OBTAINING VITAL SIGNS

PETER JOHN P. GONO, BSN,RN, MAN

WHAT ARE VITAL SIGNS?

• Vital signs (often shortened to just ”vitals”)

are a group of the 4 to 6 most
important signs that indicate the status of the
body’s vital (life-sustaining) functions.
• These measurements are taken to help assess the
general physical health of a person, give clues to
possible diseases, and show progress toward
recovery.
• The normal ranges for a person’s vital signs vary
with age, weight, gender, and overall health.
 PRIMARY VITAL SIGNS
• Body temperature- T

• Heart rate or Pulse

rate – HR or PR

• Respiratory rate- RR

• Blood pressure- BP

• Pain
BODY TEMPERATURE
• Temperature recording gives an indication of core
body temperature which is normally tightly
controlled (thermoregulation) as it affects the rate
of chemical reactions.
• Body temperature is maintained through a balance
of the heat produced by the body and the heat lost
from the body.
• Temperature can be recorded in order to establish a
baseline for the individual's normal body
temperature for the site and measuring conditions.
• The main reason for checking body temperature is
to solicit any signs of systemic infection or
inflammation in the presence of a fever temp >
38.5 °C/101.3 °F or sustained temp >
38 °C/100.4 °F), or elevated significantly above the
individual's normal temperature. Other causes of
elevated temperature include hyperthermia.
• Temperature depression (hypothermia) also needs
to be evaluated. It is also noteworthy to review the
trend of the patient's temperature.
Body Temperature Should be Evaluated
in Relation to:
• ENVIRONMENTAL TEMPERATURE- the
body temperature is lower in cold weather and
warmer in hot weather.
• THE TIME OF THE DAY- the body
temperature upon awakening is generally low-
normal range due to inactivity of muscles.
Conversely in the afternoon temperature maybe
high-normal due to metabolic processes activity
and the temperature of the atmosphere.
• The amount of PHYSICAL EXERCISES the
patient perform.
• The AGE of the patient- at birth, heat regulating
mechanisms are generally not fully developed, so
occurring during the first year of life. In old age,
the loss of subcutaneous tissue and decrease of
blood flow due to arterial changes may cause less
tolerance for cold weather. The muscle activity
of older patients is limited and therefore less
heat is produced.
• The EMOTIONAL STATUS of the patient-
highly emotional states use an elevation in body
temperature. The emotions increase the activity
of secreting glands and thereby increase the heat
production.
• The DISEASE CONDITION of the patient-
toxins from some infective agents, pathogenic
disease or chemical reactions may produce
elevated body temperatures or fever.
• The phase of the patient’s MENSTRUAL
CYCLE and pregnancy- body temperature
drops slightly just before ovulation, and then
may rise to one whole degree above normal
during ovulation. Within a day or two preceding
the onset of the next menstrual period, the
temperature may consistently stay at high-
normal due to an increase in the patient’s
metabolic rate.
• The method of measuring body temperature- a
rectal temperature usually measures slightly
higher than oral and an axillary temperature
measures lower than oral.
Normal Body Temperature
Contraindications (ORAL)
• Infants
• Unconscious and irrational patients
• Patients who breathe through their
mouths
• Those with disease of the oral cavity or
surgery of the nose or mouth
• Patients who have had taken cold or hot
foods fluids
Parts of the Thermometer
Equipments

• 1. Tray containing:
• a. Thermometer
• b. Jar of cotton ball with alcohol
• c. Jar of cotton ball soaked in water
• d. Jar of dry cotton ball
• e. Waste receptacle
f. Tissue paper
•
• 2. Watch with second hand
• 3. Pocket notebook and pen
• 4. Alcohol for hand rub
• 5. Wrist watch
Obtaining Pulse Rate

• PULSE- is a wave of blood created by

contraction of the left ventricle of the heart.
• The heart is a pulsating pump, and the blood
enters the arteries with each contraction causing
pressure pulses or pulse waves.
• It represents the stroke volume output and the
amount of blood that enters the arteries with
each ventricular contraction.
• PERIPHERAL PULSE
• is a pulse located in the periphery of the body.
Example: in the foot, hand or neck.

