VITAL SIGNS 3.

FACES Pain Rating Scale (Wong-Baker)

- usually assesses pain for children ages 3
How Do you Assess Pain? years and up.
(PQRST)
P - recipitating factors
Q - uality
R - adiation/region
S - everity
T - timing

(COLD/SPA)
C - haracter Terms to remember:
O - onset  Afebrile - core body temperature is within
L - ocation the normal range (35.8°C to 37.5°C)
D - uration  Body mass index (BMI) - a standard
S - everity measure of weight for height and an
P - attern indicator of overweight, obesity or protein–
A - associated factors calorie malnutrition
 Bradycardia - heart rate <60 beats per
(OLDCART) minute in the adult
O - nset  Cardiac Output - the stroke volume
L - ocation multiplied by the heart rate
D - uration  Centripetal (truncal) obesity - fat
C - haracteristics concentrated in face, neck, trunk, with thin
A - ggravating factors extremities, as seen in Cushing’s
R - adiation syndrome (hyperadrenalism)
T - reatment  Cyanosis - bluish discolouration
 Diastolic - elastic recoil, or resting pressure
Pain Scales that the blood exerts constantly between
 Various instruments are available to contraction
assess pain.  Dyspnoea - shortness of breath
 Consider the patient’s age and  Febrile - core body temperature is
developmental status along with his or her elevated, e.g. >37.5°C
cultural background when selecting a pain  Hyperthermia or hyperpyrexia - an
scale. excessively high temperature (exceeding
 Select the one that will best meet your 39°C / 41.1 °C ); caused by pyrogens
patient’s needs. secreted by toxic bacteria during infections
or from tissue breakdown such as that
1. Numeric Rating Scale following myocardial infarction, trauma,
- rates pain on a scale of 0 (no pain) to either 5 surgery or malignancy
or 10 (worst pain) by asking the patient to rate  Hypothermia - occurs when the body
her or his current pain level. temperature registers between 25°C and
35°C; is usually due to accidental,
2. Categorical Scales prolonged exposure to cold; may be
- use verbal or visual descriptors to identify purposefully induced to lower the body’s
pain intensity. oxygen requirements during heart or
- patient selects the descriptor that she or he peripheral vascular surgery, neurosurgery,
feels best represents the current pain level. amputation or gastrointestinal
- Verbal descriptors include: haemorrhage
Mild, discomforting, distressing, horrible,  Korotkoff sounds - sounds heard during
excruciating. the taking of a blood pressure reading
 No pain, mild pain, moderate pain, using a sphygmomanometer and
 severe pain, very severe pain, worst stethoscope
possible pain.  Orthostatic hypotension - a drop in systolic
pressure of more than 20 mmHg or an
increase of orthostatic pulse by 20 bpm or
 more; occurs with a quick change to a
standing position; changes are due to
abrupt peripheral vasodilatation without a
compensatory increase in cardiac output;
orthostatic changes occur with prolonged
bedrest, older age, hypovolaemia and
some drugs
 Pallor - unnaturally pale skin
 Pulse oximeter - a non-invasive method to
assess arterial oxygen saturation (SpO2).
 Simple obesity - even fat distribution
 Sphygmomanometer - instrument for
measuring arterial blood pressure
 Stridor - harsh high-pitched wheezing
sound made on inspiration or expiration
 Stroke volume - amount of blood pumped
out of the heart with each heartbeat
 Systolic - maximum pressure felt on the
artery during left ventricular contraction
 Tachycardia - heart rate of >100 bpm in
the adult
 Tachypnoea - rapid breathing
 Vital indicators of one's bodily functions
 provide information about the status of
several body systems including but not
limited to the cardiovascular, neurological,
peripheral vascular, and respiratory
systems of the patient.
 FECES
 RESPIRATIONS
 PERSPIRATION
Temperature Measurement Sites
 BODY TEMPERATURE IS MEASURED IN
ONE OF FOUR AREAS OF THE BODY
1. THE MOUTH – ORAL
2. THE RECTUM – RECTAL
3. THE AXILLA (UNDERARM) – AXILLARY
4. THE EAR – TYMPANIC
WE NOW ALSO HAVE THE TEMPORAL SITE - FOREHEAD
 RECTAL TEMPERATURES ARE THE
MOST ACCURATE
 AXILLARY TEMPERATURES ARE THE
LEAST ACCURATE
 The human body temperature typically
ranges from 36.5 to 37.5 degrees
centigrade (97.7 to 99.5 degrees
Fahrenheit.
Types of Thermometer:
1. GLASS THERMOMETER
- 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.

