Vital Signs- are body temperature, pulse,
respirations, and blood pressure.
Times to Assess Vital Signs
 On admission to a health care agency to obtain
baseline data
 When a client has a change in health status or reports
symptoms
 such as chest pain or feeling hot or faint
 Before and after surgery or an invasive procedure
 Before and/or after the administration of a medication
that could affect the respiratory or cardiovascular
systems; for example, before giving a digitalis
preparation
 Before and after any nursing intervention that could
affect the vital signs (e.g., ambulating a client who has
been on bed rest).
BODY TEMPERATURE- reflects the balance
between the heat produced and the heat lost from the
body and is measured in heat units called degrees.
There are two kinds of body temperature:
Core temperature- is the temperature of
the deep tissues of the body, such as the abdominal
cavity and pelvic cavity. It remains relatively
constant.
Surface temperature- is the temperature of the skin,
the subcutaneous tissue, and fat. It, by contrast, rises
and falls in response to the environment.
Several factors affect the body’s heat production.
The most important are these five:
1. Basal metabolic rate. is the
rate of energy utilization in the body required to
maintain essential activities such as breathing.
Metabolic rates decrease with age. In general, the
younger the person, the higher the BMR.
2. Muscle activity. Muscle activity, including
shivering, increases the metabolic rate.
3. Thyroxine output. Increased thyroxine output
increases the rate of cellular metabolism throughout
the body.
4. Epinephrine, norepinephrine, and sympathetic
stimulation/ stress response. These hormones
immediately increase the rate of cellular metabolism
in many body tissues.
5. Fever. Fever increases the cellular metabolic rate
and thus increases the body’s temperature further.
Heat is lost from the body through radiation,
conduction, convection, and evaporation.
Conduction is the transfer of heat from one molecule
to a molecule of lower temperature. Conductive
transfer cannot take place without contact between
the molecules and normally accounts for minimal
heat loss except, for example, when a body is
immersed in cold water. The amount of heat
transferred depends on the temperature difference
and the amount and duration of the contact.
Radiation is the transfer of heat from
the surface of one object to the surface of another
without contact between the two objects, mostly in
the form of infrared rays.
Convection is the dispersion of heat by air currents.
The body usually has a small amount of warm air
adjacent to it. This warm air rises and is replaced by
cooler air, so people always lose a small amount of
heat through convection.
Evaporation is continuous vaporization of moisture
from the respiratory tract and from the mucosa of the
mouth and from the skin.
This continuous and unnoticed water loss is called
insensible water loss, and the accompanying heat loss
is called insensible heat loss. Insensible heat loss
accounts for about 10% of basal heat loss. When the
body temperature increases, vaporization accounts
for greater heat loss.
Regulation of Body Temperature
The system that regulates body temperature has three
main parts:
sensors in the periphery and in the core, an
integrator in the hypothalamus, and an effector
system that adjusts the production and loss
of heat.

When the skin becomes chilled over the entire body,

three physiological processes to increase the body
temperature take place:
5. Stress. Stimulation of the sympathetic nervous
1. Shivering increases heat production. system can increase the production of epinephrine
2. Sweating is inhibited to decrease heat loss. and norepinephrine, thereby increasing metabolic
3. Vasoconstriction decreases heat loss. activity and heat production. Nurses should anticipate
that a highly stressed or anxious client
Factors Affecting Body Temperature could have an elevated body temperature for that
reason.
1. Age. Infants are greatly influenced by the
6. Environment. Extremes in environmental
temperature of the environment
temperatures can affect a person’s temperature
and must be protected from extreme changes.
regulatory systems. If the temperature is assessed in a
Children’s temperatures vary more than those of
very warm room and the body temperature
adults do until puberty. Many older people,
cannot be modified by convection, conduction, or
particularly those over 75 years, are at risk of
radiation, the temperature will be elevated. Similarly,
hypothermia (temperatures below 36°C, or 96.8°F)
if the client has been outside in cold weather without
for a variety of reasons, such as inadequate diet, loss
suitable clothing, or if a medical
of subcutaneous fat, lack
condition prevents the client from controlling the
of activity, and reduced thermoregulatory efficiency.
temperature in the environment (e.g., the client has
Older adults are also particularly sensitive to
altered mental status or cannot dress self), the body
extremes in the environmental
temperature may be low.
temperature due to decreased thermoregulatory
controls.
2. Diurnal variations (circadian rhythms). Body Alterations in Body Temperature
temperatures normally change throughout the day, The normal range for adults is between
varying as much as 1.0°C (1.8°F) between the early 36°C and 37.5°C (96.8°F to 99.5°F).
morning and the late afternoon. The
point of highest body temperature is usually reached There are two primary alterations in body
between 1600 and 1800 hours (4:00 pm and 6:00 temperature: pyrexia and hypothermia.
pm), and the lowest point is reached during sleep
between 0400 and 0600 hours (4:00 am and 6:00 am) 1. pyrexia, hyperthermia or (in lay terms) fever. –
(Figure 29–3 •). Older adults’ temperatures may vary A body temperature above the usual range
less than those of younger persons due to the changes 2. hyperpyrexia- A very high fever, such as 41°C
in autonomic functioning common in aging (105.8°F).
(Marigold, Arias, 3. febrile- The client who has a fever
Vassallo,Allen, & Kwan, 2011). 4. afebrile- the one who does not
3. Exercise. Hard work or strenuous exercise can
increase body temperature to as high as 38.3°C to
40°C (101°F to 104°F) measured rectally.
4. Hormones. Women usually experience more
hormone fluctuations than men. In women,
progesterone secretion at the time of ovulation raises Four common types of fevers;
body temperature by about 0.3°C to 0.6°C
(0.5°F to 1.0°F) above basal temperature. 1. intermittent fever- the body temperature
alternates at regular intervals between periods of
fever and periods of normal or subnormal
temperatures. An example is with the disease
malaria.
2. remittent fever- such as with a cold or influenza, a
wide range of temperature fluctuations (more than
2°C [3.6°F]) occurs over a 24-hour period, all of
which are above normal.
Persons experiencing heat stroke generally have
been exercising in hot weather, have warm, flushed
skin, and often do not sweat. They usually have a
temperature of 41.1°C (106°F) or higher, and may be
delirious, unconscious, or having seizures.

