Vital signs
1
Objectives
At the end of this lesson the students will be able to:-
Define the term “vital sign”
Identify the four main vital signs
List the purpose of taking vital signs
Discuss how to take patient’s blood pressure, pulse
rate, respiratory rate and body temperature
2
Vital signs
Vital signs are measurements of the body's most basic
functions.
Vital signs reflect the body’s physiologic status and
provide information critical to evaluating homeostatic
balance.
The term “vital” is used because the information
gathered is the clearest indicator of overall health
status.
3
Vital signs
Purposes:
To obtain baseline data about the patient condition.
To aid in diagnosing patient condition
(diagnostic purpose)
For therapeutic purpose so that to
intervene accordingly.
4
Cont’d
The four main vital signs routinely monitored by
medical professionals and healthcare providers
include the following:
Blood pressure (BP)
Pulse rate (PR)
Respiration rate (rate of breathing)(RR)
Body temperature(T)
Nowadays pain is considered as the 5th vital sign.
5
Times to assess vital signs
On admission– to obtain baseline data
When a client has a change in health status or
reports symptoms such as chest pain or fainting
According to a nursing or medical order
Before and after the administration of certain
medications that could affect patient’s V/S
Before and after surgery or an invasive
diagnostic procedures
Before and after any nursing intervention that
could affect the vital signs. E.g. Ambulation
According to hospital /other health institution
6 policy.
1. Blood pressure
Blood pressure is the force exerted by the blood
against the walls of the arteries in which it is flowing.
It is expressed in terms of millimeters of mercury
(mmHg).
There are two types of blood pressure:
1. Systolic pressure: Is the pressure of the blood as a
result of contraction of the ventricles while
pumping blood into the vessels.
2. Diastolic pressure: is the minimum pressure of
the blood against the walls of the vessels
following closure of aortic valve (ventricular
relaxation). Blood returns to the heart from the
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veins.
Cont’d
Blood pressure is always given by two numbers,
the systolic and diastolic pressures.
Usually they are written one above or before the
other, such as 120/80 mmHg.
The top number is the systolic and the bottom the
diastolic.
A number of conditions are reflected by changes in
blood pressure.
An increase in blood pressure is called
hypertension;
A decrease is called hypotension.
8
Blood pressure…
Pulse pressure: is the difference between the systolic
and diastolic pressure.
It is an indicator of cardiac function.
Pulse pressure between 40-60 mmHg is
considered normal.
Deviation from this range might be manifestation
of cardiac problems.
9
Cont’d
Purpose of taking blood pressure
To determine the patient’s conditions (the
clients homodynamic status)
To identify and monitor changes in blood
pressure resulting from a disease process and
medical therapy.
To aid in diagnosis
Factors affecting blood pressure
Age Arteriosclerosis
Autonomic nervous Exposure to cold
system Obesity
Medications Hemorrhage
Circulating volume Low hematocrit
Fever External heat
Stress
11
Blood pressure…
Sites for measuring Blood pressure
Upper arm: using brachial artery the commonest one
Fore-arm: using radial artery
Thigh around: popliteal artery
Leg: using posterior tibia or dorsal pedis
12
Cont’d
BP is measured by using an instrument called BP
cuff (sphygmomanometer) & stethoscope.
The average normal value is 120/80mmHg for
adults.
Brachial artery and popliteal artery are most
commonly used.
It is measured by securing the BP cuff to the upper
arm & thigh placing the stethoscope on brachial
artery in the antecubital space & popliteal artery at
the back of the knee.
13
Cont’d
A persistently high BP, measured for greater than
three times is called hypertension & that
persistently less than normal range is called
hypotension.
Because of many factors influencing BP a single
measurement is not necessarily significant to
confirm hypertension.
When the cause of hypertension is known it is
called secondary hypertension and when the cause
is unknown is called primary/essential
hypertension.
