it also help in providing comprehensive care to patient.....with update knowledge.....

1. PRESENTED BY: MR.J.G SAMBAD
MSC.NURSING
IKDRC COLLEGE OF NURSING

2.  INTRODUCTION :
Vital sign are the indicator of
the body’s physiologic status and response to
physical environment and psychological
stressor.The vital sign or the cardinal sign are
temperature, pulse, respiration, and blood
pressure. The findings are governed by the
vital organs.

3. 1. Temperature
2. Pulse
3. Respiration
4. Blood pressure
5. oxygen saturation
6. Pupillary reaction/ pain

4.  Vital sign are otherwise called cardinal signs.
These are the indicator of health status, as
these indicate the effectiveness of
circulatory, respiratory, neural, & endocrine
body functions.

5.  To determine change in client status.
 To recognize variation from normal and its
significance.
 To help physician to prescribe right
treatment.
 To identify specific life threatening
condition.
 To detect changes in client health status.
 To help in diagnosis of disease, the result of
treatment and medication.

6.  Upon admission.
 On a routine basis.
 Before and after invasive procedure.
 Before and after administration of medication.
 Any detoraition of patient’s general condition.
 Before and after nursing intervention that may
influence vital sign.
 Prior to medical emergency call MET team.

7.  Body temperature – 98.6˚F or 37˚C in adults
Pulse – 72/minute in adults
 Respiration – 16/ minute in adult
 Blood pressure – 120/80 mm of Hg

8. Thermometer is the equipment ,that use to
monitor the temperature. 4 types of
thermometer.
• Clinical thermometer
• Rectal thermometer
• Digital thermometer
• Lotion thermometer

9.  Two parts of thermometer-bulb and stem
 Blub is fragile part, containing mercury,
sensitive to temperature.
 Stem is hollow tube in which mercury can
rise.
 there are two scales, Fahrenheit and Celsius
(centigrade).


10.  Mercury, a liquid metal, with silvery
appearance is used in thermometers,
because it is very sensitive to a small changes
in temperature, expansion of mercury is
uniform, easily visible.
 CELSIUS AND FAHRENHEIT SCALES –
• C = (F-32) × 5/9
• F = (C × 9/5 )+32

11.  Shake the mercury down, grasp
securely, hold it from the upper end of
the stem.
 Be careful from fall, shake it away from
all articles and furniture.
 Never wash it with hot water
 Never store it in disinfectant solution.

12. NAME OF THE
DISINFECTION
STRENGTH TIME
Dettol 1:40 5 min.
Savlon 1:20 5 min
Lysol 1:40 3min.
Fairgenol 1:40 5 min.

13. CLINICALTHERMOMETER -
 ELECTRONICTHERMOMETER –
 TYMPANIC MEMBRANE -THERMOMETER
 DISPOSABLETHERMOMETER –
CHEMICAL DOT -

16. • Definition :
It is a measurement of the average kinetic
energy of the molecules in an object or
system and can be measured with a
thermometer or calorimeter. It is determining
the internal energy contained within the
system. Body temperature is the difference
between the amount of heat produced by
body process and the amount of heat lost to
the external environment.

17.  To get accurate temperature , the bulb
of thermometer must be placed
surrounded by body tissue and more
blood circulation, air and moisture should
be avoid.
COMMON SITES: - Mouth - Groin
- Axilla
-Vagina and Rectum

18.  There is good blood supply under
tongue, so correct temperature is
recorded.
 There is less chance of bulb coming in
contact with air.
 Thermometer can held easily under
tongue.
 No privacy is needed

20.  If patient keep it in oral cavity not under
tongue, then possibility of false temperature
recording.
 If thermometer is not adequately disinfected
then chances of cross infection.
 children can bite thermometer.
 Patient feels bad test, if disinfectant is not
properly removed.
 Patient feels tired by keeping it in mouth

21. 1. Explain the procedure to the patient also find out
if the patient has taken cold or hot food or fluids
or has smoked. fso, the nurse should wait for 30
minutes.
2. Perform hand hygiene.
3. Place the patient in a comfortable position.
4. Read mercury level while gently rotating
thermometer at eye level. Shake it until reading
lowers mercury level to 35.6 C.