3. relapsing fever- short febrile periods of a few days

are interspersed with periods of 1 or 2 days of normal
temperature.

4. constant fever- the body temperature fluctuates

minimally but always remains above normal. This
can occur with typhoid fever. A temperature that rises
to fever level rapidly following a normal
temperature and then returns to normal within a few
hours called a fever spike. Bacterial blood infections
often cause fever spikes.

An elevated temperature is not a true fever.

Two examples are:

Heat exhaustion- is a result of excessive heat and

dehydration. Signs of heat exhaustion include

HYPOTHERMIA- is a core body temperature

below the lower limit of normal.

three physiological mechanisms of hypothermia:

(a) excessive heat loss,
(b) inadequate heat production to counteract
heat loss,
(c) impaired hypothalamic thermoregulation.

Accidental hypothermia can occur as a result:

(a) exposure to a cold environment,
(b) immersion in cold water,
(c) lack of adequate clothing, shelter, or heat.

paleness, dizziness, nausea, vomiting, fainting, and a

moderately increased temperature (38.3°C to 38.9°C
[101°F to 102°F]).
 both inpatient and ambulatory care settings.

5. The temperature may also be measured on the

forehead using a chemical thermometer or a
temporal artery thermometer. Forehead
temperature measurements are most useful for infants
and children when a more invasive measurement is
not necessary.

TYPES OF THERMOMETERS
Assessing Body Temperature
most common sites for measuring body temperature: Electronic thermometers can provide a reading in
1. The body temperature may be measured orally. If
a client has been taking cold or hot food or fluids or
smoking, the nurse should wait 30 minutes before
taking the temperature orally to ensure that the
temperature of the mouth is not affected by the
temperature of the food, fluid, or warm smoke.

2. Rectal temperature readings are considered to be

very accurate. Rectal temperatures are
contraindicated for clients who are undergoing
rectal surgery, have diarrhea or diseases of the
rectum, are immunosuppressed,
have a clotting disorder, or have significant
hemorrhoids.

