VITAL SIGNS

The “taking of vitals signs”

refers to the measurement of the
client’s body temperature, pulse,
respiratory rates and blood
pressure. They are fundamental
to physical assessment to establish
baseline values of the client’s
cardiorespiratory integrity.
General Consideration:
1. Before the vital signs are taken, be sure that
the client has rested.
2. The frequency of taking vital signs depends
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 sings.
4. Explain the procedure to the patient so that
he / she will feel at ease.
When to Take Vital Sign:
1. On the client’s admission to a health care
agency to obtain a baseline data.
2. In a hospital on a routine schedule according
to a physician’s order or hospital policy.
3. Before and after a surgical procedure.
4. Before and after an invasive, diagnostic
procedure.
5. Before and after the administration of
certain medication that affects
cardiovascular, respiratory and
temperature – control functions.
6. When the client’s general physical
condition changes.
7. Before and after nursing interventions
influencing vital signs.
8. When the client reports non – specific
symptoms of physical distress.
Factors Influencing Vital Signs
1. Age – normal values and variations in vital sign
measurement are usually based on age. In
newborns, thermoregulation and the respiratory
center are immature. In the elderly, the efficiency
of thermoregulation is reduced by physiological
changes and the aging process causes changes in
respiratory functions.
2. Gender – women usually experience greater
temperature fluctuations than men because of
hormonal changes. Males in general have higher
blood pressure than do females of the same age.
3. Heredity
4. Race – Some ethnic groups are more
susceptible than others to homodynamic
alterations.
5. Lifestyle – cigarette smoking, stimulants
such as caffeinated beverages and
tobacco elevates heart rate.
6. Environment – factors such as temperature
and noise level can alter heart rate. Acid
rain and industrialized area are often
associated with a high occurrence of
respiratory diseases.
7. Medications – digitalis and narcotic
analgesics
8. Pain – with acute pain, sympathetic
stimulation increase the heart rate. Chronic
pain causes parasympathetic stimulation
and decreases the pulse rate.
9. Anxiety and stress – stimulates the
sympathetic nervous system resulting to
increase metabolic activities and heat
production, increases heart rate, pulse and
blood pressure.
TEMPERATURE
• A relative measure of sensible heat or cold;
measure of sensible heat associated with the
metabolism of the human body, normally
maintained at a constant level of 37C.
• The balance between the heat production and heat
loss of the body.
• Thermoregulation – the body’s physiological
function of heat regulation to maintain a constant
internal body temperature. The heat of the body is
measured in units called degrees.
 Factors Affecting Body
Temperature:

1. Age –infant greatly influenced by the temp of the envt.

elderly-hypothermic-inadequate diet, lack of activity, decrease
thermoregulatory control, loss of subcutaneous fat.
2. Exercise/muscular activity produces heat from the breakdown of
CHO and fats like in shivering increases metabolic rate.
3. Hormonal level - thyroid hormones, thyroxin and triiodothyronin
increases basal metabolism by breaking down glucose and fat.
4. Stress-stimulation of the sympathetic nervous system can increase
the production of epinephrine and norepinephrine, thereby
increasing the metabolic rate and heat production.
5. Environment – extreme temperature can affect temp, clothing
exposure to sun and ingestion of hot foods
6. Basal metabolic rate- the rate of energy utilization in the body required
to maintain essential activities such as breathing.
7. Diurnal variation-time of the day
highest 4pm-7pm
lowest 4am-6am
8. Thyroxine output- Increased thyroxine output increases the rate of
the cellular metabolism throughout the body.
9. Epinephrine, norepinephrine, and sympathetic stimulation/stress
response-the hormones immediately increases the rate of cellular
metabolism in many body tissues.
10. Fever-fever increases the cellular metabolic rate and thus increases
the body’s temperature further.
 Mechanism of Heat Loss
• 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.

• Conduction is the transfer of heat from one molecule to a molecule of

lower temperature.

• Convection is the dispersion of heat by air currents.

