Vital Signs

Vital Signs
• The most frequent measurements obtained by health
practitioners are those of temperature, pulse, blood pressure,
respiratory rate.

• Many agencies such as the Veterans Administration,

American Pain Society, and The Joint Commission have
designated pain as a fifth vital sign.

• Oxygen saturation is also commonly measured at the same

time as the traditional vital signs and could be considered
the sixth vital sign.
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 Vital Signs
• As indicators of health status, these measures indicate
the effectiveness of circulatory, respiratory, neural and
endocrine body functions.

• Because of their importance they are referred to as vital

signs.

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 When to Assess Vital Signs
• On admission
• Change in client’s health status
• Client reports symptoms such as chest pain, feeling hot, or
faint.
• Pre and post surgery/invasive procedure
• Pre and post medication administration that could affect CV
system
• Pre and post nursing intervention that could affect vital signs

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 Sites Used for Body Temperature Measuremen

Oral temperature in adults normally ranges from (36.1° to 37.5° C).

Rectal temperature, the most accurate reading, is usually (0.6° C) higher.

Axillary temperature, the least accurate, reads (0.6° to 1.1° C) lower.

Tympanic temperature reads (1° to 0.6° C) higher.

Temporal (forehead) temperature is 0.5-1 degrees F lower than oral temperature

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Site Advantages Disadvantages

Oral Accessible and convenient Thermometers can break if bitten.

client has just ingested hot or cold
food or fluid or smoked.Could injure
the mouth following oral surgery.

Rectal Reliable measurement Inconvenient and more unpleasant for

clients; difficult for client who cannot
turnto the side.
Could injure the rectum.
Presence of stool may interfere with
thermometer placement.

Axillary Safe and noninvasive The thermometer may need to be left

Tympanic membrane Readily accessible; reflects the core
temperature; very fast
in place a long time to obtain an
accurate measurement.
Can be uncomfortable and involves
risk of injuring the membrane if the
probe is
inserted too far.
Repeated measurements may vary.
Right and left measurements can differ
if
there are anatomic or pathologic
differences (e.g., infection).
Presence of cerumen can affect the
reading.

Temporal artery Safe and noninvasive; very fast Requires electronic equipment that
may be expensive or unavailable.
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technique needed if the client has
 Temperature
• Temperature can be measured with a mercury, an
electronic digital, or a chemical-dot thermometer.

7
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 Temperature
• Keep the following principles in mind:

• If a client has been taking cold or hot food or fluids or smoking , the
nurse should wait 30 minutes before taking the temperature orally to
ensure that the temperature of the mouth is not affected by the
temperature of the food, fluid, or warm smoke.

• Rectal temperatures are contraindicated for clients who are

undergoing rectal surgery, have diarrhea or diseases of the rectum,, or
have significant hemorrhoids.

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 Equipment
1. Thermometer
2. Thermometer sheath or cover
3. Water-soluble lubricant for a rectal temperature
4. Clean gloves for a rectal temperature
5. Towel for axillary temperature
6. Tissues or wipes

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 PREPARATION OF EQUIPMENT

• If a thermometer is included in the admission pack, keep it at

the patient's bedside and, on discharge, allow him to take it
home.

• Otherwise, obtain a thermometer from the nurses' station or

central supply department.

• If you use an electronic thermometer, make sure it's been

recharged.
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 IMPLEMENTATION

Prior to performing the procedure, introduce self .

Explain to the client what you are going to do, why it is
necessary, and how to participate.
Discuss how the results will be used in planning further care
or treatments.
Perform hand hygiene and observe appropriate infection
prevention procedures.
Apply gloves if performing a rectal temperature.
Provide for client privacy.
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 Using a mercury Thermometer
• Hold the thermometer between your thumb and index finger at the
end opposite the bulb.

