Vital Signs

These are indices of health, or signposts in determining client’s condition. This is also known as cardinal signs and it includes body temperature, pulse, respirations, and blood pressure. These signs have to be looked at in total, to monitor the functions of the body.
Vital Signs or Cardinal Signs are:
  • Body temperature
  • Pulse
  • Respiration
  • Blood pressure
  • Pain
Alteration in body Temperature
  • Pyrexia – Body temperature above normal range( hyperthermia)
  • Hyperpyrexia – Very high fever, 41ºC(105.8 F) and above
  • Hypothermia – Subnormal temperature.
Normal Adult Temperature Ranges
  • Oral 36.5 –37.5 ºC
  • Axillary 35.8 – 37.0 ºC
  • Rectal 37.0 – 38.1 ºC
  • Tympanic 36.8 – 37.9ºC
Normal Pulse rate
  • 1 year 80-140 beats/min
  • 2 years 80- 130 beats/min
  • 6 years 75- 120 beats/min
  • 10 years 60-90 beats/min
  • Adult 60-100 beats/min
Tachycardia – pulse rate of above 100 beats/min
Bradycardia– pulse rate below 60 beats/min
Irregular – uneven time interval between beats.
Respiration
  • Is the exchange of oxygen and carbon dioxide between the atmosphere and the body
Assessing Respiration
  • Rate – Normal 14-20/ min in adult
  • The best time to assess respiration is immediately after taking client’s pulse
  • Count respiration for 60 second
  • As you count the respiration, assess and record breath sound as stridor, wheezing, or stertor.
  • Respiratory rates of less than 10 or more than 40 are usually considered abnormal and should be reported immediately to the physician.
Blood Pressure
  • This is the force exerted by the blood against a vessel wall. Arterial blood pressure is a measure of the pressure exerted by the blood as it flows through the arties. There are two blood pressure measures:
  1. Systolic pressure. This is the pressure of the blood because of contraction of the ventricles, which is the height of the blood wave.
  2. Diastolic pressure. This is the pressure when the ventricles are at rest. It is the lower pressure present at all times within the arteries.
  • Ensure that the client is rested
  • Use appropriate size of BP cuff.
  • If too tight and narrow- false high BP
  • If too lose and wide-false low BP
  • Position the patient on sitting or supine position
  • Position the arm at the level of the heart, if the artery is below the heart level, you may get a false high reading
  • Use the bell of the stethoscope since the blood pressure is a low frequency sound.
  • If the client is crying or anxious, delay measuring his blood pressure to avoid false-high BP
Pain
How to Assess Pain

1. You must consider both the patient’s description and your observations on his behavioral responses.
2. First, ask the client to rank his pain on a scale of 0-10, with 0 denoting lack of pain and 10 denoting the worst pain imaginable.
3. Ask:
  • Where is the pain located?
  • How long does the pain last?
  • How often does it occur?
  • Can you describe the pain?
  • What makes the pain worse?
4. Observe the patient’s behavioral response to pain (body language, moaning, grimacing, withdrawal, crying,restlessness muscle twitching and  immobility)
5. Also note physiological response, which may be sympathetic or parasympathetic.
Managing Pain
  • Giving medication as per MD’s order
  • Giving emotional support
  • Performing comfort measures
  • Use cognitive therapy

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