes:
a. To determine number of respiration occurring per minute
b. To gather information about rhythm and depth
c. To assess response of patient to any related therapy/ medication

BLOOD PRESSURE
Definition: Monitoring blood pressure using palpation and/or
sphygmomanometer.
Purpose:
a. To obtain baseline data for diagnosis and treatment
b. To compare with subsequent changes that may occur during care of
patient
c. To assist in evaluating status of patient’s blood volume, cardiac output and
vascular system
d. To evaluate patient’s response to changes in physical condition as a result
of treatment with fluids or medications

STEPS/ PROCEDURES RATIONALE

1. Reads the chart.
2. Perform hand hygiene. Wash
hands or do hand rubbing using
antiseptic solution.
3. Prepare the equipment and
brings to the bedside.
To elicit correct information and proper
client identification.
Hand hygiene reduces the transmission
of microorganisms and prevents
nosocomial infection.
Organization facilitates accurate skill
performance for proper time
management, planning and improve
efficiency.

Equipment needed to prepare:

4. Identify the patient and explains
the procedure.
TEMPERATURE TAKING
5. Wipe the thermometer from the
bulb towards the stem with
alcohol swab or tissue wipes.
a. Digital Thermometer
b. Cotton balls with alcohol/ Alcohol
swab
c. Wash cloth/ Tissue
d. Watch with second hand rotation
e. BP Apparatus/ Sphygmomanometer
(Aneroid manometer)
f. Stethoscope
g. Jotdown notebook and ballpen
Proper identification provides patient
safety measures for safe care and gain
patient’s cooperation during the
procedure.
Wiping down the bulb with a clean wipe
is uncontaminated with bacteria and once
picked up decontaminates towards the
stem.
6. Pat the axilla dry using wash
cloth or dry tissue.
7. Place the thermometer between
the axilla directed upward.
Position patient's arm across the
chest.
8. Leave the thermometer in place
until it beeps or as per
manufacturer instruction.
9. Remove thermometer from axilla
and wipe from the stem to the
bulb using alcohol swab or CB
with alcohol. Record the
temperature reading in the
jotdown notebook as ___ºC.
PULSE RATE and RESPIRATION
RATE
10. Place fingertips on the radial
pulse of the other arm feeling for
the pulsation while using the
watch with second hand rotation
to count the pulse rate for one full
minute. Mentally note the pulse
rate result as ____ beats per
minute.
11. While the fingertips are still in
place after taking the radial
pulse, note the rise and fall of the
patient's chest upon respiration.
Count the respiratory rate for one
full minute and record as
____breaths/ cycles per
minute.
12. Record both PR and RR
including any unusual
characteristics in the jotdown
notebook.
BLOOD PRESSURE TAKING
13. Setting the position: Assist the
client to a comfortable position.
Be sure room is warm, quiet and
relaxing.
14. Support the selected arm. Turn
Excessive moisture will cool the skin and
could result in an inaccurate temperature
reading. Be sure to pat the area dry
rather than rubbing the area. Rubbing the
axillary area could cause an inaccurate
reading due to the heat caused by friction
(rubbing).
Placing the thermometer in the correct
position for proper and close contact of
the bulb of the thermometer with the
superficial blood vessels in the axilla
ensures a more accurate temperature
reading.
To ensure an accurate reading.
Wiping down the stem with a clean wipe
from uncontaminated towards the stem
which is now contaminated after use.
The fingertips are sensitive and better
able to feel the pulse. Do not use your
thumb because it has a strong pulse of
its own.
Count respiratory rate modestly while
you are taking the pulse rate so that the
patient is not aware that you are taking
the respiration rate. Count for 30
seconds or for a full minute if irregular.
Documentation provides on-going data
collection.
The client's perceptions that the physical
or interpersonal environment is stressful
affect the blood pressure measurement.
Ideally, the patient may be sitting or lying
 the palm upward.
15. Remove any constrictive clothing.
16. Palpate for the brachial artery.
Center the cuff’s bladder
approximately 2.5 cm (1 inch)
above the site where you
palpated the brachial pulse.
17. Wrap the cuff snugly around the
client’s arm and secure the end
approximately.
18. Check the manometer whether if
it is at level with the client’s heart.
19. Measure blood pressure by two
step method:
(A) Palpatory method:
 Palpate brachial pulse distal to
the cuff with fingertips of non-
dominant hand.
 Close the screw clamp on the
bulb. Inflate the cuff while still
checking the pulse with other
hand.
 Observe the point where pulse
is no longer palpable.
 Inflate cuff to pressure 20-30
mmHg above point at which
pulse disappears.
 Open the screw clamp, deflate
the cuff fully and wait for 30
seconds.
20. (B) Auscultation method:
Position the stethoscope’s
earpieces comfortably in your
ears (turn tips slightly forward). Be
sure sounds are clear, not
muffled.
