Nursing Journal

Saint Mary’s University
SCHOOL OF HEALTH and NATURALSCIENCES

Nursing Department
Bayombong, Nueva Vizcaya
JOURNAL REPORT:
Vital Sign Assessment
(TEMPERATURE, PULSE RATE, RESPIRATORY RATE, BLOOD PRESSURE)
NCM 101 RLE
Submitted by:
Renee Dwi Permata L. Messakaraeng
BSN 1C
Submitted to:
Ma’am Rosalie C. Carreon, RN, MSN
Clinical Instructor
1st Floor, Constant Jurgens (UB) Building

Saint Mary’s University, Ponce St., Bayombong, Nueva Vizcaya, 370 Philippines
Telephone: (078) 321-2221 ext. 122; Telefax: (078) 321-2117; Mobile No.: 0936-286-7269
Saint Mary’s University
SCHOOL OF HEALTH and NATURALSCIENCES
Nursing Department
Bayombong, Nueva Vizcaya
I. ARTICLE
Definition/Introduction
Vital signs are an objective measurement of the essential physiological functions of a living
organism. They have the name "vital" as their measurement and assessment is the critical
first step for any clinical evaluation. The first set of clinical examinations is an evaluation of
the vital signs of the patient. Triage of patients in an urgent/prompt care or an emergency
department is based on their vital signs as it tells the physician the degree of derangement
that is happening from the baseline. Healthcare providers must understand the various
physiologic and pathologic processes affecting these sets of measurements and their
proper interpretation. If we use a triage method where we select patients without
determining their vital signs, it may not give us a reflection of the urgency of the patient's
presentation.[1] The degree of vital sign abnormalities may also predict the long-term
patient health outcomes, return emergency department visits, and frequency of
readmission to hospitals, and utilization of healthcare resources. Traditionally, the vital
signs consist of temperature, pulse rate, blood pressure, and respiratory rate. Even though
there are a variety of parameters that may be useful along with the traditional four vital sign
parameters, studies have only found pulse oximetry and smoking status to have
significance in patient outcomes.[2] Pulse oximetry sometimes helps to clarify the patient's
physiological functions, which would sometimes be unclear by checking just the traditional
vital signs. The inclusion of smoking status has the premise that the patient will be
provided counselling by the provider on quitting smoking. In the past, some health care
systems in the United States had used "pain as the fifth vital sign'. This approach is being
abandoned due to the unintended opioid crisis that the country is currently facing.[3]
Issues of Concern
Patient safety is a fundamental concern in any health care organization, and early
detection of any clinical deterioration is of paramount importance whether the patient is in
the emergency department or on the hospital floor. The early detection of changes in vital

signs typically correlates with faster detection of changes in the cardiopulmonary status of
the patient as well as up-gradation of the level of service if needed. Vital signs assessment
currently uses electronic equipment, but there is evidence that, outside of the intensive
care units, respiratory rate assessment through observation, leading to insufficient,
subjective, and unreliable results.[4] In a case-control study conducted by Rothschild and
colleagues, early warning criterion among patients on the medical floor, the presence of
respiratory rate over 35/min (OR=31.1) was most strongly associated with a life-
threatening adverse event.[5] Early warning score (EWS) tools, mostly using vital sign
abnormalities, are critical in predicting cardiac arrest and death within 48 hours of
measurement, even though the effect on in-hospital health outcomes and utilization of
resources remains unknown.[5]
It seems intuitive that the higher the frequency of vital sign measurement, the faster the
chances of clinical deterioration are detected. There is variability between institutes within
and across nations depending on the acuity of clinical condition, any active intervention
carried out, the amount of staff availability, cost issues, organizational practices, and
leadership styles. The weighted average score deduced from the vital sign measurements
(i.e., an early warning score) is used to determine the timing of the next observation sets.
[4][5]
Clinical Significance
Temperature
Body temperature is a variable, which is complex as well as nonlinear and is affected by
many sources of internal and external variables. The normal body temperature for a
healthy adult is approximately 98.6 degrees Fahrenheit/37.0 degrees centigrade. The
human body temperature typically ranges from 36.5 to 37.5 degrees centigrade (97.7 to
99.5 degrees Fahrenheit.[6] Body temperature is regulated in the hypothalamus in a
narrow thermodynamic range and maintained to optimize the synaptic transmission of
biochemical reactions.[7] Clinical decisions, especially in the pediatric population regarding
the investigation and management, are based on the results of temperature measurement
alone. Whereas at one end, missing that the patient's fever is severe or detecting a falsely
positive fever reading can cause the patient to receive wrongful management. Galileo was
the first scientist to uncover the concept of thermometers that began in the 16th century. In
the year, 1709 Daniel Fahrenheit developed an alcohol-filled thermometer as well as a
mercury-filled thermometer.[8] Health care providers use the axillary, rectal, oral, and
tympanic membrane most commonly to record body temperature, and the devices most

