VITAL SIGNS

TAKING
 also referred to as Vital Signs
cardinal signs
 include temperature,
pulse, respiration, and
blood pressure,
abbreviated TPR B/P.
 Reflects the body’s
physiological status and
provides information
essential for evaluating
homeostatic balance

with regular monitoring,

may measure patient
response to treatment.
Purpose of assessing vital signs
• To establish baseline data on admission and for
further evaluation.

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• To assess patient’s response to treatment or
medication.
• To provide critical information needed to make life
saving decisions.
• To confirm feedbacks on treatment, procedures or
management performed.
• To monitor patient’s condition after invasive
procedures or surgical management.
 Two important habits must be
developed by the
medical assistant before taking a
patient’s vital
signs:
1. Aseptic technique in the form of
hand washing and recognition

2. Correction of factors that may

influence results of vital signs.
Example of  factors can affect
Vital Signs
 emotions and
mood
Presence of
diseases
Food and nutritional
status
Climate and
environment
Exercise and mood
Variations in results can
indicate:

a. a new disease process

b. patient’s response to treatment
c. patient’s compliance with a
treatment plan
TEMPERATURE
•Body temperature- the
balance between heat
produced by the body
and heat lost from the
body.
•Normal values: 35.5-37.5
centigrade/ 97.6-99.6
fahrenheit
•The delicate balance
between heat production
and heat loss is
maintained by the
hypothalamus in the brain.
Body heat is produced by
the actions of voluntary
and involuntary muscles.
-as the muscles move, they
use energy, which produces
heat.
Cellular metabolic
activities, such as the
process
of breaking down food
sugars into simpler
components (catabolism),
are another source
The body loses heat by a combination of
five processes:
1. Convection.
The process by which heat is
lost through the skin by being
transferred from the skin by air
currents flowing across it,
such as a fan used on a hot
day for cooling purposes.
2. Conduction.
The transfer of heat from within
the body to the surface of the
skin and then to surrounding
cooler objects touching the
skin, such as clothing.
The body loses heat by a
combination of
five processes:
3. Radiation.
Body heat lost from the surface of the skin to a
cooler environment, much like a cool room
becoming warm when occupied by many
people.
4. Evaporation.
A heat loss mechanism that uses heat
absorption through vaporization of perspiration.
5. Elimination.
Heat that is lost through the normal functioning
of the intestinal, urinary, and respiratory tracts.
Identify the following response in
temperature. Increased or
decreased
a. bacterial infection
b. increased physical activity
c. fasting
d. Exposure to cold temperature
e. exposure to heat
f. Pregnancy
g. drugs that increase metabolism
h. stress and severe emotional reactions
i. Viral infection
j. Decreases muscular activity/ inactivity
k. Time of the day: early morning vs late of the
day
Terms Used to Describe
Body Temperature
1. Afebrile: absence of fever

2. Febrile: fever is present

3. Fever: body temperature increased

beyond normal range; pyrexia is another
term for fever
4. Intermittent: a fluctuating fever that returns to or
below baseline, then increases again

5. Remittent: a fluctuating fever that does not return to

the baseline temperature; it fluctuates but remains
increased.

• 6. Continuous:
a fever that remains above the baseline; it does not
fluctuate but remains fairly constant
Types of Thermometers
1. Disposable Thermometers.
 are individually wrapped strips with heat-sensitive dots that
change color to indicate temperature
are used once and then discarded
there are strips for use on the forehead and others for oral
use
although strips are easy to use and prevent patient cross
contamination , accuracy is questionable.
Types of Thermometers
2. Electronic and Digital
Thermometers
are widely used, handheld,
battery-operated or plug-in
units
that have easy-to-read
electronic display screens
to indicate results Electronic
thermometers in Fahrenheit or
Celsius scales are available.
Provides a temperature
reading in just 2-60seconds.
Types of Thermometers
3. Tympanic
Thermometers / Infrared
type
Senses body temp in a form
of infrared
More popular because they are
fast, provide no discomfort to
the patient, can be used on
patients over 2 years of age as
well as adults, and usually are
accurate.
They consist of a handheld unit
with a probe tip that is inserted
into the ear securely to make a
seal
Types of Thermometers
• Inaccurate readings can result if patients:

a. have impacted cerumen in the ear of which they may be

unaware
b. has otitis media, a middle ear infection, the reading
tends to be inaccurate and the procedure is painful.
Measuring Temperature
To convert °F to °C:
Subtract 32 from F temperature, then
multiply by 5/9
97 ° F = 36.1 °C

To convert °C to °F:
Multiply C temperature by 9/5, then add
32.
36.1 °C = 97 ° F
Sites used to assess body temperature

• 1. Oral- used for easy accessability and convenience.

