vital signs consisting of temperature, pulse, respiration, blood pressure, oxygen saturation & pain.

1. Prof. Mrs. Meha Rawat
Principal
Patidar Nursing Institute
Ujjain

2. Vital Signs
The term vital signs suggests assessment
of vital or critical physiological functions.
Temperature, pulse, respiration & blood
pressure are 4 importalkkjnt VS. pain is 5th .

3. Vital sign
• Vital signs are physical
signs that indicate an
individual is alive, such as
heart beat, breathing rate,
temperature, blood
pressures and recently
oxygen saturation.
• These signs may be
observed, measured, and
monitored to assess an
individual's level of
physical functioning.

4. Vital Signs
• Temperature, pulse, respiration, blood pressure
(B/P) & oxygen saturation are the most frequent
measurements.
• Because of the importance of these
measurements they are referred to as Vital
Signs. They are important indicators of the
body’s response to physical, environmental, and
psychological stressors.

5. Vital Signs
• VS may reveal sudden changes in a client’s condition in
addition to changes that occur progressively over time.
A baseline set of VS are important to identify changes in
the patient’s condition.
• VS are part of a routine physical assessment and are not
assessed in isolation. Other factors such as physical
signs & symptoms are also considered.
• Important Consideration:
• A client’s normal range of vital signs may differ from the standard
range.
• Normal vital signs change with age, sex, weight, exercise tolerance,
and condition.

6. Observation
• Does the patient
seem anxious, in
pain, upset? What
about their dress and
hygiene? Remember,
the exam begins as
soon as you lay eyes
on the patient.

7. Vital sign
• Prior to measuring
vital signs, the patient
should have had the
opportunity to sit for
approximately five
minutes.
• Before diving in, take
a minute or so to look
at the patient in their
entirety.

8. When to take vital signs
1. On a client’s admission
2. According to the physician’s order or the institution’s policy or
standard of practice
3. When assessing the client during home health visit
4. Before & after a surgical or invasive diagnostic procedure
5. Before & after the administration of meds or therapy that affect
cardiovascular, respiratory & temperature control functions.
6. When the client’s general physical condition changes
LOC, pain
7. Before, after & during nursing interventions influencing vital signs
8. When client reports symptoms of physical distress

9. Body Temperature
• Body Temperature is the degree of heat
maintained by the body. It is the difference
between heat produced by the body &
heat lost to the environment. Balance
between heat produced and heat lost
by the body
• Thermogenesis
• Thermolysis
• Heat Regulation:
Hypothalamus.

10. Body Temperature
• Core temperature – temperature of the body tissues, is
controlled by the hypothalamus (control center in the
brain) – maintained within a narrow range.
• Skin temperature rises & falls in response to
environmental conditions & depends on bld flow to skin
& amt. of heat lost to external environment
• The body’s tissues & cells function best between the
range from 36 deg C to 38 deg C
• Temperature is lowest in the morning, highest during the
evening.

11. Temperature
• Old people, people
with disabilities,
babies and young
children typically
feel more
comfortable at
higher
temperatures.

12. Temperature
• Women notice that
they are feeling
cool quicker than
men, which may be
related to their
different body size.

13. Temperature
• 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.

14. WAYS OF PRODUCING HEAT IN BODY
• Oxidation of food
• Specific dynamic action of food
• Exercise
• Strong emotions
• Hormonal effect
• Change in environmental & atmospheric
conditions
• Diseased condition

15. WAYS OF LOSING HEAT FROM
THE BODY
• Through the skin
• Through the lungs
• Through the kidneys
CONSERVATION OF
BODY HEAT

16. Thermometers – 3 types
• Glass mercury – mercury expands or contracts in
response to heat. (just recently non mercury)

17. Cont…
• Electronic – heat sensitive
probe, (reads in seconds)
there is a probe for
oral/axillary use (red) & a
probe for rectal use (blue).
There are disposable
plastic cover for each use.
Relies on battery power –
return to charging unit
after use.

