PROCEDURES in VS Taking

Procedures in taking V/S
Assessing Body Temperature

Assessing Pulse:
Radial & Apical
Assessing Respirations
Assessing Blood Pressure
Assessing O2 saturation
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Measuring Body Temperature
Equipment
> Thermometer (selected based on site used)
>Soft tissue or wipe
>Alcohol swab
>Water-soluble lubricant (for rectal measurements only)
>Pen and vital sign flow sheet, record form, or electronic
health record (EHR)
>Clean gloves (optional), plastic thermometer sleeve,
disposable probe or sensor cover
>Towel
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Assessment
1. Determine need to measure patient’s body
temperature:
a. Note patient’s risks for temperature
alterations:
b. Assess for signs and symptoms that
accompany temperature alterations:
c. Assess for factors that normally influence
temperature
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Assessment
2. Determine appropriate measurement site and
device for patient . Use disposable thermometer for
patient on isolation precautions.
3. Determine previous baseline temperature and
measurement site (if available) from patient’s
record.
4. Assess patient’s knowledge of procedure.
Encourages cooperation; minimizes risks and
anxiety. Identifies teaching needs.
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Planning
1. Expected outcomes following completion of
procedure:
• Body temperature is within acceptable range
for patient’s age-group.
• Body temperature returns to baseline range
following therapies for abnormal temperature.
2. Explain to patient the way you will measure
temperature and importance of maintaining
proper position until reading is complete.
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Planning
3. Collect and bring appropriate supplies to the
patient’s bedside.
4. Verify that patient has not had anything to eat
or drink and not has chewed gum or smoked
within the past 15 minutes of having oral
temperature measured (Davie and Amoore,
2010).
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Implementation
1. Perform hand hygiene.
2. Assist patient to comfortable position that
provides easy access to temperature measurement
site.
3. Obtain temperature reading.
a. Assess oral temperature (electronic):
(1) Optional: Apply clean gloves when there are
respiratory secretions or facial or mouth
wound drainage.
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Measuring Body Temperature (Oral)
(2) Remove thermometer pack from charging

unit. Attach oral thermometer probe stem
(blue tip) to thermometer unit. Grasp top of
probe stem, being careful not to apply
pressure on ejection button.
(3) Slide disposable plastic probe cover over
thermometer probe stem until cover locks in
place
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(4) Ask patient to open mouth; gently place
thermometer probe under tongue in posterior
sublingual pocket lateral to center of lower jaw
(see illustration).
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(5) Ask patient to hold thermometer probe with
lips closed
(6) Leave thermometer probe in place until
audible signal indicates completion and
patient’s temperature appears on digital
display; remove thermometer probe from
under patient’s tongue.
(7) Push ejection button on thermometer probe
stem to discard plastic probe cover into
appropriate receptacle. ipm
(8) If wearing gloves, remove and dispose in

appropriate receptacle and perform hand hygiene.
(9) Return thermometer probe stem to storage
position of thermometer unit.
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Measuring Body Temperature (Rectal)
b. Assess rectal temperature (electronic):
(1) Draw curtain around the bed and/or close
room door. Assist patient to side-lying or
Sims’
position with upper leg flexed. Move aside
bed linen to expose only anal area. Keep
patient’s upper body and lower extremities
covered with sheet or blanket.
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(2) Perform hand hygiene and apply clean gloves.
Cleanse anal region when feces and/or
secretions are present. Remove soiled gloves
and reapply clean gloves.
unit. Attach rectal thermometer probe stem
(red tip) to thermometer unit. Grasp top of
probe stem, being careful not to apply pressure
on ejection button.
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thermometer probe stem until cover locks in
place.
(5) Using a single use package, squeeze a liberal
amount of lubricant on tissue. Dip probe cover
of thermometer, blunt end, into lubricant,
covering 2.5 to 3.5 cm (1 to 1.5 inches) for adult.
(6) With nondominant hand separate patient’s
buttocks to expose anus. Ask patient to breathe
slowly and relax.
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(7) Gently insert thermometer into anus in

direction of umbilicus 3.5 cm (1.5 inches) for
adult. Do not force thermometer.
(8) If you feel resistance during insertion,
withdraw immediately. Never force
thermometer.
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(9) Once positioned, hold thermometer probe in