commonly used are the electronic and infrared thermometers. They can monitor
temperature at different sites, and each site has its range as well as advantages and
disadvantages. As clinicians, the understanding of these site-specific differences is crucial.
For example, the oral temperature, which is the most commonly used method, is
considered very convenient and reliable. Here we place the thermometer under the
tongue and close the lips around it. The posterior sublingual pocket is the area that gives
the highest reliability. The other commonly used methods are tympanic temperature,
where the thermometer where we insert the thermometer into the ear canal, and the
axillary temperature where we place the thermometer in the axilla while adducting the arm
of the patient. Both these sites are convenient but generally considered less accurate and
hence not recommended.[8] For measuring the rectal temperature, the thermometer is
inserted through the anus into the rectum after applying a lubricant. This method is very
inconvenient, but since it measures the internal measurement, it is very reliable. It is
usually considered the "gold standard" method of recording temperature. Gut temperature,
measured with an ingested pill, also gives readings close to the rectal temperature.
Besides the site, the time of day is an essential factor leading to variability in the
temperature record, secondary to the circadian rhythm. The inability to consider this
physiological diurnal variation of temperature can lead to the wrong conclusion that an
individual's temperature suggests a disease state when it is a normal temperature at that
time of day. There is also a variation of the body temperature in a regularly cycling female,
referred to as the "circamensal" rhythm. Understanding of this rhythm is paramount in
teaching patients, trying to conceive about the fertile period of the cycle. Besides the
change with diurnal variation and menstrual variation, a person's relative physical fitness
and age can affect the degree of temperature change during a day. Studies show that
younger patients and fitter record larger temperature amplitudes, while older and less fit
people record lesser amplitude changes.[9] Some studies have demonstrated a seasonal
variation in body temperature; we need more research in this regard to reach a definitive
conclusion.[9]
Pulse Rate
The most common sites of measuring the peripheral pulses are the radial pulse, ulnar
pulse, brachial pulse in the upper extremity, and the posterior tibialis or the dorsalis pedis
pulse as well as the femoral pulse in the lower extremity. Clinicians measure the carotid
pulse in the neck. In day-to-day practice, the radial pulse is the most frequently used site
for checking the peripheral pulse, where the pulse is palpated on the radial aspect of the

