2. Vital sign definition
Vital signs are measurement of the body’s
most basic functions that reflect essential
body function including heart rate,
respiratory rate, temperature and blood
pressure.
Vital sign are also known as ‘cardinal sign’.
4. VITAL SIGN
Measurement of various basic body conditions
which provide information about a patients
condition.
Homeostasis is the ideal state of health and fluid
balance in which all body systems are functioning
within normal limits
Deviations in any of vital sign from the normal
range is often the first indicator of a problem in a
patient.
5. Vital Signs
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. They are
important indicators of the body’s response to
physical, environmental, and psychological
stressors.
6. Vital Signs
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.
7. 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
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
LOC, pain
7. Before, after & during nursing interventions influencing vital signs
8. When client reports symptoms of physical distress
8. Temperature
Measurement of balance of heat lost & heat produced
Heat lost through perspiration, respiration and excretion
Heat produced by metabolism as well as muscle & gland activity
Low or High reading can be indication of disease process
Measured in Fahrenheit or Celsius
Normal Adult
Temperature Ranges
Axillary
97.6
96.6 to 98.6
Oral &
Tympanic
98.6
97.6 to 99.6
Rectal
99.6
98.6 to 100.6
9. Factors Influencing Temperature
Time of day
Part of body where temperature taken
Illness, infection exercise, excitement, high
environmental temperatures
Starvation, sleep, oral breathing, exposure
to cold temperatures, certain illnesses
Recent ingestion of food, drink or smoking
10. 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 & amount 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.
12. Thermometers – 3 types
Glass mercury – mercury expands or contracts in response to
heat. (just recently non mercury)
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.
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 – ret’n
to charging unit after use.
13. Sites (P&P p. 216)
Oral
Posterior sublingual pocket –
under tongue (close to carotid
artery)
No hot or cold drinks or smoking
20 min prior to temp. Must be
awake & alert.
Not for small children (bite
down)
Leave in place 3 min
Axillary
Bulb in center of axilla
Lower arm position across chest
Non invasive – good for
children. Less accurate (no
major bld vessels nearby)
Leave in place 5-10 min.
Measures 0.5 C lower than oral
temp.
Rectal
Side lying with upper leg flexed,
insert lubricated bulb (1-11/2
inch adult) (1/2 inch infant)
When unsafe or inaccurate by
mouth (unconscious, disoriented
or irrational)
Side lying position – leg flexed
Leave in place 2-3 min.
Measures 0.5 C higher than oral
Ear
Close to hypothalmus – sensitive
to core temp. changes
Adult - Pull pinna up & back
Child – pull pinna down & back
Rapid measurement
Easy assessibility
Cerumen impaction distorts
reading
Otitis media can distort reading
2-3 seconds
15. HEAT LOSS THROUGH…
Evaporation
Continuous vaporization of moisture from the
respiratory tract and the mucosa of the mouth and
from the skin.
Insensible Water Loss
The continuous and unnoticed water loss from the
process of evaporation.
16. CONT…
Radiation
The transfer of heat from the surface of one object to the
surface of another without direct contact.
Conduction
The transfer of heat from one molecule to a molecule of
lower temperature.
Convection
Dispersion of heat by air currents. (i.e. rising warm air and
sinking cooler air currents.)
20. 1.Continuous fever is a type or pattern
of fever in which temperature does not touch
the baseline and remains above normal
throughout the day.
E.G Typhoid fever, Fungal diseases.
2.remittent fever elevated body temperature
showing fluctuation each day, but never fallin
g to normal.
Eg. Infective endocarditis, Typhoid
21. 3.Intermittent fever is a type or pattern of fever in
which there is an interval where temperature is
elevated for several hours followed by an interval
when temperature drops back to normal
Eg. Malaria
4.Undulant fever: The disease is called undulant
fever because the fever is typically undulant,
rising and falling like a wave. Eg Brucellosis
22. 5. Definition of relapsing fever
A variable acute epidemic disease that is
marked by recurring high fever usually lasting
three to seven days and is caused by a
spirochete (genus Borrelia) transmitted by the
bites of lice and ticks
30. Normal Ranges
Normal range vary depending on sex, age, body
size
Normal adult range 60 – 90 beats per minute
Children 80 – 110
Infants 100-160
31. Terms to Know
Tachycardia – pulse rate over 100 (adults)
Bradycardia – Pulse rate less than 60
Rhythm – refers to the regularity of the pulse –
regular, irregular
Volume – refers to the strength of the pulse –
strong, weak, thready, or bounding
33. Apical Pulse
Taken with a stethoscope at the apex of the
heart
Counted for 1 full minute
Pulse deficit occurs when there is a
difference between apical and radial pulses
Most accurate way to check a pulse
Each lubb-dubb counted as 1 beat
34.
35. Assessing Radial Pulse
Left ventricle contracts causing a wave of bld 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 P&P p. 226
Assess: rate, rhythm, strength – can assess by using palpation &
auscultation.
