VITAL SIGNS
The frequency of taking the TPR depends
Also called cardinal signs
Term that includes temperature, pulse,
respiration and blood pressure.
– should be looked @ in total with objectivity:
a. thoughtful
b. scientific assessment
Pain – often called the 5th vital sign
These signs provide excellent clues to the
physiological functioning of the body
- change in VS may indicate a change of
health.
— Routinely done or more frequently –
depending on patient’s condition ex.
Post-op – Monitor every 15 mins. for 2º
- (when and how to assess the clients VS
depends on the nurse judgment, client’s
health status, and doctor’s order)
— Examples of appropriate times to
measure VS:
1. screenings at health fairs and clinics
2. at home
3. upon admission to a healthcare
setting
4. when certain medications are given
5. before and after diagnostic and
surgical
procedures
6. before and after certain nursing
interventions
7. emergency situations
TPR results are recorded on the bedside flow
chart, bedside computer terminal, central
clipboard in the nursing station and/or graphic
record in patient’s chart
Measured by both professional (registered
nurse) and assistive personnel except for apical
pulse-midclavicular line 5th ICS, nipple line
Can be delegated but it is nurse’s responsibility
to ensure accuracy of the data, interpret
vital sign findings, and to report
abnormal findings
Purposes in taking vital signs:
1. To afford an opportunity to observe the
general condition of the patient.
2. To serve as guide in meeting the needs
of the patient.
3. To aid the physician in making his
diagnosis and planning the patients care.
General Considerations:
1. Before vital signs are taken, be sure that
patient has rested and is placed on a
comfortable position.
2.
upon the condition of the patient and
the policy of the agency.
3. Inform the physician or head nurse
promptly for any significant change in
the vital signs.
4. Explain the procedure to the patient so
that he/she will feel at ease.
When to assess VS:
1. On admission to a health care agency to
obtain baseline data.
2. When a client has a change in health
status or reports symptoms such as
chest pain or feeling hot or faint.
3. Before and after surgery or an invasive
procedure.
4. Before and/or after the administration
of a medication that could affect the
respiratory or cardiovascular systems,
for example, before giving a digitalis
preparation.
5. Before and after any nursing
intervention that could affect the vital
signs.
(e.g., ambulating a client who has been
on bed rest.)
TEMPERATURE
— balance between heat produced by the
body and heat lost from the body
— HYPOTHALAMUS – heat regulating
system
KINDS OF BODY TEMPERATURE
1. Core temperature – temperature of the
deep tissues of the body Example:
rectum and tympanic membrane. Can
also be measured in esophagus,
pulmonary artery and bladder by
invasive monitoring device
2. Surface body temperature – is the
temperature of the skin, the
subcutaneous tissue and fat Ex. Oral
(sublingual) and axillary sites
Factors that affect the body’s heat production
1. AGE – temperature regulation is
unstable until CHILDREN reach puberty.
The normal temperature range gradually
drops as individual approach adulthood.
OLDER ADULTS are sensitive to
temperature extremes because of
deterioration in control mechanisms
(lack of central heating), particularly
poor vasomotor control (lack of activity),
reduced amount of subcutaneous tissue,
reduced sweat gland activity, and
reduced metabolism
 2. INFECTION – due to inflammatory
process
3. Temperature of ENVIRONMENT – if
temperature is assessed in a very warm
room, a client maybe unable to regulate
body temperature by heat loss
mechanisms, and the body temperature
will be elevated
4. Amount of EXERCISE – muscle activity
increases metabolism which causes an
increase in heat production. Increased
metabolism causes an increase in body
temperature.
5. METABOLISM – the complex of physical
and chemical processes concerned with
the disposition of the nutrients
absorbed into the blood following
digestion
Basal Metabolic Rate - is the rate of energy
utilization in the body required to maintain
essential activities
6. EMOTIONAL STATUS – physical and
emotional stress increase body
temperature through hormonal and
neural stimulation
7. CIRCADIAN RHYTHM – also known as
diurnal variations. The temperature is
usually lowest between 1:00 – 4:00 am.
During the day, body temperature rises
steadily, until about 6:00 pm, and then
declines to early morning levels
8. HORMONE LEVEL – among women,
there is a rise in body temperature of 0.4
– 1.0˚C following ovulation. The
temperature shift is caused by
progesterone. When the temperature
rises to such degree, it indicates that
ovulation is about to occur
PROCESS INVOLVED IN HEAT LOSS AND HEAT
GAIN
1. RADIATION- is the transfer of heat from
the surface of one object to the surface
of another without direct contact
between the two. Radiation occurs
between heat transfers through
electromagnetic waves.
2. EVAPORATION – is the transfer of heat
energy when a liquid is changed to a gas.
3. CONDUCTION – is the transfer of heat
from one object to another with direct
contact. When the warm skin touches a
cooler object, heat is lost.
4. CONVECTION – is the transfer of heat
away by air movement. Heat is first
conducted to air molecules directly in
contact with skin. Air currents carry
away the warmed air.
ABNORMALITIES OF BODY TEMPERATURE
• pyrexia / hyperthermia
- elevation in body temperature
Classification of Hyperthermia
˚C ˚F
High fever 39 – 41 103 - 106
Moderate fever 38 – 39 101 - 103
Slightly febrile 37 – 38 99 - 101
PATTERNS OF FEVER
1. CONTINUOUS OR CONSTANT FEVER – a
fever is said to be continuous when it
remains constantly high but with slight
variation in its diurnal fluctuations.
Example: Pneumonia, typhoid fever.
