VITAL SIGNS

▪The vital signs or cardinal signs are body temperature,

pulse, respiration and blood pressure. (sometimes
pain). These signs are the clearest indicators of overall health
status.
BODY TEMPERATURE
▪ The balance between the heat produced by the body and
the heat lost from the body.
▪ Types of Body Temperature
1. Core Temperature. The temperature of the deep tissues of the body.
Measured by taking oral and rectal temperature. The normal oral
temperature is 37°C {98.6°F) with a range of 35.8°C to 37.3°C {96.4°F to
99.1°F). The rectal temperature measures 0.4°C to 0.5°( (0.7°F to 1 °F)
higher.
2. Surface temperature. The temperature of the skin, subcutaneous
tissue and fat. Measured by taking axillary temperature.
▪ Body heat is primarily produced by metabolism.
▪ The heat regulating center is found in the hypothalamus
FACTORS AFFECTING BODY
HEAT PRODUCTION
▪ HEAT PRODUCTION
▪ BMR
▪ Muscle Activity
▪ Thyroxine Output
▪ Epinephrine/
norepinephrine and
sympathetic nervous
system stimulation
▪ Fever
▪ HEAT LOSS
▪ Radiation
▪ Conduction
▪ Convection
▪ Evaporation
FACTORS AFFECTING BODY
TEMPERATURE
▪ Age
▪ Infants and older people (<75 y.o.) are very vulnerable to temperature changes

▪ Diurnal Variations (circadian rhythms)

▪ Highest at between 4pm – 6pm
▪ Lowest at between 4am – 6am

▪ Exercise
▪ Hormones
▪ Women usually experience more hormone fluctuations than men

▪ Stress
▪ Stimulation of the sympathetic nervous system can increase metabolic activity and heat
production.
▪ Environment
▪ . Extremes in environmental temperatures can affect a client’s temperature regulatory system
ALTERATIONS IN BODY
TEMPERATURE
▪ The normal range for adults is
considered to be between 36°C and
37.5°C (96.8°F to 99.5°F).
▪ There are two primary alterations in
body temperature: pyrexia and
hypothermia
PYREXIA
▪ A body temperature above the usual range is called pyrexia,
hyperthermia, or (in lay terms) fever
▪ Hyperpyrexia - < 41°C (105.8°F)
▪ Febrile - client who has a fever
▪ Afebrile - clients who does not have a fever
▪ Four common types of fever
▪ intermittent fever
▪ remittent fever
▪ Relapsing fever
▪ constant fever
PHASES OF FEVER
▪ The clinical signs of fever vary with the
onset, course, and abatement stages of the
fever (Box 28.2).

▪ These signs occur as a result of changes in

the set point of the temperature control
mechanism regulated by the
hypothalamus.
HYPOTHERMIA
▪ Hypothermia is a core body temperature below the lower limit of normal.

▪ The three physiologic mechanisms of hypothermia are

▪ (a) excessive heat loss,
▪ (b) inadequate heat production to counteract heat loss, and
▪ (c) impaired hypothalamic thermoregulation

▪ Hypothermia may be induced or accidental. Accidental hypothermia can

occur as a result of
▪ (a) exposure to a cold environment,
▪ (b) immersion in cold water, and
▪ (c) lack of adequate clothing, shelter, or heat.
ASSESSING BODY TEMPERATURE
▪ The most common sites for measuring body temperature are oral, rectal,
axillary, tympanic membrane, and temporal artery
TEMPERATURE SCALES
 TYPES OF THERMOMETERS
Mercury in glass Thermometers Electronic Thermometers

Chemical disposable
thermometers
 TYPES OF THERMOMETERS
Temperature-sensitive tape Temporal artery thermometers Infrared thermometers
ASSESSING TEMPERATURE
● Check physician’s order of NCP for frequency and route
● identify patient
● explain the procedure to patient
● gather equipment
● make sure the electronic/ digital thermometer is in operating conditions
● perform hand hygiene and don gloves if appropriate or indicated
● select appropriate site
● follow steps as outlined for appropriate type of thermometer
● (after Procedure) Perform hand hygiene. if wearing gloves, discard them
properly
● record temperature on paper flow sheet or computerized record. report
any abnormal findings and identify assessment site
RELATED NURSING SKILL
Methods of Temperature –Taking

• Oral. Most accessible and convenient method.

