Vital signs are measurements of the body's most basic functions. They should be looked at in total, to monitor the vital functions of the body. They help reflect changes in the body, determine the patient’s usual state of health, and signal early physiological deterioration.

There are four primary vital signs, often noted as BT, BP, HR, and RR:

• Body Temperature (BT)
• Blood Pressure (BP)
• Pulse / Heart Rate (HR)
• Breathing Rate / Respiratory Rate (RR)

• To assess the baseline health status of an individual.
• To plan and implement appropriate nursing care.
• To modify or change the mode of medical treatment based on physiological response.
• As a routine part of a complete physical assessment.
• To help understand the present problem and assist in accurate diagnosis.
• To understand and evaluate the effectiveness of the prescribed treatment or interventions.

• On the patient’s admission to the hospital or health unit to establish a baseline.
• On a routine schedule according to the physician’s order or hospital policy (e.g., 6:00 am to 6:00 pm).
• During a patient’s visit to the clinic or physician’s office.
• Before and after any invasive diagnostic procedure.
• Before and after a surgical procedure (e.g., 1st 48 hrs postoperatively or 4-hourly with very ill patients or those presenting with fever).
• Before and after administration of medication that affects the cardiovascular, respiratory, and temperature control functions (e.g., antihypertensives, antipyretics, digitalis, or opioids).
• When the patient’s general physical condition changes abruptly (e.g., loss of consciousness, increased intensity of pain, or signs of shock).
• Before and after nursing interventions influencing any one of the vital signs (e.g., before ambulating a patient who has been previously on bed rest, before range of motion exercises, blood transfusions, or tepid sponging).
• Whenever the patient reports to the nurse about any non-specific symptoms of physical distress (e.g., “feeling funny,” dizzy, or "different").

• Normal value: 98.4°F or 37°C in adults.
• Normal ranges: 97°F - 99°F or 36°C - 37.2°C.

• Normal value: 72 b/m in adults.
• Normal ranges:
  • Adult (18yrs +): 60 - 90 b/m
  • Children (1 - 18yrs): 90 - 120 b/m
  • Infants (1 month - 1yr): 120 - 140 b/m
  • Neonate / Newborn (0 - 28 days - 1 month): 140 - 160 b/m
• Old age: May be slower.
• Extremely old age: May be more rapid.

• Normal value: 16 breaths/minute (adults).
• Normal ranges:
  • Adults: 16 - 20 breaths/minute
  • Neonates: 30 - 44 breaths/minute
  • Children: 20 - 22 breaths/minute
  • Old age: 10 - 24 breaths/minute

• Normal value: 120/80 mmHg (in adults).
• Normal ranges:
  • Adult: 90/60 - 120/90 mmHg. (Note: 90-120 / 60-90 mmHg).
  • Infants: 70-90 / 50 mmHg
  • Newborn (neonates): 30-50 / 10 mmHg (Note: Diastolic can be very low and difficult to auscultate in neonates, often measured via mean arterial pressure on monitors).

• The primary nurse caring for the patient is the best one to take vital signs, interpret their significance, and make decisions about the care.
• Equipment used to measure vital signs must be appropriate and working properly to ensure accurate findings. (e.g., using the correct BP cuff size prevents falsely elevated or lowered readings).
• Knowing the normal range for all vital signs helps the nurse to detect abnormalities rapidly.
• A client’s normal range may differ from the standard range for that age or physical state. (e.g., highly trained athletes naturally have bradycardia).
• A normal value for the client serves as a baseline for comparing conditions over time.
• Know the client’s medical history and therapies or medications for vital sign changes.
• Control or minimize environmental factors that may affect vital signs. For example, measuring a pulse immediately after the patient experiences an emotional upset will give unclear results for the client’s actual resting state.
• An organized, systemic approach when taking vital signs ensures accuracy of findings and efficiency of care.

Temperature is the degree of heat maintained by the body, monitored and measured using a clinical thermometer. Alternatively, it is the degree of warmth or the balance maintained between heat produced (thermogenesis) and heat lost (thermolysis) in the body, or the degree of heat of a substance or body as measured by a thermometer.

• To determine the exact core body temperature.
• To assist in medical and nursing diagnosis.
• To evaluate the patient’s recovery from illness.
• To plan immediate nursing interventions (e.g., administering antipyretics or initiating tepid sponging).
• To evaluate the patient’s response to treatment.
• To recognize any variation from the normal and understand its clinical significance.