• APICAL PULSE
• Is also called a central pulse, located in the apex
of the heart.
Factors affecting Pulse Rate

1. Age
• As the age increases, the pulse rate gradually
decreases.
2. Sex
After puberty, the average male pulse rate is
slightly lower than the female’s.
3. Exercise
The pulse rate normally increases with activity.
• 4. Fever
• The pulse rate increases (a) response to the
lowered blood pressure that results from
peripheral vasodilation associated with elevated
body temperature and (b) because of the
increased metabolic rate.
• 5. Medications
• Some medications decrease the pulse rate, and
others increase it. For example cardiotonics (eg:
digitalis) decrease the heart rate, wherein
epinephrine increase it.
• 6. Hemorrhage
• Loss of blood from the vascular system normally
increases heart rate. In adults the loss of small
amount of blood (500 mL, the amount loss after
blood donation) results in the temporary
adjustment of the heart rate as the body
compensate for the lost blood volume.
• An adult has about 5 liters of blood in the system
and can usually lose up to 10% without adverse
effects.
• 7. Stress
• In response to stress, sympathetic nervous
stimulation increases the overall activity of the
heart.
• Stress increases the rate as well as the force of
the heartbeat. Pain and Anxiety as well as the
perception of severe pain stimulate the
sympathetic system.
• 8. Position
• When the person assumes a sitting or standing
position, blood usually pools in dependent
vessels of the nervous system.
• Pooling results in a transient decrease in the
venous blood return to the heart and a
subsequent reduction in blood pressure and
increase in heart rate.
9 Pulse Sites in Human Body
Reasons for Using Specific Sites
• Radial- readily accessible
• Temporal- used when radial pulse is not
accessible
• Carotid- used for infants, cardiac arrest
• Apical- for infants and children up to 3years of
age
• Brachial- measure the blood pressure, cardiac
arrest for infants
• Femoral- determine circulation of the leg
• Popliteal- determine circulation of the lower
leg
• Posterior Tibial and Pedal- determine
circulation of the foot.
Assessing the Pulse
• A pulse is commonly assessed by palpation or
auscultation.
• The middle 3 fingertips are used for palpating all
pulse sites except the apex of the heart.
• A stethoscope is used for assessing apical pulses
and fetal heart tone (FHT).
• A pulse is normally palpated by applying
moderate pressure with the 3 middle fingers of
the hand.
• The pads on the most distal aspect of the finger
are most sensitive areas for detecting pulse.
Normal Values
• Newborn
• (80- 180 bpm)
• 1- 3 years
• (80-140 bpm)
• Children
• (75- 120 bpm)
• Teen years
• (50- 90 bpm)
• Adult
• (60- 100 bpm)
• Kozier, Fundamental of Nursing
Procedure
• Definition

• Expansion of the arterial walls occurring with

each ventricular contraction.

• Purpose

• To provide clinical data regarding the heart’s

pumping action and the adequacy of the
peripheral artery blood flow.
Equipments
• 1. Watch with second hand
• 2. Paper and pen
1. Introduce your self. Identify the client and
explain the procedure.
2. Do hand rub.
3. Gather equipment needed.
4. Have the patient rest his arm along side of his
body with the wrist extended and the pal of the
hand downward.
5. Place the tips of your middle fingers on the
palm side of the patient’s wrist. Rest thumb on
the back of the patient wrist.
6. Apply enough pressure so that you can feel the
pulse (not too hard, not too light).
• 7. Using a watch with second hand count the
number of pulsations felt on the patient for one
full minute.
• 8. If the pulse rate is abnormal, repeat the
counting in order to determine accurately its
rate, quality and rhythm.
• 9. Do hand rub.
• 10. Inform the patient of the pulse rate taken.
• 11. Record the pulse rate, rhythm and force
immediately in the graphing sheet.
Obtaining Respiration
• RESPIRATION- is the act of
breathing.

• EXTERNAL RESPIRATION- refers

to the interchange of oxygen and carbon
dioxide between the alveoli of the lungs
and the pulmonary blood.

• INTERNAL RESPIRATION- the

interchange of these same gases
between the circulating blood and the
cells of the body tissues.
• INHALATION OR INSPIRATION- refers to the
intake of air into the lungs.

• EXHALATION OR EXPIRATION- refers to the

breathing out or the movement of gases from the
lungs to the atmosphere.