place until audible signal indicates completion
and patient’s temperature appears on digital
display; remove thermometer probe from anus
(see illustration).
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(10) Push ejection button on thermometer stem to

discard plastic probe cover into appropriate
receptacle. Wipe probe stem with alcohol
swab, paying particular attention to ridges
where probe stem connects to probe.
(11) Return thermometer stem to storage position
of recording unit.
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(12) Wipe patient’s anal area with soft tissue to

remove lubricant or feces and discard tissue.
Assist patient in assuming a comfortable
position.
(13) Remove and dispose of gloves in appropriate
receptacle. Perform hand hygiene.
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c. Assess axillary temperature (electronic):
(1) Draw curtain around bed and/or close room
door. Assist patient to supine or sitting
position. Move clothing or gown away from
shoulder and arm.
unit. Attach oral thermometer probe stem
(blue tip) to thermometer unit. Grasp top of
thermometer probe stem, being careful not
to apply pressure on ejection button.
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thermometer stem until cover locks in place.
(4) Raise patient’s arm away from torso. Inspect
for skin lesions and excessive perspiration; if
needed, dry axilla. Insert thermometer probe
into center of axilla (see illustration), lower
arm over probe, and place arm across
patient’s chest.
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Measuring Body Temperature (Axillary)
(5) Once thermometer probe is positioned, hold it

in place until audible signal indicates
completion and patient’s temperature appears
on digital display; remove thermometer probe
from axilla.
(6) Push ejection button on thermometer stem to
discard plastic probe cover into appropriate

receptacle.
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Measuring Body Temperature (Axillary)
(7) Return thermometer stem to storage position

of recording unit.
(8) Assist patient in assuming comfortable
position , replacing linen or gown.
(9) Perform hand hygiene.
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d. Assess tympanic membrane temperature
(electronic):
(1) Assist patient in assuming comfortable
position with head turned toward side, away
from you. If patient has been lying on one side,
use upper ear. Obtain temperature from
patient’s right ear if you are righthanded.
Obtain temperature from patient’s left ear if
you are left-handed.
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(tympanic membrane)
(2) Note if there is an obvious presence of cerumen
(earwax) in patient’s ear canal.
(3) Remove thermometer handheld unit from
charging base, being careful not to apply
pressure to ejection button.
(4) Slide disposable speculum cover over the
otoscope-like lens tip until it locks in place. Be
careful not to touch lens cover.positioning:
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Measuring Body Temperature (tympanic membrane)
(5) Insert speculum into ear canal following

manufacturer instructions for tympanic probe
positioning:
(a) Pull ear pinna backward, up, and out for
an adult (see illustration). For children less
than 3 years of age, pull pinna down and
back, point covered probe toward midpoint
between eyebrow and sideburns.
For children older than 3 years, pull pinna
up and back (Hockenberry and Wilson, 2011).
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(b) Move thermometer in a figure-eight pattern.

(c) Fit speculum tip snug in canal, pointing
toward the nose.
(6) Once positioned, press scan button on

handheld unit. Leave speculum in place until
audible signal indicates completion and
patient’s temperature appears on digital
display.
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(7) Carefully remove speculum from auditory

meatus. Push ejection button on handheld unit
to discard speculum cover into appropriate
receptacle.
(8) If temperature is abnormal or second reading is
necessary, replace probe cover and wait 2

minutes before repeating in same ear or repeat
measurement in other ear. Consider an
alternative temperature site or instrument.
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(9) Return handheld unit to thermometer base

(10) Help patient assume a comfortable position.
(11) Perform hand hygiene.
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Measuring Body Temperature (temporal artery)
(1) Ensure that forehead is dry; dry with a towel if needed

