Vital signs include measurements of respiration, pulse, blood pressure, temperature, and pain level. They provide important information about a patient's health status and should be assessed regularly, including upon admission, before/after procedures, and with any changes in condition. The five vital signs are used to monitor patients and detect issues that may require medical intervention.
2. Vital signs, which may also be called “life
signs” are indicators of a persons health
status. Vital signs may reveal sudden or
gradual changes in a patient’s condition.
3. VITAL SIGNS
MONITOR A CLIENT’S CONDITION
IDENTIFY PROBLEMS
EVALUATE RESPONSE TO INTERVENTION
INDICATORS OF HEALTH STATUS
ESTABLISH BASELINE DATA FOR CLIENT
4. There are five measurements of vital signs that a
nurse must always consider when performing a
patient assessment.
Respiration
Pulse
Blood Pressure
Temperature
Pain Level
5. When should the nurse assess vital
signs?
Upon admission to
a health care
facility.
Routinely,
according to
physician’s or
hospital policy.
During physician’s
office visits or clinic
visits.
6. When should the nurse assess vital
signs?
Before, during and
after a surgical
procedure.
Before and after
Invasive diagnostic
procedures
Certain
medications are
administered.
7. When should the nurse assess vital
signs?
With any changes in
patient’s physical
condition.
Before and after and
nursing intervention
which may effect V/S
readings.
Anytime a patient
reports a change in
symptoms or exhibits
signs of distress.
8. Temperature
What is temperature?
Body temperature is the measurement in
degrees Fahrenheit or Celsius.
Heat produced - heat lost = body temp
Normal body temperature varies greatly from
one person to the other and with age.
- Skin temperature can range from 96.9 –
100.0 degrees. (go by your ebook values)
9. CORE TEMPERATURE
TEMP OF DEEP BODY TISSUES
UNDER CONTROL OF HYPOTHALMUS
RELATIVELY CONSTANT
PULMONARY ARTERY BEST SITE
OTHER SITES INCLUDE TYPANIC
MEMBRANE, ESOPHAGEAL, RECTAL,
URINARY BLADDER
10. SURFACE TEMPERATURE
Flucuates depending on
blood flow to the skin
and the amount of heat
lost to the external
environment.
11. Temp in Adults Depends on:
AGE
EXERCISE
HORMONE LEVEL
GENDER
CIRCADIAN RHYTHM
STRESS
ENVIRONMENT
19. HYPOTHERMIA INTERV.
PREVENT FURTHER DECREASE IN BODY
TEMPERATURE
REMOVE WET CLOTHES
WRAP IN BLANKETS
IF CONSCIOUS, GIVE WARM LIQUIDS
HEATING PAD OR WARM ENVIRONMENT
20. Temperature
An appropriate thermometer with probe cover
- Digital thermometer (oral/rectal)
-Tympanic membrane thermometer
-Glass thermometer (alcohol or mercury filled)
-Disposable-taped on forehead
Lubricant ( rectal temperature assessment
only)
Gloves
21. Pulse
What is pulse?
- Pulse is the palpable bounding of blood flow
noted at various points caused by the
contraction and alternate expansion of an
artery as the wave of blood passes through
the vessel.
22. Pulse
Pulse rate may be calculated by assessing
the number of pulsations that occur, in a one
minute period, at any of the following ten
pulse sites:
- Temporal
- Carotid
- Apical
- Brachial
- Radial
24. Pulse
The most common pulse site used to assess one’s
pulse is the radial pulse sight.
How to assess the radial pulse.
- Palpate the wrist just below the thumb
using the pads of the second and third
fingers.
- Count the number of beats you feel in a
one minute cycle.
25. Pulse
Normal pulse rate may also vary with age and
can range from:
- _______/minute at rest in infants.
-________/ minute at rest in toddlers.
-________/minute at rest in preschoolers
-________/minute at rest in school-agers
-________/ minute at rest in adolescents
-________/minute at rest in adults
Fundamentals ebook
29. RESPIRATIONS
PROCESS OF GAS EXCHANGE BY WHICH
OXYGEN IS OBTAINED AND CARBON
DIOXIDE IS ELIMINATED.
