VITAL SIGNS

OBJECTIVES
• Recognize common terminology and
abbreviations used in documenting and
discussing vital signs.
• Describe the instruments used to measure vital
signs and body measurements.
• Explain the procedure used to measure vital
signs and body measurements.
• Demonstrate the procedures for measuring vital
signs and body measurements.
 INTRODUCTION
• Temperature, pulse, respiration, blood
pressure (B/P) & oxygen saturation are the
most frequent measurements taken by
HCP.
• Because of the importance of these
measurements they are referred to as
Vital Signs.
 INTRODUCTION
• They are important indicators of the body’s
response to physical, environmental, and
psychological stressors.

• Vital signs and body measurements are

used to evaluate health problems,
therefore, accuracy is essential.
 INTRODUCTION
• VS may reveal sudden changes in a client’s condition in
addition to changes that occur progressively over time.
A baseline set of VS are important to identify changes in
the patient’s condition.

• VS are part of a routine physical assessment and are not

assessed in isolation. Other factors such as physical
signs & symptoms are also considered.

• Important Consideration:
• A client’s normal range of vital signs may differ from the standard
range.
 When to take vital signs…
1. On a client’s admission
2. According to the physician’s order or the
institution’s policy or standard of practice
3. When assessing the client during home
health visit
4. Before & after a surgical or invasive
diagnostic procedure
 When to take vital signs…
5. Before & after the administration of meds or
therapy that affect cardiovascular, respiratory
& temperature control functions.
6. When the client’s general physical condition
changes, decreased LOC and increased pain.
7. Before, after & during nursing interventions
influencing vital signs
8. When client reports symptoms of physical
distress.
Body Temperature
 Body Temperature
• Core temperature – temperature of the
body tissues, is controlled by the
hypothalamus (control center in the brain)
– maintained within a narrow range.

• Skin temperature rises & falls in response

to environmental conditions & depends on
blood flow to skin & amt. of heat lost to
external environment
• The body’s tissues & cells function best
between the range from 36 deg C to 38
deg C

• Temperature is lowest in the morning,

highest during the evening.
 TYPES OF THERMOMETER
• GLASS MERCURY – mercury expands or
contracts in response to heat.
• Glass thermometers have been standard for many years, however because of
risk of mercury exposure from accidental breakage, many health care
agencies have eliminated mercury thermometers.
• Mercury is highly permeable through the skin & mucous membranes, inhaled
vapors diffuse rapidly into the blood.
 TYPES OF THERMOMETER
• ELECTRONIC – heat
sensitive probe, (reads
in seconds) there is a
probe for oral/axillary
use (red) & a probe for
rectal use (blue). There
are disposable plastic
cover for each use.
Relies on battery power
– return to charging unit
after use.
 TYPES OF THERMOMETER
• INFRARED
TYMPANIC (Ear) –
sensor probe shaped
like an otoscope in
external opening of ear
canal. Ear canal must
be sealed & probe
sensor aimed at
tympanic membrane –
return to charging unit
after use.
 SITES for
TEMPERATURE TAKING
Oral
Posterior sublingual pocket –
under tongue (close to carotid
artery)
Axillary
Bulb in center of axilla
Lower arm position across chest
Rectal
Side lying with upper leg flexed,
insert lubricated bulb (1-11/2
inch adult) (1/2 inch infant)
Tympanic
Close to hypothalmus –
sensitive to core temp. changes
Adult - Pull pinna up & back
Child – pull pinna down & back
No hot or cold drinks or Leave in place 3 min
smoking 20 min prior to temp.
Must be awake & alert.
Not for small children (bite
down)
Non invasive – good for Leave in place 5-10 min.
children. Less accurate (no Measures 0.5 C lower than oral
major blood vessels nearby) temp.
When unsafe or inaccurate by Leave in place 2-3 min.
mouth (unconscious, disoriented Measures 0.5 C higher than oral
or irrational)
Side lying position – leg flexed
Rapid measurement 2-3 seconds
Easy assessibility
Cerumen impaction distorts
reading
Otitis media can distort reading
NORMAL RANGE
 Taking Temperatures
 Tympanic
Temperature
 Pull ear up and back for
adults, then insert
thermometer
 Pull ear down and back
for children
 Fast, easy to use, and
preferred in pediatric
offices
 Axillary Temperature
 Place patient in seated or lying position
 Tip of thermometer is placed in middle of
axilla with shaft facing forward
 Patient’s upper arm is pressed against side
and lower arm should be crossed over
stomach to hold thermometer in place
 Oral Temperatures
 Must wait at least 15 minutes if patient has
been eating, drinking or smoking
 Thermometer is placed under tongue in
either pocket just off-center in lower jaw
 Rectal Temperatures
 Gloves are donned
 Patient is positioned on side (left side preferred) or stomach
 Lubricated tip of thermometer is slowly and gently inserted into
anus ½ inch for infants and 1 inch for adults
 Hold thermometer in place while temperature is taken
 Let’s practice!
You are about to take the temperature
of a 6-month old infant being seen at
the pediatrician’s office for vomiting
and diarrhea.
Which route will you use and why?
What are special considerations to keep
in mind with this specific patient situation
and why?
 ANSWER
• Route -Tympanic
– A 6-month old would not be able to hold the
thermometer under their tongue.
• Special considerations include:
– Take the temperature after the pulse and
respirations.
– Use proper technique and pull the ear down
and back to prevent injury
PULSE and RESPIRATION
 LINKAGE

