Vital Signs

Argie Trinidad,RN
• Temperature
• Pulse
• Respirations
• Blood Pressure
• Pain Assessment (Fifth Vital Sign)
 Temperature

• the balance between the

amount of heat produced
by and heat lost from the
body (thermoregulation)
 types of body temperature
a. core body temperature (CBT)

i. temperature of the deep tissues of the body

ii. fluctuates very little in healthy adults

b. surface temperature (ST)

i. temperature of the surface of the body

ii. fluctuates widely in healthy adults

influencing body temperature
factors

a. developmental state g. genetic

b. diurnal variations h. circulatory impairment
(circadian rhythms) i. integumentary impairment
c. hormones j. infection
d. stress k. exercise
e. environment l. altered cognitive states
f. nervous system m. altered nutrition
impairment
body temperature regulation

• methods of heat • methods of heat loss

production by the from the body
body
 physiologic
 physiologic mechanisms
mechanisms  behavioral
 voluntary mechanisms mechanisms
normal temperature ranges at various ages

• a. infant • c. adult
36.1 - 37.7° C (97 - 100° F) 37 - 37.6° C (98.6 - 99.6° F)

• b. child • d. older adult

37 - 37.6° C (98.6 - 99.6° F) 36 - 36.9° C (96.9 - 98.3° F)
abnormal body temperature

increased body temperature

the state in which an individual's CBT is

elevated above his/her normal range
severity of fever
• a. low-grade fever
 a fever between 37.1° C to 38.2° C (98.8° F to 100.6° F)

• b. high-grade fever
 a fever between 38.3° C to 40.4° C (100.9° F to 104.7° F)

• c. hyperpyrexia
 a fever over 41° C (105.8° F)
types of fever

• constant fever
• intermittent fever
• remittent fever
• relapsing fever
phases of fever

a. onset (cold or chill) phase

b. course (fever) phase
c. defervescence (flush or crisis) phase
abnormal body temperature

decreased body temperature

(hypothermia)

the state in which an individual's body

temperature is reduced below normal range
types of hypothermia

a. induced hypothermia

b. accidental hypothermia
clinical signs of hypothermia
• reduction of body temperature below normal
range
• increased respirations, poor judgment, shivering
• bradycardia or tachycardia, myocardial
irritability/dysrhythmias, muscle rigidity,
shivering, lethargy/confusion, decreased
coordination
• hypoventilation, generalized rigidity, coma
• no apparent vital signs, heart rate unresponsive
to drug therapy, cyanosis, dilated pupils,
areflexia, no shivering, appearance of death
common interventions for hypothermia

• a. remove the patient from the cold

• b. apply blankets
• c. hyperthermia blankets
• d. warmed intravenous solutions
• e. remove wet clothing and keep dry
• f. keep environment warm
• g. apply layers of clothing to trap air between
them to act as insulation
• h. warm gradually to prevent vasodilation which
can lead to shock
types of thermometers

• mercury-in-glass

a. oral, approximately 3 - 5 minutes

b. rectal, approximately 2 - 3 minutes
c. axillary, approximately 10 minutes
types of thermometers

• digital electronic

• tympanic membrane
 Pulse

• perceptible throbbing sensation (pulsation)

felt over a peripheral artery as a wave of
blood is created by contraction of the left
ventricle of the heart or auscultated over
the apex of the heart with a stethoscope
factors influencing the pulse

• a. developmental • d. fever
state • e. medications
• developmental state • f. hemorrhage
• b. gender • g. stress
• c. exercise • h. position changes
pulse regulation

• regulated by the autonomic nervous system

through the sinoatrial node (pacemaker)

 parasympathetic nervous system stimulation

decreases the heart rate
 sympathetic nervous system stimulation increases
the heart rate
pulse rate

 the number of perceptible throbbing

sensations (pulsations) felt over a
peripheral artery as a wave of blood is
created by contraction of the left ventricle
of the heart, or auscultated over the apex
of the heart, in one minute
 expressed in beats per minute (bpm)
normal pulse rates per minute at various ages

• i. newborn to 1 month • iv. 2 to 6 years

 approximate range =  approximate range =
120 - 160 bpm 75 - 120 bpm
• ii. 1 to 12 months • v. 6 to 12 years
 approximate range =  approximate range =
80 - 140 bpm 75 - 110 bpm
• iii. 12 months to 2 yrs • vi. adolescence to
 approximate range = adult
80 - 130 bpm  approximate range =
60 - 100 bpm
abnormal pulse rates per minute

 Tachycardia

 Bradycardia
Character of pulse

• Rate
• Rhythm
• Strength
methods of assessing the pulse

• Peripheral
Palpation
Compressing a peripheral artery against an
underlying bone with the tips of the fingers
Do not use the thumb, which has its own pulse
peripheral pulse sites

• i. temporal • v. femoral
• ii. carotid • vi. popliteal
• iii. brachial • vii. posterior tibial
• iv. radial • viii. dorsalis pedis
methods of assessing the pulse

 Doppler ultrasound
assessing the pulse by auscultating a
peripheral pulse using a device (doppler
ultrasound) that detects the movement of
blood flow through blood vessels and converts
the velocity of the blood flow into sounds
methods of assessing the pulse

• Apical
Auscultation
assessing the pulse by auscultating the apical
pulse located in the 5th intercostal space in the left
mid-clavicular line (LMCL) in adults using a device
(stethoscope) consisting of two earpieces
connected by means of flexible tubing to a
diaphragm that amplifies sounds
Doppler ultrasound

