Vital Signs

By: Canton
Montano
Prias
 Definition
Temperature pulse, respiration and
blood pressure some indications of the
state of health of an individual. They
represent interrelated physiologic
systems of the body.
 Purpose
The purpose of recording vital signs is to
establish a baseline on admission to a
hospital, clinic, professional office, or
other encounter with a health care
provider.
 Equipments
Sphygmomanometer

An instrument for
measuring blood
pressure, particularly in
arteries.
 Equipments
Stethoscope
a medical instrument for
detecting sounds
produced in the body that
are conveyed to the ears of
the listener through
rubber tubing connected
with a piece placed upon
the area to be examined.
 Equipments
Thermometer
An instrument for
measuring and indicating
temperature, typically one
consisting of a narrow,
hermetically sealed glass
tube marked with
graduations and having at
one end a bulb
 Procedure
Temperature

It is the difference between heat produced

and heat lost by the body and is measured
through the use of a thermometer
 Procedure
Temperature (Axillary method)
1. Follow steps 1,2,3, and 4 of oral temperature taking

2. Expose arm and shoulder by removing one sleeve of client’s gown.

Avoid exposing chest

3. Rinse it 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
 Procedure
Temperature (Axillary method)
4. Pat the client’s axilla dry with a face towel. Place the
thermometer or probe into the center of axilla bring the client’s
arm down close to his body and place his forearm over his chest.

5. Leave the thermometer in place until signal is heard

6. Remove, dry and read measurement on digital display of

electronic thermometer.
 Procedure
Temperature (Axillary method)
7. Inform client of temperature reading

8. Put back the sleeve

9. Cleanse the thermometer from the stem to the bulb using CB

with water, then dry and return to the container

10. Record the temperature in the jot down notebook

11. Wash hands

12. Record the temperature on the master list sheet and graphic
chart
 Procedure
Pulse
-It is a rhythmical throbbing that results from a wave of
blood through an artery as the heart contracts.
 
Equipment used: watch with second hand, jot down
notebook and pen, alcohol swab, stethoscope
 Procedure
Radial Pulse
1. Explain the procedure.

2. Have the client rest his arm alongside his body with the
wrist extended and the palm of the hand downward, or
place arm on top of the client’s upper abdomen.

3. Place your fist, second and third fingers along the radial
artery and press gently against the radius, rest the
thumb on the back of the client’s wrist.
 Procedure
Radial Pulse
4. Apply enough pressure so that client’s pulsating artery
can be felt.

5. Using a watch with a second hand, count the number

felt for one full minute.

6. If the pulse rate is abnormal in any way, repeat the

counting to determine accurately the rate.
 Procedure
Radial Pulse
7. Record pulse rate on the jot down notebook.

8. Refer anything unusual to the clinical instructors and

head nurse.

9. Record in the client’s chart and master list.

 Procedure
Cardiac Pulse
1. Explain the procedure.

2. Position the client on a supine and drape him.

3. Raise client’s gown and left side of chest.

4. Cleanse earpieces and diaphragm of stethoscope using

alcohol swab.
 Procedure
Cardiac Pulse
5. Warm the diaphragm of the stethoscope using alcohol
swab.

6. Place the diaphragm of the stethoscope over the apex of

the heart, located at the fifth intercostal space, left
midclavicular line . Then, insert the earpieces in your
ears.

7. Move the diaphragm to the site of the loudest beats.

Count the beats for 60 seconds and note their rhythm
and rate. Also evaluate the intensity of heart sounds.
 Procedure
Cardiac Pulse
8. Remove the stethoscope and make the client
comfortable.

9. Record the apical pulse on the jot down notebook.

10. Refer anything unusual to the CI or head nurse.

 Procedure
RESPIRATION

It is the exchange of oxygen and carbon dioxide

between the atmosphere and body cells and is initiated by
the act of breathing

Equipment used: watch with second hand and jot down

notebook and pen
 Procedure
RESPIRATION
1. While the fingertips are still in place after counting the pulse rate,
observe the client’s respiration.

2. Note the rise and fall of the client’s chest with each inspiration
and expiration. This observation can be made without disturbing
the client’s bedclothes.  

3. Using a watch with second hand, count the number of respiration

for on full minute.

4. If respirations are abnormal, repeat to determine accurately the

rate, the characteristics of breathing.
 Procedure
RESPIRATION

5. Record respiration rate on the jot down notebook including

abnormalities in rhythm and depth.

6. Refer to CI and head nurse for any unusuality .

7. Record the result in the client’s chart and TPR master list.
 Procedure
BLOOD PRESSURE

Blood pressure is the lateral force extended by

the blood in the arterial wall.
 
Equipment used: Stethoscope, alcohol swab, jot
down notebook and pen, sphygmomanometer
with appropriate size of cuff
 Procedure
BLOOD PRESSURE

1. Explain the procedure to the client. Make sure that the client has
not smoked cigarette or ingested beverages that contains
caffeine within 30 minutes.

2. Place the client in a comfortable position with the forearms

supported and the palm upward.

3. Position yourself so that the calibration of the apparatus can be

read at eye level and no more than 1 feet away.
 Procedure
BLOOD PRESSURE

4. Place the cuff so that the inflatable bag is centered over the
brachial artery, so that the lower edge of cuff is 2.5-5cm above
antecubital fossa.

5. Wrap the cuff smoothly around the arm with the end of cuff
secure.  

6. Use the fingertips to feel a strong pulsation on the antecubital

space. Place the bell or diaphragm directly over the pulse.
 Procedure
BLOOD PRESSURE
7. Inflate the cuff to 30 mmHg where the pulsation appears.

8. Gradually deflate cuff all the way to zero taking note of the first
and last clear, loud sound.

9. Remove the cuff and make client comfortable

10. Record the reading on the jot down notebook.

11. Report to the CI and headnurse for any unusualities.

12. Record BP on the VS sheet and BP masterlist.

 Procedure
BLOOD PRESSURE
7. Inflate the cuff to 30 mmHg where the pulsation appears.

8. Gradually deflate cuff all the way to zero taking note of the first
and last clear, loud sound.

9. Remove the cuff and make client comfortable

10. Record the reading on the jot down notebook.

11. Report to the CI and headnurse for any unusualities.

12. Record BP on the VS sheet and BP masterlist.

 Nursing Responsibilities
BEFORE THE PROCEDURE
• Identifies patient’s chart correctly

• Determines patient’s diagnosis, current

condition, medications and treatment.

• Checks out for any special orders

• Assess patient’s readiness

 Nursing Responsibilities
DURING THE PROCEDURE
• Introduce Self and identifies patient

• Explain the procedure to the patient/relatives

• Place patient in a comfortable position

 Nursing Responsibilities
AFTER THE PROCEDURE
• Document all data in the Graphic Sheet

• Ensure appropriate referral if necessary