As part of the preparation, we need to check the patient’s chart.

● We need to pay attention to their personal information, medical diagnosis, medications,

and baseline vital signs for comparison of the vital signs after a treatment or procedure,
and to monitor any significant change in the patient.
After this, you may introduce yourself to your patient
Nurse: hi, I am ______ from UC-Banilad, College of Nursing level 1. I am your student Nurse
for today. May I have your name please?
Patient: I am _______
Nurse: Alright, how would you like me to address you?
Px: please call me Ma’am ____
Nurse: Alright, ma’am, I am here today to assess your vital signs. This is necessary so that we
can detect and monitor potential health problems. Is that okay with you Ma’am ___?
Px: Okay, sure.
Nurse: Alright, ma’am. I am just going to remind you to remain still and relax. Please refrain
from eating, drinking, or talking while vital signs are taken as this can possibly alter or cause
inaccuracies in your assessment.
Px: okay
We need to inform our clients beforehand like so because informing the client of what will be
assessed leads to better cooperation and understanding.

Then, assess the patient’s toileting needs to promote patient comfort, to efficiently use time, and
to avoid disruptions during the assessment.

Nurse: Ma’am, do you want to pee or go to the CR before we proceed with your vital signs
assessment?
Px: No, I’m fine.

Next, we need to Position the client in a sitting position to have an accurate measurement and
easy access to the area that we’re going to assess. Then provide privacy (close curtain, inform
significant others or visitors to minimize the noise) this is done to avoid embarrassment

After this, Perform medical hand washing to prevent the spread of the virus.
Then, gather all the necessary materials
● This includes the tray with tray lining, cotton balls with alcohol in a container, waste
receptacle with plastic lining, tissue paper, alcohol-based hand rub, a digital
thermometer (also, check if the thermometer is working beforehand). Finally, you should
also have a jot down notebook with a pen and a watch with a second hand.
● We need to do this to save time and avoid potential problems during assessment.
Then, wash your hands again to prepare for the next procedure

Alright, we are finally ready to assess our patient’s vital signs. The first vital sign you need to
take is the temperature.
Nurse: Ma’am, the first vital sign that I am going to assess is your temperature, which helps
detect disease or early infections. Can I push your sleeves upward to expose your arm and
provide access to your armpit?
Px: sure
Nurse: Here is a tissue paper, kindly pat dry your armpit, maam, as moisture may alter your
actual temperature.
Px: okay. *patient pats dry axilla*
Nurse: please discard the tissue paper in this waste receptacle ma’am.
Px discard tissue paper
After doing this, prepare your thermometer. Wipe from the probe to the tip with the use of an
alcoholized cotton ball to prevent the spread of infection. Then, turn it on.

Nurse: I am going to place the thermometer on your armpit now, ma’am. Is that okay with you?
Px: yes, sure.

Place the thermometer at the center of the axilla of the patient. Fold the patient's arm across the
chest and abdominal area supporting the wrist of the patient with your thumb and placing your
index and middle finger on the radial pulse. Then, wait for the beep which means that
temperature reading is done. Through this, accurate reading is ensured.

While waiting for the “beep”, proceed to pulse rate assessment. Start palpating the radial pulse
using the index and middle finger. Do not use your thumb; it has a pulse which can help to avoid
compressing the artery. Apply light to moderate palpation until pulse is determined. Then, count
for one full minute using a second-hand watch. This allows for precise measurement of time, as
each second is easy to count. Also, don’t forget to identify the rhythm and volume of the pulse.

After this, proceed to respiratory rate assessment. Observe the rise and fall of the patient’s
chest and count as one, this is done in one full minute. Place the client’s hand across her
abdomen and your hand over the client’s wrist to ensure the accuracy of the assessment. Pay
attention to the rate and character of the respirations.

Finally, we are done assessing our patient’s vitals signs except for her blood pressure which will
be taken next week. For now, you need to inform the patient of the vital signs reading
Nurse: Maam, your temp is ___, while your re and or is ____ and ___, respectively. So far, your
vital signs are normal.
Px: okay, thank you.

Now that you are done, you may do the after care of materials and equipment, wash hands, and
Record and document findings in the jot down notebook and TPR sheet to allow continuous
data collection and communication to other health personnel.