VITAL SIGNS
beats per minute.
Vital Signs include the client’s temperature,
pulse, respiration, and blood pressure and is
important for basis of nursing care. Today
“pain” is considered to be the “fifth vital
sign” (Flaherty, 2001).
The first thing to do is to take the
temperature of the client, followed by pulse
or respiration, and then blood pressure.
Temperature
Temperature is between the heat produced
by the body and heat lost from the body.
There are two types of body temperature;
the core temperature and surface
temperature.
The normal temperature is between 36.5C –
37.5C.
Temperature may be taken through various
anatomic sites; the tympanic, orally,
through the axillary, or anal.
Alterations in body temperature
 Pyrexia/ Hyperthermia/ Fever
 Hyperpyrexia (Very high fever 41C)
 Hypothermia (Subnormal core body
temp)
Temperature Procedure
 Clean the thermometer before
inserting to client
 Clean the thermometer after using
 Take note of the temperature
Pulse
Pulse reflects the amount of blood ejected
with each heartbeat. It notes the rate,
rhythm, and amplitude.
The normal pulse rate is between 60-100
Pulse may be taken through various
anatomic sites; temporal, carotid, brachial,
radial, femoral, popliteal, posterior tibial,
and dorsalis pedis. The radial pulse is the
most accessible.
Grading Pulses
 4+ = bounding
 3+ =
 2+ =
 1+ =
 = absent
Pulse Rate Procedure
 Use the pads of your index and
middle fingers
 Pres the area over the artery until
you feel pulsations
 Count for the pulse within one
minute
Respirations
Respiration is the act of breathing
One should asses for rate, depth, rhythm,
and quality.
When the nurse is assessing the respiratory
rate of a client he or she should not inform
the client because of Hawthorne effect –
Normal Respiratory Rate
 12-20 cpm
Blood Pressure
Blood Pressure is determined by the
amount of blood the heart pumps and the
amount of resistance to blood flow in the
arteries. It is also the measure of pressure
exerted by blood as it pulses through the  Look for the radial pulse
arteries.  Then pump, once you do not feel
the radial pulse add 20mm hg then
Systolic pressure is the pressure of blood as
stop
result of contraction of the ventricles (110-
 Release the air slowly
140mmhg)
 Take note of the first and last beat
Diastolic pressure is the pressure when the
ventricles are at rest (60-90mmhg).
Hypertension – Also known as high blood
pressure. Where systolic pressure >140mm
hg and diastolic pressure >90mm hg, based
on the average of two or more accurate BP
measurements taken during two or more
contacts with a health care provider (JNC 7).
Classification of Blood Pressure for Adults
age 18 and Older
BP Classification Systolic BP (mm Diastolic BP
Hg) (mm Hg)
Normal <120 and <80
Prehypertension 120 – 139 or 80 – 89
Stage 1 hypertension 140 – 159 or 90 – 99
Stage 2 hypertension ≥ 160 or ≥ 100

The Right BP Cuff

The width of the bladder of the cuff should
be about 40% of the circumference of the
upper arm
The length of the bladder of the cuff should
be about 80% of the circumference of the
patient’s arm
Blood Pressure Procedure

 Look for the brachial pulse

 Put the cuff on the arm of the client.
Be sure that it is not too tight and
not to lose. It should be fitted
snugly.
 Put the diaphragm of the
stethoscope on the brachial pulse
Breast Self-Examination
1. In front of a mirror check for the breasts
symmetry in size and shape, noting any
puckering and discoloration of skin and
retraction of the nipple.
2. Raise arm overhead, again studying
breast in the mirror for the same signs.
3. Arms on the hips, again studying breast in
the mirror for the same signs.
4. Lean forward, again studying breast in
the mirror for the same sign.
5. Lie back on bed with a flat pillow under
the shoulder on the breast that will be
examined.

6. Using the finger pads of