Vital Signs

Vital signs
• Are measurements of the body's most basic
functions.
• Are useful in detecting or monitoring medical
problems.
• Can be measured in a medical setting, at home, at
the site of a medical emergency, or elsewhere.
• Help to assess general physical health of a
person, give clues to possible diseases, and
progress toward recovery.
• Monitoring V/S should be thoughtful, and
scientific assessment.
• Assessment of V/S are chiefly nursing judgments.
 Vital signs
 5th vital signs: PAIN (according to US Veterans administration)
 pain scale : 1 to10
 other 5th vital signs are:
• menstrual cycle
• Glasgow Coma scale
• Pulse Oximetry ( traditional vital signs)
• Blood Glucose level
 When to assess vital signs?

• Upon admission
• When client has change in health status or
reports symptoms
• Before and after an invasive procedure /
surgery
• Before and after giving medication
• Before and after any nursing intervention
Equipment needed for assessing
vital signs
 1. BODY TEMPERATURE

• Reflects the balance between the

heat produced and the heat lost
form the body.
Heat Produced – Heat Loss = Body
Tdemperature
• Measured in heat units : degrees
 Kinds of Body Temperature

 Core temperature: temperature of the

deep tissues of the body
 Surface temperature : it rises and fall
in response to the environment
 Factors that affect body’s heat
production
1.BMR ( basal metabolic rate)
 rate of energy utilization in the body
 it decreases with age: the younger the
age, the higher the BMR
2. Muscle activity
 Factors that affect body’s heat
production
3. Thyroxine output
 chemical thermogenesis: increased
thyroxine output / heat production through
cellular metabolism
4. Epinephrine, norepinephrine, and
sympathetic stimulation/ stress response.
5. Fever
 Mechanism of Heat Loss

1.Radiation : transfer of heat from the

surface of one object to the surface of
another surface without contact
between the two objects.
2.Conduction: one molecule to a
molecule of lower temperature
 Mechanism of Heat Loss

3. Convection : dispersion of heat

through air currents
4. Vaporization : moisture from the
respiratory tract, from mucosa of the
mouth or from the skin
Parts of the body that regulates
Body Temperature
1.Skin:
shivering to increase heat production
 sweating is inhibited to decrease heat loss
 vasoconstriction to decrease heat loss
2. Hypothalamus: controls core temperature
 Parts of the body that regulates
Body Temperature
Effector system: adjusts the
3.
production and loss of heat
 vasoconstriction
 shivering
 release of epinephrine
Factors affecting body
temperature
1. Age
2. Circadian rhythms/
diurnal variations
3. Exercise
4. Hormones

5. Stress
6.
Environment
Alterations in Body
Temperature
 1. PYREXIA
 aka: hyperthermia/ fever
 body temperature above normal
• febrile
• afebrile
• hyperpyrexia : very high fever ( 41◦ C or
185.8 ◦ F )
Types of Fever
Intermittent
Remittent
Relapsing
Constant
•Fever spike: a body temp
that rises rapidly
following to normal and
returns to normal within
few hours.
• Heat exhaustion: result of
excessive heat and DHN
 paleness
 dizziness/ fainting
 nausea/ vomiting
 increase temperature
• Heat stroke: experience by person
exercising in hot weather or warm
area that results to flushed skin,
high temp, they do not sweat,
having seizures or unconsciousness
 2. HYPOTHERMIA
 a core body temperature below the lower
limit of normal
 physiologic mechanisms:
 excessive heat loss
 inadequate heat production to counteract
heat loss
 impaired hypothalamic thermoregulation
 Types of
hypothermia
Induced/Therapeutic
hypothermia
Accidental hypothermia

• Occur as a result of
exposure to cold
environment, immersion in
cold water, lack of
clothing.
 Clinical manifestations of
fever/hyperthermia
1. Onset ( cold or chill phase )
 increased HR
 increased RR and depth
 shivering
 Cold skin/ Complaints of feeling cold
 cyanotic nail beds
 “ gooseflesh” appearance of the skin
 cessation of sweating
 Clinical manifestations of fever/
hyperthermia
2. Course/ plateau phase
 absence of chills
 skin warm to touch
 photosensitivity
 glassy eyed appearance
 increased PR and RR
 Clinical manifestations of
fever /hyperthermia
 increased thirst
 mild to severe DHN
 drowsiness, restlessness, delirium or convulsions
 herpetic lesions of the mouth
 loss of appetite
 malaise, weakness and aching muscles
 Clinical manifestations of
fever/hyperthermia
3. Defervescence/ fever abatement or flush phase
 skin that appears flush and feels warm
 sweating
 decreased shivering
 possible dehydration
 Nursing interventions: Fever
• Monitor v/s
• Assess skin color and temperature
• Monitor laboratory exams
• Remove excess blankets / extra warmth
• Provide adequate nutrition and fluids
• Measure I and O
 Nursing interventions: Fever

