Vital Signs

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Prepared by Eftu Hawera
 Vital Sign measurement
Learning Objectives
At the end of this session the students will be able
to:-
• Define vital sign
• Describe the procedures used to assess the vital
signs
• Explain factors that can influence each vital
sign.

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1. Measuring Vital sign

• Vital sign is also called cardinal sign

• It is defined as the procedure that takes the sign
of basic physiology that includes temperature,
pulse, respiration and blood pressure.
• If any abnormality occurs in the body, vital
signs change immediately.

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 Cont---
• The term “vital” is used because the
information gathered are signs that reflect
changes in the functions of the body.
Vital sign Includes:
Temperature (T0)
Pulse Rate (PR)
Respiratory Rate (RR)
 Blood Pressure (BP)

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 Cont..
Purposes
• To assess the client’s condition
• To determine the baseline values for future
comparisons
• To detect changes and abnormalities in the
condition of the client

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 Times to Assess Vital Signs
• On admission – to obtain baseline date
• When a client has a change in health status or reports
symptoms
• According to a nursing or medical order
• Before and after the administration of certain medications
• Before and after surgery or an invasive diagnostic
procedures
• Before and after any nursing intervention that could
affect the vital signs. E.g. Ambulation
• According to hospital /other health institution policy.

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 Equipment
• Vital sign tray
• Stethoscope
• Sphygmomanometer
• Thermometer(glasses , electronic , tympanic)
• Second hand watch
• Red and blue pen
• Vital sign sheet
• Cotton swab in bowel
• Disposable gloves if available
• Dirty receiver kidney dish
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 1.Temperature
• Body temperature is the measurement of heat
inside a person’s body
• It is the balance between heat produced and
heat lost.
• Normal body temperature using oral
measurement remains as appropriately 370
Celsius or 98.60 F.

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There are Two Kinds of Body Temperature

1. Core Temperature
• Is the Temperature of the deep tissues of the body,
such as the cranium, thorax, abdominal cavity, and
pelvic cavity
• Remains relatively constant
• Is the Temperature that we measure with thermometer
2. Surface Temperature:
• The temperature of the skin, the subcutaneous tissue
and fat

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 Alterations in Body Temperature

• Normal body temperature is 370C or 98.60F

(Average) the range is 36-380C (96.8 – 1000F)
• Pyrexia: a body temperature above the normal
ranges 380c – 410C (100.4 – 105.8 F)
• Hyper pyrexia: a very high fever, such as 410C
 > 420C leads to death.

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 Cont..
• Hypothermia: – body temperature between
340C – 350C,
< 340C is death
• A client who has fever is referred as febrile;
the one who has not is afebrile.

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 Factors Affecting Body Temperature

 Age
 Diurnal variations (circadian rhythms)
 Exercise
 Hormones
 Stress
 Environment

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 Cont..
Most common Sites to Measure Temperature
are:
• Oral
• Rectal
• Axillary
• Tympanic
 Thermometer: is an instrument used to
measure body temperature
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 Types
1.Oral thermometer
• Has long slender tips

2.Rectal thermometer
• Short, rounded tips

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 Cont..
3.Auxiliary thermometer
• Long and slender tip
4.Tympanic thermometer
• In other way it is also divided as mercury,
digital and electronic types.

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 Cont..

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 Measuring Body Temperature
Equipment
1. Thermometer
2. Lubricant (rectal, glass thermometer)
3. Two pairs of non sterile gloves
4. Tissues

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 Procedure
1. Review medical record for baseline data and factors that
influence vital signs.
2. Explain to the client that vital signs will be
assessed. Encourage client to remain still and
refrain from drinking, eating, or smoking.
3. Assess client’s toileting needs and proceed as appropriate.
4. Gather equipment as indicated above.
5. Provide for privacy.
6. Wash hands and don gloves.
7. Position the client

