Vital Sign

Measurement
Introduction
WHAT IS:
 VITAL
 SIGN
 Learning objectives
At the end of the unit the learner will be able to:
• Describe the procedures to assess the vital signs
• Identify factors that can influence each vital sign.
• List equipment routinely used to assess vital signs.
• Identify common anatomical sites for vital signs.
• Take vital signs and interpret the finding.
• Demonstrate Documenting vital signs.
 VITAL SIGNS (CARDINAL SIGNS)

• Reflect the body’s physiologic status and provide information

critical to evaluating homeostatic balance.

• Vital sign Includes: T (temperature), PR (Pulse Rate), RR

(Respiratory Rate) & BP (Blood Pressure)

• Oxygen saturation and Pain are considered as part of routine

baseline assessment.
 Vital sign…
Purposes:-
• To obtain base line data about the patient condition
• To aid in diagnosing patient condition (diagnostic
purpose)
• For therapeutic purpose so that to intervene accordingly
• To monitor response to treatment.
Times to Assess Vital Signs
On admission – to obtain baseline date
When a client has a change in health status such as
chest pain or fainting
According to a nursing or medical order
Before & after the administration of certain
medications that could VS.
TIME TO…
Before and after surgery or an invasive diagnostic

procedure
Before & after any nursing intervention that could

affect the vital signs. E.g. Ambulation

According to hospital /other health institution

policy.
 Equipment for Vital sign measurement

Vital sign tray with

• Second hand watch
• Stethoscope
• Cotton swab in bowel
• Sphygmomanometer
• Disposable gloves if
• Thermometer
Necessary
• Blue &red pen
• Dirty receiver & kidney dish
• Pencil
• Vital sign sheet
 Equipment required for vital sign measurement
signs
 SPHYGMOMANOMETER
• A device that is used to measure blood pressure
• Two types:
• Manual
• Mercury and
• Aneroid
• Digital

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Aneroid
manual
sphygmom
anometer

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 STETHOSCOPE
 The stethoscope is an acoustic medical device for
listening to the internal sounds of the body.
 It is often used to listen to lung and heart sounds.
 It is also used to listen to intestines and blood flow in
arteries and veins.
 In combination with a sphygmomanometer, it is
commonly used for measurements of blood pressure

Acoustic Type
Fetal Type
Electronic Type 12
 FETAL HEART RATE MONITOR

 This device uses a probe to detect high

frequency sound waves that are produced by the
baby's heart.
 Because these sound waves aren't easily heard
under normal conditions, a gel, oil or water
solution is spread onto the belly.
 The probe is then moved around this area and
the sound waves will be amplified.
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PULSEOXIMETER
A pulse oximeter indirectly
monitors the oxygen
saturation of a patient's blood
and changes in blood volume
in the skin.
•Most monitors also display
the heart rate

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 THERMOMETERS
• Glass thermometers
• Oral
• Rectal
• Basal thermometers – predict
ovulation
• Digital thermometers
• Tympanic thermometers
• Skin thermometers