Pulse deficit – the difference between the radial pulse and the apical
pulse – indicates a decrease in peripheral perfusion from some heart
conditions ie. Atrial fibrillation.
36. Procedure for Assessing Pulses
Peripheral – place 2nd
, 3rd
& 4th
fingers lightly on skin where an artery
passes over an underlying bone. Do not use your thumb (feel
pulsations of your own radial artery). Count 30 seconds X 2, if
irregular – count radial for 1 min. and then apically for full minute.
Apical – beat of the heart at it’s apex or PMI (point of maximum
impulse) – 5th
intercostal space, midclavicular line, just below lt.
nipple – listen for a full minute “Lub-Dub”
Lub – close of atrioventricular (AV) values – tricuspid &
mitral valves
Dub – close of semilunar valves – aortic & pulmonic valves
37. Assess: rate, rhythm, strength & tension
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)
Strength or size – or amplitude, the volume of bld 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
38. Normal Heart Rate
Age Heart Rate (Beats/min)
Infants 120-160
Toddlers 90-140
Preschoolers 80-110
School agers 75-100
Adolescent 60-90
Adult 60-100
39. Assess (cont.)
Tension – or elasticity, the compressibility of the
arterial wall, is pulse obliterated by slight pressure
(low tension or soft)
Stethoscope
Diaphragm – high pitched sounds, bowel, lung & heart sounds
– tight seal
Bell – low pitched sounds, heart & vascular sounds, apply bell
lightly (hint think of Bell with the “L” for Low)
40. Respirations
Assess by observing rate, rhythm & depth
Inspiration – inhalation (breathing in)
Expiration – exhalation (breathing out)
I&E is automatic & controlled by the medulla oblongata
(respiratory center of brain)
Normal breathing is active & passive
Women breathe thoracically, while men & young children
breathe diaphramatically ***usually
Asses after taking pulse, while still holding hand, so pt is
unaware you are counting respiratons
41. Respirations
Process of taking in oxygen and expelling
carbon dioxide from the lungs or
One breath in (inspiration) and one breath out
(expiration)
42. Respiratory Rates
Normal adult respiratory rate is 14 – 20
wider range 12 – 24 breaths per minute
Children range from 16 – 25
Infants range from 30 – 50
Tachypnea = respiratory rates 25 or >
Bradypnea = respiratory rate > 12
43. Respiratory Terms
Character = deep, shallow, labored, difficult
Rhythm = regular, irregular
Dyspnea = difficult or labored breathing
Apnea = absence of respirations
Orthopnea = must sit or stand to breath
Cheyne Stokes = periods of dyspnea
followed by apnea
44. Pulse & Respiration
Count each for 1 full minute initially
Respirations partially under voluntary control,
so do not let patient know you are counting
respirations
Count pulse 1st
, without removing hands,
count respirations
After it is established the patient has a regular
pulse, count can be decreased to 30 sec.
45. Assessing Respiration
Rate # of breathing cycles/minute (inhale/exhale-1cycle)
N – 12-20 breaths/min – adult - Eupnea – normal rate & depth breathing
Abnormal increase – tachypnea
Abnormal decrease – bradypnea
Absence of breathing – apnea
Depth Amt. of air inhaled/exhaled
normal (deep & even movements of chest)
shallow (rise & fall of chest is minimal)
SOB shortness of breath (shallow & rapid)
Rhythm Regularity of inhalation/exhalation
Normal (very little variation in length of pauses b/w I&E
Character Digressions from normal effortless breathing
Dyspnea – difficult or labored breathing
Cheyne-Stokes – alternating periods of apnea and hyperventilation, gradual
increase & decrease in rate & depth of resp. with period of apnea at the end of
each cycle.
46.
47. Blood Pressure
Measurement of the pressure that exerts on
the walls of the arteries during various
stages of heart activity
Systolic pressure occurs during the
contracting phase (1st
sound)
Diastolic pressure occurs during the resting
phase (last sound)
48. Normal Blood Pressure Ranges
Systolic pressure 90 – 140
Diastolic Pressure 60 – 90
Systolic pressures > 140 or Diastolic
pressures > 90 = Hypertension
Systolic pressure < 90 or Diastolic pressure <
60 = Hypotension
New guidelines indicate prehypertension rates
of 120-140 systolic and 80-90 diastolic
49. Factors Influencing Blood
Pressure
Factors increasing Blood Pressure include
excitement, anxiety, nervous tension, stimulant
drugs, exercise and eating
Factors decreasing blood pressure include rest or
sleep, depressant drugs, shock, excessive blood loss
Blood pressure can vary from sitting, standing and
lying positions
50. Terms Pertaining to Blood Pressure
Sphygmomanometer – instrument used to
measure blood pressure
Aneroid Gauge – Round gauge – each line
represents 2
Mercury gauges are vertical and may still
be used in some facilities – each vertical
line represents 2
Electronic sphygmomanometers also
available
Always remember never trust your
monitors – when in doubt check it manually
51. Blood Pressure
Force exerted by the blood against vessel walls. Pressure of blood within the
arteries of the body – left. ventricle contracts – blood is forced out into the
aorta to the large arteries, smaller arteries & capillaries
Systolic- force exerted against the arterial wall as left. ventricle
contracts & pumps blood into the aorta – max. pressure exerted on
vessel wall.
