Professional Nursing Skill

VITAL SIGNS
BASIT ALI
TQIN SWABI
 Objectives
 By the end of the session, the participants will be able to:
1. Define vital signs.
2. Define terms related to vital signs.
3. Describe physiological concept of temperature, respiration
and blood pressure
4. Develop understanding of mechanism and principles of
thermoregulation.
5. Identify ways that affect heat production/loss.
6. Define types of body temperature according to its
characteristics.
7. State factors of affecting temperature and respiration.
8. Identify sign and symptoms of fever.
9. Discuss the normal ranges for temperature, pulse, respiration
and blood pressure.
10. List the factors affecting temperature, pulse, respiration and
blood pressure.
11. List factors responsible for maintaining normal blood
pressure.
DEFINITION
Vital signs/Cardinal Signs are TPR , O2 saturation, BP and Pain.

TEMPERATURE:
Temperature is the balance between the heat produced by the
body and the heat lost from the body.
OR
“Heat of the body measured in heat units called ‘degrees’ .”

There are two Kinds of temperature:

CORE:
Temperature of the deep tissues of the body.
SURFACE:
Temperature of the skin, subcutaneous tissues and fat.
Factors Affecting Body Temperature
 Age

 Diurnal Variations (Circadian Rhythm)

 Exercise

 Hormones

 Stress

 Environment
Patterns/Types Of Fever / Alterations In Body
Temperature
 Constant / Sustained fever: Persistent elevation over 24 hours
varying by 1C – 2 C (1.8 F – 3.6 F). (e.g. typhoid fever)

 Remittent Fever: Fever spikes and falls without a return to normal

temp levels. (e.g. Influenza)

 Intermittent Fever: Fever spikes & temp. returns to normal at least

once in 24 hours. (e.g. malaria)

 Relapsing: Periods of febrile episodes intersperse with normal temp.

levels. Febrile episodes and periods of normothermia may be longer than 24
hours.
 Patterns/Types Of Fever / Alterations In
Body Temperature

 Pyrexia/Hyperthermia/Fever (in lay term):

“A body temperature above the usual range.”
 Hypothermia: Body temp. below usual range.

 Hyperpyrexia: A very high fever, eg, 41 C

(105.8 F).

 Normothermia: Normal body temperature.

 Febrile: The client who has fever.

 Afebrile: The one who doesn’t have fever.

TEMPERATURE SCALE

 Celsius (Centigrade) 34°.0 C 42.0 ° C

 Fahrenheit 94° F 108 ° F

CONVERSION
C=(f-32) x 5/9
E.g. Fahrenheit=100
C=(100-32) x 5/9
=68x 5/9
=37.7 C
F =(Celsius temperature x 9/5) + 32
e.g. Celsius= 40
F =(40x 9/5) + 32
=72+32
=104 F
Types of Thermometer
 Mercury in Glass Thermometer
 Oral (Long slender tip)
(Allows greater exposure of bulb against blood vessels in
the mouth).

 Rectal (Pear shaped tip)

Types of Thermometer
 Electronic Thermometer(Rechargeable battery):
1. Pencil like non breakable probes for oral/ axillary & rectal use.

2. Infrared (Tympanic) : Infrared sensor tip detects heat radiated

from the tympanic membrane.

 Disposable Thermometer:
1. Temperature sensitive tapes (Contains temperature sensitive patch
or tape, applied to forehead / abdomen, patch changes color at
different temperatures.
 DIFFERENT SITES FOR MEASURING BODY TEMPERATURE
Site Advantage Disadvantage Contraindication
Oral Accessible & Inaccurate if the client Children till 6 years
convenient has taken hot or cold Confused patients
Easy to use food/fluid. Patients having convulsive
Inaccurate if client
disorders e. g. seizures
breathing through Patients with oral or nasal
mouth. surgery.
Breakable & mercury
hazard

Rectal Most reliable Inconvenient and Following rectal surgery.

Measurement unpleasant for clients Diarrhea.
Reflects core Difficult for clients Constipation.
temperature. who are not able to turn Patients with myocardial
to the side infarction.

Axillary Safestand most The thermometer must

noninvasive be left in place for a
longer time to obtain
accurate measurement
Variation In Body Temperature By Age

Age Site Average Temperature

Newborn Axillary: 36.1-37.5 C (97.0-100 F)

3-5 years Oral: 37.0 C (98.6 F)
Adults Oral: 37.0 C (98.6 F)
Axillary : 36.4 C (97.6 F)
Rectal: 37.6 C (99.6 F)
Forehead: 34.4 C (94.0 F)
Tympanic: 37.7 C (99.9 F)
Elderly (over 70 yr) Oral: 36.0 c (96.8 F)
SIGN AND SYMPTOMS OF FEVER