14
Blood pressure…
Procedure
Essential equipment
Sphygmomanometer with cuff, tubing, bulb and
mercury
Stethoscope
Paper, pencil & v/s chart.
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Blood pressure
Sphygmomanometer
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Stethoscope
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Blood pressure…
Procedure
1. Prepare and position the patient appropriately (wash
hands, collect equipment and explain the procedure
to the patient)
Make sure that the client has not smoked or ingested
caffeine, within 30 minutes prior to measurement.
Expose the upper arm
Position the patient in lying, sitting or standing
position, but always ensure that the
sphygmomanometer is at the level of the heart with
the arm supported & the palm facing upwards.
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Blood pressure…
2. Wrap the deflated cuff evenly around the upper arm.
Apply the center of the bladder directly over the
medial aspect of the arm.
The bladder inside the cuff must be directly over the
artery to be compressed if the reading to be
accurate.
For adult, place the lower border of the cuff
approximately 2 cm above antecubital space.
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Blood pressure…
3. Position the stethoscope appropriately
Insert the ear attachments of the stethoscope in your
ears so that they tilt slightly fore ward.
Place the diaphragm of the stethoscope over the
brachial pulse; hold the diaphragm with the thumb
and index finger.
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Blood pressure…
4. Auscultate the client's blood pressure
Pump up the cuff until the sphygmomanometer
registers about 30 mmHg above the point where the
brachial pulse disappeared.
Release the valve on the cuff carefully so that the
pressure decreases at the rate 2-3 mmHg per second.
As the pressure falls, the first pulse heard is the
systolic reading, continue to deflate until there is a
change in tone to a muffled beat, this is the diastolic
reading.
Repeat the above step once or twice as necessary to
confirm the accuracy of the reading.
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Blood pressure…
5. Remove the cuff from the client’s arm
For initial determination, repeat the procedure on the
client's other arm, there should be a difference of no
more than 5 to10 mmHg between the arms.
The arm found to have the higher pressure, should
be used for subsequent examinations.
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Blood pressure…
6.Document and report pertinent assessment data, report
any significant change in client's blood pressure.
Also report these finding:
When Bp above 140/90 mmHg
or below 100/60 mmHg.
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Cont’d
Korotkoff sounds: are generated when a blood
pressure cuff changes the flow of blood through
the artery.
These sounds are heard through either a
stethoscope or a doppler that is placed distal to the
blood pressure cuff.
There are five distinct phases of Korotkoff sounds:
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Blood pressure…
The first Korotkoff sound is the snapping sound first
heard at the systolic pressure. Clear tapping,
repetitive sounds for at least two consecutive beats
are considered the systolic pressure.
The second sounds are the murmurs heard for most
of the area between the systolic and diastolic
pressures. (The period during deflation when the
sound has a swishing quality)
The third sound is a hard tapping sound. (The period
during which the sounds are harder and more
28 intense.)
Blood pressure…
The fourth sound, at pressures within 10mmHg
above the diastolic blood pressure, were described
as "thumping" and "muting".(The time when the
sounds become lowered and have a soft blowing
quality).
The fifth Korotkoff sound is silence as the cuff
pressure drops below the diastolic blood pressure.
The disappearance of sound is considered diastolic
blood pressure: 2 mmHg above the last sound heard.
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2. Pulse rate
Pulse: is a wave of blood created by contraction of the
ventricle of the heart. i.e. the pulse reflects the
heartbeat.
Pulse rate is a measurement of the heart rate, or the
number of times the heart beats per minute.
Pulse rate is regulated by autonomic nervous system.
31
Cont’d
Peripheral pulse: is a pulse located in the periphery
of the body.
E.g. in the foot, or neck
Apical pulse (central pulse): it is located at the apex
of the heart.
Pulse deficit- It is a difference that exists between the
apical and radial pulse.
The PR is expressed in beats/ minute (BPM)
The normal pulse for healthy adults ranges from 60 to
100 beats per minute.
