PRESENTATION

VITAL SIGNS
GROUP MEMBERS
HIRA YOUSAF -
QUDSIA HAFEEZ – 19309
MEMONA GUL –
SAADIA MARYAM –
MISBAH ASHRAF -
 VITAL SIGNS
• Vital signs  are a group of the 4 to 6 most
important signs that indicate the status of the
body’s vital(life-sustaining) functions.
• These measurements are taken to help assess
the general physical health of a person, give
clues to possible diseases, and show progress
toward recovery. The normal ranges for a
person’s vital signs vary with age, weight,
gender, and overall health.
 VITAL SIGNS
• Temperature
• Pulse
• Respirations
• Blood pressure
• Pain(considered to 5th vital sign)
 When to measure vital signs?
• On admission to health care facility.
• In a hospital on regular hosp schedule.
• Before and after procedures (surgery, invasive
diagnostic procedures).
• Before, during, and after blood transfusions.
• When patient’s general condition changes
(nursing judgment).
 GUIDELINE FOR ASSESMENT
• Taken by nurse giving care.
• Equipment should be in good condition.
• Know normal range for pt and age group.
• Know pt’s medical history.
• Minimize environmental factors.
• Be organized in approach
• Increase frequency of VS as condition worsens
• Compare VS readings with the whole picture
• Record accurately
• Describe any abnormal VS
 1-BODY TEMPERATURE
• Difference between heat produced by body processes
and the heat lost to the external environment.
• Range 96.8 – 100.4 F (36 – 38 degree C).
• Average for healthy young adults 98.6F or 37degrees C.
• Body temperature is maintained within a fairly constant
range by hypothalamus which is located in a brain.
• The hypothalamus functions as body’s thermostat.
• The purpose of measuring body temperature is to
establish the patient’s baseline and to monitor any
abnormality.
 TEMPERATURE OR FEVER?
• TEMPERATURE—the
measurement of heat in
the body
• FEVER—the
measurement of heat in
the body that is above
normal for the individual
 TYPES OF THERMOMETER
• The measuring tool for temperature is
thermometer.
READING A THERMOMETER
NORMAL RANGE THROUGHOUT LIFE CYCLE

• Adults- 96.8- 100.4 •Newborn range – 95.9-

degree F 99.5F.
• Adult Average 98.6 F •Infants and children –
Oral same as adults.
• Adult Average 99.5 F •Elderly – Average 96.8F.
Rectal
• Adult Average 97.7 F
Ax
 FREQUENTLY USED TERMS
• Pyrexia or fever
• Febrile
• Hyperthermia
• Hypothermia
• Afebrile
 FEVER-A DEFENSE MECHANISM
• Indicator of disease in body
• Pathogens release toxins
• Toxins affect hypothalamus
• Temperature is increased
• Rest decreases metabolism and heat
production by the body
 PATTERENS OF FEVER
• SUSTAINED- remains above normal with
little change
• RELAPSING – periods of febrile episodes
interspersed with acceptable temp values
• INTERMITTENT—varies from normal to
above normal to below normal (may have
a fairly predictable pattern)
• REMITTENT—fever spikes and falls w/o a
return to normal temp values
• Age ( newborn- temp •Stress
control mechanism •Environment
immature, elderly- sensitive
to temp changes)
• Exercise
• Hormonal level
• Circadian rhythm (temp
normally changes 0.9 to 1.8
degree F /24hr Lowest 1-
4AM Max-6PM )
 ORAL TEMPERATURE
• Accessible
• Dependable
• Accurate
• Convenient
• Wait 15-30 minutes after
eating, drinking, chewing
gum or smoking
• If mouth breather-do not
take orally
• Leave in place 2 – 4
minutes with glass
thermometer
 RECTAL TEMPERATURE
• Most reliable.
• MUST hold thermometer in place.
• MOST accurate.
• MUST hold thermometer in place.
• Very high temperature.
• Unconscious.
• Do not take rectal temp on clients
with heart conditions.
• Leave in place 2-3 min with glass
thermometer
• Lubricate thermometer
• DO Not take hand from
thermometer while rectal in
progress
 AXILLARY TEMPERATURE
• Safe
• Non-invasive
• Least accurate
• Not good method
for persons with
elevated temp
• Used when cannot
get oral or tympanic
• Leave in place 10
minutes
TYMPANIC TEMPERATURE
• Non-invasive
• Safe
• Accurate
• Disadvantages
– Excessive cerumen
– Improper technique
• Oral & tympanic readings will be
same/ similar
• Must direct probe toward TM
(eardrum)
• Follow instructions
• Keep plugged in and on charger
when not in use
• Usually preferred method
• Adults –pull pinna of ear up &
back
• Children under 3y/o-pull pinna of
ear down & back
 DIAGNOSIS
• Hyperthermia> 100.4F
• Hypothermia <96.8F
• Risk for altered body
temperature
• Ineffective
Thermoregulation
 PULSE
• Pulse- is the palpable bounding of the blood
noted at various points on the body. It is an
indicator of circulatory status.
 PULSE SITES
• Temporal •Radial
• Carotid •Ulnar
• Apical •Femoral
• Brachial •Popliteal
• Radial and •Posterior
Apical are Tibial
most common
pulse sites
used!
 PULSE RANGES
AGE RANGE
ELDERLY(65+) 60-100

