This document provides information on assessing vital signs, including temperature, pulse, respiration, and blood pressure. It defines each vital sign and outlines the purposes, equipment, procedures, and normal ranges for assessing each one. For temperature, it describes different thermometer types and appropriate sites for taking a reading. For pulse, it identifies common sites and the procedure for counting the pulse rate. For respiration, it explains that assessing respiration involves monitoring inspiration and expiration. The document emphasizes the importance of following proper procedures to obtain accurate vital sign readings and ensure patient comfort.

1. Assessment of
vital signs
-By Akshita Negi
From (Kinnaur )
BSc. Nursing 1st year
Govt .Nursing college SLBSGMCH Ner chowk Mandi ,(HP)

2. Definition Vital signs or cardinal signs are basic
components of assessment of physiological and
psychological health of client (it is an indication of
vital organs ie Brain, Heart, Lungs, Liver & Kidney.
 it reflects the body’s physiological status.

3. It includes :
Temperature
Pulse
Respiration
Blood pressure
Spo2
Hydration
Pain .

4. Purposes for assessing vital signs
To assess the health status of an
individual .
To plan and implement the nursing care .
To recognize variation from normal and
its significance .
To understand the effectiveness of the
treatment .

5. To modify or change the mode of treatment .
To understand the present problem
To assess the functioning of vital organs .
To identify specific life threatening condition

6. Assessment of body temperature
It includes the assessment of body
temperature using clinical thermometer
Definition :
The body temperature is the difference
between the amount of heat produced by
body processes & the amount of heat lost to
the external environment .

7. Temperature is the ‘hotness and coldness of
the body .
It is the somatic sensation of heat or cold .It is
the degree of or intensity of heat of body in
relation to external environment

8. Types of thermometer
1. Mercury glass thermometer :
Oral
Rectal

9. Parts of glass thermometer

10. 2.Digital thermometer

11. 3.Tympanic membrane thermometer

12. 4.sensor touch thermometer

13. 5.Disposable single use thermometer

14. Purposes for assessing body temperature
To assess the patient’s health status .
To obtain the accurate temperature for
making diagnosis .
To monitor patients condition after invasive
procedure .
To help physician to prescribe right
treatment .

15. To assess the patient’s condition .
To assess for any alterations in health
status .
To determine whether measures should
be implemented to reduce dangerously
elevated body temperature and how to
conserve body heat when body
temperature is low

16. Common sites for assessing body
temperature
Oral
Rectal
Axillary
 tympanic membrane

17. Indications for assessing body
temperature
It is the routine part of assessment for
establishing a baseline data upon admission .
Any change in patient’s condition should be
monitored according to the agency policy

18. Temperature should be checked before,
during and after administration of any drugs
that affects temperature control function .
If there is any change in the general condition
of the patient .
It should be checked before and after any
nursing intervention that affects the body
temperature of the patient .

19. Contraindications for oral site
Patients who are not able to hold a
thermometer in their mouth .
Patients who may bite the thermometer such
as psychiatric patients .
Infants and small children.
Surgery /infection in oral cavity.
 Trauma to face /mouth .
Mouth breathers.

20. Patients with history of convulsion .
Unconscious /semiconscious /disoriented
patients .
Patients having chills .
Uncooperative patients .

21. Contraindications for rectal method
Patients after rectal surgery .
Any rectal pathology (piles /tumor)
Patients having difficulty in assuming the
required position .
Acute cardiac patients .
Patients having diarrhea .
Patients with reduced platelet count .

22. Contraindications for axillary method
Patients with any surgery /lesion in axilla .
Constricted peripheral blood vessel .

23. Articles required for assessing body
temperature
A clean tray containing :
A bottle with disinfectant solution(Dettol 1:40/
Savlon 1:20)
A bottle with water
Thermometer ( rectal thermometer in case of
rectal method )

24.  Paper bag /kidney tray .
A small bowl with cotton swabs ,pen .
Flow sheet /graphic chart /paper ).
Lubricant (for rectal method ).
Use two bottles of antiseptic solution and one
bottle of water if more than one thermometer is
used .
A bowl containing dry gauze pieces to wipe
axilla .

25. Points to be remember
It is always best to use the separate
thermometer for each patient .
When individual thermometer is not used in
patient care units ,then axillary method is
recommended .
For converting temperature from centigrade to
Fahrenheit ,following conversion formula can
be used { C=5/9 *(F-32 )}

26. Document the reading on the graph chart
with blue pen .
A normal axillary temperature is between
90.6 degree Fahrenheit and 98 degree
Fahrenheit .
Normal axillary temperature is usually a
degree lower than the oral temperature
and 2 degree lower than the rectal
temperature .

27. Route Normal range
(degree F/C)
Sites
Oral 98.6/37.0 Mouth
Tympanic
Rectal
99.6/37.6
99.6/37.6
Ear
Rectum
Axillary 97.6/36.6 Axilla or armpit
Normal ranges of temperature

28. Alterations in body temperature
Hypothermia :
fall in body temperature below 95 degree
Fahrenheit.
Hyperthermia : elevation in body temperature
above 99.5-100.9 degree Fahrenheit

29. Procedure
Nursing action
Before procedure
Ascertain the method of taking
temperature ,explain the
procedure to patient ,and
instruct him/her how to
cooperate .
a) in case of oral method
,ensure that the patient had not
taken any hot or cold food and
orally or smoked about 15-30 min
prior to the procedure.
Rationales
Cause alteration in
temperature reading

30. Nursing action
b) for rectal method ,provide
privacy and position the patient
in sim’s position .position young
children laterally with knees
flexed or prone across lap.
c) in axillary method ,expose
axilla and pat dry with a towel .
Avoid vigorous rubbing .
Rationales
Position of the body
ensures easy access to
insert thermometer .
Friction produced by
rubbing can increase in
the temperature .

31. During procedure
Nursing action
Wash hands
Prepare equipment
a) If the glass thermometer is
placed in disinfectant solution
,transfer it to a container
containing plane water using
dominant hand
b) wipe the thermometer dry
,using the clean cotton swab by
rotatory motion from bulb to
stem
Rational
Ensures complete
removal of disinfectant
and reduces irritation to
tissue
Usage of dominant hand
reduces chances of
accidental breakage .

32. Nursing action
C) shake the thermometer to
bring down the mercury level (if
needed )by holding it between
the thumb and fore finger at the
tip of the stem .shake till the
mercury is below 35 degree C
(95 degree F)
Rationales
Wiping down the
thermometer from an
area of least
contamination to an
area of highest
contamination prevents
spread of organism
.reduces the chances of
erroneous reading of
temperature .

33. Nursing action
checking the temperature
a) oral method
1. place the thermometer bulb
at the base of tongue at the
side of frenulum in the
posterior sublingual pocket.
Rationales
Blood supply is more in
this area and the reading
reflects the temperature of
blood in the larger blood
vessels
.

34. Nursing action
2.instruct the patient to close
the lips and not the teeth around
thermometer .
3. leave the thermometer in
place for 2-3 min .
b) Rectal method
1.Don clean pair of gloves .
2..apply a lubricant on the bulb
of the thermometer using a
cotton ball .
Rationales
Clenching the teeth may
break the thermometer
and cause injury.
Ensures accurate recording
.
Lubricant facilitates easy
insertion of thermometer
without irritating the mucus
membrane.

35. Nursing action
3. with non dominant hand
,expose the anus raising upper
buttocks .
4. instruct patient to breath
deeply and insert thermometer
into anus .
3.5-4cm in adults .
1.5cm in infant.
2.5 cm in child
Do not force the insertion.
5. Hold the thermometer in
place1-2minute.
Rationales
Deep breath helps to
relax the external
sphincter thereby
facilitating easy insertion
Ensures accurate
recording .

36. Positioning patient for inserting rectal thermometer
c) Axillary method :
1.Place thermometer bulb in the centre of axilla .
2.place the arm tightly across the chest to hold
thermometer in place

37. Nursing action
3. Hold the thermometer for 2-3
minutes .
 Removal of thermometer :
Wipe down the thermometer
using a cotton ball from stem to
bulb in rotatory manner .
Rationales
Wiping from an area of
least contamination to most
contamination will help in
preventing spread of
microorganisms

38. Nursing action
Read the temperature by
holding the thermometer
at eye level and rotate it
until till reading is visible
,read it accurately .
Shake the thermometer to
bring down he mercury
level .
Rationales
Holding at eye level
prevents error in
reading

39. After procedure
Clean the thermometer
using soap and water .
Dry and store it in a
disinfectant solution .
Document the temperature
reading .
Wash hands .
Replace articles .
This removes any
organic material
sticking to the
thermometer .
 Normal body
temperature is 37
degree C(98.6
degree F)
Reduce the risk of
transmission of
microorganism.

40. Assessment of pulse
Definition :
Pulse is the regular expansion and recoil of an
artery caused by the ejection of blood into the
arterial system by the contraction of the heart .
A pulse is a wave of blood created by the
contraction of the left ventricle of the heart
A pulse rate is measurement of the heart rate
or the number of times the heart beats per
minute .

41. Purposes for assessing pulse
To establish baseline data.
To check abnormalities in rate ,rhythm
,and volume .
To monitor any change in health status
of the patient .
To check the peripheral circulation .
To assess the response of heart to
cardiac drugs .

42. Articles required for assessment of pulse
Wrist watch with second’s hand .
Pen as per agency policy .
Vital sign chart
Stethoscope

43. Points to be remember
Never press both carotid at same time ,as
this can cause reflex drop in blood pressure
/pulse rate .
Carotid pulse is used for victim of shock
and cardiac arrest when pulse is not
palpable at other sites .
Brachial and femoral sites are used with
cardiac arrest in infants .

44. Sites for assessing pulse
Radial: commonly used
Brachial: commonly used
Temporal : children
Carotid :check during emergency
Apical : both adult and children
Femoral :children

45. Popliteal
Posterior tibial
Dorsalis pedis :
check to evaluate
peripheral disease

46. Procedure
Nursing action
Before procedure
Explain the procedure to
the patient and inquire
about patients recent
activity .If the patient was
involved in strenuous
activity .Allow the patient to
rest for the 10 min before
taking pulse
Rationales
Activity may
increase the pulse
rate.

47. During procedure
Nursing action
Sanitize hands or wash
hands as per hospital
policy.
Select pulse site .
Assist to a patient in a
comfortable position .
Rationales
Prevents cross
infection .
Usually radial pulse
is selected .choice of
site depends on the
particular extremity to
be assessed .

48. Nursing action
For radial pulse ,keep the
arm resting over chest or
on the side with palm
facing downward .in sitting
position ,keep the arm
resting over the thigh with
pam facing downward .
Rationales
The relaxed position of
the lower arm and
extension of the wrist
permits full exposure
to the artery to
palpation.

49. Nursing action
Place tip of 3 fingers (except
thumb ) lightly over the site
where pulse needs to be
assessed .
After getting pulse regularly
,count the pulse for one whole
minute looking at the second
hand on the wrist watch .
Assess for rate ,rhythm and
volume of pulse and condition
of blood vessels .
Rationales
Thumb is not used for
assessing pulse as it
has its own pulse
which can mistaken for
patient’s pulse
Irregularities can be
noticed only if pulse is
counted for one whole
minute .
Normal pulse is regular
and rate is 60-100 bpm

50. After procedure
 wash hands.
Document and report patient data in the
appropriate record .

51. Respiration
Definition :
Respiration is the process of breathing and
consist of inspiration and expiration .
Assessing respiration involves monitoring
inspiration and expiration in patient .

52. Purposes for assessing respiration
To assess rate ,rhythm ,volume of
respiration .
To assess for any change in condition and
health status .
To monitor effectiveness of therapy related
to respiratory system .

53. Articles required for assessment of
Wrist watch with second hand .
Graphic record .
Pen .

54. Procedure
Nursing action
Before procedure
Ensure that patient is relaxed
and assess other vital signs
such as pulse or temperature
prior to counting respiration .
Assess for factors that may
affect respiration .
Wait for 5-10 min before
assessing respiration if
patient had been active .
Rationales
Awareness of the
procedure may alter the
rate of respiration.
Allow nurse to accurately
assess for presence and
significance of respiratory
alteration
Activity may increase the
rate and depth of
respiration .

55. Nursing action
During procedure
Position patient in sitting
or supine with head
elevated at 45-60 degree
Keep your fingers over
the wrist as if checking
pulse ,and position
patient’s hand over his
lower chest or abdomen .
Rationales
Ensures proper
assessment .
Makes the patient
less aware of his
respiration
.keeping hand over
chest or abdomen
makes the
movement of chest
more visible .

56. Nursing action
Observe one complete
respiratory cycle-inspiration
and expiration
Assess rate ,depth , rhythm
and character of respiration .
Count respiration for 1 whole
min.
After procedure
Wash hands
Record the finding and report
any abnormal findings .
Rationales
Depth of respiration
reveals volume of air
moving in and out of
lungs .abnormalities of
rhythm and character
reveals specific disease
condition .

57. Thank you