Vital signs
Signs
Vital Signs
These are indices of health or
signposts in determining client’s
condition. Also known as
CARDINAL SIGNS and it includes
body temperature, pulse,
respirations and
Blood pressure.
Purpose:
- As indicator of health status,
these measures indicate the
effectiveness of circulatory,
respiratory, neural and
endocrine body functions.
Vital SIgns
 Body temperature
 Pulse
 Respiration
 Blood Pressure
 Pain
 (Oxygen Saturation)
Different Consideration in Taking VS
 The frequency of taking TPR and BP
depends upon the condition of the
client and the policy of the institution.
 The procedure should be explained to
the client before taking his TPR and
BP.
 Obtain baseline data.
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 BODY TEMPERATURE

 The difference between the amount of

heat produced by the body process and
the amount lost to external
environment.
 HEAT PRODUCED – HEAT LOST = BODY
TEMPERATURE
Diaphoresis – a visible perspiration
primarily occurring on the forehead and
the upper thorax, although you can see
it in other places on the body.
 CORE TEMPERATURE – temperature
of the deep tissues of the body;
remains relatively constant
 SURFACE BODY TEMPERATURE –
temperature of the skin, the
subcutaneous tissue and fat; rises
and falls in response to the
environment.
 HEAT BALANCE – when the amount
of heat produced by the body
equals the amount of heat loss.

 Physiological or behavioral  Heat Loss:

mechanisms regulate the balance
between heat loss and heat
produced or thermoregulation.
 For the body temperature to stay
constant and within acceptable
range, various mechanisms maintain
the relationship between heat
production and heat loss.
● Radiation – is the transfer of heat from one surface
of one object to the surface of another without
direct contact between the two.
● Conduction – is the transfer of heat from one object
to another with direct contact.
● Convection – transfer of heat away by air
movement.
● Evaporation – transfer of heat energy when the
liquid is changed to gas.

Relapsing fever – s hort febrile

Intermittent fever – BT peri ods of a few days are interspersed Hyperpyrexia – very
alternates a regular intervals wi th periods of 1-2 da ys of normal hi gh fever, 41˚C (105.8
between periods of fever and temperature. ˚F) a nd a bove
periods of normal or subnormal Constant fever – body temperature Hypothermia – core
temperatures. fl uctuates mi nimally but a lways body temp below the
rema i ns a bove norma l . l ower limit of normal.

Pyrexia(fever) – Remittent fever – a wide range Fever Spikes – temp

body temperature of temperature fluctuations rises to fever level
above normal rapidly following a
that occurs over the 24 hrs
ranger normal temp then
interval, all of which is above
(hyperthermia) returns to normal
normal.

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 NORMAL ADULT
TEMPERATURE RANGES

 Oral: 36.5 – 37.5

 Axillary: 35.8 – 37.0
 Rectal: 37.0 – 38.1
 Tympanic – 36.8 – 37.9
SITES FOR MEASURING BODY TEMPERATURE
1. Oral – accessible and convenient
Contraindication – if the client has been
taking cold or hot fluids or smoking the
nurse should wait 30 minutes before taking
the temp orally.
2. Rectal – considered to be very accurate.
Contraindication – clients who undergone
rectal surgeries, diarrhea or disease of the
rectum, immunosuppressed, have clotting
disorder or have significant hemorrhoids.
3. Axilla – preferred site for measuring temperatur e
in newborn because it is accessible and safe.
4. Tympanic membrane – ear canal is a frequent
site for estimating core body temperature.
TYPES OF THERMOMETER
1. Glass Thermometer
 Most commonly used to measure body
temperature.
 Hazardous due to exposure to mercury,
which is toxic to humans, and broken
glass should the thermometer crack or
break.
 Hospitals no longer use mercury in glass
thermometers.
2 PARTS OF THERMOMETER
 Bulb – Contains mercury which expands
when exposed to heat and rise in the stem.
 Stem – is calibrated in degrees of Celsius or
Fahrenheit.
2. Electric Thermometer
 Can provide a reading in only 2 – 60
seconds, depending on the model.
 The equipment consists of a battery
operated portable electronic unit, a
probe that the nurse attaches to the
unit and a prove cover, which is
disposable.
3. Chemical Disposable Thermometers
 Using liquid crystal dots or bars or heat
sensitive tape or patches applied to the
forehead change color to indicate
temperature.
4. Temperature Sensitive Tape
 May also be used to obtain a general
indication of body surface
temperature.
 It does not indicate the core body
temperature
5. Infrared Thermometers
 Sense the body heat in a form of
infrared energy given of by a heat
source which is the ear canal.
6. Temporal Artery Thermometers
 Determine temperature usually in scanning
infrared thermometer that compares
arterial temperature in the temporal artery
of the forehead to the temperature in the
room and calculate the heat balance to
approximately the core temperature of the
blood in the pulmonary artery.
Taking the temperature procedure
 Explain the procedure to the patient.
 Wipe the armpit with tissue paper or ask the
client to do it if able.
 Get the thermometer, disinfect from bulb to
stem.
 Wait for appropriate amount of time.
 Remove the thermometer and read the
temperature.
 Wipe the thermometer with alcoholized cotton
ball from stem to bulb, return to the container.