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 Cont----
8. Oral Temperature: Glass Thermometer
a. Select correct color tip of thermometer from client’s bedside
container.
b. Remove thermometer from storage container and cleanse
under cool water.
c. Wipe thermometer dry with a tissue from bulb’s end toward
fingertips.
d. Read thermometer by locating mercury level. It should read
35.5°C (96°F).
e. If thermometer is not below a normal body temperature
reading, grasp thermometer with thumb and forefinger and
shake vigorously by snapping the wrist in a downward
motion to move mercury
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Prepared Hawera below normal. 19
 Cont----
f. Place thermometer in mouth under the tongue and along the gum
line to the posterior sublingual pocket. Instruct client to hold lips
closed.
g. Leave in place as specified by agency policy, usually 3–5 minutes
h. Remove thermometer and wipe with a tissue away from fingers
toward the bulb’s end.
i. Read at eye level and rotate slowly until mercury level is visualized.
j. Shake thermometer down, and cleanse glass thermometer with
soapy water, rinse under cold water, and return to storage
container.
k. Remove and dispose of gloves in receptacle. Wash hands.
l. Record reading and indicate site as “OT.”
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 Cont----
9. Oral Temperature: Electronic
Thermometer
a. Place disposable protective sheath
over probe.
b. Grasp top of the probe’s stem. Avoid
placing pressure on the ejection
button.
c. Place tip of thermometer under the
client’s tongue and along the gum line
to the posterior
sublingual pocket lateral to center of
lower jaw (see Figure).
d. Instruct client to keep the mouth
closed around thermometer.

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 Cont----
e. Thermometer will signal (beep) when a constant
temperature registers.
f. Read measurement on digital display of electronic
thermometer. Push ejection button to discard disposable
sheath into receptacle and return probe to storage well.
g. Inform client of temperature reading.
h. Remove gloves and wash hands.
i. Record reading and indicate site “OT.”
j. Return electronic thermometer unit to charging base.

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 Contraindication
– Child below 7 yrs
– If the patient is delirious, mentally ill
– Unconscious
– Uncooperative or in severe pain
– Surgery of the mouth
– Nasal obstruction
– If patient has nasal or gastric tubs in place

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 Cont----
10. Rectal Temperature
a. Place client in the Sims’ position with upper knee flexed. Adjust
sheet to expose only anal area.
b. Place tissues in easy reach. Don gloves.
c. Prepare the thermometer (refer to steps 8b and 8c)
d. Lubricate tip of rectal thermometer or probe (a rectal
thermometer usually has a red cap).
e. With dominant hand, grasp thermometer. With non-dominant
hand, separate buttocks to
expose anus.

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 Cont----
f. Instruct client to take a deep breath. Insert thermometer or
probe gently into anus: infant, 1.2 cm (0.5 in.); adult, 3.5 cm (1.5
in.) (see Figure ). If resistance is felt, do not force insertion.
g. Length of time (3-5 min).
h. Wipe secretions off glass thermometer with a
tissue. Dispose of tissue in a receptacle.

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 Cont----
i. Read measurement and inform client of
temperature reading.
j. While holding glass thermometer in one hand,
wipe anal area with tissue to remove lubricant
or feces with other hand and dispose of soiled
tissue. Cover client.
k. Cleanse thermometer (refer to step 8j).
l. Remove and dispose of gloves in receptacle.
Wash hands.
m. Record reading and indicate site as “RT.”
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 Cont..
Contraindications
– Rectal or perineal surgery;
– Fecal impaction – the depth of the thermometer
insertion may be insufficient;
– Rectal infection;
– Neonates –can cause rectal perforation and
ulceration;

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 Cont----
11.Axillary Temperature
a. Remove client’s arm and
shoulder from one sleeve of
gown. Avoid exposing chest.
b. Make sure axillary skin is dry; if
necessary, pat dry.
c. Prepare thermometer
d. Place thermometer or probe
into center of axilla (see Figure
A). Fold client’s upper arm
straight down and place arm
across client’s
chest (Figure B).
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 Cont----
e. Leave glass thermometer in place as specified
by agency policy (usually 6–8 minutes). Leave
an electronic thermometer in place until signal is heard.
f. Remove and read thermometer.
g. Inform client of temperature reading.
h. Cleanse glass thermometer and return to storage
container.
i. Assist client with replacing gown
j. Record reading and indicate site as “AT.”

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 Cont----
12.Disposable (Chemical Strip) Thermometer
a. Apply tape to appropriate skin area, usually
forehead.
b. Observe tape for color changes.
c. Record reading and indicate method.
13.Tympanic Temperature: Infrared Thermometer
a. Position client in Sims’ position.
b. Remove probe from container and attach probe
cover to tympanic thermometer unit.
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 Cont----
c. Turn client’s head to one side. For an adult, pull
pinna upward and back; for a child, pull down and
back. Gently insert probe with firm pressure into
ear canal.
d. Remove probe after the reading is displayed on
digital unit (usually 2 seconds).
e. Remove probe cover and replace in storage
container.
f. Return tympanic thermometer to storage unit.
g. Record reading and indicate site as “ET.”
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 2. Pulse
• It is a wave of blood created by contraction of
the left ventricle of the heart i.e. the pulse
reflects the heart beat or is the same as the
rate of ventricular contractions
• In some types of cardiovascular diseases
heartbeat and pulse rate differs.
E.g Client's heart produces very weak or small
pulses that are not detectable in a peripheral
pulse far from the heart
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 Pulse Sites

