ANGELES UNIVERSITY FOUNDATION

College of Nursing

SUMMER, ACADEMIC YEAR 2013 – 2014

HEALTH ASSESSMENT

MODULE NO. 2
VITAL SIGNS

RATIONALE
This self-instructional module is designed to aid students in understanding the
principles of vital signs which is a basic aspect or foundation of health assessment. It
provides data that reflect the status of several body systems including but not limited to
the cardiovascular, neurological peripheral, vascular and respiratory systems. It measures
the client’s temperature, pulse rate, respirations and blood pressure.

LEARNING OBJECTIVES
Upon the completion of this module, the learner should be able to:
1. Understand the principles of vital signs and describe general assessment
observations.
2. Determine and understand different factors affecting the client’s temperature, pulse
rate, respirations and blood pressure.
3. Identify variations in normal body temperature, pulse, respirations, and blood
pressure that occur from infancy to old age.

Recommended Preparation:
Before going through the program, the learner must have a sufficient knowledge on
Human Anatomy and Physiology. More so, the learner is encouraged to read the following
terms which may be helpful in understanding the contents of the lecture:
 Apical pulse – a central pulse located at the apex of the heart.
 Apnea – lack of spontaneous respirations for 10 or more seconds.
 Bradycardia – Pulse rate under 60 beats per minute in a resting adult.
 Bradypnea – respiratory rate under 12 breaths per minute in a resting adult.
 Eupnea – respirations are 12-20 breaths per minute in a resting adult.
 Hypertension – blood pressure remaining consistently above 140 mmHg systolic or
90 mmHg diastolic in an adult.
 Hyperthermia - generalized or localized cooling of the skin; body temperature that
is exceeds 38.5°C or 101.5°F.
 Hypotension - blood pressure that is lower than what is needed to maintain
adequate tissue perfusion and oxygenation.
 Hypothermia – generalized or localized cooling of the skin; body temperature that
is below 34°C or 93.2°F.

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  Peripheral pulse – a pulse located in the periphery of the body (e.g. foot, wrist).
 Tachypnea – rapid shallow breathing pattern exceeding 20 breaths per minute.
 Tachycardia – heart rate exceeding 100 beats per minute.

VITAL SIGNS
 Are signs that reflect the body’s physiologic status and ability to regulate maintain
local and systemic flow and oxygenate tissues.
 Recently, many health agencies considers the oxygen saturation with the use of a
pulse oximetry as an added vital sign.

Guidelines for taking Vital Signs

1. The health care worker caring for the client measures the vital signs.
2. Equipment should be functional and appropriate.
3. Know the normal range for all the vital signs.
4. Know the client’s normal range of vital signs.
5. Know the client’s medical history and any therapies or medication prescribed.
6. Control or minimize any therapies or medication prescribed.
7. Use an organized, systematic approach when taking vital signs.
8. Decide the frequency of vital signs assessment on the basis of the client’s condition.
9. Analyze the results of vital signs measurement.
10. Verify and communicate significant changes in vital signs.

When to take vital signs:

1. On admission
2. According to institution’s policy and physician’s order
3. Before and after administration of any medication that affects the cardiovascular
system
4. Before and after any invasive procedure such as surgery
5. When a client complains of any changes in conditions, e.g. dizziness, headache
6. When the client’s condition worsens, as in sudden increase in pain

A. TEMPERATURE – is the balance between heat produced and heat lost by the body.
2 types:
1. Core Temperature
2. Surface Temperature

HYPOTHALAMUS – considered as the body’s thermostat; controls and maintains the

body’s core temperature; maintain normal body temperature by balancing heat production
and heat loss.

THERMOREGULATION – is the body’s physiologic function of heat regulation to maintain

a constant internal body temperature. The heat of the body is measured in units called
degrees.