Does not vary more than two degrees
and does not go down to normal.
2. INTERMITTENT FEVER – this is marked
by very wide ranges between
fluctuation, the temperature alternately
rising to about 104˚F or 40˚C or over, and
then falling to or even below normal as
in malaria
3. REMITTENT FEVER – there is a moderate
range between the highest and lowest
points, but the temperature until the
convalescence begins is always above
normal. Examples: Typhoid fever and
septic fever. May vary more than two
degrees and does not go down to
normal.
4. RECURRENT OR RELAPSING FEVER – it
pertains to a fever that follows a period
of normal to subnormal. ( 1 – 2 days)
• Hypothermia
refers to abnormally low temperature
Classification of Hypothermia
˚C ˚F
Mild 33.1 – 36 91.5 – 96.8
Moderate 30.1 – 33 86.1 – 91.4
Severe 27 – 30 80.6 – 86
Profound Less than 27 Less than 80.6
HEAT STROKE – prolonged exposure to the sun
or high environmental temperatures can
overwhelm the body’s heat loss mechanisms
HEAT EXHAUSTION – occurs when profuse
diaphoresis results in excess water and
electrolyte loss. It is caused by environmental
heat exposure, the signs and symptoms of fluid
volume deficit are common.
FROSTBITE – occurs when the body is exposed to
subnormal temperatures. Ice crystals forming
inside the cell can result in permanent
circulatory and tissue damage. Areas particularly
susceptible to frost bite are ear lobes, tip of the
nose, fingers and toes. The injured area is white,
waxy and firm to the touch.
METHODS OF MEASURING BODY TEMPERATURE
Oral Method 3 minutes
Rectal Method 2- 3 minutes
Axillary Method 10 minutes
TYPES OF THERMOMETERS
Glass thermometers – contain mercury; no
longer the instrument of choice because of
hazards of mercury spill.
Electronic thermometers – available for oral
and rectal use. Makes use of thermistor –
contain stainless probe to sense temperature
Tympanic thermometer
– also an electronic thermometer. Makes use of
infrared technology (reflectance) to measure the
temperature on the tympanic membrane
Chemical dot thermometers
– for one-time use. They are disposable and
consist of a flat plastic device holding many
temperature-sensing chemical “dots” that
change color when they reach a certain
temperature. Advantages include it is
inexpensive, unbreakable, and suitable for use in
an isolation room.
Infrared thermometers measure temperature
using blackbody radiation (generally infrared)
emitted from objects. They are sometimes called
laser thermometers if a laser is used to help aim
the thermometer, or non-contact
thermometers to describe the device’s ability to
measure temperature from a distance.
CONVERSION FORMULA
Rule: to change from Fahrenheit to Celsius
Subtract 32 degrees from the Fahrenheit reading
Multiply by 5/9
˚C = (F-32) x 5/9
Rule: to change from Celsius to Fahrenheit
Multiply Celsius reading by 9/5
Add 32
˚F = (9/5 ˚C) + 32
PULSE
It is an index of heart rate and rhythm. It is the
palpable bounding of blood flow noted at
various points on the body
It is a throbbing sensation that can be palpated
over a peripheral artery or auscultated (listened
to) over the apex of the heart. It results from a
wave of blood being pumped into the arterial
circulation by the contraction of the left
ventricle.
Circulation – is the means by which cells receive
nutrients and remove waste products of
metabolism.
Characteristics of the pulse, including rate,
quality(amplitude), and rhythm provide
information about the effectiveness of the heart
as a pump and the adequacy of peripheral blood
flow.
The heart normally pumps about 5 liters of blood
or 5000 ml through the body each minute.
Pulse rates – are measured in beats per minute
Amplitude – describes the quality of the pulse in
terms of its fullness. It is assessed by the feel of
the blood flow through the vessel
Pulse rhythm – is the pattern of the pulsations
and the pauses between them. It is normally
regular; the pulsations and the pauses between
occur at regular intervals. An irregular pulse
rhythm occurs when the pulsations and pauses
between beats occur at unequal intervals.
FACTORS AFFECTING THE PULSE RATE
Changes in body temperature
• Exercise
• Medications
• Emotions
• Hemorrhage
• Heart disease
• Age/position
ASSESSMENT OF PULSE
1. By palpating peripheral arteries
2. By auscultating the apical pulse with
stethoscope
3. By using a portable Doppler ultrasound
PERIPHERAL PULSES
Pulses located away from the heart
Sites where the pulse waves palpated at the
arteries are close to the surface
Palpated using the tips of two or three fingers
NOT THE THUMB because it has a pulse of its
own
Pulse points are called temporal, carotid,
brachial, radial, femoral, popliteal, dorsalis
pedis, posterior tibial
Supine position- easiest way to assess peripheral
pulses
Dorsalis pedis and posterior tibial pulses- used
to assess the circulation of the foot and is
referred to as pedal pulses.
APICAL PULSE
Central pulse, measured by listening over the
apex of the heart on the left side of the chest
using the diaphragm of the stethoscope.
Found at the 5th intercostals space just inside the
mid-clavicular line
Counted and measured for a Full 60 secs.
APICAL-RADIAL pulses- assessed when a patient
has a cardiovascular disorder. Two people count
the radial pulse and the apical pulse
simultaneously for exact comparison of the two
pulses and is recorded.
Gadget: stethoscope, wrist watch with second
hand
PARTS OF STETHOSCOPE
INTERMITTENT PULSE – when there is an
intermission of pulsation of regular or irregular
intervals, there is a missing beat.
Water Hammer or Corrigan’s pulse – is an
abnormal condition characterized by a quick
powerful beat which suddenly collapses.
Arrhythmia – is the absence of rhythm.
Thready Pulse – is one that is very fine and
scarcely perceptible.
Running Pulse – is when there are more than
120 pulsation per minute for adults.

