Topic: Vital Signs Observation:

Learning Objectives:
At the end of the lesson the learners will be able to:
● Define Vital sign observation.
● List any four (4) purposes of vital sign.
● Identify any four (4) cardinals of vital sign.
● Enumerate stags of rigor
● State the requirements of vital sign.
● Explain the steps in taking temperature.
Introduction:
● Vital signs are measurements of the body's most basic functions.
● Vital signs are useful in detecting or monitoring medical problems.
● Vital signs can be measured in a medical setting, at home, at the site of a
medical emergency, or elsewhere.
The four main vital signs routinely monitored by medical professionals and
health care providers include the following:
● Body temperature.
● Pulse rate.
● Respiration rate (rate of breathing).
● Blood pressure (Blood pressure is not considered a vital sign, but is often
measured along with the vital signs.)
Definition:
● Vital signs are cardinal signs that tell you the health status of your client or
patient.
Purposes of Vital Signs Observation:
● To determine the state of hotness or coldness of the patient body.
● To determine the rate, rhythm and character of pulse and respiration.
● To aid in diagnosis.
● To assess improvement in the patient's condition.
● To determine the effectiveness of some drugs.
Temperature:
Introduction:
The normal body temperature of a person varies depending on:
● Gender.
● Recent activity.
● Food and fluid consumption.
● Time of day.
● And, in women. The stage of the menstrual cycle.
Normal body temperature can range from 97.7 degrees (or Fahrenheit,
equivalent to 36.5 degrees Celsius).
99 degrees F (37.2 degrees C) for a healthy adult.
 A person's body temperature can be taken in any of the following ways.
● Orally.
● Rectally.
● Axillary.
● By ear.
● By skin.

Orally:
Temperature can be taken by mouth using either the classic glass
thermometer, or the more modern digital thermometers that use an electronic
probe to measure body temperature.
Rectally:
Temperatures taken rectally (using a glass or digital thermometer) tend to
be 0.5 to 0.7 degrees F higher than when taken by mouth.
Axillary:
Temperatures can be taken under the arm using a glass or digital
thermometer.
Temperatures taken by this route tend to be 0.3 to 0.4 degrees F lower than
those temperatures taken by mouth.
By ear:
A special thermometer can quickly measure the temperature of the ear
drum, which reflects the body's core temperature (the temperature of the internal
organs).
By skin:
A special thermometer can quickly measure the temperature of the skin on
the forehead.
Body temperature may be abnormal due to fever (high body temperature) or
hypothermia (low body temperature).
A fever is indicated when body temperature rises about one degree or more
over the normal temperature of 98.6 degrees Fahrenheit, according to the
American Academy of Family Physicians.
Hypothermia is defined as a drop in body temperature below 95 degrees
Fahrenheit.
Normal Body Temperature
The average of human body temperature is 37 degrees Celsius to 98.6-degree Fahrenheit

Method Normal body Temperature

o o o o
Armpit 36.5 c to 37.5 c (97.8 f to 99.5 f)
 o o o o
Mouth 35.5 c to 37.5 c (95.9 f to 99.5 f)
o o o o
Ear 35.8 c to 38 c (96.4 f to 100.4 f)
o o o o
Rectal 36.6 c to 38 c (97.9 f to 100.4 f)

Definition: (Temperature)
Is the degree of hotness or coldness of the body as obtained by a standard
scale called Thermometer by used of mercury/digital.
Terms Used in Describing Temperature
Pyrexia (fever):
Is the elevation of body temperature above the normal range.
There are three types of pyrexia namely.
0 0 0
● Low (from 37.3 C - 38.2 C (99°F – 101 F)
● 0 0c)
Moderate (from 38.3 C - 39.4
0
● Hyperpyrexia (over 41 C)
Hypothermia (Subnormal body Temperature):
A body temperature below the average normal range.
Types of Pyrexia:
● Continuous Fever.
● Intermittent Fever.
● Inverse Fever.
● Remittent Fever.
Continuous Fever:
0
Temperature remains high, varying not more than 1 C in a day.
Intermittent Fever:
Variation is between normal and subnormal up to high fever or hyperpyrexia
every one, two or three days, regularly.