• Oral: 37°C or 98.4°F (Range: 36°C - 37°C).
• Rectal: 37.6°C or 99.6°F. Generally 1° higher than mouth temperature. It is considered the most accurate core temperature.
• Axilla: 36.4°C or 97.6°F. Generally 1° lower than mouth temperature (Range: 36°C - 37°C).
• Groin: Same as for the axilla.

• Temperature varies at different times of the day, with the evening temperature being about 1° (one degree) higher than that of the morning because of muscular and metabolic activity.
• The temperature also varies according to the site used for taking it. (e.g., the skin temperature i.e., axilla in a healthy person may be 36.1°C while the oral/mouth temperature is usually a degree higher and the rectal temperature may be 37.2°C or 99°F).
• When taking temperature, never be satisfied with anything but an accurate result. Incorrect results mislead diagnosis, prescription, and treatment.
• The mouth, axilla, groin, rectum, and vagina are suitable places for taking temperature, but as the reading varies according to the site, the same place must be used each time for the same patient to ensure consistency.

• Time of the day: Morning (lower) vs. evening (higher due to diurnal rhythms).
• Site used: Rectal is highest; axillary is lowest.
• Gender: Women normally have a higher temperature than men, especially during ovulation (due to progesterone surge).
• Age: Temperature is highest in neonates and lowest in the elderly (due to reduced metabolic rate and subcutaneous tissue loss).
• Emotional conditions: Stress and anxiety elevate body temperature.
• Environment: Extreme weather changes affect thermoregulation.

• Metabolism and oxidation of food (Basal Metabolic Rate).
• Muscle activity and exercise.
• Strong emotions, excitement, anxiety, and nervousness.
• Change in atmospheric temperature.
• Diseases/conditions: Bacterial invasions or infections trigger the hypothalamus to raise the set point.
• Sympathetic stimulation: Release of epinephrine and nor-epinephrine.

• Sleep: Body temperature lowers due to reduced muscle activity.
• Fasting: Leads to decreased heat production.
• Illness and lower vitality: Due to a depressed nervous system, heat production is lowered.
• Prolonged exposure to cold environment.
• Use of narcotic drugs: Suppress the temperature-regulating center in the hypothalamus.

• Conduction: Transfer of heat from the body to a substance (air, water, and clothes) directly in contact.
• Radiation: Transfer of heat from the body to heat waves which travel through space.
• Evaporation: Transfer of heat from the body in the form of vapor (liquid sweat is converted into vapor).
• Convection: Transfer of heat from the surface of one subject to the surface of another, such as skin, by the movement of heated air or fluid particles.

• The mouth is the usual place to take temperature, but it must not be used for:
  • A child under 5 years.
  • Patients with difficulty breathing or much coughing.
  • Unconscious or mentally confused patients.
  • Patients with disease or recent surgery of the mouth or nose.
• It should not be taken immediately after hot or cold fluids. Wait for 10 minutes after the patient has eaten or drunk. (This allows the oral mucosa to return to normal core temperature).
• Grasp the thermometer securely by the upper end of the stem; never hold it by the bulb as it will easily be broken or contaminated.
• If the patient bites or breaks a thermometer in the mouth, quickly give cold water to rinse (to prevent mercury or glass ingestion) and inform the in-charge for further management.
• If taking temperature by rectum, always hold the thermometer for the patient in place, especially in children, to prevent injury.
• Report to the supervisor a temperature below 35°C (Hypothermia) or above 38°C (Pyrexia).
• Always wash the used thermometer with cold water and soap or disinfect with a disinfectant. Never use hot water to wash a glass clinical thermometer as it will expand the mercury and shatter the glass.
• Never take oral and rectal temperature at the same time.
• Shake it by a quick movement of the wrist below 35°C or 94°F. Care should be taken when shaking near objects to avoid breakages.
• Patients are never told what the exact vital sign reading is directly; simply explain and reassure the patient, i.e., “you are fine, okay, don’t worry.”

