Vital signs are body temperature, pulse, respiration, and blood pressure. Pain is the fifth vital sign Monitoring a client’s vital signs should not be an automatic or routine procedure; it should be a thoughtful, scientific, assessment.

1. Prepared by: Lendell Kelly B. Ytac, RN
ASSESSMENT OF VITAL SIGNS

2. What is vital Signs?
 Vital signs are body temperature, pulse,
respiration and blood pressure.
 Pain is the fifth vital sign
 Monitoring a client’s vital signs should not be an
automatic or routine procedure; it should be a
thoughtful, scientific, assessment.

3. When to Assess Vital Signs?
 On admission to a health care agency to obtain baseline
data
 When a client has a change in health status or reports
symptoms such as chest pain of feeling hot or paint.
 Before and after surgery or an invasive procedure.
 Before and or/ after administration of a medication that
could affect the respiratory or cardiovascular systems,
for example giving a digitalis preparation.
 Before and after any nursing interventions that could
affect the vital signs (e.g.,ambulating a client who has
been on bed rest).

4. 1. CONSCIOUSNESS
Human ability to be aware of own thoughts,
emotions, surroundings → adequate responses
GLASGOW COMA SCALE (GCS)
Patient’s response to:
- verbal stimulation
- painful stimulation
- movement
Scale 3 – 15

5. CONSCIOUSNESS
Changes in consciousness
QUALITATIVE QUANTITATIVE
anxiety
depression
delirium
somnolent
stupor
coma (shallow/deep)

6. 2. 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
Types of thermometers:
- mercury-in-glass
- electronic
- chemical

7.  Core temperature –is the temperature of the deep
tissues of the body. Such as the abdominal cavity
and pelvic cavity. It remains relatively constant.
 Surface temperature-is the temperature of the skin,
the subcutaneous tissue, and fat. It rises and fall in
response to the environment.
Two kinds of body temperature

8. Factors affecting body’s heat
production
 Basal Metabolic Rate (BMR)- is the rate of energy utilization in the
body required to maintain essential activities such as breathing.
 Muscle activity-Muscle activity, including shivering, increases the rate
of metabolic rate.
 Thyroxine output- Increase thyroxine output increases the rate of
cellular metabolism throughout the body. This effect is called chemical
thermogenesis, the stimulation of heat production in the body
through increased cellular metabolism.
 Epinephrine, norepinephrine and symphathetic stimulation/
stress response. These hormones immediately increase the rate of
cellular metabolism in many body tissues. Epinephrine and
norepinephrine directly affect liver and muscle cells, thereby increasing
cellular metabolism.

9. Factors affecting body’s heat lost
 Radiation-is transfer of heat from the surface
on one object to the surface of another
without contact between the two objects.
 Conduction-is the transfer of heat from one
molecule to a molecule of lower temperature.
 Convection- is the dispersion of heat by air
currents.

10.  Vaporization- is continuous evaporation of
moisture from the respiratory tract and from
the mucosa of the mouth and from the skin.
This continuous and unnoticed water loss in
called insensible water loss, and the
accompanying heat loss is called insensible
heat loss-It accounts for about 10% of basal
heat loss.

11. Factors affecting Body
temperature
 Age-The infant is greatly influence by the
temperature of the environment and must be
protected by extreme changes. Children temperature
is more variable than adults. Older people
particularly those over 75 years, are at risk of
hypothermia.
 Diurnal Variations (circadian rhythms)- Body
temperatures normally change through the day,
varying as much as 1.0 °C (1.8 °F) between the early
morning and late afternoon.

