CHECKING VITAL SIGNS (VS)

Definition: Clinical measurements specifically temperature pulse, respiration and

blood pressure that indicate the state of the patient’s essential
functions. Pain is considered the “fifth vital sign” in some organizations
across the globe

I. TEMPERATURE

Definition: It is the difference between heat produced and heat lost by the body
and is measured through the use of a thermometer.

ROUTE ADVANTAGES DISADVANTAGES

Oral • Easy, fast, accurate • Cannot be used for clients who are
unconscious, confused, prone to
seizures, recovering from oral surgery,
or under age 6.
• Need to wait 15–20 minutes after
eating.
Rectal • More reflective of core • Cannot be used for clients who have
temperature rectal bleeding, hemorrhoids, or
diarrhea or who are recovering from
rectal surgery.
• Contraindicated for cardiac clients
because it may stimulate the vagus
nerve and decrease heart rate.
• Not recommended for newborns
because of risk of perforating the anus.

Tympanic • Fast
• More reflective of core
temperature
• Safe, good for children

Axillary • Safe, good for children • Reports of accuracy are conflicting.

and newborns

Forehead • Safe and easy • Measures skin surface, which can be

variable.

Temporal • Normal: Close to rectal • Measures skin surface temperature.

temperature, 10F or 0.50C • Least accurate method
higher than an oral
temperature, and 20F or
10C higher than an axillary
temperature
Normal Body Temperature:

1. Oral Temperature = 36.1 – 37.2 0C or 97 – 99 0C (Ave = 37.00 C)

2. Rectal Temperature = 36.7 – 37.8 0C or 98 – 100 0C (Ave = 37.50 C)
3. Axillary temperature = 35.6 – 36.7 0C or 96 – 98 0C (Ave = 36.70 C)
4. Tympanic = 37.5 0C or 99.5 0F

Types of thermometers include:

• Electronic digital thermometer: Used for oral, rectal, or axillary temperature

measurements.
• Tympanic thermometer: For taking the temperature via the ear
• Temporal artery thermometer: Measures arterial temperature through infrared
scanning of the temporal artery.
• Disposable paper strips with temperature sensitive dots: Used for skin/surface
temperature measurements.

A. Oral Method
Contraindications:
1. infants
2. unconscious and irrational patients
3. patients who breathe through their mouths
4. those with disease of the oral cavity or surgery of the nose or mouth
5. patients who have just taken cold or hot foods or fluids

Equipment:

1. Tray containing:
a. thermometer
b. jar of CB in water
c. jar with cut tissue paper
d. waste receptacle (must not be carton because waste fluid will
contaminate the surface on where it stands)
2. Watch with second hand
3. Jot down notebook and pen

Procedure:

ACTION RATIONALE
1. Read the chart. To obtain necessary data.

2. Wash hands. To deter the spread of microorganism.

3. Determine any previous activity that Smoking or oral intake of foods/ fluids
would interfere with accuracy of can cause false temperature reading.
temperature measurement.

4. Bring the tray to the bedside and When the patient knows what is to be
explain the procedure to the patient done, he will cooperate better.

5. Rinse the thermometer by using CB Chemical solutions may irritate mucus

with water in a firm twisting motion membrane and may have an
from the bulb to the stem and then objectionable odor or taste. CB or soft
dry using same motion using dry CB tissues will approximate the surface
or clean soft tissues. and twisting helps to come in contact
with the thermometer’s entire surface.
6. Place tip of thermometer under the When the bulb rests against the
client’s tongue and along the superficial blood vessels under the
gumline to the posterior sublingual tongue and the mouth is closed, a
pocket lateral to center of lower jaw reliable measurement of body
and instruct him to close his lips temperature can be obtained.
tightly.

7. An electronic thermometer will Allowing sufficient time for the oral

signal (beep) when a constant tissues to come in contact with the
temperature registers. Wait 1-3 thermometer results in a more nearly
minutes for ordinary glass accurate measurement of body
thermometer. temperature.

8. Remove the thermometer and wipe Cleansing from an area where there
it at once with dry CB or soft tissue are few organisms minimizes the
from stem down to the bulb using a spread of organisms to cleaner area.
firm twisting motion. Friction helps to loosen matter from
the surface.