20. Cont.
• Infrared Tympanic (Ear) – sensor probe
shaped like an otoscope in external
opening of ear canal. Ear canal must be
sealed & probe sensor aimed at tympanic
membrane – ret’n to charging unit after
use.

22. o MEASURES THE TEMPERATURE IN THE TYMPANIC MEMBRANE (EARDRUM)
o FAST AND ACCURATE - 1 TO 3 SECONDS
INFANTS – PULL
THE EAR
STRAIGHT BACK
ADULTS AND
CHILDREN OVER
ONE YEAR –
PULL THE EAR UP
AND BACK

23. CONT…
• Disposable paper thermometer: single use
paper thermometers are tin strips of
chemically treated paper.
• Temperature sensitive strips & chemical
dots: it give general indication of body
surface temperature.
CARE OF THERMOMETER

24. USE A DISPOSABLE SHEATH

25. Celsius & Fahrenheit scales.•
C= (F-32)x 5/9
• To convert C to F
F= (C x 9/5) + 32

27. Common Sites for taking body
temperatureOral
Posterior sublingual pocket – under
tongue (close to carotid artery)
No hot or cold drinks or smoking 20
min prior to temp. Must be awake &
alert.
Not for small children (bite down)
Leave in place 3 min
Axillary
Bulb in center of axilla
Lower arm position across chest
Non invasive – good for children.
Less accurate (no major bld vessels
nearby)
Leave in place 5min.
Measures 0.5 C lower than oral temp.
Rectal /vaginal
Side lying with upper leg flexed, insert
lubricated bulb (1-11/2 inch adult) (1/2
inch infant)
When unsafe or inaccurate by mouth
(unconscious, disoriented or irrational)
Side lying position – leg flexed
Leave in place 2-3 min.
Measures 0.5 C higher than oral
Ear
Close to hypothalmus – sensitive to
core temp. changes
Adult - Pull pinna up & back
Child – pull pinna down & back
Rapid measurement
Easy assessibility
Cerumen impaction distorts reading
Otitis media can distort reading
2-3 seconds

29. GLASS
THERMOMETER
o RINSE WITH COLD WATER
o CHECK THE THERMOMETER
FOR BREAKS AND CHIPS
o SHAKE DOWN THE
THERMOMETER SO THE
MERCURY IS BELOW THE LINES
AND NUMBERS
o PLACE A DISPOSABLE COVER
ON THE THERMOMETER
o PLACE THE THERMOMETER
UNDER THE PERSON’S TONGUE
o LEAVE THE THERMOMETER IN
PLACE FOR 2 – 3 MINUTES
o IF THE PERSON HAS BEEN
EATING, DRINKING, OR
SMOKING, WAIT 15 MINUTES
BEFORE TAKING TEMPERATURE

30. DO NOT TAKE AN ORAL TEMPERATURE ON:
o AN INFANT OR YOUNG CHILD ( UNDER AGE 6)
o AN UNCONSCIOUS PATIENT
o A PATIENT THAT HAS HAD ORAL SURGERY OR AN INJURY TO THE FACE,
NECK, NOSE, OR MOUTH
o A PERSON RECEIVING OXYGEN
o A PATIENT WITH A NASOGASTRIC TUBE IN PLACE
o A PATIENT WHO IS CONFUSED OR RESTLESS
o A PATIENT WHO IS PARALYZED ON ONE SIDE OF THE BODY
o HAS A HISTORY OF SEIZURES
o A PATIENT WHO BREATHES THROUGH THE MOUTH

31. o LUBRICATE THE THERMOMETER BEFORE INSERTING INTO THE RECTUM
o PLACE THE PERSON IN A SIDE-LYING POSITION
o INSERT THE THERMOMETER 1 INCH INTO THE RECTUM
o HOLD THE THERMOMETER IN PLACE FOR 2 MINUTES
o REMOVE THE DISPOSABLE COVER AND READ THE THERMOMETER