 Doppler ultrasound
 electrocardiogram (EKG or ECG)
assessing the apical pulse by recording the
electrical activity of the myocardium by using a
device (EKG) to detect transmission of the
cardiac impulse through conductive tissue of
the muscle
 Respiration

 the mechanism the body uses to exchange

gases between the atmosphere and the
cells
 a. pulmonary ventilation
a. inspiration (inhalation)
b. expiration (exhalation)
 b. external respiration
 c. internal respiration
factors influencing respiration

• a. developmental state
• b. exercise
• c. stress
• d. increased altitude
• e. medications
• f. increased intracranial pressure
respiratory rate

• a. the number of full inspirations

(inhalations) and expirations (exhalations)
observed or palpated in one minute
• b. expressed as breaths per minute (bpm)
• c. should be measured when the patient is
at rest and unaware that the measurement
is being taken
normal respiratory rates ranges per age

• i. newborn • iv. child

 a. approximate range =  a. approximate range =
35 - 40 bpm 20 - 30 bpm
• ii. infant (6 months) • v. adolescent
 a. approximate range =  a. approximate range =
30 - 50 bpm 16 - 19 bpm
• iii. toddler ( 2 years) • vi. adult
 a. approximate range =  a. approximate range =
25 - 32 bpm 16 - 20 bpm
abnormal respiratory rates per minute

• i. tachypnea
• ii. bradypnea
• iii. apnea
respiratory volume

• the volume of air exchanged with each full

inspiration (inhalation) and expiration
(exhalation) (usually 500 mLs)
normal respiratory volume

• consists of a normal respiratory rate and a

moderate amount of chest wall movement
and volume of air inspired or expired
during each full inspiration (inhalation) and
expiration (exhalation)
abnormal respiratory volume
• i. hypoventilation
 a. consists of a decreased
respiratory rate and an
decreased amount of chest wall
movement and volume of air
inspired or expired during each
 full inspiration (inhalation) and
expiration (exhalation)
• ii. hyperventilation
 a. consists of an increased
respiratory rate and an increased
amount of chest wall movement
and volume of air inspired and
expired during each
 full inspiration (inhalation) and
expiration (exhalation)
respiratory rhythm

• the pattern of, and intervals between, each

full inspiration (inhalation) and expiration
(exhalation)
normal respiratory rhythm

• has a regular pattern of, and intervals

between, each full inspiration (inhalation)
and expiration (exhalation)
abnormal respiratory rhythm

• have an irregular pattern of, and intervals

between, each full inspiration (inhalation)
and expiration (exhalation), e.g.:
a. Cheyne-Stokes breathing
b. Biot's respirations
respiratory ease or effort

• the amount of effort a patient must exert

during each full inspiration (inhalation) and
expiration (exhalation)
normal respiratory ease or effort

• the patient does not exert a noticeable

amount of effort during each full inspiration
(inhalation) and expiration (exhalation)
abnormal respiratory ease or effort

• the patient does exert a noticeable effort

during each full inspiration (inhalation) and
expiration (exhalation), e.g.:
a. dyspnea
b. orthopnea
methods of assessing respirations

• a. inspection of chest wall movement

• b. palpation of chest wall movement
• c. apnea monitor
• d. auscultation
 Blood pressure

• force of the blood against the arterial walls

• a. systolic pressure
• b. diastolic pressure
• c. pulse pressure
factors influencing blood pressure

• a. developmental • f. race
state • g. exercise
• b. gender • h. body position
• c. stress • i. body weight
• d. medication • j. blood volume
• e. diurnal variation
(circadian rhythms)
blood pressure regulation

• i. peripheral resistance
• ii. pumping action of the heart (cardiac
output)
• iii. blood volume
• iv. viscosity of blood
• v. elasticity of vessel walls
normal blood pressure at various ages

• a. newborn • e. 10 - 13 years
– i. 40 (mean) – i. 110/65
• b. 1 month • f. 14 - 17 years
– i. 85/54 – i. 120/75
• c. 1 year • g. middle adult
– i. 95/65 – i. 120/80
• d. 6 years • h. older adult
– i. 105/65 – i. 140 - 60/80 -90
abnormal blood pressure

• Hypertension
blood pressure elevated above normal for a
sustained period
types of hypertension

• i. primary or essential
• ii. secondary
blood pressure classifications

• i. normal
• ii. pre-hypertension
• iii. hypertension stage 1
• iv. hypertension stage 2
hypotension

• blood pressure decreased below normal

for a sustained period

• type of hypotension
– orthostatic (postural)
methods of assessing blood pressure

• directly (invasive) • indirectly (non-

– arterial line invasive)
– Auscultation
– Palpation
– doppler ultrasound
– electronic indirect
blood pressure meters
errors when assessing blood pressure

• falsely low readings

– i. hearing deficit
– ii. noise in the environment
– iii. applying too wide a cuff
– iv. inserting the eartips of the stethoscope incorrectly
– v. using cracked or kinked tubing
– vi. releasing the valve too rapidly
– vii. misplacing the bell beyond the direct area of the
artery
– viii. failing to pump the cuff 20 - 30 mm Hg above the
disappearance of the pulse
– ix. viewing the meniscus from above eye level
falsely high readings

– i. using a manometer not calibrated at the zero

mark
– ii. assessing the blood pressure immediately
after exercise
– iii. applying a cuff that is too narrow
– iv. releasing the valve too slowly
– v. reinflating the bladder during auscultation
– vi. viewing the meniscus from below eye level