VITAL SIGNS

Learning Objectives:
1. Explain the physiologic processes involved in
homeostatic regulation of TPR.
2. Discuss factors that may increase or decrease
the body temperature, pulse, respiration and
blood pressure
3. Identify sites for assessing temperature,
blood pressure, pulse and respiratory rate
4. Know the normal range for body temperature,
pulse, respiration and blood pressure
5. Accurately assess temperature, pulse,
respiratory rate and blood pressure.
6. Provide information to patients about taking
temperature, pulse and blood pressure at
home.
– What composes the Vital signs?
– body temperature
– pulse
– respiration
– blood pressure
– pain is designated 5th at the same time as
you assess the four.
– When to assess Vital Signs:
– on admission to a health care agency to
obtain baseline data.
– when a client has a change of health status or
reports symptoms such as chest pain or
feeling hot
– before and after surgery or an invasive
procedure
– before and or after the administration of a
medication that could affect the respiratory
–
– before and after any nursing interventions
that could affect the vital signs
 BODY TEMPERATURE

– reflects the balance between the heat produced

and the heat lost from the body and is measured
in degrees.
– Two kinds of Body Temperature:
– a. Core temperature – is the temperature of the
deep tissues of the body. Ex. Pelvic & abdominal
– b. Surface temperature – temperature of
the skin, subcutaneous tissue and fat
– Factors that affect the body’s heat
production:
– 1. BMR - is the rate of energy utilization in
the body required to maintain essential
activities like breathing.
– metabolic rates decrease with age
– the younger the person the higher the BMR
– 2. Muscle activity – including shivering
increases the HR
– c. Thyroxine output – increases the rate of
cellular metabolism throughout the body.
– HYPERTHYROIDISM is characterized by
increased body temperature
– d. Epinephrine – norepinephrine and
sympathetic stimulation/stress response:
these hormones increases the rate and thus
increases the body’s temperature further.
– e. Fever – increases the cellular metabolic
rate and thus increases the temp further.
– Heat is lost through :
– a. Radiation – transfer of heat from the surface
of one object to the surface of another object
without contact between the to objects.
– Ex. It feels warm in crowded room
– b. Conduction – is the transfer of heat from one
molecule to a molecule of lower temperature
– Ex. Application of moist wash cloth over the skin
– c. Convection – is the dispersion of heat by
air currents
– Ex. Exposure of the skin towards electric fan
– d. Evaporation – is continuous vaporization
of moisture from the respiratory tract and from
the mucosa of the mouth and from the skin.
– Ex. TSB increases peripheral circulation,
thereby increasing heat loss by evaporation
– Factors Affecting Body Temperature
– 1. Age – infants must be protected. Most
older people are at risk of hypothermia due to
inadequate diet, loss of subcutaneous fat lack
of activity.
– 2. Diurnal variation – body temperatures
normally change throughout the day. The
point of lowest body temperature is usually at
4 to 6 AM and highest is 4 to 6PM
– 3. Exercise – strenuous exercise can
increase body temperature
– 4. Hormones – during ovulation body rises
it is because of the progesterone secretion
which increases the body temperature,
whereas the estrogen decreases the temp.
– 5. Stress – stimulation of the sympathetic
nervous system can increase the production
of epinephrine and norepinephrine increasing
the metabolic activity and heat production
– Alteration in Body Temperature:
– Pyrexia/ Fever/Hyperthermia –a body
temperature above the usual range
– Hyperpyrexia – a very high fever such as
41C and above
– Febrile – client who has a fever
– Afebrile – client who has no fever
– COMMON TYPES OF FEVER
– Intermittent fever – body temperature
alternates at regular interval between period
of fever and period of normal. Ex. Malaria
– Remittent fever – fluctuation occur over a
24 hour period all of which are above normal.
Ex. influenza
– Relapsing - short febrile periods of a few
days are interspersed with 1 to 2 days of
normal temperature
– Constant fever- body fluctuates minimally
but always remains above normal. Ex. T.Y.