Factors that affect the body’s heat production:

a. Basal Metabolic Rate (BMR)
b. Muscle Activity
c. Thyroxine output
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 d. Epinephrine, norepunephrine, and sympathetic stimulation
e. Increased temperature of body cells (fever)

HEAT LOSS – it is the release of heat from the body through the skin, the lungs and
through the body’s waste products.

Processes involved in HEAT LOSS:

a. Radiation
b. Conduction
c. Convection
d. Evaporation

Factors affecting temperature maintenance and regulation:

1. Stress
2. Diurnal variations
3. Exercises
4. Specific Dynamic Action (SDA) of foods
5. Hormonal activity
6. Age factors

Alterations in Body Temperature:

a. Pyrexia – aka hyperthermia, fever, febrile.
b. Hyperpyrexia – very high fever, 41°C (105.8°F) and above
c. Hypothermia – is a subnormal temperature in the body to the point that there is an
inability to maintain normal cell functioning.
Measurement of Temperature:
Gabriel Daniel Fahrenheit – a German physicist who invented the mercury thermometer
in 1714.
 Fahrenheit Scale – measures that water freezes at 32°F and boils at 212°F
Anders Celsius – a Swedish scientist who invented the Celcius Scale
 Celsius Scale – measures freezing point of water and boiling point at 100°C. it is
also known as CENTIGRADE.
CONVERSION:
°F = (°C x 9/5) + 32
For example, when Celsius reading is 40:
°F = (40°C x 9/5) + 32
= 72 + 32
= 104°F
°C = (°F – 32) x 5/9
For example, when Fahrenheit reading is 100:
°C = (100°F – 32) x 5/9
= 68 x 5/9
= 37.7°C
*Normal Body Temperature

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Normal Body Temperature is not a single temperature, but a range of temperatures
influenced by age, time of day, and measurement site.

*General Rule of Thumb

Rectal (and arterial) temperatures are ˜2°F (1°C) higher than axillary and ~1°F (0.5°C )
higher than oral temperature.

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 GUIDELINES FOR TAKING TEMPERATURE

SITE ADVANTAGES DISADVANTAGES TIME NORMAL CONTRAINDICATIONS NURSING RESPONSIBILITIES

VALUE
ORAL Accessible and  Inaccurate if client 2-3 min 36.5°C to  Oral lesions or surgery  Allow 15-30 min. to elapse between a
convenient ingested hot/cold 37.0°C  Dyspnea client’s intake of hot or cold food or
 Can injure mouth  Cough smoking and the measurement.
after surgery  Nausea and vomiting  Place the thermometer under the
 Presence of oro-nasal tongue, directed towards the side.
contraptions, e.g. nasal  Wash the thermometer before use,
pack, nasogastric tube, from bulb to the stem, after use, from
endotracheal tube, etc. the stem to the bulb.
 Seizure prone
 Very young children
 Unconscious
 Restless, disoriented,
confused
RECTAL Reliable  Inconvenient and 2-3 min 37.0°C to  Anal/Rectal conditions or  Assist client to assume lateral position
measurement unpleasant surgeries, e.g. anal  Lubricate thermometer before insertion
For 37.5°C
 Presence of stool fissures, hemorrhoids,  Insert thermometer by 0.5 to 1.5 in (1.5
may interfere with neonates hemorrhoidectomy – 4cm)
the placement of 5 min  Diarrhea  Instruct client to take a deep breath
thermometer during insertion of thermometer to relax
the internal sphincter
 Hold the thermometer in place for 2
min (for neonates 5 min)
 Do not force insertion of thermometer
into a newborn.