• Allow 15 minutes to elapse between a client's intake of
hot or cold food or smoking and the measurement of
oral temperature.
• Place thermometer under the tongue, directed towards
the side. Location ensures contact with large vessels
under tongue.
• Wash the thermometer before use, from the bulb to the
stem, after use, from the stem to the bulb. This practice
ensures' medical asepsis.
• Take oral temperature for 2-3 minutes. This ensures
adequate time for recording of the temperature.
CONTRAINDICATIONS TO ORAL
TEMPERATURE TAKING

Presence of oro-
nasal pack,
Oral lesions or Nausea and
Dyspnea Cough nasogastric tube,
surgery vomiting
endotracheal
tube.

Restless,
Very young
Seizure-prone Unconscious disoriented,
children
confused
▪Rectal. Most accurate measurement of temperature.
▪Assist client to assume lateral position. To expose anal area.
▪Lubricate thermometer before insertion. To reduce friction and
prevent trauma to the mucous membrane in the anus.
▪Insert thermometer by 0.5-1.5 inches.
▪Instruct client to take a deep breath during insertion of the
thermometer. To relax the internal sphincter
▪Hold the thermometer in place for 2 mins. (for neonates-5
mins; make sure there is no imperforate anus). To ensure
recording of temperature.
▪Do not force insertion of thermometer. To prevent trauma in
the area.
▪Note: Rectal temperatures are recommended infrequently
now that tympanic thermometers are available. Most clients
are uncomfortable having their temperature taken rectally, so
avoid this route if possible.
 Anal/Rectal conditions or surgeries, e.g.
anal fissure, hemorrhoids
hemorrhoidectomy.
CONTRAINDICATIONS Diarrhea.
TO RECTAL
TEMPERATURE Quadriplegic clients. Vagal stimulation
TAKING may occur, causing bradycardia and
syncope
Heart Problem. Vagal stimulation may
occur, causing bradycardia and
syncope
▪Axillary. Safest and most non-
invasive method of
temperature taking.
▪ Pat dry the axilla. Rubbing causes
friction and will increase
temperature in the area.
▪ Place the thermometer in the
client's axilla.
▪ Place the arm tightly across the
chest to keep the thermometer in
place for 9 mins (for infants and
children-5 mins).
▪ Record Adult Temperature Ranges
▪ Tympanic. Tympanic
temperature measurement
is useful with toddlers who
squirm at the restraint
needed for the rectal
route, and is useful for
preschoolers who are not
yet able to cooperate for
an oral temperature and
yet fear for the disrobing
and invasion of a rectal
temperature.
▪An infrared thermometer is
a thermometer which infers
temperature from a portion of
the thermal radiation sometimes
called black-body radiation emitted by
the object being measured. They are
sometimes called laser
thermometers as a laser is used to
help aim the thermometer, or non-
contact
thermometers or temperature
guns, to describe the device's ability
to measure temperature from a
distance. By knowing the amount
of infrared energy emitted by the
object and its emissivity, the object's
temperature can often be determined
within a certain range of its actual
temperature. Infrared thermometers
are a subset of devices known as
"thermal radiation thermometers".
Methods of Temperature Ranges
Taking
Oral 97 .6° - 99.6°F
(36.5° - 37 .5°C)
Axillary 96.6° - 98.6°F
(35.8° - 37 .0°C)
Rectal 98.6° - 100.6°F
(37.0° - 38.1°C)
Tympanic 98.2° - 100.2°F
(36.8° - 37 .9°C)
PULSE
▪ It is a wave of blood
created by contraction of
the left ventricle of the
heart. The pulse rate is
regulated by the
autonomic nervous system
(ANS).
 ▪ Temporal. Over the temporal bone of the head; superior
and lateral to the eye.
▪ Carotid. At the lateral aspect of the neck; below the ear
lobe.
▪ Apical. At the left midclavicular line (MCL) fifth
intercostals space (ICS), Use stethoscope.
▪ Brachial. At the inner aspect of the upper arm (Biceps
PULSE muscles) or medially at the antecubital space.
▪ Radial. On the thumb side of the inner aspect of the

SITES wrist.
▪ Femoral. Along side the inguinal ligament.
▪ Posterior Tibial. At the medial aspect of the ankle,
behind the medial malleolus.
▪ Popliteal. At the back of the knee.
▪ Pedal (Dorsalis Pedis). At the dorsum of the foot.
▪ Use the middle two to three fingertips to palpate the
pulse. Do not use the thumb. The normal pulse is
detected readily, obliterated by strong pressure.
Assessment of the Pulse

Tachycardia. Pulse rate above 100 beats/min. (Adult)

Bradycardia. Pulse rate below 60 beats/min (Adult). Well-

unconditioned athletes normally experience bradycardia.
Rhythm. The pattern and intervals of beats.
Dysrhythmia is irregular rhythm.