• Evaporation is continuous vaporization of moisture from the respiratory

tract and from the mucosa of the mouth and from the skin
• Hypothalamus – located in the CNS, particularly in
the base of the brain, plays an important role as
the body’s thermostat
Two parts:
a. Anterior hypothalamus – controls heat dissipation
b. Posterior hypothalamus – governs heat
conservation efforts
• Pyrexia – an elevation of normal body
temperature. Lay term is fever.
• Hyperpyrexia/hyperthermia - a high fever usually
above 410C (1060F), and survival is risked when it
reaches 440C (1100F).
Signs and symptoms: Increase Body Temperature
• Loss of appetite
• flushed face
• Headache
• thirst
• Hot, dry skin
• general malaise
• flushed face
• Depression and periods of delirium
Hypothermia – body temperature below the average normal
range. Death may occur when temperature falls down
below approximately 34oC (93.20F)
ONSET (COLD OR CHILL PHASE) • Increased heart rate •
Increased respiratory rate and depth • Shivering • Pallid,
cold skin • Complaints of feeling cold • Cyanotic nail beds
• “Gooseflesh” appearance of the skin • Cessation of
sweating
COURSE (PLATEAU PHASE) • Absence of chills • Skin that
feels warm • Photosensitivity • Glassy-eyed appearance
• Increased pulse and respiratory rates • Increased thirst
• Mild to severe dehydration • Drowsiness, restlessness,
delirium, or convulsions • Herpetic lesions of the mouth •
Loss of appetite (if the fever is prolonged) • Malaise,
weakness, and aching muscles
DEFERVESCENCE (FEVER ABATEMENT/FLUSH PHASE) • Skin
that appears flushed and feels warm • Sweating •
Decreased shivering • Possible dehydration
Common Causes of Pyrexia and its Resolution:

• Intermittent fever- the body temperature

alternates regularly between a period of fever
and a period of normal or subnormal
temperature.
• Remittent fever – the body temperature
fluctuates several degrees more than 2 C
above normal but does not reach normal
between fluctuations
• Constant fever- body temperature remains
consistently elevated and fluctuates very
little, less than 2C.
• Relapsing fever – body temperature
returns to normal for at least a day, but
then fever recurs.
• Resolution of Pyrexia by Crisis – elevated
body temperature suddenly returns to
normal.
• Resolution of Pyrexia by Lysis – elevated
body temperature returns to normal
gradually.
•Fahrenheit to Centigrade
C = (F-32) x 5/9
•Centigrade to Fahrenheit
F = (9/5 x C) +32
Types of Thermometer
METHODS OF OBTAINING BODY TEMPERATURE:

• ORAL METHOD – Most Convenient

Normal findings Abnormal Findings
970F to 1000F Fever (Hyperthermia,
pyrexia)
(360C to 37.80C) > 1000F (37.80C)
Contraindications:
• patients who are disoriented, confused, comatose
or unable to keep the mouth closed
• intubated patients
• patient who are having chills or has a history of
seizures
• patient who have had recent oral surgery
• patient who are receiving oxygen by face mask,
mouth breathers and tachypneic,
• Oral temperature also should not be taken for at
least 15 minutes following gum chewing, ingestion
or hot or cold fluids and / or smoking.
 Articles:
Oral thermometer in bottle of chemical solution,
cotton balls, watch with second hand

• RECTAL METHOD – Most Accurate because there

are more blood vessels in the rectum

Normal findings Abnormal Findings

980F to 1010F Fever:>1010F (38.80C)
(370C to 37.60C) Hypothermia: <980F (370C)
Contraindications:
• patients who are unable to follow direction
or remain still
• patients who recently had rectal surgery and
hemorrhoids
• patients with position limitations
Articles to be Used:
• Rectal thermometer in a bottle of chemical
solution, cotton balls, watch with second
hand,gloves, piece of paper and pen.
• AXILLARY METHOD - Safest

