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UNIT 4
TAKING VITAL SIGNS
LESSON 1: COMMON EQUIPMENT IN TAKING THE VITAL SIGNS
When caring for an infant, toddler, child, elderly or person with special needs, measuring the vital signs
is of utmost concern. This is also a concern of your client. Hence, he/she has the right to know her vital signs.
It is bodily functions that reflect the body’s state of health and are easily measurable: body temperature,
pulse rate, respiratory rate, and blood pressure. In some cases, the fifth vital sign is considered to be the pain
that a person experiences.

VITAL SIGNS
Body temperature
It is a measurement of the amount of heat in the body. The balance between heat produced and heat lost is
the body temperature. The normal adult body temperature is 37 degrees Celsius. There is a normal range in
which a person’s body temperature may vary and still be considered normal. Take a look at these normal
ranges of body temperature:
Adult: 36.5 - 37.4 degree Celsius
Infant: 36.8 - 37.2 degree Celsius

Complications

37.5 - 37.7 degree Celsius slightly febrile (sinat) 1. Sponge bath

2. Increase fluid intake
3. Offer light cotton fabric
37.8 - 40 degree Celsius Pyrexia / febrile (lagnat) 1. Sponge bath
2. Increase fluid intake
3. Offer light cotton fabric
4. Ask for doctors’ help
5. Administer 1 paracetamol
Above 40 degree Celsius Hyperpyrexia / hypertermia 1. Call a doctor
(leading to convulsion)
Below body temperature Hypopyrexia / hypothermia 1. Offer a warm blanket
2. Offer warm fluid intake
3. Hot compress in the sole of the
foot (talampakan)

Oral : 36.4 to 37.2 degrees Celsius (mercurial - 3-5 mins, digital - 1 minute)
Rectal : 37 to 37.8 degrees Celsius (mercurial - 3-5 mins, digital - 1 minute)
Tymphanic: (electronic tymphanic - 2 seconds)
Axillary : 35.9 to 36.7 degrees Celsius (mercurial - 5 - 7 mins, digital - 1 minute)

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The following are the different types of thermometer
1. Clinical thermometer - It is made of glass with a narrowing above the bulb so that the mercury column stays
in position even when the instrument is removed.
2. Digital thermometer - This thermometer displays the reading in the LCD. This type of thermometer does not
use mercury which is hazardous to humans. That is why more and more people are using it now. Also, using
this is simple, quick and effective.
3. Ear digital thermometer - This release of heat is converted into a temperature and displayed on an LCD. It
is very easy to use this. You just have to place the tip in the ear of a person, press the button and in a few
seconds, the measurement is seen on the LCD.
4. Infrared thermometer with laser pointer - It measures temperature using thermal radiation emitted by the
body. It is also called laser thermometer if a laser is utilized to aid in aiming the thermometer.

Using a Digital Thermometer (mouth)

1. Wash your hands and take the thermometer from its holder.
2. Clean the probe (pointed end) of the thermometer with rubbing alcohol or soap and then rinse it in
cool water.
3. Inform the client that you are going to take his temperature orally.
4. Ask the client to wet his/her lips and pick up his tongue.
5. Place the thermometer under the client’s tongue on one side of his/her mouth. Ask him/her to close
his/her lips. (You may have to hold the thermometer specially if your client is sick and weak enough to even
hold the thermometer with his/her lips.) \
6. Leave the thermometer in place until the thermometer signals it is finished. When it beeps, it
signifies that it can be removed.
7. Remove the thermometer carefully and read the temperature on the digital display. Clean the tip of
the thermometer with a cotton ball soaked in alcohol. Put the thermometer’s tip cover. Place the thermometer
in its container.
8. Record the reading and wash your hands

Using a Digital Thermometer (armpit)

1. Wash your hands and take the thermometer from its holder.
2. Clean the probe (pointed end) of the thermometer with rubbing alcohol or soap and then rinse it in
cool water.
3. Inform the client that you are going to take his temperature under the armpit.
4. Place the thermometer under the client’s armpit. (You may have to hold the thermometer specially if
your client is very sick and weak that he/she cannot even hold the thermometer with his/her armpit.)
5. Leave the thermometer in place until the thermometer signals it is finished. When the thermometer
beeps, it means that it can be removed.
6. Remove the thermometer carefully and read the temperature on the digital display. Clean the tip of
the thermometer with a cotton ball soaked in alcohol. Put the thermometer’s tip cover. Place the
thermometer in its container.
7. Record the reading and wash your hands.

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Pulse Rate
Pulse Rate refers to the wave created by the heart when pumping blood into the circulation. It is analyzed
to determine the rate and quality which means determining the force, the pulse beat and the tension between
beats. Rythm or regularity is important.
The normal ranges of pulse rate are;
Adults 60-100 beats/min
Children 75-120 beats/min
Infants 80-140 beats/min
Rise in pulse rate may occur due to the following reasons;
Excitement Hemorrhage
Exercise Heart Disease
Infection Body Temperature
Shock

Complications:
1. Tachycardia - the pulse rate is above the normal range.
Independent Intervention
1. Reposition the patient into high fowler or sitting position
2. Recheck the pulse rate after 15-30 mins after resting
3. Ask for the doctors help.
2. Bradycardia - the pulse rate is velow the normal range.
Independent Intervention
1. Reposition the patient into Trendelenburg position
2. Recheck the pulse rate after 15-30 mins after resting
3. Ask for the doctors help.