• VENTILATION- is refers to the movement of air in

and out of the lungs.

• HYPERVENTILATION- refers to the very deep,

rapid respirations.

• HYPOVENTILATION- refers to very shallow

respirations.
Kinds of Breathing
2 Types of Breathing
• 1. COSTAL BREATHING

• Breathing involves the external intercostal

muscles and other accessory muscles such as the
sternocleidomastoid muscles.

• It can be observed by the movement of the chest

upward and downward.
• 2. DIAPHRAGMATIC BREATHING
• Involves the contraction and relaxation of the
diaphragm.
• It is observed by the movement of the abdomen
which occurs as a result of the diaphragm’s
contraction and downward movement.
Assessing Respiration
• Respiration should be assessed when the client
is relaxed because exercise affects respiration,
increasing their rate and depth.
• Anxiety was likely to affect the respiratory rate
and depth as well.
• Respirations may also need to be assessed after
exercise to identify the client’s tolerance to
activity.
Before assessing the client’s
respirations, a nurse should aware of:
The client’s normal breathing
pattern
The influence of the client’s health
problems on respirations
Any medications or therapies that
might affect respirations
The relationship of the client’s
respiration to cardio-vascular
functions
The rate, depth, rhythm and special
characteristics of the respirations
should be assessed.
Definition of terms
• EUPNEA- normal breathing pattern.
• BRADYPNEA- abnormally slow respiration.
• TACHYPNEA- abnormally fast respiration.

• ORTHOPNEA- ability to breathe only in

upright position.
• DYSPNEA- difficult and labored breathing
• APNEA- is the absence of breathing.
Normal Values
• Newborns
• (30-80 cpm)
• 1- 3 years
• (20-40 pm)
• Children
• (15- 25 cpm)
• Teen years
• (15- 20 cpm)
• Adult
• (12- 20 cpm)
Procedure
• Definition:
• The act of breathing which includes the intake of
oxygen and the output of carbon dioxide.

• Purpose:
• To provide valuable information about a
• client’s physical and emotional health.
Equipments
• Watch with second hand
• Paper and pen
• Alcohol for hand rub
1) Introduce yourself. Identify the client and explain
the procedure.
2) Do hand rub.
3) Gather equipment needed.
4) Have the patient rest in his arm alongside of his
body with the wrist extended and the palm of the
hand downward.
5) Hold the client’s wrist just as if you were taking
his/her pulse.
6) Note the rise and fall of the client’s chest with each
respiration.
7) Using a watch with second hand count the number
for one full minute.
8) Inform the client of the result.
9) Do hand rub.
10) Record the data in the graphing sheet.
Obtaining Blood Pressure
• ARTERIAL BLOOD PRESSURE- is the
measurement of the pressure exerted by the
blood as it flows through the arteries.
• SYSTOLIC PRESSURE- the pressure of blood
as a result of contraction of the ventricles, that
is, the pressure of the height of the blood wave.
• DIASTOLIC PRESSURE- which is the
pressure when the ventricles are at rest.
Diastolic pressure then is the lower pressure,
present at all times within the arteries.
Normal Values
• Adult

• Diastolic
• (60-90 mmHg)

• Systolic
• (90-130 mmHg)
Determinants of Blood Pressure

• Pumping action of the heart

• Peripheral vascular resistance (the resistance
supplied by the blood vessels through which the
blood flows)
• Blood volume viscosity
Factors Affecting Blood Pressure
• Age
• The pressure rises with age, reaching a
peak of the onset of puberty, and then
tends to decline somewhat.
• Exercise
• Physical activity increases the cardiac
output and hence the blood pressure:
thus 20-30 minutes of rest following
exercise is indicated before the resting
blood pressure can be reliably
assessed.
• Stress
• Stimulation of the sympathetic nervous system
increases cardiac output and vasoconstriction of
the arterioles, thus increasing the blood pressure
reading.
• Race
• African-American males over 35 years have
higher blood pressures than European-American
males of the same age.
• Obesity
• Pressure is generally higher in some over weight
and obese people than in people of normal
weight
• Sex
• After puberty, females have lower blood pressure
than males of the same age; this difference is
thought to be due to hormonal variations. After
menopause, women generally have higher blood
pressures than before.
• Medications
• Many medications may increase the blood
pressure; nurses should be aware of the specific
medications a client is receiving and consider
their possible impact when interpreting blood
pressure readings.
• Diurnal Variations
• Pressure is usually lowest early in the morning,
when the metabolic rate is lowest, then rises
throughout the day and peaks in the late
afternoon or early evening.
• Disease Process
• Any condition affecting the cardiac output,
volume, viscosity or compliance of the arteries
has a direct effect on the blood pressure.
• Hypertension- blood pressure that is
persistently above normal.

