Vital Signs
 The client’s vital signs (temperature. Pulse,
respirations, blood pressure, and pain) are the
body’s indicators of health.
 Provides data that reflect the status of several
body system
 Including but not limited to the
cardiovascular, neurologic, peripheral
vascular, and respiratory systems.
 Pain is the fifth vital signs
Temperature
 For the body to function at a cellular level
 Normal range of body 36.5- 37.5*C
 Factors may cause normal variations in the
core body temperature;
 Strenuous exercise, stress, and
ovulation (can raise the
temperature.)
 Hypothermia
 Lower than 36.5*C or 96.0*F can
be seen in prolonged exposure to the
cold.
 Higher than 38.5*C or 100*F may
be seen in viral or bacterial infections,
malignancies, trauma, and various
blood;
Pulse
 A shock wave is produced when the heart
contrasts and focus fully pump blood out
of the ventricles into the aorta.
 Arterial or Peripheral pulse are the fibers of
the arteries.
 Radial Pulse – gives a good overall picture of
the client’s health status
 Characteristic should be assed when
measuring radial pulse; rate,
rhythm, amplitude and contour,
and elasticity
Amplitude can be quantified as follow;
- 0 Absent
- 1+ Weak diminished (easy to
obliterate)
- 2+ Normal (obliterate with
moderate pressure)
- 3+ Bounding (Unable to
obliterate or requires firm
pressure)
Respirations
 Normal range- 12-20 breaths per minute
 The respiration rate and character are
additional clues to the client’s overall health
status.
 Notable characteristics of respirations are rate,
rhythm, and depth.
Blood Pressure  When pain is present identify the location,
intensity, quality, duration, and any
 Blood Pressure reflects the pressure exerted
alleviating to the client.
on the wall of the arteries.
 Pain intensity measurement tools such as a 1
 Blood pressure is a measurement of the
to 10 Likert scale.
pressure of the blood in the arteries
 Pain quality may be described as “dull”,
 Systolic Blood Pressure is when ventricles
“sharp”, “radiating”, or throbbing.
are contracted.
 COLDSPA may help you to remember how to
 Diastolic Blood Pressure is when ventricles
further assess pain.
are relaxed.
 Blood pressure is expressed as the ratio of REMEMBER:
systolic over diastolic.
"Normal" Vital Signs

Blood pressure
 Client’s blood pressure is affected by several
factors; • Systolic: 120 mmHg
- Cardiac output • Diastolic: 80 mmHg
- Elasticity of the arteries
- Blood volume
- Blood velocity (heart rate)
- Blood viscosity (thickness)
 Blood pressure in a normal reclining person is
slightly lower because of decreased peripheral
vascular resistance.
• Heart Rate: 60 - 100 BPM
Pain
• Respirations: 12 - 20 Breaths per min
 Pain screening is very important in developing
a comprehensive plan of care for the client. • Oxygen: 95% - 100%
 It is essential to assess for pain at the initial
• Temperature: 97.8 °F - 99 °F
assessment.
 PULSE: 60-100 bpm
MENTAL STATUS ( CHILD AND ADOLESCENT)