Vital Signs = Temperature, Pulse, Respirations, & Blood Pressure

Temperature = Warmth of the body, a balance between heat produced & lost.

The Hypothalamus = the thermostat that regulates body temperature.

Factors that influence body temp:

Food intake =
Age = newborns have temp fluctuations due to high metabolic rates
Older adults have problems with heat retention & heat loss
Gender =
Exercise = ↑ the need for energy, thus ↑ body temp
Time of Day =
Emotions =
Illness = may lead to increase or decrease temp
Medications =

Sites Used to Assess Body Temp

I. Oral Site =
Wait 30 min. if pt just
if pt is
if pt just smoked a cigarette
Advantages to Oral Site
 Convenient
Disadvantages to using the oral site (contraindicated in these pts)
Unconscious pts

Seizure disorder pts

Open-mouth breathers
II. Rectal Site = taken in pt’s rectum
~~1º higher than oral ~~ 99.6 ®
Advantages of rectal site

Pt may be too sick to hold oral thermometer in his mouth.

Disadvantages of rectal site
Could be embarrassing for the pt.

Could stimulate the

III. Axillary Site = Placed under the armpit ~~1º lower than oral ~~ 97.6
(ax)
Advantages of axillary
Convenient
Less alarming to children
Disadvantages of axillary
Requires
Poor circulation in the pt →
IV. Tympanic Site = the thermometer is placed in the ear
Advantage of tympanic
Fastest Site …..
Disadvantage of tympanic
↑ Chance for incorrect reading

Types of Thermometers
1. Glass Thermometer
Calibrated in degrees & tenths of degrees
Temp is recorded in tenths (example 97.8)
Type of glass thermometers
1. slender bulb
2. blunt bulb
3. pear shape

 For Oral temps:

1. Place under tongue for
2. If ↑ 98.6,

 For Rectal Temps:

1. Adult =
2. Child =
3. Infant

 For Axillary Temp

 1. Hold under armpit for

2. Electronic Thermometer

 For Oral or Axillary Temp =

 For Rectal Temps =

1.
2. Place thermometer….
3. Tympanic Thermometer

 Apply probe cover.

 pull ear to straighten ear canal


1. adults =
2. children =

 Temp
4. Chemical Thermometers

 Chemical Dot Thermometers

 Heat –sensitive tape

5. Monitoring Devices

Febrile (Pyrexia) = a person with elevated temp > 99.3 F orally.

What are some Signs & Symptoms of fever?
1. Flushed skin…warm-to-touch
2. Glassy-eyed…irritable
3. ↑ pulse; ↑respirations
4. Look at Nursing Interventions (pg. 148)
Hypothermia = core body temp < 95º

The Pulse = wavelike sensations felt by fingertips as blood passes thru a

peripheral artery each time the heart contracts.

Pulse Rate:

Normal Average Adult Pulse Rate =

Tachycardia = Abnormally rapid pulse =

Palpitations = Pt is aware of his own fast HR
Bradycardia =

Factors Influencing Pulse Rates

1. Age = newborns have higher pulse rates.
2. Time of Day = HR is usually lower in the morning
 3. Gender = females
4. Body Build =

5. Body Temp =If body temp↑→

6. Exercise = HR ↑ with exercise; Resting HR ↓ with regular aerobic exercise.

7. Excessive Blood Loss →

8. Meds

Pulse Rhythm =
Irregular Pulse rhythm is known as Arrhythmia or Dysrhythmia.
--------

Pulse Volume = the “Quality” of the pulsations (See: Table 11 – 6)

Thready
Weak
Normal
Bounding

Always describe pulse in Rate – Rhythm – Quality

Pulse Sites
Peripheral Pulses = Located Away From the Heart
Apical Pulse = Heard over the apex of heart

 Always listen & count

  Take apical pulse when peripheral pulses are irregular &
hard to palpate…

Apical – Radial Rate

 Rates are counted by 2 separate nurses using the same watch @

the same time

 This is done to check for

Respiration = the exchange of O2 and CO2 between air, lungs, blood vessels,
and body cells.
Ventilation = Act of breathing

 Inspiration (Inhalation) = breathing in

 Expiration (Exhalation) = breathing out

Ventilation is controlled by the Medulla = the respiratory center in the brain.

Factors that influence pulse rates → respiratory rates.

To count Resp. Rate: Count each Inhalation & Exhalation as one respiration.
-----------(Count for 30 seconds and multiply by 2)

Average Normal Adult Respiratory Rates:

Male:
Female:
Eupnea = Even depth, regular rate (this is term for normal breathing)
**Abnormal Breathing Patterns:
1. Tachypnea =
2. Hyperpnea (Hyperventilation) = fast & very deep breathing
3. Bradypnea =
4. Cheyne-Stokes = gradual ↑in depth, then↓ in depth, then → No
breathing for a while.
5. Apnea =
6. Hypoventilation = Diminished breathing due to obstruction
7. Dyspnea =
8. Orthopnea = Breathing eased by sitting up
9. Stertorous Breathing = Noisy Ventilations
10. Stridor = Harsh, high-pitched sound

Blood Pressure = the force of blood within arterial walls.

Blood Pressure tells us about:
1.
2.
3. The amount of resistance the heart must overcome when it pumps
…how good the heart is working as a pump
Factors that influence Blood pressure:
1. Age = BP ↑’s with age….due to
2. Time of Day = BP is lowest from 12mn -- 5am
& highest from late morning to early afternoon
3. Women =
4. BP ↑ during exercise …regular aerobic exercise → normal BP
5. Emotions →
6. Miscellaneous items:

 Increase BP with a full bladder

 Meds =

BP is expressed as a fraction: Systolic

Diastolic

Normal BP: < 140 example: 120

90 80

(***Remember, a rise or fall of 20 – 30 mmHg pressure from the person’s

usual pressure is significant.)

Pulse Pressure: The difference between the systolic & diastolic pressure.

Sites used to get the BP:

1. The Brachial Artery * most common site
2. The popliteal Artery
 3. May use the Lower Arm using the Radial Artery

Equipment Used for BP

1. Sphygmomanometer…BP Cuff
2. Stethoscope...carries sound to the nurse’s ears.

Taking BP:

 The cuff is applied to the pt’s arm and inflated briefly to occlude
the artery.

 As the valve on the BP Cuff is released, listen for a series of

sounds thru your stethoscope known as
1. Systolic Pressure = the 1st sound of clear repetitive tapping as the
cuff is deflated.
2. Phase II ---
3. Phase III---Loud, crisp knocking sound
4. Phase IV---Muffled sound (this is diastolic for children.)
5. Diastolic Pressure =
Abnormal BP Measurements:
1. Hypertension = elevated BP
2. Hypotension = Low BP
3. Postural Hypotension or Orthostatic Hypotension = BP ↓


 

Common Causes of BP Errors (see Table 11-9)