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 PULSE

 This is a wave of blood created by  1 year old: 80 – 140 bpm

contraction of the left ventricle of the
heart.
 PERIPHERAL PULSE – pulse located in the
periphery of the body, away from the
heart.
 APICAL PULSE – the central pulse. Located
at the apex of the heart. Referred to as the
point of maximum impulse (PMI).
SITES FOR MEASURING BODY TEMPERATURE
 2 years old: 80 – 130 bpm
 6 years old: 75 – 120 bpm
 10 years old: 60 – 90 bpm
 Adult: 60 – 100 bpm
 Pedia: 120 – 160 bpm
 Tachycardia – pulse rate of above 100
bpm
 Bradycardia – pulse rate of below 60
bpm
 Irregular – uneven time interval between
beats.

1. Temporal – Lateral to the eyes; when radial pulse is

not accessible. Remember:
2. Carotid – Under the mandible; used during cardiac
 Use the apical pulse for the
arrest, used to assess circulation in the brain.
heart rate of the newborns,
3. Apical – Left sternal border midclavicular line, 5th
infants and children 2 – 3 years
interrcostal space
old.
4. Brachial – 1 ½ inches above the antecubital space
of fossa; used measure blood pressure; cardiac
arrest for infants
5. Radial – were the radial artery runs along the radial
bone, on the thumb site of the inner aspect of the
wrist; readily accessible
6. Femoral – to check for the bleeding after a cardiac
catheterization
7. Popliteal – pulse to check for the circulation to the
leg
8. Posterior Tibial – medial surface of the ankle
where the posterior tibial artery passes behind the
medial.
9. Dorsalis Pedis – pulse to check for the circulation
to the foot.

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 RESPIRATION
 The mechanism of the body uses to
exchange gases between the atmosphere
and the blood and the cells.
 INHALATION/INSPIRATION – Intake of air
into the lungs.
 EXHALATION/EXPIRATION – Breathing out
or the movement of gases from the lungs
to the atmosphere.
ASSESSING RESPIRATION
Normal Rate: 14 – 20 cpm in adult.
- The best time to assess respiration is
immediately after taking client’s pulse.
- Count respiration for 60 seconds (DO NOT
SHORTCUT!)
- As you count the respiration, assess and record
breath sound as stridor, wheezing or stertor.
- Respiratory rates of less than 10 or more than 40
are usually considered abnormal and should be
reported immediately to the physician.
CHARACTERISTIC OF NORMAL RESPIRATION
1. Respiratory Rate
- Described in breaths per minute.
Breathing Patterns
- EUPNEA – breathing that is normal in rate and
depth.
- BRADYPNEA – rate of breathing is regular but
abnormally slow (<12 bpm)
- TACHYPNEA – rate of breathing is regular but
abnormally rapid. (>20 bpm)
- HYPERPNEA – respiration are labored increased
in depth, and increased in raye
- APNEA – Absence of breathing
2. Depth
- This can be established by watching the
movement of the chest. It is generally described
as normal, deep or shallow.
 Ventilation: Movement of air in and out
of the lungs
 Diffusion: the movement of oxygen and
carbon dioxide between the alveoli and
the RBC.
 Perfusion: the distribution of RBC to and
from the pulmonary capillaries.
 Types of breathing:
O COSTAL BREATHING (Thoracic) –
involves the external intercostal
muscles and other accessory
muscles. Movement of the chest
upward and out ward.
O DIAPHRAGMATIC BREATHING
(abdominal) – involves the
contraction and relaxation of the
diaphragm, and it is observed by
the movement of the abdomen.
3. Respiratory Rhythm or Pattern
- This refers to the regularity of the expirations
and the inspirations. Normally, respiration are
evenly spaced. Respiratory rhythm can be
described as regular or irregular.
4. Breath Sounds
- STRIDOR – a shrill, harsh sounds heard during
inspiration with laryngeal obstruction.
- STERDOR – snoring or sonorous respiration
- WHEEZE – continuous high pitch musical squeak
or whistling sound occurring on expiration and
sometimes on inspiration when air moves
through a narrowed or partially obstructed
airway.
- BUBBLING – gurgling sound heard as air passes
through the moist secretion in the respiratory
tract.
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 BLOOD PRESSURE