AXILLARY Safe and non-  Thermometer must 6-9 min. 36.0°C to  Skin breakdown (armpit  Pat dry the axilla
invasive be left in place a 36.5°C area)  Place the thermometer in the client’s
long period to axilla
obtain an accurate  Place the arm tightly across the chest
measurement. to keep the thermometer in place for 9

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 min. (for infants and children 5 min.)
TYMPANIC Readily  Can be Few mins .  Perforated tympanic  Pull the pinna slightly upward and
MEMBRANE accessible, uncomfortable and membrane backward for adults and children > 3
reflects the core involves risk of  Otitis media y/o, while downward and backward for
temperature very injuring the  Other ear structure children < 3 y/o
fast membrane abnormalities  Point the probe slightly anteriorly,
 Right and left toward the eardrum.
measurement can  Insert the probe slowly using a circular
differ motion until snug.
 Presence of
cerumen can affect
the reading
TEMPORAL Readily  cooling of the skin Few 37.0°C to  The thermometer reads the
accessible, poses associated with minutes infrared heat waves released by the
ARTERY no risk of injury sweating can 37.5°C temporal artery which runs across the
for patient or interfere with forehead just below the skin.
clinician, contains temperature
no mucous measurement  Place the sensor head at the
membranes,  The temporal center of the forehead midway between
would eliminate scanner has no way the eyebrow and the hairline.
any of identifying the
 To scan for your child’s
need for disrobing location of the
or unbundling, temperature, depress the scan button
temporal artery.
and seemingly and keep it depressed.
could become a  Slowly slide the TA thermometer
standard straight across the forehead toward the
temperature top of the ear keeping in contact with
measurement site the skin.
free from any age
limitations.  Stop when you reach the hairline
and release the scan button.

 Remove the thermometer from the

skin and read your child’s temperature
on the display screen.

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Health Assessment Module 2 VITAL SIGNS Page 7
B. PULSE
- It is the wave of blood created by contraction of the left ventricle of the heart. The
pulse rate is regulated by the autonomic nervous system (ANS).
- The wave felt when the finger is placed over an artery.
- It is felt peripherally or heard each time the heart (left ventricle) contracts and forces
the blood into the arterial circulation.

CARDIAC OUTPUT
- The volume of blood pumped into the arteries by the heart.
APICAL PULSE – pulse located at the apex of the heart.
PERIPHERAL PULSE – pulse located in the periphery of the body; located away from the
heart.
Purposes:
1. To obtain a baseline measure of the clients heart rate and rhythm.
2. To monitor changes in the client’s cardiovascular status.
3. To monitor the heart’s response to a disease, procedure or therapy and treatment.
4. To monitor blood flow to a specific body part.

Pulse Sites / Location:

1. Apical pulse
2. Radial pulse
3. Temporal pulse
4. Carotid pulse
5. Brachial pulse
6. Femoral pulse
7. Popliteal pulse
8. Dorsalis Pedis
9. Posterior Tibial Pulse

PULSE CHARACTERISTICS:
1. Pulse Quality – refers to the “feel” of the pulse, its rhythm, and forcefulness
2. Pulse Rate – is an indicated measurement of cardiac output obtained by counting the
number of apical or peripheral pulse waves over a pulse point. A normal pulse rate
for adults is between 60 to 100 beats per minute.
3. Pulse Rhythm – is the regularity of the heartbeat. It describes how evenly the heart
is beating: regular (the beats are evenly spaced), irregular (the beats are not evenly
spaced). Dysrhythmia (arrhythmia) is an irregular rhythm caused by an early, late,
or missed heart beat.
4. Pulse Volume – is the measurement of the strength or amplitude of force exerted by
the ejected blood against the arterial wall with each contraction.

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 5. Elasticity of Arterial Wall – reflect expansibility or its deformities; normal: feels
smooth, straight and soft; Older: feel twisted and irregular
6. Bilateral Equality – normal: bilaterally equal

Factors that may alter pulse rate:

a. Age
b. Sex/Gender
c. Exercise
d. Fever/Changes in body temperature
e. Medications
f. Hemorrhage
g. Stress/Emotions
h. Position changes
i. Application of heat and cold
j. Heart Disease

Terms used to describe character of the pulse:

a. Arrhythmias – refers to the irregularities of rhythm; that is, the intervals between
beats are of different lengths or the beats are of equal force.
b. Bradycardia – refers to a very slow pulse rate (adult less than 60/min) which indicate
slow heart rate.
c. Tachycardia – refers to a pulse rate above normal (adult more than 100/min)
d. Bounding – strong pulse volume
e. Thready or weak – use to describe a pulse of diminished strength.
f. Dicrotic – means one heart beat for the arterial pulsation gives the sensation of a
double beat.
g. Intermittent pulse – refers to on and off pulsation
h. Pulse Deficit – it is the difference between the apical and radial counts taken
simultaneously.