– Very high temperature 41-42 C case
irreversible brain cell damage
– Fever spike – temperature that rises to fever
level rapidly following normal temperatures
and then returns to normal within a few hours.
Ex. Bacterial blood infection
– Hyperpyrexia – 41to 42C
– Pyrexia – 38 to 40C
– Normal 36 to 37 C
– Hypothermia – 34 to 35
– in some conditions an elevated temperature
is not a true fever
– Like HEAT EXHAUSTION –is the result of
excessive heat and dehydration
– s/sx: paleness, dizziness, nausea, vomiting,
fainting and a moderately increased temp like
38.3 to 38.9
– Heat stroke – are persons who are staying in
hot weather: they have warm flushed skin
they usually have 41.1 C temp or even higher
– INTERVENTIONS FOR CLIENTS ITH FEVER
– monitor v/s
– assess skin color and temperature
– monitor wbc
– remove excess blankets when the client feels
warm
– provide adequate nutrition and fluids (to meet
the metabolic demand and prevent dehydration
– measure intake and output
– reduce physical activity to limit heat
production
– administer antipyretics
– provide oral hygiene ( to keep mucus
membrane moist)
– provide tsb ( to increase heat loss through
conduction)
– provide dry clothing and bed linens
– HYPOTHERMIA
– is a core body temperature below the lower
limit of normal
– three physiological mechanisms:
– a.) heat loss
– b.) inadequate heat production to counteract
heat loss
– c.) impaired hypothalamic thermoregulation
– Hypothermia can be :
– a. Induced – is the deliberate lowering of the body
temp to decrease the need for oxygen by the body
tissues.
– Example. During surgeries
– b. Accidental – can occur as a result of exposure
to a cold environment, immersion in cold water, lack
of adequate clothing, shelter or heat.
– the problem is because of decreased metabolic
rate, and the underlying tissues are damaged by
freezing cold and this results in frostbite
– INTERVENTION FOR HYPOTHERMIA
– provide a warm environment
– apply warm blankets for severe hypothermia
or a hyperthermia blanket
– give warm intravenous fluids
– provide dry clothing
– keep limbs close the body
– cover the patient’s scalp with cap
– apply arming pads
– ASSESSING BODY TEMPERATURE:
– Oral – accessible, wait for 30 minutes before
getting the oral temp after taking hot or cold.
– Rectal –reliable measurement but
inconvenient
– Axilla – safe and noninvasive
– Tympanic – reflects the core temperature
very fast, safe, noninvasive, but require
electronic equipment that may be expensive
– nearby tissue near the ear canal
– Temporal artery – measured in the forehead
– useful for infants and children
– very fast
– requires electronic equipment that may be
expensive or unavailable
– TYPES OF THERMOMETERS (topic)
– Electronic thermometer /digital– can
provide a reading 2 to 60 seconds
– Chemical thermometer – have liquid
crystals dots or bars that change color.
– Temperature sensitive tape – contains
liquid crystals that change color according to
temperature
– Infrared thermometers – the thermometer
does not make contact with the ear canal \
– Temporal artery – use of a scanning infrared
thermomrtrd
–
– C = (Fahrenheit temp-32)x5/9
– C (100-32) x5/9 = 68x5/9= 37.8

– F(celcius temp x 9/5) + 32

– F =(40x9/5) +32 = 72 + 32 = 104
– If you are using the tympanic route place the
infant in a supine position
– pull the pinna straight back and slightly
downward
– for children over 3 years and adults: pulled the
pinna upward
– for children younger than 3 pull the pinna
downward
– avoid this route if active ear infection is
present
– Older adults temperature are influenced by
both the environmental and internal
temperatures changes so they are prone to
hypothermia and hyperthermia.
