Checking The Vital Signs

CHECKING THE VITAL SIGNS(VS)
Definition: Clinical measuremants specifically temperature pulse, respiration and blood

pressure that indicate the state ofth patient’s essential functions.Pain is
considered the “ fifth vital sign” in some organizations across the globe
I - TEMPERATURE
A. 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
1. Read the chart.

To obtain necessary data.
2. Wash hands.
To deter the spread of microorganism.
3. Determine any previous activity that would interfere with accuracy of temperature
measurement.
Smoking or oral intake of foods/ fluids can cause false temperature reading.
4. Bring the tray to the bedside and explain the procedure to the patient.
When the patient knows what is to be done, he will cooperate better.

5. Rinse the thermometer 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.
Chemical solutions may irritate mucus membrane and may have an
objectionable odor or taste.
6. Expose arm and shoulder by removing one sleeve of client’s gown. Avoid exposing
chest.
7. Pat the patient’s axilla dry with a wash cloth or tissue. Place the probe of the
thermometer into the center of the axilla. Bring the patient’s arm down close to his body
and place his forearm over his chest.
Moisture in the axilla may alter the result of the temperature. The deepest area
of the axilla provides the most accurate temperature measurement.
8. Leave the thermometer in place until signal or beep is heard or 1-3 minutes of ordinary
thermometer.
Allowing sufficient time for the axillary tissue to come in contact with the
thermometer bulb results in a reasonably accurate measurement of body temperature.
9. Remove, dry with tissue paper and read measurement on digital display of the
thermometer.
10. Inform client of temperature reading.
11. Assist client in putting back the sleeve of gown.
12. Cleanse the thermometer from the stem to bulb using CB with water twice, then dry
with tissue wipe and return to the container.
13. Dispose the used CB and tissue paper in the waste receptacle.
Confining contaminated articles help to reduce the spread of
pathogens.
14. Record reading in the jotdown notebook. Report to the CI/HN for unusualities.
15. Wash hands.
16. Document on the TPR master list and graphic chart.
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.
Equipment: a. Watch with second hand. c. Alcohol swab
b. Jot down notebook and pen d. stethoscope
A. RADIAL PULSE AND RESPIRATION
Procedure
1. Explain the procedure to the patient.
To gain cooperation and make client at ease.
2. Have the patient rest his arm along side of his body then place fingers on the radial pulse
with the arm across the client’s chest with the palm positions downward.
This position places the radial artery on the inner aspect of the patient’s wrist.
3. Apply enough pressure so that the patient’s pulsating artery can be felt distinctly.
4. With a watch with swift second hand, counts the pulse rate for a full minute.
Sufficient time is necessary to detect irregularities or other defects.
5. With fingers still in place after taking radial pulse, notes the rise and fall of patient’s
chest upon respiration.
Counting the respiration while presumably still counting the pulse keeps the
client from becoming conscious of his breathing which can possibly alter his usual
rate.
6. Counts respiratory rate for one full minute.
Sufficient time is necessary to observe rate, depth and other characteristics.
7. Records PR and RR and notes for any unusual characteristics in the jotdown notebook.
8. Refer anything unusual to the clinical Instructors and/ or head nurse.
9. Record the result in the client’s graphic chart and the TPR master list.
I - 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.

Equipment:
1. Stethoscope
2. Sphygmomanometer with appropriate size of cuff
3. Jotdown notebook and pen
4. Alcohol swab
Procedure
Action
1. Make sure that client has not smoked cigarette or ingested beverages that contains
caffeine within 30 minutes. Explain the procedure to the patient.
Nicotine causes vasoconstriction in peripheral and coronary blood vessels which may cause
increase in blood pressure.
2. Place the cuff so that the inflatable bag is centered and lies midway over the anterior
surface of the brachial artery, so that the lower edge of cuff is 2.5– 5 cm. above
antecubital fossa.
Pressure applied directly to the artery will yield most accurate readings.
3. Use the fingertips to feel a strong pulsation on the antecubital space.
Accurate blood pressure reading is possible when the stethoscope is directly
over the artery.
4. Inflate the cuff to 30 mmHg where the pulsation disappears. Place the diaphragm of the
stethoscope directly over the pulse.
This will prevent you from missing the first tap sound as a result of the
auscultatory gap
5. Gradually deflate cuff all the way to zero taking note of the first and the last clear, loud
sound.
First sound is the systolic BP and last sound is diastolic BP.
6. Remove the cuff and make patient comfortable.
7. Record the reading on the jot down notebook.
8. Report any unusualities to the CI and/or Headnurse.
9. Record BP on the VS sheet and VS masterlist.
A. CARDIAC RATE OR APICAL PULSE
Procedure
Action
1. Explain the procedure to the patient and/or significant others.

Elicits cooperation from the client.
2. Raise the gown and properly drape the client exposing the sternum and the left side of
chest.
Allows access to patient’s chest for proper placement of stethoscope.
3. Warm the diaphragm of the stethoscope with your hand before applying it to the
patient’s chest.
Placing a cold diaphragm against the skin may startle the patient and
momentarily increase the heart rate.
4. Place the diaphragm of the stethoscope over the apex of the heart, located at the fifth
intercostal space, left midclavicular line 5th ICS, LMCL). Then, insert the earpieces in
your ears.
This gives the loudest and most distinctive sound of the heart.
5. Counts the beat for one full minute. and note their rhythm and volume. Also evaluate
the intensity (loudness) of heart sounds.
A full minute count is important for an accurate assessment.
6. Remove the stethoscope and make the client comfortable
7. Record the apical pulse on the jot down notebook.
8. Refer anything unusual to the CI or Head nurse.
9. Record the result on the chart and VS master list.

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CHECKING THE VITAL SIGNS(VS)

Definition: Clinical measuremants specifically temperature pulse, respiration and blood

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

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

2. Jot down notebook and pen

1. Read the chart.

When the patient knows what is to be done, he will cooperate better.

2. To observe changes in a patient’s condition.

1. Explain the procedure to the patient and/or significant others.

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