This document provides information on measuring and assessing vital signs including temperature, pulse, respirations, and blood pressure. It describes how to take each vital sign measurement accurately using the proper techniques and equipment. Normal ranges for adults are provided for each vital sign. Factors that can influence vital sign measurements are also outlined. The importance of recording vital signs accurately and notifying the nurse of any abnormal readings is emphasized.

1. VITAL SIGNS
RIGEL L. LICMOAN, RN, RM, MAN, MD
EMERGENCY ROOM PHYSICIAN

3. TEMPERATURE
PULSE
RESPIRATIONS
BLOOD PRESSURE
VITAL SIGNS MUST BE MEASURED, REPORTED, AND
RECORDEDACCURATELY
IF YOUARE NOT SURE OFAMEASUREMENT,
RECHECK IT

4. oWHEN APERSON ISADMITTED TOAHEALTH CARE
FACILITY
o SEVERALTIMESADAY FOR HOSPITALIZED PATIENTS
o BEFOREANDAFTER SURGERY
o AFTER SOME NURSING PROCEDURES
oBEFORE MEDICATIONS ARE GIVEN THATAFFECT THE
RESPIRATORY OR CIRCULATORY SYSTEM
oWHENEVER THE PERSON COMPLAINS OF PAIN,
SHORTNESS OF BREATH, RAPID HEART RATE, OR NOT
FEELING WELL
oWITH THE PERSONAT REST INALYING OR SITTING
POSITION

5. o ILLNESS
o EMOTIONS – ANGER, FEAR, ANXIETY, PAIN
o EXERCISEANDACTIVITY
o AGE
o SEX
o ENVIRONMENT - WEATHER
o FOODAND FLUID INTAKE
o MEDICATIONS
o TIME OF DAY– ↓ IN THE MORNING, ↑ IN THEAFTERNOON/EVENING
o NOISE
ACHANGE IN ONE VITAL SIGN WILL CAUSE ACHANGE IN
THE OTHERS

6. oANYVITAL SIGN IS CHANGED FROMAPREVIOUS
MEASUREMENT
o VITAL SIGNSAREABOVE THE NORMAL RANGE
o VITAL SIGNSARE BELOW THE NORMAL RANGE

7. MANYAGENCIES HA
VE TEMP BOARDS OR TPR BOOKS
RECORD VITAL SIGN MEASUREMENTSAS SOON AS
POSSIBLE
CARRYASMALL NOTEBOOK IN YOUR POCKET SO YOU
CAN RECORD THEMAS YOU TAKE THEM
ABBREVIATIONS
TEMPERATURE – T
PULSE – P
RESPIRATIONS – R
BLOOD PRESSURE - BP

8. BODY TEMPERATURE IS THEAMOUNT OF HEAT IN THE
BODY
IT ISABALANCE BETWEEN THEAMOUNT OF HEAT
PRODUCED AND THEAMOUNT 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
RESPIRA
TIONS
FECES
PERSPIRA
TION

9. BODY TEMPERATURE IS MEASURED IN ONE OF FOUR
AREAS OF THE BODY
THE MOUTH – ORAL
THE RECTUM – RECTAL
THEAXILLA(UNDERARM) –AXILLARY
THE EAR – TYMPANIC
WE NOWALSO HA
VE THE TEMPORAL SITE - FOREHEAD
MOST TEMPERATURES ARE TAKEN ORALLY
RECTALTEMPERA
TURES ARE THE MOSTACCURA
TE
AXILLARY TEMPERA
TURESARE THE LEASTACCURA
TE

10. SITE NORMAL RANGE
ORAL
RECT
AL
98.6 °
99.6 °
97.6 °
97.6 ° TO 99.6 °
98.6 ° TO 100.6 °
96.6 ° TO 98.6 °
AXILLARY
TYMPANIC
TEMPORAL
98.6 ° 98.6 °
98.6° 98.6°

11. 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

12. o THE SCALE IS MARKED FROM 94° TO 108°
o THE LONG LINES REPRESENT ONE DEGREE
o THE SHORT LINES REPRESENT TWO TENTHS OFADEGREE
o ONLY EVERY OTHER DEGREE IS MARKED WITHANUMBER

13. o BA
TTERY OPERA
TED
o HA
VEAN ORAL PROBEANDARECTAL PROBE
o DISPOSABLE PROBE COVER IS PLACED ON THE PROBE
o THE TEMPERATURE REGISTERS INABOUT 30 SECONDS