• Reduce physical activity during the flush stage

• Administer antipyretics as ordered
• Provide oral hygiene
• Provide TSB
• Provide dry clothing and linens
 Clinical manifestations :
Hypothermia
• Decreased BT, PR, RR
• Severe shivering ( initial )
• Feelings of cold and chills
• Pale, cool, waxy skin
• Frostbite ( nose. Fingers, toes )
• Hypotension
 Clinical manifestations :
Hypothermia
• Decreased urinary output
• Lack of muscle coordination
• Disorientation
• Drowsiness progressing to coma
 Nursing interventions:
Hypothermia
• Provide a warm
environment
• Provide dry clothing
• Apply warm blankets
• Keep limbs close to the
body
Nursing interventions:
Hypothermia
• Cover clients scalp
• Supply warm oral
or IVF
• Apply warming pads
 Assessing
Body
temperature
 Sites: Measuring
Body Temperature
 1. ORAL
oFood, fluids, or warm smoke can affects
mouth temperature.
o If patient has just ingested hot or cold
food, wait 30 minutes before taking a
temperature
o Undergone oral surgery to prevent injury. 
The proper placement of thermometer
bulb is on either side of the frenulum
(small fold of integument or mucous
membrane).
 2. RECTAL
 accurate but inconvenient and unpleasant
for patients.
 difficult for patient who cannot turn to the
side.
 contraindicated for patient with MI or
Myocardial Infarction ( can produce vagal
stimulation which results   myocardial
damage)
contraindicated for patients with
diarrhea,
immunosuppressed,
 with rectal disease,
have a clotting disorder,
hemorrhoids
 undergoing rectal operation. 
• Before performing this
method, use clean glove and
instruct the patient to take a
slow deep breath during
insertion. Never force the
thermometer if you felt
resistance. For adults, insert
3.5 cm or 1 1/2 inch.
 3. AXILLA

 safe and noninvasive

 appropriate for newborn.
Research says its inaccurate ( Bindler
& Ball. 2003).
• To obtain an accurate measurement
 make sure you left the thermometer
in place for a long time
 The proper placement of bulb is
in the center of the axilla. Pat the
armpit dry with tissue or ask
patient to do it if able. Moisture
can affect the reading.
 4. TYMPANIC MEMBRANE
 
 It reflects our core body temperature
which abundant of arterial blood supply.
 readily accessible and very fast because it
uses sensors that applied directly to the
tympanic membrane.
• Uncomfortable and involves risk
of injuring the membrane if probe
is inserted too far
• Disadvantages:
repeated measurements may vary
 presence of cerumen can affect
the reading
Inserting a Tympanic Thermometer:

• Adult = Pull the pinna slightly

upward and backward. Point the
probe slightly anteriorly, toward the
eardrum. Insert the probe slowly
using a circular motion until snug.
• Infant = Pull the pinna straight back and
slightly downward. Direct the probe tip
anteriorly and insert as far as enough to
seal the canal.
• Over 3 years old = Pull the pinna of the
ear back and up.
• Under 3 years old = Pull the pinna of the
ear back and down
 5. TEMPORAL ARTERY
 safe and non invasive, very fast
 useful in infants and children
 expensive and unavailable
 readings vary if client has perspiration on the
forehead
 TYPES OF
THERMOMETER
 1. MERCURY-IN-GLASS
THERMOMETERS
 hazardous because it is made of glass and
toxic chemical inside called mercury.
 eliminated in 1988 and no longer exists in
health care environment.
 three types of thermometer tips, long, short,
slender or rounded tips.
 2. CHEMICAL DISPOSAL
THERMOMETER
 method of assessing body temperature which uses a
liquid crystal dots or bars or heat-sensitive tape or
patches that is applied to the forehead.
 to read the temperature, the nurse notes the
highest reading among the dots that have changed
color.
 3. ELECTRONIC
THERMOMETER
 
 can provide a temperature reading in just 2 to 60
seconds.
 often called digital thermometer because they
display a numeric values.
 consists of a battery-operated portable electronic
unit, a probe, and a disposable probe cover .
 4. TEMPERATURE-SENSITIVE
TAPE
 
