Name:________________________________________ Section____________________

Instructor:_____________________________________ Date of Lecture Demo________

VITAL SIGNS
Basic Concept: Vital signs are physiologic measurements of the neurologic, metabolic,
respiratory, hormonal and cardiovascular status of the body. They include the body
temperature, pulse rate, respiratory rate, blood pressure and oxygen saturation. These
measurements are of utmost importance because they are the basis for identifying physiologic
disturbances or even life threating health conditions. Thus, vital signs are monitored
periodically.

Blood Temperature- The balance between heat produced and heat loss from the body. Body
heat is primarily produced by metabolism. The heat regulating center is found in the
hypothalamus.

Pulse Rate- It is the wave of blood created by contraction of the left ventricles of the heart. It
is regulated by Autonomic Nervous System (ANS).

Respiratory Rate- The act of breathing, transport of oxygen from the atmosphere to the
body cells and transport of carbon dioxide from the cell to the atmosphere.

Blood Pressure- Refers to the force of blood against the arterial walls. Maximum blood
pressure exerted on the walls of arteries when the left ventricle of the heart pushes blood
through the aortic valve into the aorta during systole.

I. Objectives: Vital Signs are measured for the following purpose

1. To monitor the client’s physiologic health status.
2. To provide baseline data for future comparisons
3. To identify health alterations
4. To identify contraindications prior to administration of medications
5. To identify contraindications prior to any diagnostic or invasive procedures.
II. Materials
Thermometer
BP apparatus
Cleansing Alcohol balls in a container
Picking Forceps soak in antiseptic solutions, if using cotton balls soaked in
alcohol
Clean Gloves
Waste Receptacles or Kidney Basin
Face towel of patient
Wrist watch with second hand
III. Preparation
1. Prepare all necessary materials
2. Determine frequency of measuring vital signs
3. Determine appropriate site and device for patient
4. Obtain previous baseline data or measurement or previous patient’s record
5. Assess the following
a. Signs and symptoms of vital signs alterations
 b. Risk factor of vital signs
c. Factors affecting or influencing vital signs
d. Determine previous activity that interferes in assessing or measuring vital
signs.
e. Determine degree of assistance
f. Assess the immediate environment of the client
g. Perform hand hygiene or hand washing.
h. Check the client’s chart for name, birthdate, age and gender

PROCEDURE RATIONALE
ASSESSING THE TEMPERATURE
1. Greet the client, introduce yourself and
verify the client’s identity.

2. Ensure that the client is calm and quiet. Ask

what the client did for the past 12 minutes.
If patient was engaged in a strenuous
activity, allow 10-15 minutes to rest.

3. Expose the patient axilla by securely folding

the client’s shirt sleeve or gown up to the
deltoid region.

4. If axilla, is moist, dry it with the patient’s

towel using patting motion.

5. Remove thermometer from the container.

6. With a cotton ball, wipe the thermometer in

a rotating motion from the temperature
sensor to the neck.

7. Place the thermometer in the center of the

patient’s axilla.

8. Assist the patient to place the arm tightly

across the abdomen to keep thermometer in
place.

9. Wait until the thermometer will buzz

10. Note the result of the temperature

Note: Remain holding the thermometer in
place if the client is irrational or is very young.

ASSESSING PERIPHERAL PULSE

11. Assist the client to a comfortable supine
position or to a sitting position on a chair or
at the edge of the bed.
12. Select the pulse site point. Normally the
radial pulse is taken.

13. Place the two or three fingertips (index,

middle and ring) lightly and squarely over
the pulse point. Never use the thumb in
assessing pulse.

14. Rest the arm in a 90 degrees angle across

the abdomen with palm facing downward.

15. Observe the first minute the regulatory of

the pulse, count for one full minute.

16. Note the pulse rhythm and volume.

ASSESSING THE RESPIRATORY

17. Feel the rise and fall of the diaphragm while
supposedly taking the radial pulse.

18. Count the RR in 60 seconds. One inhalation

and one exhalation are counted as one cycle.

19. When abnormal breathing pattern is noted

use the next 60 seconds to carefully observe
the characteristics of the client’s
respirations.

20. Note the rate, depth, rhythm and character

of respiration

21. Refer any abnormal findings or any

complaints of the clients (Ex. Difficulty of
breathing).

