Vital signs are a general term for body temperature, pulse, respiration, and blood pressure. Vital signs are controlled by the cerebral cortex and are a reliable indicator of the body’s physical and mental condition. Normal individuals have relatively constant vital signs within a certain range, with minimal changes. In pathological conditions, its changes are extremely sensitive. Mastering the observation skills of vital signs and nursing is one of the extremely important aspects of clinical nursing for nursing staff.
1： Body temperature
（1） Normal body temperature: Oral temperature 36.3-37.2 (37.0)
Anal temperature 36.5-37.7 (37.5)
Axillary temperature 36.0-37.0 (36.5)
（2） Common anomalies:
1. Classification of fever levels due to high body temperature (based on oral temperature)
① Low fever body temperature 37.3-38 ℃.
② Moderate body temperature 38.1-39.0 ℃.
③ High fever body temperature 39.1-41.0 ℃
④ Ultra high heat above 41 ℃ body temperature
2. Clinical classification of hypothermia:
Mild 32~35 ℃;
Moderate 30-32 ℃;
Severe<30 ℃ pupil dilation, disappearance of light reflex;
The lethal temperature is 23-25 ℃.
（3） Measurement precautions:
Before and after measuring body temperature, the number of thermometers should be counted and checked for any damage. When manually shaking the watch, do not touch it to prevent it from being smashed. Do not wash the thermometer in hot water or boil it in boiling water to avoid explosion.
2. Mental abnormalities, coma, infants and young children, oral and nasal surgery, breathing difficulties, and incompatibility with the author, oral temperature measurement is prohibited; It is not advisable to measure axillary temperature for patients undergoing axillary surgery, trauma, inflammation, excessive sweating, or those with loose shoulder joints; Rectal or anal surgery, diarrhea, contraindications for rectal temperature measurement. Patients with myocardial infarction should not measure anal temperature.
3. Infants, critically ill individuals, and restless individuals should be taken care of by dedicated personnel.
4. If a patient accidentally bites the thermometer and swallows mercury, they should immediately remove the glass debris in the oral cavity to avoid damaging the lips, tongue, oral cavity, esophagus, and gastrointestinal mucosa. Then, they should take egg white or milk orally to combine protein with mercury and delay the absorption of mercury. Patients with conditions can consume fiber rich foods (such as chives) to promote the excretion of mercury.
5. Avoid various factors that may affect body temperature measurement.
(1) After sitz baths or enemas, the rectal temperature should be measured after a 30 minute interval.
(2) After eating water or applying cold or hot compress on the cheeks, the oral temperature should be measured after a 30 minute interval.
(3) Infectious disease patients should use specialized thermometers and be cleaned and disinfected separately to prevent cross infection.
6. The temperature of newly admitted patients should be measured four times a day for three consecutive days. After three days, if the temperature is normal, it should be measured twice a day.
7. For surgical patients, their body temperature was measured at 8pm one day before surgery, and 4 times a day after surgery for 3 consecutive days. After the temperature returned to normal, it was measured twice a day.
2： Pulse
（1） Normal values: The pulse rate of adults in a quiet state is 60-100 beats per minute, the average pulse rate of children is about 90 beats per minute, and the average pulse rate of elderly people is about 55-60 beats per minute. The ratio of pulse rate to respiration is 4-5:1.
（2） Common anomalies
1. Abnormal pulse rate:
(1) Adult tachycardia is greater than 100 beats per minute;
(2) Adults with bradycardia have less than 60 beats per minute;
2. Abnormal rhythm:
(1) Intermittent pulse occurs in a series of normal and regular pulses, with an earlier and weaker pulse, including a longer interval than normal.
Each normal pulse followed by an early beat (premature contractions) is called a triad rhythm, and every two beats followed by an early beat is called a triad rhythm.
(2. Short pulse rate is lower than heart rate per unit of time.).
3. Abnormal strength:
(1) The pulse of the flood is strong and large
(2) The pulse is weak and small, touching it like a fine thread
(3) Alternating pulse strength alternating appearance
(4) The water rushes and the pulse rises and falls suddenly, rapid and powerful
(5) The normal pulse of Chongbo pulse has a repeated rising pulse during its descending phase, but it is lower than the first wave.
(6) When inhaling, the pulse significantly weakens or disappears.
（3） Measurement precautions:
1. Abnormal pulse measurement for 1 minute
2. Do not use the thumb for pulse diagnosis, as the pulsation of the small artery in the thumb can easily be confused with the patient's pulsation.
3. Short pulse: Recorded in fractional form as heart rate/pulse rate
4. If the patient experiences tension, intense exercise, crying, etc., measurements should be taken after stabilization.
5. Patients with short pulse should measure their pulse as required, with one nurse taking the pulse and the other nurse listening to the heart rate while measuring for one minute.
3： Breathing
（1） Normal breathing: The breathing rate of a normal adult in a quiet state is 16-20 beats per minute
（2） Common anomalies:
1. Abnormal frequency
(1) Respiratory tachycardia, also known as shortness of breath, occurs when the respiratory rate exceeds 24 beats per minute. Generally, for every 1 ℃ increase in body temperature, the respiratory rate increases by approximately 3-4 times per minute.
(2) Respiratory delay in adults<12 breaths per minute
2. Abnormal rhythm:
Tidal breathing, also known as Cheyne Stokes breathing, is characterized by a gradual change in breathing from shallow slow to deep fast, then from deep fast to shallow slow, followed by a pause in breathing for a period of time
After 5 to 30 seconds, repeat the above periodic changes, with a shape like tidal fluctuations. The cycle of tidal breathing can reach up to 30 seconds to 2 minutes
3. Abnormal sound: Cicada like breathing, snoring breathing
（3） Measurement precautions:
The rate of breathing is influenced by consciousness, and there is no need to inform the patient when measuring.
If the patient has tension, intense exercise, crying, etc., it should be measured after stabilization.
Patients and infants with irregular breathing should be measured for 1 minute.
4： Blood pressure
（1） Normal blood pressure
Systolic blood pressure 90-139mmHg (12-18.6kPa) Diastolic blood pressure 60-89mmHg (8-12kPa) Pulse pressure 30-40mmHg
(4-5.3kPa)
（2） Abnormal blood pressure:
1. Hypertension:
Graded systolic blood pressure (mmHg) and diastolic blood pressure (mmHg)
Ideal blood pressure<120<80
Normal blood pressure<130<85
Normal high value 130-139 85-89
Grade 1 hypertension (mild) 140-159 90-99
Subgroup: Critical hypertension 140-149 90-94
Secondary hypertension (moderate) 160-179 100-109
Grade III hypertension (severe) ≥ 180 ≥ 110
Simple systolic hypertension>140<90
Sub group: Critical systolic hypertension 140-149<90
2. Low blood pressure: Blood pressure below 90/60mmHg (12/8KPa), commonly seen in cases of massive blood loss, shock, acute heart failure, etc.
（3） Measurement precautions:
1. Four fixed points: fixed time, fixed location, fixed position, and fixed blood pressure monitor.
2. The cuff width is appropriate: if it is too narrow, the measured blood pressure value may be too high; Too broad and low blood pressure value.
3. The cuffs should be elastic enough to fit one finger. If they are too tight, blood pressure may be low, while if they are too loose, blood pressure may be high.
4. Patients should have calm emotions and rest for 30 minutes after exercising, being nervous, smoking, or experiencing emotional stress.
5. The tested limb is at the same level as the heart.
6. The speed of deflation should also be moderate, with a decrease of 4mmHg per second being advisable.