Circulatory Respiratory

Pulse and respirations are related since

heart and lung functioning work together.
Normally, increases or decreases with one
causes the same effect on the other.
 An indirect gauge of cardiovascular functioning
 Is measured using index and middle fingers
not the thumb since it has a pulse of its own



 The radial artery is the common pulse site to

locate in adults
 The brachial artery is used in young children.

 A stethoscope is used to listen to the apical pulse.

 Electronic devices are also used to measure pulse
rates.
 PULSE
• The left ventricle contracts causing a wave of blood to surge
through arteries – called a pulse.
• Felt by palpating artery lightly against underlying bone or muscle.
• Carotid
• Brachial
• Radial
• Femoral
• Popliteal
• posterior tibial
• dorsalis pedis
• Assess: rate, rhythm, strength – can assess by using palpation &
auscultation.
 Taking Pulse Rates
 Press lightly with your index and middle finger
pads at the pulse site to locate the pulse.

 Count the number of beats you feel against your

fingers in one full minute.

 If the pulse rate is regular, some institutional

policy may be to count the number of beats for
30 seconds and multiply this number by 2 to
obtain the beats per minute.
Taking the RADIAL pulse
 Taking the APICAL pulse
• Locate for the PMI (point of maximum
impulse) – Left midclavicular line, 5th
intercostal space, (just below the nipple)
– listen for a full minute “Lub-Dub”
• Apical heart beat is best auscultated with
the HOB elevated or with the patient
sitting up.
 Assess:
RATE and RHYTHM
• Rate – N – 60-100, average 80 bpm
• Tachycardia – greater than 100 bpm
• Bradycardia – less than 60 bpm

• Rhythm – the pattern of the beats (regular or irregular)

Regular Pulse Rhythm

Irregular Pulse Rhythm

 Assess:
STRENGTH
• Strength or size or amplitude - the volume of blood pushed against
the wall of an artery during the ventricular contraction
• weak or thready (lacks fullness)
• Full, bounding (volume higher than normal)
• Imperceptible (cannot be felt or heard)

0------------------ 1+ ---------------------2+-------------- 3+ ------------------4+

Absent Weak NORMAL Full Bounding

 Normal Heart Rate
Age Heart Rate (Beats/min)

Infants 120-160

Toddlers 90-140

Preschoolers 80-110

School aged children 75-100

Adolescent 60-90

Adult 60-100
 RESPIRATION
• Respiratory rate is an indication of how
well the body is providing oxygen to the
tissues.
• One respiration consists of both inhaling
and exhaling air also referred to as
breathing in and breathing out.
• Respiratory rates are higher in infants and
children than in adults.
NORMAL RESPIRATORY RATES
 Assess:
RATE and RHYTHM
• Inspiration – inhalation (breathing in)
• Expiration – exhalation (breathing out)
• I&E is automatic & controlled by the medulla oblongata
(respiratory center of brain)
• Usually, WOMEN breathe thoracically, while MEN & YOUNG
CHILDREN breathe diaphragmatically
• Assess after taking pulse, while still holding hand, so
patient is unaware that you are counting respirations.