AVERAGE ADULT 60-100(5O OR BELOW IF

EXTREMELY ATHLETIC)
NEWBORN 120-160
0-20 HOURS
INFANT 100-120
1 MONTH-1 YEAR
CHILDREN (VARIES WITH AGE)
 TECHNIQUE
• Feel over BONY area
• DO NOT use thumb
• Use 2-3 fingers
• DO NOT squeeze
• Count 30 seconds if regular
x2
• Note Rate, Rhythm, Quality
• If irregular, count for 1 full
minute or take apical pulse
for 1 minute.
 FACTORS AFFECTING PULSE RATE
• Exercise
• Temperature
• Emotions
• Drugs
• Hemorrhage
• Postural Changes
• Pulmonary Conditions
 VARIATIONS OF PULSE RATE
• Tachycardia – Abnormally elevated pulse rate.
(above 100 beats/ min)
• Bradycardia – Abnormally slow pulse rate
(less than 60 beats / min)
 PULSE RYTHUM
• Regular – A regular interval of time occurs
between each heartbeat or pulse felt.
• Irregular – Interval interrupted by early, late,
or missed beat.
STRENGTH AND QUALITY OF PULSE
• Pulse strength may be described as weak,
strong, bounding, or thready.
• PULSE GRADING (0-4 rating scale)
• 0 – absent, not palpable
• 1+ - diminished, barely palpable
• 2+- easily palpable, normal pulse
• 3+ - full, increased strength
• 4+ - bounding, cannot be obliterated
 RESPIRATIONS
• Mechanism the body uses to exchange gases
between the atmosphere, blood, and the cells.
• Involves three processes:
 Ventilation
 Diffusion
 Perfusion
 CONTINUED….
• Chest Cavity—airtight vacuum with
negative pressure
• INSPIRATION—diaphragm contracts and
pulls down, ribs move up, lungs fill with air
• EXPIRATION—diaphragm relaxes and
moves up, ribs move down, lungs expel air
 NORMAL RESPIRATION RANGE
AGE RANGE

ELDERLY(65+) 12-20

AVERAGE ADULT 12-20

NEWBORN 30-60
0-24 HOURS
INFANT 30-50
1 MONTH-6 MONTHS
CHILDREN (VAREIES WITH AGE)
 COUNTING RESPIRATIONS
• Note rate, rhythm,
quality, and character
• Observe a full
inspiration and
expiration
• Respiratory rates
below 12 or greater
than 20 require further
assessment.
 CONTINUED….
• If respirations regular, count respirations for 30
seconds and multiply times 2.
• If irregular, less than 12 or greater than 20,
count for 1 full minute.
• Quality of respirations- assess movement of
chest or abdominal wall- deep, normal, shallow
• Deep- full expansion of lungs
• Normal- normal
• Shallow- limited expansion of lungs
 Factors influencing characteristics of
respirations
• Exercise •Medications
• Acute Pain •Neurological injury
•Age
• Anxiety
•Environmental Temp
• Smoking •Hemoglobin Function
• Body position
 BLOOD PRESSURE
• Blood pressure (BP) is the pressure of
circulating blood on the walls of blood vessels.
Used without further specification, "blood
pressure" usually refers to the pressure in
large arteries of the systemic circulation.
BLOOD PRESSURE APPARATUS
 LOW BLOOD PRESSURE
• low blood pressure might seem desirable, and for some
people, it causes no problems.
• However, for many people, abnormally low blood
pressure (hypotension) can cause dizziness and fainting.
• In severe cases, low blood pressure can be life-
threatening.
• A blood pressure reading lower than 90 millimeters of
mercury (mm Hg) for the top number (systolic) or 60
mm Hg for the bottom number (diastolic) is generally
considered low blood pressure.
 SYMPTOMS OF LOW BLOOD PRESSURE

• Dizziness or lightheadedness
• Fainting (syncope)
• Blurred vision
• Nausea
• Fatigue
• Lack of concentration
 TREATMENT
• Medications
• Use more salt
• Drink more water
 HIGH BLOOD PRESSURE
• High blood pressure is a common condition in
which the long-term force of the blood against
your artery walls is high enough that it may
eventually cause health problems, such as
heart disease.
 SYMPTOMS OF HTN
• A few people with high blood pressure may
have
• headaches
• shortness of breath or nosebleeds
• but these signs and symptoms aren't specific
and usually don't occur until high blood
pressure has reached a severe or life-
threatening stage.
 TREATMENT
• Eating a heart-healthy diet with less salt
• Getting regular physical activity
• Maintaining a healthy weight or losing weight if
you're overweight or obese
• Limiting the amount of alcohol you drink
• Renin inhibitors
• Beta blockers
• Vasodilators
• Alpha blockers
 COMMON MISTAKES IN BLOOD PRESSURE
ASSESMENTS
• Cuff too wide or too •Arm above or below
narrow heart level or not
• Cuff wrapped too supported
loose or unevenly •Repeating assessment
too quickly
• Inflating cuff too
•Inaccurate inflation level
slowly
•Poorly fitting
• Deflating cuff too stethoscope
slowly or too quickly •Impairment of examiners
hearing
DOCUMENTATIONS OF VITAL SIGNS
• Graphic sheets
• Flow sheets
• Nurses notes
• Computerized
 PAIN(5 VITAL SIGN)
TH

• Process of measuring pain:

• Verbal and nonverbal
• Characteristic of pain- onset, duration, location,
quality, intensity, variations
• Factors affecting pain – culture, developmental
stage, gender, anxiety, previous experience
• Pain scale- numerical (0-10), verbal (descriptive),
visual analog( faces pain rating scale)