Checklist for Vital Signs Taking

Assessing the Temperature Performed Not Performed Remarks

1. Prior to performing the procedure, introduce self and verify

the client’s identity using agency protocol. Explain to the client
what you are going to do, why it is necessary, and how to par ticipate.
Discuss how the results will be used in planning further
care or treatments.

2. Perform hand hygiene and observe appropriate infection

prevention procedures. Apply gloves if performing a rectal
temperature.
3. Provide for client privacy.

4. Position the client appropriately (e.g., lateral or Sims’ position

for inserting a rectal thermometer).

5. Place the thermometer

6. Wait the appropriate amount of time. Electronic and tympanic

thermometers will indicate that the reading is complete through
a light or tone. Check package instructions for length of time to
wait prior to reading chemical dot or tape thermometers
7. Remove the thermometer and discard the cover or wipe with a
tissue if necessary. If gloves were applied, remove and discard
them.
• Perform hand hygiene
8. Read the temperature and record it on your worksheet. If the
temperature is markedly high, low, or inconsistent with the
client’s condition, recheck it with a thermometer known to be
functioning properly.
9. Wash the thermometer if necessary and return it to the storage
location.
10. Document the temperature in the client record.

Assessing the Pulse Performed Not Performed Remarks

1. Prior to performing the procedure, introduce self and verify

the client’s identity using agency protocol. Explain to the client
what you are going to do, why it is necessary, and how to
participate. Discuss how the results will be used in planning
further care or treatments.
2. Perform hand hygiene and observe appropriate infection
prevention procedures.
3. Provide for client privacy.
4. Select the pulse point. Normally, the radial pulse is taken,
unless it cannot be reached or circulation to another body area
is to be assessed.
5. Assist the client to a comfortable resting position. When the
radial pulse is assessed, with the palm facing downward, the
client’s arm can rest alongside the body or the forearm can rest
at a 90-degree angle across the chest. For the client who can
sit, the forearm can rest across the thigh, with the palm of the
hand facing downward or inward.
6. Palpate and count the pulse. Place two or three middle fingertips
lightly and squarely over the pulse point.
(Rationale: Using
the thumb is contraindicated because the nurse’s thumb has a
pulse that could be mistaken for the client’s pulse.)
• Count for 15 seconds and multiply by 4. Record the pulse
in beats per minute on your worksheet. If taking a client’s
pulse for the first time, when obtaining baseline data, or if
the pulse is irregular, count for a full minute. If an irregular
pulse is found, also take the apical pulse.
7. Assess the pulse rhythm and volume.
• Assess the pulse rhythm by noting the pattern of the
intervals between the beats. A normal pulse has equal
time periods between beats. If this is an initial assessment,
assess for 1 minute.
• Assess the pulse volume. A normal pulse can be felt with
moderate pressure, and the pressure is equal with each beat.
A forceful pulse volume is full; an easily obliterated pulse is
weak. Record the rhythm and volume on your worksheet.
8. Document the pulse rate, rhythm, and volume and your actions
in the client record

Assessing Respirations Performed Not Performed Remarks

1. Prior to performing the procedure, introduce self and verify

the client’s identity using agency protocol. Explain to the client
what you are going to do, why it is necessary, and how to par ticipate.
Discuss how the results will be used in planning further
care or treatments.
2. Perform hand hygiene and observe appropriate infection pre vention
procedures.
3. Provide for client privacy.
4. Observe or palpate and count the respiratory rate.
• The client’s awareness that the nurse is counting the
respiratory rate could cause the client to purposefully alter
the respiratory pattern. If you anticipate this, place a hand
against the client’s chest to feel the chest movements with
breathing, or place the client’s arm across the chest and
observe the chest movements while supposedly taking the
radial pulse.
• Count the respiratory rate for 30 seconds if the respirations
are regular. Count for 60 seconds if they are irregular. An
inhalation and an exhalation count as one respiration.
5. Observe the depth, rhythm, and character of respirations.
• Observe the respirations for depth by watching the move ment of the
chest. Rationale: During deep respirations, a
large volume of air is exchanged; during shallow respira tions, a small
volume is exchanged.
• Observe the respirations for regular or irregular rhythm.
Rationale: Normally, respirations are evenly spaced.
• Observe the character of respirations—the sound they
produce and the effort they require. Rationale: Normally,
respirations are silent and effortless.
6. Document the respiratory rate, depth, rhythm, and character
on the appropriate record

Assessing the Blood Pressure Performed Not Performed Remarks

1. Prior to performing the procedure, introduce self and verify

the client’s identity using agency protocol. Explain to the client
what you are going to do, why it is necessary, and how to par ticipate.
Discuss how the results will be used in planning further
care or treatments.
2. Perform hand hygiene and observe appropriate infection
prevention procedures
3. Provide for client privacy.

