ASSESSMENT OF

VITAL SIGNS
VITAL SIGNS: DEFINITION

 defined as the procedure that takes the

sign of basic physiology which includes
temperature, pulse, respiration and
blood pressure.
 If any abnormality occurs in the body,
vital signs change immediately.
PURPOSE OF VITAL SIGNS

To assess the client’s condition.

To determine the baseline values

for future comparisons

To detect changes and abnormalities

in the condition of the client
When to measure VITAL SIGNS?

 On admission to health care facility

 In a hospital on regular hospital schedule
or as doctor’s order (ex. q8hr, q4hr,etc.)
 Before and after procedures (surgery,
invasive diagnostic procedures)
 Before, during, and after blood
transfusions
 When patient’s general condition changes
(nursing judgment)
GUIDELINES FOR ASSESSMENT

1. Taken by healthcare team giving care

2. Equipment should be in good
condition
3. Know baseline VS and normal range
for pt. and age group
4. Know pt’s medical history
5. Minimize environmental factors
GUIDELINES…cont’d

6. Be organized in approach
7. Increase frequency of VS as
condition worsens
8. Compare VS readings with the
whole picture
9. Record accurately
10. Describe any abnormal VS
VS MUST BE ACCURATE…

 Both measuring and recording

 VS vary according to pt’s
illness/condition
 Compare results with pt’s normal
 Results are used to determine
treatments, medications,
diagnostic work, etc
REPORTING ABNORMAL VS

 WHEN—grossly abnormal, return to normal,

noted change for that pt
 WHY—indicates change in metabolism or
physiological function within the body
 WHO—student reports to instructor, then to
Staff RN, Doctor (follow chain of command)
 HOW—orally to appropriate person, then
document on chart
What are the Vital Signs?

I. Consciousness
II. Temperature
III. Respirations
IV. Blood Pressure
V. Pulse
VI. Pain
I. CONSCIOUSNESS

Human ability to be aware of own

thoughts, emotions, surroundings
 adequate responses

Use GLASGOW COMA SCALE (GCS)

Patient’s response to:
- Verbal Stimulation
- Painful Stimulation
- Movement Scale 3 – 15
*CONSCIOUSNESS

Changes in Consciousness
QUALITATIVE QUANTITATIVE

Anxiety Somnolent
Depression Sopor
Delirium Coma
(Shallow/Deep)
II. BODY TEMPERATURE

Balance between heat produced and

heat lost by the body
Heat regulating centre hypothalamus
Heat production caused by increasing
cell metabolism
Heat losses (cool off process):
- Perspiration
- Respiration
- Radiation
HEAT IS PRODUCED BY:

 Metabolism
 Increased muscle
activity
 Vasoconstriction
 External sources
HEAT IS LOST BY:

Vasodilation
Convection
Radiation
Conduction
Evaporization
BODY TEMPERATURE

Difference between heat produced by

body processes and the heat lost to
the external environment
 Range 96.8 – 100.4°F (36 – 38°C)
 Average for healthy young adults
98.6°F or 37°C
 No single temp is normal for all
people
TEMP or FEVER?

 TEMPERATURE—the
measurement of heat in
the body
 FEVER—the
measurement of heat in
the body that is above
normal for the individual
 TYPES OF THERMOMETERS
Tympanic Thermometer

Mercury-in-glass (Banned)

Electronic
Thermometer
Chemical
Thermometer
READING A THERMOMETER

Mercury-in-glass (Banned)
Frequently used terms:

 Pyrexia –slight fever

 Febrile –feverish
 Hyperthermia –above 37.6 °C
 Hypothermia –below 36 °C
 Afebrile –normal or non-febrile
 *BODY TEMPERATURE
BODY TEMPERATURE SYMPTOMS
Hypothermia ↓ 36 °C Skin paleness, Tiredness
Normal 36 – 36.9 °C Lowest 5 – 6am
Highest 4 – 6pm
Pyrexia/ Slight fever Perspiration, Skin redness,
37.0-37.9°C Headache
Fever  38°C General weakness,
Presence of infection Tachycardia / hyperpnea,
body defense Skin paleness/ redness,
mechanism
Shivers, Perspiration
FEVER: A DEFENSE MECHANISM

Indicator of disease in body

Pathogens release toxins
Toxins affect hypothalamus
Temperature is increased
Rest decreases metabolism and
heat production by the body
PATTERNS OF FEVER

 SUSTAINED- remains above normal with

little change
 RELAPSING – periods of febrile
episodes interspersed with acceptable
temp values
 INTERMITTENT—varies from normal to
above normal to below normal (may have
a fairly predictable pattern)
 REMITTENT—fever spikes and falls w/o
a return to normal temp values
FACTORS AFFECTING BODY
TEMPERATURE