• If the thermometer has been soaking in a disinfectant, rinse it in

cold water.
• Rinsing removes chemicals that may irritate oral or rectal mucous
membranes or axillary skin.
• Avoid using hot water because it expands the mercury, which
could break the thermometer.
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 Using a mercury Thermometer
• Using a twisting motion, wipe the thermometer from the bulb
upward.

• Then quickly snap your wrist several times while holding the
thermometer to shake it down to below (36.7 C).

• Shaking causes the mercury to descend into the bulb.

• The mercury will then expand in response to the patient's body
temperature and be forced upward.
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 Using An Electronic Thermometer

• Insert the probe into a disposable probe cover.

• If taking a rectal temperature, lubricate the probe cover

to reduce friction and ease insertion.

• Leave the probe in place until the maximum

temperature appears on the digital display.

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 Electronic Thermometer/Probe

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 Taking an Oral Temperature
• Position the tip of the thermometer under the patient's tongue,
as far back as possible on either side of the frenulum.

• Placing the tip in this area promotes contact with superficial

blood vessels and contributes to an accurate reading.

• Instruct the patient to close his lips but to avoid biting down
with his teeth.

• Biting can break the thermometer, cutting the mouth or lips or

causing ingestion of broken glass or mercury.
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 Taking an Oral Temperature
• Leave a mercury thermometer in place for at least 2 minutes to
register temperature; for an electronic thermometer, wait until the
maximum temperature is displayed.

• For a mercury thermometer, remove and discard the disposable

sheath; then read the temperature at eye level, noting it before
shaking down the thermometer.

• For an electronic thermometer, note the temperature; then remove

and discard the probe cover.
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 Using A Tympanic Thermometer
• Make sure the lens under the probe is clean and shiny.
• Attach a disposable probe cover.

• Stabilize the patient's head; then gently pull the ear

straight back (for children up to age 3) or up and back
(for children age 3 and older to adults).

• Insert the thermometer until the entire ear canal is

sealed.

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 Using A Tympanic Thermometer
• The thermometer should be inserted toward the tympanic
membrane in the same way that an otoscope is inserted.

• Then press the activation button and hold it for 1 second.

• The temperature will appear on the display.

• Pediatric alert For infants younger than age 3 months, take

three readings and use the highest.

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 Taking a Rectal Temperature
• Apply clean gloves.
• Instruct the client to take a slow deep breath during
• insertion.
• Never force the thermometer if resistance is felt.
• Position the patient on his side with his top leg flexed, and drape him to
provide privacy.
• Then fold back the bed linens to expose the anus.
• Squeeze the lubricant onto a facial tissue to prevent contamination of the
lubricant supply.
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 Taking a Rectal Temperature
• Lubricate about (1.3 cm) of the thermometer tip for an
infant, (2.5 cm) for a child, or about (3.8 cm) for an
adult.
• Lubrication reduces friction and thus eases insertion.
• This step may be unnecessary when using disposable
rectal sheaths because they're pre-lubricated.

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 Taking a Rectal Temperature
• Lift the patient's upper buttock, and insert the
thermometer about (1.3 cm) for an infant or (3.8 cm)
for an adult.
• Gently direct the thermometer along the rectal wall
toward the umbilicus.
• This will avoid perforating the anus or rectum or
breaking the thermometer.

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 Taking a Rectal Temperature
• Hold the mercury thermometer in place for 2 to 3 minutes, or the
electronic thermometer until the maximum temperature is displayed.

• Holding the thermometer prevents damage to rectal tissues caused by

displacement or loss of the thermometer into the rectum.

• Carefully remove the thermometer, wiping it as necessary.

• Then wipe the patient's anal area to remove any lubricant or feces.

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 Taking an Axillary Temperature
• Position the patient with the axilla exposed.

• Gently pat the axilla dry with a facial tissue because moisture conducts heat.

• Avoid harsh rubbing, which generates heat.

• Ask the patient to reach across his chest and grasp his opposite shoulder, lifting
his elbow.