NOTE: If patients are aware that you are counting their

respirations they may unintentionally alter their breathing
BREATHING ABNORMALITIES
• EUPNEA – Normal breathing
• APNEA - Temporary absence of breathing
• TACHYPNEA – Breathing ABOVE normal
• BRADYPNEA – Breathing BELOW normal
• DYSPNEA – Difficulty in breathing
• HYPERPNEA – Deep and rapid breathing
 Apply your knowledge
• A 26-year old athlete visits the medical
office for a routine check-up. The medical
assistant takes T-P-R and obtains the
following: Temperature 98.8° F
Pulse 52 beats/minute
Respirations 18/minute

What should the medical assistant

do about these results?
 ANSWER
• The temperature and pulse are within the
normal range.
• The pulse of 52 is below the normal range.
Check the patient’s previous vital sign
results. Remember for some patients,
especially athletes, a low pulse rate is
normal so these results may be within
normal limits for this patient.
BLOOD PRESSURE
 BLOOD PRESSURE
• The force at which blood is pumped
against the walls of the arteries yields
blood pressure.
• Two pressure measurements are obtained
with blood pressure readings:
– Systolic pressure (measurement of pressure during
contraction of left ventricle) is the top number.
– Diastolic pressure (measurement of minimal amount
of pressure against vessel walls at all times) is the
bottom number.
 BLOOD PRESSURE

120/80
Systolic Pressure Diastolic Pressure
• Left ventricle of • Heart is at rest
heart is contracting • Bottom or second
• Top or first number number

Measured in mmHg – millimeters of mercury

 Factors affecting B/P
• Lower during sleep
• Lower with blood loss
• Position changes B/P
• Anything causing vessels to dilate or constrict
- medications
 HYPERTENSION
 High blood pressure readings
 Major contributor to heart attacks and
strokes
 Physicians often request a re-check of
patient’s blood pressure within two
months or less when readings are
elevated
 HYPOTENSION
 Low blood pressure reading
 Is generally not a chronic health
problem and may be normal for
some patients
 Severe low blood pressure
readings occur with:
 Shock
 Heart failure
 Severe burns
 Excessive bleeding
BLOOD PRESSURE EQUIPMENT
• A sphygmomanometer is the
instrument used to measure blood
pressures consisting of a cuff,
pressure bulb, and manometer.
• Three types of sphygmomanometers:
– Mercury
– Aneroid
– Electronic
 Mercury Sphygmomanometers
• Consists of a column of mercury that rises to
reflect increased pressure as the cuff is inflated
• Very accurate, yet mercury has an ill effect on
the environment, so these are no longer
manufactured
• Require calibration every 6 to 12 months
• When properly calibrated the column of mercury
will rest on “zero” when viewed at eye level
 Aneroid Sphygmomanometers
• Consists of a circular gauge with needle
dial that measures pressure
• Each line on the circular dial represents 2
mmHg
• Aneroid sphygmomanometers not as
reliable as mercury due to the metal parts
in the aneroid are subject to temperature
expansion and contraction.
• Must be checked, serviced, and calibrated
every 3 to 6 months
 Electronic Sphygmomanometers
• Provides a digital readout
of the blood pressure on
a lit display
• Unlike mercury and
aneroid devices, no
stethoscope is needed
• Considered to be the
least accurate, yet are
easy to use
 STETHOSCOPE
• Amplifies body
Earpieces
sounds
Binaurals
• Consists of
earpieces,
binaurals, tubing
and a chestpiece Rubber or plastic
(bell and tubing