 Age
 Exercise
 Hormonal level
 Stress
 Environment
 Circadian rhythm (temp normally changes
0.9 to 1.8 degree F /24hr Lowest 1-4AM Max-
6PM)
 Routes For Measuring
The Body Temperature
Oral, Axillary, Rectal, Tympanic
ORAL TEMPERATURE

 Accessible
 Dependable
 Accurate
 Convenient
 But invasive
 best site for measuring in the clinical settings
 triangle shaped thermometer
 axillo – oral difference 0.3 °C
ORAL TEMPERATURES: POINTS

 Wait 15-30 minutes

after eating, drinking,
chewing gum or
smoking
 If mouth breather-do
not take orally
 Leave in place 2 – 4
minutes with glass
thermometer
AXILLARY TEMPERATURE

 Safe
 Non-invasive
 Least
accurate

 more likely to be affected by the

environmental temperature changes
 used in children/adults
AXILLARY TEMPERATURE
IMPORTANT POINTS

 AXILLA MUST HAVE

ADEQUATE TISSUE & be
free of perspiration
 Not good method for
persons with elevated
temp
 Used when cannot get oral
or tympanic
 Leave in place 5 mins
RECTAL TEMPERATURE

 Most reliable
 But most invasive
 MUST hold
thermometer in
place
 fast thermometer, used in infants/unconscious
patients/receiving O2 therapy
 axillo – rectal difference 0.5 °C
 RECTAL TEMPERATURE: POINTS

 Very high temp

 Uses for Unconscious
patients
 Do not take rectal temp on
clients with heart conditions
 Leave in place 2-3 min with
glass thermometer
 Lubricate thermometer
 DO Not take hand from
thermometer while rectal in
progress
TYMPANIC TEMPERATURE

 Non-invasive
 Safe
 Accurate
 Disadvantages:
– Excessive cerumen
– Improper technique
 TYMPANIC TEMPERATURE: POINTS

 Oral & tympanic readings will be

same/ similar
 Must direct probe toward TM
(eardrum)
 Follow instructions
 Keep plugged in and on charger
when not in use
 Adults –pull pinna of ear up &
back
 Children under 3y/o-pull pinna of
ear down & back
NURSING DIAGNOSES

 Hyperthermia >100.4F
 Hypothermia <96.8F
 Ineffective
Thermoregulation
 Risk for altered body
temperature
TEMPERATURE CONVERSION

 Temperature can be measured in

Fahrenheit (F) or centigrade or Celsius
(C)
 To convert °F to °C, subtract 32 from °F
reading and multiply times 5/9.
Ex.(104°F – 32) x 5/9 = 40°C
 To convert c to F, multiply the c reading by
9/5 and add 32 to the product.
Ex. (40 x 9/5) + 32 = 104°F
III. RESPIRATION

Mechanism the body uses to

exchange gases between the
atmosphere, blood, and the cells.
Involves three processes:
 Ventilation
 Diffusion
 Perfusion
PROCESS OF RESPIRATION

 EXTERNAL RESPIRATION
– Inhaled air enters lungs, at alveoli O2
crosses over to bloodstream
– CO2 and other wastes cross over from
bloodstream to alveoli and are exhaled
 INTERNAL RESPIRATION
– O2 carried in bloodstream crosses over
to body cells
– CO2 and other wastes from body cells
cross over to the bloodstream
RESPIRATION TERMS…

 Chest Cavity—airtight vacuum with

negative pressure
 INSPIRATION—diaphragm
contracts and pulls down, ribs move
up, lungs fill with air
 EXPIRATION—diaphragm relaxes
and moves up, ribs move down,
lungs expel air
Counting Respirations…cont’d

NORMAL RESPIRATION should be:

Effortless, Regular, Smooth
 If respirations regular, count
respirations for 30 seconds and
multiply times 2.
 If irregular, less than 12 or greater
than 20, count for 1 full minute.
NORMAL RESPIRATION RANGES
AGE RANGE
ELDERLY (65+) 12-20 cpm
AVERAGE ADULT 12-20 cpm
NEWBORN 30-60
0-24 HOURS
INFANT 30-50
1mon – 6 mons
CHILDREN (varies with age)
QUALITY OF RESPIRATIONS

 assess movement of chest or

abdominal wall if deep, normal,
shallow
 Deep- full expansion of lungs
 Normal- normal
 Shallow- limited expansion of lungs
TERMS USED IN RESPIRATION

RESPIRATORY RATE
 Normal 12-20 breaths/ min
 Bradypnea ↓ 10 breaths/ min
 Tachypnea  25 breaths/ min
 Apnea RESPIRATORY RHYTHM
 Eupnea (normal)
 Dyspnea (exertion/rest)
 Cheynes-Stokes respiration
(irregular deep/slow/shallow )
 Kussmaul’s breathing (deep)
COUNTING RESPIRATIONS