12. Alteration in Body Temperature
 Hypothermia-Body Temperature below
normal range
 Pyrexia, Hyperthermia, Fever- body
temperature above normal range
 Hyperpyrexia – a very high fever as 41°C
(105.8°F)
 Febrile- the client who has fever
 Afebrile- the one who does not have fever

13. BODY TEMPERATURE
BODY TEMPERATURE SYMPTOMS
Hypothermia
<36 °C
Skin paleness
Tiredness
Normal
36 – 37.9 °C
Lowest 5 – 6am
Highest 4 – 6pm
Pyrexia
38 – 40 °C
Perspiration
Skin redness
Headache
hyperpyrexia
 >40 °C
Presence of infection → body defence
General weakness
Tachycardia / hyperpnea
Skin paleness/redness
Shivers
Perspiration

14. BODY TEMPERATURE
ROUTES FOR MEASURING THE BODY TEMPERATURE
- ORAL
best site for measuring in the clinical settings
triangle shaped thermometer
axillo – oral difference 0,3 °C
- AXILLARY
more likely to be affected by the environmental temperature,
used in children/adults
- RECTAL
fast thermometer, used in infants/confused patients/receiving O2 th.
axillo – rectal difference 0,5 °C
-

15. 3. RESPIRATION
NORMAL RESPIRATIONS
 Effortless
 Regular
 Smooth
AVERAGE RESPIRATIONS
 Infant to 2 years 24–34/min
 To puberty 20-26/min
 Adults 12-18/min
RESPIRATORY RATE
 Normal 12 – 20 / min
 Bradypnea ↓ 10 / min
 Tachypnea  25 / min
 Apnea
RESPIRATORY RHYTHM
 Normal
 Dyspnea (exertion/rest)
 Cheynes-Stokes respiration
(irregular deep/slow/shallow )
 Kussmaul’s breathing (deep)

16. Variations in Respirations by Age
Age Respiration Average and (Ranges)
Newborn 35 (30-80)
1 year 30 (20-40)
5-8 years 20(15-25)
10 years 19 (15-25)
Teen 18 (15-20)
Adult 16 (12-20)
Older Adult 16 (15-20)

17. Assessment of Oxygen saturation
 Pulse Oxymeter
 O2 saturation

18. 4. BLOOD PRESSURE (BP)
The pressure of blood in the arterial wall
Factors affecting BP:
- blood volume
- strength of contraction
- elasticity of artery wall
Assessment:
- Normal 100-130/60-90 mmHg
- Hypertension  >=140/90 mmHg
- Hypotension <mmHg
Measurements stated in terms of millimetres of mercury (mmHg)

19. BLOOD PRESSURE (BP)
BP reading:
- systolic pressure (ventricle contraction)
- diastolic pressure (ventricle at rest)
BP readings record: BP 120/80
Equipment:
- sphygmomanometer
- stethoscope

20. BLOOD PRESSURE (BP)
Places for measuring:
- upper arm (brachial artery)
- calf / thigh (popliteal artery)
Measuring techniques:
- auscultation
(sphygmomanometer+stethoscope)
- palpation
(sphygmomanometer)
- invasive methods (CVP)

21. 5. PULSE
Expansion of an artery with each heart beat
Measuring techniques / places of assessing:
- PALPATION
a. carotid artery
a. brachialis, radialis
a. femoral, popliteal etc.
- AUSCULTATION
stethoscope

22. PULSE
PULSE RATE
 Normal 60 – 90 / min
 Bradycardia < 50 / min
 Tachycardia  >100 /
min
PULSE RHYTHM
 Regular
 Irregular – arrythmia
PULSE QUALITY
 Strong (fever)
 Weak (shock/heart failure)

23. Variations in Pulse by Age
Age Pulse Average and (Ranges)
Newborn 130 (80-180)
1 year 120 (80-140)
5-8 years 100 (75-120)
10 years 70 (50-90)
Teen 75 (50-90)
Adult 80 (60-100)
Older Adult 70 (60-100)

24. ElectroCardiogram
 A heartbeat is a series of electrical events,
and the electrical changes generated by the
myocardium can be recorded by placing
electrodes on the body surface. Such a
recording is called an electrocardiogram
(ECG)
 typical ECG consists of three distinguishable
waves or deflections: the P wave, the QRS
complex, and the T wave. Each represents a
specific electrical event.

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