Vital sign

Presented by,
Mrs. Laxmi Kamat
Senior tutor
KAHER Institute OF Nursing Sciences,
Belagavi

Introduction:
vital signs are basic components and objective of
assessment of physiological and psychological health of
a client.
These are the signs of life:
1. Temperature
2. Pulse
3. Respiration
4. Blood pressure

Purposes:
• Identify specific life threatening conditions and
plan for needed nursing interventions
• Detect changes in the clients health status
(improvement or regression may be detected by
the observing of these things)
• Through these signs ,specific information may be
obtained that helps in diagnosis of disease.

Why these signs are called as vital?
• These findings are governed by vital organs and often
reveal even the slightest deviation from the normal
body function.
• These signs helps to identify the specific life
threatening conditions and plan needed nursing
interventions.
• To detect changes in the client’s health condition

 Normal body temperature - 98.6°F or 37°C in adults (97 to
99° F)
 Normal pulse is – 72 beats / minute in adult ( 60 to 100)
 Normal respiration is –16 breaths / minute in adult (12 to 20)
 Normal blood pressure is – 120/80 mm of Hg in adults.

Temperature:
Body temperature may be defined as the
degree of heat maintained by the body, or it is
balance between the heat production and the heat
lost by the body.
-The heat regulating center is the hypothalamus
situated in the brain. By balancing between
producing heat and loss of heat in the body.

The regulation of the body temperature is
maintained by two mechanisms:
• Thermogenesis: a chemical regulation by the
production of heat.
• Thermolysis: a physical regulation by loss of
heat.

Ways of producing heat:
• Oxidation of food
• Specific dynamic action of the food
• Exercise
• Strong emotions such as excitement, anxiety,
nervousness etc.
• Hormonal effects
• Changes in the environment
• Disease condition

Ways of losing heat from the body:
The heat is lost from the body through different
organs:
• Through the skin
• Through the lungs
• Through the kidneys
• Through the bowels

Normal variations in the body temperature
In the healthy individual, the body temperature may
vary between 97 to 99 F
The following factors may influence the variations in the body
temperature:
 Time of the day
 Time of the month
 Age of person
 Part of the body where the temperature is taken
 Emotions
 Exercises
 Fasting
 Environmental factors

Temperature alteration:
1. Body temp. that fall between 99°F and 100.4° F is
termed as a low grade fever.
2. Body temp. that is above 100.4° F is termed as a
normal fever.
3. Temp. that reaches 105.8° F is a serious condition.
4. Temp. that reaches 109.4° F is generally fetal
condition.

Types of thermometer:
1. Glass thermometer (mercury thermometer)
2. Electronic thermometer
3. Tympanic membrane thermometer
4. Disposable paper thermometer
5. Temperature sensitive strips and Chemical Dot

The common site for taking body temp. are-
• Mouth
• Axilla
• Groin
• Vagina
• rectum

Temperature by mouth
Advantages Disadvantages
• Good blood supply
under the tongue.
• Less chance for the bulb
coming in contact with
the outside air.
• The thermometer can be
held easily under the
tongue, so there is less
chance of the
thermometer falling
down from the mouth.
• No privacy is need.
• The nurse may not know whether
the bulb of the thermometer is in
place.
• The children and insensible persons
may bite the thermometer.
• If thermometer are not adequately
disinfected, there is possibility of
cross infection.
• If the disinfectant is not removed
completely, the client will get the
bad taste of the disinfectant .
• The client will get tired if the
thermometer is kept for a long time.

Contraindications:
The temperature is not taken by mouth in the
following clients:
• Extremely nervous clients, Ex- unconscious, mentally
confused, and those who cannot follow the instruction.
• The client having convulsion.
• Mouth breather.
• Client who have injuries, inflammation or operations of
the mouth.
• Extremely weak persons , who are not able to hold the
thermometer under the tongue.
• Persons suffering from frequent attacks of cough.
• Children under 6 years of age.

• Less discomfort for the client
• Nurse will be able to keep
thermometer in position
without difficulty
• Taking hot or cold drinks will
not affect the temperature
reading
• The client does not get the ill
taste of the disinfectants
• There is no fear of biting the
thermometer
• Presence of moisture
can give a false reading
• You may get false
reading if the
thermometer is not
placed correctly
Temperature by Axilla:

• It is used when the oral
method is contraindicated
• It is most reliable method.
It contains large amount of
blood supply
• It is not influenced by
external air
• It fully surrounded by the
body tissue and we get a
more accurate reading
• The client needs privacy
• Needs lubrication of the
bulb
• There is a chance of
soiling the hands of the
nurses
• If the rectum is loaded
with fecal matter we get
a false reading.
Temperature by Rectum:

Contraindications:
The temperature is not taken by rectum in the
following clients:
• The client who have rectal surgery or inflammation of
the rectum
• The client who are having diarrhea.
• When the rectum is packed with faecal matter.
• the client who are having some kinds of treatment, Ex:
bowel wash, enema etc.