Vital Signs include: TPR-BP ELECTRONIC THERMOMETER

TEMPERATURE  BATTERY OPERATED
PULSE  HAVE AN ORAL PROBE AND A RECTAL
RESPIRATIONS PROBE
BLOOD PRESSURE  DISPOSABLE PROBE COVER IS
PLACED ON THE PROBE
VITAL SIGNS MUST BE MEASURED, REPORTED, AND RECORDED
ACCURATELY  THE TEMPERATURE REGISTERS IN
* IF YOU ARE NOT SURE OF A MEASUREMENT, RECHECK IT ABOUT 30 SECONDS

TYMPANIC THERMOMETER
 MEASURES THE TEMPERATURE IN
Body Temperature THE TYMPANIC MEMBRANE
 Is the AMOUNT OF HEAT IN THE BODY (EARDRUM)
 It is a balance between the amount of  FAST AND ACCURATE - 1 TO 3
HEAT produced and the amount of heat SECONDS
LOST.
TAKING AN ORAL TEMPERATURE
 HEAT IS PRODUCED BY : GLASS THERMOMETER
1. The contraction of the muscles during  RINSE WITH COLD WATER
exercise  CHECK THE THERMOMETER FOR
2. The breakdwn of food during digestion BREAKS AND CHIPS
3. The environmental temperature  SHAKE DOWN THE THERMOMETER SO
THE MERCURY IS BELOW THE LINES
 HEAT IS LOST THROUGH : AND NUMBERS
 URINE
 PLACE A DISPOSABLE COVER ON THE
THERMOMETER
 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 15
MINUTES BEFORE TAKING
TEMPERATURE
GUIDELINES FOR TAKING AN
ORAL TEMPERATURE
DO NOT TAKE AN ORAL TEMPERATURE
ON:
 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
TAKING A RECTAL TEMPERATURE
 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
GUIDELINES FOR TAKING A
RECTAL TEMPERATURE
DO NOT TAKE A RECTAL TEMPERATURE
ON:
 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 )
TAKING AN AXILLARY TEMPERATURE
 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
 YOU NEED TO HOLD THE
THERMOMETER IN PLACE WHILE THE
TEMPERATURE IS BEING TAKEN
 THE THERMOMETER IS LEFT IN PLACE
FOR 10 MINUTES
PULSE
 The pulse rate is a measurement of the
heart rate, or the number of times the heart
beats per minute.
 an indication of how the cardiovascular is
meeting the needs of the body.
 As the heart pushes blood through the
arteries, the arteries expand and contract
with the flow of the blood causing a shock
wave.
 A shock wave is produced when the heart
contracts and forcefully pumps blood out of
the ventricles into the aorta.
 The shock wave travels along the fibers of
the arteries and is commonly called the
arterial or peripheral pulse.
 Taking a pulse not only measures the
heart rate, but also can indicate the
following:
1. Heart rhythm
2. Strength of the pulse
TAKING A PULSE
 THE PULSE RATE IS AFFECTED BY
MANY FACTORS:
AGE, FEVER, EXERCISE, FEAR. ANGER,
ANXIETY, EXCITEMENT, HEAT, POSITION,
AND PAIN.
 MEDICATIONS CAN BE TAKEN THAT
EITHER INCREASE OR DECREASE A
PERSON’S PULSE RATE.
 The most common sites of measuring the
peripheral pulses are the radial pulse,
ulnar pulse, brachial pulse in the upper
extremity, and the posterior tibialis or the
dorsalis pedis pulse as well as the femoral
pulse in the lower extremity.
 Clinicians measure the carotid pulse in the
neck.
 Assessing whether the rhythm of the pulse
is regular or irregular is essential. The
pulse could be regular, irregular, or
irregularly irregular.
COUNTING A PULSE
 WE USUALLY COUNT A PULSE FOR 30
SECONDS AND MULTIPLY THE
NUMBER TIMES 2 TO GET THE PULSE
RATE FOR 1 MINUTE
 WE NOTE THE RHYTHM (PATTERN) OF
THE HEART BEAT – IF THE HEART
BEAT IS IRREGULAR WE COUNT THE
PULSE FOR A FULL MINUTE
 WE ALSO OBSERVE THE FORCE
(STRENGTH) OF THE HEARTBEAT.
 DOES THE PULSE FEEL :
STRONG FULL BOUNDING
WEAK THREADY FEEBLE
RADIAL PULSE
 MOST COMMON SITE USED FOR
TAKING A PULSE
 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 YOUR THUMB TO TAKE A
PERSON’S PULSE
 USE GENTLE PRESSURE
 COUNT THE PULSE FOR 30 SECONDS
AND MULTIPLY BY TWO
USING A STETHOSCOPE
 ALWAYS CLEAN THE EARPIECES 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
APICAL PULSE
 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.
APICAL - RADIAL PULSE
 THE APICAL AND RADIAL PULSE
RATES SHOULD BE EQUAL
 SOMETIMES THE HEART BEAT IS NOT
STRONG ENOUGH TO CREATE A