C. RESPIRATION – it refers to the act of breathing and involves the exchange of gases
between an organism and its environment.
2 Kinds of Respiration:
1. External/Pulmonary Respiration – takes place in the lungs where carbon dioxide is
eliminated and oxygen is absorbed by the blood.
2. Internal / Cellular Respiration – takes place between the blood and the tissues;
involves oxygenation of the cells for heat production and liberation of water waste
products

2 Phases of External Respiration:

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 1. Breathing-In Process / Inspiration – contractions of the diaphragm and external
intercostals may increase the size of the chest cavity and create a partial vacuum.
2. Breathing-Out Process / Expiration – the relaxation of the diaphragm and external
intercostals may decrease the size of the chest cavity and forces air out of the lungs.

2 Types of Breathing:
1. Costal (thoracic) breathing – involves the external intercostal muscles and other
accessory muscles, such as sternocleidomastoid muscles. It can be observed by the
movement of the chest upward and outward.
2. Diaphragmatic (abdominal) breathing – involves the contraction and the relaxation of
the diaphragm, and it is observed by the movement of the abdomen, which occurs
as a result of the diaphragm’s contraction and downward movement.

Ventilation – refers to the movement of air in and out of the lungs

Respiratory rate – number of ventilation per minute
Normal breathing – carried automatically and effortless; controlled by respiratory centers

Respiratory Centers:
1. Medulla Oblongata – primary center
2. Pons contains the following:
 Pneumotaxic center – responsible for the rhythmic quality of breathing
 Apneustic center – responsible for deep, prolonged inspiration
3. Carotid and aortic bodies – respond to changes in the concentrations of O2, CO2,
and Hydrogen
4. Muscles and joints – has sensory receptors known as proprioceptors that responds to
movement and exercise. Exercise increases respiratory rate.

Factors Affecting Respiratory Rate and Depth:

1. Emotional status/stress – SNS stimulation thus increase RR
2. Drugs – sedatives slows down RR, stimulants speed up RR
3. Exercise – increases RR
4. Mechanical interference or distress condition – asthma
5. Changes in altitude – increased altitude increases RR
6. Exposure to extreme temperature – increased temperature increases RR

Before assessing a client’s respiration, a nurse should assess:

 The client’s normal breathing pattern.
 The influence of the client’s health problems on respiration
 Any medications or therapies that might affect respirations
 The relationship of the client’s respiration to cardiovascular function.

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Assessing Respiration
a. Respiratory Rate – normally described in breaths per minute
Normal:
*Eupnea – normal in rate and depth (12-20 breaths per minute)
Abnormal:
*Tachypnea – quick shallow breaths (>20 breaths per minute)
*Apnea – absence or cessation of breathing.

b. Depth – refers to the volume of air that is inhaled and exhaled, observed by the
movement of the chest
Normal respirations – takes about 500 ml of air during inspiration and expiration
(tidal volume)
Abnormal:
*Deep respirations – are those in which a large volume of air is inhaled and exhaled,
inflating most of the lungs
*Hyperventilation – refers to very deep, rapid respirations
*Shallow respirations – involved the exchange of a small volume of air and often the
minimal use of lung tissue.
*Hypoventilation – very shallow respirations

c. Rhythm – observe for regularity of exhalations and inhalations

Normal:
*Regular – respirations are evenly spaced
Abnormal:
*Irregular – unevenly spaced respirations
*Cheyne-Stokes breathing – rhythmic waxing and waning of respirations, from very
deep to very shallow breathing and temporary apnea
*Kussmaul Breathing – very deep and slightly rapid, usually accompanied by a sigh

d. Quality or character – refers to respiratory effort and sound of breathing

Normal: quiet effortless breathing
Abnormal:
*Dyspnea – difficult labored breathing during which the individual has a persistent,
unsatisfied need for air and feels distressed
*Orthopnea – ability to breathe only in upright sitting or standing positions