 Heart rate
 Shivering
 Respiration rate
 Temperature
 Excessive thirst, dry mouth
 Drowsiness, restlessness
 General malaise and body ache
NURSING CARE
 Remove excessive clothes/blankets.
 Give Tepid sponge.
 Provide dry linen.
 Monitor vital signs frequently.
 Assist and provide oral hygiene.
 Provide cool air.
 Provide protein caloric diet.
 Measure intake and output.
 NURSING CARE
Chill Stage:
 Provide extra warmth
 Reduce physical activity/exercise.
 Provide high caloric high protein diet.
NEW RESEARCHES
 Mercury in glass thermometer: Safety risks due to glass
breakage and potential for mercury poisoning.
 Tympanic thermometers can be used more reliably than any
other type of thermometer. Readings are not significantly
different to core temperature.
PULSE

A wave of blood within an artery that is created

by contraction of the left ventricle of the heart.
CHARACTERISTICS OF PULSE

AMPLITUDE:
0= Absent
1= Diminished / Weak / Thready / Difficult to feel
2= Normal
3= Bounding / Strong / Easily palpated

4. Equality: Pulses on both sides of the body should be assessed, e.g.,

both radial pulses to compare the characteristics of each. Carotid pulse
should never be measured simultaneously to prevent occluded
blood supply to brain.
Pulse Sites
CRITICAL QUESTION
Which pulse site is used to assess in newborns
and children?
PULSE CHART(AMPLITUDE)
 Factors affecting pulse rate
1. Age:
As age increases the pulse rate gradually
decreases.
Age Average/min Range/min

Newborn-1 month 130 80-180

1 year 120 80-140

2 years 110 80-130

6 years 100 75-120

Adults 80 60-100
Factors affecting pulse rate
2. Gender
(females 7-8 beats
faster).

3. Exercise

4. Fever
Factors affecting pulse rate
5. Medications

6. Hemorrhage

7. Stress

8. Position changes
PULSE ASSESSMENT
 PALPATORY METHOD

 AUSCULTATION METHOD
(Used to assess apical rate)

 CARDIAC MONITORING

 DOPPLER ULTRASOUND
PALPATION FOR DIFFERENT PULSES
BLOOD PRESSURE
Blood pressure is a measure of the force exerted
by the blood as it passes through the arteries.
Systole Phase
The heart contracts and pumps blood out into the
circulation i.e. Aorta and arteries.
 Highest pressure
 Contraction of ventricles

Diastole Phase
It is the minimal pressure exerted against he arterial
walls at all times.
 Lowest pressure.
 Pressure when ventricles at rest.
Physiology of arterial BP / Hemodynamic factors
affecting BP / Factors responsible for maintaining
BP

1. Pumping action of heart / Cardiac output.

2. Peripheral vascular resistance

3. Blood volume

4. Blood viscosity/ Thickness

 FACTORS THAT CREATE RESISTANCE & AFFECT BP

 Compliance / Elasticity of
arteries

 Pathological Change
CRITICAL THINKING QUESTION
 What’s hypertension?

 What’s hypotension?

 Orthostatic hypotension?
SITES FOR TAKING BP

 Usually assessed in upper arm using brachial artery.

 If upper arm too big, use forearm or lower leg.
 In emergency situations, use thigh.
FACTORS AFFECTING BLOOD
PRESSURE
 Age
 Sex
 Stress
 Medication
 Exercise
 Diurnal
 Disease
AVERAGE & HYPERTENSIVE BP RANGES
SOME CONDITIONS AFFECTING
BLOOD PRESSURE
Condition Effect Causes

Fever Increase Increased Metabolic rate

Hemorrhage Decrease Decreased blood volume

Hematocrit Decrease Decreased blood

viscosity

External Heat Decrease Vasodilatation peripheral

vascular resistance
Aneroid manometer & cuff
Mercury
manometer & cuff
TECHNIQE OF TAKING BP
TECHNIQE OF TAKING BP
COMMON ERRORS IN BLOOD PRESSURE ASSESSMENT

ERRORS EFFECTS
Bladder or cuff too wide False low reading

Bladder or cuff too narrow False high reading

Cuff wrapped too loosely False high reading

Deflating cuff too slowly False high diastolic reading

•Deflating cuff too quickly •Low systolic, high diastolic

•Arm above heart level •Low
•After meal, pain, while smoking •High
 RESPIRATION
Is the act of breathing it includes intake of oxygen
and output of carbon dioxide.
 Inhalation/Inspiration

 Exhalation/Expiration
FACTORS INFLUENCING RESPIRATORY
RATE
 Exercise increases metabolism.

 Stress / Anxiety

Environment (Increased temperature)

High altitude.

Medication
FACTORS INFLUENCING RESPIRATORY
RATE
 Smoking

 Anemia

 Body Posture

 Brain Stem Injury

Variation In Respiratory Range By Age.
Age Respiratory Rate/Minute
Average Range
Newborn 35 30-80

1 year 30 20-40

2 years 25 20-30

8 years 20 15-25

Adults 16 12-20
NEW ADDITION IN VITAL SIGNS

 Pain , A 5th vital sign.

MESSAGE OF THE DAY
 BE COURAGEOUS 

Smooth roads never make good drivers, smooth

sea never makes good sailors, clear skies never
make good pilots, problem free life never
makes a strong & good person.
SO, Have a tough but winning day ahead,
Be strong enough to accept the challenges of
life.
Don’t ask life, “WHY ME?”
Instead say “TRY ME”