 Nursing Interventions in Clients with Fever
 monitor v/s
 assess skin color and temperature
 monitor white blood cells, hematocrit ,
elevated hematocrit indicates dehydration,
elevated WBC indicates presence of infection
 remove excess blankets when the client feels
warmth
 provide adequate foods and fluids
 measure intake and output
 maintain prescribed IV fluids as ordered by the
physician
 promote rest to reduce body heat production
 provide good oral hygiene
 provide cool, circulating air using a fan
 Provide dry clothing and bed linens
 provide tepid sponge bath (TSB) to enhance
heat loss by evaporation and conduction
 administer antipyretics as ordered
 Methods of Temperature Taking
1. Oral – most accessible and convenient method
- Allow 15 minutes to elapse between a client’s
intake of hot or cold food or smoking
- place the thermometer under the tongue
- take oral temp 2-3 minutes
2. Rectal – most accurate measurement
- Insert thermometer 0.5 to 1.5 inches
- hold the temperature in place for 2 mins.
3. Axillary – safest and most non-invasive
method
- Place the thermometer the thermometer in
place for 9 minutes
 PULSE

– 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
– the pulse wave represent the amount of blood that
enters the arteries with each ventricle contraction.
– the pulse reflects the heartbeat
– The pulse rate is the same as the rate of the
ventricular contraction of the heart.
– however in some types of cardiovascular
disease, the heartbeat and pulse rates can
differ
– Ex. Client’s heart may produce very weak
pulse that are not detectable in the peripheral
pulse
– A peripheral pulse – is a pulse located away
from the heart
– Apical pulse/ Point of Maximal Impulse –
is the central pulse which is located at the
apex of the heart
– Factors Affecting the Pulse:
– the rate of the pulse is expressed in bpm
– 1. Age – younger persons have higher PR than
older persons
– P R
– NB 130 (80-180) 35 (30-60)
– 1 yr 120 (80-140) 30 (20-40)
– 5-8 100 (75-120) 20 (15-25)
– 10 70 (50-90) 19 (15-25)
– Teen 75 (50-90) 18 (15-20)
– Adult 80 (60-100) 16 (12-20)
– Older adult 70 (60-100) 16 (15-20)
– 2. Sex – after puberty females have higher PR
than the males.
– 3. Exercise – PR normally increases with activity
– 4. Fever – the PR increases increase due to
lowered BP that results from peripheral
vasodilation due to elevated temp and also due to
increased metabolic rate
– 5. Medications –digitalis, beta blockers
decrease PR, Epinephrine, atropine SO4
increase PR
– 6. Dehydration – loss of blood increase the
PR.
– in adults the loss of circulating volume results
in an adjustment of the heart to increase BP
in order to compensate for the lost blood
volume
– 7. Stress - in response to stress sympathetic
nervous stimulation increases the overall
activity of the heart.
– 8. Position changes
– in sitting or standing position there is
decrease venous return to the heart,
decrease BP, therefore increase in the HR
– PULSE SITES (use the middle 3 fingertips to palpate)
– wait 10 to 15 mins until the client pulse has its usual
rate
– Baseline data about the normal HR of the client
– 1. Temporal – over the temporal bone of the head
– 2. Apical –located on the L side of the chest about 3
inches to the left sternum
– before 4 years old the apex is at the midclavicular line
– for 7 to 9 y/0 it is located at the 4th and 5th intercostal
space
– use stethoscope
– 3. Carotid – lateral aspect of the neck, below
the earlobe
– 4. brachial – inner aspect of the biceps
muscles upper of the arm
– 5. Radial – inner aspect of the wrist
– 6. Femoral- alongside of inguinal ligament
– 7. Popliteal – at the back of the knee
– 8. Posterior tibial-medial aspect of the ankle
– 9. Dorsalis pedis – dorsum of the foot
 Assessment of the Pulse
1. Rate – the normal pulse is…..60-100beats per
minute
Tachycardia – PR above 100bpm for adults
Bradycardia – PR below 60 bpm
2. Rhythm – pattern and intervals of beat
Dysrhythmia – is irregular rhythm
3. Volume – the strength of the pulse
a normal pulse can be felt with moderate pressure
full or bounding – strong pulse
– Thready pulse – weak pulse
– 4. Arterial wall elasticity – the artery feels straight,
smooth, soft and pliable- this is the characteristic
of a healthy normal artery
– 5. Presence or Absence of bilateral equality –
indicates cardiovascular.