Diastolic – arterial pressure during ventricular relaxation, when the
heart is filling, minimum pressure in arteries.
Factors affecting B/P
lower during sleep
Lower with blood loss
Position changes B/P
Anything causing vessels to dilate or constrict - medications
52. B/P (cont.) P&P p. 240 see table 9-3
Measured in mmHg – millimeters of mercury
Normal range
syst 110-140 dias 60-90
Hypertensive - >160, >90
Hypotensive <90
Non invasive method of B/P measurement
Sphygmomanometer, stethoscope
3 types of sphygmomanometers
• Aneroid – glass enclosed circular gauge with needle that registers
the B/P as it descends the calibrations on the dial.
• Mercury – mercury in glass tube - more reliable – read at eye level.
• Electronic – cuff with built in pressure transducer reads systolic &
diastolic B/P
53. B/P (cont.)
Cuff – inflatable rubber bladder, tube connects to the manometer, another to the
bulb, important to have correct cuff size (judge by circumference of the arm not
age)
Support arm at heart level, palm turned upward - above heart causes false low reading
Cuff too wide – false low reading
Cuff too narrow – false high reading
Cuff too loose – false high reading
Listen for Korotkoff sounds – series of sounds created as bld flows through an
artery after it has been occluded with a cuff then cuff pressure is gradually released.
P&P p. 240.
Do not take B/P in
Arm with cast
Arm with arteriovenous (AV) fistula
Arm on the side of a mastectomy i.e. rt mastectomy, rt arm
54. Procedure – B/P
Assessment Determine best site & baseline B/P
Nursing Diagnosis Decreased cardiac output
Fluid volume excess
Fluid volume deficit
Planning Expected outcome
Have pt rest 5 min before taking B/Pa
Wash hands
Implementation Palpate brachial pulse
Position cuff 1inch above pulse - Arm at level of
heart, wrap snugly around arm
Manometer at eye level
55.
56. Procedure (cont.)
Implementation
Inflate cuff while palpating brachial Artery. Note
reading at which pulse disappears continue to
Inflate cuff 30 mmHg above this point. Deflate
cuff slowly and note when reading when pulse is
felt. Deflate cuff completely and wait 30 sec.
With stethoscope in ears locate the brachial artery –
place diaphragm over site
Close valve of pressure bulb. Inflate cuff 30 mm
hg above palpated systolic pressure
Slowly release valve
Note point on manometer when first clear sound is
heard (1st
phase Korotkoff) – systolic pressure
Continue to deflate noting point @ which sound
disappears – 5th
phase Korotkoff (4th
korotkoff in
children
Deflate & remove cuff
57. B/P 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
58. Oxygen Saturation (Pulse Oximetry)
Non-invasive measurement of oxygen saturation
Calculates SpO2 (pulse oxygen saturation) reliable estimate of arterial oxygen
saturation
Probes – finger, ear, nose, toe
Patient with PVD or Raynaud's syndrome – difficult to obtain.
Normal – 90-100%
Remove nail polish
Wait until oximeter readout reaches constant value & pulse display
reaches full strength
During continuous pulse oximetry monitoring – inspect skin under
the probe routinely for skin integrity – rotate probe.
59.
60. PAIN
Considered to be the 5th
Vital Sign
Assessment of pain should
include:
•Location – does it radiate
•Intensity – best to assess
with a scale.
•Character – is it sharp,
dull, throbbing, burning
•Onset/Duration – when
did it start, how long does
it last
61. Procedure – Vital Signs
Assessment Route of temperature – po, tympanic, axilla, rectal
Determines if client has had anything hot/cold to drink or
smoked (20 min)
Planning Obtain equipment – thermometer, watch, stethosope, B/P
cuff & graphic sheet
Wash hands
Implementation Explains procedure to client
Temperature tympanic - thermometer
Pulse - Position client’s arm @ side or across chest, palpate
radial artery
Resp – Keeps fingers on wrist – count respirations
Documents TPR on graphic sheet
B/P – correct position, client’s arm supported @ heart level
Document
62. Vital Signs (cont.)
Evaluation V/S within normal range
Critical Thinking You are assessing a client’s pulse and the
rate is irregular. How would you
proceed?
63. Summary
Vital signs are single most important
indicator of optimal or abnormal state of
health
Accuracy is essential when measuring vital
signs
Vital signs are often delegated, but
delegating a skill to someone else does not
release the nurse from responsibility.