Procedure in Taking the Pulse Rate

Radial Pulse
1. Place resident in the supine or sitting position.
2. If the resident is lying supine, place arm straight at side or fold arm over chest; if sit- ting, support
arm with your arm or place on flat surface.
3. Place fat pads (just below finger tip) of first two fingers over groove along thumb (radial) side of
resident’s wrist; slightly extend the wrist.
4. Lightly press against the radial bone until the pulse is absent momentarily, and then release
pressure to feel the strongest pulse.
5. Determine the strength of the pulse: pounding-bounding (+4); strong (+3); weak (+2); thready
(+1), or absent (0).
6. Count the pulse for 30 seconds; multiply the total count by 2.
7. If the pulse rate is irregular or less than 50 beats per minute (BPM), count the pulse for 60
seconds.
8. Record the rate, strength, and rhythm of the radial pulse on the facility form.

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Apical Pulse
1. Clean earpieces and diaphragm of stethoscope.
2. Assist resident to supine or sitting position. Expose sternum (breastbone) and left side of chest.
3. With two or three fingers of your hand, locate the point of maximum intensity (PMI or apical pulse)
of the heartbeat on the left chest wall.
4. Place the diaphragm of stethoscope over PMI and auscultate (listen) to the heartbeat for 30
seconds and multiply the count by 2; if the pulse is irregular, listen for 60 seconds.
5. Reposition resident’s gown or clothing over chest area and clean ear pieces and diaphragm of
stethoscope.
6. Record the rate, strength, and rhythm of the apical pulse on the facility form.

Pulse Sites

Respiratory Rate
The respiration rate is the number of breaths a person takes per minute. The rate is usually measured
when a person is at rest and simply involves counting the number of breaths for one minute by counting how
many time the chest rises.
When checking for respiratory rates, take note if the patient is difficulty in breathing. Following are the
normal respiratory rate.
Adults 12 to 20 cycles/min
Children 15 to 25 cycles/min

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Infants 20 to 40 cycles/min

Procedures in Taking Respiratory Rate

1. Place resident in supine or sitting position; be sure you can view the chest.
2. Place resident’s arm across the chest comfortably, keeping your hand on the chest or the upper
abdomen.
3. While talking to the resident to provide distraction, observe complete respiratory cycle (one
inspiration and one expiration); while watching the sweep hand on your watch, count respirations
for 30 seconds; multiply the count by 2.
4. If the respirations are irregular, count them for 60 seconds.
5. Record respiratory effort (unlabored to labored), depth (shallow to deep), and rate on the facility
form.

Complications
1. Tachypnea - above Respiratory rate
Independent Intervention
1. Reposition the patient into high fowler or sitting position
2. Recheck the respiratory rate after 15-30 mins after resting
3. Apply brown bag technique
4. Ask for the doctors help.
2. Bradypnea - below Respiratory rate
Independent Intervention
1. Reposition the patient into Trendelenburg position
2. Recheck the respiratory rate after 15-30 mins after resting
3. Apply oxygen about 2-3 L per minute
4. Ask for the doctors help.
3. Apnea - absence of Respiratory rate
4. Eupnea - normal Respiratory rate
5. Dysnea - difficulty of breathing

B. Volume
1. Hyperventilation - over expansion of the lungs characterized by rapid and deep breaths
2. Hypoventilation - under expansion of the lungs characterized by shallow respiration.

Blood Pressure
Blood pressure is the force of the blood pushing against the walls of the blood vessels. The heart contracts
as it pumps the blood into the arteries. When the heart is contracting, the pressure is highest. This pressure
is what we know as the systolic pressure. Now, as the heart relaxes between each contraction, the
pressure decreases. When the heart is at its most relaxed state, the pressure is lowest. And we call this
diastolic pressure. It is measured in milliliters of mercury (mmHg).

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1. Position the resident in supine or sitting position; if the resident has been active, wait at least five
minutes before measuring the blood pressure.
2. Select proper size blood pressure cuff (sphygmomanometer). The cuff should fit 40% of the upper
arm (if cuff is too small, the reading will be falsely high; if too large, the reading will be a false low reading).
3. Locate brachial artery (in bend of elbow on the side closest to the resident).
4. Place the cuff snugly around the upper arm approximately two-finger widths above the elbow.
5. Position the resident’s arm at the level of the heart if sitting or at the resident’s side while lying.
6. If a dial is connected to the cuff, place the cuff so the dial is easily seen.
7. Place the bell of the stethoscope diaphragm over the brachial artery and hold snugly with the fingers
of your non-dominant hand; avoid touching the resident’s clothing or blood pressure cuff with the
stethoscope.
8. Close valve of the cuff pump clockwise until tight.
9. Quickly inflate the cuff (around 8 seconds) to within 30 mmHg above estimated systolic pressure.
10. Slowly release pressure valve deflating the cuff, and allow needle of manometer gauge to fall at the
rate of 2 to 3 mmHg/second.
11. Listen for the first clear sound and the point on the gauge at which you heard the first sound.
If you become distracted and miss the point on the gauge where the first sound was heard,
slowly and completely remove the cuff; wait at least one minute and repeat the procedure.
12. Continue to slowly deflate the cuff, noting the point at which the muffled sound completely
disappears.
13. Listen as the needle moves 10 to 20 mmHG beyond last sound and allow cuff to completely deflate.
14. Remove cuff and return resident to comfortable position.

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Blood Pressure Chart
Nornal 110/70 mmHg (new)
120/80 mmHg (old)
Mild Hypertension 140/90 mmHg 1. Reposition the patient into high
Moderate Hypertension 150/100 mmHg fowler or sitting position
Severe Hypertension 200/180 mmHg 2. Rest for 15 mins.
3. Advise the patient about proper
diet. Avoid cholesterol or fatty
foods, intake of sodium, and
carbon intake. Eat more protein
and fiber foods.
Hypotension Lower than normal range 1. Reposition the patient into
Trendelenburg position
2. Eat foods rich in iron.