Ear tips/ ear piece – allows sound to be heard by Infrequent Pulse - is one which is abnormally
the user. When placing the earpiece in the ear slow.
canal they should be facing in a forward position.
ABNORMAL/IRREGULAR RHYTHM
Binaural/ ear tubes – metal portion of the
FASTER THAN NORMAL
stethoscope unto which the tubing and the ear
tips are fitted. Some binaural rotate to help the SLOWER THAN NORMAL
user achieve a more comfortable fit.
SPLITTING PULSE
Rubber tubing – transmits sound from the chest
piece to ear pieces. FORCEFUL BUT SUDDENLY COLLAPSES

Chest piece/ head – single-sided or double- VERY FINE HARD TO PALPATE

sided. A double-sided chest piece rotates to Approximate Pulse Rates by Age
alternate between two sides. The flatter,
diaphragm side is used for listening to high Newborn 120
frequency sounds. The cup-shaped, bell side is 4 year old 100
used for hearing low pitched sounds.
8 year old 90
PRECAUTIONS
14 year old 85
Do not make too great pressure on the arterial
regions Adult 70

Do not use thumb to feel the pulse Newborn 80-180 30-80

Allow the arm to be at rest when taking the pulse 1 y/o 80-140 20-50
at the radial artery
5-8 y/o 75-120 15-25
Be sure that artery is not constricted
10 y/o 50-90 15-25
Always take the pulse in the right and left radial
Teen 50-90 15-20
arteries when admitting a patient. Record if
there is any appreciable difference or if the pulse Adult 60-100 12-20
cannot be felt on one wrist.
Older adult 60-100 15-20
Abnormalities of the Pulse
RESPIRATION
BRADYCARDIA – pulse rate less than 60 in adults
It is the process of bringing oxygen to the body
and 70 in children. Causes; decreased thyroid
and removing carbon dioxide, the ability of
activity, hyperkalemia and increased intracranial
oxygen to reach body cells and for carbon
pressure.
dioxide to be removed from the cells.
TACHYCARDIA – pulse rate over 100
Respiration is controlled by:
beats/minute in adults and 140 in children.
Causes: stressful conditions, hypoxia, exercise 1. Respiratory centers in the MEDULLA
and fever. OBLONGATA which is the primary center and the
PONS of the brain, and
LOW TENSION PULSE – is the result of decreased
tone of the muscular walls of the arteries and 2. By chemoreceptors located centrally in the
feels soft to touch. The artery is easily medulla and peripherally in the carotid and
compressed and lacks tones. This pulse is the aortic bodies.
result of destruction and dilation of the arteries.
Phases of Breathing
DICROTIC PULSE – is a sign of low tension. The
dicrotic wave feels like a second weak beat. Do 1. Inspiration/ inhalation - is an active
not count it as a beat or pulse. Two marked process in which the diaphragm
expansions to one beat. descends, the external intercostals
 muscles contract, and the chest expands
to allow air to move into the trachea-
bronchial tree.
2. Expiration/ exhalation - is a passive
process in which the air flows out of the
respiratory tree.
Two Types of Breathing
1. Costal (Thoracic) breathing – involves
chiefly the external intercostals muscles and
other accessory muscles, such as the
sternocleidomastoid muscles. It can be
observed by the movement of the chest
upward and outward.
2. Diaphragmatic (Abdominal) breathing –
