Vital Signs

Pulse & Respiration Rate

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 Taking a Radial Pulse

EQUIPMENT

.Watch with second hand

• pen and TPR chart.

• Claen gloves.

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 IMPLEMENTATION
1. Check medical order or nursing care plan for
frequency of pulse assessment.

2. Perform hand hygiene.

3. Identify the patient. Introduce yourself to the

patient.

4. Explain procedure and purpose of assessment to

the patient. If the patient was recently active, wait
5 to 10 minutes.

5. Select the appropriate peripheral site.

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6. Put on gloves if needed.
7. Put the patient into a sitting or supine
position.

8. Place index and middle fingers (or three

fingers) on inner aspect of client’s wrist over
the radial artery, lightly compress the artery so
pulsations can be felt and counted.

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9. Note the rhythm and amplitude of the pulse
(pulse volume).

10. Count pulse rate by using

second hand on a watch:

A. For a regular rhythm, count number of beats

for 30 seconds and multiply by 2.

B. For an irregular rhythm, count number of

beats for a full minute.
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11. When measurement is completed, remove

gloves, if worn. Cover the patient and help him

or her to a position of comfort.

13. Perform hand hygiene.

12. Record on TPR chart and report any deviation

in rate, rhythm or strength to the doctor.

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 Assessing Respiratory Rate

EQUIPMENT
• Watch with second hand
. Pencil or pen, TPR chart.

IMPLEMENTATION

1. Be sure chest movement is visible. Client may need

to remove heavy clothing.
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2. While your fingers are still in place for the pulse
measurement, after counting the pulse rate,
observe the patient’s respirations by placing the
patient’s arm in a relaxed position across the
abdomen or lower chest, or place your hand
directly over the patient’s upper abdomen.

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3. Note the rise and fall of the patient’s chest.

4. Using a watch with a second hand, count the

number of respirations for adult in 30 seconds
then multiply by 2. For infants or young
children, count the respirations for 1 full minute.

5. If respirations are abnormal in any way, count

the respirations for at least 1 full minute.

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6. While counting, note whether the depth of respirations
is shallow, normal, or deep and whether the rhythm is
regular or altered.

7. Record the results in the TPR chart.

8. Report any signs of respiratory alterations to the

physician.

9. When measurement is completed, remove gloves, if

worn. Cover the patient and help him or her to a position
of comfort.

10. Perform hand hygiene. 10