CHECKING THE VITAL SIGNS(VS)

Definition: Clinical measuremants specifically temperature pulse, respiration and blood

pressure that indicate the state ofth patient’s essential functions.Pain is
considered the “ fifth vital sign” in some organizations across the globe

I - 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 • Easy, fast, accurate • Cannot be used for clients who
are unconscious, confused, prone
to seizures, recovering from oral
surgery, or under age 6.
• Need to wait 15–20 minutes after
eating.

Rectal • More reflective of core • Cannot be used for clients who

Temperature have rectal 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 the
anus.

• Fast
Tympanic
• More reflective of core temperature
• Reports of accuracy are
• Safe, good for children
conflicting.

• Measures skin surface, which can

Axillary
• Safe, good for children and be variable.
newborns
• Measures skin surface
Forehead
• Safe and easy temperature.

• Least accurate method

Temporal Normal: Close to rectal temperature,
arterial 10F or 0.50C higher than an oral
temperature, and

20F or 10C higher than an axillary

temperature)

Normal Body Temperature:

1. Oral Temperature - 36.1 – 37.2 0 C or 97 – 99 0 C (Ave = 370 C)

2. Rectal Temperature - 36.7 – 37.8 0 C or 98 – 100 0 C (Ave = 37.50 C)
3. Axillary temperature - 35.6 – 36.7 0 C or 96 – 98 0 C (Ave = 36.70 C)
4. Tympanic - 37.5_ C or 99.5_F

Types of thermometers include:

• Electronic digital thermometer: Used for oral, rectal, or axillary temperature

measurements.
• Tympanic thermometer: For taking the temperature via the car
• Temporal artery thermometer: Measures arterial temperature through infrared
scanning of the temporal artery.
• Disposable paper strips with temperature sensitive dots: Used for skin/surface
temperature measurements.

A. Oral Method
Contraindications:
1. infants
2. unconscious and irrational patients
3. patients who breathe through their mouths
4. those with disease of the oral cavity or surgery of the nose or mouth
5. patients who have just taken cold or hot foods or fluids

Equipment:

1. Tray containing:
a. thermometer
b. jar of CB in water
c. jar with cut tissue paper
d. waste receptacle (must not be carton because waste fluid will contaminate the
surface on while it stands)
2. Watch with second hand
3. 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 and
explain the procedure to the
patient.
5. Rinse the thermometer 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 tissues.
6. Place tip of thermometer under the
client’s tongue and along the
gumline to the posterior sublingual
pocket lateral to center of lower jaw
and instruct him to close his lips
tightly.
7. An electronic thermometer will
signal (beep) when a constant
temperature registers.Wait 1-3
minutes for ordinary glass
thermometer.
8. Remove the thermometer and wipe
it at once with dry CB or soft tissue
from stem down to the mercury
bulb using a firm twisting motion.
9. Read measurement on display of
digital thermometer.
10. Inform client and/or watcher of
temperature reading.
11. Cleanse the thermometer from the
stem to bulb using CB with water
Rationale
To obtain necessary data.
To deter the spread of microorganism.
Smoking or oral intake of foods/ fluids can
cause false temperature reading.
When the patient 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 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 the surface.
Increases involvement and trust of the client.
 twice, then dry with tissue wipe and
return to the container.
Confining contaminated articles help to
12. Dispose the used CB and tissue reduce the spread of pathogens.
paper in the waste receptacle.

13. Record the temperature in the

jotdown notebook. Report to the CI
or headnurse any unusualities.

14. Wash hands.

Accurate documentation allows for
15. Record the temperature on the TPR comparison of data.
masterlist sheet and graphic chart.

B. Axillary Method

Many hospitals in the Philippines obtain patient’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.

1. Tray containing:
a. thermometer
b. jar of CB in water
c. jar with cut tissue paper
d. waste receptacle

2. Jot down notebook and pen

3. Client’s wash cloth or tissue wipes

Procedure

Action Rationale

6. Follow steps 1 to 5 of
oraltemperature taking.

7. Expose arm and shoulder by

removing one sleeve of client’s
gown. Avoid exposing chest.

