Learning objectives
Accreditation competency
Key terminology
Pre-procedure considerations

We acknowledge that there may be variations in the technique presented.

You should perform this procedure under the supervision of an appropriately skilled supervisor until you are confident and competent enough to do it on your own.

Before using any medication or equipment in this procedure, please read the approved product information for instructions, contraindications, adverse effects, and warnings. Familiarize yourself with the equipment. The equipment or medication available to you may differ from what is used in this demonstration. You must inquire with a supervisor or instructor if there are variations or questions related to the equipment, medication, or procedures.

Assemble and prepare the equipment required to measure each vital sign. Clean and disinfect the sphygmomanometer, thermometer, pulse oximeter, and any other reusable equipment. If necessary, calibrate the equipment according to the relevant maintenance schedule for your institution.

Equipment to
measure vital signs

For obtaining a temperature, select an appropriate thermometer and prepare it according to the manufacturer's instructions. Place a disposable cover over the thermometer probe to reduce the risk of infection. If the thermometer model uses color-coded probes, ensure that the correct color is used.

Probe covers

To obtain an apical pulse or blood pressure, clean the stethoscope. Ensure that there is a range of different-sized arm cuffs, and that a watch or clock is in sight for counting pulse and respiration.

Familiarize yourself with the specific equipment available, as items may vary between different institutions. If possible and if necessary, read through the manufacturer's instruction sheet in its entirety, to ensure correct use.

Wash your hands before beginning the procedure.

Washing hands

Always take standard precautions.

Use aseptic technique.

Confirm patient details.

Explain the procedure to the patient and address any questions or concerns. Check that in the last 30 minutes prior to the procedure, the patient has not eaten, consumed any hot or cold fluids, smoked, exercised, or engaged in any stressful or emotional situation. Any of these activities may change their vital signs and cause an inaccurate measurement.

Obtain informed consent from the patient before proceeding.

Ask the patient to allow access to the site to take the vital sign, if necessary. Instruct the patient to remove their upper garments to measure axillary temperature, or apical pulse properly. If the patient needs to remove clothing or change into a gown, ensure that patient privacy is maintained.

When taking the patient's radial pulse or blood pressure, ensure that there is clear and unobstructed access to the upper arm. The patient's sleeve on the testing arm may need to be unbuttoned, rolled up, or removed entirely. When rolling up a sleeve, make sure it does not constrict the brachial artery, as this may affect the reading.

Instruct the patient either to sit in an upright position, or to lie in a supine position, depending on which provides better access to the test site. Provide assistance with repositioning if necessary.

Ask the patient to open their mouth, and lift up their tongue. Place and hold the probe under the patient's tongue, with the shaft resting against either side of the mouth.

Probe under tongue

Ask the patient to close their mouth firmly, without biting on the thermometer. Closing the mouth ensures that air cannot enter and interfere with the temperature reading.

Once the thermometer signals, instruct the patient to open their mouth, and remove the probe. Immediately discard the disposable probe cover into a biohazard waste container. Use a discard button on the thermometer, or use gloves so that you do not directly touch the probe cover. Check the manufacturer's instructions to see if the thermometer probe cover should be discarded in any other way.

Read the oral temperature in the display window of the thermometer, or the processing unit.

Record the reading on the patient record.

Inspect both ears for signs of infection or other contraindications for aural temperature-taking. Select one ear to take the aural temperature, and ask the patient to turn it toward you.

Gently pull the top of the ear up and back to open the external ear canal for an accurate reading.

Opening ear canal

Insert the probe into the ear canal. Insert the probe far enough to seal the opening completely. Do not apply any pressure on the ear.

Insert the thermometer
in the ear canal

Press the button on the probe, as directed by the manufacturer's instructions. The reading appears on the display window of the thermometer within 1 to 2 seconds. Remove the probe from the ear, and discard the probe cover in a biohazard waste container. Note the reading on the patient record, recording a "T" for tympanic.

Ask the patient to lift up their arm. If necessary, pat the patient's axillary area dry with a gauze or tissue. This is to ensure an accurate reading, and for hygiene purposes. Do not rub the area, since friction may elevate the temperature.