3. The axillary is often the preferred site for

measuring temperature in newborns because it is
accessible and safe. Axillary temperatures
are lower than rectal temperatures. Some clinicians
recommend rechecking an elevated axillary
temperature with one taken from another
site to confirm the degree of elevation. Nurses should
check agency protocol when taking the temperature
of newborns, infants, toddlers, and children. Adult
clients for whom the axillary method of temperature
assessment is appropriate include those for whom
other temperature sites are contraindicated.
4. The tympanic membrane, or nearby tissue in the
ear canal, is a frequent site for estimating core body
temperature. However, tympanic
temperature measurements have been shown to be
imprecise (Rubia-Rubia, Arias, Sierra, & Aguirre-
Jaime, 2011). If the probe fits
too loosely in the ear canal, the reading can be lower
than the true value. Electronic tympanic
thermometers are found extensively in
only 2 to 60 seconds, depending on the model. The
equipment consists of an electronic base, a probe, and
a probe cover, which is usually disposable. Some
institutional models have a different circuit and probe
for oral and rectal measurement.
Two special types of oral thermometers are basal
and hypothermia.
A basal thermometer is calibrated with 0.1°F
intervals and is for fertility purposes, indicating the
temperature rise that is associated with ovulation.
Hypothermia thermometers have a greater low
range than everyday thermometers, usually
measuring temperatures from 27.2°C to 42.2°C (81°F
to 108°F).
Chemical disposable thermometers are also used to
measure body temperatures. Chemical thermometers
have liquid crystal dots or bars
that change color to indicate temperature. Some of
these are single use and others may be reused several
times. One type that has small chemical
dots at one end.
To read the temperature, the nurse notes the highest
reading among the dots that have changed
color. These thermometers can be used orally,
rectally, or in the axilla.
Temperature-sensitive tape may also be used to
obtain a general indication of body surface
temperature. It does not indicate the core
temperature. The tape contains liquid crystals that
change color according to temperature. When applied
to the skin, usually of the forehead or abdomen, the
temperature digits on the tape respond by changing
color. The skin area should be dry. After the length of
time specified by the manufacturer (e.g., 15 seconds),
a color appears on the tape. This method is
particularly useful at home and for infants whose
temperatures are to be monitored.
Infrared thermometers sense body heat in the form
of infrared energy given off by a heat source, which,
in the ear canal, is primarily
the tympanic membrane. The infrared thermometer
makes no contact with the tympanic membrane.
Temporal artery thermometers determine
temperature using a scanning infrared thermometer
that compares the arterial temperature in the temporal
artery of the forehead to the temperature in the
room and calculates the heat balance to approximate
the core temperature
of the blood in the pulmonary artery. The probe is
placed in the middle of the forehead and then drawn
laterally to the hairline. If the client has perspiration
on the forehead, the probe is also touched behind the
earlobe so the thermometer can compensate for
evaporative cooling.
TEMPERATURE SCALES
Sometimes a nurse needs to convert a body
temperature reading in Celsius (centigrade) to
Fahrenheit, or vice versa. Although the
conversion can be accomplished using several
different formulas, the most common is described
here. To convert from Fahrenheit to Celsius, deduct
32 from the Fahrenheit reading and then multiply by
the fraction 5/9; that is:
C = (Fahrenheit temperature -32) x 5/9
For example, when the Fahrenheit reading is 100:
C = (100-32) = (68)x 5/9 = 37.8
To convert from Celsius to Fahrenheit, multiply the
Celsius reading by the fraction 9/5 and then add 32;
that is:
F = (Celsius temperature x 9/5) +32
For example, when the Celsius reading is 40:
F = (40 x 9/5) = 72 +32 = 104
PULSE
The pulse is a wave of blood created by contraction of
the left ventricle of the heart. Generally, the pulse
wave represents the stroke volume output or the
amount of blood that enters the arteries with each
ventricular contraction.
Compliance of the arteries is their ability to
contract and expand. When a person’s arteries lose
their distensibility, as can happen with age, greater
pressure is required to pump the
blood into the arteries.
Cardiac output is the volume of blood pumped into
the arteries by the heart and equals the result of the
stroke volume (SV) times the heart rate (HR) per
minute. For example, 65 mL x 70 beats per minute 5
4.55 L per minute. When an adult
is resting, the heart pumps about 5 liters of blood
each minute. In a healthy person, the pulse reflects
the heartbeat; that is, the pulse rate is the same as the
rate of the ventricular contractions of the
heart. However, in some types of cardiovascular
disease, the heartbeat and pulse rates can differ. For
example, a client’s heart may produce
very weak or small pulse waves that are not
detectable in a peripheral pulse far from the heart. In
these instances, the nurse should assess the
heartbeat and the peripheral pulse. A peripheral pulse
is a pulse located away from the heart, for example,
in the foot or wrist. The apical
pulse, in contrast, is a central pulse; that is, it is
located at the apex of the heart. It is also referred to
as the point of maximal impulse (PMI).
Factors Affecting the Pulse
The rate of the pulse is expressed in beats per minute
(beats/min). A pulse rate varies according to a
number of factors. The nurse should
consider each of the following factors when assessing
a client’s pulse:
• Age. As age increases, the pulse rate gradually
decreases overall. See Table 29–2 for specific
variations in pulse rates from birth to adulthood.
• Sex. After puberty, the average male’s pulse rate is
slightly lower than the female’s.
• Exercise. The pulse rate normally increases with
activity. The rate of increase in the professional
athlete is often less than in the average person
because of greater cardiac size, strength, and
efficiency.
• Fever. The pulse rate increases (a) in response to the
lowered blood pressure that results from peripheral
vasodilation associated with elevated body
temperature and (b) because of the increased
metabolic rate.
• Medications. Some medications decrease the pulse
rate, and others increase it. For example, cardiotonics
(e.g., digitalis preparations) decrease the heart rate,
whereas epinephrine increases
it.
• Hypovolemia/dehydration. Loss of blood from the
vascular system increases the pulse rate. In adults, the
loss of circulating volume
results in an adjustment of the heart rate to increase
blood pressure as the body compensates for the lost
blood volume.
• 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. Fear and anxiety as
well as the perception of severe pain stimulate the
sympathetic system.