 It obtains only your body surface temperature
and does not indicate the core temperature.
 The tape is applied to the skin, forehead and
abdomen.
 Inside the tape is a liquid crystals that
change color according to temperature.
5. INFRARED THERMOMETER

 Infrared (tympanic) thermometer is

an example, which senses a body in
the form on infrared energy given
off by a heat source
 6. TEMPORAL ARTERY
THERMOMETER
 measures the arterial temperature in the
temporal artery of the forehead
 prove is placed midline in the forehead
then drawn laterally in the hairline
How to Convert Degree Celsius to Fahrenheit, or vise
versa?

C= ( degree Fahrenheit- 32 ) x
5/9
C= ( 100-32) x 5/9
C = ( 68 ) x 5/9
C = 37.8
F= ( Celsius temperature x 9/5 )
+ 32
F= ( 40 x 9/5 ) +32
F= ( 72 + 32 )
F= 104
Lifespan Considerations: Infants

• Body temperature of NB are

extremely labile, NB must be kept
warm to prevent HYPOTHERMIA
• Holds infants arm against the
chest when using the axillary site
Lifespan Considerations: Infants

• Axillary route may not be accurate

to detect fever in children ( Bindler
&Ball, 2003)
• Avoid tympanic route when child is
in active ear infections or presence
of tubes
Lifespan Considerations: Infants

• Tympanic route may be more accurate in

determining temperature in febrile infants
• Touching only the forehead or behind the
ear is needed when using a temporal artery
thermometer
• Rectal route is least desirable in infants
 Lifespan Considerations:
Children
• Tympanic or temporal sites are preferred
• Oral route maybe used in children over age 3, but
non breakable, electronic thermometers are
recommended
• Rectal route may be used: place child prone against
your lap or in side lying position with knees flexed.
Lifespan Considerations: Elders
• Elders temperatures tend to be lower than those
of the middle aged adults
• Strongly influenced both environmental and
internal temperature changes
• Elders may develop build up of ear cerumen that
may interfere with tympanic thermometer
readings
Lifespan Considerations: Elders

• Elders are prone to hemorrhoids. Inspect

anus when taking rectal temperature
• Elders temperature may not be a valid
indication of the seriousness of the
pathology of disease
PULSE
 PULSE

• is simply your cardiac performance that

can be palpated ( neck, wrist, inner
aspect of biceps etc. )
• is a wave of blood created by the
contraction of the left ventricle of the
heart
• It represents the stroke volume output
or the amount of blood that enters the
arteries with each ventricular
contraction
• Heart rate = Pulse rate
 Related terms

• Compliance : the arteries ability to

contract and expand
• Cardiac output: is the volume of blood
pumped into the arteries by the heart and
equals the result of the stroke volume (SV)
times the heart rate (HR) per minute
 • CO= SV x HR per minute
• CO= 65ml x 70 bets per minute
• CO= 4.55L per minute
 when an adult is resting, the heart
pumps about 5 liters of blood each
minute
 Related terms

• Peripheral pulse: is a pulse located away

from the heart
• Apical pulse: central pulse, referred to as
the point of maximal impulse ( PMI)
 The pulse rate can be measured by
listening directly to the heartbeat
using a stethoscope or through
palpation
 NORMAL PULSE RATE
AGE AVERAGE RANGES
Newborns 130 80 to 180
1 year 120 80 to 140
5 to 8 years 100 75 to 120
10 years 70 50 to 90
Teen 75 50 to 90
Adult 80 60 to 100
Older adults
(more than 70
years) 70 60 to 100
Factors Affecting Pulse

Gende Exerci
Age
r se
 Factors Affecting Pulse

Medicati Hypovole
Fever ons mia
 Factors Affecting Pulse

Positio
n Patholo
Stress
Change gy
s
Pulse Reasons for use
site
Radial Readily accessible
Temporal Used when radial pulse is not accessible
Carotid Used during cardiac arrest/ shock in adults; determine
circulation in the brain
Apical Routinely used for infants/ children up 3 years old; used to
determine discrepancies with radial pulse; used in
conjunction with some medications
Brachial Used to measure blood pressure; cardiac arrest in
infants
Femoral Used in cases of cardiac arrest/ shock; determine circulation
of the leg
Popliteal Determine circulation in the lower leg
Posterior Determine circulation to the foot
 Palpation