• 2. Rectal- considered to be very accurate but

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inconveniently and unpleasant for the client.
• 3. Axilla- considered inaccurate but most preferred
site because it is safe , noninvasive and convenient
for the patient.
• 4. Tympanic- readily accessible and very fast
because it uses sensor or infrared energy.
Types of temperature
• 1. Core
temperature- at the

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deep tissues of the
body. (tympanic and
rectal routes)
• 2. Surface
temperature-
superficial areas of
the skin of the body.
• Example?
 
Purpose measuring/monitoring
patient’s body temperature:
• 1. To provide baseline data for further
evaluation.
• 2. To determine changes in body
temperature in response to specific
medical intervention, therapies, minor or
invasive procedure.
• 3. To determine alteration in disease
condition.
• PREPARATION
• Assess for:
• Site most appropriate for measurement
• Clinical signs of fever
•

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ASSEMBLE THE EQUIPMENT
• 1. Type of thermometer used
• 2. Tissue and alcohol wipes
• 3. Small towel from the client (for axilla temperature)
• 4. Water soluble lubricant (for rectal temperature)
• 5. Disposable gloves if needed
• 6. Waste receptacle- optional
Axilla temperature
• Consideration:
• Least reliable method, but safer that the oral route.

ACTIONS
1. Do hand hygiene
2. Identify the client and explain
the procedure
3. Clean the thermometer with
alcohol wipes from tip (bulb) to
top
4. Assist the client to a
comfortable position and
expose the axilla.
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RATIONALE
To prevent the spread of
microorganism
To ensure accuracy and gains
cooperation
To minimize contamination
To lessen the anxiety of the
client, avoid rubbing the axilla
ACTIONS RATIONALE
5. Using a towel pat the axilla Moisture can affect the reading
dry of perspiration if there is. of the temperature
6. Turn on the thermometer and To secure the thermometer in
place it in the center of the axilla. place and to ensure accurate
Lower the arm so the tip of the reading.

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thermometer is snug in the
middle of the armpit and the
entire tip (bulb) is covered.
7. Remain with the client and To prevent the thermometer
hold the thermometer in place from falling out of place.
especially if the clients are
children
8. Remove the thermometer To determined the temperature
when it beeps. Look at the of the client. Temp above 37.5 is
numerical value display for the considered febrile.
reading.
9. Clean the thermometer after To disinfect the thermometer
use. Wipe with alcohol from top and prevent contamination.
towards the tip (bulb)
ACTIONS RATIONALE
10. Inform the client of the To have proper evaluation and
result and record correctly documentation of the results

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11. Throw the used wipes To maintain cleanliness and
properly. Do hand hygiene. reduces the spread of
microorganisms
PULSE
 PULSE is the beat of the
heart felt at an artery as a
wave of blood passes through
the artery
A wave of blood caused by
the rhythmic expansion of the
artery with each heartbeat.
 is felt every time the heart
beats
 The pulse is the same as the
heart rate.
can be felt in areas of the
body where an artery is close
Different sites of peripheral pulses

• PULSE RATE-
number of
heartbeat or

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pulses felt in 1
minute.
• Normal values:
• Adult- 60-80
beats/min
• Children- 80-110
• Infants- 100-160
Pulse Sites
Pulse sites are also used when necessary as pressure
points for controlling severe bleeding.
• radial pulse
is located at the thumb side of the wrist
approximately 1 inch above the base of the thumb.
the most commonly used site for obtaining a pulse
rate.
Pulse Sites
• carotid pulse
used during emergency situations and when
performing cardiopulmonary resuscitation (CPR)
is found between the larynx and sternocleidomastoid
muscle in the front side of the neck on either side of
the trachea
when measuring the pulse at the carotid site,
compress only one side at a time.
Pulse Sites
brachial pulse
 is found in the inner aspect of the elbow called the
antecubital space
this pulse site is the most commonly used site to
obtain blood pressure measurements
Pulse Sites
•temporal pulse
is located at the temple area of the head