forearm, just proximal to the wrist joint. Parameters for assessment of pulse include its
rate, rhythm, volume, amplitude, and rate of increase, besides its symmetry The rate of the
pulse is significant to measure for assessing the physiological and pathological processes
affecting the body. The normal range used in an adult is between 60 to 100 beats/minute
with rates above 100 beats/minute and rates below 60 beats per minute, referred to as
tachycardia and bradycardia, respectively. The age-specific heart rate given for the
paediatric age range appears in table -2. Assessing whether the rhythm of the pulse is
regular or irregular is essential. The pulse could be regular, irregular, or irregularly irregular.
Changes in the rate of the pulse, along with changes in respiration are called sinus
arrhythmia. In sinus arrhythmia, the pulse rate becomes faster during inspiration and slows
down during expiration. Irregularly irregular pattern is more commonly indicative of
processes like atrial flutter or atrial fibrillation. We should also be checking for the radial
and the femoral pulse simultaneously. If there is any delay between the pulses, it could
indicate conditions like the coarctation of the aorta. Assessing the volume of the pulse is
equally essential. A low volume pulse could be indicative of inadequate tissue perfusion;
this can be a crucial indicator of indirect prediction of the systolic blood pressure of the
patient. If we can palpate the radial pulse, the systolic blood pressure is generally more
than 80 mmHg. If we can palpate the femoral pulse, the systolic blood pressure is more
than 70 mmHg, and if we can palpate the carotid pulse, the systolic blood pressure is
more than 60 mmHg.[10] Checking for symmetry of the pulses is important as
asymmetrical pulses could be seen in conditions like aortic dissection, aortic coarctation,
Takayasu arteritis, and subclavian steal syndrome. Besides the above-stated parameters,
amplitude and rate of increase is also an important consideration. Low amplitude and low
rate of increase could be seen in conditions like aortic stenosis, besides weak perfusion
states. High amplitude and rapid rise can be indicative of conditions like aortic
regurgitation, mitral regurgitation, and hypertrophic cardiomyopathy.
Respiratory Rate
The respiratory rate is the number of breaths per minute. The normal breathing rate is
about 12 to 20 breaths per minute in an average adult. In the pediatric age group, it is
defined by the particular age group. Parameters important here again include rate, depth
of breathing, and pattern of breathing. Rates higher or lower than expected are termed as
tachypnea and bradypnea, respectively. Tachypnea is described as a respiratory rate of
more than 20 breaths per minute that could occur in physiological conditions like exercise,
emotional changes, or pregnancy. Pathological conditions like pain, pneumonia,

pulmonary embolism, asthma, foreign body aspiration, anxiety conditions, sepsis, carbon
monoxide poisoning, and diabetic ketoacidosis can also present with tachypnea.
Bradypnea described as ventilation less than 12 breaths per minute can be seen due to
worsening of any underlying respiratory condition leading to respiratory failure or due to
usage of central nervous system depressants like alcohol, narcotics, benzodiazepines, or
metabolic derangements. Apnea is the complete cessation of airflow to the lungs for a total
of 15 seconds. It appears in cardiopulmonary arrests, airway obstructions, the overdose of
narcotics, and benzodiazepines. The depth of breathing is also a crucial parameter.
Hyperpnea is described as an increased depth of breathing and is seen during exercise
and in anxiety states, lung infections, and congestive heart failure. Hyperventilation, on the
other hand, is described as both increased in the rate and depth of breathing and can
again be seen in anxiety states like anxiety or due to exercise but is also seen in
pathological conditions like diabetic ketoacidosis or lactic acidosis. The term
hypoventilation describes the decreased rate and depth of ventilation. This condition
results from excessive sedation, metabolic alkalosis, and in instances of obesity
hypoventilation syndrome. The pattern of breathing also gets affected in various conditions
and indicates the underlying pathology. Biot respiration is a condition where there are
periods of increased rate and depth of breathing, followed by periods of no breathing or
apnea. These can vary in length of time. This pattern is suggestive of raised intracranial
pressure as in space-occupying lesions of the skull or conditions like meningitis. Cheyne-
Stokes respiration is a peculiar pattern of breathing where there is an increase in the depth
of ventilation followed by periods of no breathing or apnea. This presentation occurs in
conditions of raised intracranial pressure but is also seen with excessive usage of
sedatives and worsening congestive heart failure. Kussmaul breathing refers to the
increased depth of ventilation, although the rate remains regular. This presentation is in
patients with renal failure and diabetic ketoacidosis. Orthopnea refers to difficulty in
respiration occurring on lying horizontal but gets better when the patient sits up or stands It
is seen characteristically in congestive heart failure. Paradoxical ventilation refers to the
inward movement of the abdominal or chest wall during inspiration, and outward
movement during expiration, which is seen in cases of diaphragmatic paralysis, muscle
fatigue, and trauma to the chest wall.
Blood Pressure
Blood pressure is an essential vital sign to comprehend the hemodynamic condition of the
patient. Unfortunately, though, there are a lot of inter-person variabilities when measuring

