Vital Signs

(Body Temperature, Pulse Rate, Respiration Rate, Blood Pressure)

By: Arturo G. Garcia Jr.RN.,MSN

What are vital signs?

• Vital signs are measurements of the body's most basic functions. The four
main vital signs routinely monitored by medical professionals and health
care providers include the following:

• Body temperature
• Pulse rate
• Respiration rate (rate of breathing)
• Blood pressure (Blood pressure is not considered a vital
sign, but is often measured along with the vital signs.)
• Vital signs are useful in detecting or monitoring medical problems. Vital signs can be
measured in a medical setting, at home, at the site of a medical emergency, or elsewhere.

• These are indices of health, or signposts in determining client’s condition.

This is also known as cardinal signs and it includes body temperature, pulse, respirations, and
blood pressure. These signs have to be looked at in total,
to monitor the functions of the body.

Different considerations in taking Vital signs

1. The frequency of taking TPR and BP depends upon the condition of the
client and the policy of the institution.

2. The procedure should be explained to the client before taking his TPR and BP.

3. Obtain baseline data.

 What is body temperature?

• The normal body temperature of a person varies depending on gender,

recent activity, food and fluid consumption, time of day, and, in women, the
stage of the menstrual cycle.
• The balance between the heat produced by the body and the heat loss from
the body.

• A person's body temperature can be taken in any of the following ways:

• Orally. Temperature can be taken by mouth using either the classic glass
thermometer, or the more modern digital thermometers that use an electronic probe to
measure body temperature.
• Rectally. Temperatures taken rectally (using a glass or digital
thermometer) tend to be 0.5 to 0.7 degrees F higher than
when taken by mouth.
• Axillary. Temperatures can be taken under the arm using a
glass or digital thermometer. Temperatures taken by this
route tend to be 0.3 to 0.4 degrees F lower than those
temperatures taken by mouth.

• By ear. A special thermometer can quickly measure the

temperature of the ear drum, which reflects the body's core
temperature (the temperature of the internal organs).

• Body temperature may be abnormal due to fever (high temperature) or

hypothermia (low temperature).

• A fever is indicated when body temperature rises about one degree or more
over the normal temperature.
• Hypothermia is defined as a drop in body temperature below 95 degrees
Fahrenheit.
 Types of Body Temperature
▪ Core temperature –temperature of the deep tissues of the body.

▪ Surface body temperature

Alteration in Body Temperature

▪ Pyrexia – Body temperature above normal range (hyperthermia)

▪ Hyperpyrexia – Very high fever, 41ºC (105.8 F) and above

▪ Hypothermia – Subnormal temperature.

 Normal Adult Temperature Ranges
▪ Oral 36.5 –37.5 ºC

▪ Axillary 35.8 – 37.0 ºC

▪ Rectal 37.0 – 38.1 ºC

▪ Tympanic 36.8 – 37.9ºC

About glass thermometers containing mercury

• According to the Environmental Protection Agency, mercury is a toxic

substance that poses a threat to the health of humans, as well as to the
environment.

• Because of the risk of breaking, glass thermometers containing mercury

should be removed from use and disposed of properly in accordance with
local, state, and federal laws.
To convert Fahrenheit to Centigrade
 The number 32 degrees must first be subtracted in order that the
degrees may count from the same point on the scale, and then
multiplied by 5/9 since 1 degree Fahrenheit is only to 5/9 of a
degree centigrade.

FORMULA:
C=5/9 (F-32)
Example: Convert 98.6F to Centigrade
5/9x(98.6-32)66.6=333.0/9=37degree Centigrade
To convert Centigrade to Fahrenheit
 Since 1 degree centigrade is equal to 9/5 of a degree Fahrenheit, the centigrade
temperature is multiplied by 9/5. The number 32 must then be added since there are
no degrees on the centigrade scale which correspond to the 32 degrees below
freezing point on the Fahrenheit scale.

FORMULA
F= 9/5 C plus 32
Example: Convert 37 C to Fahrenheit
37x9/5=333/5=66.6 t 32= 98.6 F
 Methods of Temperature-Taking

I. Oral – most accessible and convenient method.

1. Put on gloves, and position the tip of the thermometer under the patient’s
tongue on either of the frenulum as far back as possible. It promotes contact
to the superficial blood vessels and ensures a more accurate reading.

2. Wash thermometer before use.

3. Take oral temp 2-3 minutes.

4. Allow 15 min to elapse between client’s food intakes of hot or cold food,
smoking.

5. Instruct the patient to close his lips but not to bite down with his teeth to avoid breaking the
thermometer in his mouth.
Contraindications

• Young children an infant

• Patients who are unconscious or disoriented

• Who must breathe through the mouth

• Seizure prone

• Patient with N/V

• Patients with oral lesions/surgeries

 II. Rectal- most accurate measurement of temperature

1. Position- lateral position with his top legs flexed and drapes him to provide
privacy.

2. Squeeze the lubricant onto a facial tissue to avoid contaminating the

lubricant supply.