Inverse Fever:
Temperature rises in morning and falls in evening e.g. in tuberculosis.
Remittent Fever:
0
Temperature varies more than 1 C and does not reach normal within 24 hours.
Termination of Pyrexia:
By Crisis:
A sudden drop to normal within twenty-four hours, accompanied by a
corresponding drop in pulse and respiration rates.
By Lysis:
When there is a gradual drop to normal over two to ten days.
Requirements on a Tray:
● Thermometer in a container with antiseptic solution e.g. Dettol I-in 40.
● A watch with second hand or digital.
● Gallipot with cotton wool swabs.
● Gallipot containing water.
● Receiver for used swabs.
 ● TPR Chart

Taking of Temperature, Pulse and Respiration:

Oral Method:
Procedure:
● Explain the procedure to the client.
● Prepare tray and take to bed side.
0 0
● Shake down the thermometer to below 35 C or 94 F and rinse thermometer in
the gallipot containing water.
● Dry thermometer gently with cotton wool swabs being careful not to allow your
finger tips to touch the bulb of the thermometer.
● Ask your client to open his mouth, insert thermometer under his tongue and ask
him to close his lips and not clinch teeth then proceed to take pulse and
respiration.
● Leave thermometer for time stated on it (usually two minutes).
● See arm is at rest, find pulse at radial artery and count for one minute.
● Before removing hand from taking pulse, count respiration. That is count the
number of times the chest walls rise and falls in one minute.
● Withdraw thermometer, read at eye level and return to container then proceed to
record your observation on TPR chart.
● Discard tray, then wash hands and dry.
Skin Method:
Requirement:
● Thermometer in a container with antiseptic solution e.g. Dettol I-in 40.
● A watch with second hand or digital.
● Gallipot with cotton wool swabs.
● Gallipot containing water.
● Receiver for used swabs.
● TPR chart.

Procedure:
● Explain the procedure to the client /patient.
● Prepare tray and take to bed side.
0 0
● Shake down the thermometer to below 35 C or 94 F and rinse thermometer in
the galipot containing water.
● Dry thermometer gently with cotton wool swabs being careful not to allow your
finger tips to touch the bulb of the thermometer.
● Expose the area where temperature is to be taken e.g. axilla, groin or popliteal
space and dry with cotton wool swab. Insert thermometer and then hold arm or
leg in position so that thermometer is in touch with folds of skin.
● Leave thermometer for time stated on it (usually two minutes).
 ● See arm is at rest, find pulse at radial artery and count for one minute.
● Before removing hand from taking pulse, count respiration. That is count the
number of times the chest walls rise and falls in one minute.
● Withdraw thermometer, read at eye level and return to container then proceed to
record your observation on T.P.R. chart.
● Discard tray, then wash hands and dry.
NOTE: You write 'S' (Skin) on the (chart) reading to indicate route used.
Axilla Method:
Requirements:
● Thermometer in a container with antiseptic solution e.g. Dettol I-in 40.
● A watch with second hand or digital.
● Gallipot with cotton wool swabs.
● Gallipot containing water.
● Receiver for used swabs.
● TPR chart.
Procedure:
● Wash hand and inform patient.
● The axilla should be wipe with patients own towel, flannel or dry cotton.
● Checked thermometer and place in position (axilla).
● The arm is folded across the chest and held is position if necessary.
● The thermometer should be left in position for at least two minutes.
● Remove thermometer, read, wipe and shake down before replacing in the
container of antiseptic.
Rectal Method:
Requirements:
same as for oral except the following:
● Rectal Thermometer in a container with antiseptic solution e.g. Dettol 1-in-40.
● Lubricant e.g. Vaseline in a container.
● A watch with second hand or digital.
● Gallipot with cotton wool swabs.
● Gallipot containing water.
● Receiver for used swabs.
● TPR chart.