32. DO NOT TAKE A RECTAL TEMPERATURE ON:
o A PERSON WHO HAS HAD RECTAL SURGERY OR RECTAL INJURY
o IF THE PERSON HAS DIARRHEA
o IF THE PERSON IS CONFUSED OR AGITATED
o IF THE PERSON HAS HEART DISEASE ( STIMULATES THE VAGUS NERVE
WHICH SLOWS THE HEART RATE )

34. o TAKEN ONLY WHEN NO OTHER SITE CAN
BE USED
o MAKE SURE THE UNDERARM IS CLEAN
AND DRY
o THE ARM IS HELD CLOSE TO THE BODY
o YOU NEED TO HOLD THE THERMOMETER
IN PLACE WHILE THE TEMPERATURE IS
BEING TAKEN
o THE THERMOMETER IS LEFT IN PLACE
FOR 10 MINUTES

35. FEVER
A fever is indicated when body temperature
rises above 98.6° F orally or 99.8° F rectally.
Cause: infections, diseases of CNS malignant
neoplasm, blood diseases, heat stroke,
dehydration, crushing injury etc.

36. EFFECT OF FEVER
• Respiratory system: shallow & rapid
breathing
• Circulatory system: increased pulse rate
& palpitation.
• Alimentary system: dry mouth, coated
tongue, loss of appetite, indigestion,
nausea, vomiting, constipation, or
diarrhea.
• Urinary system: diminished urinary
output, burning micturition, high colored
urine.

37. Cont….
• Nervous system: head ache, restlessness,
irritability, insomnia, convulsions, delirium.
• Musculoskeletal system: malaise, fatigue,
body pain, joint pain.
• Integumentary system: heavy sweating, hot
flushes, shivering or rigors.

38. 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
37,0 – 37,9 °C
Perspiration
Skin redness
Headache
Fever
 38 °C
Presence of infection → body defence
General weakness
Tachycardia / hyperpnea
Skin paleness/redness
Shivers
Perspiration

39. TYPES OF FEVER
• ONSET OR INVASION: It is the period
when the body temp. is rising & it may be a
sudden or gradual process.
• FASTIGIUM OR STAGIUM : it is the
period when the body temp. reach its max.
& remains constant at a high level.
• DEFERVESCENCE or DECLINE: it is the
period when elevated temp. is returning to
normal. The fever subsides
suddenly(crisis) or gradually (lysis).

40. Cont………
• CRISIS: A sudden return to a normal temp.
from a very high temp. within few hrs. or
days.
• True crisis: tem. Falls within few hrs &
touches normal with improvement in client’s
condition.
• False crisis: sudden fall but not
accompanied by with improvement in client’s
condition.
• Lysis: fall of temp. in a zig-zag manner for
2-3 days or week.

41. Cont…
• Constant or continuous fever: temp.
varies not more than 2 degree between
morning & evening. It doesn’t reach normal
for a period of days or wk.
• Remittent fever: variation of more than 2
degree between morning & evening, but
doesn’t reach normal.
• Intermittent or quodition fever: temp.
rises from normal to subnormal to high
fever & back at regular intervals which may
from few hrs to 3 days. Temp is higher in
evening.

42. Cont.
• Inverse fever: highest range is recorded in
morning hrs & lowest in evening.
• Hactic fever: difference between high &
low point is very great.
• Relapsing fever: brief febrile period
followed by 1 or more days of normal temp.
• Rigor: sudden attack of shivering.
• Low pyrexia: 99-100 F or 37.2-39.4C
• Moderate pyrexia: 100-103 F or 37.8 -
39.4C

43. Cont…
• High pyrexia: 103-105F or 39.4- 40.6C
• Hyperpyrexia: temp higher than 105 F.
• Hypothermia: temp.falls below 95F or 35C

44. NURSING CARE DURING FEVER
REGULATION OF BODY TEMPRETURE
• Maintain room ventilation
• Exposure to cool by fan or cooler
• Plenty of fluids
• Application of cold compress or ice bags
• Cold sponging
• Cold bath
• Ice cold lavage or enema
• Use of hypothermic blanket