chiefly 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.
Assessing Respiration
by inspection (observing and listening) or by
listening with the stethoscope
a. Rate- counting the number of breaths
per minute
b. Depth – movement of the chest; maybe
normal, deep or shallow
C. RHYTHM – regularity of exhalations and
inhalations; can be regular or irregular
d. QUALITY / CHARACTER – refers to respiratory
effort and sound of breathing
Approximate Respiration Rate by Age
Newborn- 35(30 – 60)
4 year old-23(20 – 30)
8 year old – 20(20 – 26)
14 year old- 20(18-22)
Adult- 18(12- 20)
Major Factors Influencing Respiratory Rate
Exercise
Stress
Environmental
Increased altitude
Medications
ABNORMALITIES IN RATE AND RHYTHM OF
BREATHING
1. Apnea – absence of breathing or a
temporary cessation of breathing.
2. Dyspnea – is a labored or difficult
breathing.
3. Orthopnea – is severe dyspnea and the
patient cannot breathe except in sitting
position.
4. Polypnea - the respirations are rapid and
panting.
5. Eupnea – refers to the normal rate and depth
of ventilation.
6. Tachypnea – rapid shallow breathing.
Respiratory rate increased above 20 breaths per
min. Causes: restrictive lung disease, pleuritic
chest pain and elevated diaphragm.
1. Bradypnea- slow breathing.
Rate is below 10 breaths per
min. Causes: diabetic coma,
drug-induces respiratory
depression, increased
intracranial pressure.
8. Edematous respiration – this
characterized by loud, moist, rattling
rales. It is accompanied by dyspnea and
cyanosis.
9. Accelerated respiration – when the
respiration exceeds 25 breaths per min.
10. Stridulous breathing wheezing – is
noticeable behind the sternum or localized one
side of the chest base. E.g., stenosis of the
bronchi in cavernous tuberculosis
11. Hyperpnea or Hyperventilation – rapid deep
breathing. Causes: exercise, anxiety, metabolic
acidosis, infarction, hypoxia, hypoglycemia
12. Hypoventilation – shallow and slow or
irregular respirations.
13. Cheyne- stokes respiration – periods of
apnea appear throughout cycle.
Respirations become deeper and faster
than normal then followed by slow rate
and progressing to periods of apnea
lasting up to 60 secs.
14. Kussmaul’s breathing – difficult breathing
that occurs in paroxysms. Also known as air
hunger, and often precedes diabetic coma
15. Biot’s respiration – periods of normal
breathing (3-4 breaths) followed by a varying
period of apnea (usually 10-60 secs.)
NORMAL
ABSENCE OF BREATHING
FASTER than NORMAL
FASTER and DEEPER
SLOWER than NORMAL
SLOWER and SHALLOW
DIFFICULTY OF BREATHING
DIFFICULTY OF BREATHING EXCEPT IN SITTING
POSITION
AIR HUNGER in DIABETIC COMA
BREATH SOUNDS
Stertorous – snoring sound produced by Hypertension stage 1 140-159
secretion in the trachea and large bronchi 90=99

Stridor – noisy respiration as air is forced Hypertension stage 2 >160 >100

through a partially obstructed airway
Factors affecting the Blood Pressure
Wheeze – high pitch musical sounds that occur
1. Activity
with partial obstructions in the smaller bronchi
and bronchioles during expiration 2. Anxiety or strong emotion
Sigh – a deep inspiration followed by a 3. Intake of food
prolonged expiration
4. Disease process
Rales – crackles; crackling sound; indicates
vibration of fluid in the lungs 5. Pain