Place the tip of the thermometer on the center of the axilla. Ensure that the probe points toward the upper chest, and make sure that it touches skin and not clothing. If necessary, roll up the sleeve, or ask the patient to remove more clothing.

Take axillary
temperature

Instruct the patient to fold their arm against their chest or abdomen, to hold the thermometer probe in place.

Fold arm against
body

When the thermometer has signaled that the reading is complete, ask the patient to lift their arm. Remove the thermometer, and discard the probe cover in a biohazard waste container. Read the temperature on the display window of the thermometer.
As it is not an internal body site, readings at the axilla are roughly 1^oF or 0.6^oC lower than those at other sites.

Record the reading on the patient record.

Put on a properly disinfected stethoscope, and warm the diaphragm of the stethoscope against your open palm. Uncover the left side of the patient's chest, while ensuring that the patient's privacy is maintained.

To locate the apex of the patient's heart, use your fingertips to palpate the left chest wall. Count the ribs down five spaces to the fifth intercostal space, between the fifth and sixth ribs. The apex is located in the fifth intercostal space, in line with the middle of the left clavicle and just under the left nipple.

For an alternative method of locating the apex, place your outstretched left hand on the chest. Place the tip of your middle finger on the suprasternal notch. Extend your thumb at a 45-degree angle. The end of your thumb will now be roughly positioned over the apex (see reference).

Locate the apex

Place the stethoscope, or your palpating fingers, on the patient's chest over the apex.

Place the stethoscope

Listen or feel carefully for the patient's heartbeat. The contraction of the heart emerges as two sounds ("lubb dupp"); this counts as one beat.

Count the beats for one full minute to ensure the most accurate reading. Resting adult pulse rates usually range from 60 to 100 beats per minute. Identify any irregularities in rhythm and rate (eg, arrhythmia, bradycardia, tachycardia).

Record the rate on the patient record, and any anomalies noted.

Ask the patient to hold their arm in a relaxed and well-supported position (eg, resting on the examination bed, or their knee). The patient's palm should be facing away from the examiner, and at or below the level of the patient's heart.

With one hand, grasp the patient's wrist, so that your first three fingertips wrap over it. Place your fingers about 1 inch (2.54 cm) below the base of the patient's thumb, directly over the radial artery.

Taking a radial pulse

Press your fingertips firmly, but not too hard, on the patient's wrist. Feel the pulse, and count it for one minute. In adults, resting pulse rates range from 60 to 100 beats per minute.

Note any irregularities in pulse pattern. Also feel the condition of the arterial wall while taking the pulse. Healthy arterial walls feel soft and elastic, while an abnormal arterial wall feels hard, knotty, wiry, or like a combination of these characteristics.

Counting the pulse

Release the patient's wrist and record the pulse and any anomalies on the patient record (eg, P = 72, irregular).

Position yourself so that the rise and fall of the patient's chest is visible. If the movement needs to be seen more clearly, place the patient's arm across their chest.

Place the patient's
arm across their
chest

Use a distracting technique, to prevent the patient from changing their breathing rate. For example, gently grasp the palm side of the patient's wrist, as if taking the patient's radial pulse.

Pretend to count
the radial pulse

Ensure that a complete respiration, or breathing cycle, can be observed. Count the number of respirations for 30 seconds. Normal adult respiration ranges from 12 to 20 breaths per minute.

Watch for any abnormalities in breathing rate, rhythm, and depth, such as apnea, bradypnea, dyspnea, hyperpnea, hyperventilation, tachypnea, and orthopnea. Listen for any noticeable breath sounds, such as rales, rhonchi, wheezing, or stertorous breathing. Prolonged breathing problems may present with more serious symptoms, such as cyanosis.

If any breathing irregularity is observed, count the patient's respiration for one full minute.

Release the patient's wrist. If needed, multiply the number counted in 30 seconds by two. Record the respiratory rate per minute and any anomalies in the patient record (eg, R = 18, wheezing).

Ensure that the patient is in a comfortable position. To avoid artificially influencing the blood pressure reading, ensure that the patient's legs are not crossed.