Normal findings Abnormal Findings

960F to 990F Fever:>990F (36.80C)
PULSE RATE:
• Pulse is the bounding of blood flow in an
artery that is palpable in various points of
the body. It is caused by the stroke volume
ejection and distension of the walls of the
aorta, which creates a pulse wave as it
travel’s rapidly towards the distal ends of the
arteries. Assessment of the pulse provides
clinical data regarding the heart’s pumping
action and adequacy of peripheral artery
blood flow.
•Pulse Rate is an indirect measurement
of cardiac output obtained by counting
the number of apical or peripheral
pulse waves over a pulse point.
Peripheral Pulse – a pulse that is
located away from the heart
Apical pulse – a central pulse that is
located at the apex of the heart
Special Consideration:
• One complete rise and fall of the arterial wall
is considered as one beat.
• Take the pulse at a convenient site for the
patient and the nurse.
• When taking the pulse, note the rate,
rhythm, volume and quality of the arterial
wall.
• Do not take the pulse when the patient is
restless or when the child is crying.
• If the peripheral pulse is difficult to obtain,
take the apical or cardiac rate.
 Physiology
• SA node (sinoauricular/sinoatrial node) in the
upper part of the right atrium sets the place of the
beat
• Left ventricle contracts to an already full aorta
Expansion of the aorta
• Arterial in the blood system expand or distend to
compensate for increase in pressure
Sends a wave through the walls of the arterial
system
• PULSE
•Stroke Volume – the quantity of
blood forced out of the left
ventricle with each contraction
•Cardiac Output – the volume of
blood forced out of the ventricle
each minute of the stroke
volume / minute.
Factors Affecting Pulse Rate:
•Age
•Gender
•Exercise - the heart's
compensatory ability attempts to
meet the need for increased blood
circulation and increases metabolic
rate.
• Fever and Heat – Increase metabolic
rate. It causes an increase of 7-10
beats for each 0.60C (10F) of
elevation above normal.
• Medications
• Acute and chronic pain - stimulates
the sympathetic nervous system
• Hemorrhage
• Position changes
Pulse Sites:
• Site Assessment Criteria
1. Temporal: over the temporal bone and lateral to
the eye
2. Carotid
3. Apical
4. Brachial
5. Radial
6. Ulnar
7. Femoral
8. Popliteal
9. Posterior Tibial
10. Dorsalis Pedis
Sites Commonly Used for Assessing a Pulse:
• Assessment of the Pulse Rate
To effectively assess the pulse, we should take not of the
pulse characteristics:
1. Rate. The normal pulse are as follows:
Newborn to 1 month 130(80-180 beats/min)
1 year 120(80-140 beats/min)
5 years 100(75-120 beats/min)
10 years 70(50-90 beats/min)
Adults 70(60-100 beats/min)
 Bradycardia - heart rate less than 60 beats/min in adults
 Tachycardia - pulse rate above 100 beats/min in adults
 2. Pulse Quality - refers to the feel of the pulse,
its rhythm and forcefulness
3. Pulse Rhythm - refers to the pattern and
intervals of beats (regularity of Heartbeats ), it
describes how the heart evenly beats.
 Regular - the beats are evenly spaced
 Irregular - the beats are not evenly spaced
• Dysrhythmia - an irregular rhythm caused
by an early, late or missed heartbeat
4. Pulse Volume - a measurement of the strength or
amplitude or force exerted by the ejected blood
against the arterial wall with each contraction
(strength of the pulse ), It is described as:
 Normal - can be felt with moderate pressure, full
and easily palpable
 Thready - weak and usually rapid
 Strong/Bounding - a pulse that reaches higher
level than normal, men disappears quickly. It can
be
obliterated only by great pressure.
 Running - a pulse that is too fast to be counted
