Name: Section

Clinical Instructor (Lecture Demo): 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 The rationale behind the procedure/steps for
1. Greet the client, introduce yourself and verify the assessing the temperature are as follows:
client’s identity.
2. Ensure that the client is calm and quiet. Ask what 1. Greet the client, introduce yourself and
the client did for the past 12 minutes. If patient was verify the client's identity:
engaged in a strenuous activity, allow 10-15 minutes - This step establishes a rapport with the
to rest. client, helps to create a comfortable
3. Expose the patient axilla by securely folding the environment, and ensures that the right
client’s shirt sleeve or gown up to the deltoid region. individual is being assessed.
4. If axilla, is moist, dry it with the patient’s towel
using patting motion. 2. Ensure that the client is calm and quiet. Ask
5. Remove thermometer from the container. what the client did for the past 12 minutes. If
6. With a cotton ball, wipe the thermometer in a the patient was engaged in a strenuous activity,
rotating motion from the temperature sensor to the allow 10-15 minutes to rest:
neck. - Physical exertion or activity can
7. Place the thermometer in the center of the patient’s temporarily elevate body temperature. By
axilla. ensuring that the client is calm and has had
8. Assist the patient to place the arm tightly across the sufficient rest, you obtain a more accurate
abdomen to keep thermometer in place. baseline temperature reading.
9. Wait until the thermometer will buzz
10. Note the result of the temperature 3. Expose the patient's axilla by securely
Note: Remain holding the thermometer in place if the folding the client's shirt sleeve or gown up to
client is irrational or is very young. the deltoid region:
- The axilla (underarm) is a common site for
temperature measurement. Exposing this area
allows for direct contact between the
thermometer and the skin, facilitating accurate
temperature assessment.

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

towel using a patting motion:
- Moisture on the skin can interfere with the
accuracy of temperature readings. Drying the
axilla removes any sweat or moisture that
could affect the thermometer's reading.

5. Remove the thermometer from the container:

- This step prepares the thermometer for use.

6. With a cotton ball, wipe the thermometer in

a rotating motion from the temperature sensor
to the neck:
- Cleaning the thermometer helps maintain
proper hygiene and reduces the risk of
contamination.

7. Place the thermometer in the center of the

patient's axilla:
- Placing the thermometer in the center of the
axilla ensures that it is in the optimal position
to measure body temperature accurately.

8. Assist the patient to place the arm tightly

across the abdomen to keep the thermometer in
place:
- Securing the arm across the abdomen helps
maintain the position of the thermometer
during the temperature measurement process.

9. Wait until the thermometer buzzes:

 - The buzzing sound indicates that the
thermometer has completed the temperature
measurement. Waiting for the buzzing ensures
that the thermometer has sufficient time to
obtain an accurate reading.

10. Note the result of the temperature:

- Recording the temperature allows for
documentation and monitoring of the client's
health status over time.

Note: Remaining holding the thermometer in

place if the client is irrational or is very young:
- This precaution is taken to prevent the
client from accidentally removing or
dislodging the thermometer, which could
compromise the accuracy of the temperature
measurement. Holding the thermometer in
place ensures a consistent and reliable reading.
ASSESSING PERIPHERAL PULSE The rationale behind the procedure/steps for
11. Assist the client to a comfortable supine position or assessing peripheral pulse are as follows:
to a sitting position on a chair or at the edge of the
bed. 11. Assist the client to a comfortable supine
12. Select the pulse site point. Normally the radial pulse position or to a sitting position on a chair or at
is taken. the edge of the bed:
13. Place the two or three fingertips (index, middle and - Positioning the client in a comfortable and
ring) lightly and squarely over the pulse point. relaxed position helps promote accurate
Never use the thumb in assessing pulse. assessment of the peripheral pulse. Different
14. Rest the arm in a 90 degrees angle across the positions may be preferred depending on the
abdomen with palm facing downward. client's comfort and the pulse site being
15. Observe the first minute the regulatory of the pulse, assessed.
count for one full minute.
16. Note the pulse rhythm and volume. 12. Select the pulse site point. Normally, the
radial pulse is taken:
- The radial pulse, located on the wrist, is the
most common site for assessing the peripheral
pulse. It is easily accessible and provides a
reliable representation of the overall pulse rate
and quality.