BLOOD PRESSURE – is the measurement of pressure pulsations exerted against the blood
vessel walls during systole and diastole. It is measured in terms of millimeters of mercury
(mmHg)

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 The body has hemodynamic regulators for blood pressure control:
1. Pumping action of the heart (cardiac output) – the major factor that influences
systolic pressure.
2. Peripheral vascular resistance (PVR) – the size and distensibility of the arteries,
which is the most important determinant of diastolic pressure.
3. Blood volume – the volume of blood in the circulatory system. Blood pressure is
proportional to the blood volume. Hemorrhage causes a loss in blood volume that in
turn, lowers the blood pressure. Rapid infusion of intravenous fluids causes an
increase in volume and subsequent rise in pressure.
4. Viscosity – the thickness of the blood based on the ratio of proteins and cells to the
liquid portion of blood.
5. Elasticity or compliance of blood vessels – in older people, elasticity of blood
vessels decreases thereby increasing BP.

Blood pressure is a result of the cardiac output and peripheral vascular resistance.
Normal arteries expand during systole and contract during diastole, creating 2 distinct
pressure phases:
 Systolic blood pressure – is a measurement of the maximal pressure exerted
against arterial wall during systole (when myocardial fibers contract and tighten
to eject blood from the ventricles), primarily a reflection of cardiac output.
 Diastolic blood pressure – is a measurement of pressure remaining in the
arterial system during diastole (period of relaxation that reflects the pressure
remaining in the blood vessels after the heart has pumped), primarily a reflection
of peripheral vascular resistance.

Pulse pressure – the difference between the systolic and diastolic pressure; normal is 30-
40 mmHg.

Purpose of taking Blood Pressure:

a. To obtain baseline blood pressure measurement
b. To assess the client’s response to blood or fluid volume loss after surgery, child birth,
trauma or burns.
c. To assess the client’s cardiovascular status
d. To evaluate the client’s response to changes in his condition after treatment with
fluids, medications or other therapies.

Terms used to describe blood pressure:

1. Korotkoff’s sound – the sounds that indicate systolic and diastolic pressure when
determining blood pressure.
2. Hypertension – an abnormally high blood pressure.

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 b. Essential Hypertension – an abnormally high blood pressure with no known cause
c. Secondary Hypertension – an abnormally high blood pressure that is caused by
known pathology e.g. stroke
3. Hypotension – abnormally low pressure. A systolic pressure below 100mmHg.
4. Orthostatic hypotension – a low blood pressure associated with weakness and
fainting when rising to an erect position.

Factors affecting blood pressure:

A. Can cause a rise in BP
a. Age – older people have higher BP due to decreased elasticity of blood vessels
b. Exercise – increases cardiac output, hence increases BP
c. Stress – SNS stimulation causes increased BP
d. Race – Hypertension is one of the 10 leading causes of death among Filipino.
African American males of the same age
e. Obesity – BP generally is elevated among overweight and obese people.
f. Diet – increase intake of fatty and salty foods increases risk for hypertension
g. Sex/Gender – after puberty and before age 65 years, males have higher BP. After
age 65 years, females have higher BP due to hormonal variations.
h. Medications – some medications may increase or decrease BP
i. Diurnal Variations – BP is lowest in the morning, and highest in the late afternoon
or early evening.
j. Disease process – Diabetes Mellitus, renal failure, hyperthyroidism, cushings’s
disease increases BP

B. Can cause fall in BP

a. Blood loss
b. Dilation of blood vessels
c. Postural or orthostatic hypotension

