Vital Signs

Vital
Signs
PURPOSE:
 To educate nurses on how to take vital signs and know the normal values.
OBJECTIVE:
 At the end of the program the nurse will be able to demonstrate correct vital signs taking and differentiate
normal from abnormal range.
EQUIPMENTS/ SUPPLIES NEEDED:

 Stethoscope
 Oral/ rectal glass mercury thermometer or digital thermometer
 Sphygmomanometer
 Watch with second hand
 Tissues
 Cottonballs
 Lubricant on a paper wipe for rectal method
Vital signs/ Cardinal Signs- measure your body’s basic functions. The measurements check your general physical
health. They’re the first step of any medical exam or evaluation. Vital signs are important because they give a
healthcare provider clues about any underlying conditions that affect your health or show your progress toward
recovery.
The four vital signs include four critical areas of assessment :

 Temperature
 Pulse
 Respiration
 blood pressure.
Vitals should be taken on a regular basis: to provide baseline data so that you can monitor changes and
recognize them as signs or symptoms of illness. All vital signs should be taken when the individual is “at rest.”
You should wait 30 minutes to take the vital if a person has just eaten, drank hot or cold beverage, just smoked
or exercised.
When to assess vital signs:
1. Upon admission to any health care agency or
institution
2. Based on agency or institutional policy and
procedures
3. Anytime there is a change in the patient’s
condition
4. Anytime there is a loss of consciousness
5. Before and after any surgical procedure or
invasive procedure
6. Before and after any activity that may increase
risk such as ambulation after surgery
7. Before administering medication that affect
cardiovascular and respiratory function
Vital Signs on
Temperature
-Degree of heat or cold in the human body.
Body temperature is measured by a clinical
thermometer and represents a balance between
the heat produced by the body and the heat it
loses.
Definition of terms:
1. Fever/ Febrile/ Pyrexia- feverish, increased body temperature (37.5 – 38.3°C)
2. Hyperpyrexia or hyperthermia- unusually high body temperature (>41- 42 °C)
3. Hypothermia- a body temperature below the average normal range. (Below < 35 °C)
maybe caused by accidental exposure, frost bite
4. Intermittent or quotidian fever- one in which the body temperature is elevated but return to normal
temperature within 24 hour period
5. Remittent Fever- wide range of temperature over 24 hour period , all of which are above normal
6. Relapsing Fever- short febrile periods for few days are interspersed with periods of 1 or 2 days of
normal temperature
Site /Types
1. Oral- the most accessible and most convenient
Contraindications:
infants, children less than 6 years old and confused patient
2. Rectal- the most reliable measurement of the body temperature
Contraindications:
clients with Myocardial Infarction
diarrhea , undergone rectal surgery and bleeding
3. Axillary- safest and non-invasive method for infants. Used in recovery rooms to avoid turning the clients
4. Tympanic membrane thermometer- used an infrared sensor to detect heat given off the tympanic
membrane.
Pulse on Vital Signs
The pulse rate is a measurement of the heart rate.
This is the number of times the heart beats per
minute
Definition of terms:
 Tachycardia- refers to the pulse rate higher than
150 bpm
 Bradycardia- is a slower than normal heart rate.

When taking your pulse:
Which is fewer than 60 beats per minute
1. Using the first and second fingertips, press
firmly but gently on the arteries until you
feel a pulse.
2. Start counting the pulse when the clock's

second hand is on the 12.
3. Count your pulse for 60 seconds.

Pulse Pressure Points
Vital Signs on Respiration
It is the act of breathing. It includes intake of oxygen and the output of
carbon dioxide. Normal breathing per minute: 12- 20 cpm
DEFINITION OF TERMS:
1. dyspnea- difficulty of breathing
2. Polypnea- increase in the rate of respiration
3. Tachypnea- fast, shallow breathing. Associated with fever, anxiety, exercise
4. Bradypnea- lower than normal number of brathing per minute
5. Hyperpnea- This is when you’re breathing in more air but not necessarily breathing faster. It can
happen during exercise or because of a medical condition that makes it harder for your body to get
oxygen, like heart failure or sepsis (a serious overreaction by your immune system).
6. Apnea- cessation of breathing
7. Kussmaul breathing-pattern of fast, deep breaths
Vital Signs: Blood Pressure
Blood Pressure- it is the measurement of the pressure exerted by the blood as it passes through the blood
vessel
Blood pressure is measured in millimeters of mercury (mm Hg) with two numbers:
•Systolic pressure (top number): when the heart contracts
•Diastolic pressure (bottom number): when the heart relaxes
Four categories to define blood pressure readings in adults:
•Healthy: The systolic number is 120 or less, and the diastolic number is 80 or less.
•Elevated: The systolic number is between 120 and 129, and the diastolic number is less than 80.
•Stage 1 hypertension: The systolic number is between 130 and 139, or the diastolic number is between
80 and 89.
•Stage 2 hypertension: The systolic number is 140 or higher, or the diastolic number is 90 or higher.
AGE NEWBORN PULSE RESPIRATION BLOOD PRESSURE
BEATS/ MIN BREATHS/ MIN
Newborn 36.8 °C (maxilla) 80-180 30-80 73/55
1-3 yrs 37.7°C (rectal) 80-140 20-40 90/55
6-8 yrs 37°c (oral) 75-120 15-25 95/75
10 years 37°c (oral) 75-110 15-25 102/62
Teens 37°c (oral) 60-100 15-20 102/80
adults 37°c (oral) 60-100 15-20 120/20
>70 years 37°c (oral) 60-100 15-20 120/80 (may

normally be up to
160/95)
End

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Vital

EQUIPMENTS/ SUPPLIES NEEDED:

The four vital signs include four critical areas of assessment :

 Bradycardia- is a slower than normal heart rate.

2. Start counting the pulse when the clock's

3. Count your pulse for 60 seconds.

Four categories to define blood pressure readings in adults:

Newborn 36.8 °C (maxilla) 80-180 30-80 73/55

1-3 yrs 37.7°C (rectal) 80-140 20-40 90/55

6-8 yrs 37°c (oral) 75-120 15-25 95/75

10 years 37°c (oral) 75-110 15-25 102/62

Teens 37°c (oral) 60-100 15-20 102/80

adults 37°c (oral) 60-100 15-20 120/20

>70 years 37°c (oral) 60-100 15-20 120/80 (may

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