 Count pulse first, then

count respirations while
holding wrist
 Note: Rate, rhythm, quality,
and character
 Observe a full inspiration
and expiration
 Respiratory rates below 12
or greater than 20 require
further assessment.
Factors Influencing
Characteristics of Respirations

 Exercise  Medications
 Acute Pain  Neurological injury
 Anxiety  Age
 Smoking  Environmental
 Body position Temp
 Hemoglobin
Function
IV. BLOOD PRESSURE (BP)

The pressure of
blood in the arterial
wall
Force exerted on the
walls of the artery
created by the pulsing
blood under pressure
of the heart.
Blood Pressure Terms:

 SYSTOLIC- Peak and maximum pressure

of ejection of blood from the heart into the
aorta. This is the top number.
 DIASTOLIC- The minimal pressure
remaining the heart when the heart relaxes.
This is the bottom number.
 PULSE PRESSURE- Difference between
the systolic and diastolic. (120/80 – Pulse
pressure 40)
EQUIPMENT FOR BP TAKING

Sphygmomanometer Stethoscope
(BP Apparatus)
“DOPPLER” OR ELECTRONIC BP
READINGS
BP ASSESSMENT:

 Normal Range
Systolic 120-140 mmHg
Diastolic 60-80 mmHg
 Hypertension  140/90 mmHg
 Hypotension ↓100/80 mmHg
NOTE: Measurements stated in terms
of millimetres of mercury (mmHg)
BP READING:
Systolic Pressure
(ventricle contraction)
Diastolic Pressure
(ventricle at rest)

BP readings record as
ratio: 120/80mmHg
BP MEASURING AREAS:

Places for measuring:

 upper arm (brachial artery)
 calf/ thigh (popliteal artery)
Measuring techniques:
 Auscultation
(sphygmomanometer+stethoscope)
 Palpation (sphygmomanometer only)
 Invasive methods (CVP)
ALTERNATIVE SITES

Calf/ Thigh (Popliteal Artery)

 MEASURING BLOOD PRESSURE

 Applies cuff on arms

 Cuff must be
appropriate size
 Cuff should be snug, not
loose
 Feel for strong pulsation
on the brachial artery
with the use of 2-3
fingertips.
 MEASURING BP…cont’d

 Position the bell of the

stethoscope on the
brachial site with the
earpiece into ears.
 Do not put
stethoscope under
cuff (place cuff 1-2
inches above elbow)
 MEASURING BP…cont’d

 Pumps the bulb on the manometer until

the mercury rises to approximately
20mmHg above point where the systolic
pressure is noted
 Release air gradually with the use of the
valve of the bulb while taking note on the
manometer point of the first distinct sound
(systolic) and continues to listen for the
last sound (diastolic)
MEASURING BP…cont’d

 Make mental note of systolic and

diastolic number then record in the
jotdown notebook
 If unsure of reading, wait 30 seconds
and recheck-if unsure, have
someone else check with you
 Loosen cuff even if to be checked
q15 minutes
 Make sure all air is out cuff before
applying
POINTS ON BP TAKING:

 False high if cuff too small,

false low if cuff is too loose
 Auscultatory gap –temporary
disappearance of sound
between first sound and next
sound.
 Don’t take BP on arm with IV,
sling, surgery, mastectomy,
renal dialysis shunt, etc.
POINTS ON BP TAKING: cont’d

 Pt should be sitting or
lying with arm at the
level of the heart
 Distinguish Korotkoff
sounds (sounds heard
when taking BP) from
artifact
ASSESSMENT OF BP IN BOTH
ARMS

 Heart disease
 1st time BP
 5-10 mm Hg
difference-use reading
that is highest
 Difference of 10mm
Hg should be reported
HOW and WHY BP TAKEN BY
PALPATION

 HOW-apply cuff over

brachial artery
 Pump up to 20-30 points
above last systolic reading
 Feel with 2 fingers for
systolic pressure; will not
feel diastolic pressure
 WHY- unable to hear weak
BPs
FACTORS AFFECTING BP

 Exercise-increases
 Arteriosclerosis (loss of
vessel elasticity) &
Atherosclerosis (build
up of plaque)-increases  Drugs
 Transfusions- increases  Medications
with blood flow  Diurnal
 Emotions -increases variations
FACTORS AFFECTING BP…cont’d

 PAIN-increases
 Hemorrhage -decrease
 Sex/Gender
 RACE-Blacks more
prone increase
 Age
 Heredity-increased
chance if immediate
family history
ALTERATIONS IN BLOOD
PRESSURE