• Position the thermometer in the center of the axilla, with the tip pointing toward
the patient's head.
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 Taking an Axillary Temperature
• Tell him to keep grasping his shoulder and to lower his elbow and hold it against
his chest.

• This promotes skin contact with the thermometer.

• Remove a mercury thermometer after 10 minutes;

• Axillary temperature takes longer to register than oral or rectal temperature

because the thermometer isn't enclosed in a body cavity.

• Grasp the
Nov 29, end of the thermometer and remove it from the axilla.
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Nov 29, 2023 31
 Pulse
• The pulse is the palpable bounding of blood flow in the peripheral artery noted
at various points on the body.

• The pulse is an indicator of circulatory status.

• Pulse reflects the heartbeat.

• The pulse rate is the same as the rate of the ventricular contractions of the heart.

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 Pulse: Keep the following principles in mind:

 Stress increases the rate as well as the force of the heartbeat.

 Fear and anxiety as well as acute pain stimulate the sympathetic system.

 Position. When a client is sitting or standing, increase in heart rate.

 Certain diseases such as some heart conditions or those that impair

oxygenation can alter the resting pulse rate.

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 9 Peripheral Pulse Sites

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 PULSE CHARACTERISTICS
• Rate: Normal pulse for adults 60-100 beats /
minutes for infants 120-160 beats/minutes

• Rhythm: Regular intervals between pulses.

• Strength: Can be described as strong, weak and

bounding.

• Equality: Pulse should be the same in both sides

of the body.
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 Taking a Radial Pulse
• Place the patient in a sitting or supine position, with his arm at his side or across
his chest.

• Gently press your index, middle, and ring fingers on the radial artery, inside the
patient's wrist.

• You should feel a pulse with only moderate pressure.

• Excessive pressure may obstruct blood flow distal to the pulse site.

• Don't use your thumb to take the patient's pulse because your thumb's own
strong pulse may be confused with the patient's pulse.

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 Taking a Radial Pulse
• After locating the pulse, count the beats for 60 seconds, or
count for 30 seconds and multiply by 2.

• Counting for a full minute provides a more accurate picture

of irregularities.

• While counting the rate, assess pulse rhythm and volume by

noting the pattern and strength of the beats.
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 Taking a Radial Pulse
• If you detect an irregularity, repeat the count, and note
whether it occurs in a pattern or randomly.
• If you're still in doubt, take an apical pulse.

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Respiration
Respiration
• Is the mechanism the body uses to exchange gases between
the atmosphere and the blood then between the blood and
the cells.
• Respiration involves both inspiration and expiration.
Inspiration: the movement of muscles that enlarge the chest
wall and allow air entry.

Expiration: the relaxation of that muscles that collapse the

chest wall and push the air out side.
 Characteristics of Respiration:

1. Respiratory rate:
• Adult 12-20
• Infant 30-50
2. Respiratory rhythm: regular
3. Respiratory depth: not deep not shallow
• Normal saturation of oxygen inside the blood is
between 95% and 100%.
 Equipment

Watch with second hand.

Implementation

• The best time to assess the patient's respirations is

immediately after taking his pulse rate.

• Keep your fingertips over the radial artery, and don't tell the
patient you're counting respirations.

• If you tell him, he'll become conscious of his respirations and

the rate may change.
 Implementation

• Count respirations by observing the rise and fall of the

patient's chest as he breathes.

• Alternatively, position the patient's opposite arm across

his chest and count respirations by feeling its rise and fall.

• Consider one rise and one fall as one respiration.

 Implementation

• Count respirations for 30 seconds and multiply by 2 or

count for 60 seconds if respirations are irregular to
account for variations in respiratory rate and pattern.

• As you count respirations, be alert for and record such

breath sounds as stridor, wheezing
 Implementation

• Stridor is an inspiratory crowing sound that occurs with

upper airway obstruction in laryngitis, croup, or the
presence of a foreign body.

