Vital signs include measurements of respiration, pulse, blood pressure, temperature, and pain level. They provide important information about a patient's health status and should be assessed regularly, including upon admission, before/after procedures, and with any changes in condition. The five vital signs are used to monitor patients and detect issues that may require medical intervention.

1. Vital Signs
The Signs of Life!

2. Vital signs, which may also be called “life
signs” are indicators of a persons health
status. Vital signs may reveal sudden or
gradual changes in a patient’s condition.

3. VITAL SIGNS
 MONITOR A CLIENT’S CONDITION
 IDENTIFY PROBLEMS
 EVALUATE RESPONSE TO INTERVENTION
 INDICATORS OF HEALTH STATUS
 ESTABLISH BASELINE DATA FOR CLIENT

4. There are five measurements of vital signs that a
nurse must always consider when performing a
patient assessment.
 Respiration
 Pulse
 Blood Pressure
 Temperature
 Pain Level

5. When should the nurse assess vital
signs?
 Upon admission to
a health care
facility.
 Routinely,
according to
physician’s or
hospital policy.
 During physician’s
office visits or clinic
visits.

6. When should the nurse assess vital
signs?
 Before, during and
after a surgical
procedure.
 Before and after
 Invasive diagnostic
procedures
 Certain
medications are
administered.

7. When should the nurse assess vital
signs?
 With any changes in
patient’s physical
condition.
 Before and after and
nursing intervention
which may effect V/S
readings.
 Anytime a patient
reports a change in
symptoms or exhibits
signs of distress.

8. Temperature
What is temperature?
 Body temperature is the measurement in
degrees Fahrenheit or Celsius.
 Heat produced - heat lost = body temp
 Normal body temperature varies greatly from
one person to the other and with age.
- Skin temperature can range from 96.9 –
100.0 degrees. (go by your ebook values)

9. CORE TEMPERATURE
 TEMP OF DEEP BODY TISSUES
 UNDER CONTROL OF HYPOTHALMUS
 RELATIVELY CONSTANT
 PULMONARY ARTERY BEST SITE
 OTHER SITES INCLUDE TYPANIC
MEMBRANE, ESOPHAGEAL, RECTAL,
 URINARY BLADDER

10. SURFACE TEMPERATURE
 Flucuates depending on
blood flow to the skin
and the amount of heat
lost to the external
environment.

11. Temp in Adults Depends on:
 AGE
 EXERCISE
 HORMONE LEVEL
 GENDER
 CIRCADIAN RHYTHM
 STRESS
 ENVIRONMENT

12. TEMP REGULATION
 HYPOTHALMUS
 HEAT PRODUCTION REGULATED BY:
 SHIVERING
 VASOCONTRICTION
OCCURS DURING REST,
VOLUNTARY MOVEMENTS, SHIVERING,
NONSHIVERING THERMOGENISIS

13. TEMP REGULATION
 HEAT LOSS REGULATED BY:
 SWEATING
 VASODILATION OF BLOOD VESSELS
METHODS OF HEAT LOSS
- RADIATION
- CONDUCTION
- CONVECTION
- EVAPORATION

14. TEMP ALTERATIONS
 FEVER OR HYPERPYREXIA
 FEBRILE
 AFEBRILE
 FEVER OF UNKNOWN ORIGIN (FUO)

15. FEVER TYPES
 SUSTAINED
 INTERMITTENT
 REMITTENT
 RELAPSING

16. TEMP ALTERATIONS
 HEAT EXHAUSTION
 HYPERTHERMIA
 HEATSTROKE
 HYPOTHERMIA

17. HYPERTHEMIA INTERV.
 ASSESS CORE TEMP
 CONTRIBUTING FACTORS
 VITALS
 ADDITIONAL SIGNS & SYMPTOMS
 COMFORT MEASURES
 COLLECT SPECIMENS
 I & O

18. HYPERTHERMIA INTERV.
 MEDICATIONS (ANTIBIOTICS &
ANTIPYRETICS)
 PREVENT COMPLICATIONS
 MANIPULATE ENVIRONMENT
 NUTRITION
 LIMIT PHYSICAL ACTIVITY

19. HYPOTHERMIA INTERV.
 PREVENT FURTHER DECREASE IN BODY
TEMPERATURE
 REMOVE WET CLOTHES
 WRAP IN BLANKETS
 IF CONSCIOUS, GIVE WARM LIQUIDS
 HEATING PAD OR WARM ENVIRONMENT

20. Temperature
An appropriate thermometer with probe cover
- Digital thermometer (oral/rectal)
-Tympanic membrane thermometer
-Glass thermometer (alcohol or mercury filled)
-Disposable-taped on forehead
 Lubricant ( rectal temperature assessment
only)
 Gloves

21. Pulse
 What is pulse?
- Pulse is the palpable bounding of blood flow
noted at various points caused by the
contraction and alternate expansion of an
artery as the wave of blood passes through
the vessel.

22. Pulse
 Pulse rate may be calculated by assessing
the number of pulsations that occur, in a one
minute period, at any of the following ten
pulse sites:
- Temporal
- Carotid
- Apical
- Brachial
- Radial

23. Pulse
 Pulse sites (continued):
- Ulnar
- Femoral
- Popliteal
- Posterior tibial
- Dorsalis pedis

24. Pulse
 The most common pulse site used to assess one’s
pulse is the radial pulse sight.
 How to assess the radial pulse.
- Palpate the wrist just below the thumb
using the pads of the second and third
fingers.
- Count the number of beats you feel in a
one minute cycle.

