vitals sign is the basic parameter used for all the patients to know the vital and general parameter for the patients and any changes in this parameter can cause the life threatening condition for the patients or clients life the proper technique and its alternatives assessment knowledge can help the nurses to improve academic performance and can be apply this knowledge in their clinical practices

1. Vital sign
measurements
1

2.  Describe the procedures used to assessthe vital
signs: temperature, pulse, respiration, and blood
pressure.
 Identify factors that caninfluence eachvital
sign.
 Identify equipment routinely usedto assessvital
signs.
 Identify rationales for using different routes for
assessingtemperature.
 Takevital signsand interpret the finding.
 Document the vitalsigns.
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3. Introduction
•Vital sign are a basic component of assessment
of physiological and psychological health of a
client.
• body temperature, pulse, respiration and blood
pressure are the sign of life
•Assessment of vitals sign allow the nurses to
identify specific life threatening conditions and
plan the needed nursing intervention
•Detect changes in the client health status

4.  Vital signs reflect the body’s physiologic
status and provide information critical to
evaluating homeostatic balance.
 Includes:
 temperature,
 Pulse Rate,
 Respiratory Rate), and
 Blood Pressure)
4

5.  To obtain base line data about the patient
condition
 for diagnostic purpose
 For therapeutic purpose
5

6.  Vital sign tray
 Stethoscope
 Sphygmomanometer
 Thermometer
 Second hand watch
 Red and blue pen
 Pencil;
 Vital sign sheet
 Cotton swab in bowel
 Disposable gloves if available
 Dirty receiver kidney dish
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7.  On admission – to obtain baseline date
 When a client has a change in health status or reports
symptoms such as chest pain or fainting
 According to a nursing or medical order
 Before and after the administration of certain
medications that could affect RR or BP (Respiratory
and CVS
 Before and after surgery or an invasive diagnostic
procedures
 Before and after any nursing intervention that could
affect the vital signs. E.g. Ambulation
 According to hospital /other health institution policy.
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8. Body temperature may be defined
as the degree of heat maintained by
the body. It is the balance between
heat production & heat loss of the
body.
Normal body temperature using
oral 370 Celsius or 98.6 0 F.
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9. Mechanism of temperature regulation
•Thermogenesis – a chemical regulation by the
production of heat
•Thermolysis – a physical regulation by loss of
heat
•The heat regulating centre is the hypothalamus
situated in the brain. Heat is produced in the
body continuously. Unless it is lost from the
body, no balance can be maintained

10. 1. Core Temperature
 Is the temperature of internal organs and it
remains constant most of the time (37oc);
with range of 36.5-37.5oc.
 Is the Temperature of the deep tissues
of the body
 Remains relatively constant
 measure with thermometer
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11. 2. Surface Temperature:
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o Surface body temperature: - is the
temperature of the skin, subcutaneous tissue
& fat cells and it rises & falls in response to
the environment
o (Ranges b/n 20-40oc).
o It doesn’t indicate internalphysiology.

12. Way of producing heat in the body
•Oxidation of the food
•Specific dynamic action of food
•Exercise
•Strong emotions
•Hormonal effects
•Change in the environment and atmospheric
conditions
•Diseased conditions

13. Way of loosing heat from the body
•Through the skin
•Through the lungs
•Through the kidneys
•Through the bowels

14. Normal variation in the body temperature
•Time of the days
•Time of the month
•Age of the person
•Part of the body where the temperature is taken
•Emotions
•Exercise
•Fasting
•Environmental factors

15.  Normal body temperature is 370 C or 98.60F
 range is 36-38 0c (96.8 – 98.6 0F)
 Body temperature may be abnormal due to fever
(high temperature) or hypothermia (low
temperature).
 Pyrexia, fever: a body temperature above
the normal ranges 38 0c – 410 c (100.4 –
105.8 F)
 Hyper pyrexia: a very high fever, such as
410 C > 42 0c leads to death.
 Hypothermia: – body temperature between
34 0c – 35 0c, < 34 0c is death
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16. Assessing temperature

17.  Oral
 Rectal
 Auxiliary
 Tympanic
 Thermometer: is an instrument used to
measure body temperature
17

18. The common sites for taking body
temperature
1. Oral method – advantage , disadvantage and
contraindication
2. Axilla – advantage, disadvantage and
contraindication
3. Rectum - advantage , disadvantage and
contraindication
4. Ear- advantage , disadvantage and
contraindication