– Example. WHen assessing the blood flow to the R
foot the nurse assess the R dorsalis pedis
– if the clients R and L pulses are the same volume
and elasticity. The PR does not need to be
counted hen assessing for perfusion
– APICAL-RADIAL PULSE
– may need top be assessed for clients with
certain cardiovascular disorders.
– normally they are identical
– an Apical pulse rate greater than a radial
pulse rate can indicate that the thrust of the
blood from the heart is too weak .
– any discrepancy between the 2 pulse rate is
called Pulse Deficit
– RESPIRATION – the act of breathing
– There are three process of Respiration:
– a. Ventilation- the movement of gases in and out
of the lung: Inhalation (Inspiration), Exhalation
(Expiration).
– b. Diffusion – the exchange of gases from an
area of higher pressure to an area of lower
pressure.
– c. Perfusion – the availability and movement of
blood for transportation of gases and nutrients and
metabolic waste
– Two types of Breathing:
– 1. Costal (thoracic) – involves movement of
the chest
– 2. Diaphragmatic (abdominal) = involves
movement of the abdomen
– RESPIRATORY CENTERS
– 1.Medulla Oblongata – is the primary
respiratory center
– 2.Pons contains the following:
– Pneumotaxic center – responsible for the
rhythmic breathing
– Apneustic center – responsible for deep,
prolonged inspiration
– 3. Carotid and aortic bodies – contain
peripheral chemoreceptors who take up the
work of breathing when central
chemoreceptors the medulla oblongata are
damaged. Respond to low concentration in
the blood. Respond to pressures. If the BP is
elevated the RR become slow.
– 4. Muscle and joints – they contain
proprioreceptors
– ASSessing Respiration:
– 1. Rate – normal is 12-20/minute in adult
– 2. Depth – observe the movement of the
chest, it ,maybe normal, shallow
– 3. Rhythm –observe for regularity of
exhalation and inhalation
– 4. Quality or Character – respiratory effort
– Factors Affecting Respiratory rate
– 1. Exercise – increase RR because
metabolism increases
– 2. Stress – readies the body for flight and
flight
– 3. Environment – increased temperature of
the environment decreases RR, decreased
altitude increases RR
– 4. Medications – narcotics decrease RR`
– Assessing Respiration
– Eupnea – normal respiration
– Tachypnea – rapid respiration above 20 beats
– Bradypnea – slow breathing less than 12/bpm
– Hyperventilation – deep rapid respiration
( carbon dioxide is excessively exhaled)
– Hypoventilation – slow shallow respiration
(carbon dioxide is retained)
– Dyspnea – difficult and labored breathing
– Orthopnea – ability to breath only in upright
position
– Apnea – absence of breathing
– Cheyne stokes breathing – rhythmic waxing
and waning of respiration from very deep to
very shallow breathing and temporary apnea.
– Different Breath Sounds:
– Stridor – a shrill, harsh sound heard during
inspiration with laryngeal obstruction
– Stertor – snoring respiration due to partial
obstruction of the upper airway
– Wheeze – high pitch musical sound
– Bubbling – gurgling sounds heard as air
passes through moist secretions
 – Secretions and Coughing
– Hemoptysis – presence or coughing out of
blood
– productive cough – cough accompanied by
expectorated secretions
– Nonproductive – a dry, harsh cough without
secretion.
– the amount of hemoglobin in arterial blood
that is saturated with oxygen can be
measured indirectly through the pulse
oximeter.
– Pulse oximeter – provides a digital readout of
both the clients PR and oxygen saturation
– assess the skin and mucous membrane for
cyanosis or pallor
– Signs of lack of O2 to the brain – irritability,
restlessness, drowsiness or loss of
consciousness
– you will need a watch with a second hand
– observe the depth, rhythm and character
– Sample of documentation
– 2/2/20 Respiration irregular, from 18-34/ min
in past hour.