Inspect both arms and select one to apply the cuff, taking into consideration that cuff inflation will temporarily block circulation to the limb:

• Do not select an arm that has been recently injured, appears diseased, or is on the same side as a recent mastectomy.
• If both arms are suitable, palpate the brachial artery in both arms, and select the arm with strongest pulse. 
• If the pulses are the same in either arm, select the right arm.

Position the selected arm with palm facing upward. Expose the arm, and check that it is resting at heart level.

Choose the correct cuff size. Check that the cuff would not be too loose or too tight on the patient, as an incorrectly-sized cuff may produce inaccurate results.

Cuff is too tight
around arm

Position the cuff on the patient's arm. Check that the cuff is centered over the brachial artery (this may be indicated by an arrow, or a pair of parallel lines), and that the lower edge of the cuff rests approximately 1 inch (2.54 cm) above the palpable brachial pulse (this can normally be found at the inner crease of the elbow). The bladder of the cuff should sit between the lines designated on the cuff, and over the brachial artery.

Check that the tube connecting the cuff to the manometer is positioned away from the body, and that the tube connected to the bulb used to inflate the cuff is close to the patient's body.

Position the blood
pressure cuff

Wrap the cuff firmly around the upper arm, so that it is a snug fit. If the cuff is wrapped too tightly, the reading will be artificially elevated. If the cuff is wrapped too loosely, circulation may not be completely occluded when the cuff is inflated.

Adjust the position of the sphygmomanometer, so that the gauge is visible. If using an aneroid gauge, check that the needle lies within the zero mark.

Position the
sphygmomanometer

Palpate for the brachial pulse, which is normally found at the inner crease of the elbow.

Palpating the
brachial pulse

Close the valve on the air pump, while holding your fingers over the brachial artery.

Inflate the cuff until the brachial pulse can no longer be felt. Note this point on the gauge, which is the estimated systolic pressure. If using the auscultatory method, mentally add 30 mmHg to the reading.

Open the valve and deflate the cuff completely, and wait for 15 seconds to allow the patient's blood to return to normal circulation.

Insert the stethoscope earpieces, turned forward, into your ear canals.

Position the stethoscope's diaphragm over the patient's palpated brachial artery. Press firmly, but not so much that the artery becomes constricted. Do not to touch the cuff and its tubing with the diaphragm.

Place the
stethoscope bell

Close the valve on the air pump. Inflate the cuff rapidly and smoothly, using the bulb, until the pressure is at 30 mmHg above the estimated systolic pressure.

Carefully open the valve on the air pump slightly, to deflate the cuff at a constant rate of 2 to 3 mmHg per heartbeat. During cuff deflation, listen for the emergence of the Korotkoff phase sounds.

Deflate the cuff

Listen and note the point on the gauge (to the closest even number) where the first Korotkoff sound is heard. This is the systolic pressure.

Continue listening to the changing Korotkoff sounds, and note the point on the gauge where they become inaudible (Korotkoff phase V). Note this point on the gauge; it is the diastolic pressure.

Continue deflating the cuff for at least another 10 mmHg following the last sound. Make a note of any abnormal silence, or diminished sound that was heard during the Korotkoff phases. Silence or diminished sound is called an auscultatory gap, and may be a sign of vascular disease (see reference).

Record the blood pressure measurement.

Normal systolic pressure in adults ranges from 100 to 119 mmHg, while normal diastolic pressure ranges from 60 to 79 mmHg. Normal pulse pressure is usually between 30 and 40 mmHg. A pulse pressure above 60 mmHg is considered to be elevated, and may be a marker for increased cardiovascular risk in middle-aged and elderly patients (see reference).

Inform the physician of any abnormal blood pressure measurements.

Quickly deflate the remaining air from the cuff. Wait for 30 to 60 seconds, and repeat the procedure if necessary. Blood pressure readings should be retaken from the same arm if the heartbeat was not heard well enough, or the first reading was inaccurate.

Blood pressure should be measured on both arms during an initial examination, or when the patient has hypertension. Different measurements between arms may indicate a cardiovascular problem (see reference).