• Position. When a person is sitting or standing, 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 and increase in heart rate.
• Pathology. Certain diseases such as some heart
conditions or those that impair oxygenation can alter
the resting pulse rate.
Pulse Sites
A pulse may be measured in nine sites:
1. Temporal, where the temporal artery passes over
the temporal bone of the head. The site is superior
(above) and lateral to (away
from the midline of) the eye.
2. Carotid, at the side of the neck where the carotid
artery runs between the trachea and the
sternocleidomastoid muscle. the left side of the chest,
about 8 cm (3 in.) to the left of the sternum
(breastbone) at the fifth intercostal space (area
between the ribs). In older adults, the apex may be
further left if conditions are present that have led to
an enlarged heart. Before 4 years of
age, the apex is left of the midclavicular line (MCL);
between 4 and 6 years, it is at the MCL . For a child 7
to 9 years of age, the apical pulse is located at the
fourth or fifth
intercostal space.
4. Brachial, at the inner aspect of the biceps muscle
of the arm or medially in the antecubital space.
5. Radial, where the radial artery runs along the
radial bone, on the thumb side 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.
8. Posterior tibial, on the medial surface of the ankle
where the posterior
tibial artery passes behind the medial malleolus.
9. Dorsalis pedis, where the dorsalis pedis artery
passes over the bones of the foot, on an imaginary
line drawn from the middle of the ankle to the space
between the big and second toes.
The radial site is most commonly used in adults. It is
easily found in most people and readily accessible.
Assessing the Pulse
A pulse is commonly assessed by palpation (feeling)
or auscultation (hearing). The middle three fingertips
are used for palpating all pulse sites except the apex
of the heart. A stethoscope is used for assessing
apical pulses. A Doppler ultrasound stethoscope is
used for pulses that are difficult to assess. The DUS
headset has earpieces similar to standard stethoscope
earpieces, but it has a long cord attached to a volume-
controlled audio unit and an ultrasound transducer.
The DUS detects movement of red blood cells
through a blood vessel. In contrast to the
conventional stethoscope, it eliminates environmental
sounds.
A pulse is normally palpated by applying moderate
pressure with the three middle fingers of the hand.
The pads on the most distal
aspects of the finger are the most sensitive areas for
detecting a pulse. With excessive pressure, one can
obliterate a pulse, whereas with too little pressure one
may not be able to detect it. Before the nurse assesses
the resting pulse, the client should assume a
comfortable position.
The nurse should also be aware of the following:
• Any medication that could affect the heart rate.
• Whether the client has been physically active. If so,
wait 10 to 15 minutes until the client has rested and
the pulse has slowed to its usual rate.
• Any baseline data about the normal heart rate for
the client. For example, a physically fit athlete may
have a resting heart rate below 60 beats/min.
• Whether the client should assume a particular
position (e.g., sitting). In some clients, the rate
changes with the position because of changes in
blood flow volume and autonomic nervous system
activity. When assessing the pulse, the nurse collects
the following data: the rate, rhythm, volume, arterial
wall elasticity, and presence or
absence of bilateral equality. An excessively fast
heart rate (e.g., over 100 beats/min in an adult) is
referred to as tachycardia. A heart rate in an adult of
less than 60 beats/min is called bradycardia. If a
client has either tachycardia or bradycardia, the
apical pulse should be assessed.
The pulse rhythm 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
(documented as “regularly irregular”). When a
dysrhythmia is detected, the apical pulse should be
assessed. An electrocardiogram (ECG) is necessary
to define the dysrhythmia further.
Pulse volume, also called the pulse strength or
amplitude, refers to the force of blood with each beat.
Usually, the pulse volume is the same 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 An electrocardiogram (ECG) is necessary to
define the dysrhythmia
further.
Pulse volume, also called the pulse strength or
amplitude, refers to the force of blood with each
beat. Usually, the pulse volume is the same 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.
The elasticity of the arterial wall reflects its
expansibility or its deformities. A healthy, normal
artery feels straight, smooth, soft, and
pliable. Older adults often have inelastic arteries that
feel twisted (tortuous) and irregular on palpation.
When assessing a peripheral pulse to determine the
adequacy of blood flow to a particular area of the
body (perfusion), the nurse
should also assess the corresponding pulse on the
other side of the body. The second assessment gives
the nurse data with which to compare
the pulses. For example, when assessing the blood
flow to the right foot, the nurse assesses the right
dorsalis pedis pulse and then the left dorsalis pedis
pulse. If the client’s right and left pulses are
the same volume and elasticity, the client’s dorsalis
pedis pulses are bilaterally equal. The pulse rate does
not need to be counted when
assessing for perfusion and equality. When a
peripheral pulse is located, it indicates that pulses
more proximal to that location will also be present.
For example, if the dorsalis pedis, the most distal
pulse of the lower extremity, cannot be felt, the nurse
next palpates for the posterior tibial pulse. If it is not
felt, the popliteal pulse must be assessed. If the
popliteal pulse is found, it is
not necessary to assess the femoral pulse since it
must also be present in order for the more distal pulse
to exist.
Apical Pulse Assessment
Assessment of the apical pulse is indicated for
clients whose peripheral pulse is irregular or
unavailable and for clients with known
cardiovascular, pulmonary, and renal diseases. It is
commonly assessed prior to administering
medications that affect heart rate. The apical
site is also used to assess the pulse for newborns,
infants, and children up to 2 to 3 years old.
APICAL-RADIAL PULSE ASSESSMENT
An apical-radial pulse may need to be assessed for
clients with certain cardiovascular disorders.
Normally, the apical and radial rates are identical.
An apical pulse rate greater than a radial pulse rate
can indicate that the thrust of the blood from the heart
is too weak for the wave to be felt at the peripheral
pulse site, or it can indicate that vascular disease is
preventing impulses from being transmitted. Any
discrepancy between the two pulse rates is called a
pulse deficit and needs to be reported promptly. In no
instance is the radial pulse greater than the apical
pulse.
An apical-radial pulse can be taken by two nurses or (H+) in the arterial blood
one nurse, although the two-nurse technique may be
more accurate.