Assessing Blood Pressure

1. Measured with a blood pressure cuff, sphygmomanometer, and a stethoscope
Types of sphygmomanometer
a. Aneroid – calibrated dial with a needle that point to the calibrations
b. Mercury – calibrated cylinder filled with mercury. The pressure is indicated at the
point to which the round curve of the meniscus (the crescent shape dome) Note:
the BP reading should be made with the eye at the level of the rounded curve in
order to be accurate
c. Electronic – eliminates the need to listen to the sounds of the client’s systolic and
diastolic pressure through a stethoscope.
2. Bladder – the blood pressure cuff consists of a rubber bag that is inflated with air.
3. Blood pressure sites

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*ARM (BRACHIAL ARTERY) – MOST COMMON SITE

Assessing BP on the thigh is indicated on the following:

1. The BP cannot be measured on either arm (because of burns or other trauma)
2. The BP in 1 thigh is to be compared with the BP of the other thigh.

BP assessment on the arm or thigh is contraindicated when:

1. The shoulder, arm, or hand (or the hip, knee, or ankle) is injured or diseased.
2. A cast or bulky bandage is on any part of the limb
3. The client has had removal of axilla (or hip) lymph node on that side
4. The client has intravenous infusion in that limb
5. The client has an arteriovenous fistula in that limb

Common causes of BP assessment errors:

1. Inaccurate manometer calibration – falsely high or low reding
2. Loosely applied cuff – high reading
3. Cuff too small for extremity - high reading
4. Cuff too large for extremity - low reading
5. Cuff applied over clothing – creates noises or interferes with sound perception
6. Tubing that leaks – rapid loss of pressure
7. Improper positioning of the ear tips – poor sound conduction
8. Improper hearing altered sound perception
9. Loud environmental noise – interferes with sound perception
10. Impaired vision – inaccurate observation of the gauge
11. Rapid cuff deflation – Inappropriate observation of the gauge

Nursing consideration in assessing BP:

1. Ensure that the client is rested
2. Allow 30 minutes to pass if the client had smoked or ingested caffeine before taking
BP
3. Use appropriate size of BP cuff
4. Position the patient in sitting or supine position
5. Position the arm at the level of heart, with the palm of the hand pacing up
6. Apply BP cuff snugly, 1 in. above the antecubital space
7. Determine palpatory BP before auscultatory BP to prevent ausculatory gap
8. Use the bell the stethoscope since BP is a low frequency sound
9. Inflate and deflate BP cuff slowly, 2-3 mmHg at a time
10. Wait 1-2 minutes before making further determinations

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Five phases of Korotkoff’s sounds:
1. Phase I – the period marked by the first appearance of faint, clear, TAPPING sounds
which gradually increase in intensity. Reflects the systolic pressure.
2. Phase II – the period during which a murmur or swishing sound is heard
3. Phase III – period during which sounds are louder and increased in intensity
(KNOCKING SOUNDS)
4. Phase IV – the point at which it is marked by the distinct, abrupt, muffling of sound
5. Phase V – the point at which sounds disappears, reflects the diastolic pressure.

VARIATIONS IN NORMAL VITAL SIGNS BY AGE

AGE ORAL TEMP PULSE RESPIRATIONS BLOOD
PRESSURE
Newborn 36.8 (98.2) 130 (80- 35 (30-80) 73/55
axillary 180)
1 y/o 36.8 (98.2) 120 (80- 30 (20-40) 90/55
axillary 140)
5-8 y/o 37 (98.6) 100 (75- 20 (15-25) 95/57
120)
10 y/o 37 (98.6) 70 (50-90) 19 (15-25) 102/62
Teen 37 (98.6) 75 (50-90) 18 (15-20) 120/80
Adult 37 (98.6) 80 (60-100) 16 (12-20) 120/80
Older Adult 37 (98.6) 70 (60-100) 16 (15-20) Possible
increased
diastolic

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