Vital signs (VS) Also called (signs of life,or cardinal signs): are an
indicators checked to monitor the body function or to sustain life.
Traditionally,temperature(T), pulse(P), respirations(R), andbloodpressure
(BP) were considered VS; Now, many health-care professionals view arterial
blood oxygen saturation (SaO2) and the presence of pain as additional
VS.
Vital Signs must be measured, reported, and recorded accurately
If not sure of a measurement, recheck it
• When a person is admitted to a health care facility
• Several times a day for hospitalized patients
• Before and after surgery
• After some nursing procedures
• Before medications are given that affect the respiratory or
circulatory system
• Whenever the person complains of pain, shortness of breath,
rapid heart rate, or not feeling well
• With the person at rest in a lying or sitting position
• Illness
• Emotions – anger, fear, anxiety, pain
• Exercise and activity
• Age
• Sex
• Environment - Weather
• Food and fluid intake
• Medications
• Time of day (diurnal time) – ↓ in the morning, ↑ in the afternoon/evening
• Noise
• Any vital sign is changed from a previous
measurement
• Vital signs are above the normal range
• Vital signs are below the normal range
Many agencies have temp boards or TPR books
Record vital sign measurements as soon as possible
Carry a small notebook in pocket to record them
Abbreviations
Temperature – T
Pulse – P
Respirations – R
Blood Pressure - Bp
Body Temperature Is The Amount of heat In The Body
It Is A Balance Between The Amount Of Heat ProducedAnd The Amount Of
Heat Lost
Heat Is Produced By:
The contraction of muscles during exercise
The breakdown of food during digestion
The environmental temperature
Heat Is Lost Through :
Urine
Feces
Respirations
Perspiration
Body temperature is measured by these areas of the
body:
1. Mouth – oral, most temperatures are
taken
2. Rectum – rectal, are the most accurate
3. Axilla (underarm) – axillary, least
accurate
4. Ear – tympanic
5. • Temporal Site – Forehead
The normal rang of Temperature are: (36.5 -37.5) c
A small hollow glass tube that contains mercury or a
mercury-free substance in a bulb at one end. when heated the
mercury rises in the tube.
Pear – shaped tip
• The scale is marked from 94° to 108°
• The long lines represent one degree
• The short lines represent two tenths of a degree
• Only every other degree is marked with a number
• Battery operated
• Have an oral probe and a rectal probe
• Disposable probe cover is placed on the probe
• The temperature registers in about 30 seconds
Use a disposable sheath
• Measures the temperature in the tympanic membrane (eardrum)
• Fast and accurate - 1 to 3 seconds
Infants – pull pinna of
ear down and back
Adults and children
over one year –
Pull pinna of ear up
and back
Glass thermometer
• Rinse with cold water
• Check the thermometer for breaks
and chips
• Shake down the thermometer so the
mercury is below the lines and
numbers
• Place a disposable cover on the
thermometerﮫ
• Place the thermometer under the
person’s tongue
• Leave the thermometer in place for
2 – 3 minutes
• If the person has been eating,
drinking, or smoking, wait 30
minutes before taking temperature
Contraindications of oral temperature:
• An infant or young child ( under age 6)
• An unconscious patient
• A patient that has had oral surgery or an injury to the face, neck, nose, or
mouth
• A person receiving oxygen
• A patient with a nasogastric tube in place
• A patient who is confused or restless
• A patient who is paralyzed on one side of the body
• Has a history of seizures
• A patient who breathes through the mouth
• Lubricate the thermometer before inserting into the rectum
• Place the person in a side-lying position
• Insert the thermometer 1 inch into the rectum
• Hold the thermometer in place for 2 minutes
• Remove the disposable cover and read the thermometer
Contraindications of a rectal
temperature:
• A person who has had rectal surgery or rectal injury
• If the person has diarrhea
• If the person is confused or agitated
• If the person has heart disease ( stimulates the vagus
nerve which slows the heart rate )
• Taken only when no other site
can be used
• Make sure the underarm is
clean and dry
• The arm is held close to the
body
Hold the thermometer in place
while the temperature is being
taken
• The thermometer is left in
place for 5-10 minutes
Pulse: is the beat of the heart felt at an artery as a wave of
blood passes through the artery
o A pulse is felt every time the heart beats
o More easily felt in arteries that come close to the skin and can
be gently pressed against a bone
o The pulse should be the same in all pulse sites on the body
o The pulse is an indication of how the cardiovascular system is
meeting the body’s needs
o The pulse rate is affected by many factors – age, fever,
exercise, fear. Anger, anxiety, excitement, heat, position, and
pain.
o Medications can be taken that either increase or decrease a
person’s pulse rate..
Usually count a pulse for 30 seconds and multiply the number
times 2 to get the pulse rate for 1 minute if person in unstable
status
Check the pulse for:
• Rate: normal range (60-100 beats /minute) and
normal value (72 beats / minute)
• Rhythm (pattern) of the heart beat regular or
irregular - if the heart beat is irregular count the
pulse for a full minute
• Observe the force (strength) of the heartbeat and
record score of pulse:
• Strong (+3)
• Normal (+2)
• Weak (+1)
• Thread feeble (0)
• Can be taken without disturbing or
exposing the person
• Place the first two or three fingers
of one hand against the radial artery
• The radial artery is on the thumb
side of the wrist
• Do not use thumb to take a person’s
pulse
• Use gentle pressure
• Count the pulse for 1 minute
• Always clean Theearpieces of
the stethoscope with alcohol
before and after use
• Warm the diaphragm in your
hand before placing it on the
person
• Hold the diaphragm in place
over the artery
• Do not let the tubing strike
against anything while the
stethoscope is being used
• Taken with a stethoscope
• Counted by placing the stethoscope over
the heart
• counted for one full minute
• The heart beat normally sounds like a lub-
dub. Each lub-dub is counted as one
heartbeat.