• Hypotension- blood pressure that is below

normal.

• Orthostatic Hypotension- is the blood

pressure that falls when the client sits or stands.
Parts of Stethoscope
Parts of Sphygmomanometer
Procedure
• Definition
• Pressure exerted on the wall of the
arteries when the left ventricle of
the heart pushes blood into the
aorta.

• Purpose
• To determine vascular resistance
to blood flow.
• To determine the effectiveness of
cardiac muscle in the pumping
blood to overcome the vascular
resistance.
•
• Equipments
•
• Sphygmomanometer
• Stethoscope
• Paper and pen
• Alcohol for hand rub
Introduce yourself. Identify the client and
explain the procedure.
Do hand rub.
Gather equipment needed.
Assess the client’s physical status.
Place the client in a comfortable position (lying
or sitting) and position the arm at the level of the
heart with the palm of the hand facing up.
(Preferably use the left arm because it is nearer
to the heart)
Apply enough pressure so that you can feel the
pulse (not too hard, not too light).
Place the cuff so that the inflatable bag is
centered over the brachial artery, approximately
midway of the arm. The lower edge of the cuff is
about 2.5 cm (1-2 inches) above the inner aspect
of the elbow. The tubing should leave the edge
on the cuff nearer the client’s elbow.
Wrap cuff around arm smoothly and snugly (not
too loose, not too tight).
Feel the pulse beat over the brachial artery at the
inner aspect of the elbow with the use of the
fingertips and do not allow diaphragm or bell of
the stethoscope to touch clothing of cuff.
Place the stethoscope earpiece in your ears and
close the air release valve.
Palpate the brachial artery, turn valve clockwise
to close and compress inflation bulb to inflate
cuff to 30 mmHg above points where palpated
pulse disappears, then slowly release the valve to
deflate the cuff. Noting the reading when pulse is
felt again.
Release the air in the cuff slowly so that the
pressure goes down at the rate of 2-3
mmHg/second and listen to the sound (first
distinctly loud muffling sound is systolic
pressure).
Continue to release the air evenly and
slowly (last muffling sound is diastolic
pressure).
After the final sound has disappeared
deflate cuff rapidly and completely.
Inform the client of the result taken.
Roll the cuff and place it in the case. Wipe
the ear pieces of the stethoscope with
antiseptic swab and put it back to its
proper place.
Do hand rub.
Record the result.
ASSESSING PAIN: THE FIFTH VITAL
SIGN
• Pain is an unpleasant feeling
often caused by intense or
damaging stimuli.

• Acute: Less than 6 mos.

• Chronic: More than 6 mos.
OTHER TYPES OF PAIN:
• NEUROPATHIC PAIN is caused by damage or disease
affecting any part of the nervous system involved in bodily feelings
(the somatosensory system). Peripheral neuropathic pain is often
described as "burning", "tingling", "electrical", "stabbing", or "pins
and needles". Bumping the "funny bone" elicits acute peripheral
neuropathic pain.

• PHANTOM PAIN is pain felt in a part of the body that has been
lost or from which the brain no longer receives signals. It is a type of
neuropathic pain. Phantom limb pain is a common experience of
amputees.

• PSYCHOGENIC PAIN, also called psychalgia or somatoform

pain, is pain caused, increased, or prolonged by mental, emotional,
or behavioral factors.
• REFERRED PAIN, also called
reflective pain, is pain perceived at
a location other than the site of the
painful stimulus.
• An example is the case of ischemia
brought on by a myocardial
infarction (heart attack), where
pain is often felt in the neck,
shoulders, and back rather than in
the chest, the site of the injury.
PQRST OF PAIN
COMMON PAIN TOOL
END