32
Cont’d
Factors Affecting Pulse Rate:
Age
Gender
Exercise
Fever
Medications
Stress
Position changes
33
Cont’d
Normal pulse Rate range
Infant up to 1 year: 100 to 160 b/m
Children ages 1 to 10 year: 60–140 b/m
Children age 10 and Adult: 60 to 100 b/m average
72 b/m
Well-conditioned Athletes:40–60 b/m
34
Cont’d
Each heart beat consists of two sounds:
S1 - is caused by closure of the mitral and tricuspid
valves separating the atria from the ventricles.
S2 – is caused by the closure of the pulmonic and
aortic valves.
The sounds are often described as a muffled “lub –
bub”.
35
Cont’d
Pulse sites
Temporal – is superior/above and lateral to (away
from the midline of) the eye.
Carotid – is at the side of the neck below tube of
the ear /where the carotid artery runs b/n the trachea
and the sternoclidiomastoid muscle)
Apical- is at the apex of the heart: routinely used for
infant and children < 3 yrs.
Brachial- is at the inner aspect of the biceps muscle
of the arm or ideally in the antecubital space (elbow
crease)
36
Cont’d
Radial- is on the thumb side of the inner aspect of
the wrist. Readily available and routinely used.
Femoral – is along the inguinal ligament and used
for infants and children.
Popilital - is behind the knee.
Posterior tibia is on the medial surface of the ankle.
Pedal (Dorsalis pedis) is palpated by feeling the
dorsum (upper surface) of the foot on an imaginary
line drawn from the middle of the ankle to the
surface between the big and 2nd toes.
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38
Cont’d
Pulse characteristics
A normal pulse has defined characteristics:
Quality
Rate
Rhythm
Volume (strength or amplitude).
39
Cont’d
Pulse quality refers to the “feel” of the pulse,
and its forcefulness.
Pulse rate is obtained by counting the number
of apical or peripheral pulse waves over a pulse point.
A normal pulse rate for adults is between 60
and 100 beats per minute.
Bradycardia is a heart rate less than 60 beats
per minute in an adult.
Tachycardia is a heart rate in excess of 100
beats per minute in an adult.
40
Cont’d
Pulse rhythm
Is the regularity of the heartbeat.
It describes how evenly the heart is beating:
Regular (the beats are evenly spaced) or
irregular (the beats are not evenly spaced).
Dysrhythmia (arrhythmia) is an irregular
rhythm caused by an early, late, or missed heartbeat.
41
Cont’d
Pulse volume
Is a measurement of the strength or amplitude
force of exerted by the ejected against the
blood arterial wall with each
contraction.
It is described as
Normal (full, easily palpable),
Weak
Strong (bounding).
42
Cont’d
PULSE VOLUME SCALE
Scale Description of Pulse
0 Absent pulse
1+ Weak pulse
2+ Normal pulse
3+ Bounding pulse
43
Cont’d
Method of taking pulse rate
Pulse is commonly assessed by palpation
(feeling) or auscultation (hearing).
Themiddle 3 fingertips are used with
moderate pressure for palpation of all pulses except
apical.
A stethoscope may be used to auscultation of
the apical pulse.
44
Cont’d
Equipment
Watch with second hand or pulse meter
Stethoscope for apical pulse
Paper and pencil
45
Cont’d
Procedures:
Wash your hands.
Assemble equipment as needed
Greet & Explain the procedure to the patient
Place the pt in a comfortable position, lying or seated
with the arm resting across the chest.
Place two or three fingers over the radial artery and
count the number of pulses for 60 seconds, and this
will be the heart-rate in beats-per-minute.
The pulse can be counted for 30 sec and multiplied by
2 to obtain a one minute rate.
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Radial artery
pulse
47
• Stethoscope for apical pulse
48
Cont’d
Too much pressure should not be used over the radial
artery as it may cut off the circulation and the pulse
cannot be felt.