9. Read measurement on display of

digital thermometer.
10. Inform client and/or watcher of Increases involvement and trust of the
temperature reading. client.

11. Cleanse the thermometer from the

stem to bulb using CB with water
twice, then dry with tissue wipe and
return to the container.
12. Dispose the used CB and tissue Confining contaminated articles help
paper in the waste receptacle to reduce the spread of pathogens.

13. Record the temperature in the

jotdown notebook. Report anything
unusual.
14. Wash hands.
15. Record the temperature on the TPR Accurate documentation allows for
masterlist sheet and graphic chart. comparison of data.

B. Axillary Method

Many hospitals in the Philippines obtain patient’s temperature by the axillary

method. If the axilla has just been washed, obtaining temperature should be
delayed.

Equipment: Same as oral method except for the axillary thermometer.

1. Tray containing:
a. thermometer
b. jar of CB in water
c. jar with cut tissue paper
d. waste receptacle
2. Jot down notebook and pen
3. Client’s wash cloth or tissue wipes
Procedure

ACTION RATIONALE
6. Follow steps 1 to 5 of oral temperature
taking.

7. Expose arm and shoulder by removing

one sleeve of client’s gown. Avoid
exposing chest.

8. Pat the patient’s axilla dry with a wash Moisture in the axilla may alter the
cloth or tissue. Place the probe of the result of the temperature. The
thermometer into the center of the deepest area of the axilla provides
axilla. Bring the patient’s arm down the most accurate temperature
close to his body and place his measurement.
forearm over his chest.

9. Leave the thermometer in place until

signal or beep is heard or 1-3 minutes
of ordinary thermometer.
10. Remove, dry with tissue paper and
read measurement on digital display
of the thermometer.
11. Inform client of temperature reading. Allowing sufficient time for the
axillary tissue to come in contact
with the thermometer bulb results in
a reasonably accurate
measurement of body temperature.
12. Assist client in putting back the sleeve
of gown.
13. Follow subsequent steps of cleaning
like in oral method. (Steps 11 and 12)
14. Record reading in the jotdown
notebook. Report anything unusual.
15. Wash hands.
16. Document the data.

C. Rectal Method

Purposes:
a. To obtain the first temperature of newborn to check for rectal patency.
b. To check the core temperature of an adult.

Contraindications:
This method is contraindicated to the following patients:

1. With recent rectal surgery.

2. With diarrhea.
3. With disease of the rectum.
4. With cardiovascular alteration because the presence of the thermometer in the
rectum may stimulate the vagus nerve causing bradycardia or rhythm disorder.
5. With leukemia which may traumatize the rectal mucosa causing bleeding.
Equipment: Same as in oral method with the addition of:
1. lubricant 3. toilet paper (patient’s supply)
2. working gloves 4. thermometer (patient’s supply)

Procedure:
Action Rationale
1. Read the chart. To obtain data.
2. Bring the preparation to the Elicits the cooperation and
bedside and explain the procedure. understanding of the significant other.
3. Place client in lateral position/ Proper positioning ensures
Sim’s position. visualization of anus. Flexing knee
relaxes muscles for ease of insertion.
4. Drape patient exposing only the Avoid embarrassment and provide
rectum. privacy.
5. Don working gloves. Gloves are used to avoid contact with
bodily secretions and to reduce
transmission of microorganisms.
6. Lubricate tip of rectal thermometer Lubrication reduces friction and
or probe to approximately 1 inch facilitates the insertion of the
above the bulb. thermometer. This minimizes irritation
of the mucus membrane of the anal
canal.
7. With the dominant hand, hold the Aids in visualization of anus.
thermometer. With the non-
dominant hand, separate buttocks
to expose anus.
8. Instruct client to take a deep Relaxes anal sphincter.
breath. Gently insert the
thermometer approximately 0.5 -1
inch. Release buttocks to allow
falling in place.
9. Hold the thermometer in place until Allows sufficient time for thermometer
the beep sound is heard. to register a more accurate
measurement of body temperature.
10. Remove the thermometer and wipe Removes lubricant/ feces that may
with dry tissue. Discard used tissue have attached to the probe of the
in the waste receptacle. thermometer.
11. Read measurement on digital
display of the thermometer
12. Wipe anal area with tissue and
make client comfortable. Dispose
soiled tissue in the yellow bin
13. Cleanse thermometer, as
previously learned.
14. Remove and dispose gloves in the
yellow bin.
15. Wash hands.
16. Record temperature in the jotdown
notebook.
17. Report anything unusual.
18. Document in the findings
D. Disposable (Chemical Strip) Thermometer

Procedure

Action Rationale
7. Follow steps 1 to 6 of oral
temperature-taking.
8. Apply tape to appropriate skin area,
usually forehead.