rarely used to obtain a pulse rate but may be used to

monitor circulation, control bleeding from the head and
scalp, and to take a temporal artery temperature
Pulse Sites
femoral pulse
is located in the groin area
a deep artery and must be compressed firmly to be
felt.
Pulse Sites
popliteal pulse
is located at the back of the knee
patient must be in a supine position with the knee
flexed for it to be felt because the artery is deep
within the knee
this artery is used for leg blood pressure
measurements and to monitor circulation
Pulse Sites
dorsalis pedis
is felt on the top of the foot slightly to the side of
midline next to the extensor ligament of the great toe,
between the first and second metatarsal bones
commonly used to monitor lower limb circulation.
Pulse Sites
Apical pulse

is found at the apex of the heart, located at the fifth

intercostal space left side, midclavicular line, that is,
between the fifth and sixth ribs perpendicular to the
middle of the clavicle, left of the sternum
A stethoscope is required to obtain an apical pulse.
Apical pulse is used for cardiac patients and patients
with an arrhythmia, and to obtain infant pulse rates
because they are difficult to obtain by the usual
methods.
Apical pulse

• Pulse rates may vary according to age, activities,

general health, sex, emotions, pain, and
medications.
• The rate is lower when sleeping and higher when
active or exercising.
• Rates for infants and children are greater than for
adults.
Heart Rate Chart: Babies to
Adults
AGE Beats Per Minute (BPM)

Babies to Age 1 100 - 160

Children
  ages 1-10 60 - 140

Children age 10+ and adults 60 - 100

Athletes: 40 - 60

 Well-conditioned athletes have a lower than average

resting rate because their cardiovascular system has
been developed to function more efficiently.
Rationale for assessing pulse
rate
• 1. To determine if the pulse is within
the normal range and if the rhythm is

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regular.
• 2. To establish baseline data
• 3. To monitor and evaluate changes in
the clients health status
• 4. To determine the adequacy of
peripheral pulses.
• 5. To determine the pulse deficit.
Characteristics of pulse to be assessed.
• 1. Quality of pulse- strong
rhythm and easily palpated.
• 2. Pulse rhythm- regular and
even time interval between

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each heartbeat. (dysrhythmia)
• 3. Pulse rate- within normal
range. (bradycardia &
tachycardia)
• 4. Pulse volume- degree and
strength of expansion or size
of pulse not faint nor too
bounding.
Pulse Abnormalities
Bradycardia
•a pulse rate less than 60 beats per
minute

Tachycardia
• a pulse rate greater than 100 beats per
minute
Procedure
ACTIONS
1. Do hand hygiene
2. Explain the procedure to the
client and assist him in a
comfortable position. When
radial pulse is assess, the arm
can rest alongside the clients
body with palm facing slightly
upward or the forearm can rest
at a 90 degree angle across the
chest with palm downward.
3. Assess the client
4. Select the pulse point. Ex. The
radial pulse is taken unless it
cannot be palpated or specified
that circulation to another body
RATIONALE
To prevent the spread of
microorganism
To gain the clients cooperation
and to promote clients comfort
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To determine factors that may
affect the pulse rate and rhythm
To promote ease and comfort on
both the client and the nurse
because it is readily accessible
and convenient.
Procedure
ACTIONS
5. Palpate and count the pulse:
-Place 2 or 3 middle fingertips
lightly and squarely over the
pulse point. Use the pads of the
fingers in palpating.
- Count the pulse for a full
minute
6. Assess the pulse rhythm and
volume
-Assess the pulse rhythm by
noting the pattern of intervals
between beats.
-Assess the pulse volume a
normal pulse can be felt with
moderate pressure
RATIONALE
To ensure the accuracy of
assessment, using your thumb is
contraindicated because it has a
pulse which can be mistaken as
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the clients pulse.
To ensure accuracy of
assessment
To determine for any
abnormalities or deviation from
normal that may indicate a
circulatory compromise or a
pathological conditions
A forceful pulse volume is full
and bounding. An obliterated
 Procedure
ACTIONS RATIONALE
7. Check to see the client is in To ensure safety and comfort
comfortable safe position
before leaving

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8. Do hand washing

other ways to take the Pulse rate

Placing the client’s forearm on the armrest
of chair and
putting your the fingertips over the radial
pulse

Placing the client’s forearm straight of

across the chest or upper abdomen and
putting the fingertips over the radial
pulse
RESPIRATION
• Act of breathing which
includes the intake of
oxygen (inhalation) and
output of carbon dioxide
(exhalation) = 1
respiration.