PULSE IN THE RADIAL ARTERY
 THIS WOULD CAUSE THE RADIAL
PULSE TO BE LESS THAN THE APICAL
PULSE
 ONE PERSON COUNTS THE APICAL
WHILE THE OTHER PERSON COUNTS
THE RADIAL
 THE DIFFERENCE IN PULSES IS
CALLED THE PULSE DEFICIT, may
indicate mitral stenosis.
 NORMAL ADULT PULSE RATE IS – 60
TO 100 BEATS PER MIN.
 TACHYCARDIA – HEART RATE OVER
100
 BRADYCARDIA – HEART RATE BELOW
60
RESPIRATION
 CONSISTS OF ONE INSPIRATION AND
ONE EXPIRATION
 THE CHEST RISES DURING
INSPIRATION (BREATHING IN) AND
FALLS DURING EXPIRATION
(BREATHING OUT)
COUNTING RESPIRATIONS
 COUNT EACH TIME THE CHEST RISES
 COUNT FOR 30 SECONDS AND
MULTIPLY X 2
 DO NOT LET THE PERSON KNOW YOU
ARE COUNTING THEIR RESPIRATIONS
 COUNT AFTER TAKING THE PULSE –
KEEP YOUR FINGERS ON THE PULSE
SITE
 NORMAL RESPIRATORY RATE FOR
ADULT IS 12 – 20 BREATHS PER MIN.
ABNORMAL RESPIRATIONS
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
Blood Pressure
 THE MEASUREMENT OF THE AMOUNT
OF FORCE THE BLOOD EXERTS
AGAINST THE ARTERY WALLS
 Blood pressure measurement identifies the
amount of pressure in the arteries when
the ventricles of the heart contract (systole)
and when they relax (diastole).
 The difference between systolic and
diastolic pressure is termed the pulse
pressure. The pulse pressure should be
determined after the blood pressure is
measured because it reflects the stroke
volume—the volume of blood ejected with
each heartbeat.
 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
 120/80
 BP IS MEASURED IN MM
(MILLIMETERS) OF HG (MERCURY)
NORMAL BLOOD PRESSURE
 AVERAGE ADULT SYSTOLIC RANGE –
100 TO 140
 AVERAGE ADULT DIASTOLIC RANGE –
60 TO 90
ABNORMAL BLOOD PRESSURE
 HYPERTENSION – MEASUREMENTS
ABOVE THE NORMAL SYSTOLIC OR
DIASTOLIC PRESSURES
 HYPOTENSION – MEASUREMENTS
BELOW THE NORMAL SYSTOLIC OR
DIASTOLIC PRESSURES
A client’s blood pressure is affected by several
factors:
• Cardiac output — Blood pressure increases
with increased cardiac output and decreases
with decreased cardiac output.
Distensibility of the arteries — Blood pressure
increases when more effort is required to push
blood through stiffened arteries.
• Blood volume — Blood pressure increases
with increased volume and decreases with
decreased volume.
• Blood velocity — Blood pressure increases
when blood
flow is slowed due to resistance and decreases
when blood flow meets no resistance.
• Blood viscosity (thickness) — Blood pressure
increases when the blood is thickened and
decreases with thinning of the
blood.
 A client’s blood pressure will normally vary
throughout
the day due to external influences. These
include the time of day, caffeine or nicotine
intake, exercise, emotions, pain, and
temperature.
FACTORS THAT AFFECT
BLOOD PRESSURE
 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
GUIDELINES FOR MEASURING  RECORD VITAL SIGN MEASUREMENTS
BLOOD PRESSURE AS SOON AS POSSIBLE
 CARRY A SMALL NOTEBOOK IN YOUR
 DO NOT TAKE A BLOOD PRESSURE ON POCKET SO YOU CAN RECORD THEM
AN ARM WITH AN IV, A CAST, OR A AS YOU TAKE THEM
DIALYSIS SHUNT.  ABBREVIATIONS
 DO NOT TAKE A BLOOD PRESSURE ON TEMPERATURE – T
THE SIDE THAT A PERSON HAS HAD PULSE – P
BREAST SURGERY ON. RESPIRATIONS – R
 MEASURE BLOOD PRESSURE WITH BLOOD PRESSURE - BP
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
YOUR READINGS, HAVE THE NURSE
CHECK YOUR MEASUREMENTS.

FACTORS THAT AFFECT

VITAL SIGNS
 ILLNESS
 EMOTIONS – ANGER, FEAR, ANXIETY,
PAIN
 EXERCISE AND ACTIVITY
 AGE
 SEX
 ENVIRONMENT - WEATHER
 FOOD AND FLUID INTAKE
 MEDICATIONS
 TIME OF DAY – ↓ IN THE MORNING, ↑
IN THE AFTERNOON/EVENING
 NOISE
*A CHANGE IN ONE VITAL SIGN WILL
CAUSE A CHANGE IN THE OTHERS

REPORT THE VITAL SIGNS

TO THE NURSE IF:
 ANY VITAL SIGN IS CHANGED FROM A
PREVIOUS MEASUREMENT
 VITAL SIGNS ARE ABOVE THE
NORMAL RANGE
 VITAL SIGNS ARE BELOW THE
NORMAL RANGE

REPORTING AND RECORDING

VITAL SIGNS

 MANY AGENCIES HAVE TEMP BOARDS

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