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ASSESSING VITAL SIGNS

Vital Signs or Cardinal Signs are:


Body temperature
Pulse
Respiration
Blood pressure

Vital signs are fundamental in establishing baseline values of the clients


cardiorespiratory integrity.
Baseline values establish the norm against which subsequent measurements can
be compared. Variations from normal findings may indicate potential problems with
the clients health status.
We should confirm normal measurements with clients because the perception of
what is normal may vary among clients.
Vital signs are taken whenever the client is admitted to a health care facility or
service, for example, home health care, clinic, or other ambulatory setting, and on a
routine basis in the hospital.
The frequency of vital sign measurements for the hospitalized client is determined
by the clients health status, physician orders, and the established standards of care
for the particular clinical setting or service. Whenever a change is suspected in the
clients status, we should measure the vital signs, regardless of the setting.
I. Body Temperature
The balance between the heat produced by the body and the heat loss
from the body.
Body heat is primarily produced by metabolism.
The heat regulating center is found in the hypothalamus.
Types of Body Temperature
Core temperature
Surface body temperature
Factors affecting the bodys heat production
1. Basal metabolic rate the younger the person, the higher the BMR. The
older the person, the lower the BMR.
2. Muscle Activity increases cellular metabolic rate.
3. Thyroxine Output increases cellular metabolic rate.
4. Epinephrine, Nor-epinephrine and sympathetic stimulation increases
the rate of cellular metabolism.
5. Increased temperature of body cells (fever) increases the rate of
cellular metabolism. Fever further causes fever.
Processes involved in heat loss are as follows:
1. Radiation the transfer of heat from the surface of one object to the surface
of another without contact between two objects.
2. Conduction the transfer of heat from one surface to another. It requires
two temperature differences from one another.
3. Convection the dissipation of heat by air currents.
4. Evaporation the continuous vaporization of moisture from the skin, oral
mucous, respiratory tract.
Alteration in body Temperature
Pyrexia Body temperature above normal range( hyperthermia)
Hyperpyrexia Very high fever, 41C(105.8 F) and above
Hypothermia Subnormal temperature.

Factors affecting temperature are as follows:


1. Age the infants body temperature is greatly affected by the temperature
of the environment. Elderly people are at risk of hypothermia due to
decreased thermoregulatory controls, decreased subcutaneous fat,
inadequate diet, and sedentary activity.
2. Diurnal variations highest temperature is usually reached between 8:00
PM to 12 MN
3. Exercise
4. Hormones progesterone, thyroxine, norepinephrine and epinephrine
increases body temperature, estrogen decreases body temperature.
5. Stress SNS stimulation increases production of epinephrine and
norepinephrine, thereby increasing the BMR and heat production.
NORMAL ADULT TEMPERATURE RANGES
ROUTE
C
F
Oral
36.5 37.5 C
97.6 99.6 F
Axillary
35.8 37.0 C
96.6 98.6 F
Rectal
37.0 38.1 C
98.6 100.6 F
Tympanic
36.8 37.9C
98.2 100.2 F
TYPES OF FEVER
1. Intermittent fever temperature fluctuates between periods of fever and
periods of normal/subnormal temperature.
2. Remittent fever temperature fluctuates within a wide range over the 24
hour period but remains above normal range.
3. Relapsing fever the temperature is elevated for few days, alternated with
1 or 2 days of normal temperature.
4. Constant fever body temperature is consistently high.
CLINICAL SIGNS OF FEVER
1. Onset (cold or chill stage) of fever
Increased heat rate
Increased respiratory rate and depth
Shivering
Pale, cold skin
Cyanotic nail bed
Complaints of feeling cold
goose flesh appearance of the skin
Cessation of sweating
Rise in body temperature
2. Course of fever
Absence of chills
Skin that feels warm
Feeling of neither hot nor cold
Increased pulse and respiratory rates
Increased thirst
Mild to severe dehydration
Drowsiness, restlessness, delirium and convulsions
Herpetic lesions of the mouth (fever blisters)
Loss of appetite to eat
Malaise, weakness and aching muscles
3. Defervescence (fever abatement)
Skin that appears flushed and feels warm
Sweating
Decreased shivering
Possible dehydration

CG INTERVENTIONS
Monitor VS
Assess skin color and temperature
Remove excess blankets when the client feels warm; provide extra warmth
when the client feels chilled
Provide adequate foods and fluids
Promote rest. To reduce body heat production
Provide good oral hygiene. To prevent herpetic lesions of the mouth
Provide cool, circulating air using a fan to dissipate heat by convection
Provide dry clothing and bed linens
Provide TSB (water is 80-98OF)
Administer antipyretic as ordered.
Methods of Temperature-Taking
1. Oral most accessible and convenient method.
Contraindications
Young children and infants
Patients who are unconscious or disoriented
Who must breath through the mouth
Seizure prone
Patient with N/V
Patients with oral lesions/surgeries
2. Rectal- most accurate measurement of temperature
Contraindications
Patient with diarrhea
Recent rectal or prostatic surgery or injury because it may injure inflamed
tissue
Recent myocardial infarction
Patient post head injury
3. Axillary safest and non-invasive
4. Tympanic thermometer
5. Chemical-dot/ chemical Strip thermometer
II. Pulse It is the wave of blood created by contractions of the left ventricles of
the heart.
FACTORS AFFECTING THE PULSE RATE
1. Age
2. Sex/gender
3. Exercise
4. Fever
5. Medications
6. Hemorrhage
7. Stress
8. Position changes
PULSE SITES
1. Temporal over the temporal bone of the head; superior and lateral to the
eye.
2. Carotid at the lateral aspect of the neck; below the ear lobe.
3. Apical at the left mid-clavicular line, 5th ICS. Use stethoscope.
4. Brachial inner aspect of the upper arm or medially at the antecubital space
5. Radial on the thumb side of the inner aspect of the wrist.
6. Femoral along the side of the inguinal ligament.
7. Posterior tibial at the medial aspect of the ankle, behind the medial
malleolus.
8. Popliteal at the back of the knee.
9. Pedal (dorsalis pedis) at the dorsum of the foot.

