VITAL SIGNS

Mrs. Ruth Banda

 WHAT ARE VITAL SIGNS?
• These are measurements of the body’s most
basic functions. They are used to detect or
monitor medical problems.
• These include:-
- Body temperature (T)
- Pulse rate (PR)
- Respiration rate(breathing rate-RR)
- Blood pressure (BP)
 TEMPERATURE
• Monitors health and illness- it reflects bodys’
ability to manage heat loss and gain.
• Its regulated by the hypothalamus in the brain
• It can be altered by:
- infection, dehydration, injury
• It can be affected by:
- Gender, Recent activity, Food & fluid
consumption, Time of day, stage of
menstrual cycle in women
 Temp cont’….
• High temperature is referred to as
fever/Hyperthermia
• Low temperature is referred to as
hypothermia (usually caused by cold exposure
or bleeding)
• It is recorded either in degrees Celsius (C) or
fahrenheit(F)
• Converting F to C: (F -32)/1.8
• F=(C*1.8)+32
e.g 36C*1.8+32=96.8F
 Temp……NORMAL RANGE
• The normal body temperature range for a
healthy adult is 36.5 to 37.2 degrees celcius
OR
• 97.8 to 99 degrees Fahrenheit.
 REGULATION OF BODY
TEMPERATURE
• The heat regulation centre of the brain causes
the skin (blood vessels ,sweat glands) to react
according to the temperature of the
surrounding.
• If the environment is hot the nerves of the
skin send a message to the brain and the brain
to the skin: dilation of blood vessels, sweating
 Note
• There are other conditions that can cause a rise
in temperature:
Normal-Eating increases metabolism
- Emotion/stress
- Environmental temp/exposure
- Hormones: women have wider flactuations
because of menstrual cycle changes
- Exercise: muscle activity increases heat
production
 Note cont’….
- Age: older adults have narrower range. A
temperature within normal range for an
adults may reflect fever in older adults.
Undeveloped temperature control
mechanism in newborn and infants can
also cause temperature to rise and fall
rapidly
Abnormal- anything that interferes with heat
regulation centre of the brain-brain injury,
pressure e.g from tumors, Toxin from
infection
 Conditions causing low
temperature
Normal- long exposure to cold
- low metabolism
- Rest/Sleep-reduced activity
Abnormal-Malnutrition
- Excess heat loss-bleeding, profuse
sweating
- Depression of the central nervous
system
 Management
Hypothermia - Close doors/windows
- Heat room environment
- Warm clothing/blankets
- Encourage taking warm fluids
- Use of hot water bottles, avoid drafts
Hyperthermia – cool environment(open
door/windows)
- remove blankets and heavy clothing
- Increase fluid intake unless
contraindicated
 Management….
• Limit physical activity and source of
emotional stress if any
• Prevent or control spread of infection if any
e.g – wound care, hygien, urinary elimination
 MEASURING TEMPERATURE
• Thermometer is used to measure temperature
• Can be checked orally, rectally, axillary, skin or
in the ear.

TYPES of Thermometres
1.Electronic: Digital
2.Chemical: Disposable single use
 Checking temperature axillary
• Wash hands
• Put on gloves if likely to be in contact with
body fluids
• Assist client to a comfortable position
• Expose axilla and dry to prevent false reading
if wet
• Place thermometer in the centre of the axilla
and lower arm across chest to allow contact
with large vessels.
• Record temperature, clean and return
thermometer to its cover. Wash hands
 PULSE
• As the heart ventricles contract and blood is
ejected into the aorta, a wave of pressure is
initiated through the arterial system.
• This can be felt as pulsations wherever an
artery passes near the skin and over a firm or
bony surface of the body.
• The rate of these pulsations can be measured
to provide a pulse rate.
 Pulse cont’…..
• Measuring the pulse provides information on
the regularity of heart beat (heart rhythm),
and an indication of the strength of heart
contraction (pulse volume)
• These are essential for basic cardiovascular
assessment.
 Pulse cont’…..
• Measuring pulse is a reliable means of getting
valuable information concerning condition of
the heart, blood vessels and circulation.
• Slow pulse may result from hyperkalemia,
diseases of the thyroid gland, heart disease,
increased pressure in the brain fluid.
• Rapid rate is associated with stress, exercise,
fever, loss of blood, shock, dehydration
 Factors that may affect pulse rate
& rhythm
• Age
• Exercise
• Position changes: Sitting to standing
• Temperature
• Sympathetic nervous system stimulation:
stress, anxiety, fear
• Medications: caffeine increases HR,
anesthesia, narcotic analgesia slows HR
 Normal Values
• Adults & Adolescent: 60-90 beats per minute