• Clinical thermometer: An instrument used for recording body temperature. It is made of glass with a hollow tube running through the center. At one end is a bulb containing mercury which rises into the center tube when heated. The mercury remains stationary at the registration point until shaken down due to a constriction in the tube. Degrees of temperature are marked from 35°C - 43°C or 94°F - 110°F.
• Electronic or digital thermometer: Consists of a battery-powered display unit, a thin wire cord, and a temperature-sensitive probe covered by a disposable plastic sheath to prevent the transmission of infection. Separate probes (often color-coded) are available for oral and rectal insertion.
• Disposable thermometer: A single-use thermometer made of thin plastic strips with chemically impregnated paper. Used for children to take oral and axillary temperatures only. Needs about 45 seconds to record; generally less accurate.
• Tympanic membrane thermometer: Small hand-held devices similar to otoscopes with disposable speculums. Uses infrared-sensing electronics and liquid crystal displays. Results are displayed in 1-2 seconds after placing the speculum in the outer third of the ear canal. It is highly accurate as it reflects core temperature from the tympanic membrane (which shares blood supply with the hypothalamus).

Requirement: Temperature tray containing an oral clinical thermometer in a jar containing a disinfectant solution (e.g., hibitane cetrimide 1-20), a gallipot of swabs, a gallipot of water, a receiver for used swabs, a watch with a second hand ticker, a temperature chart, and a pen.

Contraindications for Oral Temperature: Disease, injuries, inflammation, and surgeries of the oral cavity. Infants, children below 5 years, mentally disturbed, delirious, uncooperative, and unconscious patients. Patients with breathing problems, convulsions, oxygen masks, or severe cough. Should not be taken immediately after a hot bath, smoking, or consuming hot/cold drinks.

Used when oral temperature is contraindicated.

Contraindications for Axillary Temperature: Sores or burns at the site. Emaciated or very thin patients (as they cannot form a proper skin-fold cavity to trap the heat).

Rules apply as for the axilla, but one leg is flexed over the other.

Contraindications for Groin Temperature: Sores or burns at the site. Emaciated or thin patients.

Used for head injuries, head operations, and children under 5 years. The rectal thermometer has a blunt end colored blue (or red in some regions) to prevent inadvertent use elsewhere.

Requirement: Rectal thermometer, gallipot of swabs, gallipot of water (2: lukewarm and cool), receiver for used swabs, watch, chart, pen, Vaseline/lubricant, and gloves.

Contraindications for Rectal Temperature: Injuries, disease, inflammation, and surgeries of the rectum. Patients with fecal impaction or chronic diarrhea. Patients requiring bowel wash/enema.

• The Fahrenheit scale ranges from 32°F to 212°F whereas the Centigrade scale ranges from 0°C to 100°C.
• Fahrenheit to Centigrade: C = (F - 32) × 5/9
• Centigrade to Fahrenheit: F = (C × 9/5) + 32

Rigor is a sudden attack of intense shivering when the heat-regulating center in the brain is disturbed. It is seen in certain infections like malaria and in allergic reactions (e.g., after an intravenous infusion).

1. Cold stage: The patient feels a severe chill, experiences extreme shivering, and body temperature rises (hyperpyrexia). The hypothalamus has reset to a higher temperature, making the body feel cold and initiating shivering to generate heat.
   • Provide rest and supplementary oxygen (shivering highly increases oxygen demand).
   • Offer hot drinks and use hot water bottles to provide warmth.
   • Provide an extra blanket. Give more fluids.
2. Hot stage: The patient feels extremely hot. The new set-point has been reached, shivering stops, and vasodilation begins to attempt to release the trapped heat.
   • Remove extra blankets and hot water bottles.
   • Perform cold/tepid sponging and apply ice pack compresses.
3. Sweating stage: The patient sweats profusely. The fever is "breaking" and the hypothalamus resets to normal. Evaporative cooling takes over.
   • Wipe the patient with a wet towel and cover with a clean, dry sheet.

N.B: During all three stages, monitor the temperature closely and record it in the patient’s chart.

Pulse is the wave of expansion and recoil of an artery in response to the pumping action of the heart (specifically the left ventricle). This can be felt by the examining fingers over superficial arteries.

• To determine the number of heartbeats occurring per minute.
• To evaluate the amplitude (strength) of the pulse.
• To assess the vascular status of the distal limbs (perfusion).
• To assess the response of the heart to cardiac medications, physical activity, blood volume changes, and gas exchange.
• To assess the heart’s ability to deliver oxygenated blood to distant areas of the body.
• To obtain information about the heart rhythm and patterns of beats (regularity).

• Rate: The number of beats per minute. Corresponds with age (average for adults is 72 b/m).
• Rhythm: The regularity of beats. The distance/time between beats is equally spaced if regular.
• Volume: The fullness of an artery; the force of blood felt at each beat (described as full/bounding, large, small, weak, or thready). Represents the amount of blood distending the artery with each stroke.
• Tension: The degree of arterial compressibility (high/low). The pulse should feel soft. If it is difficult to compress or obliterate, tension is high (suggesting hypertension or arteriosclerosis); if easy to compress, it is low (suggesting hypotension or hypovolemia).