Scale for Measuring Pulse Strength:
0 Absent
1+ Pulse is diminished, barely
palpable, easy to obliterate
2+ easily palpable, normal pulse
3+ Full pulse increased
4+ Strong bounding pulse, cannot be
obliterated
Pediatric Variations:
•Radial pulses on infants are not
reliable because of the small
size of the client and the rapid
heart rate normal in infants. A
temporal or apical pulse is
preferable.
•The PMI in an infant is usually
located at the third to fourth
intercostals space near the
sternum.
•A child may be more comfortable
sitting on her parent's lap while
having her pulse assessed.
•A curious child may be more
cooperative if she can listen to her
own heart with a stethoscope.
Geriatric Variations:
•Tremors in geriatric clients can
interfere with evaluating the radial
pulse accurately.
•An apical or carotid pulse might be the
better option in older clients.
PMI – POINT OF MAXIMAL IMPULSE
In adults it is located in the left mid
clavicular line between the 4th and 5th
intercostal space just below the nipple.
Respiration :
•The act of breathing
•The process by which oxygen and
carbon dioxide are interchanged.
Oxygen is delivered to body cells while
carbon dioxide is eliminated.
Tidal Volume = 0.5L of air given out in
each breathing
Vital Capacity = 4.8 L
•External Respiration. Includes lung
ventilation. Oxygen and carbon dioxide
interchanged between the alveoli of the
lungs and pulmonary artery.
•Internal Respiration. Also called tissue
respiration, includes the use of oxygen
by body for the production of heat
through oxidation and the liberation of
energy from the food we eat.
Three Processes:
1. Ventilation – the movement of gases in
and out of the lungs.
– Inspiration/Inhalation – the act of breathing in
– Expiration/Exhalation – act of breathing out.
2. Diffusion – the exchange of gases from an
area of higher pressure to an area of lower
pressure. It occurs at the alveolo-capillary
membrane.
3. Perfusion – the availability and movement
of blood transport of gases, nutrients and
metabolic waste products.
Two Types of Breathing:
1.Costal (Thoracic) – involves movement of
the chest. It occurs when the external
intercostals muscles and accessory muscles
are used to move the chest upward and
outward. Used by adults.
2. Diaphragmatic (Abdominal) – occurs when
the diaphragm contracts and relaxes as
observed by the movement of the abdomen.
Used by baby
Respiratory Centers:
A. Medulla Oblongata – the primary
center
B. Pons which contains the following:
–Pneumotoxic center – responsible for
the rhythmic quality of breathing.
–Apneustic center – responsible for
deep, prolonged inspiration
C. Carotid and Aortic Bodies:
– Peripheral Chemoreceptor – takes up
the work of breathing when the central
chemoreceptor in the medulla oblongata
are damaged. It responds to low oxygen
concentration in the blood pressure. If
the BP is elevated. The respiratory rate
slows down {hypertension leads to
respiratory acidosis}. If the BP is
decreased. RR becomes rapid
hypotension leads to respiratory
alkalosis}. The primary chemical
stimulation for breathing is high carbon
dioxide level in the blood.
D. Muscle and Joints
– Proprioceptors – one of the
sensory nerves terminals of the
afferent nerves in the deeper
structures of the body. e.g..
exercises - increase RR
Factors Influencing the Character of
Respirations:
1. Exercise –increases metabolism
and RR
2. Acute pain – Increases RR
3. Anxiety – Increases RR
4. Smoking – Increases RR
4. Medications – narcotics, morphine sulfate
decreases RR
5. Increases altitude – increases RR
6. Brainstem injury – increase ICP will depress the
respiratory center, resulting to irregular or shallow,
slow breathing or both.
7. Body Positions
