Catherine G.

Sacdalan

Vital signsare measures of various

physiological statistics, often taken by
health professionals, in order to
assess the most basic body functions.
1. Temperature
2. Pulse
3. Respiration
4. Blood Pressure
5. Pain
6. GCS

Nursing
Responsibilities
Wash
hands before and after taking vital
signs
Gather equipment (like watch with a
second hand, thermometer with cover, BP
apparatus with stethoscope/dynamap,
alcohol swab, pen etc)
Properly identify patient, explain procedure
Assist to a comfortable resting position
Document and transfer readings to TPR
sheet after every vital signs monitoring
Inform the doctor for abnormal vital signs

BODY
TEMPERATURE

the
balance
between
the heat
produced
by the body
and the
heat lost
from the

TEMPERATURE NORMAL
VALUES
Age
0-1

Age
16

Age
6 - 11

Age
11 16

Adult

36.1
37.4
degrees
Celcius

36.9
37.5
degrees
Celcius

36.3
37.6
degrees
Celcius

36.4
37.6
degrees
Celcius

36.4
37.4
degrees
Celcius

FACTORS THAT INFLUENCE

TEMPERATURE

Age
Stress
Medications
Environment
Fever
Heat stroke
Hyperpyrexia/hyperthermia
Hypothermia

*Duration of taking temperature is every 4

hours or as ordered by the physician

ORAL ROUTE
- thermometer is
placed under the
tongue
Nursing
Considerations:
Allow 15 minutes to
elapse between
clients intake of hot or
cold food or smoking
and the measurement
of oral temperature

Contraindications to Oral Temperature Taking

oral lesions or oral surgery

dyspnea
cough
nausea and vomiting
presence of oronasal pack, nasogastric tube
seizure prone
very young children
unconscious
restless, disoriented, confused

AXILLARY ROUTE
- safest and most noninvasive method
Nursing
Considerations:
Pat dry the axilla. Rubbing
causes friction and will
increase temperature in
the area
Place thermometer in the
center of clients axilla
Place the arm tightly
across the chest to keep
the thermometer in place.

TYMPANIC ROUTE
- measurement of
temperature via
ears
Nursing
Considerations:

risk of injuring the

membrane if probe
inserted too far
Presence of
cerumen can affect
reading

RECTAL ROUTE
most accurate measurement of
temperature
Indications:
-

When there is respiratory obstruction which

prevents closure of the mouth
mouth is dry, parched and inflamed
oral/nasal surgery or disease
for very young, restless and irrational children
for mentally disturbed, unconscious, dyspneic,
irrational, restless and convulsive patients
When a patient is mouth breather and with
oxygen

RECTAL ROUTE
CONTRAINDICATIONS
Diarrhea
Patients with cardiac problems (due to stimulation
of vagal nerve that could trigger arrythmia)
Hemorrhoids
Imperforated anus
Rectal surgery
Patients with bleeding tendencies
Fecal impaction
Age related contraindications (80 years above) it
causes tissue damage to the rectum

RECTAL ROUTE
Pediat
ric

Adult

position in lateral
position upper legs
flexed, wear gloves,
and lubricate the tip
of the thermometer.
Instruct the patient
to breath slowly and
relax. Insert the
thermometer at
least 2.5 cm, do not
force thermometer if
there is resistance
-

- It is the rhythmic

expansion and
Normal Pulse Rate
Values
recoil of elastic
Age Age Age Age
artery caused by Adul
6-11 1-6
0-1
t
11the ejection of
16
60- 55- 70- 75- 80blood from the
100 110 115 130 160
ventricle. Palpated bp bp bp bp bp
where an artery
m
m
m
m
m
near the body
surface can be
pressed against

PULSE POINTS

Temporal
Carotid
Apical
Brachial
Apical
Radial
Femoral
Popliteal
Dorsalis Pedis
Pedal