13. Place the two or three fingertips (index,

middle, and ring) lightly and squarely over the
pulse point. Never use the thumb in assessing
the pulse:
- Using the fingertips rather than the thumb
allows for better sensitivity in feeling the
pulsations. The thumb has its own pulse, which
can interfere with accurately detecting the
client's pulse.

14. Rest the arm in a 90 degrees angle across

the abdomen with the palm facing downward:
- Placing the arm in this position helps relax
the muscles and minimizes tension, making it
easier to feel the pulse. The palm facing
downward allows for better stability and
support while palpating the pulse.

15. Observe the first minute for the regularity

of the pulse, count for one full minute:
- Observing the pulse for a full minute allows
 for an accurate assessment of the pulse rate and
rhythm. This duration provides a
comprehensive understanding of any
irregularities or variations in the pulse.

16. Note the pulse rhythm and volume:

- Assessing the pulse rhythm (regular,
irregular, or irregularly irregular) and volume
(weak, strong, or bounding) provides important
information about the cardiovascular health of
the client. It helps identify any abnormalities or
changes in the pulse pattern.

By following these steps, healthcare

professionals can gather valuable information
about a client's peripheral pulse, which is
essential for evaluating their cardiovascular
status and overall health.
ASSESSING THE RESPIRATORY The rationale behind the procedure/steps for
17. Feel the rise and fall of the diaphragm while assessing peripheral pulse are as follows:
supposedly taking the radial pulse.
18. Count the RR in 60 seconds. One inhalation and one 11. Assist the client to a comfortable supine
exhalation are counted as one cycle. position or to a sitting position on a chair or at
19. When abnormal breathing pattern is noted use the the edge of the bed:
next 60 seconds to carefully observe the - Positioning the client in a comfortable and
characteristics of the client’s respirations. relaxed position helps promote accurate
20. Note the rate, depth, rhythm and character of assessment of the peripheral pulse. Different
respiration positions may be preferred depending on the
21. Refer any abnormal findings or any complaints of client's comfort and the pulse site being
the clients (Ex. Difficulty of breathing). assessed.

12. Select the pulse site point. Normally, the

radial pulse is taken:
- The radial pulse, located on the wrist, is the
most common site for assessing the peripheral
pulse. It is easily accessible and provides a
reliable representation of the overall pulse rate
and quality.

13. Place the two or three fingertips (index,

middle, and ring) lightly and squarely over the
pulse point. Never use the thumb in assessing
the pulse:
- Using the fingertips rather than the thumb
allows for better sensitivity in feeling the
pulsations. The thumb has its own pulse, which
can interfere with accurately detecting the
client's pulse.

14. Rest the arm in a 90 degrees angle across

the abdomen with the palm facing downward:
- Placing the arm in this position helps relax
the muscles and minimizes tension, making it
easier to feel the pulse. The palm facing
downward allows for better stability and
support while palpating the pulse.

15. Observe the first minute for the regularity

of the pulse, count for one full minute:
- Observing the pulse for a full minute allows
for an accurate assessment of the pulse rate and
 rhythm. This duration provides a
comprehensive understanding of any
irregularities or variations in the pulse.

16. Note the pulse rhythm and volume:

- Assessing the pulse rhythm (regular,
irregular, or irregularly irregular) and volume
(weak, strong, or bounding) provides important
information about the cardiovascular health of
the client. It helps identify any abnormalities or
changes in the pulse pattern.