The pulse is commonly taken over the radial artery,
but it can be taken at other arteries.
Record the rhythm(regularity) and strength or volume
of the pulse on the pt’s chart.
Return the equipment
Wash hands
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3. Respiration
Respiration: is defined as the physiologic process of
inhaling air into lungs and exhaling carbon
dioxide the from lungs; and controlled by the
thein the brain.
Respiratory center
Ventilation is another word, which refer to
the physical movement of air in and out of the lungs.
Hyperventilation: very deep, rapid respiration
Hypoventilation: very shallow respiration
50
Cont’d
Two Types of Breathing
Costal (thoracic)
Involves the external muscles and other accessory
muscles (sternoclodiomastoid)
Observed by the movement of the chest up ward
and down ward.
Diaphragmatic (abdominal)
Involves the contraction and relaxation
of the diaphragm.
Observed by the movement of abdomen.
51
Cont’d
Rate, rhythm, depth
1. Rate:
Is described in breath per minute (BPM).
Healthy adult normal range RR = 12- 20 b/ min.
It is measured for full minute if irregular and for
30 seconds x 2 if regular rhythm.
For infant and children 30-60 b/m .
52
Cont’d
Terms related with rate
Eupnoea- normal breathing rate and depth
Bradypnea- slow respiration < 12 b/m
Tachypnea - fast breathing > 20 b/m
Apnea - temporary cessation of breathing
Dyspnea -refers to difficulty in breathing.
53
Cont’d
2.Rhythm: is the regularity of expiration and
inspiration.
Normal breathing is automatic & effortless.
3. Depth: described as normal, deep or shallow
Deep: a large volume of air inhaled &
exhaled, inflates most of the lungs.
Shallow: exchange of a small volume of
air minimal use of lung tissue.
54
Cont’d
Factors affecting normal respiration:-
Age
Medication
Stress
Exercise
Altitude
Fever
55
Cont’d
Count the respiration by watching the rise and fall of
the chest or abdomen.
The pt should not be aware that you are counting his
respirations as he might control his breathing.
Full minute count for:
Children
Irregular respirations
Very fast or very slow respirations
Observe the rate and depth of respiration.
Charting: time, rate, and any abnormal rhythm.
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4. Temperature
Temperature is the hotness or coldness of the body.
It is the balance b/n heat production & heat loss of
the body.
Our internal body temperature is regulated by a
part of our brain called the hypothalamus.
There are two types of body temperature:
Core temperature
Surface temperature
57
cont’d
Core Temperature
It is the temperature of the deep tissues of the body,
such as the cranium, thorax, abdominal cavity, and
pelvic cavity.
Remains relatively constant
It is the temperature that we measure with
thermometer.
Surface Temperature
The temperature of the skin, the subcutaneous tissue
and fat.
It rises & falls in response to the environment.
58
Cont’d
Thermometer:
Is an instrument used to measure body temperature
Types of thermometer:
Oral thermometer
Rectal thermometer
Axillary thermometer
Tympanic thermometer
59
Cont’d
Centigrade and fahrenheit conversion formulas
Centigrade to Fahrenheit conversion:
°F = (°C × 9/5) + 32
Fahrenheit to centigrade conversion:
°C = (°F – 32) × 5/9
60
Cont’d
Normal range of body temperature
Oral temperature
Normal range = 36.5C-37.5C (97.6F - 99.6F)
(average 37 C)
Axillary temperature
Normal range = 36.0C-37.0C (96.6F-98.6F)
(average 36.5C)
Rectal temperature
Normal range = 37.0C-38.0 C (98.6 F-100.6F)
(average 37.5 C)
61
Cont’d
Factors affecting body temperature
1. Age
2. Diurnal variations (circadian rhythms)
3. Exercise
4. Hormones
5. Stress
6. Environment
62
Cont’d
Alterations in body temperature
Pyrexia (fever): a body temperature above the
normal ranges 38 0c – 410 c (100.4 –
105.8 0F)
Hyper pyrexia: a very high fever, such as 410 C ,
> 42 0c leads to death.