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TEMPERATURE
• Body temperature is the measurement of heat inside a
person’s body (core temperature); it is the balance
between heat produced and heat lost.
• Body temperature can be taken at different body parts:
Oral measurement-370c or 98.6 0 F,
Rectum (Rectal temperature) 37.50C or 99.30F,
Axilla (auxiliary temperature) & 36.50C or 97.60F
Purpose: – to determine the patient condition to aid in
diagnose
 Kinds of Body Temperature:- there 2 kinds
1. Core Temperature:-Is the Temperature of the deep
tissues of the body such as the cranium?
•Thorax, abdominal cavity & pelvic cavity
• Remains relatively constant
• Is the Temperature that we measure with thermometer
2. Surface Temperature:- the temperature of the skin, the
subcutaneous tissue and fat
Determined as normal to touch, hot to touch, afebrile to touch
or febrile to touch.
 Terms of abnormal temperature
• Normal Temperature range for adult-36.6-37.4c
• Fever-body temperature measuring above 37.4 c
• Pyrexia:- an increased body temperature ranges
38 0c – 410c
• Hyper pyrexia:- a very high fever, such as 410C, > 42 0c
leads to death.
• A client who has fever is referred as febrile; the one who has
not is afebrile.
• Hypothermia: – body temperature between 34 0c – 36.6 0c,
• If < 34 0c is death
Common Types of Fevers
• Intermittent fever: the body temperature alternates at
regular intervals between periods of fever and periods
of normal or subnormal temperature.
• Remittent fever: a wide range of temperature
fluctuation (more than 2 c0) 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
 Factors Affecting Body Temperature:-
• Age:-
• Children’s temperature more labile than adults until puberty
• Elderly people, particularly those > 75 are at risk of
hypothermia
• Normal body temperature of the newborn if taken orally is 37
0
C.
Diurnal variations:-
• Body temperature varies throughout the day with about 2c
• The point of highest body temperature is usually reached
between 8:00 p.m. & midnight & lowest point is reached
during sleep between 4:00 & 6:00 a.m
 Factors affecting Temperature…
• Exercise:-strenuous exercise can increase body
temperature to as high as 38.3-40 0c (rectally)
• Hormones:- In women progesterone secretion at the
time of ovulation raises body temperature by about 0.3
– 0.6oc above basal temperature.
• Stress:-Stimulation of skin can increases the production
of epinephrine & nor epinephrine – which increases
metabolic activity and heat production.
• Environment:-Extremes in temperature can affect a
person’s temperature regulatory systems
Measuring Body Temperature:-
 Sites to Measure Temperature Most common are:-
 Oral Rectal
Auxiliary Tympanic
Thermometer: is an instrument used to measure body
temperature
Types:-
Oral thermometer- has long slender tips
Rectal thermometer- Short, rounded tips
Auxiliary-Long and slender tip
Tympanic
Rectal Temperature

• Readings are considered to be more accurate, most reliable, is > 0.650c

(1 0F) higher than the oral temperature; the normal temperature of rectal
is 37.50C
• Equipment:– add lubricant & rectal thermometer to oral temperature
tray & watch.
• Rectal temperature taken in the following condition:-
• All children < 6 years
• Very sick patient
• Patients who has nose/mouth/operation
• Unconscious patient
• Un co-operative Pt
Contraindications of rectal temperature
• Rectal or perennial surgery
• Fecal impaction- the depth of the thermometer insertion may be
insufficient
• Rectal infection
• Neonates –can cause rectal perforation and ulceration;
N.B.
• The auxiliary method is safest and most non invasive.
• Shake and place bulb in the axilla
• Do not allow clothing in contact with thermometer & hold
by upper arm as well as place Lower arm across his chest.
• Axillaries thermometer are not accurate as oral or rectal
thermometer because auxiliary temperature is about 1
degree lower than mouth while 2 degree than rectal
temperature.
• The normal auxiliary temperature is 36.5 0C (97.60F)
 PULSE

•It is a wave of blood created in an artery by contraction of the left

ventricle of the heart. i.e. the pulse reflects the heart beat or is the same
as the rate of ventricular contractions of the heart – in a healthy person.
In some types of cardiovascular diseases heart beat and pulse rate
differs.
•E.G. Client's heart produces very weak or small pulses that are not
detectable in a peripheral pulse far from the heart.
Purpose:- •Tells the condition and progress of the patient
• To compare the abnormal with normal
• Help for Diagnosis
Peripheral Pulse: is a pulse located in the periphery of the
body e.g. in the foot, hands and neck
Apical Pulse (central pulse): is located at the apex of the
heart; PR is expressed in beats/ minute (BPM)
Pulse Deficit- It is a difference that exists between the apical
and radial pulse
 Factors Affecting Pulse Rates