14. USE A DISPOSABLE SHEATH

15. o MEASURES THE TEMPERATURE IN THE TYMPANIC MEMBRANE (EARDRUM)
o FAST ANDACCURATE - 1 TO 3 SECONDS
INFANTS – PULL
THE EAR
STRAIGHT BACK
ADULTSAND
CHILDREN OVER
ONEYEAR –
PULLTHE EAR UP
AND BACK

16. DO NOT TAKE AN ORAL TEMPERATURE ON:
o AN INFANT OR YOUNG CHILD ( UNDERAGE 6)
o AN UNCONSCIOUS PATIENT
oAPATIENT THAT HAS HAD ORAL SURGERY ORAN INJURYTO THE FACE,
NECK, NOSE, OR MOUTH
o APERSON RECEIVING OXYGEN
o APA
TIENT WITHANASOGASTRIC TUBE IN PLACE
o APA
TIENT WHO IS CONFUSED OR RESTLESS
o APA
TIENT WHO IS PARALYZED ON ONE SIDE OF THE BODY
o HASAHISTORY OF SEIZURES
o APA
TIENT WHO BREA
THES THROUGH THE MOUTH

17. o LUBRICATE THE THERMOMETER BEFORE INSERTING INTO THE RECTUM
o PLACE THE PERSON INASIDE-LYING POSITION
o INSERT THE THERMOMETER 1 INCH INTO THE RECTUM
o HOLD THE THERMOMETER IN PLACE FOR 2 MINUTES
o REMOVE THE DISPOSABLE COVERAND 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
oIF THE PERSON HAS HEART DISEASE ( STIMULATES THE VAGUS NERVE
WHICH SLOWS THE HEART RATE )

19. oTAKEN ONLYWHEN NO OTHER SITE CAN
BE USED
oMAKE SURE THE UNDERARM IS CLEAN
AND DRY
o THEARM IS HELD CLOSE TO THE BODY
oYOU NEED TO HOLD THE THERMOMETER
IN PLACE WHILE THE TEMPERATURE IS
BEING TAKEN
oTHE THERMOMETER IS LEFT IN PLACE
FOR 10 MINUTES

20. THE PULSE IS:
o THE BEAT OF THE HEART FELTATANARTERYASAWAVE OF BLOOD PASSES
THROUGH THEARTERY
o APULSE IS FELT EVERYTIME THE HEART BEA
TS
oMORE EASILY FELT INARTERIES THAT COME CLOSE TO THE SKINAND CAN
BE GENTLY PRESSEDAGAINSTABONE
o THE PULSE SHOULD BE THE SAME INALL PULSE SITES ON THE BODY
oTHE PULSE IS AN INDICATION OF HOW THE CARDIOVASCULAR SYSTEM IS
MEETING THE BODY’S NEEDS
oTHE PULSE RATE IS AFFECTED BY MANY FACTORS – AGE, FEVER, EXERCISE,
FEAR.ANGER,ANXIETY, EXCITEMENT, HEAT, POSITION,AND PAIN.
oMEDICATIONS CAN BE TAKEN THAT EITHER INCREASE OR DECREASEA
PERSON’S PULSE RATE.

22. WE USUALLY COUNTAPULSE FOR 30 SECONDS AND
MULTIPL
YTHE 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 FORAFULL MINUTE
WE ALSO OBSERVE THE FORCE
(STRENGTH) OF THE HEARTBEAT.
DOES THE PULSE FEEL :
STRONG FULL BOUNDING
WEAK THREADY FEEBLE

23. oMOST COMMON SITE USED FOR
TAKINGAPULSE
oCAN BE TAKEN WITHOUT
DISTURBING OR EXPOSING THE
PERSON
oPLACE THE FIRST TWO OR THREE
FINGERS OF ONE HANDAGAINST THE
RADIALARTERY
oTHE RADIALARTERY IS ON THE
THUMB SIDE OF THE WRIST
oDO NOT USE YOUR THUMB TO TAKE
APERSON’S PULSE
o USE GENTLE PRESSURE
oCOUNT THE PULSE FOR 30 SECONDS
AND MULTIPLY BYTWO

24. ALWAYS CLEAN THE
EARPIECES OF THE
STETHOSCOPE WITH
ALCOHOL BEFOREAND AFTER
USE
WARM THE DIAPHRAGM IN
YOUR HAND BEFORE
PLACING IT ON THE PERSON
HOLD THE DIAPHRAGM IN
PLACE OVER THEARTERY
DO NOT LET THE TUBING
STRIKEAGAINSTANYTHING
WHILE THE STETHOSCOPE IS
BEING USED

