Definition of Vital Signs
Vital signs are a group of the four to six most critical medical signs that indicate the status of the body’s vital
(life-sustaining) functions. These measurements provide a snapshot of a patient's overall physiological
health and are essential for monitoring, diagnosing, and determining medical treatments.
The four primary vital signs are:
1. Body Temperature: The balance between heat produced and heat lost by the body.
2. Pulse Rate: The number of times the heart beats per minute.
3. Respiration Rate: The number of breaths a person takes per minute.
4. Blood Pressure: The force of circulating blood on the walls of the arteries.
Often, a fifth sign is included:
5. Oxygen Saturation (SpO2): The percentage of hemoglobin in the bloodstream that is saturated with
oxygen.
Pain is frequently considered the "sixth" vital sign, as it is a critical indicator of a patient's well-being.
II. Purpose of Measuring Vital Signs
Measuring vital signs serves several crucial purposes in clinical and emergency settings:
1. To Establish a Baseline: The initial set of vital signs provides a reference point for comparing all
future measurements.
2. To Monitor a Patient's Condition: Regular tracking helps detect changes in a patient's health status,
indicating improvement or deterioration.
3. To Screen for Medical Disorders: Abnormal readings can be the first sign of an underlying illness
(e.g., fever indicating infection, high blood pressure indicating hypertension).
4. To Aid in Diagnosis: Vital signs help clinicians form a diagnosis (e.g., rapid pulse and low blood
pressure may suggest shock or dehydration).
5. To Evaluate the Response to Treatment: They are used to assess whether a patient is responding to
medication or therapy (e.g., checking if a fever reducer has lowered the temperature).
6. To Make Critical Decisions: Vital signs determine the urgency of a situation and guide decisions
about treatment, medication, and the need for hospitalization.
III. Procedure for Measuring Vital Signs
The procedure should be systematic, performed with care, and the findings must be accurately documented.
General Guidelines:
Ensure the environment is calm, quiet, and comfortable.
Wash your hands thoroughly before and after the procedure.
Ensure the equipment is clean, functional, and calibrated.
Explain the procedure to the patient to gain cooperation and reduce anxiety.
The patient should be at rest (sitting or lying down) for at least 5 minutes before measurement.
A. Body Temperature
, Purpose: To assess the body's ability to produce and get rid of heat.
Common Routes & Procedure:
1. Oral (Mouth):
Use a digital or disposable thermometer.
Place the probe under the tongue in the posterior sublingual pocket.
Instruct the patient to keep their mouth closed.
Wait for the thermometer to beep (usually 10-30 seconds).
Normal Range: 36.1°C - 37.5°C (97.0°F - 99.5°F).
2. Tympanic (Ear):
Use a tympanic thermometer with a disposable probe cover.
Gently pull the ear pinna upward and backward (for adults).
Insert the probe snugly into the ear canal and press the button.
Normal Range: Similar to oral, but the device often converts it.
3. Axillary (Armpit):
Place the thermometer in the center of a dry armpit.
Have the patient hold their arm down against their chest.
This is the least accurate method.
Normal Range: 35.5°C - 36.9°C (96.0°F - 98.4°F).
4. Temporal (Forehead):
Use a temporal artery thermometer.
Gently swipe the probe across the forehead to the temporal area.
Normal Range: Similar to oral.
B. Pulse Rate
Purpose: To assess heart rate, rhythm, and strength.
Common Site: Radial artery (wrist).
Procedure:
1. Place your index and middle fingers gently over the patient's radial artery, on the thumb side
of their wrist.
2. Do not use your thumb, as it has its own pulse.
3. Count the number of beats for 30 seconds and multiply by 2. If the rhythm is irregular, count
for a full 60 seconds.
4. Note the Rate (beats per minute), Rhythm (regular or irregular), and Strength (strong, weak,
thready).
, o Normal Range (Adults): 60 - 100 beats per minute.
C. Respiration Rate
Purpose: To assess the function of the lungs and respiratory system.