 Place the diaphragm over the
client’s brachial artery.
 Do not allow chest piece to
touch cuff or clothing.
down with the bare arm at heart level.
The arm should be at heart level for
accurate measurement. Rotate the arm
so the brachial pulse is easily accessible.
Not constricted by clothing is allowed to
access the brachial pulse easily and
measure accurately. Do not use an arm
where circulation is compromised in
anyway.
Palpate the brachial artery just above the
antecubital fossa medially. Center the
cuff’s bladder to ensure even cuff
inflation over the brachial artery.
Loose-fitting cuff causes false high
readings. Appropriate way to wrap is that
you can put only 2 fingers between the
arm and cuff.
Improper height can alter perception of
reading.
Palpation identifies the approximate
systolic reading. Estimating prevents
false low readings, which may result in
the presence of an auscultory gap.
Maximal inflation point for accurate
reading can be determined by palpation.
Short interval eases any venous
congestion that may have occurred.
Each earpiece should follow angle of ear
canal to facilitate hearing.
Proper stethoscope placement ensures
optimal sound reception.
Stethoscope improperly positioned
sounds that often result in false low
systolic and high diastolic readings.
21. Close the valve on the bulb and Ensure that the systolic reading is not
inflate the cuff to a pressure 30 under-estimated.
mmHg above the point where the
pulse had disappeared.
22. Open the valve and allow the If deflation occurs too rapidly, reading
aneroid dial to fall at rate of 2 to may be inaccurate.
3mmHg per second.
23. Note the point on the dial when This first sound heard represents the
first clear sound is heard. The systolic pressure or the point where the
sound will slowly increase in heart is able to force blood into the
intensity. brachial artery.
24. Continue deflating the cuff and This is the adult diastolic pressure. It
note the point where the sound represents the pressure that the artery
disappears. Listen for 10 to 20 walls exert on the blood at rest.
mmHg after the last sound.
25. Release any remaining air quickly Continuous cuff inflation causes arterial
in the cuff and remove it. occlusion, resulting in numbness and
tingling of client’s arm.
NOTE: If you must recheck the The interval eases any venous
reading for any reason, allow a 1 congestion and provides for an accurate
minute interval before taking reading when you repeat the
blood pressure again. measurement.
26. Removes the cuff and assist Indicate your interest in the client's well-
client to a comfortable position. being and allow him/her to participate in
Advise client of the reading. care.
27. Perform hand hygiene. To deter the spread of microorganisms
and nosocomial infections.
28. Records the result in the jotdown Documentation provides on-going data
notebook as ____/___ mmHg. collection.
CARDIAC/ APICAL PULSE Warming the metal or
29. Warm the diaphragm of the plastic diaphragm prevents the patient
stethoscope with the palm of the from being startled and result in an
hand. inaccurate reading.
30. Instruct the patient to place the To maintain patient’s privacy. Apical
diaphragm of the stethoscope pulse rate should be taken for a full
over the chest or over the point of minute for accuracy, and is located at the
maximal impulse when on sitting fifth intercostal space in line with the
position and drape if necessary. middle of the clavicle or below the
nipple in adults.
31. Count the apical pulse rate for Upon auscultating the apical pulse, you
one full minute and record as will hear the sounds “lub dub” – this
____beats per minute. counts as one beat. Count the apical
pulse for one minute to ensure accuracy.
32. Records the result in the jotdown Documentation provides on-going data
notebook. collection.
33. Does aftercare and perform hand To maintain standard precautions and
hygiene prevent the spread of infection.
 Republic of the Philippines
SULTAN KUDARAT STATE UNIVERSITY
ACCESS. E.J.C. Montilla, Tacurong City

College of Health Sciences

PERFORMANCE CHECKLIST
ON VITAL SIGNS TAKING

Name: ____________________________________ Date: _________________

Course/Year/Section: _______________

Direction: In using the checklist, please use the following rating scale in
determining the performance of the student.
5 Excellent: Student performs the procedure correctly, and perfectly.
Student states the rationale correctly and completely. Student is able to
answer questions accurately.
4 Very Satisfactory: Student performs the procedure correctly. Student
states the rationale correctly but incompletely. Student is able to answer
questions.
3 Satisfactory: Student performs the procedure correctly but failed to
states the rationale. Student is able to answer questions when cued.
2 Fair: Student performs the procedure when cued. Student failed to states
the rationale. Student is able to answer questions when cued.
1 Poor: Student fails to perform the procedure correctly even when cued.
Student does not know the rationale.

RATING
STEPS/ PROCEDURES
E V S F P
1. Reads the chart. 5 4 3 2 1
2. Perform hand hygiene. Wash hands or do hand rubbing 5 4 3 2 1
using antiseptic solution.
3. Prepare the equipment and brings to the bedside. 5 4 3 2 1
4. Identify the patient and explains the procedure. 5 4 3 2 1
TEMPERATURE TAKING 5 4 3 2 1
5. Wipe the thermometer from the bulb towards the stem
with alcohol swab or tissue wipes.
6. Pat the axilla dry using wash cloth or dry tissue. 5 4 3 2 1
7. Place the thermometer between the axilla directed 5 4 3 2 1
upward. Position patient's arm across the chest.
8. Leave the thermometer in place until it beeps or as per 5 4 3 2 1
manufacturer instruction.
9. Remove thermometer from axilla and wipe from the stem 5 4 3 2 1
to the bulb using alcohol swab or CB with alcohol. Record
the temperature reading in the jotdown notebook as
___ºC.
PULSE RATE and RESPIRATION RATE 5 4 3 2 1
10. Place fingertips on the radial pulse of the other arm
feeling for the pulsation while using the watch with
 second hand rotation to count the pulse rate for one full
minute. Mentally note the pulse rate result as ____ beats
per minute.
11. While the fingertips are still in place after taking the radial 5 4 3 2 1
pulse, note the rise and fall of the patient's chest upon
respiration. Count the respiratory rate for one full minute
and record as ____breaths/ cycles per minute.
12. Record both PR and RR including any unusual 5 4 3 2 1
characteristics in the jotdown notebook.
BLOOD PRESSURE TAKING 5 4 3 2 1
13. Setting the position: Assist the client to a comfortable
position. Be sure room is warm, quiet and relaxing.
14. Support the selected arm. Turn the palm upward. 5 4 3 2 1
15. Remove any constrictive clothing. 5 4 3 2 1
16. Palpate for the brachial artery. Center the cuff’s bladder 5 4 3 2 1
approximately 2.5 cm (1 inch) above the site where you
palpated the brachial pulse.

17. Wrap the cuff snugly around the client’s arm and secure 5 4 3 2 1
the end approximately.
18. Check the manometer whether if it is at level with the 5 4 3 2 1
client’s heart.
19. Measure blood pressure by two step method: 5 4 3 2 1
(A) Palpatory method:
 Palpate brachial pulse distal to the cuff with fingertips
of non-dominant hand.
 Close the screw clamp on the bulb. Inflate the cuff
while still checking the pulse with other hand.
 Observe the point where pulse is no longer palpable.
 Inflate cuff to pressure 20-30 mmHg above point at
which pulse disappears.
 Open the screw clamp, deflate the cuff fully and wait
for 30 seconds.
20. (B) Auscultation method: Position the stethoscope’s 5 4 3 2 1
earpieces comfortably in your ears (turn tips slightly
forward). Be sure sounds are clear, not muffled.
 Place the diaphragm over the client’s brachial artery.
 Do not allow chest piece to touch cuff or clothing.
21. Close the valve on the bulb and inflate the cuff to a 5 4 3 2 1
pressure 30 mmHg above the point where the pulse had
disappeared.
22. Open the valve and allow the aneroid dial to fall at rate of 5 4 3 2 1
2 to 3mmHg per second.
23. Note the point on the dial when first clear sound is heard. 5 4 3 2 1
The sound will slowly increase in intensity.
24. Continue deflating the cuff and note the point where the 5 4 3 2 1
sound disappears. Listen for 10 to 20 mmHg after the last
sound.
25. Release any remaining air quickly in the cuff and remove 5 4 3 2 1
 it. NOTE: If you must recheck the reading for any reason,
allow a 1 minute interval before taking blood pressure
again.
26. Removes the cuff and assist client to a comfortable 5 4 3 2 1
position. Advise client of the reading.
27. Perform hand hygiene. 5 4 3 2 1
28. Records the result in the jotdown notebook as ____/___ 5 4 3 2 1
mmHg.
CARDIAC/ APICAL PULSE 5 4 3 2 1
29. Warm the diaphragm of the stethoscope with the palm of
the hand.
30. Instruct the patient to place the diaphragm of the 5 4 3 2 1
stethoscope over the chest or over the point of maximal
impulse when on sitting position and drape if necessary.
31. Count the apical pulse rate for one full minute and record 5 4 3 2 1
as ____beats per minute.
32. Records the result in the jotdown notebook. 5 4 3 2 1
33. Does aftercare and perform hand hygiene 5 4 3 2 1
Sub-total =
Total Score: _______________
RD Grade: _______________
Instructors’ Remarks:
________________________________________________________________
________________________________________________________________
________________________________________________________________

___________________________________________
Signature over Printed Name of Clinical Instructor