WHAT ARE VITAL SIGNS?

• A quick and efficient way of monitoring a client’s condition or identifying problems and evaluating
the client’s response to intervention
• Temperature, Pulse, Respiratory Rate, Blood Pressure, Oxygen Saturation
PROCEDURE RATIONALE
1. Prepare the materials
2. Wash hands/ Perform handwashing procedure To remove any microorganisms.
3. Explain the procedure to the client When the client knows what is to be done, he/she will
cooperate easily.
4. Place the patient in a comfortable lying or sitting
position.

TEMPERATURE REQUISITES:
- Tray or container with:
✓ Digital thermometer
✓ Clean cotton balls
✓ Cotton balls soaked in 70% alcohol
✓ Waste receptacle
✓ Jot down notebook or TPR Sheet
5. Take the client’s axillary temperature using the
digital thermometer:
a. Wipe the thermometer from bulb to stem Wiping from an area where there are few or no
using cotton balls with alcohol followed by a organisms to an area where organisms may be
dry cotton ball. present minimizes spread of organism to cleaner
areas.
b. Pat the axilla dry with tissue paper and
switch on the thermometer
c. Place the thermometer in the armpit with the When the bulb rests against the superficial blood
end directed towards the client’s chest. vessels in the axilla and the skin surfaces are brought
together to reduce the amount of air surrounding the
bulb, a reasonable reliable measurement of body
temperature can be obtained.
d. After hearing the beeping sound, remove the
thermometer from axilla.
e. Wipe the thermometer from the stem to the This minimizes the spread of organisms.
bulb using a dry cotton ball.
f. Obtain temperature reading and switch off
the thermometer.
g. Wipe the thermometer with a cotton ball with
alcohol from stem to bulb and return to the
container.
6. Record the temperature reading on the jot down
notebook.

RADIAL PULSE RATE & RESPIRATORY RATE REQUISITES:

7. Take the client’s radial pulse rate and respiratory
rate:
a. Position the client’s arm at a 45-degree
angle across the chest/abdomen.
✓ Watch with second hand
✓ Jot down notebook
These positions are ordinarily comfortable for the
client and convenient for the nurse.
 b. Place 3 middle finger pads on radial artery The fingertips are sensitive to touch. This will help to
with thumb at the back of the patient’s wrist. feel the pulsation of the radial artery.
c. Applying sufficient pressure, count pulsation Moderate pressure allows the nurse to feel the
for one full minute using wrist watch with superficial artery as it expands and contract with
second hand. each heartbeat. Too much pressure will obliterate
pulse. Sufficient time is necessary to assess pulse
rate, rhythm, and volume.
d. With fingers still on the client’s radial artery, Counting the respiration while still presumably
take RR by counting the rise and fall of the counting the client’s pulse, keeps the client from
chest/abdomen for one full minute. becoming conscious of his breathing hence possibly
altering his usual rate.
8. Record the PR and RR on the jot down
notebook.
APICAL PULSE RATE/CARDIAC RATE REQUISITES:
✓ Watch with second hand
✓ Cotton balls soaked in 70% alcohol
✓ Stethoscope
✓ Jot down notebook
9. Take Apical Pulse Rate/Cardiac Rate:
a. Wipe the earpiece & diaphragm of the To cleanse both earpieces and diaphragm which may
stethoscope using the cotton ball with harbor pathogenic bacteria.
alcohol.
b. Locate the apical pulse at the 5th ICS/MCL.
c. Insert the earpieces of the stethoscope into This position facilitates hearing.
the ears in the direction of the ear canal,
slightly forward.
d. Warm the diaphragm of the stethoscope by To prevent startling the client since metal of the
holding in the palm of the hand for a few diaphragm is usually cold.
seconds.
e. Place the diaphragm of the stethoscope over The heart beat is normally loudest at the apex of the
PMI. heart, this will give an accurate count.
f. Count the CR for one full minute.
10. Record the CR & any unusual observations on
the jot down notebook.

BLOOD PRESSURE REQUISITES:

11. Proceed to taking BP:
a. Extend the client’s arm with palm facing
upward on a support at the level of the
client’s heart.
b. Wrap the cuff smoothly around the client’s
arm 2 inches above the elbow or 1-2 inches
above the antecubital space with rubber
tubing placed along brachial artery.
c. Attach the calibrated dial to the cuff.
d. Using the finger pads, feel for the pulsation
of the brachial artery on the antecubital
space.
✓ Watch with second hand
✓ Sphygmomanometer
✓ Stethoscope
✓ Jot down notebook
✓ Cotton balls soaked in 70% alcohol
Blood pressure increases when arm is below heart
level and decreases when arm is above level.
The bladder inside the cuff must be directly over the
artery to be compressed to yieled most accurate
reading.
Locating the artery allows the stethoscope to be
placed for maximum auscultation.
 e. Insert the earpieces of the stethoscope into
the ears in the direction of the ear canal,
slightly forward and place diaphragm of the
stethoscope over the brachial artery.
f. Inflate the rubber cuff up to 20-30 mmHg
more than the normal reading/usual/last
reading.
g. Deflate the rubber cuff at 2-3mmHg per
second until SBP & DBP are determined.
h. Deflate the BP cuff fully and remove from the
client’s arm.
12. Record in the jot down notebook and inform the
client of the result.
13. Wipe the earpiece & diaphragm of the
stethoscope using the cotton balls with alcohol.
14. Discard the used cotton balls properly after use
and do after care.
15. Graph accurately findings on the VS sheet.
The transmission of sounds can be distorted when
the stethoscope is misplaced. Sounds are heard
more clearly when earpieces follow the direction of
ear canal.
Pressure on the inflated cuff must be greater than the
systolic pressure to occlude the flow of blood through
the brachial artery.
If the rate is faster or slower, an error in measurement
may occur. There is no clinical significance at phases
2-3 mmHg.
This permits the blood trapped in the veins to be
released.