VITAL SIGNS

 These are basic components of assessing the physiological and psychological conditions
of a client.
 They are vital because they are governed by the vital organs in body (cardiorespiratory).

They include:
 Temperature (T)
 Pulse (P) and apex beat
 Respiratory Rate (R)
 Blood Pressure (BP)
 Pulse Oximetry (SpO2)
Importance of taking vital signs
 They help establish baseline values of the cardiorespiratory integrity.
Baseline values establish the norms against which subsequent
measurements can be compared
 Monitor patients progress by comparing with previous findings
 To make a diagnosis and determine treatment options. Variations from
the normal findings may indicate potential problems with the client’s
health status.
 Monitor for side – effects of drugs
TIME TO ASSESS VITAL SIGNS

• On admission to provide a baseline which can be compared with

subsequent measurements, thereby providing objective data and
trends.
• When a client has a change in the health status or reports symptoms
such as chest pain.
• Before and after surgery or an invasive procedure
• Before and/ or after administration of medication
• Before and after any nursing intervention that could affect the vital
signs e.g ambulating a client who has been on bedrest.
1.TEMPERATURE

• Body Temperature is the heat of the body and is measured in degrees.

Temperature measurement is by Thermometers
• The average normal human core temperature is around 98.2 F (36.8 C),
plus or minus 1.3 degrees Fahrenheit (0.7 C) when taken orally, and
about 1.0 F (0.5 C) higher when taken rectally
DIFFERENT TYPES OF THERMOMETERS

• 1. Mercury and Alcohol Thermometers

 Mercury thermometers have mercury filled in a glass tube and has a
glass bulb at the bottom.
 As the temperature increases, the mercury rises in the glass tube.

• Alcohol thermometers have ethanol instead of mercury in the glass

tube. All the other mechanism of the thermometer are same as that of
the mercury thermometer
2. Digital Thermometers
 Digital thermometers
 senses the change in temperature and display the temperature on a
digital display.

 Infrared thermometers use the infrared sensors to determine the

temperature and have a digital display.
Normal Temperature Readings
 The temperature reading vary depending on the age of the client and which part of the body is
being measured.
 Temperature can be taken from the following parts of the body:
 Axillary
 Groin
 Rectal
 Oral
 Ear/Tympanic
 The typical daytime temperatures among healthy adult is 36.5 – 37.5 degrees Celsius
FACTORS AFFECTING BODY
TEMPERATURE
• Age - As people age they become more sensitive to extremely hot or cold environments,
which can affect body temperature
• Diurnal variations (circadian rhythms) - in health, a person’s temperature fluctuates
throughout the day
• Exercise - increases heat production, which results in an increased body temperature.
• Hormones - During ovulation, for example, women’s temperatures can be raised
• Stress
• Environment - Environmental climates where individuals are exposed to extreme
temperature conditions may result in them developing heat stroke or hypothermia.
• Hot and cold food and drink may affect temperature
2.PULSE

• Is a wave of blood created by contraction of the left ventricle of the

heart.
• Pulse wave represents the stroke volume output and the amount of
blood that enters the arteries with each ventricular contraction.
• In a healthy person, the pulse reflects the heart beat
TAKING PULSE

• The pulse can be recorded anywhere that a surface artery runs over a
bone.
• To measure a pulse, one should place the index, middle, and ring
fingers over the radial artery. It is located above the wrist, on the
anterior or front surface of the thumb side of the arm.
• Gentle pressure should be applied, taking care to avoid obstructing
blood flow.
• The rate, rhythm, strength, and tension of the pulse should be noted.
PULSE SITES

• Temporal – when radial pulse is not accessible

• Carotid – in cases of cardiac arrest
• Apical – routinely for infants and children upto 3 years, determine discrepancies with radial
pulse
• Brachial – to measure blood pressure
• Radial – readily accessible
• Femoral – in cases of cardiac arrest
• Popliteal – determine circulation of the lower leg
• Posterior tibial - – determine circulation of the foot
• Dorsalis pedis - – determine circulation of the foot
PULSE CHARACTERISTICS

