How to Check Vital Signs | Checking Vitals (2024)

Checking vitals is an essential skill nurses learn in nursing school. The vital signs assessment is performed routinely in all health care settings by both nurses and nursing assistants.

Vital signs allow the nurse toknow how well the patient is doing or responding to treatment.

In this article, I will demonstrate how to check vitals as a nurse. You will learn the following:

  • How to assess a patient’s pain rating
  • How to take a temperature
  • How to assess oxygen saturation
  • How to count a heart rate
  • How to count respirations
  • How to take a manual blood pressure

Video Demonstration on Checking Vital Signs

Supplies Needed to Check Vital Signs:

  • Stethoscope
  • Blood pressure cuff withsphygmometer
  • Thermometer
  • Pulse oximetry
  • Watch
  • Disinfectant wipes and gloves

Before you Collect Vital Signs:

Perform hand hygiene, don PPE (if needed…example: patient is in some type of isolation precaution), perform patient identification checks, and explain to the patient about the procedure for collecting vitals.

Assess Pain Rating

This is best done at the beginning of your vital signs check. Ask the patient to rate their pain by rating it on a scale 0 to 10 (with 0 being NO pain and 10 being the absolute worst pain they have ever experienced). If they are having pain, ask them to tell you the location and quality of the pain.

Taking a Temperature

This can be done in various locations, such as:

  • Mouth (oral)
  • Armpit (axillary)
  • Forehead (temporal)
  • Rectum (rectal)
  • Ear (tympanic)

Remember that temperatures taken axillary and temporally will read 1 degree LOWER than an oral temperature, and temperatures taken in the rectum and ear will reading 1 degree HIGHER than an oral temperature.

A normal temperature in adults is: 97’F to 99’F (36.1 ‘C to 37.2 ‘C) and a temperature greater than 100.4’F is considered a fever.

Temporal Artery:

  1. Apply the probe cover to the unit if it has one.
  2. Free the forehead of any hair or materials (if you don’t this, it will alter the temperature because the probe has to maintain contact with the skin of the forehead to get a proper reading).
  3. Touch the probe to the center of forehead and swipe the probe across the forehead to the hairline and always maintain contact with the skin.

****If the patient is sweating, then touch the probe to the back of the neck under the ear. The reason for this is because sweating will decrease the temperature if present on the forehead and the vascular area below the ear will help make sure it receives a proper reading.

  1. Dispose of probe and clean device per facility’s protocol.
  2. Document the temperature and the route taken if not orally.

Assessing Oxygen Saturation (O2 Sat)

This is performed with an oxygen saturation monitor. This device is placed on the nail bed of a finger. A normal oxygen saturation is 95% to 100%.

How to Count a Heart Rate

You can count a heart rate in various locations, such as:

  • Radial (the most commonly used in the adult)
  • Brachial
  • Carotid
  • Pedal
  • Femoral
  1. Use the first three fingers of your hand and find the radial artery.
  2. It is located in the wrist, right below the thumb along the radial bone.
  3. Note the rate, strength, and rhythm.
    1. Grade the strength of the pulse with the following scale:
      • 0: absent
      • 1+: weak
      • 2+: normal
      • 3+: bounding
  4. Count the heart rate (if regular) for 30 seconds and multiply by 2. If the heart rate is irregular count for 1 full minute.

Normal heart rate in an adult is 60-100 beats per minute.

How to Count Respirations

Count the respiratory rate right after counting the heart rate. To do this, keep you fingers on the radial site and look at the rate of breathing, depth, and rhythm. The patient should be UNAWARE you are counting the respiratory rate so they don’t change their rate of breathing.

Count the respirations for 30 seconds if regular and multiply by 2, and if the respirations are irregular count for 1 minute. Remember one breath in and one breath out equals 1 respiration.

Normal respiratory rate in an adult is 12-20 breaths per minute.

How to take a Manual Blood Pressure

  • Ask the patients to sit up straight with their arms stretched forward. The patient’s palms should face up, and the arm in which their blood pressure will be taken should be slightly bent. The upper arm should be level with the heart, and the feet should remain flat on the floor (not crossed) during the process. Some patients may wish to rest their arm on a table or armrest for added support while having their blood pressure taken.
  • Make sure that the patient is relaxed and calm before proceeding.
  • First estimate the systolic blood pressure measurement: The reason for doing this is so you will avoid missing the auscultatory gap (if present). This is an abnormal silence that can occur in some patients, and it may cause you to miscalculate the systolic number, which is the first sound heard.
    • Palpate the brachial artery with your first three fingers: It’s found in the bend of the arm, closest to the patient.
    • Secure the cuff about 2 inches above the bend of the arm on the patient and line up the arrow of the cuff with the brachial artery.
    • Palpate the brachial artery again and inflate the cuff until you NO longer feel the artery.
    • The point where you no longer feel the artery on the gauge is the estimated systolic blood pressure measurement. Remember this number because when you take the blood pressure you will inflate the cuff 30 mmHg ABOVE this number.
    • Deflate the cuff and wait 30-60 seconds before you take the blood pressure.
  • After waiting about 30-60 seconds, palpate the brachial artery again and secure your stethoscope in your ears and place the bell or diaphragm of the stethoscope over the location of the brachial artery. You can use either the bell or diaphragm of the stethoscope. However, the bell is best for assessing low-pitched sounds.
  • Inflate the cuff 30 mmHg above the estimated systolic blood pressure you obtained earlier. Example: If you estimated 100 as the systolic, inflate the cuff to 130.
  • Then let the needle of the gauge fall about 2 mmHg per second.
  • The first sound you hear if the systolic number.
  • The last sound you hear if the diastolic number.
  • Once you note the diastolic number, deflate the cuff and remove it from the patient.
  • Document your findings and what arm you measured the blood pressure in.