Volume. (Amplitude). The strength of the pulse.

• A normal pulse can be felt with moderate pressure.

• Full or bounding pulse. It can be obliterated only by great pressure.
• Thready pulse. It can easily be obliterated (also weak, feeble).
• The pulse volume or amplitude is recorded using a three - point scale:
• 3+ full, bounding
• 2+ normal
• 2+ normal
•1+ weak, thread
•0 absent
▪ Arterial Wall Elasticity. The artery feels straight, smooth, soft
and pliable.
▪ Presence/ Absence of bilateral equality. Absence of
bilateral equality indicates cardiovascular disorder.
▪ Use the pads of the three fingers to palpate the pulse (index, middle,
ring finger).
APICAL –RADIAL PULSE
ASSESSMENT
▪ An apical-radial pulse may need to be
assessed for clients with certain
cardiovascular disorders.
▪ Normally, the apical and radial rates are
identical
▪ AP < RP, may indicate vascular disease
▪ PULSE DEFICIT is Any discrepancy between
the two pulse rates and need to be reported
promptly
▪ can be taken by two nurses or one nurse,
although the two-nurse technique may be
more accurate.
ASSESSING PULSE
● identify the patient
● explain the procedure. encourage the patient to relax and not speak. if
patient is active, wait for 5 to 10 minutes before assessing the pulse
● perform hand hygiene
● provide privacy
● select appropriate site (radial or apical)
● follow steps for appropriate pulse assessment
● (after procedure): perform hand hygiene
● document pulse rate and site. report any abnormal finding and identify
assessment site
PALPATING RADIAL PULSE
● patient may either be supine with arm alongside body, wrist extended
and palms lateral or facing down or sitting with forearm at a 90 degree
angle to the body resting on a support with arm extended and palm
downward
● place your first, second and third fingers along patient’s artery and press
gently against the radius. rest your thumb on back of patient’s wrist
● apply only enough pressure to distinctly feel the artery
● using a watch with second hand, count the number of pulsation felt for 1
full minute.
AUSCULTATING THE APICAL
PULSE
▪ use alcohol swab to clean the stethoscope ear pieces and diaphragm
▪ assist patient to sit in chair or sit up in bed and then expose the chest
area
▪ hold the stethoscope diaphragm against the palm of your hand for a few
second
▪ palpate the 5th intercostal space and move to the left midclavicular line.
palace the diaphragm over the apex of the heart
▪ listen for heart sounds, identified as “lub-dub” sound
▪ using watch with 2nd hand , count the heartbeat for 1 full minute
RESPIRATION
▪ The act of breathing.
▪ Three Process:
▪ Ventilation. The movement of gases
in and out of the lungs
▪ Inhalation (Inspiration)
▪ Exhalation (Expiration)
▪ Diffusion. The exchange of gases
from an area of higher pressure to an
area of lower pressure. It occurs at
the alveolo-capillary membrane.
▪ Perfusion. The availability and
movement of blood for transport of
gases, nutrients and metabolic waste
products.
Two Types of
Breathing
•Costal (thoracic).
Involves movement of
the chest.
•Diaphragmatic
(abdominal). Involves
movement of the
abdomen
▪ Medulla Oblongata is the primary respiratory center.
▪ Pons contains the following:
▪ Pneumotaxic center, responsible for the rhythmic
quality of breathing.
▪ Apneustic center, responsible for deep, prolonged
inspiration.
RESPIRA
▪ Carotid and aortic bodies contain peripheral
chemoreceptors. These take up the work of breathing
when central chemoreceptors in the medulla oblongata
TORY
are damaged. Respond to low oxygen concentration in
the blood. Respond to pressures. If the BP is elevated
the respiratory rate becomes slow. (Hypertension leads
CENTER
S
to respiratory acidosis). If the BP is decreased, the
respiratory rate-is rapid.(Hypotension leads to
respiratory alkalosis.) The primary chemical stimulation
for breathing is high carbon dioxide level in the blood.
▪ Muscle and joints contain proprioreceptors.
▪ Proprioreceptors. Exercise increases respiratory rate.
ASSESSING RESPIRATION
Rate. Normal is 12-20/ minute in adult.