9. Observe tape for color changes.

10. Follow steps 16, 17, 18 of oral

temperature-taking.

Tympanic Temperature: Infrared Thermometer

It uses infrared sensors to sense the temperature of the tympanic membrane.

Procedure

Action Rationale
5. Follow steps 1, 2, & 4 of oral
temperature taking.

6. Remove probe from container

and attach probe cover to
tympanic thermometer unit.
7. Turn client’s head to one side. This technique straightens the ear canal
For an adult, pull pinna upward to facilitate insertion of the probe.
and back; for a child, pull down
and back. Gently insert probe
with firm pressure into ear canal.
8. Remove probe from ear after the
reading is displayed on digital
unit (usually 2 seconds).
9. Remove probe cover and discard
and place the thermometer in
storage container.
10. Follow steps 16, 17, 18 of oral
temperature-taking.

II. PULSE
Definition: It is a rhythmical throbbing that results from a wave of blood passing
through an artery as the heart contracts.

Purpose: To obtain an estimate of the quality of the heart’s action per minute.
Possible sites for taking the pulse:
a. apical
b. radial artery f. popliteal artery
c. temporal artery g. carotid artery
d. dorsalis pedis h. brachial artery
e. femoral artery i. posterior tibialis

What to note while counting the pulse:

a. rate c. tension or compressibility
b. rhythm or regularity d. volume

Normal pulse rate per minute:

Children: Adult:

0 – 1 mo. = 120 – 160 (Ave: 140) Male = 70 – 80 beats/minute

11 – 12 mos. = 100 – 140 (Ave: 120) Female = 80 – 90 beats/minute
Toddler = 80 – 120 (Ave: 100)
Preschooler = 75 – 120 (Ave: 100)

Equipment: a. Watch with second hand. c. Alcohol swab

b. Jot down notebook and pen d. stethoscope

A. RADIAL PULSE

Procedure

Action Rationale
1. Explain the procedure to the To gain cooperation and make client
patient. at ease.

2. Have the patient rest his arm This position places the radial artery
alongside of his body with the wrist on the inner aspect of the patient’s
extended and the palm of the hand wrist. The nurse’s fingers rest
downward, or place arm on top of conveniently on the artery with thumb
the patient’s upper abdomen with in a position to the outer aspect of the
the palm downward position. patient’s wrist.

3. Place your first, second and third The fingertips which are sensitive to
fingers along the radial artery and touch will feel the pulsation of the
press gently against the radius; rest patient’s radial artery. If the thumb is
the thumb on the back of the used to palpate the patient’s pulse,
patient’s wrist. the nurse may feel her own pulse

4. Apply enough pressure so that the Moderate pressure allows the nurse to
patient’s pulsating artery can be felt feel the superficial artery expand and
distinctly. contract with each heartbeat.

5. Using a watch with a second hand, Sufficient time is necessary to detect

count the number of pulsation felt irregularities or other defects.
for one full minute.

6. If the pulse rate is abnormal in any When the pulse is abnormal, longer
way, repeat the counting to counting and palpation are necessary
determine accurately the rate, the to identify most accurately the unusual
quality and the volume. characteristics of the pulse.
7. Record pulse rate on the jot down
notebook.
8. Refer anything unusual.

9. Document the data.

B. CARDIAC RATE OR APICAL PULSE

If a peripheral pulse is irregular, weak, or extremely rapid, causing it to be

difficult to assess accurately, the apical rate may be assessed. The apical pulse is
also used to assess newborns, infants, and young children.

Procedure

Action Rationale
1. Explain the procedure to the patient Elicits cooperation from the client.
and/or significant others.

2. Assist the client on supine position.

3. Cleanse earpieces and diaphragm Swabbing action removes dirt. ROH

of stethoscope using alcohol swab. evaporates fast and render the parts
dry easily

4. Raise the gown and properly drape Allows access to patient’s chest for
the client exposing the sternum and proper placement of stethoscope.
the left side of chest.