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 Cont...
1. Temporal: is superior (above) and lateral to (away
from the midline of) the eye. The pulse is taken at
temporal bone area.
2.Carotid: at the side of the neck below tube of the ear
3. Apical: at the apex of the heart: routinely used for
infant and children < 3 yrs
 In adults – Left mid-clavicular line under the 4 th, 5th,
6th intercostals space
 Children < 4 yrs of the Lt. mid clavicular line

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 Cont----
4.Brachial: at the inner aspect of the biceps
muscle of the arm or medially in the antecubital
space (elbow crease)
5.Radial: on the thumb side of the inner aspect
of the wrist – readily available and routinely used
6.Femoral: along the inguinal ligament. Used for
infants and children

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 Cont..
7.Popiliteal: behind the knee. By flexing the knee
slightly
8.Posterior tibial: on the medial surface of the
ankle
9.Pedal (Dorslais Pedis): palpated by feeling the
dorsum (upper surface) of the foot on an
imaginary line drawn from the middle of the
ankle to the surface between the big and 2nd toes

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 Type of Pulse
• Peripheral Pulse: is a pulse located in the
periphery of the body e.g. in the foot, and or
neck
• Apical Pulse (central pulse):it is located at the
apex of the heart
• The PR is expressed in beats/ minute (BPM)
• Pulse Deficit- It is a difference that exists
between the apical and radial pulse.

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 Cont---

• When a difference exists between the apical and

radial pulses, the deficit is assessed by simultaneously
measuring the apical and radial pulses for a minute.
• This procedure is usually performed by two nurses;
however, it can be performed by one nurse if
necessary.
 If pulse count differs by more than 2 a pulse deficit is
exist .
 Both counts are to be charted and recorded as A/R,
79/78 on graph
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 Factors Affecting Pulse Rates
• Age
• Sex
• Exercise
• Fever
• Medications
• Heat
• Stress
• Position changes
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 Assess the Pulse for
• Rate
• Rhythm
• Volume
• Elasticity of the arterial Wall
1.Pulse Rate
• Normal 60-100 b/min (80/min)
• Tachycardia – excessively fast heart rate (>100/min)
• Bradycardia < 60/min
2.Pulse Rhythm
• The pattern and interval between the beats, random,
irregular beats – dysrhythmia

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 Cont---
3.Pulse Volume
• The force of blood with each beat
• A normal pulse can be felt with moderate
pressure of the fingers and can be demolished
with greater pressure.
• Full or bounding pulse forceful or full blood
volume is reduced with difficulty
• Weak, feeble or thready is demolished with
pressure from the finger tips
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 Cont..
4.Elasticity of arterial wall
• A healthy, normal artery feels, straight, smooth,
soft and flexible, easily bent after breaking
• Reflects the status of the clients vascular system
If the pulse is regular, measures (count) for 30
seconds and multiply by 2
If it is irregular count for 1 full minute

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 Equipment
• Watch with second hand or pulse meter.
• If apical (heart) and radial (Wrist) beats are to
be counted, compared, and recorded, a
stethoscope is needed.
General instruction
• Do not use thumb to feel pulse.
• Do not make too great pressure.

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 Procedure for measuring radial pulse

• Wash hands
• Explain the procedure to the
client
• Position the client’s for arm
comfortably with the wrist
extended and the palm down
• Place the tips of your first,
second, and third fingers over the
client’s radial artery on the inside
of the wrist on the thumb side.

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•
Cont---
Press gently against the client’s
radial artery to the point where
pulsation can be felt distinctly
• Using a watch, count the pulse
beats for 30 seconds and multiply
by two to get the rate per minute
• Count the pulse for full minute if
it is abnormal in any way or take
an apical pulse
• Record the rate (BPM) on paper
or the flow sheet. Report any
irregular findings to appropriate
person
• Wash your hands
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 Measuring apical pulse
• Inform client that you are
going to listen to
his heart.
• Instruct client to remain silent.
• With dominant hand, put
earpiece of the
stethoscope in your ears and
grasp diaphragm of the
stethoscope in palm of your
hand for 5 to 10 seconds.