• Measure by observing
chest rise and fall.
• Measured in breaths per
minute.
• Normal values: 12-20
breaths/min
NORMAL RESPIRATORY RATES
 
• Newborns 44 rpm
• Infants 20–40 rpm
• Children (1–7 years) 18–30 rpm
• Adults 12–20 rpm
Characteristics of breathing
• Eupnea - normal breathing
• Tachypnea - breathing more than 24
cycles per minute; respiratory rate
greater than 40 respirations per
minute
• Kussmaul respiration- rapid deep
breathing .
• Bradypnea - breathing less than 16
cycles per minute
• Dyspnea - difficulty in breathing
• Apnea is the temporary complete
absence of breathing.
• Cheyne-Stoke- breaths that gradually
become faster and deeper than
normal followed by periods of apnea.
• Biots respiration- rapid deep breathing
with abrupt periods of apnea between
each breath.
Purpose of taking the
respiration
• 1. To determine the clients respiratory rate,
rhythm and depth.

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• 2. To monitor abnormal respirations and
breath sounds.
• 3. To identify alterations in respiratory or
breathing pattern resulting from a disease
condition.
• 4. To establish baseline data
• 5. To assess respiration before and after a
procedure or administration of medications.
Equipment
• Wrist watch with a
functional second

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hand.
Consideration
• 1. Young children are diaphragmatic
breathers, so observe the rise and fall

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of the abdomen when getting the
respiration
• 2. If the infant or child is crying, it will
need quieting before assessing in
order to have an accurate
measurement.
ACTIONS
1. Do hand hygiene
2. Explain the procedure and
provide privacy
3. Position the client in a
comfortable supine , fowlers or
sitting position.
4. Observe or palpate and count
the respiratory rate by placing
the clients arm across the chest
and observe the chest
movement while pretending to
take the radial pulse
5. Observe the depth, rhythm
and characteristics of respiration. appear shallow, rapid, labored,
RATIONALE
To prevent spread of
microorganism
T gain cooperation and to
promote ease and comfort.
To ensure accurate
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measurement
To prevent alteration in
assessing the respiration.
Abnormal respiration may
deep, noisy. Normal respiration
are evenly spaced.
Normal respiration are not too
fast nor too slow, silent and
BLOOD  PRESSURE
 Blood pressure measures
cardiovascular function by
measuring the force of blood
exerted on peripheral arteries during
the cardiac cycle or heartbeat.
Normal- 120/80mmhg.
 The measurement consists of two
components. The first is the force
exerted on the arterial walls during
cardiac contraction and is called
systole. The second is the force
exerted during cardiac relaxation
and is called diastole.
 They represent the highest (systole)
and lowest (diastole) amount of
pressure exerted during the cardiac
TERMS
1. Hypertension
• PERSISTENT elevation of either diastolic or systolic
blood pressure in different occasions.
2. Essential (Primary) Hypertension - high blood
pressure with no identifiable cause.
3. Secondary Hypertension
• high blood pressure with a known cause
eg. Drug-induced or related causes
4. Korotkoff Sounds
Distinct blood pressure sounds were first described by a
Russian physician named Korotkoff.
FACTORS THAT AFFECT BP
1. Blood volume
2. Peripheral
resistance
3. Vessel
elasticity
4. Viscosity of
the blood
Equipment for Measuring
Blood Pressure
Blood pressure is measured by the auscultatory (listening)
method using a sphygmomanometer and a stethoscope
Aneroid Manometer
is a cuff containing a
rubber bladder
attached to a dial.
the blood pressure is
read at the point of the
needle descending the
dial.
 Aneroid manometers
need to be calibrated
regularly because they
do not maintain
calibration easily.
Cuff sizes for manometers
 The appropriate cuff
size is necessary to
obtain an accurate
blood pressure
measurement.
A cuff that is too small
will give an artificially
high blood pressure
reading, whereas a cuff
that is too large will give
an artificially low
reading.
The selection of the cuff
size depends on the size
of the arm, not the age
Stethoscope consists of:
1. ear pieces
2. tubing
3. two heads
a. the bell
b. the diaphragm
Errors in Blood Pressure
Measurement Procedures
1. Improper cuff size.