– shallow respiration. Wheezing noted on
inspiration
– Blood Pressure – is the measure of the
pressure exerted by the blood as it pulsates
through the arteries
– Systolic –is the pressure of blood as a result
of contraction of the ventricles (100-
140mmHg)
– Diastolic – is the pressure when the
ventricles are at rest ( 60-90 mmHg)
– Pulse pressure – is the difference between
systolic and diastolic pressures
– Normal is 30-40 mmHg
– BP is measured in mmHg and recorded as
fraction systolic over diastolic
– Hypertension- is abnormally high blood
pressure over 140 mmHg systolic and or
above 90 mmHg diastolic for at least two
consecutive readings
– a consistently elevated Bp occur in
atherosclerotic patient
– Hypotension – is an abnormally low blood
pressure; systolic pressure below 100/60
mmHg
 – Determinants of BP
– Pumping action of the heart- when the
pumping action of the heart is weak less blood
is pumped into arteries and BP decrease.
– Peripheral vascular resistance -
vasoconstriction elevates BP, vasodilation
lowers BP
– Blood Volume – when blood volume
decreases (like dehydration) BP decreases
because of decrease fluid in the arteries
– Blood Viscosity – when the blood is viscous
(thick) when the proportion of RBC to the
blood plasma is high
– hematocrit is more than 60-65%
– increased blood viscosity raises the BP
 – factors affecting BP
– age – older people have higher BP due to
decreased elasticity of blood vessels
– pressure rises with age
– Exercise – physical activity increases the
cardiac output. Wait for 20 to 30 minutes before
you take the BP. (topic 1-A)
– Stress
– Race – African American older 35 y/o tend to
have higher BP
– Sex – after puberty females usually have lower
BP than males of the same age due to
hormonal variations
– Medications – Many medications including
caffeine may increase or decrease BP
– Obesity – predispose to hypertension
– Diurnal variation – pressure is usually lowest
early in the morning hen the metabolic rate is
lowest then rises throughout the day and peaks
in the late afternoon or early evening
– Medical condition – any condition affecting
the cardiac output, blood volume, blood
viscosity has direct effect on the BP.
– Temperature – because of increased
metabolic rate it can increase BP
– Hypertension- a persistently above normal
– a single elevated BP needs for
reassessment.
– it is usually asymptomatic and often
contributing factor to MI (heart attack)
– an elevated BP of unknown origin is called
Primary Hypertension
– an elevated of known cause is called
Secondary Hpn.
– hypertension is a worldwide problem
– everybody with diastolic of 80 -90 mmHg and
systolic of 120-139 is considered Pre-
hypertension and without intervention might
develop to cardiac disease
– Factors associated with hypertension:
– lifestyle factors like: cigarette smoking,
obesity, alcohol consumption, lack of physical
exercise, high blood cholesterol and
continued exposure to stress
– thickening of the arterial walls which reduces
the size of the arterial lumen
– inelasticity of the lumen
– the national guidelines for high blood
pressure management recommend that
hypertensive individuals age 60 or older
receive a treatment toward a goal of less than
150/90
– age 30 to 59 diastolic goal of less than 90
mmHg
– over all goal is less than 140/90 mmHg
– HYPOTENsion – is a blood pressure that is
below normal, that a systolic reading
consistently between 85 and 110 mmHg.
– Orthostatic hypotension – is a BP that
decreases when the client sits or stands
– it is usually the result of peripheral vasodilation
– in which blood leaves the central body organs
especially the brain, and moves to the periphery,
often causing the person to feel faint.
– Hypotension can also be caused by
analgesics such as meperidine hydrochloride,
severe burns, bleeding, dehydration
– How to assess patient for Orthostatic
hypotension
– place the client in a supine position for 10
minutes
– record the clients to slowly sit or stand
– immediately recheck the BP in the same site
as previously
– repeat the pulse and BP after 3 minutes
– record the results
– Assessing BP
– Bp is measured with BP cuff, a
sphygmomanometer, stethoscope
– 2 types of sphygmomanometer: aneroid,
digital
– BP cuff must be the correct size width , length
for the clients arm
– the width should be 40% of the circumference
– the arm circumference should be used to
determine the bladder size.