Depth. Observe the movement of the chest.

May be normal, deep or shallow.
Rhythm. Observe for regularity of exhalations
and inhalations.
Quality or character. Refers to respiratory
effort and sound of breathing.
MAJOR FACTORS AFFECTING
RESPIRATORY RATE (RR)
Environment.
Increased
temperature of the
Exercise. Increases environment
Stress. Increases RR
RR. decreases RR;
Decreased
temperature,
increases RR.

Medications.(e.g.
Increased altitude.
narcotics decrease
Increases RR.
RR)
NORMAL RESPIRATORY RATES
Age Breaths per minute
Newborn 30-60
1 20-40
2 25-32
4 23-30
6 21-26
8 20-26
10 20-26
12 18-22
14 18-22
16 12-20
18 16-20
Adult 10-20
ASSESSING RESPIRATION
▪ while your fingers are still in place after counting the pulse rate, observe
for patient’s respiration
▪ note rise and fall of patient’s chest
▪ using watch with 2nd hand, count the number of respiration for 1 dull
minute
▪ perform hand hygiene
▪ document the respiratory rate and report and abnormal findings
▪ Eupnea. Normal respiration that is quiet, rhythmic and effortless.
▪ Tachypnea. Rapid respiration, above 20 breaths/ minute in an adult.
▪ Bradypnea. Slow breathing, less than 12 breaths / minute in an adult.
▪ Hyperventilation. Deep rapid respiration. Carbon dioxide is
excessively exhaled (respiratory alkalosis).
▪ Hypoventilation. Slow shallow respiration. Carbon dioxide is
excessively retained (respiratory acidosis).
▪ Dyspnea. Difficult and labored breathing.
▪ Orthopnea. Ability to breath only in upright position.
▪ Apnea. Absence of respirations.
 ▪ Is the measure of the pressure
exerted by the blood as it pulsates
through the arteries

BLOOD ▪ BP= Cardiac Output x Total Peripheral

Resistance or C.O. x TPR

PRESSURE ▪ Systolic Pressure. Is the pressure

of blood as a result of contraction of
the ventricles (100-140 mmHg).
▪ Diastolic pressure. Is the pressure
when the ventricles are at rest (60-90
mm Hg).
▪ Pulse Pressure. Is the difference
between the systolic and diastolic
pressures (S-D=P.P.) Normal is 30-40
mmHg
 ▪ Blood Volume. Hypervolemia raises
BP. Hypovolemia lowers BP
▪ Peripheral Resistance.
Vasoconstriction elevates BP.
Vasodilation lowers BP.

DETERMINANT ▪ Cardiac Output. When the pumping

action of the heart is weak (decreased
S OF BLOOD CO), BP decreases.
▪ Elasticity or Compliance of Blood
PRESSURE Vessels. In older people, elasticity of
blood vessels decreases thereby
increasing BP.
▪ Blood Viscosity (viscosity Increases
markedly when the Hct is more than 60
- 65 %). Increased blood viscosity
raises the BP
 ▪ Age. Older people have higher BP due to
decreased elasticity of blood vessels.
▪ Exercise. Increases cardiac output; hence the

FACTORS BP
▪ Stress. Sympathetic nervous system

AFFECTING stimulation causes increased BP

▪ Race. Hypertension is one of the 10 leading

BLOOD causes of death among Filipinos

▪ Obesity. BP generally is elevated among

PRESSURE
overweight and obese people.
▪ Sex/Gender. After puberty and age 65 years,
males have higher BP. After age 65 years,
females have higher BP due to hormonal
variations in menopause.
FACTORS AFFECTING BLOOD PRESSURE

Medications. Some medications may increase or

decrease BP.

Diurnal variations. BP is lowest in the morning

and highest In the late afternoon or early evening.

Disease Process- Diabetes Mellitus, Renal Failure,

Hyperthyroidism, Cushing's Disease cause increase
in BP
Hypertension is an abnormally high blood pressure over
140 mm Hg systolic and or above 90 mm Hg diastolic for at
least two consecutive readings.

Hypotension is an abnormally low blood pressure, systolic

pressure below 100/60 mm Hg.