Assessi
Moderate ng the
pressure Auscultation
pulse

DUS
 Nursing responsibilities:
assessing the PR
• Any medication that could affect the heart rate
• Whether the client has been physically active.
• Any baseline data about the normal heart rate
for the client.
• Whether client should assume a particular
position .
 Related terms:

• Tachycardia
• Bradycardia
• Pulse rhythm : pattern of the beats
and intervals between the beats.
• Dysrhythmia/ arrhythmia :
irregular rhythm
• Pulse volume/ pulse strength /
amplitude: force of the blood with
each beat
• Bounding pulse : forceful full blood
volume
• Weak/thready / feeble pulse :
• Elasticity of the arterial wall:
expansibility or its deformities
 Lifespan Considerations: Pulse

• INFANTS:
 use apical pulse for the heart rate in
newborns, infants, and children
 place baby in supine or offer pacifier if
baby is crying or restless
locate apical pulse : 4th intercostal
space lateral to the midclavicular line
 NB infants may have heart murmurs
that are not pathological ( incomplete
closure of ductus arteriosus )
 Lifespan Considerations: Pulse
• CHILDREN:
 position child in adult’s arm or have adult
remain close by
 demonstrate procedure to the child using
stuffed animal or doll and allow child to
handle the stethoscope
 assist the young child to supine or sitting
position
 Lifespan Considerations: Pulse
• ELDERS:
radial pulse may be difficult to count ( presence of
tremors)
obtaining apical pulse will be more accurate ( cardiac
changes)
 pedal pulse should be checked for regularity,
volume and symmetry
 SCALE TO RATE PULSE
QUALITY

• 0= No pulse detected
• 1+= Thready, weak pulse; easily obliterated
with pressure; pulse may come and go
• 2+= Pulse difficult to palpate; may be
obliterated with pressure
• 3+= Normal pulse
• 4+= Bounding, hyperactive
pulse; easily palpated and
cannot be obliterated
Clinical
Alert

•Never press both carotids

at the same time because
this can cause a reflex
drop in blood pressure or
pulse rate
Assessing the
Respirations
 Respirations

•Is the act of breathing

• Varies with age
 Respirations

• Normal : for an adult is 12–20

breaths/minute
• Is a clear indicator of acidotic states, as the
main function of respiration is removal of
CO2 leaving bicarbonate base in circulation
 Respirations
• Normal breathing is automatic and
involuntary.
• Normal tidal volume (the amount
of air moving in and out with each
breath) is 500 mL or 6 to 8 L/min.
 Related terms

Inhalation/inspiration
 refers to the intake of air into the lungs
Exhalation / expiration
 refers to the breathing out or the movement
of gases from the lungs to the atmosphere .
 Related terms

• Respiratory rhythm: regularity of

inspirations and expirations ( regular
or irregular )

• Ventilation: refer to the movement of

air in and out of the lungs
 Types of breathing

• Costal/ thoracic
 involves the external intercostal muscles
and other accessory muscles
( sternocleidomastoid muscles)
 movement of the chest upward and
outward
• Diaphragmatic / abdominal muscles
 involves contraction and relaxation of
the diaphragm
 movement of the abdomen
( diaphragm contract )
Mechanism of breathing

Inhalatio Exhalatio
n n
Diaphragm contracts
(flattens) relaxes
Upward/outward movement
Downward/ inward
of ribs

Sternum moves outward Inward

Decrease thorax
Enlarging thorax
size

Lungs expand
Lungs
compressed
 Exercise
Factors Age
that
Altitude
affect
respiratio
n Medicatio
Gender
ns
 Assessing respirations
 the clients normal breathing pattern
 the influence of the clients health problems
on respirations
 any medications or therapies that might
affect respirations
 the relationship of the clients respirations to
cardiovascular functions
 Altered
breathing
patterns and
sound
 Breathing patterns: Rate

• Tachypnea/ Polypnea: Persistent respiratory

rate above 20 beats per minute
 Bradypnea: Respiratory rate below 12 beats
per minute
 Apnea
 Eupnea
 Breathing patterns: Volume

 Hyperventilation: over expansion of

the lungs characterized by rapid and
deep breaths
 Hypoventilation : under expansion of
the lungs characterized by shallow
respirations
 Breathing patterns: Rhythm/Effort
Cheyne- stokes breathing: rhythmic
waxing and waning of respirations
Kassmaul : Increased rate (above 20 beats
per minute) and depth of respirations:
Biot : period of apnea and hyperpnea
 Dyspnea
 Orthopnea
 BREATH SOUNDS