• Age: Children have faster beats; very old persons typically have a slower pulse rate.
• Sex: It is generally slower in men than in women.
• Stature: Slower in tall people than in short people.
• Position: Slower at rest and sleep than in a standing position (gravity compensation).
• Emotions: Anger or excitement increases the rate temporarily via sympathetic stimulation.
• Exercise: Much faster during exercise due to increased cellular oxygen demand.
• Fever: Increases the pulse rate (tachycardia) as metabolic rate increases.
• Extreme heat and cold: Generally increase the heart rate.
• Drugs: May increase (e.g., adrenaline, caffeine) or decrease (e.g., digitalis, beta-blockers, morphine) the pulse.
• Shock and hemorrhage: Rapid, weak pulse to compensate for low blood volume.
• Diseases: Thyrotoxicosis and myocardial failure increase the rate.
• Fasting: Can increase the pulse.
• Head tumors: Increased intracranial pressure generally causes a slow, bounding pulse (part of Cushing's triad).

• Tachycardia: Rapid heart action indicated by a pulse rate of more than 100 b/m. Commonly found in patients with fevers, thyrotoxicosis, organic heart disease, nervous disorders, and intake of drugs like morphine, caffeine, and alcohol.
• Bradycardia: An abnormally slow heart rate indicated by a pulse rate of less than 60 b/m. Commonly caused by opium poisoning, heart muscle disorder, cerebral tumors (increased ICP), and myxedema (severe hypothyroidism).
• Dicrotic pulse (abnormal volume): There is one heartbeat but two arterial pulsations felt, giving the sensation of a double beat due to a flabby, weak arterial wall.
• Abnormal rhythm: Intermittent pulse and extra systoles due to cardiac irritability, hypoxia, digitalis overdose, potassium imbalance, or arrhythmias.
• Water hammer or Corrigan’s pulse: A full volume, collapsing pulse. Found in aortic regurgitation, where blood is forcefully ejected into the artery but then leaks back into the left ventricle due to non-closure of the aortic valve.

• Count the pulse for one full minute, especially when there is an irregularity.
• Observe the rate, rhythm, volume, and tension.
• Do not take the pulse immediately after exercise, emotional stress, or painful treatment (wait 10-15 minutes).
• Choose a suitable site and be aware of any medications interfering with heart rate (e.g., digitalis).
• Notify the physician if the rate is <60 or >100, or if there are abnormal patterns (missing beats). If abnormal, assess again by having another nurse conduct the measurement.

Requirement: Small tray, watch with a second hand, pen, TPR chart.

Respiration is the act of breathing in / taking in oxygen (inspiration/inhalation) and breathing out / expelling out of carbon dioxide (expiration/exhalation). The exchange of gases between the blood and lungs is called external or pulmonary respiration, while the exchange of gases between the blood and cells is known as internal respiration.

• To determine the baseline respiratory status of the patient.
• To determine the number of respirations occurring per minute.
• To gather information about the rhythm and depth of breathing.
• To assess the response of a patient to any related therapy or medication (e.g., bronchodilators, opioid analgesics).

• Sex: Females have a slightly more rapid respiratory rate than males.
• Exercise: Exertion increases the metabolic rate, creating an oxygen demand and stimulating faster respiration.
• Rest and sleep: Metabolism decreases, so respiratory rate is normal or decreased.
• Emotions: Sudden stressful conditions (fear, anxiety, excitement) influence and rapid the respiratory rate via sympathetic arousal.
• Atmospheric pressure changes: In high altitudes where oxygen content is low, the rate of respiration is increased to fulfill oxygen demands.
• Disease: Respiratory rate increases in some heart/lung diseases (to compensate for hypoxia) and decreases when there is pressure on the brain's respiratory center (medulla) due to tumors or injury.

Normal breathing is effortless, painless, quiet, and automatic. It consists of the rhythmical rising and falling of the chest wall. Regular and even, producing no noise. (Resting adult rate: 16-20 b/m).