• Age: at infancy and childhood, PR is higher than adult, then as age increase the PR
gradually decreases.
• Sex: after puberty the average males PR is slightly lower than female
• Exercise: PR increase with exercise
• Fever: increases PR in response to the lowered B/P that results from peripheral
vasodilatation – increased metabolic rate
• Medications: caffeine, digitalis preparation decreases PR, Epinephrine– increases PR
• Heat: increase PR as a compensatory mechanism
• Stress: increases the sympathetic nerve stimulation – increases the rate and force of heart
beat
• Position changes: when a patient assumes a sitting or standing position blood usually
pools in dependent vessels of the venous system.
Pooling results in a transient decrease in the venous blood return to heart and subsequent
decrease in BP increases heart rate.
Common sites of Pulse
• Carotid: at the side of the neck below tube of the ear (where the
carotid artery runs between the trachea and the sternoclidio mastoid
muscle)
• Temporal: the pulse is taken at temporal bone area.
• Apical: (most) at the apex of the heart: routinely used for infant &
children < 3 yrs
location– Left mid clavicular line under the 4th, 5th,
• Brachial: at the inner aspect of the biceps muscle of the upper arm or
medially in the antecubital space (elbow crease); is taken on the
brachial artery above the elbow on the inner part of the arm. It is the
best place to take pulse for the baby.
• Radial: (common) on the thumb side of the inner aspect of
the wrist – readily available and routinely used
• Femoral: along the inguinal ligament; at the groin. Used for
infants and children
• Popiliteal: behind the knee. By flexing the knee slightly
• Posterior tibial: on the medial surface of the ankle
• Pedal (Dorsalis Pedis): at the ankle; 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 2nd toes
 Methods of pulse assessment.
• Pulse: is commonly assessed by palpation (feeling) or auscultation
(hearing)
• The middle 3 fingertips are used with moderate pressure for palpation of
all pulses except apical; the most distal parts are more sensitive,
Assess the Pulse for
• Pulse Rate:- • Normal 60-100 b/min (80/min)
• Tachycardia – excessively fast heart rate (120/min)
• Bradycardia < 60/mi
• Volume
• Elasticity of the arterial wall
• Rhythm
Pulse Rhythm
• The pattern and interval between the beats, random, irregular beats –
dysrythymia
Pulse Volume: the force of blood with each beat
• A normal pulse can be felt with moderate pressure of the fingers and can be
obliterated/diminished with greater pressure.
• Full or bounding pulse forceful or full blood volume obliterated with difficulty
• Weak, feeble or thread readily obliterated with pressure from the finger tips
Elasticity of arterial wall
• A healthy, normal artery feels straight, smooth, soft and pliable, easily bent after
breaking
• Reflects the status of the clients vascular system
If the pulse is regular, measure (count) for 30 seconds and multiply by 2
 If it is irregular count for 1 full minute
 BLOOD PRESSURE

 Is the pressure exerted by blood against the wall of blood vessels. It

includes arterial, venous and capillary pressures.
• Arterial BP: it is a measure of a pressure exerted by the blood as it
flows through the arteries.
• Arterial blood pressure (BP) = cardiac output (CO) x total peripheral
resistance (TPR).
Normal range of B/P
•Systolic = 90 – 120 mm/Hg
•Diastolic = 60 -90 mm/Hg
N:B Tricusipd & mitral value closed – systolic 90, 100, 120, 140,
Aortic & pulmonic value closed – diastolic 60,90
Two types of blood pressure; to measure the force of blood against the
arteries
• 1. Systolic pressure: is the pressure of the blood as a result of
contraction of the ventricle (is the pressure of the blood at the height
of the blood wave);
• 2. Diastolic blood pressure: is the pressure when the ventricles are at
rest.
• 3. Pulse pressure: is the difference between the systolic and diastolic
pressure
• Blood pressure is measured in mm Hg and recorded as fraction.
• An increase in blood pressure is called hypertension; a decrease is
called hypotension.
Conditions Affecting BP
• Fever Increase
• Stress
• Arteriosclerosis
• Obesity
• Hemorrhage Decrease
• Low hematocrit
• External heat
• Exposure to cold Increase
Sites for Measuring BP
1. Upper arm using brachial artery (commonest)
2. Thigh around popliteal artery
3. Fore -arm using radial artery
4. Leg using posterior tibial or dorsal pedis
When taking PB, you identifies five phases in series of sounds
called Korotkoff's sound on stethoscope.