A client who has fever is referred to as febrile; the
one who has not is afebrile.
Hypothermia:-body temperature between 34 oc-
35oc, < 34 0c is death.
63
Cont’d
Common types of fever:
Intermittent fever: the body temperature alternates at
regular intervals between periods of fever and periods
of normal temperature.
Remittent fever: a wide range of temperature
fluctuation (more than 20c) occurs over the 24 hr
period, all of which are above normal.
Relapsing fever: short febrile periods of a few days
are interspersed with periods of 1 or 2 days of normal
temperature.
Constant fever: the body temperature fluctuates
minimally but always remains above normal
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Temperature measurement
1. Oral temperature
Obtained by putting the thermometer under
the tongue. Leave 3 to 5 minutes in place.
Most accessible and convenient.
Comfortable for client
Reflects rapid change in core temperature
Purpose
To help in diagnosis
To measure body heat as an aid in determining the
pt’s condition.
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Cont’d
Contraindications of taking oral To
Child below 7 yrs
Nasal obstruction, pt with dyspnea or cough
Pt who is mentally ill, unconscious, or in
severe pain
Surgery of the mouth & infection of the mouth
66
Cont’d
2. Rectal temperature
Obtained by inserting the thermometer into
the rectum or anus.
It gives reliable measurement & reflects the core
body temperature.
Hold the thermometer in place for 3 to 5
minutes.
It should be lubricated before insertion.
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Cont’d
Contraindication
Rectal or Perineal surgery
Rectal infection
Neonates- can cause rectal perforation and
ulceration
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Cont’d
3. Axillary temperature
Safest and most non-invasive.
Thebulb of thermometer is placed in the
clients axillary hollow
Leave it in place for 5-10min
Less accurate as it is not close to major vessels and
it can be influenced by a number of factors e.g.
bathing & friction during cleaning.
Is the route of choice in pt’s that cannot have their
temp measured by other routes.
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cont’d
4. Tympanic temperature
Placed into the client’s outer ear canal.
It reflects the core body temperature
Is readily accessible and permits rapid temp
readings in pediatric, or unconscious pts
It is very fast method 1 to 2 seconds.
Disadvantages:–
It may be uncomfortable and involves risk of
injuring the membrane
Presence of wax can affect the reading.
Right & left measurements may differ.
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Pain
Pain is an unpleasant sensory and emotional
experience associated with actual or potential
tissue damage.
Pain is a subjective experience that is often
difficult for clients to describe and nurses to
understand, yet it is among the most common
complaints that cause individuals to seek health
care.
Often under-diagnosed and under-treated.
71
Cont’d
Self-report is always the most reliable indication
of pain.
Pain assessment is considered as the “fifth vital
sign”.
Patients should be assessed for pain every time
other vital signs are measured.
72
cont’d
Types of pain:
Acute pain: Short duration usually from injury,
disease, or surgery.
Chronic pain: Lasts longer than 6 months.
cancer, HIV, chronic back pain, arthritis
73
Cont’d
Factors affecting pain:
Perception of pain
Socio cultural factors
Age
Gender
Anxiety
Past experience with pain
74
Manifestations of pain:
Increased respiratory rate and heart rate
Elevated B.P.
Peripheral vasoconstriction
Increased blood glucose levels
Dilated pupils
Moaning
Restlessness
Irritability
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Pain Assessment
Precipitating/Alleviating Factors:- what causes
the pain? what aggravates it? has medication or
treatment worked in the past?
Quality of Pain:- Ask the patient to describe the
pain using words like “sharp”, dull, stabbing,
burning”
Radiation:- Does pain exist in one location or
radiate to other areas?