8. Pat the patient’s axilla dry with a
wash cloth or tissue. Place the
probe of the thermometer into the
center of the axilla. Bring the
patient’s arm down close to his
Moisture in the axilla may alter the result of
the temperature. The deepest area of the
axilla provides the most accurate temperature
measurement.
 body and place his forearm over his
chest.

9. Leave the thermometer in place Allowing sufficient time for the axillary tissue
until signal or beep is heard or 1-3 to come in contact with the thermometer bulb
minutes of ordinary thermometer. results in a reasonably accurate measurement
of body temperature.
10. Remove, dry with tissue paper and
read measurement on digital
display of the thermometer.

11. Inform client of temperature

reading.

12. Assist client in putting back the

sleeve of gown.

13. Follow subsequent steps of cleaning

like in oral method. (Steps 11 and
12)

14. Record reading in the jotdown

notebook. Report to the CI/HN for
unusualities.

15. Wash hands.

16. Document on the TPR master list

and graphic chart.
C. Rectal Method

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

Contraindications:
This method is contraindicated to the following patients:

1. With recent rectal surgery.

2. With diarrhea.
3. With disease of the rectum.
4. With cardiovascular alteration because the presence of the thermometer in the
rectum may stimulate the vagus nerve causing bradycardia or rhythm disorder.
5. With leukemia which may traumatize the rectal mucosa causing bleeding.

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

1. lubricant 3. toilet paper (patient’s supply)
 2. working gloves 4. thermometer (patient’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
and explain the procedure. the significant other.

3. Place client in lateral position/ Sim’s Proper positioning ensures visualization of

position. anus. Flexing knee relaxes muscles for ease of
insertion.

4. Drape patient exposing only the Avoid embarrassment and provide privacy.
rectum.
Gloves are used to avoid contact with bodily
5. Don working gloves.
secretions and to reduce transmission of
microorganisms.

Lubrication reduces friction and facilitates the

6. Lubricate tip of rectal thermometer
insertion of the thermometer. This minimizes
or probe to approximately 1 inch
irritation of the mucus membrane of the anal
above the bulb.
canal.

Aids in visualization of anus.

7. With the dominant hand, hold the
thermometer. With the non
dominant hand, separate buttocks to
expose anus.
Relaxes anal sphincter.
8. Instruct client to take a deep breath.
Gently insert the thermometer
approximately 0.5 -1 inch. Release
buttocks to allow to fall in place.
Allows sufficient time for thermometer to
9. Hold the thermometer in place until
register a more accurate measurement of
the beep sound is heard.
body temperature.
Removes lubricant/ feces that may have
10. Remove the thermometer and wipe
attached to the probe of the thermometer.
with dry tissue. Discard used tissue in
the waste receptacle.

11. Read measurement on digital display

of the thermometer
12. Wipe anal area with tissue and make
client comfortable. Dispose soiled
tissue in the yellow bin.

13. Cleanse thermometer, as previously

learned.

14. Remove and dispose gloves in the

yellow bin.

15. Wash hands.

16. Record temperature in the jotdown

notebook.

17. Inform CI of any unusuality

18. Document in the graphic chart and

TPR master list.

D. Disposable (Chemical Strip) Thermometer

Procedure

Action Rationale
7. Follow steps 1 to 6 of oral
temperature-taking.

8. Apply tape to appropriate skin area,

usually forehead.

9. Observe tape for color changes.

10. Follow steps 16, 17, 18 of oral

temperature-taking.

Tympanic Temperature: Infrared Thermometer

It uses infrared sensors to sense the temperature of the tympanic membrane.

Procedure

Action Rationale
 5. Follow steps 1, 2, &4 of oral
temperature taking.

