VITAL SIGNS
VITAL SIGNS = CARDINAL SIGNS
1. Body Temperature
2. Pulse
3. Respiration
4. Blood Pressure
5. *Pain
BODY TEMPERATURE
• Balance between the internal and external
environment of the body
• Balance between the heat produced and lost by
the body
• Measured in heat units (degrees)
TYPES OF BODY TEMPERATURE
1. CORE TEMPERATURE – temperature of the
DEEP TISSUES of the body, such as the:
Cranium, Thorax, Abdominal Cavity, & Pelvic
Cavity
§ It remains relatively constant (37°C / 98°F)
§ Can be accurately measured by the use of
pulmonary catheter connected to the right atrium
of the heart
2. SURFACE TEMPERATURE – temperature of
the skin, the subcutaneous tissues and fat.
§ Constantly rises and falls in relation to the
environment.
§ Varies from 20°C (68°F) to 40°C (104°F)
COMMONLY USED SITES FOR BT
o Oral – most common
o Axilla – most commonly used in infants
and children
o Rectal – second choice
o Tympanic membrane – most favorable
site
FACTORS AFFECTING HEAT PRODUCTION
1. BMR (Basal Metabolic Rate) – the rate
of energy utilization in the body required
to maintain essential activities such as
breathing, walking, speaking, and
others.
- Metabolic rate decreases with age
2. MUSCLE ACTIVITY – such as shivering
increases metabolic rate
Example: walking, jogging, etc.
3. THYROXINE OUTPUT (T4 Hormone) –
increase in thyroxine hormone,
increases the rate of cellular metabolism
throughout the body.
- This is called chemical thermogenesis,
the stimulation of heat production in the
body through increase cellular
metabolism.
4. SYMPATHETIC STIMULATION – the
release of epinephrine and nor
epinephrine thus increase the rate of
cellular metabolism.
5. FEVER – increases metabolic rate and
thus increases body temperature.
Heat Loss:
1. RADIATION (surface to surface w/o
contact) – the transfer of heat from the
surface of one object to the surface of
another without contact between two
objects.
2. CONDUCTION (molecule to another) –
the transfer of heat from one molecule to
another. (e.g. the body is immersed in
water)
3. CONVECTION (by air currents) –
dispersion of heat by air currents
4. EVAPORATION (moisture evaporation)
– continuous evaporation of moisture
from the respiratory tract and from the
mucosa of the mouth as well as the skin.
REGULATION OF BLOOD TEMPERATURE
o Sensor in the skin and in the core
o An integrator in the hypothalamus
o A system that adjusts the production
and loss of heat
NOTE: the skin has a more receptor for colds
than warmth, it therefore detects cold more
efficiently than warmth. (SKIN = cold > warmth)
FACTORS AFFECTING BLOOD TEMP
1. AGE
Þ Infants: greatly influenced by
temperature
Þ Children: more labile than adult
Þ Elderly: extremely sensitive to
environmental change due to
decreased thermoregulatory
control
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 VITAL SIGNS
2. DIURNAL VARIATIONS (Circadian
Rhythms) – BT normally change
throughout the day, varying as much as
1.0°C between early morning and late
afternoon
* Point of highest BT – usually
reached between 8pm and 12
midnight
*Lowest point – during sleep
between 4am and 6am
3. EXERCISE
4. HORMONES – women usually
experience more hormone fluctuations
than men
* progesterone secretion in women
raises BT
5. STRESS – epinephrine and nor
epinephrine increases metabolic activity
and heat production
ALTERATION IN BLOOD TEMPERATURE
Pyrexia, Hyperpyrexia, or Fever – increases BT
Þ Febrile = WITH fever
Þ Afebrile = WITHOUT fever
TYPES OF FEVER
1. Intermittent – alternate BT (time)
2. Remittent – wide-range of temp.
fluctuation
3. Relapsing – short febrile periods in few
(days) then becomes normal
4. Constant – continuous
HYPOTHERMIA – decrease in core temperature
below the limit of normal
TYPES OF THERMOMETER
• Mercury in glass
- Oral Thermometer: have a long, slender
tips
- Axillary Thermometer:
- Rectal Thermometer: have a short,
rounded tips
• Electronic Thermometer – digital
thermometer
• Chemical Thermometer – usually in
the laboratory
• Temperature Sensitive Strip –
resembles a pH paper (but it’s not
accurate because the nurse might touch
the strip)
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• Infrared Thermometer – tympanic
thermometer (most expensive)
Taking Axillary Temp
Insert at the Axillary Region > Close Arms >
Wait for timer to bustle *should be taken if the
child / infant is not in distress mood because it
can affect the BT reading*
Taking Oral Temp
Insert at the SUBLINGUAL FOSSA > Position >
Let stay (1-2 minutes) > Tell the patient to close
the mouth
TEMPERATURE CONVERSION:
— °C = (Fahrenheit – 32 ) x 5/9
— °F = (Celsius x 9/5) + 32
Normal / Average temp is between 36-37.9
°C or 96.8 – 100.3 °F
PULSE
• a wave of blood created by contraction of
LEFT VENTRICLE of the heart.
• Pulse waves = represents the stroke
volume output and the compliance of
arteries.
• Stroke volume output – the amount of
blood that ENTERS the ARTERIES with
each ventricular contraction.
• Compliance – the ability of the arteries to
CONTRACT AND EXPAND
• Adult resting = heart pumps 4 to 6 liters of
blood per minute (this volume is called
cardiac output (l of b / m)
• Cardiac output (CO) is the result of the
stroke volume (SV) times the heart rate
(HR) <heartbeats>
• CO = SV x HR
• *Note: in healthy persons, the pulse reflects
the heartbeat
• Peripheral pulse – pulse located in the
periphery of the body
• Apical pulse – central pulse located at the
apex of the heart
 VITAL SIGNS