By following these steps, healthcare

professionals can gather valuable information
about a client's peripheral pulse, which is
essential for evaluating their cardiovascular
status and overall health.
ASSESSING BLOOD PRESSURE The rationale behind the procedure/steps for
22. Position the client appropriately and allow 10-15 assessing blood pressure is as follows:
minutes rest, if the patient is engaged in a strenuous
activity before BP assessment. 22. Position the client appropriately and allow
a. In a lying positing with arms at the side, palm 10-15 minutes rest if the patient is engaged in a
facing up strenuous activity before BP assessment:
- Allowing the client to rest ensures that their
heart rate and blood pressure return to a more
stable baseline, providing a more accurate
measurement.

a. In a lying position with arms at the side,

palm facing up:
- This position promotes relaxation and
allows for easy access to the client's arm for
blood pressure measurement.

b. In a sitting position with the arm slightly

flexed, the forearm supported at heart level and
facing up:
- This position ensures proper alignment of
the arm and facilitates accurate blood pressure
measurement.
 b. In a sitting position with arm slightly flexed, the 23. Fold the patient's shirt sleeves or gown up
forearm supported at the heart level and facing to the shoulder, making sure it is secured and
up. will not fall to the brachial area:
23. Fold the patient’s shirt sleeves or gown up to the - Exposing the upper arm and shoulder
shoulder, making it sure it is secured and will not allows for proper placement of the blood
fall to the brachial area. pressure cuff and ensures accurate readings.
24. Ask the client not to speak when BP is being
measured. 24. Ask the client not to speak when BP is
25. Smoothly and evenly apply the cuff with its lower being measured:
border located at about 2.5cm above the antecubital - Talking during blood pressure measurement
space. can affect the accuracy of the readings as it can
26. Ensure the tube is place in line with the brachial temporarily raise blood pressure levels.
artery
27. Measure if the cuff is snugly fitted by inserting your 25. Smoothly and evenly apply the cuff with its
2 fingers into the BP Cuff. lower border located at about 2.5cm above the
28. Position oneself, so that the manometer is vertically antecubital space:
at the eye level. Observation should not be father - Placing the cuff at the correct location
than 1m (Approximately 1 yard) away. ensures that it compresses the brachial artery
29. Insert the earpieces of the stethoscope in your ears effectively, providing accurate blood pressure
so that they tilt slightly forward. Be sure sounds are readings.
clear not muffled.
30. Ensure that the stethoscope hangs freely and is not 26. Ensure the tube is placed in line with the
contact with any object. brachial artery:
31. Warm the diaphragm of the stethoscope - Proper alignment of the tubing with the
32. Locate the brachial artery and place the diaphragm brachial artery allows for accurate transmission
of the stethoscope over the brachial pulse. Secure of blood pressure readings to the manometer.
the chest piece by placing over the palm of the non-
dominant hand over it. 27. Measure if the cuff is snugly fitted by
33. Close the valve of the pressure bulb clockwise until inserting your 2 fingers into the BP cuff:
it is tight. - Checking the fit of the cuff ensures that it is
34. Quickly inflate cuff until the last sound then add 30 not too tight or too loose. Proper fit is
mmhg. necessary to obtain accurate blood pressure
35. Slowly release/ open the pressure valve and allow measurements.
the manometr gauge to fall at a rate of 2-3 mmhg/per
scond. 28. Position oneself so that the manometer is
36. Note the point on manometer where the first clear vertically at eye level. Observation should not
sound is heard. The sound will slowly increase in be farther than 1m (approximately 1 yard)
intensity away:
37. Continue to deflate the cuff, noting the point at - Proper positioning of the manometer allows
which sound disappears. Listen for 10-20mmh after for easy observation of the pressure readings
the last sound, then allow remaining air to escape while maintaining a suitable distance for clear
quickly. visibility.
38. Remove the cuff from the client’s arm and assist
patient to assume a comfortable position. Cover the 29. Insert the earpieces of the stethoscope in
upper arm if it was previously clothed your ears so that they tilt slightly forward. Be
39. Discuss the findings to the client and do health sure sounds are clear, not muffled:
teachings as needed - Proper placement of the stethoscope ensures
40. Wash Hands clear transmission of sound, allowing for
41. Documentation. accurate auscultation of blood pressure sounds.
A. Chart in TPRBP sheet according to hospital policy.
B. Report abnormal findings of vital signs 30. Ensure that the stethoscope hangs freely
C. Report any alterations/observable signs and and is not in contact with any object:
symptoms of the patient - Preventing contact between the stethoscope
D. Patient’s Reactions and external objects reduces interference and
ensures accurate sound transmission during
blood pressure measurement.