American College of Cardiology 2017 Updated Guidelines for High Blood Pressure:

  • Normal BP- SBP: <120 DBP: <80 mm Hg
  • Elevated BP- SBP: 120-129 DBP: <80 mm Hg
  • Hypertension Stage 1- SBP: 130-139 or DBP: 80-89 mm Hg
  • Hypertension Stage 2- SBP: ≥140 or DBP: ≥90 mm Hg

More Nursing Skills Videos

References

2017 Guideline for High Blood Pressure in Adults – American College of Cardiology. (2018). Retrieved from https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/11/09/11/41/2017-guideline-for-high-blood-pressure-in-adults

How to Check Vital Signs | Checking Vitals (2024)

FAQs

How to check vital signs step by step? ›

Using the first and second fingertips, press firmly but gently on the arteries until you feel a pulse. Begin counting the pulse when the clock's second hand is on the 12. Count your pulse for 60 seconds (or for 15 seconds and then multiply by four to calculate beats per minute).

What is the correct order to take vitals? ›

Order of Vital Sign Measurement

Healthcare providers often place the pulse oximeter probe on a client while proceeding to take pulse, respiration, blood pressure, and temperature.

How do you evaluate a patient's vital signs? ›

In this lab, you will learn the basic methods for determining a patient's vital signs.
  1. Body temperature measurement and conversion.
  2. Determination of pulse rate rate per minute.
  3. Measurement of breathing rate per minute.
  4. Taking and analyzing blood pressure readings.
Feb 1, 2021

What are the vital signs answer? ›

Body temperature. Pulse rate. Respiration rate (rate of breathing) Blood pressure (Blood pressure is not considered a vital sign, but is often measured along with the vital signs.)

What are the 5 principles of vital signs? ›

Vital Signs (Body Temperature, Pulse Rate, Respiration Rate, Blood Pressure)
  • Body temperature.
  • Pulse rate.
  • Breathing rate (respiration)
  • Blood pressure.

What is the best advised sequence when taking a patient's vital signs? ›

Temperature, pulse, respira- tion, and blood pressure are usually taken in this order. For proper charting of vital signs in the medical record, it is helpful to remember the T, P, R, BP sequence and record the results in that order.

What are the guidelines for vital signs? ›

Normal vital sign ranges for the average healthy adult while resting are: Blood pressure: between 90/60 mmHg and 120/80 mmHg. Breathing: 12 to 18 breaths per minute. Pulse: 60 to 100 beats per minute.

What is the order in which the nurse should perform vital signs? ›

The order of obtaining vital signs is based on the patient and their situation. Health care professionals often place the pulse oximeter probe on the patient while proceeding to obtain their pulse, respirations, blood pressure, and temperature.

How do nurses monitor vital signs? ›

To take vital signs, nurses will use blood pressure cuffs and thermometers to measure pulse rate and temperature. They will also listen to their patients' lungs with stethoscopes and palpate their abdomen to check for tenderness or swelling.

What should be considered when checking the client's vital signs? ›

Vital signs are critical health indicators used extensively in healthcare for diagnosis and treatment guidance. These indicators, including pulse, respiration, temperature, and blood pressure, are measured in medical checkups and emergencies and can even be monitored at home.

What to say when taking vital signs? ›

“Hello, I am XXX (state first and last name). I am a XXX (state designation, e.g., I am a registered nurse). Today, I am here to take your vital signs. It will involve me touching your arm, are you okay with that?”

How to read a hospital vitals monitor? ›

Read the numbers on the right-hand side of the monitor to learn the patient's pulse rate, body temperature, and blood pressure. Use the respiratory and oxygen saturation rates to keep tabs on the patient's breathing and circulatory system. Watch the waveforms for any signs of irregular heartbeat or breathing.

What are the 5 main vital signs that are measured? ›

Takeaway. Vital signs measure the body's basic functions. These include your temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation.

What is the proper charting procedure for vital signs? ›

Temperature, pulse, respira- tion, and blood pressure are usually taken in this order. For proper charting of vital signs in the medical record, it is helpful to remember the T, P, R, BP sequence and record the results in that order. During some office visits, only one of the vital signs may be measured.

How to take respiratory rate step by step? ›

To get an accurate measurement: Sit down and try to relax. It's best to take your respiratory rate while sitting up in a chair or in bed. Measure your breathing rate by counting the number of times your chest or abdomen rises over the course of one minute.

What are the four main vital signs and how are they measured? ›

Vital signs measure the basic functions of your body. They include your body temperature, blood pressure, pulse and respiratory (breathing) rate. Normal ranges for these signs vary by age, BMI and other factors. Pediatric vital signs aren't the same as adult vital signs.

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