25. T
o TAKEN WITHASTETHOSCOPE
o COUNTED BY PLACING THE STETHOSCOPE
OVER THE HEART
o COUNTED FOR ONE FULL MINUTE
oTHE HEART BEAT NORMALLY SOUNDS LIKEA
LUB-DUB. EACH LUB-DUB IS COUNTED AS ONE
HEARTBEAT.
oDO NOT COUNT THE LUB AS ONE HEARTBEA
AND THE DUB ASANOTHER.
oTHE APICAL PULSE IS TAKEN ON PATIENTS
WHO HAVE HEART DISEASE , AN IRREGULAR
PULSE RATE, OR TAKE MEDICATIONS THAT CAN
AFFECT THE HEART.

26. THE APICALAND RADIAL PULSE RATES SHOULD BE EQUAL
SOMETIMES THE HEART BEAT IS NOT STRONG ENOUGH TO CREATEAPULSE IN
THE RADIALARTERY
THIS WOULD CAUSE THE RADIAL PULSE TO BE LESS THAN THEAPICAL PULSE
ONE PERSON COUNTS THEAPICALWHILE THE OTHER PERSON COUNTS THE
RADIAL
THE DIFFERENCE IN PULSES IS CALLED THE PULSE DEFICIT

27. NORMALADULT PULSE RA
TE IS – 60 TO 100 BEA
TS PER MIN.
TACHYCARDIA – HEART RATE OVER 100
BRADYCARDIA – HEART RATE BELOW 60
REPORTABNORMALHEART RATES TO THE NURSE
IMMEDIATELY

28. ONE RESPIRATION CONSISTS OF ONE INSPIRATION AND
ONE EXPIRATION
oTHE CHEST RISES DURING INSPIRATION (BREATHING
IN)AND FALLS DURING EXPIRATION (BREATHING OUT)
o COUNT EACH TIME THE CHEST RISES
o COUNT FOR 30 SECONDSAND MULTIPLY X 2
oDO NOT LET THE PERSON KNOWYOUARE COUNTING
THEIR RESPIRATIONS
o COUNTAFTER TAKING THE PULSE – KEEPYOUR
FINGERS ON THE PULSE SITE
oNORMALRESPIRATORY RATE FORADULT IS 12 – 20
BREATHS PER MIN.

29. TACHYPNEA– RESPIRA
TORY RA
TE OVER 20
BRADYPNEA– RESPIRATORY RATE BELOW 12
DYSPNEA– SHORTNESS OF BREATH – DIFFICULTY IN
BREATHING
APNEA– NO BREATHING
HYPERVENTILATION – FASTAND DEEP RESPIRA
TIONS
HYPOVENTILATION – SLOWAND SHALLOW
RESPIRATIONS

30. THE MEASUREMENT OFTHEAMOUNT OF FORCE THE
BLOOD EXERTS AGAINST THEARTERY WALLS
o SYSTOLIC PRESSURE – PRESSURE EXERTED WHEN THE
HEART MUSCLE IS CONTRACTING
oDIASTOLIC PRESSURE – PRESSURE EXERTED WHEN THE
HEART MUSCLE IS RELAXING BETWEEN BEATS
BLOOD PRESSURE IS RECORDED AS A FRACTION WITH THE
SYSTOLIC PRESSURE ON TOPAND THE DIASTOLIC PRESSURE
ON THE BOTTOM
SYSTOLIC
DIASTOLIC
SYSTOLIC /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 – MEASUREMENTSABOVE THE NORMAL
SYSTOLIC OR DIASTOLIC PRESSURES
HYPOTENSION – MEASUREMENTS BELOW THE NORMAL
SYSTOLIC OR DIASTOLIC PRESSURES