• Wheezing is caused by partial obstruction in the smaller

bronchi and bronchioles. This high-pitched, musical
sound is common in patients with emphysema or asthma.
 Implementation

• Watch the patient's chest movements and listen to his

breathing to determine the rhythm and sound of
respirations.

• To detect other breath sounds such as crackles and

rhonchi or the lack of sound in the lungs, you'll need a
stethoscope.
 Implementation

• Observe chest movements for depth of respirations. If the patient

inhales a small volume of air, record this as shallow; if he
inhales a large volume, record this as deep.

• Observe the patient for use of accessory muscles, such as the

sternocleidomastoid, trapezius, and latissimus dorsi.

• Using these muscles reflects weakness of the diaphragm and the

external intercostal muscles as the major muscles of respiration.
 Blood Pressure
• Blood pressure is the force exerted on the walls of an
artery by the pulsing blood under pressure from the heart.

• Systolic blood pressure is the maximal pressure inside the

artery after cardiac contraction.

• Diastolic blood pressure is the minimal pressure inside the

artery after cardiac relaxation.
 Blood Pressure
• The standard unit of measuring blood pressure is millimeter
mercury (mmHg), the measurement indicates the height to
which the blood pressure can rise a column of mercury.

• Usually blood pressure is recorded with systolic readings

before diastolic readings (example: 120/80 mmHg).
 Hypertension
• Hypertension is the elevation of systolic blood pressure
greater than 140 mmHg or diastolic blood pressure is
the greater than 90 mmHg.

• Hypotension is the dropping of systolic blood pressure

below 90 mmHg.
 Pulse Pressure

• Pulse pressure: the difference between systolic and

diastolic pressures

• Example: BP is 120/80

• Pulse pressure = 120-80 = 40 mmHg

 Equipment
• Mercury or aneroid sphygmomanometer, stethoscope,
alcohol pad

• The sphygmomanometer consists of an inflatable

compression cuff linked to a manual air pump and a
mercury manometer.
 Implementation
• Carefully choose a cuff of appropriate size for the patient.

• An excessively narrow cuff may cause a false-high pressure

reading; an excessively wide one, a false-low reading.

• If you aren't using your own stethoscope, disinfect the

earpieces with an alcohol pad before placing them in your
ears to avoid cross-contamination
Blood Pressure – Cuff Size and Position
• Width: 40% of upper arm
circumference.

• Length: 80% of upper arm

circumference.

• If it is too small, the

readings will be
artificially elevated. The
opposite occurs if the cuff
is too large
 Implementation
• Tell the patient that you're going to take his blood pressure.

• The patient can lie supine or sit erect during blood pressure
measurement.

• His arm should be extended at heart level and be well

supported.

• Make sure the patient is relaxed and comfortable when you

take his blood pressure so it stays at its normal level.
 Implementation
• Center the inflatable cuff over the brachial artery with the
lower border 2.5 cm above the antecubital crease.

• Secure the cuff snugly, not tightly, and position the

patient’s arm so that it is slightly flexed at the elbow.

• With the fingers of your opposite hand, palpate the radial

artery and inflate the cuff until the radial pulse disappears;
add 30 mm Hg to this pressure.

• Deflate the cuff promptly and completely and wait 15-30

seconds
 Implementation
• Place the bell of the stethoscope lightly over the
brachial artery
• Inflate the cuff to the sum pressure previously
determined and deflate slowly.

• The point at which you hear the first two

consecutive beats is the systolic pressure
• The disappearance point is the diastolic
pressure.
 Implementation
• The bell of the stethoscope transmits low-pitched
arterial blood sounds more effectively than does the
diaphragm.
Cuff Position
 Implementation
• Auscultatory gap:
• A silent interval that
may be present
between the systolic
and diastolic blood
pressures; i.e., the
sound disappears for
a while, then
reappears
 Complications

• Don't take a blood pressure in the arm on the affected side

of a mastectomy.

• Don't take a blood pressure on an arm with an

arteriovenous fistula or hemodialysis shunt
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 AV Shunt for Hemodialysis

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