RESPIRATIONS
Respiration is the act of breathing. Inhalation or
inspiration Refers to the intake of air into the lungs.
Exhalation or expiration refers to breathing out or the
movement of gases from the lungs to the atmosphere.
Ventilation is also used to refer to the movement of
air in and out of the lungs.
There are basically two types of breathing: costal
(thoracic) breathing and diaphragmatic (abdominal)
breathing.
Costal breathing involves the external intercostal
muscles and other accessory muscles, such as the
sternocleidomastoid muscles. It can be observed by
the movement of the chest upward and outward. By
contrast, diaphragmatic breathing involves the
contraction and 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.

Mechanics and Regulation of Breathing

During inhalation, the following processes
normally occur: The diaphragm contracts (flattens),
the ribs move upward and outward, and the sternum
moves outward, thus enlarging the thorax and
permitting the lungs to expand. During exhalation,
the diaphragm relaxes, the ribs move downward and
inward, and the sternum moves inward, thus
decreasing the size of the thorax as the lungs are
compressed. Normal breathing is automatic and
effortless. A normal adult inspiration lasts 1 to 1.5
seconds, and an expiration lasts 2 to 3 seconds.
Respiration is controlled by (a) respiratory centers
in the medulla oblongata and the pons of the brain
and (b) chemoreceptors
located centrally in the medulla and peripherally
in the carotid and aortic bodies. These centers and
receptors respond to changes in the concentrations of
oxygen (O2), carbon dioxide (CO2), and hydrogen
Assessing Respirations
Resting respirations should be assessed when the
client is relaxed because exercise affects respirations,
increasing their rate and depth.
Anxiety is likely to affect respiratory rate and depth
as well. Respirations may also need to be assessed
after exercise to identify the client’s
tolerance to activity. Before assessing a client’s
respirations, a nurse should be aware of the
following:
• The client’s normal breathing pattern
• The influence of the client’s health problems on
respirations
• Any medications or therapies that might affect
respirations
• The relationship of the client’s respirations to
cardiovascular function.
The rate, depth, rhythm, quality, and effectiveness of
respirations should be assessed. The respiratory rate
is normally described in
breaths per minute. Breathing that is normal in rate
and depth is called eupnea. Abnormally slow
respirations are referred to as bradypnea,
and abnormally fast respirations are called tachypnea
or polypnea.
Apnea is the absence of breathing.
Factors Affecting Respirations
Several factors influence respiratory rate. Those
that increase the rate include exercise (increases
metabolism), stress (readies the body for “fight or
flight”), increased environmental temperature, and
lowered oxygen concentration at increased altitudes.
Factors that may decrease
the respiratory rate include decreased environmental
temperature, certain medications (e.g., narcotics), and
increased intracranial pressure. The depth of a
person’s respirations can be established by watching
the movement of the chest. Respiratory depth is
generally described
as normal, deep, or shallow. Deep respirations are
those in which a large volume of air is inhaled and
exhaled, inflating most of the lungs. Shallow
respirations involve the exchange of a small volume
of air and often the minimal use of lung tissue.
During a normal inspiration and expiration, an adult
takes in about 500 mL of air. This
volume is called the tidal volume. For further
information about pulmonary volumes and
pulmonary capacities, see Chapter 50 .
Body position also affects the amount of air that can
be inhaled. People in a supine position experience
two physiological processes
that suppress respiration: an increase in the volume of
blood inside the thoracic cavity and compression of
the chest. Consequently,
clients lying on their back have poorer lung aeration,
which predisposes them to the stasis of fluids and
subsequent infection. Certain
medications also affect the respiratory depth. For
example, narcotics such as morphine and large doses
of barbiturates such as pentobarbital
depress the respiratory centers in the brain, thereby
depressing the respiratory rate and depth.
Hyperventilation refers to very deep, rapid
respirations; hypoventilation refers to very shallow
respirations.
Respiratory rhythm refers to the regularity of the
expirations and the inspirations. Normally,
respirations are evenly spaced. Respiratory
rhythm can be described as regular or irregular. An
infant’s respiratory rhythm may be less regular than
an adult’s. See Chapter 50 for details about abnormal
respiratory rhythms.
Respiratory quality or character refers to those aspects
of breathing that are different from normal, effortless
breathing. Two of these aspects are the amount of
effort a client must exert to breathe and the sound of
breathing. Usually, breathing does not require
noticeable
effort. Sometimes, however, clients can breathe only
with substantial effort—this is referred to as labored
breathing. The sound of breathing is also significant.
Normal breathing is silent, but a number of abnormal
sounds such as a wheeze are obvious to the nurse’s
ear. Many sounds occur as a result of the presence of
fluid in the lungs and are most clearly heard with a
stethoscope. See
Chapter 30 for methods used to assess lung sounds.
For details about altered breathing patterns and terms
used to describe various
patterns and sounds, see Box 29–5.
The effectiveness of respirations is measured in part
by the uptake of oxygen from the air into the blood
and the release of carbon dioxide from the blood into
expired air. The amount of hemoglobin
in arterial blood that is saturated with oxygen can be
measured indirectly through pulse oximetry. A pulse
oximeter provides a digital readout of both the
client’s pulse rate and the oxygen saturation.
BLOOD PRESSURE
Arterial blood pressure is a measure of the pressure
exerted by the blood as it flows through the arteries.
Because the blood moves in waves, there are two
blood pressure measurements.
The systolic pressure is the pressure of the blood as a
result of contraction of the ventricles, that is, the
pressure of the height of the blood wave.
The diastolic pressure is the pressure when the
ventricles are at rest. Diastolic pressure, then, is the
lower pressure, present at all times within the
arteries. The difference between the diastolic and