45. MEETING THE NUTRITIONAL NEEDS
• Increase in oxygen consumption- 13% for
each *C & 7% for each *F.
• High caloric diet.
• Easily digestible & palatable.
• Plenty of fluids if not contraindicated i.e.
3000ml/day to eliminate waste products.
• I/O charting
• Small & frequent feeds
• Frequent mouth wash

46. PROVIDING REST & SLEEP
• Complete bed rest.
• Calm & quiet unit. Without light & glares.
• Changing position.
• Light, loose, smooth & non irritating cotton
clothing
MAINTAINANCE OF PERSONAL HYGEINE
• Complete Oral care 4 hrly.
• Sponge bath
• Back care.

47. SAFETY FACTORS
• Rigors & convulsions may occur so don’t
leave the client alone.
• Observation of client
• Frequent v/s check up
• Rectal temp. may taken.

48. CARE DURING RIGORS
Rigor has 3 stages:
1. Cold stage:
• uncontrollable shivering, cold skin, face is
pinched & pale.
• Temp. is high >103*F or more
• Cover the pt with blanket, apply warmth
with hot bags
• Give warm drinks & prevent from falling

49. 2. HOT STAGE
• Skin feels hot & dry. pt. is thirsty& restless.
• Shivering stops. , but temp. rises.
• Remove all blankets & hot appliances
• Give cool drinks. Cold compress to relive
congestion & head ache.
• Recording of v/s. ^ Temp & pulse
• Cold sponging may be started.
• Watch for sweating.

50. 3. STAGE OF SWEATING
• Profuse sweating & temp. falls
• Pulse improves.
• Give quick sponge & dry the pt.
• Change the cloths which are wet
• Sweet drinks
• Watch the pt cover with light blanket.

51. PULSE
• Alternate expansion & recoiling of an artery.
Normal range of pulse for an adult is 70-80
bpm.
• It can be felt on a point where an artery
crosses a bone close to the surface of skin.
• The pulse wave begins when the left
ventricle contracts & ends when it relaxes.
• Each contraction forces blood into already
filled aorta, increasing pressure within
arterial system.

52. • The intermittent pressure & expansion
of the arteries causes the blood to move in
a wave like motion towards the capillarie.
• The stroke volume is the quantity of blood
forced by each contraction of the left
ventricle which is about 70 ml.
• Cardiac output is the total quantity of blood
pumped per minute.
• Cardiac output= stroke volume x pulse
rate.

56. CHARACTERISTICS OF PULSE
• Rate
• Rhythm
• Volume
• Tension
RATE: No. of beats/min. normal pulse
rate is 60-100/m.
Pulse >100/m = tachycardia
pulse <60/m= bradycardia

57. FACTORS AFFECTING PULSE RATE
AGE:
• Before birth 140-150/m
• At birth 130-150/m
• First yr 115-130/m
• Second yr 100-115/m
• Third yr 90-100/m
• 4 to 8 yr 86-90/m
• 8 to 15 yr 80-86/m
• Adult 70-80/m
• Old age 60-70/m

58. Sex: female has rapid pulse than male
• Physique: short & small build have rapid than tall
• Exercise: increase muscular activity ^ pulse.
• Food: indigestion of food causes ^
• Posture: ^ in standing
• Emotions: strong emotions ^
• Application of heat: ^
• Pain: ^
• ^ body temp.: ^
• Diseased condition: ^
• Drugs: caffine, atropin, thyroid h. ^. Sedatives lowers
the rate.
• Cold application: lowers the rate.

59. • RHYTHM: It means regularity of pulse.
Heart beats spaced at equal interval called
regular pulse. If interval is varies it is
irregular. Count the pulse for full 1 min.
• VOLUME: fullness of an artery. It is the
force of the blood felt at each pulse. Normal
vol. of bld in arteries is called full or normal
pulse, but when vol. of bld is low it is called
weak, thready feeble or flickering pulse.
• Increase in vol. like in stroke, exercise
anxiety, hepatic failure, heart block is called
bounded pulse.