6. Remove probe from container and

attach probe cover to tympanic
thermometer unit.
7. Turn client’s head to one side. For
This technique straightens the ear canal to
an adult, pull pinna upward and
back; for a child, pull down and facilitate insertion of the probe.
back. Gently insert probe with firm
pressure into ear canal.
8. Remove probe from ear after the
reading is displayed on digital unit
(usually 2 seconds).
9. Remove probe cover and discard and
place the thermometer in storage
container.

10. Follow steps 16, 17, 18 of oral

temperature-taking.

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

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

Possible sites for taking the pulse:

a. apical
b. radial artery f. popliteal artery
c. temporal artery g. carotid artery
d. dorsalis pedis h. brachial artery
e. femoral artery i. posterior tibialis

What to note while counting the pulse:

a. rate c. tension or compressibility
b. rhythm or regularity d. volume

Normal pulse rate per minute:

Children: Adult:

0 – 1 mo. - 120 – 160 (Ave: 140) Male - 70 – 80 beats/minute

11 – 12 mos. - 100 – 140 (Ave: 120) Female - 80 – 90 beats/minute
Toddler - 80 – 120 (Ave: 100)
Preschooler - 75 – 120 (Ave: 100)
Equipment: a. Watch with second hand. c. Alcohol swab
b. Jot down notebook and pen d. stethoscope
A. RADIAL PULSE

Procedure

Action Rationale

1. Explain the procedure to the
patient.
2. Have the patient rest his arm along
side of his body with the wrist
extended and the palm of the hand
downward, or place arm on top of
the patient’s upper abdomen with
the palm downward position.
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
patient’s wrist.
4. Apply enough pressure so that the
patient’s pulsating artery can be felt
distinctly.
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.
To gain cooperation and make client at ease.
This position places the radial artery on the
inner aspect of the patient’s wrist. The nurse’s
fingers rest conveniently on the artery with
thumb in a position to the outer aspect of the
patient’s wrist.
The fingertips which are sensitive to touch will
feel the pulsation of the patient’s radial
artery. If the thumb is used to palpate the
patient’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.

7. Record pulse rate on the jot down

notebook.
8. Refer anything unusual to the
clinical Instructors and/ or head
nurse.

9. Record in client’s graphic chart and

VS master list.
B. 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 to the patient Elicits cooperation from the client.
and/or significant others.
2. Assist the client on supine position.
Swabbing action removes dirt. ROH
3. Cleanse earpieces and diaphragm of evaporates fast and render the parts dry easily
stethoscope using alcohol swab.
Allows access to patient’s chest for proper
4. Raise the gown and properly drape placement of stethoscope.
the client exposing the sternum and
the left side of chest.
Placing a cold diaphragm against the skin may
5. Warm the diaphragm of the startle the patient and momentarily increase
stethoscope with your hand before the heart rate.
applying it to the patient’s chest.
This gives the loudest and most distinctive
6. Place the diaphragm of the sound of the heart.
stethoscope over the apex of the
heart, located at the fifth intercostal
space, left midclavicular line 5th ICS,
LMCL). Then, insert the earpieces in
your ears.
A full minute count is important for an
7. Move the diaphragm to the site of accurate assessment. A longer duration helps
the loudest beats. Count the beats determine pulse rhythm and quality.
for 60 seconds and note their In no instance, is the radial pulse count greater
rhythm and volume. Also evaluate than the apical pulse count.
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. Referral of anything unusual in a patient
10. Refer anything unusual to the CI or enables the professional nurse to respond
Head nurse. immediately to the needs or problem of the
patient.
11. Record the result on the chart and
VS master list.
III - RESPIRATION
Definition: It is the exchange of oxygen and carbon dioxide between the atmosphere and
body cells and is initiated by the act of breathing.

Purpose: To obtain the respiratory rate per minute and an estimate of the
patient’s respiratory status.

Normal Rates:
Infants - 30 – 40/ minute
Children - 20 – 25/ minute
Adult - 16 – 20/ minute

Equipment: a. watch with second hand

b. jot down notebook and pen

Procedure
Action
1. While the fingertips are still in place
after counting the radial pulse rate,
observe the patient’s respiration.
Rationale
Counting the respiration while presumably
still counting the pulse keeps the client from
becoming conscious of his breathing which
can possibly alter his usual rate.