ASSESSING BLOOD PRESSURE

22. Position the client appropriately and allow
10-15 minutes rest, if the patient is engaged
in a strenuous activity before BP
assessment.
a. In a lying positing with arms at the side,
palm facing up
b. In a sitting position with arm slightly
flexed, the forearm supported at the
heart level and facing up.

23. Fold the patient’s shirt sleeves or gown up

to the shoulder, making it sure it is secured
 and will not fall to the brachial area.

24. Ask the client not to speak when BP is

being measured.

25. Smoothly and evenly apply the cuff with its

lower border located at about 2.5cm above
the antecubital space.

26. Ensure the tube is place in line with the

brachial artery

27. Measure if the cuff is snugly fitted by

inserting your 2 fingers into the BP Cuff.

28. Position oneself, so that the manometer is

vertically at the eye level. Observation
should not be father than 1m
(Approximately 1 yard) away.

29. Insert the earpieces of the stethoscope in

your ears so that they tilt slightly forward.
Be sure sounds are clear not muffled.

30. Ensure that the stethoscope hangs freely and

is not contact with any object.

31. Warm the diaphragm of the stethoscope

32. Locate the brachial artery and place the

diaphragm of the stethoscope over the
brachial pulse. Secure the chest piece by
placing over the palm of the non-dominant
hand over it.

33. Close the valve of the pressure bulb

clockwise until it is tight.

34. Quickly inflate cuff until the last sound then

add 30 mmhg.

35. Slowly release/ open the pressure valve and

allow the manometr gauge to fall at a rate of
2-3 mmhg/per scond.

36. Note the point on manometer where the first

clear sound is heard. The sound will slowly
increase in intensity

37. Continue to deflate the cuff, noting the point

 at which sound disappears. Listen for 10-
20mmh after the last sound, then allow
remaining air to escape quickly.

38. Remove the cuff from the client’s arm and

assist patient to assume a comfortable
position. Cover the upper arm if it was
previously clothed

39. Discuss the findings to the client and do

health teachings as needed

40. Wash Hands

41. Documentation.
A. Chart in TPRBP sheet according to hospital
policy.
B. Report abnormal findings of vital signs
C. Report any alterations/observable signs and
symptoms of the patient
D. Patient’s Reactions
Reference
Berman, Aubrey, Synder, Shirlee, Frandsen, Geralyn (2016). Kozier and Erb’s Fundamentals
of Nursing concepts, Process and practice 10th ed.
 PERFORMACE CHECKLIST
Assessing Vital Signs

Name: _______________________________________ Date of Return Demo: __________

Criteria for evaluation or rating the student’s performance:

1 - Performs the step or procedure independently, correctly and appropriately. Shows

excellent attitude and gives the correct rationale of the step/ procedure to be performed.
Answers the question/s correctly and analyzes the situation on or before performing the
procedure.
2 – Performs more independently with increasing dependability but occasionally needing
assistance. Shows very satisfactory attitude and gives the correct rationale of the step/
procedure to be performed but occasionally needing follow-up instructions and explanations.
3 – Performs expected step/ procedure but needs supervision, follow-up instructions and
explanations. Has knowledge about the topic, step or procedure but needs reinforcement.
4 – Performs with close supervision. The student needs repeated, specific, detailed guidance
and direction to be able to perform the step/ procedure correctly and appropriately. There is a
need to improve performance.
5 – Performs with very close supervision. The student shows poor or no interest in the step/
procedure to be performed; cannot answer the question raised by the supervising clinical
instructor based on the step or procedure to be performed; unable to grasp understanding of
the topic or procedure; unable to perform the required step and state the rationale after being
instructed, guided or directed. Student’s behavior is inappropriate and potentially harmful to
the client.