• Tympanic temperature reflects
the core body temperature.
• The ear is readily accessible
• It can use for very young,
confused and unconscious
clients.
• Smoking, drinking and eating
do not affect tympanic
temperature measurments
• Cerumen in the ear
and presence of
otitis media may
alter temperature
reading
Temperature by Ear:

Frequency of taking temperature in the hospital:
frequency of taking temperature is determined by the
condition of the client
• Who not seriously ill it needs to be taken in the morning and
evening
• The temperature is to be checked every 4 hours or even
more frequently for those who are acutely ill. Ex: high fever,
post operative client

Pulse:
Pulse is an alternate expansion (rise) and recoil (fall) of
an artery as the wave of blood is forced through it during
the contraction of the left ventricle.
The pulse is measured by applying moderate pressure
with the sensitive pads located on the tips of the three
middle fingers.
Place your three fingers on radial artery located on the
inner portion of the thumb. Count how many heart beats
you feel in one minute.

THE PULSE MAY BE FELT AT:
• The Radial artery in front of the wrist.
• Temporal artery over the temporal bone.
• Carotid artery at the sides of the neck.
• The Brachial artery above the elbow and in the antecubital
fossa ( inner part of the elbow)
• Femoral artery in the groin.
• Poplitial artery in the poplitial fossa (back of the knee)
• The Dorsalis Pedis artery on the foot.
• The Posterior Tibial artery behind the medial malleolus.

Characteristics of the pulse:
Before assessing the pulse, nurse must be familiar with the
normal characteristics of a pulse – the Rate, Rhythm, Volume and
Tension.
Rate:
Is the number of pulse beats in a minute.
• The normal rate in the resting adult is 60 to 100 beats per minute.
• If pulse rate over 100 per minute is referred to be “Tachycardia”
• If pulse rate below 60 per minute is referred to be “Bradycardia”

Factors causing variations in pulse rate are:
• Age
• Sex
• Physique
• Exercise
• Food
• Posture
• Emotions
• Application of heat
• Pain
• Increased body temperature
• Drugs
• Cold application

Rhythm:
It refers to the regularity of beats.
• Normally the heart beats are spaced at equal intervals and they are
said to be regular.
• When the interval varies between the beats it said to be irregular.
• If irregularity is present the pulse should be counted for one full
minute.
Volume:
It refers to the fullness of the artery
• It is the force of the blood felt at each beat
• Volume depends upon the amount of blood in the arteries
• If arteries contains normal volume of blood the pulse is said to be
full or large in volume.
• If the volume of the blood is decreased as by haemorrhage, the
pulse will be weak, small feeble or flickering.

Tension:
Is the degree of compressibility
• It said to be high tension when the artery is difficult to
compress
• Low tension when it is easy to compress.
Frequency of taking pulse:
• The pulse is taken along with the body temperature twice a
day for clients who are not seriously ill.
• It may be taken frequently for clients who had surgeries,
accidents or who are critically ill.

Methods of taking pulse:
1. Palpation
2. Auscultation

Abnormal Pulse:
For healthy adult the normal pulse ranges from 60 to 100
beats per minute
TACHYCARDIA: is characterized as a fast heart rate
which is more than 100 b/m. this may indicates that a
patient having some sort of heart diseases or the person
just finishing with vigorous exercise.
BRADYCARDIA: is characterized as an abnormally
low heart rate which is below 60 b/m. this may occurs
during sleep

Respiration:
Respiration is the act of breathing. It is the process of
taking oxygen and giving out carbon dioxide.
Respiration maybe external and internal
• External respiration (Pulmonary respiration): the exchange
of gases between the blood and air in the lunges
• Internal respiration (Tissue respiration): the exchange of
gases between the blood and the tissue cells of the body.