19. Types of fever
Onset or invasion : onset or invasion of fever is the period when the
body temperature is raising and it may be a sudden or gradual process.
Fastigium or stadium : fastigium or stadium of fever is the period when
the body temperature has reached its maximum and remains fairly
constant at a high level.
Defervescence or decline : defervescence or decline of the fever is
period when the elevated temperature is returning to normal. The fever
may subside suddenly (decline by crisis) or gradually (decline by lysis)
Crisis : crisis is a sudden return to normal temperature from a very high
temperature within a few hours or days

20. •True crises : the temperature falls suddenly within few hours
and touches normal, accompanied by a marked improvement in
the clients conditions
•False crises : the sudden falls in temperature not accompanied
by a improvement in the clients conditions is called false crises.
•Lysis : the temperature falls in zig-zag manner for 2 or 3 days or
a week before reaching normal, during which time the other
symptom also gradually disappear
•Constant fever or continuous fever : constant fever or
continuous fever is one in which the temperature varies not more
than two degree between morning and evening and it does not
reach normal for a period of days or week

21. Remittent fever : remitting fever is a fever characterized by
variation of more than two degree between morning and
evening but does not reach normal
Intermittent or quotidian fever : the temperature rises from
normal or sub normal to high fever and back at regular interval.
Usually the temperature is higher in the evening then in the
morning
Inverse fever: the highest range of temperature is recorded in
the morning hours and the lowest in the evening which is
contrary to that found in the normal course of fever
hectic or swinging fever : when the difference between the
high and low points is very great, the fever is called hectic fever.

22. Relapsing fever: relapsing fever is one in which there are
brief febrile period followed by one or more days of normal
temperature
Irregular fever: when the fever is entirely irregular in its
course, it cannot be classified under any one of the fever
described above is called irregular fever
Rigor : rigor is a sudden severe attack of shivering in which
the body temperature rises rapidly to a stage of hyperpyrexia
as seen in malaria

23. Route Normal Range ºF / ºC Sites
Oral 98.6 ºF / 37.0 ºC Mouth
Tympanic 99.6 ºF / 37.6 ºC Ear
Rectal 99.6 ºF / 37.6 ºC Rectum
Axillary 97.6 ºF / 36.6 ºC Axilla (armpit)
23

24. Nursing care in fever
1. Regulation of body temperature
2. Meeting the nutritional need
3. Maintenance of personal hygiene
4. Providing rest and sleep
5. Maintenance of personal hygiene
6. Safety factor
7. Observation of the client

25. Nursing care in rigor
1. Stage one or cold stage
2. Stage two or hot stage
3. Stage three or stage of sweating

26. 1.Age
2.Diurnal variations (circadian rhythm
3.Exercise
4.Hormones
5.Stress
6.Environment
26

27.  Pulse is a wave of blood created by the
contraction of left ventricle.
 pulse reflects the heart beat
 Stroke volume and the compliance of arterial
wall are the two important factors influencing
pulse rate.
 Pulse rate is regulated by autonomic nervous
system.
27

28.  Peripheral Pulse: is a pulse located in the
periphery of the body e.g. in the foot, and or
neck
 Apical Pulse (central pulse): it is located at
the apex of the heart
 The PR is expressed in beats/ minute (BPM)
 The difference between peripheral and apical
pulse is called pulse deficit, and it is usually
zero.
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29. Pulse is assessedfor
29
 rate (60-100bpm),
 rhythm (regularity orirregularity),
 Volume,
 elasticity of arterialwall.
Thepulseis commonly assessedby palpation
(feeling) andauscultation (hearing using a
stethoscope).

30. Age
30
 Theaverage pulse rate of an infant ranges from
100to 160BPM
 Thenormal range of the pulse in an adult is 60 to
100BPM
Sex: Sex: after puberty the average males
PRis slightly lower than female

31. Autonomic Nervous systemactivity
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 Stimulation of the parasympathetic nervous
system results in decreasein the PR
 Stimulation of sympathetic nervoussystem
results inan increased pulse rate
 Sympathetic nervous system activation occurson
response to avariety of stimuli including
▪ Pain ,anxiety ,Exercise,Fever
▪ Ingestion ofcaffeinated beverages
▪ Change in intravascularvolume