3. Insert thermometer by 0.5 – 1.5 inches

4. Hold in place in 2minutes

5. Do not force to insert the thermometer

Contraindications

▪ Patient with diarrhea

▪ Recent rectal or prostatic surgery or injury because it may injure inflamed

Tissue

▪ Recent myocardial infarction

▪ Patient post head injury

III.Axillary – safest and non-invasive

1.Pat the axilla dry

2. Ask the patient to reach across his chest and grasp his opposite shoulder. This promote
skin contact with the thermometer.

3.Hold it in place for 9 minutes because the thermometer isn’t close in a body cavity.
Note:

▪ Use the same thermometer for repeat temperature taking to ensure more
consistent result.

▪ Store chemical-dot thermometer in a cool area because exposure to heat

activates the dye dots.

Tympanic thermometer

1. Make sure the lens under the probe is clean and shiny.

2. Stabilized the patient’s head; gently pull the ear straight back (for children up to age 1)
or up and back (for children 1 and older to adults).

3. Insert the thermometer until the entire ear canal is sealed.

4. Place the activation button, and hold it in place for 1 second

 I. Chemical-dot thermometer

1. Leave the chemical-dot thermometer in place for 45 seconds.

2. Read the temperature as the last dye dot that has change color, or
fired.

Factors that Affect Body Temperature

1. Age

▪ The infant is greatly influenced by the temperature of the environment and

must be protected from extreme changes.

▪ Children’s temperature continues to be more labile than those of adults

until puberty.
▪ Elderly people are at risk of hypothermia for variety of reasons. Such as
lack of central heating, inadequate diet, loss of subcutaneous fat, lack of
activity, and reduced thermoregulatory efficiency.

1. Exercise

▪ Hard work or strenuous exercise can increase body temperature

2. Hormones

▪ Women usually experience more hormones fluctuations than men do.

Progesterone secretion at the time of ovulation raises body temperature
above basal temperature

3. Stress

▪ Stimulation of SNS can increase the production of epinephrine and

norepinephrine, thereby increasing metabolic activity and heat production

4. Environment

▪ Extremes in environmental temperatures can affect a person’s

temperature regulatory systems.
 Nursing Interventions in Clients with Fever

1. Monitor V.S
2. Assess skin color and temperature
3. Monitor WBC, Hematocrit and other pertinent lab records
4. Provide adequate foods and fluids.
5. Promote rest
6. Monitor I & O
7. Provide TSB
8. Provide dry clothing and linens
9. Give antipyretic as ordered by MD

Heat – producing & Heat – losing Mechanisms

▪ Heat production: most body heat is produced by the oxidation of foods; the
rate at which it is produced is called METABOLIC RATE.
Heat Loss:
▪ Radiation
▪ Conduction
▪ Convection
▪ Evaporation

Pre – optic area of the Hypothalamus

▪ Temperature regulator; thermostat

▪ Receives input from temp receptors in the skin & mucous membranes
(Peripheral thermo receptors) & internal structures (central thermo
receptors)
* If blood temp increases, neurons of the pre – optic area fire nerve if it
decreases.
Heat Promoting Centers

1. Vasoconstriction
▪ =Less blood flow from the internal organs to the skin= less heat transfer
from the internal organs to the skin= increases internal body temperature

2. Sympathetic Stimulation
▪ = stimulation of sympathetic nerves leading to the adrenal medulla =
Secretes epinephrine & norepinephrine = Increases cellular metabolism =
increases heat production

3. Skeletal Muscles
▪ = stimulation of part of the brain that increases muscle tone (stretch reflex
+ contraction of muscles = SHIVERING) = heat production

4. Thyroxine
▪ = increases metabolism = increase in body temperature
 Body Temperature Abnormalities

1. Fever/hyperthermia/hyperpyrexia

▪ An abnormally high temp mainly results from infection from bacteria (&
their toxins) & viruses. (Stimulates prostaglandin secretion)
▪ Other causes: heart attacks, tumors, tissue destruction by x – ray, surgery
or trauma & rxns to vaccines.

2. Heat cramps and Heat exhaustion

▪ Due to fluid & electrolyte loss

3. Heat Stroke

4. Hypothermia
The Thermometer
▪ A glass clinical thermometer is most commonly used to measure body
temperature.

It has 2 parts:

▪ Bulb– contains mercury which expands when exposed to heat & rise in the
stem
▪ Stem – is calibrated in degrees of Celsius or Fahrenheit

What is pulse rate?

