This document provides information on assessing and interpreting vital signs, including temperature, pulse, respiration, blood pressure, and pain. It describes the normal ranges for each vital sign and factors that can influence them. The procedures for measuring each vital sign are outlined, including the appropriate equipment and sites on the body. Reasons for routinely measuring vital signs and guidelines for documentation are also discussed.

1. VITAL SIGN
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Ms Tissymol Thomas –Ford Hospital & Research Centre

2.  Describe the procedures used to assess the vital
signs: Temperature, Pulse, Respiration, And
Blood Pressure, Pain Assessment.
 Identify factors that can influence each vital sign.
 Identify equipment routinely used to assess vital
signs.
 Identify rationales for using different routes for
assessing temperature.
 Take vital signs and interpret the finding.
 Document the vital signs.
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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, blood pressure
and Pain 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
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evaluating homeostatic balance.
Includes:
 temperature,
 Pulse Rate,
 Respiratory Rate),
 Blood Pressure)
 Pain

5.  To obtain base line data about the patient
condition
 For diagnostic purpose
 For therapeutic purpose
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6.  Vital sign tray
 Stethoscope
 Sphygmomanometer
 Thermometer
 Hand watch (With Sec. Counter)
 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
our internal boady temperature is regulated by a part of
our brain called the hypothalamus. The hypothalamus
checks our current temperature and compares it with
the normal temperature of about 37 Degree Celsius. If
our temp. is too low the hypothalamus
Makes sure that the boady generates and maintain heat.
Temp. is too high heat is given off or sweat is produced
to cool the skin.

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 itrises & falls in response to
the environment
o (Ranges b/n 20-40oc).
o It doesn’t indicate internal physiology.

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 98.6 0F (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
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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 remainsfairly 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. 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

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

25. 1. Age
2. Diurnal variations (circadian rhythm
3. Exercise
4. Hormones
5. Stress
6. Environment
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26.  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.
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27.  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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28. Pulse is assessedfor
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• rate (60-100bpm),
• rhythm (regularity orirregularity),
• Volume,
• elasticity of arterialwall.
The pulse is commonly assessed by palpation
(feeling) and auscultation (hearing using a
stethoscope).

29. Age
The average pulse rate of an infant ranges from
100 to 160BPM
The normal range of the pulse in an adult is 60
to 100 BPM
Sex: Sex: after puberty the average males
PRis slightly lower than female
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30. Autonomic Nervous systemactivity
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 Stimulation of the parasympathetic nervous
system results in decrease in the PR
 Stimulation of sympathetic nervous system
results in an increased pulse rate
 Sympathetic nervous system activation occurs
on response to a variety of stimuli including
▪ Pain ,anxiety ,Exercise, Fever
▪ Ingestion of caffeinated beverages
▪ Change in intravascular volume

31. Exercise: PRincrease with exercise Fever:
increases PRin response to the lowered
B/P that results from peripheral
vasodilatation – increased metabolic rate
Heat: increase PRas acompensatory
mechanism
Stress: increases the sympathetic nerve
stimulation
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32. * Position changes:
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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33. * Medication
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o Cardiac medication such as digoxin decrease heart
rate
o Medications that decrease intravascular volume
such as diuretics may increase pulse rate
o Atropine inhibits impulses to the heart from the
parasympathetic nervous system, causing increased
pulse rate
o Propranolol blocks sympathetic nervous system
action resulting in decreased heart rate sites used
for measuring pulse rate

34. 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: routinely used
for infant and children < 3 yrs
In adults – Left mid-clavicular line under the
4th, 5th, 6th intercostalspace
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35. Brachial: at the inner aspect of the biceps muscle
of the arm or medially in the antecubital space
(elbow crease)
Radial: on the thumb side of the inner aspect of
the wrist – readily available and routinely used
Femoral: along the inguinal ligament. Used or
infants and children
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
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38. A wave of
blood flow
created by
a
contraction
of
theheart. .
.
A.
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B.
D.
E.
F
.
C. G.
H.