Remove the stethoscope earpieces from your ears, and remove the cuff from the patient's arm.

Place the blood pressure cuff on the patient's arm according to the manufacturer's instructions.

Press the start button, and the cuff will begin to inflate itself. The digital unit on the cuff automatically detects systolic and diastolic pressures. The reading will appear on the screen.

Record the reading.

Automated blood
pressure cuff
being used

Attach the probe of the pulse oximeter to the patient's earlobe or finger. If using a finger, there must be no nail polish on it, as the polish may affect measurement accuracy.

Activate the pulse oximeter, and wait for the measurement to appear on the screen. Record the reading.

Pulse oximeter
clipped to finger

Remove and dispose of all used materials in the appropriate places.

Disinfect the work area and any equipment that has been in human contact (eg, stethoscope earpieces and bell, thermometer probe).

If necessary, remove gloves worn during the procedure.

Wash your hands.

Assess the patient, and ask them to put on any clothes that were removed during the procedure. If the patient needs to perform any subsequent vital sign measurements at home, use this time to educate them about the equipment and procedure.

Inform the patient or parent/caregiver of any follow-up required.

Ask if the patient has any other questions or concerns, and address them within your authority. Escort or direct them to the waiting room or exit.

Record the procedure and result in the patient's medical record. Highlight any results of concern to the physician.

Patient's medical record

Record the temperature, and if necessary note the site from which the reading was taken. Oral temperatures can simply be recorded with the reading in either Celsius (^oC) or Fahrenheit (^oF). For other temperatures, also record the site from which it was taken ([T] = tympanic; [A] = axillary).

To convert between ^oC and ^oF, use the following formulae:

^oC = (^oF - 32) x 5/9
^oF = (^oC x 9/5) + 32

Record the pulse rate, and if necessary note the type of pulse taken (apical = AP; all others = P). Record any irregularities in heart rate, pulse rhythm, volume, and any arterial wall anomalies felt.

Record the patient's respiration rate as a total count over one minute (eg, R = 18). Also describe any observed abnormalities in breathing rate, rhythm, and depth.

Record the patient's blood pressure as a fraction, with the systolic reading above and the diastolic reading below (eg, 130/90). The abbreviation "mmHg" does not have to be included.

Record the patient's oxygen saturation level as a percentage (eg, SpO₂ = 98%).

Record the vital signs in a Temperature-Pulse-Respiration (TPR) chart, if this is necessary and the chart is available. This is a single long-term chart that allows the physician to compare readings over time. The chart is generally laid out in a grid format, and may have spaces to fill in other repeated measurements (eg, blood glucose levels).

TPR chart

Take special care to note any symptoms or complaints from the patient, as these may provide important clues for the physician to make a correct diagnosis.

References

Keir L, Wise BA, Krebs C. Medical Assisting: Essentials of Administrative and Clinical Competencies. Clifton Park, NY: Delmar Cengage Learning; 2002.

Cavallini MC, Roman MJ, Blank SG et al. Association of the auscultatory gap with vascular disease in hypertensive patients. Ann Int Med. 1996 May 15;124(10):877-83. PMID: 8610916

Franklin SS, Khan SA, Wong ND, Larson MG, Levy D. Is pulse pressure useful in predicting risk for coronary heart disease? The Framingham Heart Study. Circulation. 1999;100(4):354-60. PMID: 10421594

Beevers G, Lip GY, O'Brien E. ABC of hypertension. Blood pressure measurement. Part I-sphygmomanometry: factors common to all techniques. BMJ. 2001 Apr 21;322(7292):981-5. PMID: 11312235

Pulseox.info. What is oxygen saturation?
Available at: http://www.pulseox.info/pulseox/what2.htm.
Accessed 23 August, 2010.

Other resources

Emedicinehealth. Fever in adults.
Available at: http://www.emedicinehealth.com/fever_in_adults/article_em.htm
Accessed 23 August, 2010.

Young A, Proctor D. Kinn's The Medical Assistant: An Applied Learning Approach. 10^th ed. St. Louis, MO: Saunders; 2007.