Dysrythmia
- It is an irregular rhythm
- Pulse volume (amplitude) strength of
the pulse
Normal pulse ca be felt with moderate
pressure
Full or bounding pulse can be obliterated
only by great pressure
Thready pulse can easily be obliterated
(weak or feeble)
Arterial wall elasticity: the artery feels
straight, smooth, soft and pliable
Presence/absence of bilateral equality:

BRADYCARDIA TACHYCARDIA cardiac rate less than cardiac rate more than
60 beats per minute
100 beats per minute

RESPIRATION
It is the exchange of
oxygen and carbon
dioxide between
cells of the body and
the atmosphere.
A respiration
consists of
inhalation and
expansion and the
pause which follow.
The act of breathing.

BRADYPNEA
respiratory
rate less than
12 breaths

TACHYPNEA
- respiratory
rate more than
20 breaths

Normal
Values
Age
Adult 1116

Age
6-11

Age
1-6

Age
0-1

12-20 16-24 18-24 20-30 26-40

breat
hs

breat
hs

breat
hs

breat
hs

breat
hs

BLOOD PRESSURE
force that blood
exerts against the
wall of the blood
vessels
SYSTOLIC first
clear sound heard
when the valve of
the
sphygmomanomet
er is released
DIASTOLIC - the
point at which the

BP NORMAL VALUES
Adult

Age
11
16

-/+ 120
15

88
120

Age 6 Age 1 Age 0

- 11
6
-1
80
120

80
112

- 74
100

Systolic

-/+ 80 80 58 80 50 80 50 70 50 Diastolic
15

MANUAL BLOOD PRESSURE

MONITORING
Ensure that the client is rested
Allow 30 minutes to pass if the client had
engaged in exercise or had smoked or
ingested caffeine before taking the BP
(might tend to increase BP)
Use appropriate size of the BP cuff. Too
narrow cuff causes high false reading and
too wide cuff causes false low reading.
Position the client in sitting or supine
position

 Select appropriate arm and palm

facing upward in the level of the
heart
Apply BP cuff snugly around the
bared arm with two finger
breaths {2.5cm} above the
Antecubital fossa
Place stethoscope ear piece in
ears and be sure sounds are
clear and not muffled
Close valve by turning clockwise

 Continue to deflate cuff gradually

and note the point at which it
disappears which indicates
diastolic pressure reading
Remove the cuff and
sphygmomanometer and clean
the ear piece and diaphragm
with alcohol swab
Wash hands
Record BP in TPR sheet and
notify doctor for abnormal BP

PAIN is an unpleasant sensory and

emotional experience associated with
actual or potential tissue damage, or
described in terms of such damage
Pain scale used: Numerical,
Descriptive, FLACC and Wong Baker

GLASGOW COMA
SCALE

A neurological scalethat aims to givea reliable,

objective way of recording the conscious state of a
person for initial as well as subsequent assessment
lowest possible GCS is 3 (deep coma)
highest : 15 (fully awake person).

Interpretation
Brain injury is classified as:
Severe, with GCS < 9
Moderate, GCS 912
Minor, GCS 13.

EYE RESPONSE (E)

1 - No eye opening
2 - Eye opening in response
to pain stimulus
3 - Eye opening to speech
4 - Eyes opening
spontaneously

VERBAL RESPONSE (V)

1 - No verbal response
2 - Incomprehensible sounds (Moaning but
no words)
3 - Inappropriate words (Random or
exclamatory articulated speech, but no
conversational exchange)
4 - Confused (The patient responds to
questions coherently but there is some
disorientation and confusion.)
5 - Oriented (Patient responds coherently
and appropriately to questions such as the
patients name and age, where they are
and why, the year, month

RESPONSE (M)
1 - No motor response
2 - Extension to pain
(decerebrate
response)
3 - Abnormal flexion
to pain ( decorticate
response)
4 - Flexion/Withdrawal
to pain
5 - Localizes to pain
6 - Obeys commands