Ronchi – coarse sound; indicates partial 6. Fluid retention

obstruction of airway. 7. Drugs
BLOOD PRESSURE 8. Blood loss/ hemorrhage
It refers to the force of the blood against arterial Equipment
walls
Sphygmomanometer- device used to measure
It is the forced exerted by the blood against the blood pressure
walls of the arteries of the body
Stethoscope – instrument used for listening to
It refers to the lateral force on the walls of an body sounds. The bell head of the stethoscope is
artery by the pulsing blood under pressure from usually used for listening when blood pressure is
the heart measured.
Measured in millimeters of mercury (mmHg) Postural Hypotension/ Orthostatic
The average BP of healthy adult is 120/80 mmHg Hypotension

The numerator is the systolic pressure; the A drop in blood pressure caused by a change in
denominator is the diastolic pressure body position

Systolic blood pressure Symptoms – dizziness, fainting, falling

The highest point of pressure on arterial walls
when the ventricles contract
It is the pressure of the blood when the heart
beats and forces blood into the vessels (systole)
Postural blood pressures – refers to blood
pressures taken in the lying, the sitting, and the
standing positions in order to compare them
Two types of Manometers

The pressure of the blood as a result of MERCURY MANOMETER

contraction of the ventricles Are the most accurate type of blood pressure
Diastolic blood pressure measuring device

The lowest pressure present on arterial walls Manufactured in variety of models – floor model,
when the heart rests between beats (diastole) portable model, wall model

It is the lowest blood pressure that is present in To ensure accurate readings, the mercury
the vessels between pulses when the heart is at column should always be at zero when the cuff is
rest and filling deflated and it should fall freely as pressure is
released.
The pressure when the ventricles are at rest
Looking at the mercury meniscus at eye level
Pulse Pressure makes accurate readings
Is the difference between the systolic blood ANEROID MANOMETER
pressure and the diastolic blood pressure
Are compact and convenient to use
Classification of Blood Pressure
An air pressure gauge that registers the blood
Category Systolic BP pressure by a pointer on a dial
Diastolic BP
Make sure that the needle points to zero.
Normal <120
<80 Parts of a Sphygmomanometer

Prehypertension 120-139 Blood Pressure Cuff

80-89 Consists of an oblong rubber bag, or bladder,
covered with a nonexpendable fabric called the
cuff
The circumference of the arm, not the age of the
patient, determines the cuff size
Whatever type of cuff is used, it is most accurate
if the center of the cuff is at the level of the heart
Read lower meniscus of the mercury level of the
sphygmomanometer at eye level to prevent
error of parallax.
Selected Sources of Error in BP Assessment

Hand Bulb

Device attached to the bladder by a rubber tube

through which air is pumped

Has a valve, regulated by a thumb-screw, which

allows air to escape from the bladder at the
desired rate.

Correct Cuff Size for Blood Pressure

Measurement

Arm circumference Recommended Cuff

Size

22 to 26 cm Small adult size:

12 to 22 cm

27 to 34 cm Adult size:
16 to 30 cm

35 to 44 cm Large adult size:

16 to 36 cm

KOROTKOFF’S Sounds – sounds heard when

taking a blood pressure using a stethoscope, the
nurse identifies phases in the series of sounds

1. Phase 1 – the pressure level at which the first

faint, clear tapping or thumping sounds are
heard. The sounds gradually become more
intense. The first tapping sound heard during
deflation of the cuff is the systolic blood pressure

2. Phase 2 – the period during deflation when the

sounds have a muffled, whooshing or swishing
quality

3. Phase 3 – the period during which the blood

flows freely through an increasingly open artery
and the sounds become crisper and more
intense and again assume a thumping quality but
softer than phase 1

4. Phase 4- the time when the sounds become

muffled and have a soft, blowing quality

5. Phase 5 – the pressure level when the last

sound is heard. This is followed by a period of
silence. The pressure at which the last sound is
heard is the diastolic blood pressure in adults.

Points to Remember

Ensure that the client is rested

Allow 30 MINUTES TO PASS if the client had

smoked or ingested caffeine before taking BP.

Use appropriate size of BP cuff

Position the arm at the level of the heart, with

the palm of the hand facing up

Determine palpatory BP before auscultated BP

to prevent auscultatory gap.