the systolic pressures is called the pulse pressure. A
normal pulse pressure is about 40 mmHg but can be
as high as 100 mmHg during
exercise. Blood pressure is measured in millimeters
of mercury (mmHg) and recorded as a fraction:
systolic pressure over the diastolic pressure. A typical
blood pressure for a healthy adult is 120/80 mmHg
(pulse pressure of 40). Because blood pressure can
vary considerably
among individuals, it is important for the nurse to
know a specific client’s baseline blood pressure. For
example, if a client’s usual blood
pressure is 180/100 mmHg, and it is assessed
following surgery to be 120/80 mmHg, this
significant drop in pressure may indicate
complications and must be reported to the primary
care provider. A consistently elevated pulse pressure
occurs in arteriosclerosis.
A low pulse pressure (e.g., less than 25 mmHg)
occurs in conditions such as severe heart failure.
Sometimes, it is useful to also determine the mean
arterial pressure (MAP) because this represents the
pressure actually delivered to the body’s organs. The
MAP can be calculated
in several different ways, one of which is to add two-
thirds of the diastolic pressure to one-third of the
systolic pressure. A normal
MAP is 70 to 110 mmHg.
Determinants of Blood Pressure
Arterial blood pressure is the result of several factors:
the pumping action of the heart, the peripheral
vascular resistance (the resistance
supplied by the blood vessels through which the
blood flows), and the blood volume and viscosity.
PUMPING ACTION OF THE HEART
When the pumping action of the heart is weak, less
blood is pumped into arteries (lower cardiac output),
and the blood pressure decreases.
When the heart’s pumping action is strong and the
volume of blood pumped into the circulation
increases (higher cardiac output), the blood pressure
increases.
PERIPHERAL VASCULAR RESISTANCE
Peripheral resistance can increase blood pressure.
The diastolic pressure especially is affected. Some
factors that create resistance in the arterial system are
the capacity of the arterioles and capillaries, the
compliance of the arteries, and the viscosity of the
blood. The internal diameter or capacity of the
arterioles and the capillaries
determines in great part the peripheral resistance to
the blood in the body. The smaller the space within a
vessel, the greater the resistance.
Normally, the arterioles are in a state of partial
constriction. Increased vasoconstriction, such as
occurs with smoking, raises the blood pressure,
whereas decreased vasoconstriction lowers the blood
pressure.
If the elastic and muscular tissues of the arteries are
replaced with fibrous tissue, the arteries lose much of
their ability to constrict and dilate. This condition,
most common in middle-aged and older
adults, is known as arteriosclerosis.
BLOOD VOLUME
When the blood volume decreases (for example, as a
result of a hemorrhage or dehydration), the blood
pressure decreases because of decreased
fluid in the arteries. Conversely, when the volume
increases (for example, as a result of a rapid
intravenous infusion), the blood pressure increases
because of the greater fluid volume within the
circulatory system.
BLOOD VISCOSITY
Blood pressure is higher when the blood is highly
viscous (thick), that is, when the proportion of red
blood cells to the blood plasma is high. This
proportion is referred to as the hematocrit. The
viscosity increases markedly when the hematocrit is
more than 60% to 65%.
Factors Affecting Blood Pressure
Among the factors influencing blood pressure are
age, exercise, stress, race, gender, medications,
obesity, diurnal variations, medical conditions,
and temperature.
• Age. Newborns have a systolic pressure of about 75
mmHg. The pressure rises with age, reaching a peak
at the onset of puberty, and then tends to decline
somewhat. In older adults, elasticity of
the arteries is decreased—the arteries are more rigid
and less yielding to the pressure of the blood. This
produces an elevated systolic pressure. Because the
walls no longer retract as flexibly with decreased
pressure, the diastolic pressure may also be high.
• Exercise. Physical activity increases the cardiac
output and hence the blood pressure. For reliable
assessment of resting blood pressure,
wait 20 to 30 minutes following exercise.
• Stress. Stimulation of the sympathetic nervous
system increases cardiac output and vasoconstriction
of the arterioles, thus increasing
the blood pressure reading; however, severe pain can
decrease blood pressure greatly by inhibiting the
vasomotor center and producing vasodilation.
• Race. African Americans older than 35 years tend to
have higher blood pressures than European
Americans of the same age although
the exact reasons for these differences are unclear
(Covelli, Wood, & Yarandi, 2012).
• Sex. After puberty, females usually have lower
blood pressures than males of the same age; this
difference is thought to be due to hormonal
variations. After menopause, women generally have
higher blood pressures than before.
• Medications. Many medications, including caffeine,
may increase or decrease the blood pressure.
• Obesity. Both childhood and adult obesity
predispose to hypertension.
• Diurnal variations. Pressure is usually lowest early of less than 90 mmHg. For all other individuals, the
in the morning, when the metabolic rate is lowest, goal is less than 140/90 mmHg (James et al., 2014).
then rises throughout the day and peaks in the late
afternoon or early evening.
• Medical conditions. Any condition affecting the
cardiac output, blood volume, blood viscosity, and/or
compliance of the arteries has a direct effect on the Hypotension
blood pressure. Hypotension is a blood pressure that is below normal,
• Temperature. Because of increased metabolic rate, that is, a systolic reading consistently between 85 and
fever can increase blood pressure. However, external 110 mmHg in an adult whose normal pressure is
heat causes vasodilation and decreased blood higher than this. Orthostatic
pressure. Cold causes vasoconstriction and
elevates blood pressure.
Hypertension
A blood pressure that is persistently above normal is
called hypertension. A single elevated blood pressure
reading indicates the need for reassessment.
Hypertension cannot be diagnosed unless an
elevated blood pressure is found when measured
twice at different
times. It is usually asymptomatic and is often a
contributing factor to myocardial infarctions (heart
attacks). An elevated blood pressure
of unknown cause is called primary hypertension.