– Supine – experiences to physiologic processes
that suppresses RR.
1) Increase in the volume of blood inside the
thoracic cavity
2) compression of the chest
– Fowler’s position – facilitates expansion of the
diaphragm
ASSESSING RESPIRATIONS:
• Normal breathing is lightly observable,
effortless, quiet, automatic and regular. It
can be assessed by observing the chest wall
expansion and bilateral symmetrical
movement of the thorax. Another method is
placing back of the hand next to the client’s
nose and mouth to feel the expired air.
• When assessing respiration, a nurse must
ascertain the rate, depth and rhythm of
ventilatory movement.
CHARACTERISTICS OF NORMAL AND
ABNORMAL BREATH SOUNDS:
A. Rate – it is measured in breaths/ minutes.
One respiratory cycle is consists of one
inhalation and one exhalation.
Normal RR: 12-20 (Adult)
35-40 (Newborns)
1. Eupnea – refers to respiration which are
easy and within a normal rate that are
age specific
2. Bradypnea- a respiratory rate of 10 or
fewer breaths/minute. Seen in patients
with increase ICP. Brain injury or drug
overdose
3. Tachypnea- a respiratory rate which is
greater than 24 breaths/minute;
4. Dyspnea – difficulty of breathing.
5. Apnea – the absence of breathing.
6. Orthopnea – difficulty of breathing in
lying position
B. Rhythm – also known as pattern which is
evaluated for regularity or irregularity.
Normal respirations are regular and even in
rhythm (evenly spaced). There are a wide
variety of rhythms that exits in relation to
different pathologies.
Ex:
 Cheyne-Stokes Resp. – irregular respiration seen
in patients with head injuries characterized by
alternating episodes of apnea and period of deep
breathing.
 Kussmaul’s breathing – deep and rapid seen in
patients with diabetic complications.
C. Chest Wall Movements:
Two Types of Breathing:
1. Costal (Thoracic) – involves movement of
the chest. It occurs when the external
intercostals muscles and accessory
muscles are used to move the chest
upward and outward.
2. Diaphragmatic (Abdominal) – occurs when
the diaphragm contracts and relaxes as
observed by the movement of the
abdomen.
D. Depth / Volume – can be established
by watching the movement of the chest
and ranges from deep to shallow.
1. Hypoventilation – characterized by shallow
and slow respirations. There is an
exchange of a small volume of air and
often minimal use of lung tissue. CO2
excessively retained. Seen in respiratory
acidosis.
2. Hyperventilation – characterized by
deep and rapid respiration. Large
volume of air is inhaled and exhaled
inflating most of the lungs (increase in
rate and depth. CO2 excessively
exhaled. Seen in respiratory alkalosis.
•Breath Sounds – audible with
amplification
A. STRIDOR – a shrill, harsh
sound heard during inspiration
with laryngeal obstruction
B. STERTOR - snoring or
sonorous respiration, usually
due to a partial obstruction of
the upper airway.
C. WHEEZE – continuous, high
pitched musical squeak or
whistling occurring during
expiration.
D. BUBBLING – gurgling sounds
heard as air passes through
moist secretions in the
respiratory tract.
Sample Lung Sound/s
BLOOD PRESURE
–The measurement of
pressure pulsations exerted
against the blood vessel walls
during systole and diastole.
–Also refers to the force of the
blood against the arterial
walls in the body.
Is a result of the cardiac output and
peripheral vascular resistance. Normal
arteries expand during systole and
contract during diastole
Pressure exerted in the arterial walls
when the left ventricle of the heart
pushes blood into the aorta.
The measurement of pressure
pulsation exerted against the blood
vessel walls during systole and diastole.
Measured in millimeter of mercury
(mmHg)
Equipment in Taking Blood
Pressure