diaphragm) Bell
Chestpiece
Diaphragm
 STETHOSCOPE
• Bell
– Cone-shaped side of chestpiece
– Amplifies low-pitched sounds such as heart sounds
– Must be held lightly against skin for proper
amplification
• Diaphragm
– Larger flat side of the chestpiece
– Amplifies high-pitched sounds like bowel and lung
sounds
– Must be held firmly against skin for proper
amplification
PREPARE YOUR MATERIALS
• What you will need:
– A quality stethoscope – quality counts with
regards to accuracy.
– An appropriately sized blood pressure cuff.

• Do HANDWASHING!
 PREPARE YOUR PATIENT
• Make sure that the patient is relaxed
(allow at least a five minute rest before a
reading if the patient just came from an
activity)
• Ideally, the patient is sitting in an upright
position with their upper arm positioned so
that it is level with their heart.
– You can use a table or armrest to make this
more comfortable for your patient.
• The patient’s feet should be flat on the
floor, if possible.
• Talking or chewing gum increases blood
pressure so the patient should refrain from
talking during the reading.
• Be sure to remove any excess clothing
that might overlap with the BP cuff or
constrict blood flow in the arm.
 CHOOSE THE PROPER CUFF SIZE

• This is one of the most important (and

often overlooked) steps in the process for
acquiring an accurate blood pressure
reading.
• If possible, measure your patient’s arm
circumference (typically in centimeters) to
determine the appropriate cuff size.
• Most blood pressure cuffs should have the
RANGE measurement on the label.
• Additionally, most BP cuffs have a range
area located on the inside of the cuff.
Measuring BLOOD PRESSURE
• Determine best site & baseline B/P
• Support arm at heart level, palm turned upward - above heart causes
false low reading
• The cuff must be placed on the upper arm 1 inch above the brachial
pulse site, wrap snugly around arm, manometer at eye level
• Palpate the brachial pulse then place stethoscope over this site.
• Inflate cuff while palpating brachial
artery. Note the reading at which pulse
disappears– that is the PALPATORY
PULSE.
• Next, on the same arm that you placed the
BP cuff, palpate the arm at the antecubical
fossa (crease of the arm) to locate the
strongest pulse sounds and place the bell
of the stethoscope over the brachial artery
at this location.
 POSITION THE STETHOSCOPE
• Check to ensure that the stethoscope ear
pieces are angled forward as you are
inserting the stethoscope into your ears so
that the sound is being transferred for
optimal listening.
• Continue inflating the cuff about 30 mmHg
above palpatory result or approximately 180
mmHg to 200 mmHg.
• Release the air in cuff and listen for the first
SIGNIFICANT heartbeat (systolic pressure) and
the last SIGNIFICANT heartbeat (diastolic
pressure).
• Record results with systolic being top number
and diastolic being bottom number (i.e. 120/70).
• Wait 15 minutes before taking readings if patient
has been engaged in strenuous exercise or has
ambulatory disabilities.
• Be sure cuff is properly fitted and placed on the
extremity or inaccurate readings may result.
• Cuff too wide – false low reading
• Cuff too narrow – false high reading
• Cuff too loose – false high reading
• DO NOT TAKE BP’s IN AN EXTREMITY IF:
– Injury or blocked artery is present
– History of mastectomy on that side
– Implanted device is under the skin (AV fistula
in dialysis patients)
– Arm cast is present
 BP TAKING ON THE
LOWER EXTREMITY
• Best position prone – if not – supine with knee
slightly flexed, locate popliteal artery (back of
knee).
• Large cuff 1 inch above artery, same procedure
as arm. Systolic pressure in legs maybe 10-40
mm hg higher
• If unable to palpate a pulse – you may use a
doppler stethoscope
SPECIAL CONSIDERATIONS

Age
Patient
Stress or Activity

Properly Fitting Cuff

Current Circulation to
Extremity Selected
THANK YOU!