– the length of the bladder should be
sufficiently long to cover at least 2/3 of the
limbs circumference
– Two types of Sphygmomanometer:
– a. Aneroid – has a calibrated dial with a
needle that point to the calibration.
– b. Digital
– Doppler ultrasound stethoscope – are also
used to assess blood pressure
– these are particular value when blood
pressure sounds are difficult to hear such as
infants, obese
– BP Assessment Sites:
– it is usually assessed in the client’s upper arm using
the brachial artery
– if the bladder is too narrow Bp is elevated, too wide
BP is low
– assessing patients BP on the thigh is done when:
– the should arm or hand is injured or diseased
– a cast or bulky bandage
– the client has surgical removal breast axillary
– client has an IV
– client has a fistula
– BP can be assessed directly (invasive
monitoring)- measurement involves the
insertion of a catheter into the brachial, radial
or femoral artery
–
– Two non invasive method
– 1. Palpatory – is used when the korotkoffs sounds
cannot be heard
– palpatory is used to prevent misdirection from the
presence of an auscultatory gap.
– Auscultatory Gap – occurs in hypertensive patients
– it is the temporary disappearance of sounds
normally heard over the brachial artery

– 2. Auscultory – most commonly used

– the pressure is read when the first pulsation
identifies the point at which the pressure in
the cuff nears the diastolic pressure
– Common Errors in Assessing BP
– bladder cuff too narrow, too wide
– arm unsupported
– insufficient rest before the assessment
– repeating the assessment too quickly
– cuff rapped too loosely or unevenly
– deflating cuff too quickly and slowly
– failure to use the same arm consistently
– Arm above the level of the heart
– assessing immediately after a meal
– failure to identify auscultatory gap
– The arm of the patient should be at the heart
level
– Apply the center of the bladder directly over the
artery. The bladder must be over the artery to
be compressed
– place the lower border of the cuff 1 inch above
the antecubital space
– if this is the clients initial examination perform
a palpatory of the systolic pressure( to prevent
underestimation of the systolic pressure)
– wait 1 to 2 minutes before measuring again
(gives the trapped blood in the veins time to be
released)
– note the pressure on the sphygmomanometer
at which pulse is no longer palpable
– Place the stethoscope directly on the skin
– Pump up the cuff until the sphygmomanometer
reads 30 mmHg above the point where the
brachial pulse disappeared
– Obtaining BP by palpation method
– palpate the radial and brachial pulse site as
the cuff pressure is released.
– the manometer reading at the point where
the pulse reappears is an estimate of systolic
value.
– Rationale of palpatory (prevents
underestimation of the systolic pressure or
overestimation of the diastolic pressure)
– Taking thigh BP
– prone position, if not supine with knees slightly
flexed
– locate the popliteal pulse
– the systolic pressure in the popliteal artery is
usually 20 to 30 mmHg higher than the brachial
artery
 – OXYGEN SATURATION
– Pulse oximeter – is a non invasive device
that estimates a clients arterial blood oxygen
saturation (SaO2) by means of a sensor
attached to the clients finger, toe, nose,
earlobe or forehead.
– it can detect hypoxemia (low O2 saturation)
before clinical sign and symptoms such as
dusky color to skin and nail beds develop
– Normal oxygen saturation is 95 to 100%
– below 70% is life threatening
– Factors Affecting Oxygen Saturation
Readings
– Hemoglobin – if the hemoglobin is fully
saturated with O2 the SPO2 will appear normal
even if the total hemoglobin is low
– Circulation – if there is impairment in the
circulation the oximeter will not give you an
accurate reading
– immobilize the clients monitoring site ( it
might be misinterpreted by oximeter as
arterial pulsation
– Clean the site with an alcohol wipe before
applying the sensor
Exercises:
1. An elevation of the body temperature above
normal is labeled __________
2. Insertion of rectal thermometer may cause
harmful condition This condition may
__________.
3. What should a student do when she found
out that the pulse rate is 140 bpm?____
4. Apical pulse is assessed by using_______
5. The normal RR in adult is ______________