32. Exercise: PRincrease withexercise
Fever: increases PRin response to the
lowered B/Pthat results from peripheral
vasodilatation –increasedmetabolic rate
Heat: increase PRasacompensatory
mechanism
Stress:increasesthe sympathetic nerve
stimulation
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33. * Positionchanges:
 a sitting or standing position blood usually
pools in dependent vessels of the venous
system. B/c of decrease in the venous
blood return to heart and subsequent
decrease in BP increases heart rate.
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34. * Medication
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o Cardiac medication such as digoxin decrease heart rate
o Medications that decrease intravascular volume such as
divretics may increase pulse rate
o Atropine in hibits impusses to the heart from the
parasympathetic nervous system, causing increased pusse
rate
o Propranolol blocks sympathetic nervous system action
resulting in decreased heart trate sites used for measuring
pulse rate

35. Carotid: at the side of the neck below tube of
the ear (where the carotid artery runs between
the trachea and the sternocleidomastoid
muscle)
Temporal: the pulse is taken at temporalbone
area.
Apical: at the apex of the heart: routinelyused
for infant and children <3yrs
In adults –Left mid-clavicular line under the
4th, 5th, 6th intercostalspace
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36. Brachial: at the inner aspectof the biceps muscle of
the arm or medially in the antecubital space(elbow
crease)
Radial: on the thumb side of the inner aspectof the
wrist –readily available and routinely used
Femoral: along the inguinal ligament. Used or
infants andchildren
Popiliteal: behind the knee. By flexing the knee
slightly
Posterior tibial: on the medial surface of the ankle
Pedal (Dorsal Pedis): palpated by feeling thedorsum
(upper surface) offoot
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39. A wave of
blood flow
created bya
contraction
of theheart.
.
.
A.
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B.
D.
E.
F
.
C. G.
H.

40.  Pulse: is commonly assessed bypalpation
(feeling) or auscultation(hearing)
 The middle 3fingertips are used with moderate
pressurefor palpation of all pulsesexcept apical;
 Assessthe pulsefor
Rate
Rhythm
Volume
Elasticity of the arterial wall
40

41. 41

42. Pulse Rate
Normal 60-100 b/min(80/min)
Adult PR>100BPM is calledtachycardia
Adult PR<60 BPM is calledbradycardia
42

43. Pulse Rhythm
Thepattern and interval between the beats,
random, irregular beats–dysrythymia
PulseVolume
the force of blood with eachbeat
Anormal pulsecanbe felt with moderate
pressure of thefingers
Full or bounding pulseforceful or full blood
volume destroy withdifficulty
Weak,feeble readily destroy with pressure from
the fingertips
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44. Elasticity of arterialwall
Ahealthy, normal artery feels, straight,
smooth, soft, easilybent
Reflectsthe status of the clients vascular
system
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45. If the pulse is regular, measure(count) for 30
seconds and multiply by 2
If it is irregular count for 1full minute.
Eachheartbeatconsistsoftwosounds
s1- is causedby closure of the mitral and tricuspid
valves separating the atria from the ventricles
S2–is causedby the closureof the plutonic and
aortic values
Thesoundsare often describedasamuffled “lub –
bub”
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46. 46

47. Respiration rate(RR):-Respiration is the act
of breathing and includes the intake of
oxygenand removal of carbon-dioxide.
Ventilation is also another word, which refers
to movement of airin and out of the lung.
Hyperventilation: - is avery deep, rapid
respiration.
Hypoventilation: -is avery shallow
respiration.
47

48. 1. Costal (thoracic)
 Observed by the movement of the chest up
ward and down ward.
 Commonly used for adults
2. Diaphragmatic (abdominal)
 Involves the contraction and relaxation of the
diaphragm, observed by the movement of
abdomen.
 Commonly used for children.
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49. Age Normal growth from infancy to adult hood
results in alarger lung capacity.Aslung capacity
increases, lower respiratory rates are sufficient
to exchange
Medications Narcotics decrease respiratory rate
& depth
Stressor strong emotions increasesthe rate &
depth ofrespirations.
Exercise increases the rate & depthof
respirations
49

50. Altitude The rate & depth of respirations at
higher elevations (altitude) increase to
improve the supply of oxygen available to the
body tissues
Gender Men may have alower respirations
rate than women becausemen normally have
alarger rung capacity than women
Fever increases respiratoryrate
50