22. 5. Ask client to open mouth and gently place
thermometer and the tongue in posterior
sublingual pocket lateral to center of lower
jaw.
6. Wait for 3 minutes.
7. Remove the thermometer ,clean from
steam to bulb and read at eye level.

23. 8. Shake gently so that mercury level falls
below 35 C.
9. Place the thermometer in disinfectant
solution.
10. Discard used tissue paper/ cotton balls.
11. Record temperature on the graph sheet of
TPR record.

24.  Unconscious patient, children under 6year.
 Patient with convulsion and mouth breather,
 Patient with injury, inflammation or
operation of mouth.
 Extremely week person who can not hold.
 Patient suffering from frequent attack of
cough.

25.  Causes less discomfort to the patient.
 Its useful in children and in the client
who cannot hold it properly.
 Taking hot and cold drink will not affect
the temperature.
 No chance of cross infection, bad test
and biting of thermometer.

26.  Neonates, infants, toddlers, & children,
intubated and sick patients.
 Patient with oral inflammation or wired jaws.
 Patients recovering from oral surgery.
 Those who cannot breathe through their
nose, irrational patients and those for whom
other temperature sites are contraindicated.
 Mentally challenged or compromised
individuals.

27. 1. Explain the procedure to the patient.
2. Perform hand hygiene.
3. Place the patient in a comfortable position.
4. Read mercury level while gently rotating
thermometer at eye level. Shake it until
reading lowers mercury level to 35.6 C.
5. Dry axilla with towel / tissue paper.
6. Place the thermometer in axilla so that the
bulb of thermometer is well in contact with
the skin, while the patients hand is held
across the chest.

29. 7. Wait for 5 minutes.
8. Remove the thermometer, clean from stem to
bulb and read at eye level. Add 1F for 0.3 C.
9. Shake gently so that mercury level falls below
95 F or 35 C.
10. Place the thermometer in disinfectant solution.
11. Discard used tissue paper/cotton balls.
12. Record temperature on the graph sheet ofTPR
record.

30.  The axilla is the moist area, so due to
moisture there is chance of false
reading.
 If the bulb is not placed properly, go
beyond the skin fold and come in
contact of air, then chance of false
reading.

31. The rectum method is used when oral
method is contraindicated.
It is most reliable method because there
is large amount of blood supply and less
chance of air contact.

32.  Its needs privacy.
 Its needs lubrication.
 Chances of soiling of hands
If the rectum is loaded with fecal matter,
we get false reading.

33.  Patient with rectal surgery and
inflammation.
Patient with diarrhoea.
 when rectum is loaded with fecal matter.
 patient is treatment with enema and bowel
wash.

35.  Tympanic membrane receives same blood
supply which supplies to hypothalamus, So it
reflects core body temperature (deep body
tissue ).
 The ear is readily accessible.
 It permits rapid temperature reading in
younger, confused, unconscious.
 Cerumen or otitis media doesn’t significantly
affects the temperature.

36.  HYPERPYREXIA –The fever goes above
105 F
HYPOTHERMIA – If the temperature
falls below 95 F
Which gland regulate our body
temperature?

43. DEFINITION :
 Pulse is a palpable bounding of the
blood flow noted at various points on
the body where the artery is passes over
a bone.When blood is pumped into the
arteries by the contraction of the left
ventricle.
 Normal pulse rate is 70 -80 per minute.