Rate
 Is an indirect measurement of cardiac output obtained by counting the number of apical
waves over a pulse point.
 Bradycardia: Is the heart rate less than the normal (60 beats/minute in an adult)
 Tachycardia: Is a heart rate more than normal (100 beats/minute in an adult)

) Rhythm
 It is the regularity of the heart beat. It describes how evenly the heart is beating
 Regular: The beats are evenly spaced
 Irregular: The beats are not evenly spaced
 Dysrhythmia (arrhythmia): Is an irregular rhythm caused by an early, late or missed beat.
 Intermittent: Pulse whose rhythm changes from being regular to irregular and vice versa
d) Volume
 It is the measurement of strength of force exerted by the ejected blood
against the artery wall with each contraction
 Normal: Full, easily palpable
 Weak: Thready and usually rapid
 Strong: Bounding
FACTORS AFFECTING THE PULSE

• Age
• Gender
• Exercise
• Fever
• Medications e.g digitalis
• Hypovolaemia
• Stress
• Position changes
• Pathology
3.RESPIRATIONS

• Respiration is the act of breathing.

• Purpose: To Exchange O2-CO2 in lungs/ tissues
• Ventilation-movement of air in & out of lungs
• However, we count respirations

Measure:
• Rate, rhythm, depth, effort of breathing

Normal:
• Rate - 16-20/ min; regular rhythm;
• Depth- subjectively measured as shallow, normal, or deep
• Effort - no effort; unlabored
• An examiner's fingers should be placed on the person's wrist, while the
number of breaths or respirations in one minute is recorded.
• Every effort should be made to prevent people from becoming aware
that their breathing is being checked.
RHYTHMS/ BREATHING PATTERNS

• Eupnea- normal rate & rhythm

• Tachypnea- rapid breathing, rate > 20/min
• Bradypnea- slow breathing, rate < 16/min
• Dyspnea- difficult or labored breathing
• Apnea- absence of breathing
• Orthopnea- inability to lie down to breathe
4.BLOOD PRESSURE

• Blood Pressure (BP) is the lateral force on the walls of artery by the
pulsing blood under pressure from the heart. The heart’ s contraction
forces blood under high pressure into the aorta.
• The peak of maximum pressure when ejection occurs is the systolic
blood pressure. When the ventricles relax, the blood remaining in the
arteries exerts a minimum a diastolic pressure.
MEASUREMENT

• Indirect Measurement: Requires use of sphygmomanometer and

stethoscope for auscultation and palpation as needed
• A mercury column sphygmomanometer and an
aneroid sphygmomanometer
• Stethoscope
• The stethoscope is an instrument for listening to sounds within the
body.
• Body sounds can be heard at the skin’s surface and transported via
enclosed columns of air to the ear.
• In order to take the blood pressure, the stethoscope diaphragm is
applied directly over the brachial pulse pressure point (inner arm).
PROCEDURE