• Children 2yrs: 90-140 beats per minute

• Infants: 100-120 beats per minute

• Newborns: 120-160 beats per minute

 Unexpected outcomes
• Pulse rate for adult over 100 beats/minute
(Tarchycardia)
- Identify if: pain, anxiety, recent exercise,
low BP, blood loss, fever or reduced oxygen
- Identify for symptoms associated with
abnormal cardiac function: difficult breating,
fatigue, chest pain, palpitations, jugular vein
distention, edema, cynosis or pallor of skin
 Cont’…..
• Weak or difficult to palpate radial pulse
- Observe for altered tissue
perfusion:pallor, cyanosis, cold extremities
- Assess for swelling in surrounding tissues
that may restrict blood flow: tight dressing, cast
- Have someone to assess the pulse
 If Pulse rate for an adult is under 60beat/min
(bradycardia) or pulse is irregular
-Assess the carotid artery-below angle of mandibular
joint or Apical pulse Just below the left nipple /breast
(4th &5th intercostal space at left midclavicular line)
 SITES TO FEEL FOR THE PULSE
• Radial artery:- At the wrist, easily accessible,
commonly used
• Brachial:- commonly used in children
• Pedal
• Femoral
• Carotid
 The procedure
• equipment:-
plastic apron and disposable gloves
stopwatch.
• Procedure
- Obtain informed consent
- Wash hands, don apron and gloves
- Note factors that may influence readings
- Ensure the patient is comfortable
 Procedure cont’…..
• Identify artery to be used
• Consider patients’ dignity if using the femoral
site
• Using the second or third finger (or both)
apply gentle pressure against the artery site
• Count the pulse rate for exactly one minute
• Wash hands thoroughly with soap
• Document the results, report as necessary
 RESPIRATION
• The mechanism of respirations exchanges
oxygen and carbon dioxide between cells of
the body and atmosphere
• Ventilation-mechanical movement of gases
into and out of the lungs
• Diffusion-movement of oxygen and carbon
dioxide between alveoli and red blood cells
• Perfusion-Distribution of red blood cells to
and from the pulmonary capillaries
 Resp… assessment
• The nurse directly assess ventilation by
observing rate, depth and rhythm of
respiratory movement
• Accurate assessment depends on recognizing
normal thoracic and abdominal movement
• Normal breathing is active and passive
• During quiet breathing, the chest wall gently
rises and falls
• More energy is required during inspiration
than expiration.
• Expiration is an active process only during
exercise, voluntary hyperventilation and
certain diseases