Procedure:
1. Keep your fingers on the patient's wrist (as if still taking a pulse) so they are unaware you are
counting breaths. This prevents them from altering their breathing pattern.
2. Observe the rise and fall of the chest.
3. Count the number of complete breaths (one inhalation + one exhalation) for 30 seconds and
multiply by 2.
4. Note the Rate, Rhythm, and Depth (deep or shallow).
o Normal Range (Adults): 12 - 20 breaths per minute.
D. Blood Pressure
Purpose: To measure the pressure in the arteries during systole (heart contraction) and diastole
(heart relaxation).
Equipment: Sphygmomanometer (cuff and gauge) and stethoscope.
Procedure:
1. Have the patient sit or lie with their arm supported at heart level.
2. Wrap the correct-sized cuff snugly around the upper arm, about 2-3 cm above the elbow.
3. Palpate the brachial artery in the antecubital space (inner elbow).
4. Place the stethoscope's diaphragm over this artery.
5. Inflate the cuff rapidly to about 180-200 mmHg, or 30 mmHg above the point where the
pulse disappears.
6. Slowly release the valve to deflate the cuff (2-3 mmHg per second).
7. Note the reading on the gauge when you hear the first clear tapping sound (Systolic
Pressure).
8. Continue deflating and note the reading when the sound disappears (Diastolic Pressure).
o Normal Range (Adults): Systolic <120 mmHg and Diastolic <80 mmHg.
E. Oxygen Saturation (SpO2)
Purpose: To measure the percentage of oxygen carried in the blood.
Equipment: Pulse oximeter.
Procedure:
1. Place the probe (sensor) on a clean, warm finger, toe, or earlobe.
2. Ensure the patient is not wearing nail polish.
3. Wait a few seconds for the reading to stabilize.
, o Normal Range: 95% - 100%.
Documentation:
All findings must be immediately and accurately recorded in the patient's chart with the date and time. Any
abnormalities must be reported to a supervisor or physician.
Tube Feeding (Enteral Nutrition)
I. Definition
Tube feeding, also known as enteral nutrition, is a medical procedure used to provide nutritional support,
fluids, and medications directly into the gastrointestinal (GI) tract via a tube. It bypasses the oral cavity and
is used when a patient cannot safely or adequately consume food and fluids by mouth but has a functioning
GI tract.
II. Purposes of Tube Feeding
The primary goal is to maintain or restore nutritional status. Specific purposes include:
1. To Provide Adequate Nutrition: To meet the body's caloric, protein, vitamin, and mineral
requirements for energy, tissue repair, and immune function.
2. To Prevent Malnutrition and Cachexia: In patients who are unable to meet their nutritional needs
orally for a prolonged period.
3. To Maintain Gut Integrity: The GI tract's barrier function is maintained by the presence of
nutrients in the gut. Enteral nutrition helps prevent bacterial translocation from the gut into the
bloodstream, which can cause sepsis.
4. To Promote Hydration and Electrolyte Balance: Provides necessary fluids and electrolytes.
5. To Administer Medications: For patients who cannot swallow pills, necessary medications can be
crushed (if safe) and administered through the tube.
6. To Support Growth and Development: In pediatric patients with failure to thrive or congenital
abnormalities.
7. To Manage Specific Medical Conditions: Such as reducing the risk of complications in pancreatitis
(via post-pyloric feeding) or providing specialized formulas for metabolic disorders.
III. Indications for Tube Feeding
Tube feeding is indicated when oral intake is insufficient, unsafe, or impossible for a period of time, but the
GI tract is functional.
A. Based on Clinical Condition:
1. Neurological and Neuromuscular Disorders:
o Stroke: Impaired swallowing (dysphagia) and reduced consciousness.
o Neurodegenerative Diseases: Advanced Parkinson's disease, Multiple Sclerosis,
Amyotrophic Lateral Sclerosis (ALS/MND).
o Brain Injury: Coma or severe cognitive impairment.
o Cerebral Palsy: With severe feeding difficulties.