1. CHECK THE EQUIPMENT. Do not use if any problems are found.

a. Look to see that the gauge - mercury meniscus or aneroid needle is at zero
b. Check the cuff for any breaks in stitching or tears in the fabric.
c. Check the rubber tubing for cracks or leaks, especially at connections.
d. Be sure three sizes of cuffs are accessible (small, regular, and adult large).
2. PLACE THE MANOMETER so it can be viewed straight on and within 15 inches
of the viewer.
3. RIGHT ARM will be used when possible. Upper arm should be bare and
unconstricted by clothing
4. SELECT THE APPROPRIATE SIZE CUFF. The bladder width should equal at least
40% of the circumference of the upper arm, and the length of the bladder
should be 80% of the circumference of the arm, but no more than 100%.
5. PALPATE the location of the brachial artery (on the upper arm's inner aspect).
6. POSITION the center of the cuff's bladder over the brachial artery.
7. APPLY THE CUFF evenly and snugly one-inch (2.5 cm) above the antecubital
fossa (bend of arm).
8. POSITION THE ARM so the cuff is at heart level. The arm should rest firmly
supported on a table, slightly abducted and bent, with palm up.
9. For the first reading only,
a. Palpate the radial artery pulse.
b. Inflate the cuff to the point where the pulse can no longer be felt.
c. Slowly deflate the cuff, noting on the gauge the point where the pulse
reappears/can again be felt. This is the estimated systolic pressure.
Rapidly deflate the cuff. Wait at least 15-30 seconds before re-inflating
the cuff to begin the first auscultatory measurement. (This allows good
circulation to be reestablished.)
10. CHECK THE CLIENT'S POSITION. Legs should be uncrossed, feet
resting firmly on the floor and the back supported while blood pressure
is being measured.
11. INSERT the stethoscope earpieces, angled forward to fit snugly.
12. PLACE THE BELL OR THE DIAPHRAGM HEAD of the stethoscope lightly
over brachial artery at the bend of the elbow, but with good skin
contact. Avoid too much pressure, which can close off the vessel and
distort the sounds, therefore altering the reading. (The bell head is
preferred because it permits more accurate auscultation of the
Korotkoff sounds than the diaphragm, especially in the interpretation of
diastolic readings.)
14. INFLATE the cuff as rapidly as possible to maximum inflation level (MIL),.
15. DEFLATE THE CUFF SLOWLY and CONSISTENTLY at the rate of 2 mm per pulse beat.
The rate of deflation should be slow enough to accurately evaluate the exact millimeter
marking of the Korotkoff sounds. Once deflation has begun, never reinflate.
16. NOTE where the first sharp rhythmic sound appears in relation to the number or
markings on the gauge. This is the systolic pressure.
17. CONTINUE DEFLATION at the established rate. NOTE on the gauge where the last
sound is heard. This is the diastolic pressure in adults.
18. CONTINUE DEFLATION for 10 mm Hg past the last sound. (This assures that the
absence of sound is not a "skipped" beat but is the true end of the sound.) Then deflate
the cuff rapidly and completely.
Classification SBP(mmHg) DBP(mmHg)

Normal 120 80
Pre-hypertension 120-139 80-89
Grade 1 140-159 90-99

Grade 2 160-179 100-109

Grade 3 >/= 180 >/= 110

INDICATIONS:

o New patients.
o Pre and post operative patients.
o Antenatal and post natal patients.
o Patients with shock and haemorrhage.
o Patients with cardiac conditions and hypertension
o Patients with neurological disorders
FACTORS THAT CAN AFFECT BLOOD
PRESSURE READING
• Emotional State - Stress or anxiety can cause large increases in blood
pressure.
• Talking - studies have shown that systolic blood pressure measurement may
increase 10 to 15mmHg.
• Smoking- Tobacco products all contain nicotine which will temporarily
increase blood pressure.
• Alcohol/Caffeine- Alcohol and caffeine consumption causes blood pressure
levels to spike.
• Temperature- Blood pressure tends to increase when you are cold.
PULSE OXIMETRY

 This is the measurement of arterial oxygen saturation using non – invasive

light
 The amount of hemoglobin saturated with oxygen is an important indicator
for patients, especially in intensive care and emergency situations.
Measurement
 A sensor is placed on a thin part of the patient's body, part of the body that
is relatively translucent and has good arterial pulsed blood flow, usually
fingertip, toe, earlobe, or in the case of an infant, across a foot.
Evaluation Of SpO2 Measurements
 An SpO2 of between 95-100% is considered normal

 An SpO2 of 92% or less (at sea level) suggests hypoxemia

 In a patient with acute respiratory illness and difficulty in breathing e.g.
asthmatic attack, an SpO2 of 92% or less may indicate need of O2
 In a patient with stable chronic disease, an SpO2 of 92% or less should
prompt referral for further investigations.