VITAL SIGNS

9 September 2016
Vital signs (often shortened to just vitals) are a group of the 4 to 6 most
important signs that indicate the status of the body’s vital (life-sustaining)
functions.
These measurements are taken to help assess the general physical health of
a person, give clues to possible diseases, and show progress toward
recovery.
The normal ranges for a person’s vital signs vary with age, weight, gender,
and overall health.
There are four primary vital signs:
- body temperature
- blood pressure
- pulse (heart rate)
- breathing rate (respiratory rate), often notated as BT, BP, HR, and RR

In the U.S., in addition to the above four, it is required to record the patients
Height, Weight, and Body Mass Index

depending on the clinical setting, the vital signs may include other
measurements called the "fifth vital sign" or "sixth vital sign".
 When to take vital signs
1. On a client’s admission
2. According to the physician’s order or the institution’s policy or
standard of practice
3. When assessing the client during home health visit
4. Before & after a surgical or invasive diagnostic procedure
5. Before & after the administration of meds or therapy that affect
cardiovascular, respiratory & temperature control functions.
6. When the client’s general physical condition changes
LOC, pain
7. Before, after & during nursing interventions influencing vital signs
8. When client reports symptoms of physical distress
Oral No hot or cold drinks or smoking 20 min Leave in place 3 min
Posterior sublingual pocket – under tongue prior to temp. Must be awake & alert.
(close to carotid artery) Not for small children (bite down)

Axillary Non invasive – good for children. Less Leave in place 5-10 min.
Bulb in center of axilla accurate (no major bld vessels nearby) Measures 0.5 C lower than oral temp.
Lower arm position across chest

Rectal When unsafe or inaccurate by mouth Leave in place 2-3 min.

Side lying with upper leg flexed, insert (unconscious, disoriented or irrational) Measures 0.5 C higher than oral
lubricated bulb (1-11/2 inch adult) (1/2 Side lying position – leg flexed
inch infant)

Ear Rapid measurement 2-3 seconds

Close to hypothalmus – sensitive to core Easy assessibility
temp. changes Cerumen impaction distorts reading
Adult - Pull pinna up & back Otitis media can distort reading
Child – pull pinna down & back
- Early warning scores have been proposed that combine the individual values
of vital signs into a single score.
- This was done in recognition that deteriorating vital signs often precede
cardiac arrest and/or admission to the intensive care unit. Used
appropriately, a rapid response t
Fifth vital signs
The "fifth vital sign" may refer to a few different parameters.

Pain is considered a standard fifth vital sign in some organizations such as

the U.S. Veterans Affairs.

Other "fifth vital signs" include:

- Menstrual cycle
- Glasgow Coma Scale
- Pulse Oximetry
- Blood Glucose level
There is no standard "sixth vital sign"; its use is more informal and
discipline-dependent than the above.
- End-tidal CO2
- Functional status
- Shortness of breath
- Gait speed

https://en.m.wikipedia.org/wiki/Vital_signs
https://en.m.wikipedia.org/wiki/Vital_signs