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 Cont..
• Place diaphragm of
stethoscope over the
point of maximal
impulse PMI and
auscultate for sounds S
1 and S2 to hear lub-
dub sound
• Note regularity of
rhythm.

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 Cont..
• Start to count while looking at second hand of
watch.
• Count lub-dub sound as one beat:
• For a regular rhythm, count rate for 30 seconds.
• For an irregular rhythm, count rate for a full
minute, noting number of irregular beats.
• Share your findings with client.
• Record by site the rate, rhythm, and, if
applicable, number of irregular beats
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 3.Respiration
• Respiration is the act of breathing (includes
intake of O2 and removal of CO2)
• Ventilation is another word, which refer to the
movement of air in and out of the lungs.
• Hyperventilation: very deep, rapid respiration
• Hypoventilation: very shallow respiration

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 Two Types of Breathing
Costal (thoracic)
• Involves the external muscles and other accessory
muscles (sternoclodio mastoid)
• Observed by the movement of the chest up ward
and down ward. Commonly used for adults
Diaphragmatic (abdominal)
• Involves the contraction and relaxation of the
diaphragm, observed by the movement of
abdomen. Commonly used for children.
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 Assessment
• The client should be at rest
• Assessed by watching the movement of the
chest or abdomen.
• Rate, rhythm, depth and special characteristics
of respiration are assessed
A. Rate: is described in rate per minute (RPM)
• Healthy adult RR = 15- 20/ min. is measured for
full minute, if regular for 30 seconds.
• As the age decreases the respiratory rate
increases. Prepared by Eftu Hawera
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 Cont----
B. Rhythm: is the regularity of expiration and
inspiration
• Normal breathing is automatic & effortless.
C. Depth: described as normal, deep or shallow.
• Deep: a large volume of air inhaled & exhaled,
inflates most of the lungs.
• Shallow: exchange of a small volume of air
minimal use of lung tissue.
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 Alteration in respiration
• Eupnea- normal breathing rate and depth
• Bradypnea- slow respiration
• Tachypnea - fast breathing
• Apnea - temporary cessation of breathing

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 4. Measuring blood pressure
• Blood pressure is the measurement of
pressure pulsations exerted against the blood
vessel walls during systole and diastole.
• Blood pressure is recorded in Millimeter/mm/
of mercury.
• An average B.P of a normal adult is 120 in
systolic while diastolic in normal adult is 80

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Methods of Measuring Blood Pressure
• Blood pressure can be assessed directly or indirectly
1. Direct (invasive monitoring) measurement involves the
insertion of catheter in to the brachial, radial, or femoral
artery.
• The physician inserts the catheter and the nurse monitors
the pressure reading. With use of correct placement, it is
highly accurate.
2. Indirect (non invasive methods)
• The auscultatory and the palpatory,
• The auscultatory method is the commonest method used
in health activities.
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When taking blood pressure using stethoscope, the nurse identifies
five phases in series of sounds called Korotkoff's sound.
Phase of Blood pressure
• Phase 1: The pressure level at which the 1st joint clear tapping
sound is heard; these sounds gradually become more intense.
• To ensure that they are not extraneous sounds, the nurse should
identify at least two consecutive tapping sounds.
• Phase 2: The period during deflation when the sound has a swish
quality
• Phase 3: The period during which the sounds are crisper and
more intense
• Phase 4: The time when the sounds become muffled and have a
soft blowing quality
• Phase 5: The pressure level when the sounds disappear

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 Sites for Measuring Blood Pressure
• The most common site for indirect blood pressure
measurement is the client’s arm over the brachial
artery.
• When the client’s condition prevents auscultation of
the brachial artery, the nurse should assess the blood
pressure in the forearm or leg sites
1. Upper arm using brachial artery (commonest)
2. Thigh around popliteal artery
3. Fore -arm using radial artery
4. Leg using posterior tibial or dorsal pedis
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 Contraindications for brachial artery blood pressure
measurement

• When the client has any of the following, do not

measure blood pressure on the involved side:
1. Venous access devices, such as an intravenous
infusion or arteriovenous fistula for renal dialysis
2. Surgery involving the breast, axilla shoulder, arm,
or hand
3. Injury or disease to the shoulder, arm, or hand,
such as trauma, burns, or application of a cast or
bandage
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 Cont..
• When pressure measurements in the upper
extremities are not accessible, the popliteal
artery, located behind the knee, becomes the
site of choice.
• Since it is difficult to auscultate sounds over
the radial, tibial, and dorsalis pedis arteries,
these sites are usually palpated to obtain a
systolic reading.