 This is the force exerted by the blood against a vessel

wall.
 ARTERIAL BLOOD PRESSURE – is a measure of the  CUFF:
O NARROW – FALSE
pressure exerted by the blood as it flows through the
HIGH
arteries. There are two blood pressure measures: O WIDE – FALSE LOW
o SYSTOLIC PRESSURE – pressure of the blood O LOOSE – FALSE LOW
because of contraction of the ventricles,  ARM IS ABOVE THE HEART:
which is the height of the blood wave. - FALSE LOW
o DIASTOLIC PRESSURE – pressure when the
ventricles are at rest. It is the lower pressure
present at all times within the arteries.
 PULSE PRESSURE – difference between the diastolic
and systolic pressure. Normal: 40 mmHg but can be  ANEROID
high as 100 mmHg during exercise. SPHYGMOMANOMETER:
- Calibrated dial with a
Hypertension needle that points to
Blood pressure that is persistently above normal the calibrations.
Primary Hypertension An elevated blood pressure of unknown cause
Secondary Hypertension An elevated blood pressure of known cause
 DIGITAL
Hypotension SPHYGMOMANOMETER:
Blood pressure that is below normal, systolic reading consistently between 85 mmHg - Eliminate the need to
Orthostatic Hypotension Blood pressure that falls when the client sits or listen for the sounds of
(Postural Hypotension) stands. the clients systolic and
diastolic blood pressure
through the
stethoscope.
BLOOD PRESSURE MONITORING
1. Ensure that the client is rested
2. Use appropriate size of BP Cuff
3. If too tight and narrow – false high
BP
4. If too lose and wide – false low BP
5. Position the Patient on sitting or
supine position
6. Position the arm at the level of the
heart.
7. Use the bell of the stethoscope
since the blood pressure is a low
frequency sound.
8. If the client is crying or anxious,
delay measuring his blood pressure
to avoid false high BP

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 PAIN SCALE

ASSESSING PAIN
1. You must consider both the patient’s description
and your observation on his behavioral responses.
2. First, ask the client to rank his pain on a scale of 0-  Giving medication as per
10, with 0 denoting lack of pain and 10 denoting the physician’s order
worst pain imaginable.  Giving emotional support
3. Ask:  Performing comfort measures
a. Where is the pain located?  Use cognitive therapy.
b. How long does the pain last?
c. How often does it occur?
d. Can you describe the pain?
e. What makes the pain worse?
4. Observe the patient’s behavioral response to pain
(body language, moaning, grimacing, withdrawal,
crying, restlessness muscle twitching and
immobility)
5. Also note physiological response, which may be
sympathetic or parasympathetic.

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 Preparation
Assess:
A.) Temperature
– Clinical signs of fever
– Clinical signs of hypothermia
– Client’s readiness for the procedure
– Site most appropriate for measurement
– Factors that may alter core body temperature
B.) Pulse
– Clinical signs of cardiovascular alteration, other than pulse rate, rhythm, or volume
– Factor that may alter pulse rate
C.) Respiration
– Skin and mucus membrane color
– Position assumed for breathing
– Signs of cerebral anoxia
– Chest movement
– Activity tolerance
– Chest pain
– Dyspnea
Medications affecting respiratory rate.
D.) Blood Pressure
– Signs and symptoms of hypertension
– Signs and symptoms of hypotension
1. – Factors affecting blood pressure.