Procedure:
● Explain procedure to the patient.
● Screen bed of patient if he is an adult.
● Prepare tray and take to bed side.
● If patient is a child, remove napkin, clean buttocks and rectal area with dry
cotton wool swabs.
● Shake down thermometer to below 94°F/36°C rinse in water and dry with cotton
wool swabs and then lubricate thermometer lightly with Vaseline.
 ● Sit down and hold baby face down-wards on your lap holding legs steady.
● Insert thermometer gently into anus, clinch buttocks and hold in position for
time stated (usually one to two minute).
● If patient is an older child, it may be possible to leave him in the cot, but hold the
child as you gently insert thermometer in anus and keep in position for time
stated (1-2 minutes).++
+

● If patient is an adult e.g. unconscious patient, place in left lateral position and
insert thermometer in anus for about 2 inches (5cm) and hold in position for time
stated (1-2 minutes).
● Remove thermometer gently, wipe, clean and read at eye level and return
thermometer to antiseptic solution.
● Replace napkin in children.
● Record temperature on T.P.R. chart and indicate route by putting 'R' at the
reading.
General Instructions:
● Keep separate thermometer for each isolated patient.
● Always take a rectal temperature of unconscious, or extremely ill patients or a
child under 5 years of age.
● Never use a rectal thermometer for taking an oral temperature.
● Take the vital signs of critically ill patients and children every 4 hours.
● Take 4 hourly vital signs of all newly admitted patients and post-operative
 patients for 48 hours.
● Do not take the patient's temperature immediately after bath and do not take
oral temperature if patient has taken something hot or cold through the mouth,
wait for at least 10 minutes before taking the temperature.
● Take the vital signs of all patients twice a day or as ordered for the patient's
condition.
● Report sudden rise in temperature of 100°F or 39°C and below 96°F or 35°C.
● Take respiration and pulse at the same time with temperature.
● Patient must be at rest during vital signs observation.
● Any abnormal or subnormal reading of T.P.R is recorded with red biro on the
chart.

Rigor
Introduction:
Our body temperature is controlled by a part of the brain called the
hypothalamus.
This acts as a thermostat and 'sets' the normal body temperature to around
37°C (98.6°F).
The body then does all it can to obey the hypothalamus and hold its
temperature at this setting.
It generates heat through the processes of its metabolism. If it starts to get
cold, it takes steps to warm up; if it starts to get too hot it takes steps to cool
down.

Objective:
To reduce the level of chills and shivering.
Definition:
● A violent shivering attack due to sudden disturbance of heat regulating center
(Mechanism) OR
● Rigors are an attack of intense shivering occurring when the heat regulator
is disturbed.
● The temperature rises rapidly and may either stay elevated or fall rapidly as
profuse sweating occurs.
Stages of Rigor:
● Shivering - rise in temperature.
● Hot stage.
● Sweating - fall in temperature.
Requirements:

Top Shelf:
A tray containing tea cup with cover, a napkin and a flask containing hot water.
Bottom Shelf:
● 2 blankets.
● 1 counter pane.
● Hot water bottle.
● Extra requirements if needed on bedside of patient Oxygen cylinder and face
mask.
Management of Rigor:
● The nurse should provide the following for a patent having rigors.
● Provide adequate nourishment.
● Provide additional oxygen.
● Provide extra warmth.
● Provide additional fluids if clients health permits.
● Reduce physical activities to limit body increase need for oxygen.
During Rigor:
● Do not leave the patient alone in the cold stage.
● Give patient hot drink.
● Cover patient with extra blanket.
● Place under patient's hot water bottle.
Hot Stage (After the Cold Stage)
● Remove extra blanket and hot water bottle.
● Give cold drink.
● Sponge face and hands with tepid water. If temperature above 40°C (105°F).
● Take temperature of patient to detect decrease or rise temperature. If his
temperature reduces and patient starts sweat, discontinue the cold applications.
● Dry patient's face, neck and chest with a warm towel frequent interval.
● Change patient's clothing when necessary due to the sweating and the nursing
procedures.