PULSE SITES: (all are peripheral, except the 7. Popliteal – back of the knee
apical) - Used to determine the circulation in
the lower leg and leg BP
Tip: check the bony part because the sounds will
bounce there 8. Posterior tibial – medial aspect of the
1. Temporal – it is where the temporal ankle
artery is located, between the upper, - Used to determine the circulation in
lateral part of the eye and upper medial the foot
part of the ear.
- Used when radial pulse isn’t 9. Dorsalis pedis – space between the big
accessible toe and the 2nd toe.
- Used to determine the circulation in
2. Carotid – side of the neck, at the carotid the foot
triangle. Located between the anterior /
front of SCM and below the angle of the
mandible ASSESSING THE PULSE
- Used for infants, in cases of cardiac - Commonly assessed by palpation and
arrest and to determine the auscultation
circulation to the brain - 2-3 middle fingers are used for palpating
all pulse site, except apical pulse
3. Apical – apex of the heart
- In adult, this is located on the left side of
the chest, no more than 8cm (3in) to the VARIATIONS IN THE PULSE RATE
left sternum under the 4th, 5th, or 6th
intercostal space
- In children 7 to 9 y/o, located between Age Average Range
the 4th and 5th intercostal space Newborn to 130 80-180
- Young children, below 4 years old, 1 month
located at the left side of midclavicular
line 1 year 120 80-140
- Children between 4 and 6 y/o is at the 2 years 110 80- 130
midclavicular line 6 years 100 75- 120
- Routinely used in infants and
children up to 3 y/o
10 years 70 50-90
- Used to determine the discrepancies
with radial pulse Adult 80 60- 100
- Used in conjunction with some
medication
— Rate- referred to tachycardia- (over
4. Brachial – at the anterior part of the arm 100 beats/ minute) bradycardia –(60
in children and at the antecubital space beats/minute or less)
(elbow crease) in adult — Rhythm- is the patterns of beat and the
- Used to measure BP, used for cardiac interval between the beats.
arrest for infants — Dysrhythmia or arrhythmia is an
example of irregular rhythm.
5. Radial – loc. at the wrist (ant.), along — Volume- is the pulse strength or the
with the thumb. It is where the radial amplitude, refers to the force of blood
artery is located with each beat. E.g. bounding/full;
- Readily accessible & routinely used weak/feeble/thready pulse

6. Femoral – inguinal ligament

- Used in cases of cardiac arrest, for
infants and children, determine the
circulation in the leg

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 VITAL SIGNS
ELASTICITY OF ARTERIAL WALL
— It reflects the expansibility of the arterial
wall.
— A healthy, normal artery feel straight,
smooth, soft and pliable
— While, elderly people often have
inelastic arteries that feels twisted or
tortuous and irregular upon palpation
FACTORS AFFECTING PULSE RATE
1. Age
2. Sex- after puberty the man’s pulse rate
is slightly lower than the female
3. Exercise
4. Fever- pulse rate increases when
metabolic rate increases
5. Medications
6. Hemorrhage- loss of blood increase
pulse rate
7. Stress
RESPIRATION
— Is the act of breathing; it includes the intake
of oxygen and the output of carbon dioxide
— Types
1. External respiration - the interchange of
O2 and CO2 between the alveoli and the
pulmonary blood
2. Internal respiration - takes place
throughout the body; it is the interchange of
gases between the circulating blood and the
cells of the body tissues
TERMINOLOGIES
— Inhalation or inspiration - the act of intake
of air into the lungs
— Exhalation or expiration - the act of
breathing out of gases from the lungs to the
environment
— Ventilation - movement of air in and out the
lungs
— Hyperventilation - refers to very deep and
rapid ventilation
— Hypoventilation- refers to very shallow
respiration
— Cheyne-Stokes: respiration the breathing is
shallow, very slow and labored with periods
of apnea. This type of breathing is often seen
in the dying patient.
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Scale Description of pulse
0 Absent
1 Thready or weak; difficult to feel
2 Normal, detected readily,
obliterated by strong pressure
3 Bounding; difficult to obliterate
TYPES OF BREATHING
1. Costal or thoracic breathing
- It involves the external intercostal
muscle and other intercostal muscle.
It can be observed by the movement
of the chest upward and outward or
downward
2. Diaphragmatic or abdominal breathing
- It involves the contraction and
relaxation of the diaphragm, it is
observed by the movement of the
abdomen
RESPIRATION CONTROL CENTERS
1. Medulla oblongata and Pons
2. Chemoreceptors located centrally in the
medulla and peripherally in the carotid
and aortic bodies
— NOTE: These centers and receptors
respond to changes in the
concentration of O2, CO2 and
Hydrogen in arterial blood.
— Increased CO2 concentration in the
blood triggers chemoreceptors thus
stimulates respiration.
ASSESSING RESPIRATION
1. The client normal breathing pattern is
assessed therefore the client should be at
resting mode.
2. Identify behavior/ activities of the patient as
well as medication or therapies because
these will affect the respiration taking.
3. Identify if there are any health problems such
as heart problems and others
 VITAL SIGNS