51. o The client should be at rest
o Assessed by watching the movement of the
chest or abdomen.
oRate,
o rhythm,
odepth and
ospecial characteristics of respiration
are assessed
51

52. Rate:
Isdescribed in rate per minute (RPM)
Healthy adult RR=15-20/ min. is measured for
full minute, if regular for 30seconds.
Asthe agedecreasesthe respiratory rate
increases.
Eupnea-normal breathing rate and depth
Bradypnea- slowrespiration
Tachypnea - fastbreathing
Apnea- temporary cessation of breathing
52

53. Age Average Range/Min
New born 30-80
Early childhood 20-40
Late childhood 15-25
Adulthood-male 14-18
Female 16-20
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54. Rhythm:
is the regularity of expiration and inspiration
Normal breathing is automatic & effortless.
Depth:
describedasnormal, deepor shallow.
Deep:alarge volume of air inhaled &
exhaled,inflates most of the lungs.
Shallow: exchangeof asmall volume of air
minimal useof lung tissue.
54

55.  It is the force exerted by the blood against
the walls of the arteries in which it is flowing.
 It is expressedin terms of millimeters of
mercury (mm ofHg).
55

56. Systolic pressure is the maximum of the
pressure against the wall of the vessel
following ventricularcontraction.
Diastolic pressure is the minimum pressure
of the blood against the walls of the vessels
following closure of aortic valve (ventricular
relaxation).
56

57.  BPis measured by using an instrument called Bp
cuff (sphygmomanometer) & stethoscope and
 the averagenormal value is 120/80mmHg for
adults.
 brachial artery and popliteal artery are most
commonly used.
 It is measured by securing the Bp cuff to the
upper arm & thigh placing the stethoscope on
brachial artery in the antecubital space&
popliteal artery at the back of the knee.
 Pulse pressure: is the difference between the
systolic and diastolicpressure
57

58.  Fever
 Stress
 Arteriosclerosis
 Exposure to cold
 Obesity
 Hemorrhage
 Low hematocrit
 External heat
58

59. Upperarm (using brachial artery
(commonest)
Thigh around poplitealartery
Fore-arm using radialartery
Legusing posterior tibial or dorsal pedis
59

60.  Apersistently high Bp, measuredfor greater than
three times is called hypertension & that
persistently lessthan normal range is called
hypotension.
 Becauseof many factors influencing Bpasingle
measurement is not necessarily significant to
confirm hypertension.
 Whenthe causeof hypertension is known it is
calledsecondary hypertension and when the
causeis unknown is calledprimary/essential
hypertension.
60

61. Purpose
 Toobtain baseline measureof arterial blood
pressure for subsequentevaluation
 Todetermine the clients homodynamic
status
 Toidentify andmonitor changesin blood
pressure.
61

62. 62

63. Stethoscope
Blood pressure cuff of the appropriate size
Sphygmomanometer
63

64. Earpieces
Binaurals
Rubber or plastic
tubing
Bell
Chestpiece
Diaphragm
64

65.  Explainthe procedureto the patient & remove
any light cloth from patient’s arm
 Makesure that the client has not smoked or
ingested caffeine, within 30minutes prior to
measurement.
 Position the patient on lying, sitting or standing
position, but always ensure that the
sphygmomanometer is at the level of the heart
with the arm supported & the palm facing
upwards.
65

66.  apply cuff snugly/securely around the arm ,
2.5cmabove the antecubital space/fossa, at the
level of the heart (for every cm the cuff sites
above or below the level of the heart the BP
varies by0.8mmHg)
 Palpate the radial pulse and inflate the cuff until
the radial pulse can no longer be felt, this
provides an estimation of systolic pressure.
 Inflate cuff 30mmHg higher than estimated
systolic pressure.
66

67.  palpate the brachial artery & place the bell of the
stethoscope over the site & the ear pieces on
ear, apply enough pressure to keep the
stethoscope in place (the bell of the stethoscope
is designed to amplify/intensify low frequency
sounds)
 Deflate the cuff 2-4mmHg per second.
 Thefirst pulseheard is the systolic reading,
continue to deflate until there is achange in
tone to amuffled beat, this is the diastolic
reading.
67

68.  Deflate & remove cuff roll neatly andreplace.
 Record the systolic and diastolic pressure on
vital singsheet and compare thepresent
reading withprevious reading.
 report or treat anychange
 Clearear piecesand bell of the stethoscope
with antiseptic swab and return all
equipments.
68