 To asses the respiration you need to watch the chest
movements (chest rise and fall) as the person breaths.
 Then count for the one minute how many times the chest
falls.
 This will be how many respiration s the patient has per
minute.
Each respiration is divided into two phases
INHALATION: which is breathing in
EXHALATION: which is breathing out

Characteristics of Respiration:
respiration is observed to determine the Rate, depth,
rhythm and easiness of respiration.
• Normal breathing is effortless, automatic, regular, even
and produces no noise.it is called as Eupnoea.
Rate: is the number of full respiration in a minute.
• Normal rate of respirations for an adult will be between
16 to 20 breaths per minute.

Factors causing variations in Respiration rate
are:
• Age
• Sex
• Emotions
• Exercise
• Ingestion of food and digestion
• Change in the atmospheric pressure
• Change in the external temperature
• Drugs

Rhythm:
It refers to the regularity of breathing.
• In normal respiration the rhythm is normal. Critically ill
clients and persons nearing death are found to have irregular
respiration.

Abnormal respiration:
Tachypnea(Polypnoea): Is characterized as an abnormal
increase in respirations which is more than 24 breaths per
minute.
Bradypnea: Is characterized as an abnormal decrease in
respiration which is less than 10 breaths per minutes.
Apnoea: Total cessation of breathing.

What to observe when taking respiration:
• Rate of respiration
• Regularity and rhythm of respiration
• Easiness of respiration
• Movement of the muscles of the chest, nose and abdomen
• Position of the client during breathing

RESPONSIBILITY FOR TAKING T.P.R
• Identify the patient .
• Check the diagnosis, date & type of surgery, if
any.
• Ability to follow direction.
• Ability to retain thermometer in place.

PREPARATION OF THE ARTICLES
Sl.No Articles Purpose
1 Thermometer in a jar containing
some cotton at the bottom of
the jar.
• Cotton at the bottom of the jar prevents
the bulb of the thermometer from
breaking.
2 Bowl with soapy swabs/jar
containing Dettol lotion 1:40
To disinfect the thermometer
3 Bowl with wet Swabs To clean the thermometer
4 Bowel with dry swabs To dry the thermometer
5 Kidney try To discard the soiled swabs
6 Pen, Chart , watch with second
hand
To record T.P.R before forgetting.

PROCEDURE
Sl.No Steps of procedure Reasons
1 Wash hands. To prevent cross infection
2 Remove the thermometer from the jar and wipe
with soapy swab or dip it in antiseptic lotion and
rinse it in cold water.
To remove the
disinfectant lotion.
3 •Wipe the thermometer from bulb upwards
with a rotating movement, using a clean cotton
swab.
•Discard the swab.
To maintain the asepsis of
the bulb end.
4 •Read the level of mercury in good light.
•To read the level of the mercury in the
thermometer, hold the thermometer with the
fingers of the right hand, very slowly rotating
back & forth until the silvery mercury line
comes into view & read the measurement to
the nearest line.
The thermometers are
made in such a way that
the lines are magnified &
visible on one side.

5 • Shake the thermometer , if the mercury level is above
350c or 950 F.
• Shake it with the quick movements of the wrist.
• To shake the thermometer, hold it firmly by its stem and
move away from the wall, furniture & equipment.
• Wipe the axilla from perspiration, Presence of moisture
can give a false reading
To record the
temperature correctly,
the level of the mercury
should be well below the
actual temperature of
the patient.
6 ask the client to open his mouth & place the thermometer
under the tongue. ask the client to close his lips & not
biting thermometer.
7 Have the thermometer in place for TWO minutes. To allow enough time to
register the body
temperature.
8 Count the pulse & respirations while the thermometer is
PROCEDURE

9 • Place the patient’s hand over his chest with the
wrist extended & the palm downwards.
• Place the finger tips over the pulse point.
Arm placed over the chest helps to
count the respirations with out the
patient’s knowledge.(after counting
the pulse)
10 Holding the watch or pulsometer in the left
hand, start to count the pulse rate with zero’
then1, 2,etc.
Zero begins the time interval and
the next pulse felt is ‘1’ of the
sequence.
11 If the pulse is regular, count the number of
pulsation for HALF minute & multiply by 2. If
irregular count for 1 minute complete.
12 With the right hand still on the pulse count
respiration by watching the rise &fall of the
chest, without the knowledge of the patient.
If the patient is aware that his
respiration are counted, he may
hold the breath & the rate may be
PROCEDURE

13 Count the respiration for one minute.
14 Remove the thermometer after two
minutes.
15 •Wipe the thermometer from stem to the
bulb with wet swab, then with soapy
swab, again with wet swab, using a
rotating movements.
•Discard the swab.
•Read the level of mercury.
•Return the thermometer to the container,
after shaking it down again.
• Wipe from the area of least
contamination to that of
greatest contamination.
• This prevents dirtying the
hands.
PROCEDURE

AFTER CARE OF THE PATIENT & ARTICLES
• Make the patient comfortable.
• Tidy up the unit.
• Take the tray to the procedure room.
• Put the used swabs in dustbin.
• If the thermometer is broken it should be replaced.
• Wash the hands.
• Record the TPR in the chart.