Assemble equipment and Supply:

– Thermometer
– Cotton balls with alcohol or alcohol wipes
– Tissue /wipes
– Watch with a second hand or indicator.
– Stethoscope
– Blood pressure cuff of the appropriate size
2. – Sphygmomanometer

Procedure

Identify the client properly and explain what you are going to do, why it is necessary, and how he
1. can cooperate.

2. Wash hand and observe other appropriate infection control procedure

3. Provide for client privacy.

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4. Place the client in the appropriate position

ASSESSING BODY TEMPERATURE (AXILLARY TEMPERATURE)

1. Wipe the armpit with tissue paper or ask the client to do it if able

2. Wipe the thermometer from bulb to stem with alcoholized cotton ball.

3. Place the thermometer on the client’s opposite side.

Wait for appropriate amount of time. (While waiting for the time, the nurse can now assess the
4. other vital signs.)

5. Remove the thermometer and wipe with the tissue if necessary.

6. Read the temperature.

7. Wipe the thermometer with alcoholized cotton ball from stem to bulb. Return to container.

ASSESSING A PERIPHERAL PULSE (RADIAL PULSE)

Palpate and count the pulse. Place two or three middle fingers lightly and squarely over the pulse
1. point.

2. Count for one full minute and note the pulse rhythm and volume.

ASSESSING RESPIRATION

Place the client’s arm across the chest and observe the chest movements while supposedly taking
1. radial pulse.

Count the respiratory rate for 1 full minute. An inhalation and an exhalation is counted as one
2. respiration. Observe the depth, rhythm, and character or respiration.

ASSESSING BLOOD PRESSURE

The elbow should be slightly fixed with the palm of the hand facing up and the forearm supported
1. at heart level.

2. Expose the upper arm

Wrap the deflated cuff evenly around the upper arm. Locate the brachial artery. Apply the center
3. of the bladder directly over the artery.

For an adult, place the lower border of the cuff appropriately 2.5 cm (1 inch) above the antecubital
4. space.

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 If this is the client’s initial examination, perform a preliminary palpatory determination of systolic
5. pressure.

6. Palpate the brachial artery with fingertips.

7. Close the valve on the pump by turning the knob clockwise.

Pump the cuff until you no longer feel the brachial pulse. At that pressure, the blood cannot flow
8. through the artery. Note the pressure on the sphygmomanometer at which pulse is no longer felt.

Release the pressure completely in the cuff, and wait for one to two minutes before making further
9. measurements.

10. Position the stethoscope appropriately

11. Clean the earpieces of the stethoscope with alcohol.

12. Warm the amplifier by rubbing it with the palm of your hand.

13. Insert the ear attachments of the stethoscope in your ears so that they tilt slightly forward.

14. Ensure that the stethoscope hands freely from the ears to the diaphragm.

Place the bell of the amplifier of the stethoscope over the brachial pulse. Hold the diaphragm with
15. thumb and index finger.

16. Auscultate the client’s blood pressure.

Pump the cuff until the sphygmomanometer reads 30 mm Hg above the point where the brachial
17. pulse disappeared.

Release the valve of the cuff carefully so that the pressure decreases at the rate of 2 -3 mm Hg per
18. second.

19. As the pressure falls, identify the mamometer reading at each of five phases, if possible.

20. Deflate the cuff rapidly.

21. Wait one or two minutes before making further determinations.

22. Repeat the above steps once or twice as necessary to confirm the accuracy of the reading.

23. If this is the client initially examination, repeat the procedure on the client’s other arm.

24. Remove the cuff.

25. Wipe the cuff with an approved disinfectant.

Document in the client’s record (TPR Sheet):

A.) The temperature in the client record.
B.) The pulse rate and rhythm
C.) The respiratory rate, depth, and rhythm
26. Report pertinent assessment date according to agency policy.

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