Severity:- Have patient use a descriptive,
numeric or visual scale to rate the severity of
pain.
Timing:- Is the pain constant or intermittent, when
did it begin.
76
Cont’d
Assess for objective signs of pain:
Facial expressions:
facial grimacing (a facial expression that usually
suggests disgust or pain),
frowning, sad face
Vocalizations - crying, moaning
Body movements - guarding, resistance to moving
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Pain Assessment Tools
There are various tools that are designed to assess
the level of pain. The most commonly used tools
are:
Verbal Rating Scale
Numeric Rating Scale
Wong Baker’s Faces Pain Scale
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Wong Baker’s Faces Pain Scale
Face 0 is very happy because it doesn't hurt at all.
Face 2 hurts just a little bit.
Face 4 hurts a little more.
Face 6 hurts even more.
Face 8 hurts a whole lot.
Face 10 hurts as much as you can imagine,
although you don't have to be crying to feel this
bad.
Ask the person to choose the face that best
describes how he is feeling.
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Wong Baker’s Faces Pain Scale
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Pain management
WHO Analgesic Ladder
World Health Organization’s recommended
guidelines for prescribing, based on level of pain
(1-10, 10 is most severe pain)
Level 1 pain (1-3 rating)- Use non-opioids
Level 2 pain (4-6 rating)- Use weak opioids
alone or in combination with an adjuvant drug
Level 3 pain (7-10 rating)- Use strong
opioids
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84
Pharmacologic Therapy of Pain
Non-Opioid Analgesics
Acetylsalicylic acid (aspirin) and acetaminophen
(Tylenol) are most common.
Most are NSAIDs, including aspirin
Opioid Analgesics
Block the release of neurotransmitters in the spinal
cord.
Drugs include codeine, oxycodone, morphine,
methadone, tramadol, – morphine is the gold
standard
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Side Effects of Opioids
Nausea and vomiting – early side effects, often
antiemetic give concurrently
Constipation – inhibits peristalsis, initiate
measures such as stool softeners and laxatives
Sedation – depress CNS, monitor sedation
levels
Respiratory depression – reversal agent
(Narcan)
Addiction
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Non-pharmacologic Interventions
Used alone or in combination with drug therapy
Psychosocial therapy/counseling
Cognitive/behavioral measures
Distraction
Imagery
Relaxation techniques
Hypnosis
Acupuncture
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Measuring height and weight
Height and weight are baseline measurements
also called anthropometric measurements
obtained on admission and must be accurate.
Reasons for obtaining height and weight:
Indicator of nutritional status
Indicator of change in medical condition
Used by doctor to order medications
88
Weigh
t A key anthropometric measurement
A sensitive indicator of current nutritional status
Measure of total body mass; summation of fat,
body fluids, skeleton & lean cell mass.
89
Standardized weight measurement procedures
Place the platform scale firmly on a level or flat
surface.
Check accuracy of the scale by bringing the
sliding lever or dial to zero.
Make sure that the pointer is exactly at the middle.
If the scale is accurate, begin assessments.
90
Cont’d
Ask the client to remove extra layers of clothing,
and any items in his/her pockets or hands.
Let the client stand at the center of the scale without
touching anything, with hands hanging & relaxed on
sides.
Ensure that the body weight is evenly distributed
between both feet. Record the data.
92
Height
Assesses linear dimension composed of legs,
pelvis, spine and the skull
A sensitive indicator of current nutritional
status.
93
Standardized height measurement procedures
Tape the uppermost tip and middle part of the steel
tape to a flat wall surface keeping it straight.
Request the client to remove his/her shoes, and
any headgear.
Instruct the client to stand erect and looking
straight ahead.
Legs together, bringing the ankles or knees
together.
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cont’d
Let the client stand straight against the steel tape
with feet and heels parallel together, buttocks,
shoulders and back of head touching the wall.
Place the triangular ruler on top of the client’s head.
Record the data.
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THE END
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