44.  Pulse is regulated by the Autonomic Nervous
System through the sino-atrial node.( Often
called pace maker.)
 Para sympathetic stimulation decreases the
heart rate and sympathetic stimulates
increase the heart rate.
 The quantity of blood forced out of the left
ventricle during each contraction is called
stroke volume.(70 ml for an average adult).
 Cardiac output = Stroke volume × Pulse rate


45.  To determine the number of heart beats
occurring per minutes.
 To establish baseline data for subsequent
evaluation.
 To gather information about the heart’s
rhythm and pattern of beats.
 To evaluate amplitude of pulse.
 To assess heart’s ability deliver blood to the
various organs.

46.  To assess response of the heart to cardiac
medications, activity, blood volume, gas
exchange.
 To assess the vascular status of limbs.
 To compare the equality of peripheral pulses
on each side of the body.
 To monitor and assess the patients risk for
alterations in pulse.

47.  A watch that has a second hand.
 A pen with red ink.
 A stethoscope.
 Nurses notes

48.  Temporal artery
 Facial artery
 Carotid artery
 Apical pulse
 Brachial artery
 Radial artery
 Femoral artery
 Popliteal artery
 Posterior tibial artery.
 Dorsalis pedis.

49.  Explain the procedure.
 Wash and dry the hand.
 Encourage the patient to relax and not speak
also find out if the patient has been
ambulated or done any such activity within
the previous 15 minutes.
 Explain and discuss the procedure with the
patient.
 Where possible measure the pulse under the
same condition each time.

50.  Place the index, middle and ring finger along
the appropriate artery and apply light
pressure until the pulse is felt.
 Press gently against the peripheral artery
being used to record the pulse.
 The pulse should be counted for 60 second.

51. If the apical pulse is going to be
checked explain to the patient and
expose the sternum and the left of
the chest. Place the diaphragm of
the stethoscope over the point of
maximal impulses (PMI) at the 5th
intercostal space, medial to the
mid-clavicular line. If the beat's
regular count for 30 seconds
and multiple by two. If irregular
auscultate for one full minute.

53. Tachycardia – pulse rate is above 100
beats/min.
Bradycardia – Pulse rate is below 60
beats/min

55.  Definition:
Monitoring the involuntary process of
inspiration of oxygen and expiration of
carbon-dioxide of a person. Respirations
constitute inspiration, expiration, and a pause.
Respiration is the mechanism the body uses to
exchange gases between atmosphere and
blood (external respiration) and the blood and
the cells(internal respiration).

56.  To determine a baseline respiratory rate for
comparisons.
 To monitor changes in oxygenation or in
respiration.
 To evaluate the patient’s response to
medications or treatments that affects the
respiratory system.
 Equipment: a watch that has a second’s hand.

57. 1. Observe the pattern: rate, rhythm, volume
and ease or effort of respiration.
2. Encourages the patient to place his hand over
the abdomen or chest.The nurses place their
hand directly over patient’s upper abdomen.
3. Observe complete respiratory cycle.
4. After the cycle is observed look at the second
in the watch and begin to count rate from 0,
1, 3.

58. 5. If rhythm is regular count the number of
respiration in 30 second and multiple by two.
If it is irregular less than 12, or greater than
20, count for one full minute.
6. Observe for signs of respiratory efforts;
Nasal flaring
Pursed lips
Use of accessory such as the shoulder or
the neck muscles.
7. Record the respiratory rate on appropriate
documentation,

60.  DEFINITION:
Blood pressure is the force on the wall of blood
vessel by blood as it is pumped around the body
by the force of ventricular contraction.
SBP: pressure of the blood as a result of contraction
of ventricles.
DBP: it is the pressure when the ventricles are at
rest.

62.  To determine the patients blood pressure at
initial assessment as a base for subsequent
evaluation.
 To monitor fluctuations in blood pressure.
 To assess the cardiac status.
 To identify and monitor changes resulting
from a disease process and medical surgical
therapy.
 To determine patients hemodynamic status.

63.  A well maintained sphygmomanometer.
 Stethoscope

64. 1. Wash hand and dry hands.
2. Prepare the patient for the procedure.
3. Ask the patient if he or she has ingested caffeine
or has smoked within 30 minutes prior to
measurement.
4. Allow the patient to rest for 5 minutes either
supine or seated in a quiet room with
comfortable temperature.