• Stridor: A noisy, shrill, vibrating, or whistling inspiration occurring in obstruction of the upper airway. Commonly seen in laryngitis and foreign body obstruction.
• Wheezing: A difficult, louder/noisy expiration due to partial obstruction of smaller bronchi and bronchioles (e.g., asthma, emphysema).
• Apnoea: Temporary cessation of breathing. Seen in very ill patients or CNS disorders.
• Dyspnoea: Forced, painful, difficult, or labored breathing, sometimes accompanied by cyanosis. Seen in heart/respiratory diseases, airway obstruction, and convulsions.
• Orthopnoea: Inability to breathe easily except when sitting up in an upright position. A classic sign of congestive heart failure.
• Cheyne-Stokes breathing: Periodic breathing starting with slow/shallow respirations that gradually increase in rate/depth to a climax, followed by a pause (apnea for 5-30 seconds), then the cycle repeats. Common in patients near death.
• Asphyxia: A state of suffocation where lungs fail to get sufficient oxygen to supply vital organs.
• Rale (Crackles): An abnormal rattling or bubbling sound caused by fluid/mucus in the airway, seen in bronchitis or pneumonia.
• Hyperpnoea / Kussmaul’s breathing: Abnormal forced, deep, regular, but rapid breathing. A compensatory mechanism seen in diabetic ketoacidosis (blowing off CO2).
• Croup: Difficult, noisy breathing (barking cough) due to laryngeal spasms.
• Stertorous breathing: Heavy, noisy, snoring-like breathing occurring in unconscious patients.
• Biot’s respiration: Shallow breathing interrupted by irregular periods of apnoea; seen in severe central nervous system disorders.
• Cyanosis: Blueness or discoloration of skin/mucous membranes due to tissue hypoxia.
• Bradypnoea: Abnormal slowness of breathing.
• Tachypnoea: Abnormal rapid breathing rate.

• The patient should be placed in a comfortable sitting-up position.
• Respirations should be counted when the patient is unaware of the counting. (Do this immediately after counting the pulse, keeping fingers on the wrist so the patient does not voluntarily alter their breathing).
• Observe the full respiratory cycle (inspiration, expiration, and pause).
• For children, count respirations before disturbing them to take their temperature.
• Observe Rate, Depth (shallow/deep), Discomfort (painful breathing), and Movements (use of accessory abdominal or thoracic muscles).

Blood pressure is the force or pressure that the circulating blood exerts on the elastic walls of the blood vessels (arteries) in which it is contained.

• To obtain a baseline rate for diagnosis and treatment planning.
• To compare with subsequent changes that may occur during the care of the patient.
• To assist in evaluating the status of the patient’s overall blood volume and vascular resistance.
• To evaluate the patient’s hemodynamic response to physical condition changes or treatment with IV fluids and cardiovascular medications.

• Systolic pressure: The highest degree of pressure exerted by the blood against the arterial wall as the left ventricle contracts and forces blood into the aorta.
• Diastolic pressure: The lowest degree of pressure when the heart is in its resting period (relaxation phase) just before the next contraction of the left ventricle.

• Age: Adults’ BP tends to increase with advancing age due to decreased arterial compliance (older adults often run 140/80 to 160/90 mmHg).
• Exercise: Increases BP due to increased cardiac output.
• Stress: Anxiety, fear, pain, and emotional stress trigger sympathetic nervous system response, causing vasoconstriction and a rise in BP.
• Medication: Narcotics, analgesics, and antihypertensives lower BP; stimulants raise it.
• Diurnal variation: Lowest in the early morning and higher in the late evening.
• Sex: Generally higher in men than in women (until menopause, after which women's risk catches up).
• Bleeding/Hemorrhage: Causes a rapid drop in blood volume, leading to low blood pressure (hypotension).

• Do not take blood pressure on an arm if:
  • The arm has an active intravenous infusion line (compresses the line).
  • The arm is injured, fractured, or diseased.
  • The arm has an arteriovenous (AV) shunt or fistula for renal dialysis (cuff pressure can clot or damage the fistula).
  • It is on the same side of the body where a female patient had a radical mastectomy (risk of causing severe lymphedema).
• Postpone BP taking on a patient who is highly anxious, angry, in acute pain, or a crying child until they are calm, to avoid falsely elevated readings.
• Allow the patient to rest for at least 5-10 minutes prior to taking blood pressure.
• Do not take blood pressure more than 3 times in succession on the same arm to prevent venous congestion, which alters readings and causes discomfort.

Requirement: Sphygmomanometer, Stethoscope, Patient’s chart, Pen.

• World Health Organization (WHO) clinical guidelines for vital sign monitoring.
• Standard nursing fundamentals text regarding basic physiological measurements and physical examination (PEX).
• Local hospital or agency protocols for vital sign documentation and frequency.