Do not count the lub as one heartbeat and
the dub as another.
• The apical pulse is taken on patients who
have heart disease , an irregular pulse rate,
or take medications that can affect the
heart. .
• One respiration consists of one inspiration and one expiration
• The chest rises during inspiration (breathing in) and falls
during expiration (breathing out)
• Count each time the chest rises
• Count for 30 seconds and multiply 2 in stable status
• Do not let the person know you are counting their
respirations
• Count after taking the pulse – keep fingers on the pulse site
• Normal respiratory rate for adult is (range 12 – 20 breaths per
minute and value 14 breaths / minute).
Tachypnea – respiratory rate over 20
Bradypnea – respiratory rate below 12
Dyspnea – shortness of breath – difficulty in breathing
Apnea – no breathing
Hyperventilation – fast and deep respirations
Hypoventilation – slow and shallow respirations
The measurement of the amount of force the blood exerts
against the artery walls
• Systolic pressure – pressure exerted when the heart muscle
is contracting
• Diastolic pressure – pressure exerted when the heart muscle
is relaxing between beats
• Blood pressure is recorded as a fraction with the systolic
pressure on top and the diastolic pressure on the bottom
• Systolic
• Diastolic
• systolic /diastolic (120/80)
• Bp is measured in mm (millimeters) of hg (mercury)
Average adult systolic range – 100 to 140 mmHg
Average adult diastolic range – 60 to 90 mmHg
Hypertension – measurements above the normal systolic or
diastolic pressures
Hypotension – measurements below the normal systolic or
diastolic pressures
Orthostatic hypotension: also called postural hypotension is a
form of low blood pressure that happens when you stand up
from sitting or lying down.
Normal < or = 120 < or = 80
Prehypertension 120 -139 80 - 89
Hypertension, Stage 1 140 - 159 90 - 99
Hypertension, Stage 2ر > 160 > 100
• Age – blood pressure increases as a person grows older.
• Gender – women usually have lower blood pressure than men
• Blood volume – severe bleeding lowers the blood pressure
• Stress – heart rate and blood pressure increase as part of the body’s response to
stress
• Pain – increases blood pressure
• Exercise – increases heart rate and blood pressure
• Weight – blood pressure is higher in overweight persons
• Race – black persons generally have higher blood pressure than white persons do
• Diet – a high-sodium diet increases the fluid volume in the body which increases
blood pressure
• Medications – can be taken to raise or lower blood pressure
• Position – blood pressure is lower when lying down
MERCURY ANEROID
• Do not take a blood pressure on an arm with an iv, a cast, or a dialysis
shunt.
• Do not take a blood pressure on the side that a person has had breast
surgery on.
• Measure blood pressure with the person sitting or lying.
• Apply the cuff to the bare upper arm. Do not apply the cuff over clothing.
• Make sure the cuff is snug.
• Use a large cuff if necessary.
• Make sure the room is quiet.
• If you do not hear the blood pressure, wait 30 to 60 seconds and try again.
If you still can not hear it or are unsure of readings, the nurse check
measurements.
1. Clean the stethoscope earpieces and diaphragm with alcohol.
2. Locate the brachial pulse. This is where the stethoscope will be placed.
3. Wrap the cuff above the elbow with the arrow pointing to the brachial
artery. Fasten the cuff so it fits snugly.
4. Place the diaphragm of the stethoscope flat on the pulse site, holding it in
place with the index and middle fingers of one hand.
5. Locate the radial pulse.
6. Close the valve on the bp cuff by turning it to the right (clockwise).
7.Inflate the cuff until can no longer feel the radial pulse. ,Then inflate the
cuff 30 mm hg beyond this point.
8. Deflate the cuff slowly by opening the valve slightly and turning it
counterclockwise (to the left) with your thumb and index finger. Allow the air
to escape slowly while listening for a pulse sound.
9. Note the reading at which you hear the first clear, regular pulse sound. This
number is the systolic pressure.
10. Continue listening until the sound disappears. This is the diastolic
pressure. Note this reading.
11. Open the valve completely to deflate the cuff. Remove the cuff from the
patient.
PAIN
Pain means to ache, hurt, or be sore.
Pain is a warning from the body.
Pain is personal.
Types of pain
◦ Acute pain – felt suddenly from an injury,disease,trauma,
or surgery
◦ Chronic pain – lasts longer than 6 months.Pain can be
constant or occur on and off.
◦ Radiating pain – felt at the siteof tissue damageandin
nearby areas.
◦ Phantompain – felt in a bodypart thatis no longer there.
• COLDSPA (mnemonic system to assess pain)
• C: characteristics and description – can use words to
describe the pain?
• O: onset – when did the pain start?
• L:locationandradiation – where is thepain?
• D: duration – what period pain stay?
• Severity and intensity – rate the pain on a scale of 1 to 10,
with 10 as the most severe according numbering pain
scale?
• Patternand factorscausingpain– what were doingwhen
the pain started?
• Vital signs – takethe person’s vital signs when they
complain of pain.
• Associated signs and symptom
• Behaviors during pain – crying, groaning,holding affected
body part, irritability, restlessness