65. 5. Comfortably position the patient sitting with the
arm supported on the table at heart level or lying
down with the arms resting on the bed and has
the palm of the hand facing upwards. Position the
knee slightly flexed. (popliteal BP checking).
6. They should instruct to keep their feet flat.
7. Remove tight clothing from the limb to be used
and support the limb.

66. 8. Apply the correct sized sphygmomanometer
cuff 2.5 cm above the anticubital fossa directly
over the patient’s skin, and in level with the
heart.
9. Ensure the level of mercury meniscus in the
manometer is at the nurse’s level.
10. Locate the radial or brachial artery and inflate
the cuff until the pulse can no longer be felt.
Deflate and wait 15-30 seconds before
proceeding.

68. 11. Palpate the brachial artery and place the
stethoscope gently over the brachial artery.
Inflate the cuff to 30 mm Hg above from the
previous step.
12. The cuff is deflated at a rate of2-3 mm Hg
per second and the korotkoff sounds
listened for
- korotkoff I minus when sounds first heard
is equal to systolic value.
- korotkoffV minus when last sound is
heard is equal to diastolic value.

71. 13. Record the systolic and diastolic pressures in the
nurses chart and on the vitals record. Document
the arm used and patient’s position. Compare with
previous readings. Inform the appropriate
personnel of any irregularities.
14. When BP has to be read from a continuous cardiac
monitor do the following.
- The cuff has to be tied constantly.
- The cuff needs to be changed from one arm to
another second hourly.
- Set the monitor to read the BP as per patient
condition.

72.  The arm has an intra venous infusion/transfusion.
 The arm injured or diseased.
 The arm has a shunt or fistula for renal dialysis.
 On the same wide of the body where a female
patient has had mastectomy.

74.  Definition:
Oxygen saturation is the measurement of
oxygen attached to the hemoglobin cell in
the circulatory system.
The normal spo2 is 90 to 100% .

78.  To monitor the adequacy of arterial
hemoglobin saturation.

79.  Oximeter probe
 Acetone or nail polish remover

80.  Perform hand hygiene.
 Explain procedure to patient.
 Assess the appropriate site.
 If nail polish are applied, remove it using
acetone or nail polish remover.
 Attach sensor probe to monitoring site.
Explain the patient that he/she will like a
clothespin on the finger but will not hurt.
 Turn on Oximeter. Observe pulse wave form
on display.

81.  Leave the probe in place until Oximeter read
out reaches constant value. Read spo2 on
digital display. Record.
 If continuous spo2 is monitoring planned
preset spo2 alarm limits and volume.
 Assess skin integrity and re locate the sensor
probe every four hours.
 Discuss the finding with the patient as needed.
 Record spo2 value on nurses notes.

83. Definition: Observation of pupils construction
and dilation in response to light and
accommodation
Purpose:
To establish baseline data for subsequent
evaluations.
To assess the eye structure and visual acuity.
To monitor patients neurological status.
To identify the deviations from normal.

84.  Pen torch

85.  Partially darken the room .
 Wash hands and dry hands.
 Explain and discuss the procedure with the patient.
 Ask the patient to look straight ahead.
 Using a pen torch approach from the side shine a
light on the pupil.
 Observe the response of the illuminated pupil. It
should constrict. (direct response)
 Shine the light on the pupil again, and observe the
response of the other pupil. It should also constrict.

86. 1. Oral/ axilla / rectal thermometer (1)
2. Stethoscope (1)
3. Sphygmomanometer with appropriate cuff
size(1)
4.Watch with a second hand (1)
5. Spirit swab or cotton (1)
6. Sponge towel (1)
7. Paper bag (1): for discard dry waste (1)
8. Record form
9. Ball- point pen: blue (1) black (1) red (1)
10. Steel tray (1): to set all materials

88. 88