• AUDIBLE WITHOUT AMPLIFICATION

 Stridor: a shrill harsh sound heard during
inspiration with laryngeal obstruction
 stertor: snoring or sonorous respiration
due to partial obstruction of the upper way
 BREATH SOUNDS

 wheeze: continuous, high pitched musical

squeak or whistling sound occurring on
expiration and sometimes on inspiration
when air moves into a narrowed airway/
obstructed airway
 Bubbling: gurgling sounds heard as air
passes through moist secretions in the
respiratory tract.
 BREATH SOUNDS
• CHEST MOVEMENTS
 intercostal retraction: indrawing between the ribs
 substernal retraction: indrawing beneath the
breastbone
 suprasternal retraction: indrawing above the
clavicles
BREATH SOUNDS: secretions and
coughing

 hemoptysis
 productive
cough
 nonproductive
cough
Assessing
blood
pressure
/arterial
blood
pressure
 Blood pressure
 is the force that blood exerts against the walls
of the blood vessels.
 blood moves in two waves ( systolic and
diastolic pressure )
 measured in millimeters of mercury ( mmHg )
 recorded as a fraction
 vary from individual to individual
 Related terms
• Systolic pressure : pressure of the blood as a result
of contraction of the ventricles ( height of blood
wave)
• Diastolic pressure: pressure when ventricles are at
rest, present at all times within arteries.
• Pulse pressure: difference between SP- DP
( normal : 40 and as high as 100)
Determinants of blood
pressure
1. Pumping action of the heart
2. Peripheral vascular resistance
3. Blood volume and viscosity
1. Pumping action of the heart
2. Peripheral Vascular
Resistance
3. Blood Volume and Viscosity
Factors that affect
Blood pressure

1. Age
2. Exercise
3. Stress
4. Race
5. Gender
6. Medications
Factors that affect
Blood pressure

7. Obesity
8. Posture
9. Diurnal Variations/ circadian
rhythm
10. Disease process/illness
11. Tobacco use
 HYPERTENSIO
N
• Primary/essential/idiopathic HTN: elevated
BP of unknown cause
• Secondary HTN: elevated BP with known
cause
• White-coat HTN: clients BP level at
physician’s office (95th percentile) and
normotensive outside.
•Causes:
 thickening of arterial wall
 lifestyle
 inelasticity of the arteries
 Hypotension

• Blood pressure below normal

• Caused by analgesics, severe burns,
and dehydration
• Orthostatic hypotension: fall of BP
when client is sitting or standing
 Blood pressure sites

• Clients upper arm

• Thigh
• Not suitable site: arm is injured, diseased,
presence of cast, surgical removal of body
part, IVF in the limb, has arteriovenous
fistula due to dialysis
 Assessing BP

• Aneroid sphygmomanometer
• DUS
• Digital sphygmomanometer
 Preparation : assessing the
Blood Pressure
• Patient must be in a resting state
• Proper cuff size
• Proper positioning : measure blood
pressure in the arm at heart level
 Preparation : assessing the
Blood Pressure
• Proper inflation and deflation rate
• Auscultation
 Korotkoff’s sound: 1st – systolic; last sound-
diastolic adult; 2nd to the last for children
 Auscultatory gap: (30mmHg) is the absence of
Korotkoff sounds between phases I and II.
• Palpation
 Physiologic Factors that affect
Blood pressure
• Blood flow
 cardiac output 5.5l/minute
• Resistance
 Friction among the cells and other blood components
and between the blood and the vessel walls
 reflects blood viscosity
 Lifespan Consideration
• Infants:
 use pediatric stethoscope with a small diaphragm
 use palpation if auscultation with stethoscope or
DUS is unsuccessful
 arm and thigh pressures are equivalent in
children under 1 year of age
•Normal systolic BP=
80 + ( 2 x child’s age
in years)
Lifespan consideration: Children
• BP should be measured in all children above 3 years old
• Explain each step by using a doll
• Use palpation technique
• Cuff bladder: width 40%; length 80% - 100% of the arm
circumference
• The diastolic pressure is on phase 4
• Thigh pressure is 10mmHg higher than the arm
 Lifespan consideration: elders
• Do not allow cuff pressure to remain high
• Determine if client is taking antihypertensive
• Measuring BP while client is sitting, lying,
standing and report changes
• In presence of arm contractures, assess BP by
palpation with the arm in relaxed position