Binaural
2 DISTINCT PRESSURE PHASES:
1. SYSTOLIC BLOOD PRESSURE
The measurement of the maximal pressure
exerted against arterial walls primarily a
reflection of cardiac output.
Highest point of pressure which is
approximately 120 mmHg
Is the pressure of blood as a result of
contractions of the ventricles.
2. DIASTOLIC BLOOD PRESSURE
 Measurement of pressure remaining in the arterial
system during diastole {period of relaxation that
reflects the pressure remaining in the blood
vessels after the heart has pumped primarily a
reflection of peripheral vascular resistance.
 Is the pressure when the ventricles are at rest.
 PULSE PRESSURE-the different between systolic
and diastolic blood pressure. (S-D=P.P)
 Normal range is 30-40 mmHg.
4 Hemo dynamic Regulators for Blood
Pressure Control of the body:
1. Blood volume – the volume of blood in the
circulatory system
Ex. Hemorrhage - Rapid infusion if IV fluids
results to increased BP
2. Cardiac output- the major factor that
influences systolic pressure.
3. Peripheral Vascular Resistance- the size
and distensability of the arteries which is the
most important determinant of diastolic
pressure.
4. Viscosity- the thickness of the blood based
on the ratio of proteins and cells to the liquid
portion of blood.
FACTORS AFFECTING BP:
1. Age- increase in adults because of blood
volume.
2. Exercise – increases BP due to
increased cardiac output
3. Stress – sympathetic nervous system is
stimulated-increase blood pressure.
4. Race
5. Gender-women usually have a lower
blood pressure than men of the same
age.
6. Medication-nubain, dopamine, Demerol
increase blood pressure - calcibloc, adalat
decrease blood pressure
7. Obesity
8. Diurnal Variations-BP is usually lowest upon
rising up in the morning then as activity
commences.
9. Disease Process
Ex.
 Diabetes & Renal Failure increase blood pressure
 Severe blood loss and diarrhea decrease blood
pressure
2 BP Disturbances:
1. Hypertension-blood pressure that is
persistently above normal
Types:
a. Secondary Hypertension- elevated blood
pressure of an unknown cause.
b. Primary Hypertension- elevated blood
pressure o an unknown cause.
2. Hypotension- BP which is below normal.
a. Orthostatic / Postural Hypotension
- a low BP associated with weakness or fainting
when rising to an position
BLOOD PRESSURE SITES:
1. Brachial Artery- commonly used site
CONSTRAINDICATIONS:
– shoulder, arm or hand is injured or diseased.
– a cast or bulky bandage in many parts of the
limb
– The client had a removal of axillary lymph nodes
– IV infusion
– AV fistula
2. Popliteal Artery- first alternative if the
brachial artery cannot be used. Systolic
pressure in the leg is normally 10 mmHg
to 40 mmHg higher
3. Posterior Tibial and Dorsalis Pedis
when the poplietal and brachial arteries
are unavailable.
4. Radial Artery – when other usual arteries
are unavailable
ASSESSING BP:
Methods:
• Direct (Invasive Monitoring) - involves the
insertion of a catheter into the brachial,
radial or femoral artery.
• Indirect (Non Invasive)
2 Types:
– Auscultatory
– Palpatory
 KOROTKOFF’S SOUND
• The series of sounds for which the nurse listens
when measuring the blood pressure.
It has 5 Phases:
Phase I – characterized by the first appearance of
faint but clear tapping sounds that gradually
increase in intensity. The first tapping sound is
systole.
Phase II – characterized by muffled or swishing like
sounds. These sounds may temporarily disappear
during the latter part of Phase I and during Phase 2
is called the auscultatory gap.
Phase III – characterized by distinct, loud
sounds as the blood flows relatively freely
through and increasingly open artery.
Phase IV – characterized by a distinct,
abrupt, muffling sound with a soft blowing
quality. In children, the first sound is
considered to be diastolic pressure.
Phase V – all sounds become, inaudible and
diastolic pressure is noted for adults when
this first occurs.
•STROKE VOLUME – is the
measurement of blood that enters the
aorta with each ventricular contraction.
The heart ejects 60-70ml of blood into
the aorta.
•CARDIAC OUTPUT – is the volume of
blood pump by the heart in one minute
and is measured by multiplying the
heart rate by the ventricular stroke
volume.
ERRORS IN BP READING:
–Blood pressure cuff too narrow or too
wide.
–Arm unsupported
–Repeating assessment quickly
–Cuff wrapped too loosely or unevenly.
–Deflating cuff too quickly or too slowly.
MANAGEMENT OF HYPERTENSION:
1. Maintain normal body weight.
2. Consume a diet rich in fruits and
vegetables, low fat dairy products.
3. Reduce dietary sodium intake.
4. Engage in a regular physical
activity/exercise (at least 30 minutes
per day)
SPECIAL CONSIDERATIONS IN TAKING BLOOD
PRESSURE:
1. Keep patient physically and emotionally
rested before taking the BP.
2. For repeated reading take the blood
pressure in the same arm, in the same
position and time.
3. Take the BP reading as quickly as
possible to prevent venous congestion.
4. Allow 20-30 seconds for venous
circulation to be normal, if repeated
reading is necessary.
5. Report promptly to the physician or to the
head nurse any significant change in the
BP reading.
6. Size of cuff should be appropriate to the
size of the patient’s arm.
Video on BP Taking