• Phase 1: The pressure level at which the 1st joint clear tapping sound is
heard, these sounds gradually become more intense. To ensure that they
are not extraneous sounds, you should identify at least two consecutive
tapping sounds.
• Phase 2: The period during deflation when the sound has a
swishing/whispering like quality
• Phase 3: The period during which the sounds are crisper and more intense
• Phase 4: The time when the sounds become muffled and have a soft
blowing quality
• Phase 5: The pressure level when the sounds disappear
• Purpose of assessing BP
• To obtain base line measure of arterial blood pressure for
subsequent evaluation
• To determine the clients homodynamic status; condition of
the heart and blood vessels
• To identify & monitor changes in BP resulting from a disease
process & medical therapy
• To determine the patient’s condition
• To aid in diagnosis
RESPIRATION

• Is the act of breathing (includes intake of O 2 removal of

CO2)
• Is the gaseous interchange between tissue cells & the
atmosphere Ventilation is another word, which refer to
the movement of air in and out of the lungs.
• Hyperventilation: very deep, rapid respiration
• Hypoventilation: very shallow respiration
• Includes both inspiration and expiration
• External respiration is the exchange of O2 & CO2 between blood and air
in the lung.
• Internal respiration is refers to the same kind of exchange between
bloods and cells.

Purpose:-
1.To aid in diagnosis
2. To compare abnormal with normal
Two Types of Breathing
1. Costal (thoracic):-
• Involves the external muscles and other accessory muscles (sternoclodio
mastoid)
• Observed by the movement of the chest up ward & down ward; commonly
used for adults
2. Diaphragmatic (abdominal):-
• Involves the contraction and relaxation of the diaphragm, observed by
the movement of Abdomen; commonly used for children.
 Assessment

• The client should be at rest

• Assessed by watching the movement of the chest or abdomen.
• Rate, rhythm, depth & special characteristics of respiration are assessed
A. Rate:
Is described in rate per minute (RPM);
Healthy adult RR = 15- 20/ min. is measured for full minute, if regular for 30
seconds.
As the age decreases the respiratory rate increases.
• Eupnea- normal breathing rate and depth
• Bradypnea- slow respiration
• Tachypnea - fast breathing
• Apnea - temporary cessation of breathing
B. Rhythm:
• is the regularity of expiration & inspiration
• Normal breathing is automatic & effortless.
C. 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.
Procedure:-
• Respiration are counted while taking pulse
• After counting pulse, watching rise and fall of the chest of abdomen.
• Count for half minute and multiply by 2
• Observe rate and depth
 Pain
• Pain is an unpleasant sensory and emotional
experience associated with actual or potential tissue
damage
• It is the most common reason for seeking health care
• It is considered as fifth vital organ so should
automatically assessed with other vital signs.
(Campbell, 1995)
Types of Pain
• Pain is categorized according to its duration, location,
and etiology.
• Three basic categories of pain are generally recognized:
Acute pain

Chronic (nonmalignant) pain

Cancer-related pain.
 Types of pain…
• Acute pain can be described as lasting from seconds to 6

months.

• Usually of recent onset and commonly associated with a specific

injury

• Some arguments present because some acute conditions that

should end within less time, but if persist can indicate chronicity

or complication
Types of pain…
• Chronic pain is a pain that lasts for 6 months or
longer
• Chronic pain is constant or intermittent pain that
persists beyond the expected healing time
• It can seldom be attributed to a specific cause or
injury.
 Types of pain…
• Cancer related pain may be acute or chronic.

• Pain resulting from cancer is so ubiquitous

• It is the second most common fear of newly

diagnosed cancer patients ( next to fear of dying)
• Cancer Pain can be related directly to the tumor,
nerve compression or therapeutic procedure.
 PAIN CLASSIFIED BY LOCATION
• Headache
• Pelvic pain
• Abdominal pain
• Chest pain
• Back pain
• Flank pain
• Muscle pain
Such classification helps communication and guiding therapy
 PAIN CLASSIFIED BY ETIOLOGY
• Burn pain

• Post operative pain

• Labor pain

• Post herpetic neuralgia- pain caused by shingles-adult

chickenpox.
Such classification also help to tailor treatment and/or client
re-assurance.