(2) Place sensor firmly on patient’s forehead.
(3) Press red scan button with your thumb. Slowly slide thermometer straight across
forehead while keeping
sensor flat and firmly on skin (see Fig. 5-4).
(4) If patient is diaphoretic, keeping scan button depressed, lift sensor after sweeping
forehead and touch sensor on neck just behind the earlobe. Peak temperature occurs
when clicking sound during scanning stops. Release scan button.
(5) Gently clean sensor with alcohol swab and perform hand hygiene.
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4. Inform patient of temperature reading and
record measurement. Promotes participation in
care and understanding of health status.
5. Return thermometer to charger. Maintains
battery charge of thermometer unit.
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Evaluation
1. If you are assessing temperature for the first
time, establish it as baseline if it is within
acceptable range.
2. Compare temperature reading with patient’s previous
baseline and acceptable temperature range for
patient’s age-group.
3. If patient has fever, take temperature approximately
30 minutes after administering antipyretics and every 4
hours until temperature stabilizes.
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Recording & Reporting
• Record temperature and route on vital sign flow

sheet, nurses’ notes, or electronic health record
(EHR).
• Report abnormal findings to nurse in charge or
health care provider.
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Taking the Pulse Rate
Pulse is the palpable bounding of the blood flow.
* As the heart ejects blood, it distends the aorta
which creates a pulse wave that travels rapidly
toward the extremities and this can be felt by
palpating the artery.
Pulse Rate – is the number of pulsing sensations
occurring in 1 minute
Purpose : to determine cardiovascular integrity
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STEPS of taking Pulses
Assessment
1. Determine need to assess peripheral pulse
Certain conditions place patients at risk for pulse
alterations. A history of peripheral vascular disease
often alters pulse rate and quality.
2. Determine patient’s previous baseline pulse rate

(if available) from patient’s record.
Allows you to assess for change in condition. Provides
comparison with future pulse measurements.
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Planning
3. Wash hands. Use PPE as needed
4. Gather appropriate equipment and bring to
patient’s bedside: watch with second hand,
stethoscope (for apical pulse) & record notebook
Implementation
5. Greet the patient and introduce self
6. Identify the patient
7. Provide privacy as needed
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8. Explain to patient that you will assess PR/HR
Encourage patient to relax as much as possible.
If he or she has been active, wait 5 to 10 mins
before assessing pulse. If patient has been
smoking or ingesting caffeine, wait 15 minutes
before assessing pulse.
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For Peripheral Pulse
9. Identify the appropriate peripheral site
10. Assist patient in lying or sitting position.
For lying, place the client’s forearm straight,
next to body. If sitting, support the lower arm
and bend the client’s elbow at 90 degrees
11. Place the tips of your first, second, and third
fingers over the artery site, apply light pressure
to locate the pulsation.
12. Note the rhythm and amplitude of the pulse.
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For Apical Pulse
*Position the client supine or sitting. Expose the
sternum and left side of chest by removing bed
linens and gown.
*Locate the (PMI) by
palpating between the
fifth and six ribs (5th
ICS), LMCL.
*The heart is located behind and to left of
sternum with base at top and apex at bottom.
Find angle of Louis just below suprasternal
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notch between sternal body and manubrium;
it feels like a bony prominence.
For Apical Pulse
*Place diaphragm of stethoscope in palm of hand
for 5 to 10 seconds.
*Place the diaphragm of stethoscope at the PMI

and auscultate for normal S1 & S2 heart sounds
(heard as “lub-dub”) using second hand of watch.
*Clean earpieces and diaphragm of stethoscope

with alcohol swab routinely after each use.
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13. Using a watch with a second hand, begin
counting the number of pulsations felt in 30
seconds and multiply the number by 2.
14. If the rate, rhythm, or amplitude is abnormal

or other clinical indications, count the pulse for
one full minute.
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15. Determine strength of pulse. Note whether
thrust of vessel against fingertips is;
bounding (4+)
full increased, strong (3+)
expected (2+)
barely palpable, diminished (1+)
or absent, not palpable (0)
16. Assist patient return to comfortable position.
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Evaluation
18. Evaluate patient’s response to procedure
19. Compare pulse rate and character with patient’s
previous baseline & acceptable range for
patient’s age.
Documentation
20. Document and do necessary reporting
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Equipment
Wristwatch with second hand or digital display
Pen and vital sign flow sheet or electronic health
record (EHR)
Assessment
1. Determine need to assess patient’s respirations:
a. Assess for risk factors of respiratory alterations:
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b. Assess for signs and symptoms of respiratory
alterations such as cyanosis
c. Assess for factors that influence the character
of respirations:
2. Assess pertinent laboratory values:
a. Arterial blood gases (ABGs): Normal ranges
(values vary slightly among agencies):
b. Pulse oximetry (SpO2)
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STEPS of taking Blood pressure
Blood pressure (BP) is the force exerted by blood
against the vessel walls. The peak pressure occurs
when the ventricular contraction of the heart, or
systole, forces blood under high pressure into the
aorta. When the ventricles relax, the blood
remaining in the arteries exerts a minimal or
diastolic pressure. Diastolic pressure is the minimal
pressure exerted against the arterial wall at all times.
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Assessment
1. Determine need to assess patient’s blood pressure
(Assess risk factors for blood pressure alterations)

