VITAL SIGNS BY ILAYARAJA SAMPATH

1. S.ILAYARAJA SAMPATH
M Sc NURSING
SEA COLLEGE OF NURSING
BANAGALORE

2. TEMPERATURE
PULSE
RESPIRATIONS
BLOOD PRESSURE
 Vital Signs Must Be Measured, Reported, And
Recorded Accurately
 If You Are Not Sure Of A Measurement, Recheck It

3.  When A Person Is Admitted To A Health Care Facility
 Several Times A Day For Hospitalized Patients
 Before And After Surgery
 After Some Nursing Procedures
 Before Medications Are Given That Affect The Respiratory Or
Circulatory System
 Whenever The Person Complains Of Pain, Shortness Of Breath,
Rapid Heart Rate, Or Not Feeling Well
 With The Person At Rest In A Lying Or Sitting Position

4.  Illness
 Emotions – Anger, Fear, Anxiety, Pain
 Exercise And Activity
 Age
 Sex
 Environment - Weather
 Food And Fluid Intake
 Medications
 Time Of Day – ↓ In The Morning, ↑ In The Afternoon/Evening
 Noise

5.  Any Vital Sign Is Changed From A Previous Measurement
 Vital Signs Are Above The Normal Range
 Vital Signs Are Below The Normal Range

6. Many Agencies Have Temp Boards Or Tpr Books
Record Vital Sign Measurements As Soon As Possible
Carry A Small Notebook In Your Pocket So You Can Record Them As
You Take Them
Abbreviations
Temperature – T
Pulse – P
Respirations – R
Blood Pressure - Bp

7. Body Temperature Is The Amount Of Heat In The Body
It Is A Balance Between The Amount Of Heat Produced And The
Amount Of Heat Lost
Heat Is Produced By :
The Contraction Of Muscles During Exercise
The Breakdown Of Food During Digestion
The Environmental Temperature
Heat Is Lost Through :
Urine Feces
Respirations Perspiration

8. Body Temperature Is Measured In One Of Four Areas Of The Body
The Mouth – Oral
The Rectum – Rectal
The Axilla (Underarm) – Axillary
The Ear – Tympanic
We Now Also Have The Temporal Site - Forehead
Most Temperatures Are Taken Orally
Rectal Temperatures Are The Most Accurate
Axillary Temperatures Are The Least Accurate

9. SITE NORMAL RANGE
ORAL 98.6 ° 97.6 ° TO 99.6 °
RECTAL 99.6 ° 98.6 ° TO 100.6 °
AXILLARY 97.6 ° 96.6 ° TO 98.6 °
TYMPANIC 98.6 ° 98.6 °
TEMPORAL 98.6° 98.6°

10. A SMALL HOLLOW GLASS TUBE THAT CONTAINS
MERCURY OR A MERCURY-FREE SUBSTANCE IN A BULB
AT ONE END.WHEN HEATED THE MERCURY RISES IN
THE TUBE.
Pear – shaped tip

11. o THE SCALE IS MARKED FROM 94° TO 108°
o THE LONG LINES REPRESENT ONE DEGREE
o THE SHORT LINES REPRESENT TWO TENTHS OF A DEGREE
o ONLY EVERY OTHER DEGREE IS MARKED WITH A NUMBER

12. o BATTERY OPERATED
o HAVE AN ORAL PROBE AND A RECTAL PROBE
o DISPOSABLE PROBE COVER IS PLACED ON THE PROBE
o THE TEMPERATURE REGISTERS IN ABOUT 30 SECONDS

13. USE A DISPOSABLE SHEATH

14. o MEASURES THE TEMPERATURE IN THE TYMPANIC MEMBRANE (EARDRUM)
o FAST AND ACCURATE - 1 TO 3 SECONDS
INFANTS – PULL
THE EAR
STRAIGHT BACK
ADULTS AND
CHILDREN OVER
ONE YEAR –
PULL THE EAR UP
AND BACK

15. GLASS
THERMOMETER
o Rinse With Cold Water
o Check The Thermometer For Breaks
And Chips
o Shake Down The Thermometer So The
Mercury Is Below The Lines And
Numbers
o Place A Disposable Cover On The
Thermometer
o Place The Thermometer Under The
Person’s Tongue
o Leave The Thermometer In Place For 2
– 3 Minutes
o If The Person Has Been Eating,
Drinking, Or Smoking, Wait 15 Minutes
Before Taking Temperature

16. DO NOT TAKE AN ORAL TEMPERATURE ON:
 An Infant Or Young Child ( Under Age 6)
 An Unconscious Patient
 A Patient That Has Had Oral Surgery Or An Injury To The Face, Neck, Nose, Or Mouth
 A Person Receiving Oxygen
 A Patient With A Nasogastric Tube In Place
 A Patient Who Is Confused Or Restless
 A Patient Who Is Paralyzed On One Side Of The Body
 Has A History Of Seizures
 A Patient Who Breathes Through The Mouth

17.  Lubricate The Thermometer Before Inserting Into The Rectum
 Place The Person In A Side-lying Position
 Insert The Thermometer 1 Inch Into The Rectum
 Hold The Thermometer In Place For 2 Minutes
 Remove The Disposable Cover And Read The Thermometer

18. DO NOT TAKE A RECTAL TEMPERATURE ON:
o A PERSON WHO HAS HAD RECTAL SURGERY OR RECTAL INJURY
o IF THE PERSON HAS DIARRHEA
o IF THE PERSON IS CONFUSED OR AGITATED
o IF THE PERSON HAS HEART DISEASE ( STIMULATES THE VAGUS NERVE
WHICH SLOWS THE HEART RATE )

19.  Taken Only When No Other Site Can Be Used
 Make Sure The Underarm Is Clean And Dry
 The Arm Is Held Close To The Body
 You Need To Hold The Thermometer In Place
While The Temperature Is Being Taken
 The Thermometer Is Left In Place For 10 Minutes

20. THE PULSE IS:
 The Beat Of The Heart Felt At An Artery As A Wave Of Blood Passes Through The Artery
 A Pulse Is Felt Every Time The Heart Beats
 More Easily Felt In Arteries That Come Close To The Skin And Can Be Gently Pressed
Against A Bone
 The Pulse Should Be The Same In All Pulse Sites On The Body
 The Pulse Is An Indication Of How The Cardiovascular System Is Meeting The Body’s
Needs
 The Pulse Rate Is Affected By Many Factors – Age, Fever, Exercise, Fear. Anger, Anxiety,
Excitement, Heat, Position, And Pain.
 Medications Can Be Taken That Either Increase Or Decrease A Person’s Pulse Rate.

22. WE USUALLY COUNT A PULSE FOR 30 SECONDS AND
MULTIPLY THE NUMBER TIMES 2 TO GET THE PULSE
RATE FOR 1 MINUTE
We Note The Rhythm (Pattern) Of The
Heart Beat – If The Heart Beat Is Irregular
We Count The Pulse For A Full Minute
We Also Observe The Force (Strength) Of
The Heartbeat.
Does The Pulse Feel :
Strong Full Bounding
Weak Thready Feeble

23.  Most Common Site Used For Taking A
Pulse
 Can Be Taken Without Disturbing Or
Exposing The Person
 Place The First Two Or Three Fingers Of
One Hand Against The Radial Artery
 The Radial Artery Is On The Thumb Side
Of The Wrist
 Do Not Use Your Thumb To Take A
Person’s Pulse
 Use Gentle Pressure
 Count The Pulse For 30 Seconds And
Multiply By Two

24. Always Clean The Earpieces Of
The Stethoscope With Alcohol
Before And After Use
Warm The Diaphragm In Your
Hand Before Placing It On The
Person
Hold The Diaphragm In Place
Over The Artery
Do Not Let The Tubing Strike
Against Anything While The
Stethoscope Is Being Used

25.  Taken With A Stethoscope
 Counted By Placing The Stethoscope Over The Heart
 Counted For One Full Minute
 The Heart Beat Normally Sounds Like A Lub-dub. Each
Lub-dub Is Counted As One Heartbeat.
 Do Not Count The Lub As One Heartbeat And The Dub
As Another.
 The Apical Pulse Is Taken On Patients Who Have Heart
Disease , An Irregular Pulse Rate, Or Take Medications
That Can Affect The Heart.

26. The Apical And Radial Pulse Rates Should Be Equal
Sometimes The Heart Beat Is Not Strong Enough To Create A Pulse In The Radial Artery
This Would Cause The Radial Pulse To Be Less Than The Apical Pulse
One Person Counts The Apical While The Other Person Counts The Radial
The Difference In Pulses Is Called The Pulse Deficit

27. NORMAL ADULT PULSE RATE IS – 60 TO 100 BEATS PER MIN.
TACHYCARDIA – HEART RATE OVER 100
BRADYCARDIA – HEART RATE BELOW 60
REPORT ABNORMAL HEART RATES TO THE NURSE
IMMEDIATELY

28. ONE RESPIRATION CONSISTS OF ONE INSPIRATION AND
ONE EXPIRATION
 The Chest Rises During Inspiration (Breathing In) And
Falls During Expiration (Breathing Out)
 Count Each Time The Chest Rises
 Count For 30 Seconds And Multiply X 2
 Do Not Let The Person Know You Are Counting Their
Respirations
 Count After Taking The Pulse – Keep Your Fingers On
The Pulse Site
 Normal Respiratory Rate For Adult Is 12 – 20 Breaths Per
Min.

29. TACHYPNEA – RESPIRATORY RATE OVER 20
BRADYPNEA – RESPIRATORY RATE BELOW 12
DYSPNEA – SHORTNESS OF BREATH – DIFFICULTY IN BREATHING
APNEA – NO BREATHING
HYPERVENTILATION – FAST AND DEEP RESPIRATIONS
HYPOVENTILATION – SLOW AND SHALLOW RESPIRATIONS

30. THE MEASUREMENT OF THE AMOUNT OF FORCE THE
BLOOD EXERTS AGAINST THE ARTERY WALLS
o Systolic Pressure – Pressure Exerted When The Heart Muscle Is
Contracting
o Diastolic Pressure – Pressure Exerted When The Heart Muscle Is
Relaxing Between Beats
Blood Pressure Is Recorded As A Fraction With The Systolic
Pressure On Top And The Diastolic Pressure On The Bottom
Systolic Systolic /Diastolic
Diastolic 120/80
Bp Is Measured In Mm (Millimeters) Of Hg (Mercury)

31. AVERAGE ADULT SYSTOLIC RANGE – 100 TO 140
AVERAGE ADULT DIASTOLIC RANGE – 60 TO 90
HYPERTENSION – MEASUREMENTS ABOVE THE NORMAL
SYSTOLIC OR DIASTOLIC PRESSURES
HYPOTENSION – MEASUREMENTS BELOW THE NORMAL
SYSTOLIC OR DIASTOLIC PRESSURES

32.  Age – Blood Pressure Increases As A Person Grows Older.
 Gender – Women Usually Have Lower Blood Pressure Than Men
 Blood Volume – Severe Bleeding Lowers The Blood Pressure
 Stress – Heart Rate And Blood Pressure Increase As Part Of The Body’s
Response To Stress
 Pain – Increases Blood Pressure
 Exercise – Increases Heart Rate And Blood Pressure
 Weight – Blood Pressure Is Higher In Overweight Persons
 Race – Black Persons Generally Have Higher Blood Pressure Than White Persons
Do
 Diet – A High-sodium Diet Increases The Fluid Volume In The Body Which
Increases Blood Pressure
 Medications – Can Be Taken To Raise Or Lower Blood Pressure
 Position – Blood Pressure Is Lower When Lying Down

33. THE PROPER NAME FOR A BLOOD PRESSURE CUFF IS
SPHYGMOMANOMETER
MERCURY ANEROID

34.  Do Not Take A Blood Pressure On An Arm With An Iv, A Cast, Or A
Dialysis Shunt.
 Do Not Take A Blood Pressure On The Side That A Person Has Had
Breast Surgery On.
 Measure Blood Pressure With The Person Sitting Or Lying.
 Apply The Cuff To The Bare Upper Arm. Do Not Apply The Cuff
Over Clothing.
 Make Sure The Cuff Is Snug.
 Use A Large Cuff If Necessary.
 Make Sure The Room Is Quiet.
 If You Do Not Hear The Blood Pressure, Wait 30 To 60 Seconds And
Try Again. If You Still Can Not Hear It Or Are Unsure Of Your
Readings, Have The Nurse Check Your Measurements.

35. 1. Clean The Stethoscope Earpieces And Diaphragm With Alcohol.
2. Locate The Brachial Pulse. This Is Where The Stethoscope Will Be Placed.
3. Wrap The Cuff Above The Elbow With The Arrow Pointing To The Brachial Artery. Fasten The
Cuff So It Fits Snugly.
4. Place The Diaphragm Of The Stethoscope Flat On The Pulse Site, Holding It In Place With The
Index And Middle Fingers Of One Hand.
5. Locate The Radial Pulse.
6. Close The Valve On The Bp Cuff By Turning It To The Right (Clockwise).
7. Inflate The Cuff Until You Can No Longer Feel The Radial Pulse. ,Then Inflate The Cuff 30 Mm
Hg Beyond This Point.
8. Deflate The Cuff Slowly By Opening The Valve Slightly And Turning It Counterclockwise (To
The Left) With Your Thumb And Index Finger. Allow The Air To Escape Slowly While Listening
For A Pulse Sound.
9. Note The Reading At Which You Hear The First Clear, Regular Pulse Sound. This Number Is
The Systolic Pressure.
10. Continue Listening Until The Sound Disappears. This Is The Diastolic Pressure. Note This
Reading.
11. Open The Valve Completely To Deflate The Cuff. Remove The Cuff From The Patient.