NOTE: That during the treatment of rigor the temperature, pulse respirations are taken
every ten minutes.
● Emergency Treatment for Patient with.
● Temperature of 40°C and Over.

Pulse:
Introduction:
The pulse rate is a measurement of the heart rate, or the number of times
the heart beats per minute.
As the heart pushes blood through the arteries, the arteries expand and
contract with the flow of the blood.
Taking a pulse not only measures the heart rate, but also can indicate the
following:
√Heart rhythm.
√Strength of the pulse
The normal pulse for healthy adult’s ranges from 60 to 100 beats per minute.
The pulse rate may fluctuate and increase with exercise, illness, injury, and
emotions. Female age 12 and older, in general, tend to have faster heart rates
than do males.
Athletes, such as runners, who do a lot of cardiovascular conditioning, may
have heart rates near 40 beats per minute and experience no problems.
Definition:
Is the wave of expansion felt in an elastic artery wall, it corresponds with each
heartbeat.
It can be conveniently felt wherever a superficial artery passes over a bone e.g.
radial, temporal, femoral etc
Terms Applied to Pulse Rate in Disease:
● Tachycardia - Rapid pulse rate.
● Bradycardia - Slow pulse rate.
● Arrhythmia - The pulse rhythm is irregular.
● Intermittent - A normal pulse rhythm is broken by period of irregularity.
Sites for Palpating Pulse:
● Radial artery.
● Temporal artery.
● Carotid artery.
● Facial artery.
● Femoral artery.
● Dorsalis pedis artery.
Normal Range of Pulse Rate:

S/N MONTH/AGE RANGE RATE

1. O to 3month 100 to 160 B/M
2. Up to 1 year 80 to 120 B/M
3. 1 to 10 years 70 to 130 B/M
4. More than 10 years 60 to 100 B/M
5. Well trained athletes 40 to 60 B/M
Method of Taking Pulse:
 ● Using the first and second fingertips, press firmly but gently on the arteries until
you feel a pulse.
● Begin counting the pulse when the clock's second hand is on the 12.
● Count your pulse for 60 seconds (or for 15 seconds and then multiply by four to
calculate beats per minute).
● When counting, do not watch the clock continuously, but concentrate on the
beats of the pulse.
● If unsure about your results, ask another person to count for you.

Respiration:
Introduction:
The respiration rate is the number of breaths a person takes per minute.
The rate is usually measured when a person is at rest and simply involves
counting the number of breaths for one minute by counting how many times the
chest rises.
Respiration rates may increase with fever, illness, and with other medical
conditions.
When checking respiration, it is important to also note whether a person has any
difficulty breathing.
Normal respiration rates for an adult person at rest range from 12 to 16 breaths
per minute.
Definition:
Is the act of inspiration, expiration and a pause during the process, an
interchange of gases takes place in the lungs between the air and circulating
blood?
Terms Used to Describe Types of Respiration:
● Sighing (air hunger): long deep inspiration.
● Shallow: Found in diseases of the lungs.
● Stridor noisy: inspiration due to obstruction of upper air passages.
● Sertorius, Noisy, Snoring Inspiration.
● Wheezing: Sound made during expiration.
● Apnea: Periodic cessation of respiration.
● Hyperpnoea: Deep breathing.
● Dyspnea: Difficult or labored breathing.
● Orthopnea: Advance stage of Dyspnea.
● Cheyenne-stroke: A gradual increase in the depth of respiration and then a
period of apnea.
Normal Range for Respiration Rate:
 S/ MONTH/AGE RANGE RATE
N

2. Infant (up to 1 year) 25 to 40 B/M

3. Toddler (1 to 3 years) 20 to 30 B/M
4. Preschool (3 to 6 years) 20 to 25 B/M
5. School-age (6 to 12 years) 15 to 20 B/M
6. Adult 12 to 20 B/M

Blood Pressure (BP)

Definition:
This is pressure which blood exerts on encircling wall of blood vessels.
Purposes:
● To measure the arterial blood pressure of the patient.
● To aid in diagnosis.
● To aid treatment of patient.
● To observe improvement in patient's condition.