32. o AGE – BLOOD PRESSURE INCREASESASAPERSON GROWS OLDER.
o GENDER – WOMEN USUALLY HAVE LOWER BLOOD PRESSURE THAN MEN
o BLOOD VOLUME – SEVERE BLEEDING LOWERS THE BLOOD PRESSURE
oSTRESS – HEART RATEAND BLOOD PRESSURE INCREASE AS PARTOF THE
BODY’S RESPONSE TO STRESS
o PAIN – INCREASES BLOOD PRESSURE
o EXERCISE – INCREASES HEART RATEAND BLOOD PRESSURE
o WEIGHT – BLOOD PRESSURE IS HIGHER IN OVERWEIGHT PERSONS
o RACE – BLACK PERSONS GENERALLY HAVE HIGHER BLOOD PRESSURE
THAN WHITE PERSONS DO
oDIET –AHIGH-SODIUM DIET INCREASES THE FLUID VOLUME IN THE BODY
WHICH INCREASES BLOOD PRESSURE
o MEDICATIONS – CAN BE TAKEN TO RAISE OR LOWER BLOOD PRESSURE
o POSITION – BLOOD PRESSURE IS LOWER WHEN LYING DOWN

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

35. o DO NOT TAKEABLOOD PRESSURE ONANARM WITHAN IV,ACAST, ORA
DIALYSIS SHUNT.
oDO NOT TAKEABLOOD PRESSURE ON THE SIDE THATAPERSON HAS HAD
BREAST SURGERY ON.
o MEASURE BLOOD PRESSURE WITH THE PERSON SITTING OR LYING.
oAPPLYTHE CUFF TO THE BARE UPPERARM. DO NOTAPPLYTHE CUFF
OVER CLOTHING.
o MAKE SURE THE CUFF IS SNUG.
o USEALARGE CUFF IF NECESSARY
.
o MAKE SURE THE ROOM IS QUIET.
oIF YOU DO NOT HEAR THE BLOOD PRESSURE, WAIT 30 TO 60 SECONDS
AND TRYAGAIN. IF YOU STILL CAN NOT HEAR IT OR ARE UNSURE OF
YOUR READINGS, HAVE THE NURSE CHECK YOUR MEASUREMENTS.

36. 1. CLEAN THE STETHOSCOPE EARPIECESAND DIAPHRAGM WITH ALCOHOL.
2. LOCATE THE BRACHIALPULSE. THIS IS WHERE THE STETOSCOPE WILL BE PLACED.
3. WRAPTHE CUFFABOVE THE ELBOW WITH THEARROW 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 INDEXAND MIDDLE FINGERS OF ONE HAND.
5. LOCATE THE RADIALPULSE.
6. CLOSE THE VALVE ON THE BP CUFF BYTURNING IT TO THE RIGHT (CLOCKWISE).
7. INFLA
TE THE CUFF UNTILYOU CAN NO LONGER FEELTHE RADIALPULSE. ,THEN
INFLATE THE CUFF 30 MM HG BEYOND THIS POINT.
8. DEFLATE THE CUFF SLOWLY BY OPENING THE VALVESLIGHTLYAND TURNING IT
COUNTERCLOCKWISE (TO THE LEFT) WITH YOUR THUMBAND INDEX FINGER.ALLOW
THEAIR TO ESCAPE SLOWL
YWHILE LISTENING FORAPULSE SOUND.
9. NOTE THE READINGATWHICH 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 COMPLETELYTO DEFLATE THE CUFF. REMOVE THE CUFF FROM THE
PATIENT.

40. MEASURING WEIGHT AND HEIGHT
▶ Standing, chair, and lift scales are used.
▶ Measuring weight and height
▶ The person only wears a gown or pajamas.
▶ The person voids before being weighed.
▶ Weigh the person at the same time of day.
▶ Use the same scale.
▶ Balance the scale at zero before weighing the person.

41. PAIN
▶ Pain means to ache, hurt, or be sore.
▶ Pain is a warning from the body.
▶ Pain is personal.
▶ Types of pain
▶ Acute pain – felt suddenly from an injury, disease, trauma, or surgery
▶ Chronic pain – lasts longer than 6 months. Pain can be constant or occur
on and off.
▶ Radiating pain – felt at the site of tissue damage and in nearby areas.
▶ Phantom pain – felt in a body part that is no longer there.

42. ▶ Signs and symptoms
▶ Location – Where is the pain?
▶ Onset and duration – When did the pain start?
▶ Intensity – Rate the pain on a scale of 1 to 10, with
10 as the most severe
▶ Description – Can you use words to describe the
pain?
▶ Factors causing pain – What were you doing when
the pain started?
▶ Vital signs – T
ake the person’s vital signs when they
complain of pain.
▶ Other signs and symptom
▶ Body responses - ↑ vital signs, nausea, pale skin, sweating, vomiting
▶ Behaviors – crying, groaning, holding affected body part, irritability, restlessness