2. Head and Neck Disorders:
Vital signs are a group of the four to six most critical medical signs that indicate the status of the body’s vital
(life-sustaining) functions. These measurements provide a snapshot of a patient's overall physiological
health and are essential for monitoring, diagnosing, and determining medical treatments.
The four primary vital signs are:
1. Body Temperature: The balance between heat produced and heat lost by the body.
2. Pulse Rate: The number of times the heart beats per minute.
3. Respiration Rate: The number of breaths a person takes per minute.
4. Blood Pressure: The force of circulating blood on the walls of the arteries.
Often, a fifth sign is included:
5. Oxygen Saturation (SpO2): The percentage of hemoglobin in the bloodstream that is saturated with
oxygen.
Pain is frequently considered the "sixth" vital sign, as it is a critical indicator of a patient's well-being.
II. Purpose of Measuring Vital Signs
Measuring vital signs serves several crucial purposes in clinical and emergency settings:
1. To Establish a Baseline: The initial set of vital signs provides a reference point for comparing all
future measurements.
2. To Monitor a Patient's Condition: Regular tracking helps detect changes in a patient's health status,
indicating improvement or deterioration.
3. To Screen for Medical Disorders: Abnormal readings can be the first sign of an underlying illness
(e.g., fever indicating infection, high blood pressure indicating hypertension).
4. To Aid in Diagnosis: Vital signs help clinicians form a diagnosis (e.g., rapid pulse and low blood
pressure may suggest shock or dehydration).
5. To Evaluate the Response to Treatment: They are used to assess whether a patient is responding to
medication or therapy (e.g., checking if a fever reducer has lowered the temperature).
6. To Make Critical Decisions: Vital signs determine the urgency of a situation and guide decisions
about treatment, medication, and the need for hospitalization.
III. Procedure for Measuring Vital Signs
The procedure should be systematic, performed with care, and the findings must be accurately documented.
General Guidelines:
Ensure the environment is calm, quiet, and comfortable.
Wash your hands thoroughly before and after the procedure.
Ensure the equipment is clean, functional, and calibrated.
Explain the procedure to the patient to gain cooperation and reduce anxiety.
The patient should be at rest (sitting or lying down) for at least 5 minutes before measurement.
A. Body Temperature
, Purpose: To assess the body's ability to produce and get rid of heat.
Common Routes & Procedure:
1. Oral (Mouth):
Use a digital or disposable thermometer.
Place the probe under the tongue in the posterior sublingual pocket.
Instruct the patient to keep their mouth closed.
Wait for the thermometer to beep (usually 10-30 seconds).
Normal Range: 36.1°C - 37.5°C (97.0°F - 99.5°F).
2. Tympanic (Ear):
Use a tympanic thermometer with a disposable probe cover.
Gently pull the ear pinna upward and backward (for adults).
Insert the probe snugly into the ear canal and press the button.
Normal Range: Similar to oral, but the device often converts it.
3. Axillary (Armpit):
Place the thermometer in the center of a dry armpit.
Have the patient hold their arm down against their chest.
This is the least accurate method.
Normal Range: 35.5°C - 36.9°C (96.0°F - 98.4°F).
4. Temporal (Forehead):
Use a temporal artery thermometer.
Gently swipe the probe across the forehead to the temporal area.
Normal Range: Similar to oral.
B. Pulse Rate
Purpose: To assess heart rate, rhythm, and strength.
Common Site: Radial artery (wrist).
Procedure:
1. Place your index and middle fingers gently over the patient's radial artery, on the thumb side
of their wrist.
2. Do not use your thumb, as it has its own pulse.
3. Count the number of beats for 30 seconds and multiply by 2. If the rhythm is irregular, count
for a full 60 seconds.
4. Note the Rate (beats per minute), Rhythm (regular or irregular), and Strength (strong, weak,
thready).
, o Normal Range (Adults): 60 - 100 beats per minute.
C. Respiration Rate
Purpose: To assess the function of the lungs and respiratory system.
