Taking Vital Signs

Kavitha Samuel
Associate Professor
TAKING VITAL SIGNS
Temperature, Pulse, Respiration, Blood pressure

DEFINITION: Taking vital signs are defined as the procedure that takes the sign of
basic physiology that includes temperature, pulse, respiration and blood pressure.
If any abnormality occurs in the body, vital signs change immediately.

PURPOSE:

• 1. To assess the client’s condition

• 2. To determine the baseline values for future comparisons

• 3. To detect changes and abnormalities in the condition of the client

Vital signs equipment
A tray containing 5. Spirit swab or cotton (1)
1. Oral/ axilla / rectal thermometer (1) 6. Sponge towel (1)
2. Stethoscope (1) 7. Kidney tray
3. Sphygmomanometer with 8. Record form
appropriate cuff size (1) 9. Ball- point pen: blue / black red
4. Watch (1)
TAKING AXILLARY TEMPERATURE
DEFINITION: Measuring/monitoring patient’s body temperature using
clinical thermometer.

PURPOSE:

• 1. To determine body temperature

• 2. To assist in diagnosis

• 3. To evaluate patient’s recovery from illness

TYPES OF THERMOMETERS
PROCEDURE

• Wash hands

• Arrange all the equipment

• Check clients identification

• Explain procedure

• Provide privacy

• Provide comfortable position

• Hold thermometer at the stem and wipe it with alcoholic swab from bulb to stem

• Shake the thermometer with strong wrist movements until the mercury line falls to at
least 95F (35 c).
PROCEDURE
• Place the bulb of thermometer in hollow of axilla at 45 degree or horizontally

• Keep the arm flexed across the chest.

• Hold the glass thermometer in place for 3 minutes.

• Remove and read the level of mercury of thermometer at eye level.

• Shake mercury down carefully and wipe the thermometer from the stem to bulb with alcoholic swab.

• Explain the result and give instructions according to the findings

• Dispose & replace articles

• Wash hands

• Record findings
NORMAL BODY TEMPERATURE
CHECKING TEMPERATURE VIDEO
MEASURING A RADIAL PULSE

DEFINITION: The rhythmic dilation of an artery that results from beating of the 
heart.

PURPOSE:

• To determine number of heart beats occurring per minute. (rate).

• To gather information about heart rhythm and pattern of beats.

• To evaluate strength of pulse.

• To assess heart's ability to deliver blood to distant areas of the blood viz. fingers
and lower extremities
Various sites to check pulse
CHECKING PULSE PROCEDURE
PROCEDURE

• Wash hands.

• Arrange equipment (Pulse oximeter)

• Check the client’s identification.

• Explain the procedure

• Provide privacy

• Provide comfortable position

• If sitting bend client’s elbow 90 degrees and support lower arm on chair or on nurse’s arm and
slightly flex the wrist .
CHECKING PULSE PROCEDURE
• Count and examine the pulse:

• Check pulse for rate, rhythm and volume of throbbing of artery.

• Place the tips of your first, index, and third finger over the client's radial artery on the inside of
the wrist on the thumb side.

• Apply only enough pressure to radial pulse

• Using watch, count the pulse beats for a full minute, examine rhythm and the strength of the
pulse.(Rate, Rhythm & Volume)

• Record findings

• Wash hands
NORMAL PULSE BY AGE
COUNTING RESPIRATION
DEFINITION: Monitoring the involuntary process of inspiration and
expiration in a patient.

PURPOSES:

1. To determine number of respiration occurring per minute

2. To assess response of patient to any related therapy/medication.

PROCEDURE

• Wash hands

• Check for clients identification

• Provide comfortable position (sitting or semi fowlers position)

• Prepare counting respirations by keeping your fingertips on the client’s

pulse.

• Counting respiration:

• Observe the rise and fall of the client’s one inspiration and one expiration.
PROCEDURE

• Count respirations for one full minute.

• Examine the depth, rhythm, facial expression, cyanosis, cough and

movement of accessory muscles.

• One full cycle consists of an inspiration and an expiration.

• Wash hands

• Record the findings on the client’s chart.

Normal respiration
Normal respiration
• Effort less
• Steady
• Rhythmic
• little/no noise
Rates:
Infant 24 – 40 bpm
Child20 – 30 bpm
Adult 12 – 18 bpm
MEASURING BLOOD PRESSURE

DEFINITION: Blood pressure is defined as the amount of pressure exerted on the walls of the
arteries as the blood moves through them. It is measured in millimetres of mercury (mmHg).

Both the systolic and diastolic pressures are measured. Normal BP : 120/80mmHg

Purpose:

• To measure arterial blood pressure, both systolic and diastolic.

• To obtain baseline data for diagnosis and treatment

• To evaluate patient’s response to changes in physical condition as a result of treatment with

fluids or medications.
MEASURING BLOOD PRESSURE
Equipment Required
• Sphygmomanometer

• Stethoscope

• Spirit swab

• OR

• Non-invasive blood pressure equipment sensitive to brachial pulsation

• Invasive direct arterial monitoring for continuous blood pressure

observation
PROCEDURE
By Sphygmomanometer

• Wash your hands.

• Arrange articles (wipe the stethoscope diaphragm & ear pieces with
alcoholic wipes)

• Check the client’s identification.

• Explain procedure

• Provide privacy
PROCEDURE
• Provide comfortable position (sitting / supine position)

• Allow the client to relax at least for 5 minutes.

• Assess the previous baseline blood pressure, if available, from the client’s record.

• Support the selected arm and turn the palm upward.

• Remove any constrictive clothing.

• Place the sphygmomanometer at heart level for accurate measurement.

• Completely deflate cuff

PROCEDURE
• Palpate brachial artery and wrap the cuff snugly 2.5 cm (1 inch) above
the site where you palpated the brachial pulse

• Connect rubber tubing attached to cuff to instrument

• Find the pulsation of the brachial artery and place the stethoscope
exactly over this point
Procedure

• Inflate the cuff until thumping sounds are heard

• Continue compression until these sounds disappear

• Allow mercury column to fall a few millimetres until a faint thumping

sound is heard – This is the Systolic Pressure (120mmHg).

• Continue to deflate cuff until sound changes from a loud to a soft

thumping – This is the Diastolic Pressure. (80mmHg).
Procedure

• If you must recheck the reading for any reason, allow a 1 minute
interval before taking blood pressure again.

• Assist the client to a comfortable position

• Replace the articles and discard the waste.

• Wash your hands. (Hand washing prevents the spread of infection.)

• Record blood pressure on the client’s chart.

THANK YOU