• The pulse rate is a measurement of the heart rate, or the number of times
the heart beats per minute. As the heart pushes blood through the arteries,
the arteries expand and contract with the flow of the blood.
• Taking a pulse not only measures the heart rate, but also can indicate the
following:
PARTS OF THE THERMOMETER
▪ Heart rhythm
▪ Strength of the pulse
• The normal pulse for healthy adults ranges from 60 to 100 beats per minute.
• The pulse rate may fluctuate and increase with exercise, illness, injury, and
emotions. Females ages 12 and older, in general, tend to have faster heart
rates than do males

What is Pulse?

▪ This is a wave of blood created by contraction of the left ventricle of the

heart. The heart is a pulsating pump, and the blood enters the arteries with
each heartbeat, causing pressure pulses or pulse waves. Generally, the
represents the stroke volume and the compliance of the arteries.
▪ Stroke volume is the amount of blood that enters the arteries with each
contraction in a healthy adult.

▪ Compliance of the arteries is their ability to contract and expand. When a

person’s arteries lose their dispensability, greater pressure is required to
pump the blood into the arteries.
▪ Peripheral pulse is the pulse located in the periphery of the body, for
example in the foot, hand and neck. Apical pulse is a central pulse. It is
located at the apex of the heart.
Normal Pulse rate

▪ 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.
How to check your pulse

As the heart forces blood through the arteries, you feel the beats by firmly
pressing the arteries, which are located close to the surface of the skin at
certain points of the body. The pulse can be found on the side of the neck,
on the inside of the elbow, or at the wrist. For most people, it is easiest to
take the pulse at the wrist. If you use the lower neck, be sure not to press
too hard, and never press on the pulses on both sides of the lower neck at
the same time to prevent blocking blood flow to the brain. When taking your
pulse:

• Using the first and second fingertips, press firmly but gently on the
arteries until you feel a pulse.

• Begin counting the pulse.

• Count your pulse for 60 seconds or 1 full minute.

• When counting, do not watch the clock continuously, but concentrate

on the beats of the pulse.

• If unsure about your results, ask another person to count for you
 Factors Affecting Pulse Rate

1. Age
▪ as age increases, the pulse rate gradually decreases

2. Sex
▪ after puberty, the average male’s pulse rate is slightly lower than the
female’s.

3. Exercise
▪ Pulse rate usually increases with activity

4. Fever
▪ the pulse rate increases in response to the lowered blood pressure that
results from peripheral vasodilation associated with elevated body
temperature, and because of the increased metabolic rate.
5. Medications
▪ some medications decrease the pulse rate, and others increase it.

6. Hemorrhage
▪ Loss of blood from the vascular system normally increases pulse rate.

7. Stress
▪ In response to stress, sympathetic nervous stimulation increases the
overall activity of the heart. Stress increases the rate as well as the force
of the heartbeat.

8. Position changes
▪ when a person assumes a sitting or standing position, blood usually pools
in dependent vessels of the venous system. Pooling results in a transient
decrease in the venous blood return to the heart and a subsequent
reduction in blood pressure reduction in blood pressure and increase in
the heart rate.
 Characteristics of Normal Pulse

1. Rate
▪ this is the number of pulse beats per minute (70 – 80 beats/min in the
adult). An excessively fast heart rate (100 beats/min) is referred to as
tachycardia. A heart rate in the adult of 60 beats/minute or less is called
bradycardia.

2. Pulse rhythm
▪ this is the pattern of the beats and the intervals between the beats. Equal
time elapses between beats of a normal pulse. A pulse with an irregular
rhythm is referred to as a dysrhythmia or arrhythmia. It may consist of
random, irregular beats or a predictable pattern of irregular beats
3. Pulse volume
▪ this is also called the pulse strength or amplitude. It refers to the force of
blood with each beat. It can range from absent to bounding. A normal
pulse can be felt with moderate pressure of the fingers and can be
obliterated with greater pressure. A forceful or full blood volume that is
obliterated only with difficulty is called a full or bounding pulse. A pulse
that is readily obliterated with pressure from the fingers is referred to as
weak, feeble, or thready. A pulse volume is usually measured on a scale
0 to 3.

Pulse Sites

1. Temporal, where the temporal

artery passes over the
temporal bone of the head. The
site is superior and lateral to
the eye.
3. Apical, at the apex of the heart.

4. Brachial, at the inner aspect of

the biceps muscle of the arm
(especially in infants) or
medially in the antecubital
space (elbow crease).

5. Radial, where the radial artery

runs along the radial bone, on
the thumb site of the inner
aspect of the wrist.

6. Femoral, where the femoral

artery passes alongside the
inguinal ligament.
7. Popliteal, where the popliteal artery passes behind the knee. This point
is difficult to find, but it can be palpated if the client flexes the knee slightly.

8. Posterior tibia, on the medial surface of the ankle where the posterior
tibia artery passes behind the medial malleolus.

9. Pedal (dorsalis pedis), where the dorsalis pedis artery passes over the
bone of the foot. This artery can be palpated by feeling the dorsum of the
foot on the imaginary line drawn from the middle of the ankle to the space
between the big and second toes.