*use the middle 2 to 3 fingers to palpate.


ASSESSMENT OF THE PULSE
1. Rate the normal pulse rate area as follows.
AGE
Beats per
minute
Newborn to 1 month
80 180
beats/min
1 year
80 140
beats/min
2 years
80 130
beats/min
6 years
75 120
beats/min
10 years
60 90
beats/min
Adult
60 100
beats/min
Tachycardia pulse rate of above 100 beats/min
Bradycardia- pulse rate below 60 beats/min
Irregular uneven time interval between beats
2. Rhythm the pattern and intervals of beats. Dysrhythmia is irregular
rhythm.
3. Volume the strength of the pulse.
Normal pulse felt with moderate pressure.
Full or bounding pulse can be obliterated only by great pressure.
Thread pulse can easily be obliterated.
4. Arterial wall elasticity artery feels straight, smooth, soft, and pliable.
5. Presence or absence of Bilateral Equality absence means there is a CV
disorder.
III. Respiration
the exchange of oxygen and carbon dioxide between the atmosphere and
the body
the act of breathing
3 PROCESSES OF BREATHING
1. Ventilation the movement of gases in and out of the lungs.
a. Inhalation (Inspiration)
b. Exhalation (Expiration)
2. Diffusion the exchange of gases from an area of higher pressure to an area
of lower pressure. It occurs at the alveolar-capillary membrane.
3. Perfusion the availability and movement of blood for transport of gases,
nutrients, and metabolic waste products.
2 TYPES OF BREATHING
1. Costal (thoracic)
2. Diaphragmatic (abdominal)
Medulla Oblongata primary respiratory center.
Assessing Respiration
1. Rate Normal is 12-20 breaths/min in adult
2. Depth observe movement of the chest. Maybe normal, deep, or shallow.
3. Rhythm observe for regularity of exhalations and inhalations
4. Quality or character refers to respiratory effort and sound of breathing.

MAJOR FACTORS AFFECTING RESPIRATORY RATE


1. Exercise
2. Stress
3. Environment increased/decreased temp
4. Increased altitude
5. Medications
As you count the respiration, assess and record breath sound as:
Stridor - A whistling sound when breathing (usually heard on inspiration);
indicates obstruction of the trachea or larynx
Wheezing - breathing with a whistling sound
Stertor - act of snoring or producing a snoring sound
Medical Terms:
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
Dyspnea difficult and labored breathing
Apnea absence of respiration
Orthopnea ability to breath only in upright position
Hyperventilation deep rapid respiration. CO2 is excessively exhaled
(respiratory alkalosis)
Hypoventilation slow, shallow respiration. CO2 is excessively retained
(respiratory acidosis)
External respirationthe exchange of oxygen and carbon dioxide between
the alveoli of the lungs and the pulmonary blood system
Internal respirationthe interchange of oxygen and carbon dioxide
between the circulating blood and cells throughout the body
Vital capacitythe amount of air exhaled from the lungs after a minimal full
inspiration
IV. Blood Pressure
- The measure of the pressure exerted by the blood as it pulsates through the
arteries.
- Systolic pressure the pressure of blood as a result of contraction of the
ventricles
- Diastolic pressure the pressure when the ventricles are at rest
- BP = Cardiac Output X Total Peripheral Resistance / BP = CO x TPR
Pulse pressure - the difference between the systolic and diastolic pressures
(S-D=PP)
Normal is 30-40 mmHg
Hypertension an abnormally high BP over 140 mmHg systolic and or
above 90 mmHg diastolic for at least two consecutive readings
Hypotension an abnormally low blood pressure, systolic pressure below
100 mmHg, diastolic pressure is below 60 mmHg
DETERMINANTS OF BP
1. Blood volume Hypervolemia raises BP. Hypovolemia lowers BP
2. Peripheral resistance Vasoconstricton raises BP. Vasodilation lowers BP
3. Cardiac Output when the pumping action of blood is weak, BP will
decrease
4. Elasticity or Compliance of Blood Vessels in older people, elasticity of
blood vessels decreases thereby increasing BP
5. Blood viscosity - HcT
FACTORS AFFECTING BP
1. Age
2. Exercise
3. Stress

4.
5.
6.
7.
8.
9.

Race
Obesity
Sex/gender
Medications
Diurnal variations
Disease process

SYSTOLIC in
mmHg

DIASTOLIC in mmHg

<120

<80

NORMAL BLOOD
PRESSURE

and/o

120-139

CATEGORY

80-89

PREHYPERTENSION

140-159

90-99

STAGE 1 HYPERTENSION

160 or more

100 or more

STAGE 2 HYPERTENSION