60. • TENSION: he degree of
compressibility. It is said high tension
when artery is difficult to compress & low
tension when easy to compress.

61. • Equipment: stethoscope
• Parts
• Ear piece
• Binaurals
• Tubing about 12 inches
• Diaphragm: high pitched sound
• Bell: low pitched sound

62. Procedure for Assessing
Pulses
• Peripheral – place 2nd, 3rd & 4th fingers lightly on skin where an artery
passes over an underlying bone. Do not use your thumb (feel
pulsations of your own radial artery). Count 30 seconds X 2, if
irregular – count radial for 1 min. and then apically for full minute.
• Apical – beat of the heart at it’s apex or PMI (point of maximum
impulse) – 5th intercostal space, midclavicular line, just below lt.
nipple – listen for a full minute “Lub-Dub”
• Lub – close of atrioventricular (AV) values – tricuspid & mitral
valves
• Dub – close of semilunar valves – aortic
& pulmonic valves

63. Respirations
• It is the act of breathing
– Inspiration – inhalation (breathing in)
– Expiration – exhalation (breathing out)
• I&E is automatic & controlled by the medulla oblongata
(respiratory center of brain)
• Respiration may be external or internal.
• Normal breathing is active & passive
• Women breathe thoracically, while men & young children
breathe diaphramatically ***usually
• Asses after taking pulse, while still holding hand, so pt is
unaware you are counting respiratons

64. Characteristics of Respiration
Rate # of breathing cycles/minute (inhale/exhale-1cycle)
N – 12-20 breaths/min – adult - Eupnoea – normal rate & depth breathing
Abnormal increase – tachypnoea
Abnormal decrease – bradypnoea
Absence of breathing – apnoea
Depth Amt. of air inhaled/exhaled
normal (deep & even movements of chest)
shallow (rise & fall of chest is minimal)
SOB shortness of breath (shallow & rapid)
Rhythm Regularity of inhalation/exhalation
Normal (very little variation in length of pauses b/w I&E

65. Rate
Factors affecting rate of res.
AGE:
• At birth 30-40/m
• First yr 26-30/m
• Second yr 20-26/m
• Adolescence 20/m
• Adult 16-20/m
• Old age 10-24/m

66. • Sex: females have rapid res. than males
• Emotions: stress, anxiety & fear may ^
• Exercise: it ^ metabolic rate thus ^ rate &
depth of res. Rest keeps it normal
• Change in external temp.: cold increases
oxygen need in order to keep body warm it
shivers so person take deep breath. In
fever temp is raised so 4 breaths/1 degree
is ^
• Ingestion & digestion of food: ^
• Disease condition
• Drugs

67. Depth of respiration:
• A normal man inspires & expires abt
500ml of air/ res. If it is > then it is said
deep res. & if it is less then it is said
shallow res.
• Tachypnoea: ^ in rate of res.
• Bradypnoea: Less no. of res.
• Hyperpnoea: deep breathing
• Polypnoea: rapid breathing
• Dyspnoea: difficult, laboured or painful
breathing.

68. Rhythm of respiration: Regularity of
respiration.
ABNORMAL RESPIRATION

69. Blood Pressure
• Force exerted by the bld against vessel walls. Pressure of bld within the
arteries of the body – lt. ventricle contracts – bld is forced out into the aorta
to the lg arteries, smaller arteries & capillaries
• Systolic- force exerted against the arterial wall as lt. ventricle
contracts & pumps bld into the aorta – max. pressure exerted on
vessel wall.
• Diastolic – arterial pressure during ventricular relaxation, when the
heart is filling, minimum pressure in arteries.
– Factors affecting B/P
– lower during sleep
– Lower with bld loss
– Position changes B/P
– Anything causing vessels to dilate or constrict - medications