it. Many times, the basic measurement techniques are not followed and lead to erroneous
results. All healthcare providers should be aware of making sure all the essential pre-
requisites are met before checking the blood pressure of the patient. The patient should
not have taken any caffeinated drink at least one hour before the testing and should not
have smoked any nicotine products at least 15 minutes before checking the pressure.
They should have emptied their bladder before checking the blood pressure. Full bladder
adds 10 mmHg to the pressure readings. It is advisable to have the patient be seated for
at least five minutes before checking their blood pressure. This step takes care of or at
least minimizes the higher readings that could have occurred secondary to rushing in for
the clinic appointment. The providers should not be having a conversation with the patient
while checking his blood pressure. Talking or active listening adds 10 mmHg to the
pressure readings. The patient’s back and feet should be supported, and their legs should
be uncrossed. Unsupported back and feet add 6 mmHg to the pressure readings.
Crossed legs add 2 to 4 mmHg to the pressure readings. The arm should be supported at
the heart level. Unsupported arm leads to 10 mmHg to the pressure readings. The
patient’s blood pressure should get checked in each arm, and in younger patients, it
should be tested in an upper and lower extremity to rule out the coarctation of the aorta.
Using the correct cuff size is very important. Smaller cuff sizes give falsely high, and larger
cuff sizes give a falsely lower blood pressure reading.[11]
Nursing, Allied Health, and Interprofessional Team Interventions

Variability of Vital Signs in the Geriatric Age Group
Since vital signs are an indication of the changes in physiological processes, they tend to
change with age. With age, core body temperature tends to be lower, and the ability of the
body to change with different kinds of stressors becomes minimized. Even subtle variation
from the core body temperature can be a significant finding as fever in an older patient
often indicates a more severe infection and is associated with increased rates of life-
threatening consequences.[12] There can be a decrease in response to changes in the
oxygen and carbon dioxide at the molecular level along with anatomical changes resulting
due to stiffness of muscles and compliance of the chest wall. Respiratory rate sometimes
might be the most neglected of the vital signs reported in hospitalized patients but is more
sensitive than other vital signs in picking up a critically ill patient.[13]
The aging blood vessels also lead to higher arterial stiffness, leading to higher systolic
blood pressure and increased pulse pressure. There is also the issue of orthostatic
hypotension due to decreased autonomic responsiveness. This response becomes

exaggerated with the use of polypharmacy and reduced fluid intake. Thus, it is imperative
to check orthostatic vitals in this population. Resting heart rate, in contrast, is often
observed to increase with age due to deconditioning and autonomic dysregulation.[14]
Limitations of Vital Signs

Accurately measuring vital signs is a clinical skill that needs time and practice to refine. A
review of literature is abundant about the inter-observer variability observed and reported
secondary to lack of this skill. Clinicians should be wary of this and always re-check the
vital signs themselves if there is a profound or unexpected change. Clinics and
organizations should continuously strive to check and educate their nursing and ancillary
staff to sharpen these skills.
II. SUMMARY
Vital signs are an objective standard of a living organism's vital physiological activities.
Their measurement and assessment are the important initial stage in any clinical
evaluation, hence the name "vital." Temperature, pulse rate, blood pressure, and
respiration rate are the traditional vital signs, however some health care systems in the
United States have employed "pain as the fifth vital sign," which is being phased out
due to the country's unanticipated opioid crisis.
Patient safety is a top priority for every health-care organization, and detecting any
clinical deterioration as soon as possible, whether the patient is in the emergency room
or on a hospital ward, is critical. Early detection of changes in vital signs is usually
associated with earlier detection of changes in the patient's cardiopulmonary status as
well as, if necessary, an upgrade in service level. Although electronic technology is
now used to check vital signs, there is evidence that outside of intensive care units,
observational respiratory rate evaluation leads to insufficient, subjective, and incorrect
data. Body temperature is a complicated and nonlinear variable that is influenced by a
variety of internal and external factors. A healthy adult's normal body temperature is
around 98.6 degrees Fahrenheit/37.0 degrees Celsius. The average human body
temperature is 36.5 to 37.5 degrees Celsius (97.7 to 99.5 degrees Fahrenheit). The
axillary, rectal, oral, and tympanic membranes are the most commonly used sites for
recording body temperature, and the most commonly used devices are electronic and
infrared thermometers. They can monitor temperature at different sites, and each site
has its own range as well as advantages and disadvantages, which clinicians must be