25. Pulse
 Normal pulse rate may also vary with age and
can range from:
- _______/minute at rest in infants.
-________/ minute at rest in toddlers.
-________/minute at rest in preschoolers
-________/minute at rest in school-agers
-________/ minute at rest in adolescents
-________/minute at rest in adults
Fundamentals ebook

26. INFLUENCING FACTORS
 EXERCISE
 TEMPERATURE
 EMOTIONS
 DRUGS
 HEMORRHAGE
 POSTURAL CHANGES
 PULMONARY CONDITIONS

27. PULSE ASSESSMENT
 RATE
 RHYTHM
 STRENGTH
 EQUALITY

28. GRADING OF PULSES
 0=ABSENT, NOT PALPABLE
 1+ = WEAK, DIMINISHED, BARELY
PALPABLE, EASY TO OBLITERATE
 2+ = NORMAL, EASILY PALPABLE
 3+ = FULL, INCREASED
 4+ = BOUNDING, STRONG, CANNOT
OBLITERATE

29. RESPIRATIONS
 PROCESS OF GAS EXCHANGE BY WHICH
OXYGEN IS OBTAINED AND CARBON
DIOXIDE IS ELIMINATED.
 MOVEMENT OF CO2 BETWEEN THE
ALVEOLI AND THE RBC (DIFFUSION)
 DISTRIBUTION OF RBC TO & FROM
PULMONARY CAPILLARIES (PERFUSION)

30. INFLUENCE ON RESP.
 EXERCISE
 ACUTE PAIN
 SMOKING
 BODY POSITION
 MEDICATION
 AGE
 BRAIN STEM INJURY

31. ASSESS RESPIRATIONS
 RATE
 RHYTHM
 DEPTH
 SYMMETRY

32. Respiration
 Normal respiratory rate varies with age and
can range from:
-_____/ minute in newborns.
-_____/ minute in school-age children.
-_____/ minute in adults.
Fundamentals ebook

33. ALTERED BREATHING
 BRADYPNEA
 TACHYPNEA
 HYPERPNEA
 APNEA
 HYPERVENTILATION
 HYPOVENTILATION
 CHEYNE-STOKES

34. ALTERED BREATHING
 KUSSMAUL’S
 BIOT’S RESPIRATION

35. Blood Pressure
 What is blood pressure?
- Blood pressure is the pressure exerted on
the walls of the arteries during the
contraction and relaxation of the heart.

36. BLOOD PRESSURE
 LATERAL FORCE ON
THE WALLS OF AN
ARTERY BY THE
PULSING BLOOD
UNDER PRESSURE
FROM THE HEART

37. Blood Pressure
What instruments are needed to
assess blood pressure?
 Blood pressure is measured by using an
instrument that is known as a
sphygmomanometer which has a cuff
containing a rubber bladder, a pressure bulb
with a release valve and a manometer.
 A stethoscope should also be used.

38. Blood Pressure
How is blood pressure recorded?
 The standard unit used to measure blood pressure is
millimeters of mercury (mm Hg).
 Blood pressure is recorded by placing the systolic
pressure reading, (pressure during ventricular
contraction) over the diastolic pressure reading,
(pressure during ventricular rest).
- For example 120/80 mmHg.

39. BP INFLUENCES
 AGE
 STRESS
 RACE
 MEDS
 GENDER
 CHANGE IN CARDIAC OUTPUT
 INCREASE OR DECREASE IN BLOOD VOLUME

40. BLOOD PRESSURE
 HYPERTENSION- DIASTOLIC READING OF
90 OR MULTIPLE CONSISTENT READINGS
OF SYSTOLIC HIGHER THAN 135
 HYPOTENSION-SYSTOLIC 90 OR LOWER
 ORTHOSTATIC HYPOTENSION
 Refer to Fundamentals ebook

41. Blood Pressure
How should the nurse assess blood pressure?
 The nurse should first palpate the pulse that will be
used to assess the blood pressure. The brachial
artery in the upper arm is usually used.
 The sphygmomanometer should then be placed
about one inch above the pulse point that the nurse
will be using.

42. Blood Pressure
How should the nurse assess blood pressure?
 The nurse should then inflate the cuff to an
appropriate level (usually 30mm Hg above the
number at which the pulse is no longer felt) and then
decrease it by releasing the valve and allowing the
rate to decrease at about 2-3 mm Hg /second.

43. Blood Pressure
What is a healthy blood pressure reading?
 A healthy blood pressure reading in the
average adult is:
120/80 or less
 Readings consistently above or below these
levels should be reported to the patients
doctor.

44. BP SITES TO AVOID
 IV SITES
 SHUNTS
 SIDE OF BREAST/AXILLA SURGERY
 ARM/HAND TRAUMA
 CAST/BULKY DRESSING

45. Blood Pressure
How should the nurse assess blood pressure?
 The nurse should then wait 30 seconds and inflate
the cuff to the previously determined number and
place the stethoscope diaphragm over the
antecubital space located at the bend of the arm. The
nurse should then deflate the cuff at the rate of 2-3
mm Hg / second.
 The nurse should then listen for and note the number
at which the pulsation starts (systolic reading) and
stops (diastolic reading).

46. Pain Level
 Pain level should be assessed every time other vital
signs are assessed and more often if needed.
 Pain level should be assessed using the most
appropriate pain scale possible.
- Numeric pain scale (1-10)
-Descriptive pain scale (No pain -Worst pain)
-Face rating pain scale (Happy face - Sad face)
 Pain levels should always be assessed before and
after pain medication administration.

47. Documentation of Vital Signs
 Vital Signs should always be documented
immediately following assessment.
 Vital signs should be documented on the
appropriate flow sheet or computer chart.
 Vital signs should be documented using blue
or black indelible ink.

48. Vital Sign Assessment Is an
Important Part of Patient Care.
 The Nurse should always….
- perform vital sign assessments as ordered
or needed.
- document vital signs appropriately.
- notify the doctor of any significant vital
sign changes.