2. Determine patient’s previous baseline blood
pressure and site (if available) from patient’s
record.
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3. Determine best site for BP assessment. Avoid
applying cuff to extremity when;
-IV fluids are infusing
-an AV shunt or fistula is present
-breast or axillary surgery has been performed on
that side. And, extremity that has been traumatized
or diseased or requires a cast or bulky bandage.
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- Use lower extremities when brachial arteries
are inaccessible.
4. Determine any report of latex allergy.
Planning
5. Wash hands, use PPE as needed
6. Gather the needed materials at bedside
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STEPS of Auscultating Blood pressure
Materials needed:
- Aneroid sphygmomanometer
* Select appropriate cuff size and ensure that
other equipment is in the patient’s room.
- Cloth or disposable vinyl pressure cuff of
appropriate size for patient’s extremity
- Stethoscope
- Alcohol swab
-Pen and vital sign flow sheet or electronic
health record ipm
Implementation
8. Identify the patient.
10. Explain to patient that you will assess BP.
Encourage patient to relax as much as possible.
* If he or she has been active, wait 5 to 10 minutes
before assessing BP. If patient has been smoking
or ingesting caffeine, wait 15 minutes before
assessing BP. ipm
Implementation
11. Select the appropriate extremity to apply the
cuff.
12. Place the client in lying or sitting position
13. Support the forearm at the level of the heart

with the palm of the hand upward.
14. Visualize the client’s brachial artery by
removing any clothes or bed linens.
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15. Palpate the brachial artery, apply the cuff with
the center of the cuff bladder over the brachial
artery, midway on the arm at least 1 inch above
the antecubital.
16. Line the artery marking on the cuff with the

