Scribd
Upload
93 views6 pages

Vital Sign Taking Guide

This document provides instructions for taking a patient's vital signs, including temperature, respiratory rate, pulse, and blood pressure. It outlines the necessary materials, patient preparation, step-by-step procedures for each vital sign, and documentation requirements. The guidelines emphasize infection control measures like handwashing, using alcohol to clean equipment, and providing privacy for the patient.

Uploaded by

Jero Daclan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
93 views6 pages

Vital Sign Taking Guide

This document provides instructions for taking a patient's vital signs, including temperature, respiratory rate, pulse, and blood pressure. It outlines the necessary materials, patient preparation, step-by-step procedures for each vital sign, and documentation requirements. The guidelines emphasize infection control measures like handwashing, using alcohol to clean equipment, and providing privacy for the patient.

Uploaded by

Jero Daclan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 6

VITAL SIGN

TAKING GUIDE
By: Judy N. Vasquez,
M.A.N.
GATHER MATERIALS:
❑ Tray
❑ Tray lining
❑ Cotton balls with alcohol in a container
❑ Waste receptacle with plastic lining
ATTIRE:
❑ Tissue paper Student nurse – school uniform
❑ Alcohol-based hand rub Patient – females (bring nursing t-shirt)

❑ Digital Thermometer – check if working


❑ BP Apparatus – fully deflated, close valve
❑ Stethoscope – alcoholize earpiece down to bell
❑ Jot down notebook / Pen
❑ Watch with second hand
PREPARATION: 3

1. Check patient’s chart.


▪ Personal information
▪ Medical diagnosis
▪ Medication
▪ Baseline vital signs
2. Introduce self and explain that vital signs will be assessed.
3. Inform patient to remain still and relax. Refrain from eating, drinking or
talking while vital signs is taken.
4. Assess toileting needs.
5. Position client. (sitting / lying on bed head slightly elevated to 40-60 degree
angle or semi-fowlers position.
6. Provide privacy. ( close curtain, inform significant others or visitors to minimize
the noise)
7. Perform medical handwashing.
8. Prepare the materials. ( enumerate all the materials to be used)
9. Wash hands again.
TEMPERATURE TAKING
4

1. Ask patient to unbutton the shirt and expose axilla, fold sleeves of shirt to expose
arm.
2. Offer a tissue paper, let patient pat dry axilla area.
3. Offer waste receptacle to discard used tissue paper.
4. Prepare thermometer. Wipe from the probe to the tip with the used of cotton
ball wet with alcohol. Then put it on.
5. Place thermometer at the center of the axilla of the patient. ( ask permission)
6. Fold patient’s arm across the chest and abdominal area supporting the wrist of
patient with your thumb and placing your index and middle finger on the radial
pulse.
7. Wait for the beep which means temperature reading is done.

PROCEED TO RESPIRATORY RATE ASSESSMENT:


8. Observe for the rise and fall of the patient’s chest and count as one, this is done
in one full minute.
9. Observe for rate and character of respirations
PROCEED TO PULSE RATE ASSESSMENT: 5
10. Start palpating the radial pulse using the index and middle finger.
11. Apply light to moderate palpation until pulse is determine.
12. Count for one full minute using a second- hand watch.
13. Identify the rate, rhythm and volume of pulse.

PROCEED TO BLOOD PRESSURE MONITORING:


14. Assess extremity to be used (Ex. pain, cast, surgery etc.) – non dominant arm.
15. Position arm at heart level with palm of hand facing upward.
16. Locate brachial artery in the antecubital space.
17. Select cuff size, apply snugly about 1 inch above the antecubital space with
arrow on the brachial artery.
18. Place bell (diaphragm ) of stethoscope directly on the brachial artery.
19. Inflate bladder (adding 30 mmHg to palpatory reading taken).
20. Slowly turn valve and deflate cuff, taking note of systolic bp, diastolic bp and
Korotkoff’s sound phases.
21. Deflate cuff completely.
AFTER CARE: 6

1. Inform patient of the vital signs reading.


2. Do after care of materials and equipment.
3. Wash hands.
4. Record and document findings in the jot down notebook and TPR sheet.

THANK YOU…

You might also like