An elevated blood pressure of known cause is called

secondary hypertension.
Hypertension is a widespread health problem.
Individuals with diastolic blood pressures of 80 to
89 mmHg or systolic blood pressures of 120 to 139
Hypotension is a blood pressure that decreases when
mmHg should be considered prehypertensive and,
the client sits or stands. It is usually the result of
without intervention, may develop cardiac disease.
peripheral vasodilation in which
Hypertension is when either the systolic BP is higher
blood leaves the central body organs, especially the
than 140 mmHg or when the
brain, and moves to the periphery, often causing the
diastolic blood pressure (BP) is 90 mmHg or higher
person to feel faint. Hypotension
(see Table 29–4). The stage of hypertension is
can also be caused by analgesics such as meperidine
determined by the higher of the two values. For
hydrochloride (Demerol), bleeding, severe burns, and
example, if either of the systolic or diastolic values
dehydration. It is important
falls in the stage 2 range, stage 2 hypertension is
to monitor hypotensive clients carefully to prevent
assigned. Factors associated
falls. When assessing for orthostatic hypotension:
with hypertension include thickening of the arterial
• Place the client in a supine position for 10 minutes.
walls, which reduces the size of the arterial lumen,
• Record the client’s blood pressure.
and inelasticity of the arteries
• Assist the client to slowly sit or stand. Support the
as well as such lifestyle factors as cigarette smoking,
client in case of faintness.
obesity, heavy alcohol
• Immediately recheck the blood pressure in the same
consumption, lack of physical exercise, high blood
sites as previously.
cholesterol levels, and continued exposure to stress.
• Repeat the pulse and blood pressure after 3 minutes.
The national guidelines for high blood pressure
• Record the results. A drop in blood pressure of 20
management recommend that hypertensive
mmHg systolic or 10 mmHg diastolic indicates
individuals age 60 years or older receive treatment
orthostatic hypotension
toward a goal of less than 150/90 mmHg and
(Mager, 2012).
hypertensive individuals age 30 through 59 years
have a diastolic goal
Assessing Blood Pressure
Blood pressure is measured with a blood pressure
cuff, a sphygmomanometer, and a stethoscope. The
blood pressure cuff consists of a bag, called a
bladder, that can be inflated with air (Figure 29–18 •).
It is covered with cloth and has two tubes attached to
it. One tube connects to a bulb that inflates the
bladder. A small valve on the side of
this bulb traps and releases the air in the bladder.
The other tube is attached to a sphygmomanometer.
The sphygmomanometer indicates the pressure of the
air within the
bladder. There are two types of sphygmomanometers:
aneroid and digital. The aneroid sphygmomanometer
has a calibrated dial with a needle that points to the
calibrations (Figure 29–19 •). Many agencies use
digital (electronic) sphygmomanometers (Figure 29–
20 •), which eliminate the need to listen for the (McFarlane, 2012). Blood pressure cuffs are made of
sounds of the client’s systolic and diastolic blood nondistensible material so that an even pressure is
pressures through a stethoscope. Electronic blood exerted around the limb. Most cuffs are held in place
pressure devices should be calibrated by hooks, snaps, or hook-and-loop fabric. Others
periodically to check accuracy. All health care have a cloth bandage that is long enough to encircle
facilities should have manual blood pressure the limb several times;this type is closed by tucking
equipment available as backup. Doppler ultrasound the end of the bandage into one of the bandage folds.
stethoscopes are also used to assess blood pressure
(see Figure 29–15). These are of particular value
when blood pressure sounds are difficult to hear, such
as in infants, obese clients,
and clients in shock. Systolic pressure may be the
only blood pressure obtainable with some ultrasound
models. Blood pressure cuffs come in various sizes
because the bladder
must be the correct width and length for the client’s
arm (figure 29–21 •). If the bladder is too narrow, the
blood pressure reading will be 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 arm
circumference, not the age of the client, should
always be used to determine bladder size. The nurse
can determine whether the width of a blood pressure
cuff is appropriate:
Lay the cuff lengthwise at the midpoint of the upper
arm, and hold the outermost side of the bladder edge
laterally on the arm. With the
other hand, wrap the width of the cuff around the
arm, and ensure that the width is 40% of the arm
circumference (Figure 29–22 •). The length of the
bladder also affects the accuracy of measurement.
The bladder should be sufficiently long to cover at
least two-thirds of the limb’s circumference. For
obese clients, a standard sized bladder in an extra-
long cuff may be the most appropriate
 The blood pressure is usually assessed in the client’s
upper arm using the brachial artery and a standard
stethoscope. Assessing the blood
pressure on a client’s thigh is indicated in these
h situations:
• The blood pressure cannot be measured on either
arm (e.g., because of burns or other trauma).
• The blood pressure in one thigh is to be compared
with the blood pressure in the other thigh. Blood
pressure is not measured on a particular client’s limb
in the following
situations:
• The shoulder, arm, or hand (or the hip, knee, or
ankle) is injured or diseased.
• A cast or bulky bandage is on any part of the limb.
• The client has had surgical removal of breast or
axillary (or inguinal) lymph nodes on that side.
• The client has an intravenous infusion or blood
transfusion in that limb.
• The client has an arteriovenous fistula (e.g., for
renal dialysis) in that limb.