2. The arm is not at heart level. Do not hold the arm up

or let the patient hold up the arm. Pressure is
increased when this is done.

3. Cuff is not completely deflated after palpatory

method, resulting in a higher pressure
measurement.

4. Reinflating the cuff during the procedure without

allowing the arm to rest for 1 to 2 minutes.
Errors in Blood Pressure
Measurement Procedures
5. Patient is not relaxed and comfortable. An anxious,
apprehensive patient will have a reading that is higher
than the actual blood pressure.

6. Improper cuff placement. Cuff is too loose, too tight,

or not positioned correctly over the brachial artery.

7. Defective equipment in which there are air leaks in

the bladder or valve, the mercury column is dirty, or
air bubbles are present. Mercury and aneroid
sphygmomanometers are not calibrated at zero.
Purpose of BP taking
• 1. To promote baseline data for subsequent evaluation.
• 2. To determine the client hemodynamic status.

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• 3. To identify and monitor changes in blood pressure
resulting from a disease process, medical therapy or drug
administration.
• 4. To determine the clients safety in performing activity
after an extended bed rest or recovery from anesthesia.
• 5. To assess clients general health status.
Consideration
• 1. Make sure the
client has not
smoked or ingested

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caffeine within 30
minutes prior to the
procedure.
• 2. Rest for
10-15minutes if the
client has just
finished eating,
performed strenuous
activities.
• 3. Proper position
PROCEDURES
ACTIONS
1. Do hand hygiene or washing
2. Bring equipments to the
bedside
3. Explain the procedure and
provide privacy
4. Position the client
appropriately to ensure accurate
reading.
a.Adult client should be sitting
unless otherwise specified, both
feet should be flat on the floor.
b.The elbow should be slightly
flexed with palm of the hand
facing up and the forearm
supported at heart level.
RATIONALE
To prevent the spread of
microorganism
To save time and effort
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To gain clients cooperation and
to promote ease and comfort
Legs crossed at the knee may
result to elevated pressure.
Blood pressure increases when
the arm is below the heart level
and decreases when the arm is
above the heart level.
ACTIONS RATIONALE
5. Expose the upper arm To evenly wrap the BP cuff to
ensure an accurate reading.
6. Wrap the deflated cuff evenly To allow the bladder of the cuff
around the upper arm. Locate to compress the artery.
the brachial artery, apply the

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center of the BP cuff bladder
directly over the artery. For adult
client place the lower border of
the cuff approximately 2.5cm
above the antecubital space.
7. If this is the clients initial To prevent underestimation of
examination perform a the systolic pressure or
preliminary palpatory overestimation of the systolic
determination of the diastolic pressure.
pressure
8. Position the stethoscope
appropriately :
a. Clean the earpieces with To prevent the spread of
alcohol wipes microorganism.
ACTIONS RATIONALE
8.
b. Insert the earpiece of the To be able to hear a clear sound.
stethoscope in your ears, tilting
slightly forward.
c. Place the bell or the To ensure accuracy

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diaphragm of the stethoscope
over the brachial pulse. Hold the
bell with the thumb and index
finger.
ACTIONS RATIONALE
9. Auscultate the clients blood
pressure.
a.Close the valve on the bulb
pump by turning the knob
clockwise.

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b.Pump up the cuff until the
sphygmomanometer is 30mmhg
above the point where the
brachial pulse disappeared
(usually at 160-200mmhg)
c.By turning the knob counter-
clockwise release the valve on So that the pressure decreases
the cuff slowly. at the rate of 2-3mmhg/second.
d.As the pressure falls, identify To have a correct reading.
the manometer reading when First sound- systolic pressure
the first tapping sound is heard Second sound- diastolic pressure
and the last heard sound.
ACTIONS RATIONALE
9.
e. Deflate the cuff rapidly and
completely
f. Wait for 1-2mins. Before
making further measurement

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10. Remove the cuff from the To prevent contamination
clients arm and wipe it with an
appropriate disinfectant.
11. Assist the client to a
comfortable position
12. Do hand hygiene
•END

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