Blood pressure:
BP is the pressure is the force exerted by the blood against
the walls of the blood vessels as it flows through them.
Types of BP
1. SYSTOLIC BP: Is the highest degree of pressure exerted by the
blood against the walls of the blood vessels when the left
ventricle is forcing the blood in to the aorta.
2. DIASTOLIC BP: Is the lowest pressure that occurs when the heart
is in its resting period just before the contraction of the left
ventricle.

Factors causing variation in blood pressure:
Age
Sex
Body build ( body weight)
Climate
Time of the day
Exercise
Emotions
Posture
Disease condition
Drugs
Hemorrhage
Increased intracranial pressure

BP ranges:
BP less than 120/80 is considered normal
BP is between 120/80-139/80 is considered
prehypertension
BP above 139/80 is considered high blood pressure or
hypertension
BP below 95/60 is considered low blood pressure or
hypotension

Mercury
Sphygmomanometer
Electronic
Sphygmomanometer
Electronic
Sphygmomanometer
Automatic Blood Pressure Monitor
(Dinamap Vital Sign Monitor)
Stethoscope
BLOOD PRESSURE RECORDING ARTICLES

Nurses responsibility in measurement of B.P:
1. Preliminary assessment:
• Identify the client
• Check the diagnosis, reason for taking B.P and schedule
frequency of obtaining B.P
• Previous measurement and range of blood pressure
• Physical and mental state of the client
• Postponed B.P taking on a client who is angry, anxious or in
pain and a crying child.
2. Preparation of articles
3. Preparation of the client

Do not take B.P reading on a clients arm if:
• The arm has an intravenous infusion on it.
• The arm is injured and diseased.
• The arm has a shunt or fistula for the renal dialysis.
• On the same side of the body where a female client had
a radial mastectomy.
• Check defects in the B.P apparatus.

PROCEDURE
Sl. No Steps of procedure Reasons
1 Wash hands To prevent cross infection
2 • Take the equipment to the beside.
•Apply deflated cuff evenly with rubber
bladder over the brachial artery, the lower
edge being 2 inch above the antecubital fossa.
•The two tubes turning towards the palm.
An uneven or too loose cuff
gives a falsely high reading
because excessive amount
of pressure is needed to
occlude brachial artery.
3 •Palpate the brachial artery with the finger
tips.
•Place the bell of the stethoscope on the
brachial pulse.
•The stethoscope must hang freely from the
ears.
Any rubbing of the tubes
can mislead the sounds.

4 •Close the valve on the pump by
turning the knob clockwise, Pump up
air in the cuff until the
sphygmomanometer registers about
20mm above the point at which the
radial pulsation disappears.
If the cuff not inflated high enough,
true systolic pressure may be
missed. Inflating the cuff too high
causes unnecessary pain and may
produce vasospasm, which distorts
pressure reading.
5 •Open the valve slowly by turning the
knob anti clock wise.
•Permit the air to escape very slowly.
•Note the number on the manometer
where the sound first begins.
•This is the systolic pressure.
The first sound is heard when the
blood begins to flow through the
brachial artery again.
PROCEDURE

6 •Continue to release the pressure slowly.
•The sound become louder & clearer.
•Note the point on the manometer where
the sound cease.
•This is the diastolic pressure.
7 •Allow the air to escape & the mercury to
fall zero.
•Wait for one minute with the cuff
deflated.
Occlusion of blood during the
pressure reading causes
venous congestion in the
forearm.
8 Repeat the procedure if there is any doubts
about the reading.
Venous blood must be
allowed to drain or it will
falsely elevate the succeeding
blood pressure reading.
PROCEDURE

AFTER CARE OF THE PATIENT & ARTICLES
• Remove the cuff by rolling it & replace it in box.
• Assist the patient to cover the arm which was
exposed.
• Take the apparatus to the duty room & keep it
safely in the cupboard.
• Wash hands.
• Record the reading immediately, with the date
& time.

Vital sign

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