ASSESSING RESPIRATION
• Determine need to assess clients respiration;
assess for factors that alters respirations:
fever, pain, anxiety, disease of chest wall,
anemia, pulmonary disease, injury
• Assess for signs and symptoms of respiratory
alterations e.g bluish or cyanotic appearance
of fingernail beds, lips, skin, restlessness,
confusion, pain during inspiration,
labored/difficult breathing, use of accessory
muscle
• Assess factors that influence character of
respirations:
 Factors affecting respirations
• Exercise:-increase rate & depth to meet need
for additional oxygen and get rid of carbon
dioxide
• Anxiety:-increase rate & depth as a result of
stimulation by the sympathetic nervous
system
• Acute pain:-breaths becomes shallow, one
may inhibit or splint chest wall movement
when pain is in the chest or abdomen
• Smoking:-if chronic, it changes the airways
leading to increased rate even at rest
• Medication:-narcotic analgesics, general
anesthesia decreases rate & depth. Cocaine
increases rate & depth, bronchodilators cause
dilation of airways that can slow rate
• Position:-sitting/standing promotes full
ventilation movement/lung expansion. Lying
flat prevent full chest expansion
 Factors…
• Neurological injury:-damage to the brain
impairs respiratory centers which inhibit rate
& rhythm
• Hemoglobin(Hb):-low Hb, lowers amount of
oxygen carried in the blood which result in
increased respiratory rate to increase oxygen
delivery.
 Note
• Respiration are measured by observing the
patients’ chest during this breathing process
• The lungs control in conjunction with the
respiratory centers in the medulla brain
• Respiration helps maintain pH of the blood,
maintaining the arterial homeostasis.
• This is achieved through inspiration &
expiration
• Patient needs to be resting and unaware
when one is observing.
 INHALATION
• Diaphragm contracts (flattens)
• Ribs move upwards and outwards
• Sternum moves outwards
• Thorax enlarges and lungs expand
 EXHALATION
• Diaphragm relaxes
• Ribs moves inwards and downwards
• Sternum moves inwards
• Thorax decreases in size and lungs are
compressed
 Procedure
Equipment: - watch with second hand
• Maintain privacy
• Be sure chest is visible
• Place patients arms in relaxed position: lower
chest(sides)
• Observe complete respiration cycle(1
inspiration & 1 expiration)
• Using watch with second hand Start counting
one with full respiratory cycle count for 1 full
minute
• Note rhythm: normal breathing is regular & un
interrupted
• Periodically people unconsciuosly take single
deep breaths/sigh to expand small airways
and this should not be confused with
abnormal rhythm
• Discuss findings with client
• Wash hands
• Children usually are observed by abdominal
movement
• Infants tend to breath less regularly like slowly
for few second & then suddenly more rapidly
• Observe while chest and abdomen are
exposed
 NORMAL RANGES
• New-born: 30–60 bpm
• Early childhood: 20–40 bpm
• Late childhood: 15–25 bpm
• Adult male: 14–18 bpm
• Adult female: 16–20 bpm
 BLOOD PRESSURE (BP)
• It is the force exerted by the blood against the
vessel walls.
• During a normal cardiac cycle blood pressure
reaches a peak that is followed by low point in
the cycle
• The peak pressure occurs when the heart’s
ventricles contraction or systole, forces blood
under high pressure into the aorta
• Then the ventricle relax, the blood remaining
in the arteries exerts a minimum/diastolic
pressure
• The unit for measuring BP is millimeters of
mercury(mmHg)
• BP is measured by auscultation using
sphygmomanometer cuff (Bp machine) and
stethoscope
• As the cuff is deflated, 5 different sounds
(Korotkoff sounds) are heard over an artery
• BP is recorded with the systolic reading(first
sound) before diastolic (beginning of the 5th
sound)
• The difference between the systolic &
diastolic pressure is the pulse rate
• Bp reflects various interrelated hemodynamic
factors with the circulatory system: Peripheral
resistance, blood viscosity, vessel wall
elasticity, cardiac output etc
• BP has direct relationship with cardiac output
(CO) and vascular resistance (R)
BP= Co x R
• As CO increases more blood is pumped into
the arterial system, causing systolic BP to
increase.
• When size of the arteries is small, there is
resistance to blood flow increasing BP to rise
• As vessels dilates & vascular resistance falls BP
drops
 Definitions
• Hypertension: BP of more than 140/90 –an
average of 2 or more readings checked within
2 months
• Hypotension: considered with systolic
pressure of <90 usually associated with illness
e.g hemorrhage
 Classification of BP
CATEGORY SYSTOLIC DIASTOLIC
Normal range 90-120 60-80
Average <120 And <80
Prehypertension 120-139 Or 80-89
Stage 1 140-159 Or 90-99
Stage 2 >/=160 or >/= 100
 Factors causing rise in Bp
• Emotions
• Exercise
• Loss of elasticity of arterial walls
• Fever
• Chronic kidney disease
 Factors causing Bp to fall
• Rest
• Excess Fluid/blood loss
• Dehydration, starvation
• Thrombosis
 Equipment
• BP machine
• Stethoscope
PREPARATION/PROCEDURE
• Gather equipment
• Check appropriateness of cuff
• Wash hands
• Allow client to lie/sit comfortably
 Measuring with aneroid cuff
• Keep pressure in a cuff at 0
• Place the centre of the cuff where the rubber
tube is attached above the brachial artery,
wrap & secure it the arm
• Locate the brachial artery & inflate the cuff
sufficiently until the artery can not be felt
• Apply stethoscope over the brachial artery
and gradually reduce the pressure in the cuff
by releasing air from the cuff until the first
regular beat is heard-note the pointer on the
BP machine-This is systolic Pressure
• The level at which the last sound/beat is
heard is the diastolic pressure
• Record & remove the cuff, expel any air
remaining in the cuff.
THANK YOU!!!