31. Warm the diaphragm of the stethoscope:

- Warming the diaphragm helps to improve
sound conduction and enhances the ability to
hear and differentiate blood pressure sounds
accurately.

32. Locate the brachial artery and place the

diaphragm of the stethoscope over the brachial
pulse. Secure the chest piece by placing the
palm of the non-dominant hand over it:
- Placing the stethoscope over the brachial
artery allows for the auscultation of Korotkoff
sounds, which are used to determine systolic
and diastolic blood pressure. Securing the chest
piece with the palm provides stability and
minimizes extraneous noise.

33. Close the valve of the pressure bulb

clockwise until it is tight:
- Closing the valve ensures that no air
escapes during inflation of the cuff.

34. Quickly inflate the cuff until the last sound,

then add 30 mmHg:
- Inflating the cuff above the expected
systolic blood pressure level ensures that the
sounds will be heard during auscultation.

35. Slowly release/open the pressure valve and

allow the manometer gauge to fall at a rate of
2-3 mmHg per second:
- Gradually releasing the pressure allows for
accurate determination of both systolic and
diastolic blood pressure by auscultating the
Korotkoff sounds.

36. Note the point on the manometer where the

first clear sound is heard. The sound will
slowly increase in intensity:
- The first clear sound corresponds to the
systolic blood pressure. Noting this point is
essential for accurate blood pressure
measurement.

37. Continue to deflate the cuff, noting the

point at which sound disappears. Listen for 10-
20 mmHg after the last sound, then allow
remaining air to escape quickly:
- The point at which the sound disappears
corresponds to the diastolic blood pressure.
Listening for an additional period after the last
sound ensures accurate determination of the
diastolic pressure. Releasing the remaining air
quickly allows for prompt removal of pressure
on the client's arm.

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

assist the patient to assume a comfortable
position. Cover the upper arm if it was
previously clothed:
- Removing the cuff and assisting the client
to a comfortable position promotes their well-
being and ensures their privacy and modesty.
Covering the upper arm maintains their
comfort.
 39. Discuss the findings with the client and
provide health teachings as needed:
- Sharing the blood pressure measurement
results and discussing them with the client
promotes their understanding of their blood
pressure status. Providing appropriate health
teachings can help the client manage their
blood pressure and make necessary lifestyle
changes.

40. Wash hands:

- Hand hygiene is essential to prevent the
transmission of microorganisms and maintain
infection control standards.

41. Documentation:
- Accurate and comprehensive
documentation is crucial for proper record-
keeping and continuity of care. Charting the
vital signs, reporting abnormal findings, and
noting any alterations or observable signs and
symptoms ensure proper communication and
contribute to the overall care of the patient.
Additionally, documenting the patient's
reactions provides a comprehensive record for
future reference.

Following these steps ensures a standardized

approach to assessing blood pressure, which is
important for obtaining accurate measurements
and effectively monitoring a patient's
cardiovascular health.
Reference
Berman, Aubrey, Synder, Shirlee, Frandsen, Geralyn (2016). Kozier and Erb’s Fundamentals of Nursing
concepts, Process and practice 10th ed.
Name: Section
Clinical Instructor (Return Demo): Date of Return Demo

PERFORMACE CHECKLIST
Assessing Vital Signs

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 that 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:

Rating:

Signature Over Printed Name of CI