MOVEMENT OF CO2 BETWEEN THE
ALVEOLI AND THE RBC (DIFFUSION)
DISTRIBUTION OF RBC TO & FROM
PULMONARY CAPILLARIES (PERFUSION)
30. INFLUENCE ON RESP.
EXERCISE
ACUTE PAIN
SMOKING
BODY POSITION
MEDICATION
AGE
BRAIN STEM INJURY
32. Respiration
Normal respiratory rate varies with age and
can range from:
-_____/ minute in newborns.
-_____/ minute in school-age children.
-_____/ minute in adults.
Fundamentals ebook
35. Blood Pressure
What is blood pressure?
- Blood pressure is the pressure exerted on
the walls of the arteries during the
contraction and relaxation of the heart.
36. BLOOD PRESSURE
LATERAL FORCE ON
THE WALLS OF AN
ARTERY BY THE
PULSING BLOOD
UNDER PRESSURE
FROM THE HEART
37. Blood Pressure
What instruments are needed to
assess blood pressure?
Blood pressure is measured by using an
instrument that is known as a
sphygmomanometer which has a cuff
containing a rubber bladder, a pressure bulb
with a release valve and a manometer.
A stethoscope should also be used.
38. Blood Pressure
How is blood pressure recorded?
The standard unit used to measure blood pressure is
millimeters of mercury (mm Hg).
Blood pressure is recorded by placing the systolic
pressure reading, (pressure during ventricular
contraction) over the diastolic pressure reading,
(pressure during ventricular rest).
- For example 120/80 mmHg.
39. BP INFLUENCES
AGE
STRESS
RACE
MEDS
GENDER
CHANGE IN CARDIAC OUTPUT
INCREASE OR DECREASE IN BLOOD VOLUME
40. BLOOD PRESSURE
HYPERTENSION- DIASTOLIC READING OF
90 OR MULTIPLE CONSISTENT READINGS
OF SYSTOLIC HIGHER THAN 135
HYPOTENSION-SYSTOLIC 90 OR LOWER
ORTHOSTATIC HYPOTENSION
Refer to Fundamentals ebook
41. Blood Pressure
How should the nurse assess blood pressure?
The nurse should first palpate the pulse that will be
used to assess the blood pressure. The brachial
artery in the upper arm is usually used.
The sphygmomanometer should then be placed
about one inch above the pulse point that the nurse
will be using.
42. Blood Pressure
How should the nurse assess blood pressure?
The nurse should then inflate the cuff to an
appropriate level (usually 30mm Hg above the
number at which the pulse is no longer felt) and then
decrease it by releasing the valve and allowing the
rate to decrease at about 2-3 mm Hg /second.
43. Blood Pressure
What is a healthy blood pressure reading?
A healthy blood pressure reading in the
average adult is:
120/80 or less
Readings consistently above or below these
levels should be reported to the patients
doctor.
44. BP SITES TO AVOID
IV SITES
SHUNTS
SIDE OF BREAST/AXILLA SURGERY
ARM/HAND TRAUMA
CAST/BULKY DRESSING
45. Blood Pressure
How should the nurse assess blood pressure?
The nurse should then wait 30 seconds and inflate
the cuff to the previously determined number and
place the stethoscope diaphragm over the
antecubital space located at the bend of the arm. The
nurse should then deflate the cuff at the rate of 2-3
mm Hg / second.
The nurse should then listen for and note the number
at which the pulsation starts (systolic reading) and
stops (diastolic reading).
46. Pain Level
Pain level should be assessed every time other vital
signs are assessed and more often if needed.
Pain level should be assessed using the most
appropriate pain scale possible.
- Numeric pain scale (1-10)
-Descriptive pain scale (No pain -Worst pain)
-Face rating pain scale (Happy face - Sad face)
Pain levels should always be assessed before and
after pain medication administration.
47. Documentation of Vital Signs
Vital Signs should always be documented
immediately following assessment.
Vital signs should be documented on the
appropriate flow sheet or computer chart.
Vital signs should be documented using blue
or black indelible ink.
48. Vital Sign Assessment Is an
Important Part of Patient Care.
The Nurse should always….
- perform vital sign assessments as ordered
or needed.
- document vital signs appropriately.
- notify the doctor of any significant vital
sign changes.