1 2 3 4 5
ASSESSMENT
1. Determine frequency of measurement of vital signs
2. Obtain previous baseline data or measurement.
3. Assess the following
a. Signs and Symptoms of vital signs alterations
b. Risk factors of vital signs alterations
c. Factors affecting or influencing vital signs.
4. Determine client’s previous activity that interferes in assessing or
measuring vital signs.
5. Assess the immediate environment of the client.
6. Check the client’s chart for name, birthdate, age and gender.
PLANNING
 1. Prepare all necessary materials
2. Determine degree of assistance needed
IMPLEMENTATION
1. Greet the client, introduce self and verifies the client identity.
2. Ensure that the client is calm and quiet. Ask what the client
did for the past 15 minutes
3. If patient engages in a strenuous activity, allow 10-15 min,
rest
4. Expose the client’s axilla by securely folding the client’s shirt
sleeve or gown up to the deltoid region.
5. Dries the client’s axilla if wet or sweating
6. Remove thermometer from its container

7. With a cotton ball, wipes the thermometer in a rotating motion

from temperature sensor to the neck.
8. Places the thermometer in the center of patient’s axilla
9. Assist the patient to place the arm tightly across the abdomen
to keep the thermometer in place
10. Wait until the thermometer buzzes and note the result of the
temperature.

11. If the client is irrational, hold the thermometer

12. Assesses the client to a comfortable supine position or to a
sitting position on a chair or at the edge of the bed.
13. Select the pulse point. Normally the radial pulse is taken.
14. Places two or three fingertips (index, middle and ring)lightly
and squarely over the pulse point.
15. Rest the rms 90 degrees angle across the abdomen with plm,
facing downward
16. Observes for the first minute the regulatory of pulse , count
for one full minute.
17. Notes the pulse rhythm and volume
18. Feel the rise and fall of the diaphragm while supposedly
taking the radial pulse.
19. Count the RR for 60 seconds. One inhalation and one
exhalation are counted as one respiratory cycle
20. When abnormal breathing pattern is noted, uses the next 60
seconds to carefully observe the characteristics of the clients
respirations.
21. Note the rate, depth, rhythm and character of respiration.
22. Refer any abnormal findings or any complaints of the clients
(Difficulty of Breathing).

23. Position the client appropriately (allow 10-15 mins if the

patient is engaged in a strenuous activity before BP
assessment).
a. In a lying position with arms at the side, palm facing up
b. In a sitting position with arms slightly flexed, the forearm
supported at the heart level and palm facing up.
24. Fold the patient’s shirt sleeves or gown up to the shoulder,
making sure it is secured and will not fall to the brachial artery
25. Ask the client not to speak when BP is being measured.

26. Smoothly and evenly applies the cuff with its lower border
located at about 2.5 cm above the antecubital space
27. Ensure tat the tube is in place in line with the brachial artery

28. Measure if the cuff is snugly fitted by inserting your 2 fingers

into BP cuff.
29. Position oneself, so that manometer is vertically at the eye
level. Observation should not be farther than 1m
(approximately 1 yard) away
30. Insert the earpiece of the stethoscope in your ears so that they
tilt slightly forward. Be sure sounds are clear not muffled
31. Ensure that the stethoscope hang freely and is not in contact
with any object.

32. Warm the diaphragm of the stethoscope.

33. Locates the brachial artery
34. Places the diaphragm of the stethoscope over the brachial
artery
35. Secure the piece by placing the palm of non dominant hand
over it
36. Close the valve of pressure bulb clockwise until it is tight.
37. Quickly inflates cuff until the last sound add 30 mmhg
38. Slowly release/opens the pressure valve and allows the
mercury manometer gauge to fail at a rate of 2-3mmh per
second
39. Note the point on manometer where the first sound is heard
40. Continue to deflate the cuff, noting point at which sound
disappears.
 41. Listen for 10-20mmhg after the last sound, and then allows
remaining air to escape quickly.
42. Removes the cuff from the client’s arm and assist client to
assume comfortable position. Cover the upper arm if it was
previously clothed.
43. Discusses finding with the client and do health teachings as
needed.
44. Washes hand
45. Document the following:
46. A. Chart in the TPRBP sheet according to hospital policy
B. Report any abnormal findings of vital signs
C. Report any alterations/observable signs and symptoms of
vital signs
D.Patient’s Reaction
EVALUATION
1. Performs the procedure with ease and deftness
2. Recall and applies related principles and procedures
3. Obtain accurate data on measurement

4. Has kept patient comfortable.

5. Display a positive and caring attitude in the performance of
the procedure.

Comments and Suggestions:

Rating: ______
Signature of Supervising Clinical Instructor: _______________________