Terms Used in Describing Blood Pressure:

● Hypertension: This is a persistent rise in blood pressure above the normal range.
● Hypotension: This is fall of blood pressure below the normal range.
Sites for Obtaining Blood Pressure:
● Upper arm (Brachial artery) is the commonest site.
● Thigh (Popliteal artery).
● Forearm (radial artery).
● Foot (dorsalis pedis artery)
Method:
● Palpatory method.
● Auditory or ausucaltory method.
Palpatory Method Requirement:
● Sphygmomanometer (variety of BP apparatus exist that one has to be
conversant with, you therefore have to refer to their manuals for operation).
● Chart.
Procedure:
 ● Explain procedure to the patient and bring equipment to the patient's bed side.
● Place the patient lying down in a comfortable position, unless if the patient is
cardiac condition which will necessitate upright position.
● Place the blood pressure Apparatus carefully in a position level with the
patient's chest.
● Exposed patient's arm, deflate cuff and wrap to the patient's arm above the
elbow joint.
● Palpate the radial artery and inflate the cuff until you can no longer fill the
pulsation, then close valve.
● Then deflate the cuff until you are able to fill the radial pulse.
st
● Note the point where the pulse is 1 noticed (this is the systolic pressure).
● Remove cuff fold and place inside the container and make your patient
comfortable.
● Record the reading with red biro.
● Reassure patient and take apparatus back to the proper place
NB: Only systolic pressure is obtained by this method.

Auditory or Auscultator:
Requirement:
● Sphygmomanometer.
● Stethoscope.
● Chart.
Procedure:
● Explain procedure to the patient and bring equipment to the patient's bed side.
● Place the patient lying down in a comfortable position, unless if the patient is
cardiac condition which will necessitate upright position.
● Place BP apparatus carefully in a position level with the patient's chest.
● Exposed patient's arm, deflate cuff and wrap to the patient's arm above the
elbow joint.
● Palpate the brachial artery below the cuff and place the bell of the stethoscope
over it.
● Inflate the cuff until no pulsation then close the valve.
● Then deflate the cuff slowly until the first beat is heard.
● Note the point (this is the systolic pressure).
● Continue to deflate until the sound changes (this is the diastolic pressure).
 ● Remove the cuff from the patient's arm and place in the container and make
your patient comfortable.
● Record the systolic over diastolic pressure.
● Record as above (Palpatory method).
● Reassure patient and take apparatus back to the proper place.

NB: the students are expected to know those factors that maintain and influence the
blood
Pressure.
Factors Maintaining Blood Pressure Factors Influencing Blood Pressure
● Peripheral Resistance. ● Age.
● Pumping Action of Heart. ● Position.
● Blood Volume. ● Sex.
● Viscosity of the Blood. ● Exercise.
● Elasticity of Blood vessels. ● Emotional Stress.
● Ingestion of Food.
● Sleep/Rest.

Apex Beat
Definition:
This is listening of heart beat directly from the apex of the heart
Requirement:
● Stethoscope with bell.
● Observation Chart.
● Watch with seconds’ hand.
● Red and blue pen.

Procedure:
Explain the procedure to the patient.
Ensure privacy by screening.
Place the patient in a comfortable position.
Expose the chest and instruct the patient to breath normally.
th
Place the bell of the stethoscope over the apex (Locate in the 5 intercostal space and
approximately 8-9cm or 3.5 inches from the middle of the sternum and 2-3 inches below the
left nipple) and count the rate for a full minute.
NB: The second Nurse may count the pulse simultaneously and both rates are recorded.
Chart and indicate that the rate is apical heart rate, and if the pulse is checked
simultaneously, then distinguish between the radial pulse rate and the apical heart rate on
the chart.
Make patient comfortable.
Put away equipment and report any abnormality.