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 There are two types of blood pressure

• Systolic pressure: is the pressure of the blood

as a result of contraction of the ventricle (is
the pressure of the blood at the height of the
blood wave);
• Diastolic blood pressure: is the pressure
when the ventricles are at rest.

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 Pulse pressure
• The difference between the systolic and the
diastolic pressures is called the pulse pressure.
• Normal Pulse pressure is 30 to 40 mm Hg and
indicates how well the patient maintains
cardiac output.
• A pulse pressure of less than 30 mm Hg
signifies a serious reduction in cardiac output
and requires further cardiovascular
assessment.

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 Conditions Affecting Blood Pressure

• Fever-------------------------------------- Increase
• Stress ------------------------------------------"
• Arteriosclerosis------------------------------ "
• Obesity -----------------------------------------"
• Exposure to cold------------------------------"
• Hemorrhage ---------------------------- Decrease
• Low hematocrit------------------------------- "
• External heat ----------------------------------"
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 Equipment
• Vital sign tray and Vital sign
sheet
• Cotton swab in bowel
• Disposable gloves
• Dirty receiver kidney dish
• Sphygmomanometer (B/p
apparatus) ( Aneroid
manometer or Mercury
manometer) types
• Stethoscope
• Other necessary items like
pen

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 Procedure
1. Prepare and position the patient
appropriately
• Make sure that the client has not
smoked or ingested caffeine, within
30 minutes prior to measurement.
• Position the patient in sitting position,
unless otherwise specified.
• The arm should be slightly flexed with
the palm of the hand facing up and
the fore arm supported at heart level
• Expose the upper arm
2. Wrap the deflated cuff evenly around
the upper arm.
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 Cont----
• Apply the center of the
bladder directly over the
medial aspect of the arm.
• The bladder inside the cuff
must be directly over the
artery to be compressed.
• For adult, place the lower
border of the cuff
approximately 2 cm above
antecubital space.

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 Cont----
3. For initial examination,
perform first round
palipatory determination
of systolic pressure.
• Palpate the brachial
artery with the finger tips
• Close the valve on the
pump by turning the
knob clockwise.

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 Cont----
• Pump up the cuff until you
no longer feel the brachial
pulse
• Note the pressure on
sphygmomanometer at
which the pulse is no longer
felt
• Release the pressure
completely in the cuff, and
wait 1 to 2 minutes before
making further
measurement

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 Cont----
4. Position the stethoscope
appropriately
• Insert the ear
attachments of the
stethoscope in your ears
so that they tilt slightly
fore ward.
• Place the diaphragm of
the stethoscope over
the brachial pulse; hold
the diaphragm with the
thumb and index finger.
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 Cont---
5. Auscultate the client's blood pressure
• Pump up the cuff until the sphygmomanometer registers
about 30 mm Hg above the point where the brachial pulse
disappeared.
• Release the valve on the cuff carefully so that the pressure
decreases at the rate 2-3 mmHg per second.
• As the pressure falls, identify the manometer reading at each
of the five phases
• Deflate the cuff rapidly and completely
• Repeat the above step once or twice as necessary to confirm
the accuracy of the reading.

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 Cont---
6. Remove the cuff from the client’s arm
7. For initial determination, repeat the
procedure on the client's other arm, there
should be a difference of no more than 5 to 10
mmHg between the arms. The arm found to
have the higher pressure, should be used for
subsequent examinations

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 Cont..
• Document and report pertinent assessment data,
report any significant change in client's blood
pressure to the nurse in charge. Also report these
finding:
A. Systolic blood pressure (of adult) above 140 mmHg.
B. Diastolic blood pressure (of an adult) above 90
mmHg
C. Systolic blood pressure of (an adult) below
100mmHg

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 Precautions
• Do not let pressure drop too rapidly, the reading will be
inaccurate
• Be sure the cuff is neither too tight nor too loose.
• Do not let patient bend his arm.
• Do not let patient grip his fingers, clutch the table or objects
of any kind.
• Always place sphygmomanometer on level surface and where
there is enough light.
• Ear pieces and the diaphragm should be cleaned with alcohol
swabs.