5. Warm the diaphragm of the Placing a cold diaphragm against the

stethoscope with your hand before skin may startle the patient and
applying it to the patient’s chest. momentarily increase the heart rate.

6. Place the diaphragm of the This gives the loudest and most
stethoscope over the apex of the distinctive sound of the heart.
heart, located at the fifth intercostal
space, left midclavicular line 5th ICS,
LMCL). Then, insert the earpieces in
your ears.
7. Move the diaphragm to the site of A full minute count is important for an
the loudest beats. Count the beats accurate assessment. A longer
for 60 seconds and note their duration helps determine pulse rhythm
rhythm and volume. Also evaluate and quality. In no instance, is the
the intensity (loudness) of heart radial pulse count greater than the
sounds. apical pulse count.
1. Remove the stethoscope and make
the client comfortable.
2. Record the apical pulse on the jot
down notebook.
3. Refer anything unusual. Referral of anything unusual in a
patient enables the health providers to
respond immediately to the needs or
problem of the patient
4. Document the data.
III. RESPIRATION
Definition: It is the exchange of oxygen and carbon dioxide between the
atmosphere and body cells and is initiated by the act of breathing.

Purpose: To obtain the respiratory rate per minute and an estimate of the
patient’s respiratory status.

Normal Rates:
Infants = 30 – 40/ minute
Children = 20 – 25/ minute
Adult = 16 – 20/ minute

Equipment: a. watch with second hand

b. jot down notebook and pen

Procedure
Action Rationale
1. While the fingertips are still in place Counting the respiration while
after counting the radial pulse rate, presumably still counting the pulse
observe the patient’s respiration. keeps the client from becoming
conscious of his breathing which can
possibly alter his usual rate.
2. Note the rise and fall of the patient’s A complete cycle of inspiration and
chest with each inspiration and expiration constitutes one act of
expiration. This observation can be respiration.
made without disturbing the
patient’s bedclothes.
3. Using a watch with second hand, Sufficient time is necessary to observe
count the number of respiration for rate, depth and other characteristics.
one full minute.
4. If respirations are abnormal, repeat
to determine accurately the rate, the
characteristics of the breathing.
5. Record respiratory rate on the jot
down notebook including
abnormalities in rhythm and depth, if
any.
6. Refer any abnormalities in rate
and/or rhythm.

7. Document the data.

IV - BLOOD PRESSURE
Definition: Blood pressure is the lateral force exerted by the blood on the arterial
walls.
Purposes: 1. To aid in diagnosis
2. To observe changes in a patient’s condition.
Contraindications for Brachial Artery Blood Pressure Measurement
1. Surgery including the breasts, axilla, shoulder, arm or hands.
2. Venous Access Device such as AV shunt (in patients on hemodialysis) or
IVF in the arm.
3. Injury or disease to the shoulder, arm or hands such as trauma, burn or
application of cast or bandage.

Sites for BP taking:

1. either arm on the antecubital space
2. either leg on the popliteal space
3. dorsalis pedis
Equipment:
1. Stethoscope
2. Sphygmomanometer with appropriate size of cuff
3. Jotdown notebook and pen
4. Alcohol swab

Normal Ranges:
1. Infant - 50/40 – 80/50
2. Children - 87/48 – 117/64
3. Adult - 110/70 – 130/90

Procedure
Action Rationale
1. Explain the procedure to the patient. Nicotine causes vasoconstriction in
Make sure that client has not peripheral and coronary blood vessels
smoked cigarette or ingested which may cause increase in blood
beverages that contains caffeine pressure. Caffeine is a stimulant that
within 30 minutes increases blood pressure.

