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.

Different considerations in taking Vital signs

  1. The frequency of taking TPR and BP depends upon the condition of the client and the policy of the institution.
  2. The procedure should be explained to the client before taking his TPR and BP.
  3. Obtain baseline data.

Vital Signs or Cardinal Signs are:

  • Body temperature
  • Pulse
  • Respiration
  • Blood pressure
  • Pain

Body Temperature

  • The balance between the heat produced by the body and the heat loss from the body.
Types of Body Temperature
  • Core temperature –temperature of the deep tissues of the body.
  • Surface body temperature
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
Methods of Temperature-Taking
I. Oral – most accessible and convenient method.
  1. Put on gloves, and position the tip of the thermometer under the patients tongue on either of the frenulun as far back as possible. It promotes contact to the superficial blood vessels and ensures a more accurate reading.
  2. Wash thermometer before use.
  3. Take oral temp 2-3 minutes.
  4. Allow 15 min to elapse between client’s food intakes of hot or cold food, smoking.
  5. Instruct the patient to close his lips but not to bite down with his teeth to avoid breaking the thermometer in his mouth.
  • Young children an infant
  • Patients who are unconscious or disoriented
  • Who must breathe through the mouth
  • Seizure prone
  • Patient with N/V
  • Patients with oral lesions/surgeries
II. Rectal- most accurate measurement of temperature
  1. Position- lateral position with his top legs flexed and drapes him to provide privacy.
  2. Squeeze the lubricant onto a facial tissue to avoid contaminating the lubricant supply.
  3. Insert thermometer by 0.5 – 1.5 inches
  4. Hold in place in 2minutes
  5. Do not force to insert the thermometer
  • Patient with diarrhea
  • Recent rectal or prostatic surgery or injury because it may injure inflamed tissue
  • Recent myocardial infarction
  • Patient post head injury
III. Axillary – safest and non-invasive
  1. Pat the axilla dry
  2. Ask the patient to reach across his chest and grasp his opposite shoulder. This promote skin contact with the thermometer
  3. Hold it in place for 9 minutes because the thermometer isn’t close in a body cavity
  • Use the same thermometer for repeat temperature taking to ensure more consistent result
  • Store chemical-dot thermometer in a cool area because exposure to heat activates the dye dots.
IV. Tympanic thermometer
  1. Make sure the lens under the probe is clean and shiny
  2. Stabilized the patient’s head; gently pull the ear straight back (for children up to age 1) or up and back (for children 1 and older to adults)
  3. Insert the thermometer until the entire ear canal is sealed
  4. Place the activation button, and hold it in place for 1 second
V. Chemical-dot thermometer
  1. Leave the chemical-dot thermometer in place for 45 seconds
  2. Read the temperature as the last dye dot that has change color, or fired.
Factors that Affect Body Temperature
  1. Age
    • The infant is greatly influenced by the temperature of the environment and must be protected from extreme changes. Children’s temperature continues to be more labile than those of adults until puberty. Elderly people are at risk of hypothermia for variety of reasons. Such as lack of central heating, inadequate diet, loss of subcutaneous fat, lack of activity, and reduced thermoregulatory efficiency.
  2. Diurnal variations (circadian rhythms)
    • This refers to the sleep – wake rhythm of the body, a pattern that varies slightly from person to person. Body temperature normally changes throughout the day, varying as much as 1.0C between the early morning and the late afternoon.
  3. Exercise
    • Hard work or strenuous exercise can increase body temperature
  4. Hormones
    • Women usually experience more hormones fluctuations than men do. Progesterone secretion at the time of ovulation raises body temperature above basal temperature
  5. Stress
    • Stimulation of SNS can increase the production of epinephrine and norepinephrine, thereby increasing metabolic activity and heat production
  6. Environment
    • Extremes in environmental temperatures can affect a person’s temperature regulatory systems.
Nursing Interventions in Clients with Fever
  1. Monitor V.S
  2. Assess skin color and temperature
  3. Monitor WBC, Hct and other pertinent lab records
  4. Provide adequate foods and fluids.
  5. Promote rest
  6. Monitor I & O
  7. Provide TSB
  8. Provide dry clothing and linens
  9. Give antipyretic as ordered by MD
Heat – producing & Heat – losing Mechanisms
  • Heat production: most body heat is produced by the oxidation of foods; the rate at which it is produced is called METABOLIC RATE.

Heat Loss:

  • Radiation
  • Conduction
  • Convection
  • Evaporation
Pre – optic area of the Hypothalamus
  • Temperature regulator; thermostat
  • Receives input from temp receptors in the skin & mucous membranes (peripheral thermoreceptors) & internal structures (central thermoreceptors)

* If blood temp increases, neurons of the pre – optic area fire nerve if it decreases.

Heat Promoting Centers
  1. Vasoconstriction
    • =Less blood flow from the internal organs to the skin= less heat transfer from the internal organs to the skin= increases internal body temperature
  2. Sympathetic Stimulation
    • = stimulation of sympathetic nerves leading to the adrenal medulla = secretes epinephrine & norepinephrine = Increases cellular metabolism = increases heat production
  3. Skeletal Muscles
    • = stimulation of part of the brain that increases muscle tone (stretch reflex + contraction of muscles = SHIVERING) = heat production
  4. Thyroxine
    • = increases metabolism = increase in body temperature
Body Temperature Abnormalities
  1. Fever/hyperthermia/hyperpyrexia
    • An abnormally high temp mainly results from infection from bacteria (& their toxins) & viruses. (Stimulates prostaglandin secretion)
    • Other causes: heart attacks, tumors, tissue destruction by x – ray, surgery or trauma & rxns to vaccines.
  2. Heat cramps and Heat exhaustion
    • Due to fluid & electrolyte loss
  3. Heat Stroke
  4. Hypothermia
The Thermometer
  • A glass clinical thermometer is most commonly used to measure body temperature.
It has 2 parts:
  • Bulb– contains mercury which expands when exposed to heat & rise in the stem
  • Stem – is calibrated in degrees of Celcius or Fahrenheit


  • This is a wave of blood created by contraction of the left ventricle of the heart. The heart is a pulsating pump, and the blood enters the arteries with each heartbeat, causing pressure pulses or pulse waves. Generally, the pulse wave represents the stroke volume and the compliance of the arteries.
  • Stroke volume is the amount of blood that enters the arteries with each contraction in a healthy adult.
  • Compliance of the arteries is their ability to contract and expand. When a person’s arteries lose their distensibility, greater pressure is required to pump the blood into the arteries.
  • Peripheral pulse is the pulse located in the periphery of the body, for example in the foot, hand and neck. Apical pulse is a central pulse. It is located at the apex of the heart.
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.