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 Cont---
• Place patient in same position if possible, for each
succeeding reading.
• It is preferably to have patient as quiet &
comfortable as possible before taking blood
pressure.
• When B/P above 140/90 mm of Hg or below 90/60
mm of Hg note as there is abnormal B/P.
• Make sure that the client has not smoked or ingested
caffeine, within 30 minutes prior to measurement.

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 Respiration, pulse & temperature of an
infant
• Count the respiration while the child is sleeping or undisturbed,
by watching the movement of the chest or abdomen.
• Do not touch the child.
• A respiratory rate or pulse which has been counted after the
child has been crying or struggling is entirely inaccurate and
useless for recording.
• It is more difficult to count the pulse rate in babies than in
adults because they are restless and the volume and tension of
the pulse are less.
• It is easier to count a baby's pulse on the inner side of the ankle
than at the wrist

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 Temperature
• The best method to take the temperature of a
baby is by rectum.
• It may also be taken in the groin or axilla, but
should never be taken in the mouth.
• Quite frequently the skin of the baby is much
cooler than the actual body temperature.
• For this reason rectal temperature is the most
accurate, but special precaution must be taken:

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 Measurement of Height and Weight

•  Measuring height and weight is as

important as assessing the client’s vital
signs.
• Routine measurement provides data
related to growth and development in
infants and children and signals the
possible onset of alterations that may
indicate illness in all age groups.
 
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 Cont-----
• The client’s height and
weight are routinely
taken on admission to
acute care facilities and
on visits to physicians’
offices, clinics, and in
other health care
settings.

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 Pain assessment
•  Assessment of pain includes collection of
subjective and objective data through the use
of various assessment tools.
• Pain assessment should be performed for
every client and should be considered as fifth
vital sign.
• Documentation of pain assessment is now as
prominent as the documentation of other vital
signs.
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 Assessment Tools
• Pain assessment tools are the single most
effective method of identifying the presence
and intensity of pain in clients.
• These tools must be used, and the results
must be believed.
• Tools used for assessing pain must be
appropriate to the client’s age and cultural
context.

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 Initial Pain Assessment Tool
• The Initial Pain Assessment Tool developed by
McCaffery and Pasero .
• This tool is particularly effective when clients have
complex pain problems because it assesses location,
intensity, quality, precipitating and alleviating factors,
and how the pain affects function and quality of life.
• Once this tool is completed, another less detailed
tool can be used for ongoing monitoring of the
client’s pain level.

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 Pain Intensity Scales
• Pain intensity scales are another quick,
effective method for clients to rate the intensity
of their pain .
• The verbal rating scale (VRS) and the numeric
rating scale (NRS) are often used together to
collect more accurate client input.
• The VRS uses adjectives ranging from “no pain”
to “severe pain” in order to describe intensity.

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 Cont----
• When using the NRS, clients are asked to
assign their pain a number, with zero meaning
no pain and 10 representing the worst
possible pain.
• Frequent use of these tools will increase
understanding of the pain severity.

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 Pain Diary
• Client input is essential if accurate assessment
data are to be collected.
• Self-monitoring of symptoms can be
encouraged by having clients complete a pain
diary.

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 Psychosocial Pain Assessment
• Plaisance and Price (1999) state the following questions
should be included on the psychosocial assessment of a
client experiencing pain:
• Do the client and family/caregivers understand the
diagnosis?
• How have previous experiences with pain affected the
client and family?
• How does the client usually cope with pain and/or stress?
• What concerns do the client & family have about using
certain medications such as opioids?
• Do the client and family understand the differences
between tolerance, dependence, and addiction?
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 Cont----
• Two useful tools for assessing
pain in children are the
Wong/Baker Faces Rating Scale
and the Poker Chip Tool.
• The Wong/Baker Faces Rating
Scale can be used with children
as young as 3 years, and it helps
children express their level of
pain by pointing to a cartoon
face that most closely
resembles how they are feeling
(see at the Figures).

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 Cont----
• The Poker Chip Tool consists of
four red poker chips that can
easily be carried in a pocket to be
available when needed.
• The chips are aligned horizontally
on a hard surface in front of the
child, and they are described as
“pieces of hurt.”
• The chips are described from left
to right as just a little bit of hurt,
a little more hurt, more hurt, and
the most hurt you could ever
have.
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 Cont----
• The child is then asked, “How many pieces of
hurt do you have right now?”
• This tool can be used with children 4 to 13
years old.
• The verbal 0 to 10 scale is also frequently used
for school-age and adolescent clients in a
number of settings.

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THANKYOU
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