2. Note the rise and fall of the patient’s A complete cycle of inspiration and expiration
chest with each inspiration and constitutes one act of respiration.
expiration. This observation can be
made without disturbing the
patient’s bedclothes.

3. Using a watch with second hand, Sufficient time is necessary to observe rate,
count the number of respiration for depth and other characteristics.
one full minute.

4. If respirations are abnormal, repeat

to determine accurately the rate,
the characteristics of the breathing.

5. Record respiratory rate on the jot

down notebook including
abnormalities in rhythm and depth,
if any.

6. Refer to the CI and/or Headnurse

any abnormalities in rate and/or
rhythm.
 7. Record the result in the client’s
graphic chart and the TPR master
list.

IV - BLOOD PRESSURE
Definition: Blood pressure is the lateral force exerted by the blood on the arterial
walls.
Purposes: 1. To aid in diagnosis
2. To observe changes in a patient’s condition.

Contraindications for Brachial Artery Blood Pressure Measurement

1. Surgery including the breasts, axilla, shoulder, arm or hands.
2. Venous Access Device such as AV shunt (in patients on hemodialysis) or IVF in
the arm.
3. Injury or disease to the shoulder, arm or hands such as trauma, burn or application
of cast or bandage.

Sites for BP taking:

1. either arm on the antecubital space
2. either leg on the popliteal space
3. dorsalis pedis
Equipment:
1. Stethoscope
2. Sphygmomanometer with appropriate size of cuff
3. Jotdown notebook and pen
4. Alcohol swab

Normal Ranges:
1. Infant - 50/40 – 80/50
2. Children - 87/48 – 117/64
3. Adult - 110/70 – 130/90

Procedure
Action
1. Explain the procedure to the patient.
Make sure that client has not
smoked cigarette or ingested
beverages that contains caffeine
within 30 minutes
2. Place the patient in a comfortable
position with the forearm supported
and the palm upward.
Rationale
Nicotine causes vasoconstriction in peripheral
and coronary blood vessels which may cause
increase in blood pressure. Caffeine is a
stimulant that increases blood pressure.
This position exposes the brachial artery so
that a stethoscope can rest on it conveniently
on the antecubital area
 3. Position yourself so that the An accurate reading is obtained when the
calibration of the apparatus can be manometer column is in direct vision.
read at eye level and no more than
3 feet away.
4. Place the cuff so that the inflatable Pressure applied directly to the artery will
bag is centered and lies midway over yield most accurate readings.
the anterior surface of the brachial
artery, (the surface of the brachial
artery should be at the center of the
2 tubings of the cuff) so that the
lower edge of cuff is 2.5 – 5 cm.
above antecubital fossa.
5. Wrap the cuff smoothly and snugly A twisted cuff and wrapping could produce
around the arm with the end of the inaccurate reading.
cuff secure.
6. Use the fingertips to feel a strong Accurate blood pressure reading is possible
pulsation on the antecubital space. when the stethoscope is directly over the
artery.

7. Inflate the cuff to 30 mmHg where the This will prevent you from missing the first tap
pulsation disappears. Place the sound as a result of the auscultatory gap
diaphragm of the stethoscope (period where no sound is heard).
directly over the pulse.

8. Gradually deflate cuff all the way to First sound is the systolic BP and last sound is
zero taking note of the first and the diastolic BP.
last clear, loud sound.
9. Remove the cuff and make patient
comfortable.
10. Record the reading on the jot down
notebook.

11. Report any unusualities to the CI

and/or Headnurse.

12. Record BP on the VS sheet and VS

masterlist.

* Pulse pressure – the difference between systolic and diastolic pressures.

e.g. 120/ 80 BP
Pulse pressure is 40
– may be ordered in patients with Dengue Hemorrhagic Fever