METHODS
Blood pressure can be assessed directly or indirectly.
Direct (invasive monitoring) measurement involves
the insertion of a catheter into the brachial, radial, or
femoral artery. Arterial pressure is represented as
wavelike forms displayed on a monitor. With correct
placement,
this pressure reading is highly accurate.
Two noninvasive indirect methods of measuring
blood pressure are the auscultatory and palpatory
methods. The auscultatory method is most commonly
used in hospitals, clinics, and homes. External
pressure is applied to a superficial artery and the
nurse reads the pressure from the
sphygmomanometer while listening with a
stethoscope. When carried out correctly, the
auscultatory method is relatively accurate.
BLOOD PRESSURE ASSESSMENT SITES
When taking a blood pressure using a stethoscope,
the nurse identifies phases in the series of sounds
called Korotkoff’s sounds (Figure 29–23 •). Five phases
occur but may not always be audible
(Box 29–6). The systolic pressure is the point where
the first tapping sound is heard (phase 1). In adults,
the diastolic pressure is the point
where the sounds become inaudible (phase 5). The
phase 5 reading may be zero; that is, the muffled
sounds are heard even when there is
no air pressure in the blood pressure cuff. For
complete accuracy, the phase 4 and 5 readings should
be recorded. The palpatory method is sometimes used
when Korotkoff ’s sounds cannot be heard and
electronic equipment to amplify the
sounds is not available, or to prevent misdirection
from the presence of an auscultatory gap. An
auscultatory gap, which occurs particularly in
hypertensive clients, is the temporary disappearance
of sounds normally heard over the brachial artery
when the cuff pressure
is high followed by the reappearance of the sounds at
a lower level. This temporary disappearance of
sounds occurs in the latter
part of phase 1 and phase 2 and may cover a range of
40 mmHg. If a palpated estimation of the systolic
pressure is not made prior to auscultation,
the nurse may begin listening in the middle of this
range and underestimate the systolic pressure. In the
palpatory method of blood pressure determination,
instead of listening for the blood flow sounds, the
nurse uses light to moderate pressure to palpate the
pulsations of the artery as the pressure in the cuff is
released. The pressure
is read from the sphygmomanometer when the first
pulsation is felt. A single whiplike vibration, felt in
addition to the pulsations, identifies the point at
which the pressure in the cuff nears the diastolic
pressure. This vibration is no longer felt when the
cuff pressure is below the diastolic pressure.
Common Errors in Assessing
Blood Pressure
The importance of the accuracy of blood pressure
assessments cannot be overemphasized. Many
judgments about a client’s health are
made based on blood pressure. It is an important
indicator of the client’s condition and is used
extensively as a basis for nursing interventions.
Two possible reasons for blood pressure errors are
hurrying on the part of the nurse and subconscious
bias in which a nurse may
be influenced by the client’s previous blood pressure
measurements or diagnosis and “hear” a value
consistent with the nurse’s expectations.
OXYGEN SATURATION
A pulse oximeter is a noninvasive device that
estimates a client’s arterial blood oxygen saturation
(SaO2) by means of a sensor attached to the client’s
finger (Figure 29–25 •), toe, nose, earlobe,
or forehead (or around the hand or foot of a neonate).
The oxygen saturation value is the percent of all
hemoglobin binding sites that
are occupied by oxygen. The pulse oximeter can
detect hypoxemia (low oxygen saturation) before
clinical signs and symptoms, such as a dusky color to
skin and nail beds, develop. The pulse oximeter’s
sensor has two parts: (a) two light-emitting diodes
(LEDs)—one red, the other infrared—that transmit
light through nails, tissue, venous blood, and arterial
blood; and (b) a
photodetector placed directly opposite the LEDs
(e.g., the other side of the finger, toe, or nose).
Because the photodetector measures the
amount of red and infrared light absorbed by
oxygenated and deoxygenated
hemoglobin in peripheral arterial blood, it is reported
as SpO2. Normal oxygen saturation is 95% to 100%,
and below 70% is
life threatening. Pulse oximeters with various types
of sensors are available from
several manufacturers. The oximeter unit consists of
an inlet connection for the sensor cable, and a
faceplate that indicates (a) the oxygen
saturation measurement and (b) the pulse rate.
Cordless units are also available (Figure 29–26 •). A
preset alarm system signals high and
low SpO2 measurements and a high and low pulse
rate. The high and low SpO2 levels are generally
preset at 100% and 85%, respectively,
for adults. The high and low pulse rate alarms are
usually preset at 140 and 50 beats/min for adults.
These alarm limits can, however, be
changed using the manufacturer’s directions.
Factors
Affecting
Oxygen
Saturation
Readings
Among the
factors
influencing
oxygen
saturation
readings are
hemoglobin levels, circulation, activity, and exposure
to carbon monoxide.
• Hemoglobin. If the hemoglobin is fully saturated
with oxygen, the SpO2 will appear normal even if the
total hemoglobin level is low. Thus, the client could
be severely anemic and have inadequate
oxygen to supply the tissues but the pulse oximeter
would return a normal value.
• Circulation. The oximeter will not return an
accurate reading if the area under the sensor has
impaired circulation.
• Activity. Shivering or excessive movement of the
sensor site may interfere with accurate readings.
• Carbon monoxide poisoning. Pulse oximeters
cannot discriminate between hemoglobin saturated
with carbon monoxide versus
oxygen. In this case, other measures of oxygenation
are needed.