70. B/P (cont.) P&P p. 240 see table 9-3
• Measured in mmHg – millimeters of mercury
• Normal range
• syst 110-140 dias 60-90
• Hypertensive - >160, >90
• Hypotensive <90
• Non invasive method of B/P measurement
• Sphygmomanometer, stethoscope
• 3 types of sphygmomanometers
» Aneroid – glass enclosed circular gauge with needle that registers
the B/P as it descends the calibrations on the dial.
» Mercury – mercury in glass tube - more reliable – read at eye
level.
» Electronic – cuff with built in pressure transducer reads systolic &
diastolic B/P

71. B/P (cont.)
• Cuff – inflatable rubber bladder, tube connects to the manometer, another to
the bulb, important to have correct cuff size (judge by circumference of the
arm not age)
– Support arm at heart level, palm turned upward - above heart causes false low
reading
• Cuff too wide – false low reading
• Cuff too narrow – false high reading
• Cuff too loose – false high reading
• Listen for Korotkoff sounds – series of sounds created as bld flows
through an artery after it has been occluded with a cuff then cuff pressure is
gradually released. P&P p. 240.
• Do not take B/P in
• Arm with cast
• Arm with arteriovenous (AV) fistula
• Arm on the side of a mastectomy i.e. rt mastectomy, rt arm

72. Procedure – B/P
Assessment Determine best site & baseline B/P
Nursing Diagnosis Decreased cardiac output
Fluid volume excess
Fluid volume deficit
Planning Expected outcome
Have pt rest 5 min before taking B/Pa
Wash hands
Implementation Palpate brachial pulse
Position cuff 1inch above pulse - Arm at level of
heart, wrap snugly around arm
Manometer at eye level

73. Procedure (cont.)
Implementation
Inflate cuff while palpating brachial Artery. Note
reading at which pulse disappears continue to
Inflate cuff 30 mmHg above this point. Deflate cuff
slowly and note when reading when pulse is felt.
Deflate cuff completely and wait 30 sec.
With stethoscope in ears locate the brachial artery –
place diaphragm over site
Close valve of pressure bulb. Inflate cuff 30 mm hg
above palpated systolic pressure
Slowly release valve
Note point on manometer when first clear sound is
heard (1st phase Korotkoff) – systolic pressure
Continue to deflate noting point @ which sound
disappears – 5th phase Korotkoff (4th korotkoff in
children
Deflate & remove cuff

74. B/P Lower Extremity
• Best position prone – if not – supine with knee slightly
flexed, locate popliteal artery (back of knee).
• Large cuff 1 inch above artery, same procedure as arm.
Systolic pressure in legs maybe 10-40 mm hg higher
• If unable to palpate a pulse – you may use a doppler
stethoscope

75. Oxygen Saturation (Pulse Oximetry)
• Non-invasive measurement of oxygen saturation
• Calculates SpO2 (pulse oxygen saturation) reliable estimate of arterial
oxygen saturation
• Probes – finger, ear, nose, toe
• Patient with PVD or Raynauds syndrome – difficult to obtain.
• Normal – 90-100%
• Remove nail polish
• Wait until oximeter readout reaches constant value & pulse display
reaches full strength
• During continuous pulse oximetry monitoring – inspect skin under
the probe routinely for skin integrity – rotate probe.

76. Procedure – Vital Signs
Assessment Route of temperature – po, tympanic, axilla, rectal
Determines if client has had anything hot/cold to drink or
smoked (20 min)
Planning Obtain equipment – thermometer, watch, stethosope, B/P
cuff & graphic sheet
Wash hands
Implementation Explains procedure to client
Temperature tympanic - thermometer
Pulse - Position client’s arm @ side or across chest, palpate
radial artery
Resp – Keeps fingers on wrist – count respirations
Documents TPR on graphic sheet
B/P – correct position, client’s arm supported @ heart level
Document

77. Vital Signs (cont.)
Evaluation V/S within normal range
Critical Thinking You are assessing a client’s pulse and the
rate is irregular. How would you
proceed?