brachial artery, with the tubing extending from
the edge of the cuff. Wrap the cuff around the
arm smoothly and snuggly and fasten it.
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17. With the gauge at eye level, verify that the
needle on the aneroid manometer is at the
zero mark.
18. Position yourself no more than 3 feet away
from the gauge.
19. Clean the earpieces, bell, and diaphragm of
the stethoscope with an alcohol pad.
20. Place the earpieces in your ear and the
diaphragm or bell firmly over the brachial
artery. ipm
21. Ensure that the stethoscope is not touching
clothing or the cuff.
22. Tighten the screw valve on the air pump and
inflate the cuff, pumping the pressure to
30 mmHg over the estimated systolic pressure.
23. Open the valve and slowly release the air,
dropping the gauge about 2 to 3 mm per
second.
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24. Identify the number on the gauge when the
first faint, clear sound is heard which slowly
increases in intensity.
25. Continue to release the air, until the sound
completely disappears. Note the number on
the gauge when this occurs.
26. Deflate and remove the cuff.
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27. Position the client comfortably and cover.
28. Clean the bell and diaphragm of the
stethoscope with alcohol pad. Clean and store
the cuff per policy.
29. Perform hand hygiene
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Evaluation
30. Evaluate client response and assist him in a safe
position prior to leaving the room and has the
call light within reach.*
Documentation
31. Compare the findings with the client’s baseline,
document and do necessary reporting
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Electronically
Many different styles of electronic blood pressure
machines are available to determine blood pressure
automatically. Electronic machines rely on an
electronic sensor to detect the vibrations caused by
the rush of blood through an artery. Although
electronic blood pressure machines are fast, you
must consider their advantages and limitations.
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Electronically
The devices are used when frequent assessment is
required such as in critically ill or potentially
unstable patients, during or after invasive
procedures, or when therapies require frequent
monitoring. Verify an assessment of an abnormal
blood pressure by an electronic machine with a
sphygmomanometer and stethoscope.
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Assessing the O2 saturation (SpO2)
Equipment
❑ Oximeter
❑ Oximeter probe appropriate for patient and
recommended by oximeter manufacturer
❑ Acetone or nail polish remover if needed
❑ Pen and vital sign flow sheet or electronic health
record (EHR) ipm
https://www.youtube.com/watch?v=b1c0MJfmDTc
Assessment
1. Determine need to measure patient’s oxygen saturation.
Assess risk factors for decreased oxygen saturation (e.g.,
acute or chronic compromised respiratory problems, change
in oxygen therapy, chest wall injury, recovery from
anesthesia).
2. Assess for signs and symptoms of alterations in oxygen
saturation (e.g., altered respiratory rate, depth, or rhythm;
adventitious breath sounds; cyanotic nails, lips, mucous
membranes, or skin; restlessness; difficulty breathing).
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3. Assess for factors that influence measurement of SpO2
(e.g., oxygen therapy; respiratory therapy such as postural
drainage and percussion; hemoglobin level; hypotension;
temperature; nail polish, and medications such as
bronchodilators).
4. Review patient’s medical record for health care provider’s
order or consult agency procedure manual for standard of
care for measurement of SpO2.
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5. Determine previous baseline SpO2 (if available) from
patient’s record.
6. Determine most appropriate patient-specific site (e.g.,
finger, earlobe, bridge of nose, forehead) for sensor
probe placement by measuring capillary refill.
If capillary refill is less than 2 seconds, select alternative site.
a. Site must have adequate local circulation and be free of moisture.
b. A finger free of polish or acrylic nail is preferred (Cicek et al., 2011).
c. If patient has tremors or is likely to move, use earlobe or forehead.
d. If the patient finger is too large for the clip on probe, as may be the case with
obesity or edema, the clip-on probe may not fit properly (Mininni, 2009);
obtain a disposable (tape-on) probe.
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Assessing O2 saturation (SpO2)
Planning
7. Wash hands, use PPE as needed
8. Gather the needed materials at bedside
Implementation
10. Identify the patient.
12. Position patient comfortably and instruct him to
breathe normally. ipm
13. Explain that you are going to assess the O2 saturation.
14. Attach sensor to monitoring site. If using finger, remove
fingernail polish from digit with acetone or polish
remover. Instruct patient that clip-on probe will feel like
a clothespin on the finger but will not hurt.
15. Once sensor is in place, turn on oximeter by activating
power. Observe pulse waveform/intensity display and
audible beep.
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16. Leave sensor in place 10 to 30 seconds or until
oximeter read out reaches constant value and pulse
display reaches full strength during each cardiac
cycle. Inform patient that oximeter alarm will sound if
sensor falls off or patient moves it. Read SpO2 on
digital display.
17. If you plan intermittent or spot-checking of SpO2,
remove probe and turn oximeter power off. Cleanse
sensor and store sensor in appropriate location.
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Evaluation
19. Evaluate client response & assist him in a safe position
prior to leaving the room and has the call light
within reach.
Documentation
20. Compare SpO2 with patient’s previous baseline and

acceptable SpO2. Document & do necessary reporting.
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PROCEDURES in VS Taking

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PROCEDURES in VS Taking

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Procedures in taking V/S

Assessing Body Temperature

(2) Remove thermometer pack from charging

(8) If wearing gloves, remove and dispose in

(7) Gently insert thermometer into anus in

(9) Once positioned, hold thermometer probe in

(10) Push ejection button on thermometer stem to

(12) Wipe patient’s anal area with soft tissue to

(5) Once thermometer probe is positioned, hold it

discard plastic probe cover into appropriate

(7) Return thermometer stem to storage position

(5) Insert speculum into ear canal following

(b) Move thermometer in a figure-eight pattern.

(6) Once positioned, press scan button on

(7) Carefully remove speculum from auditory

necessary, replace probe cover and wait 2

(9) Return handheld unit to thermometer base

(1) Ensure that forehead is dry; dry with a towel if needed

• Record temperature and route on vital sign flow

2. Determine patient’s previous baseline pulse rate

*Place the diaphragm of stethoscope at the PMI

*Clean earpieces and diaphragm of stethoscope

14. If the rate, rhythm, or amplitude is abnormal

(Assess risk factors for blood pressure alterations)

13. Support the forearm at the level of the heart

16. Line the artery marking on the cuff with the

29. Perform hand hygiene

20. Compare SpO2 with patient’s previous baseline and

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