 HYPERTENSION – most common

alteration in BP. Most often
asymptomatic. Characterized by
persistently elevated BP.
 HYPOTENSION- When systolic blood
pressure falls to 90 or below.
 ORTHOSTATIC (POSTURAL)
HYPOTENSION
Common Mistakes in Blood
Pressure Assessments

Cuff too wide or Arm above or below

too narrow heart level or not
Cuff wrapped too supported
Repeating assessment
loose or unevenly too quickly
Inflating cuff too Inaccurate inflation level
slowly Poorly fitting
Deflating cuff too stethoscope
slowly or too Impairment of
quickly examiners hearing
V. PULSE RATE
Expansion of an artery with each
heart beat
the palpable bounding of the blood
noted at various points on the
body. It is an indicator of circulatory
status.
PULSE MEASURING TECHNIQUES

AREAS OF PALPATION:
Carotid, Brachial, Radial,
Femoral, Popliteal, etc.

*USE OF AUSCULTATION:
Stethoscope on apical (heart)
PULSE SITES
 1. TEMPORAL

2. CAROTID
PULSE SITES
3. APICAL

4. BRACHIAL

5. RADIAL

6. FEMORAL

7. POPLITEAL

8. DORSALIS PEDIS
LOCATION OF APICAL PULSE
TERMS RELATED TO PULSE

 Pulse—Rate, Rhythm, Quality

 Pulse Deficit
 Auscultate
 Palpate
 Tachycardia, Bradycardia
PULSE RANGES
AGE RANGES
Elderly (65+) 60-100
Average Adult 60-100 (50 or
below if extremely
athletic)
Newborn 0-24 Hrs 120-160
Infant 1mon-1yr 100-120
Children (varies with age)
PULSE TECHNIQUES

 Feel over BONY area

 DO NOT use thumb
 Use 2-3 fingers
 DO NOT squeeze
 Count 30 seconds if regular x 2
 Note Rate, Rhythm, Quality
 If irregular, count for 1 full minute or
take apical pulse for 1 minute.
APICAL-RADIAL PULSE

 Requires 2 nurses
 1 nurse counts apical
heart rate
 1 nurse counts radial
pulse
 BOTH count during the
same 60 seconds
 1 nurse acts as
timekeeper for both
nurses
PULSE DEFICIT

 Count apical-radial pulse

 The difference is the PULSE DEFICIT
 Apical pulse will always be the same or
higher than the radial pulse if both are
counted correctly
 If the radial pulse is higher, one or both
nurses counted incorrectly
FACTORS AFFECTING PULSE
RATES

 Exercise
 Temperature
 Emotions
 Drugs
 Hemorrhage
 Postural Changes
 Pulmonary Conditions
Variations of Pulse Rates

 TACHYCARDIA – Abnormally
elevated pulse rate. (above 100
beats/ min)
 BRADYCARDIA – Abnormally
slow pulse rate (less than 60 beats
/ min)
PULSE RHYTHM

 Regular – A regular interval of time

occurs between each heartbeat or
pulse felt.
 Irregular – Interval interrupted by
early, late, or missed beat.
STRENGTH AND QUALITY OF PULSE

Pulse strength may be described as

weak, strong, bounding, or thready.
PULSE GRADING (0-4 rating scale)
0 : absent, not palpable
1+ : diminished, barely palpable
2+ : easily palpable, normal pulse
3+ : full, increased strength
4+ : bounding, cannot be obliterated
SUMMARY FOR PULSE RATE

PULSE RATE PULSE RHYTHM

 Normal 60 – 90 / min  Regular
 Bradycardia ↓ 50 / min  Irregular – Arrythmia
 Tachycardia  100 / min
 Asystolia PULSE QUALITY
 Strong (fever)
 Weak (shock/heart
failure)
 VI. PAIN

Process of  Characteristic of Pain:

measuring  Onset
pain:  Duration
 Verbal
 Location
 Nonverbal
 Quality
 Intensity
 Variations
FACTORS AFFECTING PAIN

 Culture
 Developmental stage
 Gender
 Anxiety
 Previous experience
  Numerical (0-10)
 Verbal (Descriptive)
 Visual Analog (Faces
PAIN SCALE Pain Rating Scale)
Documentation of Vital Signs

 Graphic sheets
 Flow sheets
 Nurses notes
 Computerized VS
ANSWER THE FOLLOWING:
1. What do you evaluate in Glasgow Coma Scale?
2. What is the normal body temperature?
3. Name 3 symptoms of fever.
4. What is the most commonly used route for measuring
the body temperature in infant?
5. Could you define the term for the high respiratory rate?
6. What is the limit for hypertension?
7. Name 2 methods of BP measurement?
8. Name 2 arteries where the pulse is most commonly
felt?
9. Could you specify the normal pulse rate?
10. What is the point at which the beat stops during the BP
measurement called?
END OF SLIDES
Thank You!