2. Place the patient in a comfortable This position exposes the brachial

position with the forearm supported artery so that a stethoscope can rest
and the palm upward. on it conveniently on the antecubital
area

3. Position yourself so that the An accurate reading is obtained when

calibration of the apparatus can be the manometer column is in direct
read at eye level and no more than vision.
3 feet away.
4. Place the cuff so that the inflatable Pressure applied directly to the artery
bag is centered and lies midway will yield most accurate readings.
over the anterior surface of the
brachial artery, (the surface of the
brachial artery should be at the
center of the 2 tubings of the cuff)
so that the lower edge of cuff is 2.5
– 5 cm. above antecubital fossa.
5. Wrap the cuff smoothly and snugly A twisted cuff and wrapping could
around the arm with the end of the produce inaccurate reading.
cuff secure.
6. Use the fingertips to feel a strong Accurate blood pressure reading is
pulsation on the antecubital space. possible when the stethoscope is
directly over the artery.
7. Inflate the cuff to 30 mmHg where This will prevent you from missing the
the pulsation disappears. Place the first tap sound as a result of the
diaphragm of the stethoscope auscultatory gap (period where no
directly over the pulse. sound is heard).
8. Gradually deflate cuff all the way to First sound is the systolic BP and last
zero taking note of the first and the sound is diastolic BP.
last clear, loud sound.
9. Remove the cuff and make patient
comfortable.
10. Record the reading on the jot down
notebook.
11. Report anything unusual.
12. Document the data.

* Pulse pressure – the difference between systolic and diastolic pressures.

e.g. 120/ 80 BP
Pulse pressure is 40
– may be ordered in patients with Dengue Hemorrhagic Fever
 SAN PEDRO COLLEGE
Davao City

PERFORMANCE CHECKLIST
CHECKING VITAL SIGNS

Name: ________________________________________ Grade: ___________________

Year and Section: _______________________________ Date: ____________________

Legend: 5—Excellent; 4—Very good; 3—Good; 2—Fair; 1—Poor

5 4 3 2 1
1. Reads the chart.
2. Washes hands.
3. Prepares the equipment and brings to the bedside.
4. Identifies the patient and explains the procedure.
5. Wipes the thermometer from the bulb towards the stem with
alcohol swab.
6. Pats the axilla dry using washcloth or tissue paper.
7. Turns the thermometer on.
8. Places the thermometer in axilla directed upward. Positions
patient’s arm across the chest.
9. Leaves thermometer in place for 30 to 60 seconds or until a
sound (beep) is heard.
10. Removes and wipes the thermometer dry using tissue paper.
11. Reads temperature reading on the digital display.
12. Records Temperature result in the jotdown notebook. Inform
client of the result.
13. Disinfects the thermometer twice using CB with alcohol from the
stem to the bulb in a firm twisting motion.
14. Places fingers on the radial pulse with the arm across the
client’s chest with the palm positions downward.
15. With a watch with swift second hand, counts the pulse rate for a
full minute.
16. With fingers still in place after taking radial pulse, notes the rise
and fall of patient’s chest upon respiration.
17. Counts respiratory rate for one full minute.
18. Records PR and RR and notes for any unusual characteristics
in the jotdown notebook.
19. Applies the BP cuff on the arm without contraptions.
20. Feels for a strong pulsation on the brachial artery with the use
of 2-3 fingerpads.
21. Pumps the bulb until the pin of the manometer reaches to
approximately 30 mmHg above the point where the systolic
pressure is last heard or when the pulse disappears.
22. Positions the diaphragm or bell of the stethoscope over the
pulse site with the earpiece into the ears.
23. Releases the air gradually with the use of the valve of the bulb
and takes note of the systolic blood pressure.
24. Continues to release air gradually and listen for the diastolic
blood pressure.
25. Removes the cuff and makes patient comfortable.
26. Records BP result on the jotdown notebook.
27. With the patient on supine position, locates the apical pulse on
the left side of the chest and drapes for privacy.
28. Warms the diaphragm of the stethoscope with the palm.
29. Places the diaphragm of the stethoscope over the PMI.
30. Counts the beat for one full minute.
31. Records HR result on the jotdown notebook.
32. Reports abnormalities and anything unusual.
33. Documents all the findings and results.
34. Maintains body mechanics throughout the performance of
procedures.
35. Manifests neatness in the performed procedure.
36. Ensures safety and comfort.
37. Respects patient’s rights.
38. Receptive to criticisms.
39. Observes courtesy.
40. Shows calmness while performing the procedure.
41. Uses of correct English.
42. Shows mastery of the procedure.

Remarks:

Criteria: I. Knowledge (Quiz) ______ x 30%= __________

II. Performance ______ x 70%= __________

SCORE=_________

_______________________________ ________________________________
Student’s Printed Name and Signature Instructor’s Printed Name and Signature