4. Position the client appropriately.

• The adult client should be sitting unless otherwise speci fied. Both feet
should be flat on the floor. Rationale: Legs
crossed at the knee results in elevated systolic and diastolic
blood pressures (Wilson & Giddens, 2017).
• The elbow should be slightly flexed with the palm of the
hand facing up and the arm supported at heart level. Read ings in any
other position should be specified. The blood
pressure is normally similar in sitting, standing, and lying
positions, but it can vary significantly by position in certain
clients. Rationale: The blood pressure increases when the
arm is below heart level and decreases when the arm is
above heart level.
• Expose the upper arm.

5. Wrap the deflated cuff evenly around the upper arm. Locate
the brachial artery (see Figure 28.13, page 517). Apply the
center of the bladder directly over the artery. Rationale: The
bladder inside the cuff must be directly over the artery to be
compressed if the reading is to be accurate.
• For an adult, place the lower border of the cuff approxi mately 2.5 cm
(1 in.) above the antecubital space.

6. If this is the client’s initial examination, perform a preliminary

palpatory determination of systolic pressure. Rationale: The
initial estimate tells the nurse the maximal pressure to which
the sphygmomanometer needs to be elevated in subsequent
determinations. It also prevents underestimation of the systolic
pressure or overestimation of the diastolic pressure should an
auscultatory gap occur.
• Palpate the brachial artery with the fingertips
• Close the valve on the bulb.
• Pump up the cuff until you no longer feel the brachial pulse.
At that pressure the blood cannot flow through the artery.
Note the pressure on the sphygmomanometer at which
pulse is no longer felt. Rationale: This gives an estimate of
the systolic pressure.
• Release the pressure completely in the cuff, and wait 1 to 2
minutes before making further measurements. Rationale:
A waiting period gives the blood trapped in the veins time to
be released. Otherwise, false readings will occur.
7. Position the stethoscope appropriately.
• Cleanse the earpieces with antiseptic wipe.
• Insert the ear attachments of the stethoscope in your ears
so that they tilt slightly forward. Rationale: Sounds are
heard more clearly when the ear attachments follow the
direction of the ear canal.
• Ensure that the stethoscope hangs freely from the ears
to the amplifier. Rationale: If the stethoscope tubing rubs
against an object, the noise can interfere with the sounds of
the blood within the artery.
• Place the amplifier of the stethoscope over the brachial
pulse site. Because the blood pressure is a low-frequency
sound, it may be best heard with the bell-shaped dia phragm. The
American Heart Association states that either
the bell or diaphragm can be used to auscultate blood
pressure, but some research has shown that the diastolic
pressure reads slightly lower when using the diaphragm
(Liu, Griffiths, Murray, & Zheng, 2016).
• Place the stethoscope directly on the skin, not on clothing
over the site. Rationale: This is to avoid noise made from
rubbing the amplifier against cloth.
• Hold the amplifier with the thumb and index finger

8. Auscultate the client’s blood pressure.

• Pump up the cuff until the sphygmomanometer reads 30
mmHg above the point where the brachial pulse disappeared.
• Release the valve on the cuff carefully so that the pressure
decreases at the rate of 2 to 3 mmHg per second.
Rationale: If the rate is faster or slower, an error in mea surement may
occur.
• As the pressure falls, identify the manometer reading at
Korotkoff phases 1, 4, and 5. Rationale: There is no clinical
significance to phases 2 and 3.
• After hearing phase 5, deflate the cuff rapidly and completely.
• Wait 1 to 2 minutes before making further determinations.
Rationale: This permits blood trapped in the veins to be
released.
• Repeat the above steps to confirm the accuracy of the
reading—especially if it falls outside the normal range
(although this may not be routine procedure for hospitalized
or well clients). If there is greater than 5 mmHg difference
between the two readings, additional measurements may
be taken and the results averaged.

9. If this is the client’s initial examination, repeat the procedure on

the client’s other arm. There should be a difference of no more
than 10 mmHg between the arms. Inter-arm differences greater
than 10 mmHg occur more commonly in hypertensive and dia betic
clients and should be evaluated further (Clark, 2017).

10. Remove the cuff from the client’s arm

11. Wipe the cuff with an approved disinfectant. Rationale: Cuffs

can become significantly contaminated.
• Many institutions use disposable blood pressure cuffs. The
client uses it for the length of stay and then it is discarded.
Rationale: This decreases the risk of spreading infection by
sharing cuffs.
12. Document and report pertinent assessment data