aware of. For pulse rate, the radial pulse, which is palpated on the radial aspect of the
forearm just proximal to the wrist joint, is the most commonly used site for assessing
the peripheral pulse in daily practice. The pace, rhythm, volume, amplitude, and rate of
growth, as well as the symmetry of the pulse, are all factors to consider while
evaluating it. The number of breaths per minute is the respiratory rate. For the adult's
breathing rate, the average is between 12 and 20 breaths per minute. The pace, depth,
and pattern of breathing are all key parameters to consider. We have Tachypnea and
bradypnea which are terms for breathing rates that are higher or lower than expected.
The patient's blood pressure is an important vital marker to determine his or her
hemodynamic status. Unfortunately, when it comes to measuring it, there are a lot of
inter-person variations. Basic measurement approaches are typically ignored, resulting
in inaccurate results. Before checking a patient's blood pressure, all healthcare
providers should make sure that all of the necessary prerequisites have been met.
The main factor that the article also suggested that affected the attainment of accurate
vital signs is Age. Vital signs change with age because they are indicators of changes
in physiological systems. With aging, core body temperature tends to drop, and the
body's ability to adapt to various types of stressors diminishes.
Measurement of vital signs with accuracy is a clinical skill that takes time and
experience to master. Inter-observer variability has been seen and reported as a result
of a lack of this talent, according to a study of the literature.
III. PERSONAL INSIGHT
Attaining accurate vital signs of patient or client in a clinical environment or in

hospitals, require experience and time to be able to refine skill in taking it. No
healthcare professional is ever perfect and sometimes, data acquired might be
miscalculated or wrongly taken which can result in unreliable diagnosis and
inappropriate nursing intervention. Another factor is also the equipment used in taking
the vital signs which has a big impact in the accuracy of the vital signs. Another issue
needed to be addressed is the dishonesty employed by some health care
professionals where their laziness and procrastinating attitude lead them to do
observatory assessment and not take the vital signs accurately with the use of the
different equipment and services available. But despite all these, we as professionals

or students in the healthcare field, we should be able to provide and give accurate data
needed to be able to give appropriate interventions necessary.
IV. APPLICATION
As seen in the article, the vital signs include the temperature, pulse rate, respiratory
rate and the blood pressure where “pain” is considered the fifth vital sign, it is important
to be able to acquire this data from the client or patient accurately by upgrading the
services in the hospice or by not neglecting duties as healthcare professionals and not
let laziness and procrastination get the best of us. Also remember where to take the
different vital signs with the different ranges to be able to give the correct nursing
interventions necessary. And lastly to trust the process and be mindful of mistakes
during the assessment of vital signs since no one is perfect and experience can really
be the best teacher in times like this.
V. DATE PUBLISHED, AUTHOR, LINK
Sapra, A., & Malik, A. (2021, May 12). Vital Sign Assessment. STATPEARLS.
Retrieved March 23, 2022, from
https://www.statpearls.com/ArticleLibrary/viewarticle/41801


Nursing Journal

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Nursing Journal

Uploaded by

Copyright:

Available Formats

Saint Mary’s University

SCHOOL OF HEALTH and NATURALSCIENCES

Vital Sign Assessment

(TEMPERATURE, PULSE RATE, RESPIRATORY RATE, BLOOD PRESSURE)

NCM 101 RLE

1st Floor, Constant Jurgens (UB) Building

1st Floor, Constant Jurgens (UB) Building

1st Floor, Constant Jurgens (UB) Building

1st Floor, Constant Jurgens (UB) Building

1st Floor, Constant Jurgens (UB) Building

1st Floor, Constant Jurgens (UB) Building

Nursing, Allied Health, and Interprofessional Team Interventions

1st Floor, Constant Jurgens (UB) Building

Limitations of Vital Signs

1st Floor, Constant Jurgens (UB) Building

III. PERSONAL INSIGHT

Attaining accurate vital signs of patient or client in a clinical environment or in

1st Floor, Constant Jurgens (UB) Building

V. DATE PUBLISHED, AUTHOR, LINK

Retrieved March 23, 2022, from

1st Floor, Constant Jurgens (UB) Building

You might also like