Orthostatic Hypotension is a drop in systolic pressure

more than 20mmHg. It occurs with a quick change to a
standing position. This is due to abrupt peripheral
vasodilation without a compensatory increase in cardiac
output. It may also occur in prolonged bed rest.
ASSESSING BLOOD PRESSURE
▪ Manual blood pressure measurement
is performed with a blood pressure
cuff, a sphygmomanometer, and a
stethoscope.
▪ The sphygmomanometer indicates
the pressure of the air within the
bladder.
▪ There are two types of
sphygmomanometers: aneroid and
digital.
BLOOD PRESSURE
ASSESSMENT SITES
▪ Upper arm – most commonly
▪ forearm or wrist - usually using an electronic blood pressure monitor
▪ client’s thigh
▪ The blood pressure cannot be measured on either arm (e.g., because of burns or
other trauma).
▪ The blood pressure in one thigh is to be compared with the blood pressure in the
other thigh
▪ Blood pressure is NOT measured on a particular client’s limb in the
following situations:
▪ The shoulder, arm, or hand (or the hip, knee, or ankle) is injured or diseased.

▪ A cast or bulky bandage is on any part of the limb.

▪ The client has had surgical removal of breast or axillary (or inguinal) lymph nodes
on that side

▪ The client has an IV infusion or blood transfusion in that limb.

▪ The client has an arteriovenous fistula (e.g., for renal dialysis) in that limb.
METHODS
Blood pressure can be assessed directly or indirectly.
▪ Direct (invasive monitoring) measurement involves the insertion of a
catheter into the brachial, radial, or femoral artery
▪ Two noninvasive indirect methods of measuring blood pressure are the
auscultatory and palpatory methods.

▪ When taking a blood pressure using a stethoscope, the nurse identifies phases in
the series of sounds called Korotkoff sounds
▪ The palpatory method is sometimes used when Korotkoff sounds cannot be heard
▪ An auscultatory gap is the temporary disappearance of sounds normally
heard over the brachial artery when the cuff pressure is high followed by
the reappearance of the sounds at a lower level
ASSESSING BLOOD
PRESSURE
▪ identify the patient
▪ explain the procedure
▪ perform hand hygiene
▪ delay obtaining the blood pressure if the patient is emotionally upset, is
in pain, from exercised, unless it is urgent to obtain BP
▪ Select appropriate arm for application of cuff
▪ have patient be in a comfortable lying ir sitting position with forearm
supported at the level of the heart and with palm upward
▪ expose area of brachial artery by removing garments or moving sleeve
ASSESSING BLOOD
PRESSURE
▪ center the bladder of the cuff over brachial artery approximately midway
on arm, so lower edge of cuff is about 2.5 to 5 cm (1-2 inches) above the
inner aspect of the elbow. tubing should extend from the cuff edge nearer
patient’s elbow
▪ wrap the cuff smoothly and snugly around the arm. fasten it securely or
tuck end of cuff well under preceding wrapping. do not allow any clothing
to interfere with proper placement of cuff
▪ check the needle on the aneroid gauge is within the zero mark
▪ palpate the pulse at eh brachial or radial artery by pressing gently with the
fingertips
▪ tighten the screw valve on the air pump
▪ inflate the cuff while continuing palpating the artery. note the point on the
gauge where pulse disappear
ASSESSING BLOOD
PRESSURE
▪ deflate the cuff and wait for 15 seconds
▪ assume a point that is no more than 3 feet from the gauge
▪ place the stethoscope earpieces in the ears. direct the ear tips forward into
the canal and not against the ear itself
▪ place stethoscope bell or diaphragm firmly but with as little pressure as
possible over the brachial artery. do not allow stethoscope to touch clothing
or cuff
▪ pump the pressure 30 mmHg above the point at which the systolic pressure
was palpated and estimated. Open manometer valve and allow air to escape
slowly (allowing the gauge to drop 2-3mm per heartbeat)
▪ note the point on the gauge at which the first faint, but clear, sound appears
and slowly increases in intensity. note this number as systolic pressure
▪ read pressure to the closest even number
ASSESSING BLOOD
PRESSURE
▪ do not inflate cuff once air is being released to recheck the systolic
pressure reading
▪ note the pressure at which the sound first becomes muffled. also observe
point at which sound completely disappears. these may occur separately
or at the same point
▪ allow remaining air to escape quickly. repeat any suspicious reading but
wait 30 to 60 seconds between readings
▪ removed cuff. clean and store equipment
▪ perform hand hygiene
▪ record findings and report and abnormal findings. also identify arm used
and site of the assessment