39.  Pulse: is commonly assessed by
palpation (feeling) or
auscultation(hearing)
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 The middle 3 fingertips are used with
moderate pressure for palpation of all pulses
except apical;
 Assess the pulsefor
Rate
Rhythm
Volume
Elasticity of the arterial wall

40. 40

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

42. Pulse Rhythm
The pattern and interval between the beats,
random, irregular beats– dysrythymia
PulseVolume
the force of blood with each beat
Anormal pulse can be felt with moderate
pressure of thefingers
Full or bounding pulse forceful or full blood
volume destroy with difficulty
Weak, feeble readily destroy with pressure
from the fingertips
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43. Elasticity of arterialwall
Ahealthy, normal artery feels, straight,
smooth, soft, easilybent
Reflects the status of the clients
vascular
system
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44. If the pulse is regular, measure (count) for
30 seconds and multiply by 2
If it is irregular count for 1 full minute.
Each heart beat consists of two sounds
s1 - is caused by closure of the mitral and
tricuspid
valves separating the atria from the ventricles
S2 – is caused by the closure of the plutonic
and aortic values
The sounds are often described as a muffled
“lub – bub”
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45. 45

46. Respiration rate (RR):-Respiration is the
act of breathing and includes the intake of
oxygen and removal of carbon-dioxide.
Ventilation is also another word, which
refers
to movement of air in and out of the lung.
Hyperventilation: - is a very deep, rapid
respiration.
Hypoventilation: -is a very shallow
respiration.
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47. 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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48. Age Normal growth from infancy to adult
hood results in a larger lung capacity.As lung
capacity increases, lower respiratory rates
are sufficient to exchange
Medications Narcotics decrease respiratory
rate
& depth
Stress or strong emotions increases the rate
& depth of respirations.
Exercise increases the rate & depthof
respirations
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49. 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 a lower
respirations rate than women because
men normally have a larger rung capacity
than women
Fever increases respiratoryrate
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50. o The client should be at
rest
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o Assessed by watching the movement of the
chest or abdomen.
o Rate,
o rhythm,
o depth and
ospecial characteristics of respiration
are assessed

51. Rate:
Is described in rate per minute (RPM)
Healthy adult RR= 15- 20/ min. is measured
for full minute, if regular for 30 seconds.
As the age decreases the respiratory rate
increases.
Eupnea- normal breathing rate and depth
Bradypnea- slowrespiration
Tachypnea - fastbreathing
Apnea - temporary cessation of breathing
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52. 52
Age Average Range/Min
New born 30-80
Early childhood 20-40
Late childhood 15-25
Adulthood-male 14-18
Female 16-20

53. Rhythm:
is the regularity of expiration and
inspiration Normal breathing is automatic &
effortless.
Depth:
described as normal, deep or shallow.
Deep: a large volume of air inhaled &
exhaled, inflates most of the lungs.
Shallow: exchange of a small volume of air
minimal use of lung tissue.
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54.  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).
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55. 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).
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56.  BP is measured by using an instrument
called Bp cuff (sphygmomanometer) &
stethoscope and
 the average normal 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
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57.  Fever
 Stress
 Arteriosclerosis
 Exposure to cold
 Obesity
 Hemorrhage
 Low hematocrit
 Externalheat
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58. Upperarm (using brachial artery
(commonest)
Thigh around poplitealartery
Fore-arm using radialartery
Legusing posterior tibial or dorsal pedis
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59.  Apersistently high Bp, measured for greater
than three times is called hypertension & that
persistently less than normal range is called
hypotension.
 Because of many factors influencing Bp a
single
measurement is not necessarily significant to
confirm hypertension.
 When the cause of hypertension is known it is
called secondary hypertension and when the
cause is unknown is calledprimary/essential
hypertension. 60

60. Purpose
To obtain base line measure of arterial
blood pressure for subsequentevaluation
To determine the clients homodynamic
status
To identify and monitor changes in blood
pressure.
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61. 61

62. Stethoscope
Blood pressurecuff of the appropriatesize
Sphygmomanometer
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63. Earpieces
Binaurals
Rubber or plastic
tubing
Bell Chestpiece
Diaphragm
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64.  Explain the procedure to the patient &
remove
any light cloth from patient’s arm
 Make sure that the client has not smoked or
ingested caffeine, within 30 minutes 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.
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65.  apply cuff snugly/securely around the arm ,
2.5cm above 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 by 0.8mmHg)
 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.
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66.  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.
 The first pulse heard is the systolic reading,
continue to deflate until there is a change in
tone to a muffled beat, this is the diastolic
reading.
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67.  Deflate & remove cuff roll neatly and
replace.
 Record the systolic and diastolic pressure
on vital singsheet and compare the
present reading with previous reading.
 report or treat any change
 Clear ear pieces and bell of the
stethoscope with antiseptic swab and
return all equipments.
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68. Ms Tissymol Thomas –Ford Hospital & Research Centre