What do they assess?
What can they tell you?
Why are they important?
Are they objective or subjective?
Think about how they can help you ANTICIPATE
a patient’s outcome?
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TEMPERATURE
PULSE
RESPIRATION
BLOOD PRESSURE
PULSE OXIMETER
T P R BP PULSE OX
VS are taken as an assessment, whenever ordered, or
to help clarify a diagnosis.
VS are NEVER routine; you are recording
measurements which reflect a patients well being and
possible impending trouble with their vital organs.
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Measurement of body heat. It is the balance
between heat produced and heat lost. It is:
Fairly constant
Lower the closer to the body surface it is
measured
Less stable in children
Affected by:

illness, medication, age, infection, pregnancy and
dehydrations
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Hyperthermia-
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Hypothermia-
Measured in 1 of 5 areas:
1.
2.
3.
4.
5.
Rectal
Oral
Tympanic
Axillary
Temporal Scanner
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ORAL
Normal: 98.6F/37 C
Range:
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97.6-99.0
36.5-37.5
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RECTAL
Normal: 99.6/37.9
Range:
98.6-100.6
37-38.1
BATTERY OPERATED/IVACS
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Pressure of blood felt against wall of an artery
as heart contracts/relaxes.
Measured to assess how well the cardiovascular
system is meeting body’s needs.

Look at:
 RATE ??
 RHYTHM ??
 FORCE ??
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Where are the pulse sites in your body? (HAND OUT)
Temporal
 Carotid
 Brachial
 Apical
 Radial
 Femoral
 Popiteal
 Posterior Tibial (Pedal)
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Count for 60 sec
Count for 30 sec and multiply
X2
 Shorter time counts = inaccurate data
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Radial pulse- taken at wrist with 2 fingers over
radial artery site
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Pulse taken over apical site. Using your
stethoscope you count the heart sounds FOR 1
FULL MINUTE.
TACHYCARDIA
Too Fast! Greater than 100
BRADYCARDIA
Too Slow….Lower than 50
Birth- one year
120-160
Childhood
75-100
Adult
65-80
PULSE DEFICIT
Difference between the apical and
radial pulse
Count for 60 sec
Count for 30 sec and multiply X2
Respiration- 1 inspiration/1 expiration
Normals:
Adults: 16-20
Children: 18-30
Infants: 30-60
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Types of Respirations
1. Stertorous2. Tachypnea3. Shallow4. Cheyne-Stokes5. Dyspnea6. Apnea-
1.
2.
3.
4.
5.
Regular
Irregular
Shallow
Deep
Labored
To count respirations, watch or feel the patient’s
chest rise and fall. Try to observe WITHOUT
patient’s awareness to prevent a change in the
normal rate.
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Fever
Exercise
Stress
Disease
Medications
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Blood pressure- the force of blood exerted on inner
walls of arteries as blood circulates
There is ALWAYS a certain amount of pressure in
arteries because as the heart is pumping blood, it is
constantly forcing it to circulate
Blood pressure depends on:
Volume: amount of blood in circulatory system
 Force of heart beat
 Condition of arteries (elasticity)
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Your heart is an AMAZING pump. It works
reliably for decades, and it safely pumps blood
around. Your blood vessels are the pipes. They
take the output from the pump (heart) and
distribute it though out the body. A blood
pressure gauge is simply a way to measure the
performance of the pump and pipes.
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Systolic:
Pressure exerted on artery walls when the heart is
contracting
 Top number
 Always higher
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120
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Diastolic:
Pressure exerted on artery walls when heart
is relaxing
Bottom number
Always lower
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80
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Normal Blood Pressure
120
 80
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Hypotension- low blood pressure
Systolic less than 80
Hypertension- high blood pressure
Systolic higher than 140
Diastolic higher than 90
Pulse Pressure- difference between systolic
and diastolic pressure
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When the cuff is pumped up, the blood flow is
actually cut off as the pressure is exerted by the
cuff. As the pressure in the cuff is released,
blood starts flowing again and you can hear the
flow in the stethoscope. The number at
which blood starts flowing (120) is the
measure of the maximum output
pressure of the heart (systolic). You
continue releasing the pressure on the cuff and
listen until there is no sound. That number
(80) indicates the pressure in the system
when the heart is relaxed (diastolic).
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Aneroid:
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Mercury:
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Possibly considered the 5th vital sign. It is a
rough measurement of the oxygen saturation of
the blood. It allows nurses to get a good idea of
how well the patient is breathing and
oxygenating his blood. No nail polish! Why??
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Pages 620-622 in your textbook
Pulse oximeter measures the level of saturation of
the patient’s hemoglobin with oxygen.
Hemoglobin is the part of the blood that carries
oxygen to the cells to nourish them. It measures
how full the hemoglobin molecules are with
oxygen.
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Automatic vital sign machines
It is tempting to view VS as a
routine & static piece of data
but…
 VS are fluid, dynamic, & ever-
changing, just like our patients!
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Be accurate!
Be gentle!
Be observant!