ARTERIAL BLOOD PRESSURE

is a measure of the pressure exerted by the
blood as it flows through the arteries.
Two blood pressure measurements
1. Systolic pressure - is the maximum
pressure developed on the ejection of
blood from the left ventricle into the
arteries

RESPIRATORY RATE 2. Diastolic Pressure - is the lowest

— is normally described in breaths per pressure and is a measure of the
minute peripheral resistance.
— Types:
1. Eupnea - Normal Breathing
2. Bradypnea - Abnormally slow IN MEASURING BP
3. Tachypnea or polypnea- Abnormally
fast — By means of auscultation- the systolic
4. Apnea - cessation of breathing pressure is taken at the point when
beats becomes audible. As the mercury
continues to fall, the sound of the beats
RESPIRATORY DEPTHS becomes louder, then gradually
— is established by watching the diminishes until a point is reached at
movement of the chest. which there is a sudden, marked
— It is generally describe as normal, deep diminution in intensity.
or shallow, deep respiration are those — The average BP is about 120/80 at 20
in which a large volume of air is yrs old and at the age of 60 is 160/90
inhaled and exhaled. Shallow
respiration involve the exchange of
small volume of air
— NOTE: in normal inspiration and
expiration, an adult takes in about
500ml of air. This volume is called Tidal
volume

RESPIRATORY RHYTHM PATTERN

— It refers to regularity of expiration and
inspiration
— Types
1. Regular
2. Irregular
§ Dyspnea - difficulty in breathing
§ Orthopnea - ability to breath in
an upright position
BLOOD PRESSURE
1. First Sound-occurs at the beginning of
ventricular systole. It is caused by the
closure of the tricuspid and mitral
valves
2. Second Sound- marks the beginning of
ventricular diastole and is caused by the
closure of aortic and pulmonary valves.
TAKING BLOOD PRESSURE
— It is measured with a blood pressure
cuff, a sphygmomanometer and a
stethoscope
— The BP cuff has a bladder than can be
inflated with air, it is covered with cloth
and has two tubes attached to it
(sometimes it’s three), one tube is
connected to the rubber bulb.
— To introduce air turn the valve clockwise
and to release air turn it
counterclockwise, the second tube to
the sphygmomanometer and the third to
stethoscope

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 VITAL SIGNS

AUSCULTATORY METHOD OF OBTAINING

BP

— First the health care provider must

determine the Korotkoff’s sound- this is a
series of sounds heard during BP
assessment.
— Phases of Korotkoff’s sound
§ Phase 1 - The first faint clear tapping
sound is heard; gradually becomes
strong and deep
§ Phase 2 - deflation when the sounds
have a swishing quality
§ Phase 3 - forceful and powerful
§ Phase 4 - begin to decrease in
intensity, and has a less bounding
force
§ Phase 5 - wherein the sound
disappear.

READING BLOOD PRESSURE

First sound: systolic pressure
Last sound: diastolic pressure

TYPES OF SPHYGMOMANOMETER

1. Aneroid and mercury manometer

2. Aneroid is a calibrated dial with a needle
that points to the calibrations while the
other is a calibrated cylinder filled with
mercury.

OTHER TYPES
— Electric sphygmomanometer
— Doppler stethoscope

VARIATION IN BP CUFF
— If the bladder is too narrow, the obtained
BP reading is erroneously elevated; if it
is too wide the reading will be
erroneously low
— The width should be 40% of the
circumference or 20% wider than the
diameter of the midpoint of the limb on
which it is used
— The length of the bladder should be
sufficiently long almost to encircle the
limb and to cover at least 2/3 of its
circumference

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