Procedure:
1. Keep your fingers on the patient's wrist (as if still taking a pulse) so they are unaware you are
counting breaths. This prevents them from altering their breathing pattern.
2. Observe the rise and fall of the chest.
3. Count the number of complete breaths (one inhalation + one exhalation) for 30 seconds and
multiply by 2.
4. Note the Rate, Rhythm, and Depth (deep or shallow).
o Normal Range (Adults): 12 - 20 breaths per minute.
D. Blood Pressure
Purpose: To measure the pressure in the arteries during systole (heart contraction) and diastole
(heart relaxation).
Equipment: Sphygmomanometer (cuff and gauge) and stethoscope.
Procedure:
1. Have the patient sit or lie with their arm supported at heart level.
2. Wrap the correct-sized cuff snugly around the upper arm, about 2-3 cm above the elbow.
3. Palpate the brachial artery in the antecubital space (inner elbow).
4. Place the stethoscope's diaphragm over this artery.
5. Inflate the cuff rapidly to about 180-200 mmHg, or 30 mmHg above the point where the
pulse disappears.
6. Slowly release the valve to deflate the cuff (2-3 mmHg per second).
7. Note the reading on the gauge when you hear the first clear tapping sound (Systolic
Pressure).
8. Continue deflating and note the reading when the sound disappears (Diastolic Pressure).
o Normal Range (Adults): Systolic <120 mmHg and Diastolic <80 mmHg.
E. Oxygen Saturation (SpO2)
Purpose: To measure the percentage of oxygen carried in the blood.
Equipment: Pulse oximeter.
Procedure:
1. Place the probe (sensor) on a clean, warm finger, toe, or earlobe.
2. Ensure the patient is not wearing nail polish.
3. Wait a few seconds for the reading to stabilize.
, o Normal Range: 95% - 100%.
Documentation:
All findings must be immediately and accurately recorded in the patient's chart with the date and time. Any
abnormalities must be reported to a supervisor or physician.
Tube Feeding (Enteral Nutrition)
I. Definition
Tube feeding, also known as enteral nutrition, is a medical procedure used to provide nutritional support,
fluids, and medications directly into the gastrointestinal (GI) tract via a tube. It bypasses the oral cavity and
is used when a patient cannot safely or adequately consume food and fluids by mouth but has a functioning
GI tract.
II. Purposes of Tube Feeding
The primary goal is to maintain or restore nutritional status. Specific purposes include:
1. To Provide Adequate Nutrition: To meet the body's caloric, protein, vitamin, and mineral
requirements for energy, tissue repair, and immune function.
2. To Prevent Malnutrition and Cachexia: In patients who are unable to meet their nutritional needs
orally for a prolonged period.
3. To Maintain Gut Integrity: The GI tract's barrier function is maintained by the presence of
nutrients in the gut. Enteral nutrition helps prevent bacterial translocation from the gut into the
bloodstream, which can cause sepsis.
4. To Promote Hydration and Electrolyte Balance: Provides necessary fluids and electrolytes.
5. To Administer Medications: For patients who cannot swallow pills, necessary medications can be
crushed (if safe) and administered through the tube.
6. To Support Growth and Development: In pediatric patients with failure to thrive or congenital
abnormalities.
7. To Manage Specific Medical Conditions: Such as reducing the risk of complications in pancreatitis
(via post-pyloric feeding) or providing specialized formulas for metabolic disorders.
III. Indications for Tube Feeding
Tube feeding is indicated when oral intake is insufficient, unsafe, or impossible for a period of time, but the
GI tract is functional.
A. Based on Clinical Condition:
1. Neurological and Neuromuscular Disorders:
o Stroke: Impaired swallowing (dysphagia) and reduced consciousness.
o Neurodegenerative Diseases: Advanced Parkinson's disease, Multiple Sclerosis,
Amyotrophic Lateral Sclerosis (ALS/MND).
o Brain Injury: Coma or severe cognitive impairment.
o Cerebral Palsy: With severe feeding difficulties.
2. Head and Neck Disorders:
