The document discusses vital signs, which are temperature, pulse, respiration, and blood pressure. These reflect essential body processes and are important indicators of a patient's condition. Temperature, pulse, respiration are measured routinely for baseline data and to monitor for changes. Normal ranges are provided for each vital sign. Factors that influence the vital signs and techniques for accurately measuring them are described.

1. VITAL SIGNS
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2.  Temperature, pulse, respiration and blood
pressure (B/P) are the most frequent
measurements taken by Health Care
Providers as they reflect the function of
three body processes that are essential for
life.
◦ Regulation of body temperature
◦ Heart function
◦ Breathing
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3.  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.
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4.  Vital Signs may reveal sudden changes in a client’s
condition in addition to changes that occur
progressively over time.
 A baseline set of Vital Signs are important to
identify changes in the patient’s condition.
 Vital Signs are part of a routine physical
assessment.
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5. 1. On a client’s admission for baseline data
2. According to the institution’s policy or
standard of practice ( as routine).
3. When assessing the client during home health
visit
4. Before & after a surgical or invasive diagnostic
procedure
5. Before & after the administration of
medications or therapy that affect
cardiovascular, respiratory & temperature
control functions.
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6. 6. When the client’s general physical condition
changes
e.g when the level of consciousness decreases,
increased pain etc
7. Before, after & during nursing interventions
influencing vital signs
8. When client reports symptoms of physical
distress.
9. On discharge
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7. 10. When transferring the patient from one
hospital to the other or ward to another
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8.  Definition
 This is the balance between heat produced
by the body and the heat lost from body to
the external environment.
 Is the degree of warmth or coldness of a
substance compared with a recognized
standard.
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9. Types of temperature.
Core temperature
 This is temperature of deep body tissue
which remain at a constant level of 37ºC.
Surface temperature.
 This is the temperature of the skin ,
subcutaneous tissue and it varies according
to the environment.
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10.  Humans maintain a consistent internal body
temperature.
 Core temperature: Temperature inside the
body; normal body temperature ranges
between 36.5º and 37.5ºC (97.6º and
99.6ºF).
 Body temperature is controlled by the heat
regulating centre which is the
hypothalamus.
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11.  Heat is produced during the body’s
Metabolic processes and is lost through
four processes:
 Radiation; Conduction
 Convection; Evaporation
‣ Temperature is lowest in the morning,
highest during the evening
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12. ◦ Environment
◦ Time of day
◦ Exercise
◦ Stress
◦ Hormones
◦ Drugs.
◦ Presence of illness
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13. 1. Pyrexia ( also known as fever)
It is an increase in the body temperature
which is divided into high , moderate and low
such as :-
 High grade pyrexia temperature is above
39.4ºc.
 Moderate pyrexia temperature is between
38.3 ºc to 39.3 ºc
 Low grade pyrexia is temperature is between
37.5 ºc to 38.2 ºc
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14. Hyper Pyrexia:
 This is temperature above 40.6 ºc. It is
dangerous to functioning of the body cells.
2. HYPOTHERMIA
 This is a core body temperature of below the
lower limit of the normal temperature (below
36 degree Celsius).
 Below 34 is severe hypothermia and can lead
to death.
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15.  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.
 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.
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16. ◦ Sites
 Mouth -Oral;
 Rectum- Rectal;
 Ear- tympanic membrane
 Axilla
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17. Oral -
 Posterior sublingual pocket – under tongue (close
to carotid artery).
 No hot or cold drinks or smoking 20 min prior to
temperature check.
 Pt Must be awake & alert.
 Leave in place for 3 min
Axillary
 Place Bulb in center of axilla, Lower arm should
be positioned across chest.
 Leave in place 5-10 min.
 Measures 0.5 C lower than oral temp.
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18. Rectal
 Side lying with upper leg flexed, insert lubricated
bulb (1-11/2 inch adult) (1/2 inch infant)
 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
 2-3 seconds
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19.  To ensure accurate temperature readings,
measure each site correctly.
 The temperature obtained varies depending
on the sites used. Rectal temperatures are
usually 0.5oc higher than oral
 and Axillary temperatures are usually 0.5
degrees lower than oral temperature.
 Choose the safest and most accurate site for
the client and when possible use the same
site when repeated measurements are
needed.
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20.  Each of the temperature measurement site
has advantages and disadvantages.
 Oral Body Temperature
 Advantages
 easily accessible because it requires no
position change
 provides accurate surface temperature
readings
 Reflects rapid change in core temperature
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21.  Disadvantages
 Inaccurate if the client has just swallowed a
hot or cold fluid
 Glass thermometer can break if bitten –
unsuitable for small children
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22. Axillary Body Temperature Advantages
 Safe
 Convenient
 can be used in new born
 Inexpensive
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23.  Disadvantages
 Long measurement time
 May require continuous positioning by the
nurse
 Measurement lags behind the core
temperature
 Affected by the environmental temperature
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24. Rectal Body temperature
 Advantages
 it is said to be the most reliable and accurate
 Disadvantages
 Most embarrassing due to the positioning
 It lags behind the core temperature
 Not for clients with diarrhoea or rectal
surgery.
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25.  Defined as the pressure of the blood pushing
against the wall of an artery as the heart
beats and rests.
◦ Feel throbbing of the arteries caused by
contractions of the heart
◦ More easily felt in arteries that lie close to the skin
and can be pressed against a bone
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26.  Temporal: side of the forehead
 Carotid: side of the neck (used for CPR)
 Brachial: inner aspect of forearm at the antecubital
space (used for BP)
 Radial: inner aspect of wrist above thumb (most
common place to measure pulse)
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27.  Femoral: inner aspect of upper thigh
 Popliteal: behind knee
 Dorsalis pedis: top of foot arch
 Apical pulse – over apex of heart
◦ taken with stethoscope
◦ left side of chest
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28.  Pulse can be assessed by light palpation &
by auscultation.
 You assess the rate, rhythm, strength of the
tention.
 The rhythm can be regular or irregular.
 The pulse can be weak/thready or full
strong.
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29.  Pulse rate is the number of beats per
minute.
 Normal Rate ranges from 60-100, with an
average 80 beats per minute.
 Tachycardia is a pulse rate that is
greater than 100 bpm.
 Bradycardia is a pulse rate that is less
than 60 bpm (except in children) .
Note; Any variations or extremes in pulse
rates should be reported immediately.
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30.  Pulse rate varies with each individual
depending on age, sex and body size
◦ Adults: 60 – 90 bpm
◦ Adult men: 60 – 70 bpm
◦ Adult women: 65 – 80 bpm
◦ Children over 7: 70 – 90 bpm
◦ Children 1 to 7: 80 – 110 bpm
◦ Infants (less than 1): 100 – 160 bpm
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31.  Rhythm – this refers to the pattern of the
beats or the spacing of the beats.
 Which can be described as regular or
irregular.
 Irregular or abnormal rhythm of pulse is
called arrhythmia , it is usually caused by a
defect in the electrical conduction pattern
of the heart.
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32.  Strength or size
 You assess the volume of blood pushed
against the wall of an artery during the
ventricular contraction, i.e its strength or
intensity.
 weak or thready – when it lacks fullness.
 Full, bounding - when volume is higher
than normal
 Imperceptible – when the pulse cannot
be felt or heard.
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33.  Age
 Sex
 Position i.e sitting or standing
 Drugs
 Illness
 Emotions
 Activity level
 Temperature
 Physical training
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34. Increased rates can be caused by;
 exercise
 stimulant drugs
 excitement
 fever
 shock
 anxiety
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35. Decreased rates can be caused by;
 sleep
 depressant drugs
 heart disease
 coma
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36.  Position pt’s arm supported comfortably with
palm of hand turned down
 Use tips of 2 or 3 fingers to locate pulse site
on thumb side of wrist
 Count pulse for 1 full minute
 Note rate, rhythm and volume of pulse
 Record
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37.  Respiration is the process of taking in oxygen
and expelling carbon dioxide from the lungs
and respiratory tract.
 When assessing respirations you measures
the breathing of the patient.
 1 respiration consists of 1 inspiration
(breathing in) and 1 expiration (breathing
out)
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38.  Inspiration and Expiration is automatic &
controlled by the medulla oblongata (center
of brain) which is the respiratory.
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39.  Age
 Activity level
 Position
 Drugs
 Sex
 Illness
 Emotions
 Temperature
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40.  Qualities of normal respirations;
◦12-20 respirations per minute
◦Quiet
◦Effortless
◦Regular
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41.  When assessing respirations you look
at;
◦ Rate
◦ Rhythm and depth
◦ Quality: Usually automatic, quiet, and
effortless
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42.  Respiration rate is the number of breathing
cycles/minute (inhale/exhale-1cycle).
 Normal rate is ;
 12-20 breaths/min in adults
 Children: 16 – 25 rpm
 Infants: 30 – 50 rpm
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43. Eupnea – normal rate & depth breathing
tachypnea - rapid respiratory rate above 25
rpm
Bradypnea - slow respiratory rate, usually
below 10 rpm .
Apnea - Absence of respirations.
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44.  Orthopnea: severe dyspnea in which
breathing is very difficult in any position
other than sitting erect or standing.
 Rales: bubbling or noisy sounds caused by
fluids of mucus in the air passages.
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45.  The character of respirations is described
by words such as deep, shallow, labored,
moist, difficult, stertorous (abnormal
sounds like snoring).
Dyspnoea – difficult or labored breathing
Cheyne-Stokes – alternating periods of apnea
and hyperventilation, gradual increase &
decrease in rate & depth of respirations with
period of apnea at the end of each cycle.
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46.  Rhytm refers to the regularity or equal
spacing between breaths.
 Described as regular (or even) or irregular
Depth
Refers to the amount of air inhaled/exhaled
Normal - (deep & even movements of chest)
Shallow - (rise & fall of chest is minimal)
Shortness of breath - (shallow & rapid)
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47. Respirations are partially under voluntary
control Patients may breathe faster or slower
when they are aware respirations are being
counted.
It is important to keep patient unaware of
this procedure.
 Do not tell pt you are counting respirations
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48.  Keep your hand on pulse site while measuring
respirations
◦ Patient will think you are still counting pulse
◦ Patient will not be as likely to alter respiratory rate
 Count respirations for 1 full minute
 Note rate, character and rhythm of resps
 Record.
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49.  Measurement of the pressure that the blood
exerts on the walls of the arteries as the heart
contracts or relaxes.
 Measured in millimeters of mercury on an
instrument called a sphygmomanometer
 Measurements are read a 2 points
◦ Systolic
◦ Diastolic
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50.  Systolic pressure – is the force exerted
against the arterial wall as left ventricle
contracts & pumps blood into the aorta –
(max. pressure exerted on vessel wall).
 Diastolic pressure – is the arterial
pressure during ventricular relaxation,
when the heart is filling,( minimum
pressure in arteries).
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51.  Blood pressure is recorded as a fraction
Systolic is the top number (numerator)
Diastolic is the bottom number (denominator).
Measured in mmHg – millimeters of mercury
Method used can be ;
◦ Auscultation: Korotkoff sounds can be
heard with a stethoscope placed over the
artery
◦ Palpation: When Korotkoff sounds are
inaudible, blood pressure may be
estimated by palpation
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52.  Normal systolic reading is 120 mm of Hg
 Normal range is 100 – 140 mm of Hg
 Noted as the reading on the
sphygmomanometer gauge when the first
sound is heard
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53.  Constant pressure that is in the walls of the
arteries when the heart is at rest or between
contractions
 Blood has moved into the capillaries and
veins, so the volume of blood in the arteries
has decreased
 Normal diastolic reading is 80 mm of Hg
 Normal range is 60 – less than 90 mm of Hg
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54.  In Adults: Noted as the reading on the
sphygmomanometer gauge when the sound
stops or becomes very faint
 In Children: Noted as the reading on the
sphygmomanometer gauge when the sound
changes and becomes soft or muffled
 Normal range
 systolic 110-140 diastolic 60-90
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55.  High blood pressure
 Indicated when pressures are greater than
140 mm Hg systolic and 90 mm Hg diastolic
 Hypotension
 Low blood pressure
 Indicated when pressures are less than 100
mm Hg systolic and 60 mm Hg diastolic
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56.  Force of heartbeat
 Resistance of the arterial system
 Elasticity of the arteries
 Volume of blood in the arteries
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57.  Excitement, anxiety, nervous tension
 Stimulant drugs
 Exercise and eating
Factors That May Decrease
Blood Pressure
 Rest or sleep
 Depressant drugs
 Shock
 Excessive blood loss
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58. ◦ Age
◦ Circulating volume e.g Lower with
blood loss
◦ Medications
◦ Activity
◦ Position changes B/P
 Weight
 Sleep
 Emotions
 Sex
 Viscosity of blood
 Illness/Disease
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59.  Measure on upper arm
 Have correct size cuff to avoid getting false
readings.
 Identify brachial artery for correct
placement of stethoscope.
 First sound heard – systolic pressure
 Last sound heard or change - diastolic
pressure
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60.  Record - systolic/diastolic
 Resident in relaxed position, sitting or lying
down
 Blood pressure usually taken in left arm
 Do not measure blood pressure in arm with
IV, A-V shunt (dialysis), cast, wound, or
sore.
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61.  Apply cuff to bare upper arm, not over
clothing.
 Room quiet so blood pressure can be heard.
 Sphygmomanometer must be clearly visible.
 Gauge should be at eye level.
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