NUR 092

FUNDAMENTALS OF NURSING PRACTICE

2 HOURS Part I: Lecture: Vital Signs
 Objectives:
¨ After the concept discussion, the student will be able to:
¤ Describe the physiological mechanisms governing
temperature, pulse, respiration, and blood pressure
¤ Identify the normal age –related variations for vital sign
measurements
¤ Select the appropriate equipment used to take the vital signs

¤ Realize the importance of vital signs in the care of the client

¤ Demonstrate the skill in taking the vital signs

CARDINAL SIGNS
¨ Temperature
¨ Pulse

¨ Respiration

¨ Blood Pressure

¨ Oxygen Saturation (SpO2)

¨ Pain
Special Considerations in Vital Signs Taking
¨ What to use?

¨ How often?

¨ How to do it?

¨ Why is it taken?
 Guidelines for Measuring Vital Signs
¨ It is YOUR responsibility to measure vital signs

¨ Assess equipment to ensure that is working correctly and

provides accurate findings.

¨ Select equipment on the basis of the patient’s condition

and characteristics
 Guidelines for Measuring Vital Signs
¨ Know the usual range of vital signs

¨ Know your patient’s medical history, therapies, and

prescribed medications.

¨ Control or minimize environmental factors that affect vital

signs.
 Guidelines for Measuring Vital Signs
¨ Use an organized, systematic approach when taking vital
sign and use proper technique.

¨ Use vital signs measurements to determine indications for

medication administration.

¨ Verify and communicate significant changes in vital signs.

 When to Take Vital Signs
¨ Upon admission
¨ Routine schedule
¨ Before and After surgery and invasive procedures
¨ Changes in client’s health status
¨ Before, During, and After the administration of medication
¨ Before and After any nursing intervention that could affect
vital signs
 BODY TEMPERATURE
¨ Body temperature is the difference between the amount
of heat produced by body processes and the amount lost
to the external environment.

¨ HEAT PRODUCED – HEAT LOSS = BODY TEMPERATURE

TYPES OF BODY TEMPERATURE

¨ Core Temperature

¨ Surface Temperature
BODY TEMPERATURE

¨ Temperature Control
ü Hypothalamus

ü Anterior Hypothalamus

ü Posterior Hypothalamus
Negative Feedback Mechanism for Thermoregulation

HEAT LOSS = HEAT PRODUCTION

Heat Loss > Heat Production Heat Production > Heat Loss
(Posterior Hypothalamus) (Anterior Hypothalamus)

Heat Production Mechanism Heat Loss Mechanism

• Basal Metabolic Rate (BMR) • Conduction

• Radiation
• Voluntary Movement
• Convection
• Shivering • Evaporation
• Non Shivering Thermogenesis
TEMPERATURE CONTROL
¨ Heat Loss

¨ Skin in temperature regulation

¤ Insulation of the body
¤ Vasoconstriction

¤ Temperature sensation

¨ Behavioral control
Factors Affecting Temperature
¨ Age
¨ Exercise
¨ Hormones
¨ Environment
¨ Circadian Rhythm
¨ Temperature Alterations
Factors Affecting Temperature
¨ Temperature Alterations ¨ Temperature Alterations
v Pyrexia or Fever v Hyperthermia

v Heatstroke
TYPES OF FEVER
v Heat Exhaustion
1. Sustained or Constant
2. Intermittent v Hypothermia

3. Remittent
4. Relapsing
Temperature Scale

C = (F-32) X 5/9
¨Celsius
¨Fahrenheit
F = 9/5 X C + 32
ORAL ROUTE (36.5 – 37.5C)
¨ Place probe in pocket under tongue
¨ Patient have to close mouth
¨ Not accurate if patient has eaten or drank in the last
15 minutes.
ADVANTAGES DISADVANTAGES
Accessible and comfortable for the client Fluids, foods, smoking, oxygen delivery

Oral surgery, history of epilepsy, confused,

unconscious, uncooperative clients
RECTAL ROUTE (35.5 – 37.0C)
¨ Apply small amount of lubricant jelly to probe
¨ Place probe in rectum and wait for the result.
¨ Do not use excessive amounts of lubricant or results will
be inaccurate
ADVANTAGES DISADVANTAGES
Most accurate Diarrhea, rectal surgery and decreased
platelet count
Requires positioning, source of discomfort and
not used as routine for newborns
AXILLARY ROUTE (37.0 – 38.1C)
¨ Place probe in axilla and have patient put arm by
their side
¨ Least accurate
ADVANTAGES DISADVANTAGES
Safest and the most non –invasive method of Left at the axilla for a longer period of time
temperature taking
TYMPANIC ROUTE (36.8 – 37.9C)
q Use a clean probe tip each time, and follow the
manufacture's instructions carefully
q Gently tub on the ear, pulling it back.
q Gently insert the thermometer until the ear canal is
fully sealed off.
q Squeeze and hold down the button for one second
q Remove the thermometer and read the temperature
TEMPORAL ROUTE (36.5 – 37.C)
¨ Swipe across forehead and place on temple
¨ Follow the manufacturer’s instruction
ADVANTAGES DISADVANTAGES
Convenient and Fast Thought to reflect core body temperatue

Safe and Noninvasive

TYPES OF THERMOMETER
¨ Glass Thermometer
¨ Infrared Thermometer
¨ Electronic Thermometer
¨ Chemical Thermometer
¨ Tympanic Thermometer
¨ Digital Thermometer
VITAL SIGN: PULSE
¨ Palpable bounding of
blood flow in a
peripheral artery.
¤ Rhythmic expansion of an
artery produced by the
wave of blood forced into
the blood vessel with
each contraction of the
left ventricle of the heart
Factors Affecting Pulse Rate
¨ Age
¨ Sex/ Gender
¨ Exercise
¨ Fever
¨ Medication (e.g. positive cHRonotropic drugs – epi)
¨ Hemorrhage (Excessive Blood Loss)
¨ Stress and Position
Characteristic of Pulse
¨ Rate – number of pulse beats counted in one full minute
¨ Normal Age – Related Variations in Resting Pulse
AGE NORMAL RANGE
(beats per minute)
Infant 120 - 160
Toddler 90 – 140
Preschooler 80 – 110
School –Age Child 75 – 100
Adolescent 60- 90
Adult 60 - 100
Characteristic of Pulse
¨ Rhythm – pattern of pulses and the intervals between
pulses
v Regular

v Irregular

v Abnormal Rhythm
Characteristic of Pulse
¨ Volume – (pulse strength), amplitude of blood pushed
against the wall of the artery with each ventricular
contraction
SCALE DESCRIPTION OF PULSE
0 Absent Pulse
1+ Weak and Thready Pulse
2+ Normal Pulse
3+ Bounding Pulse
Pulse Sites
¨ Temporal
¨ Carotid
¨ Apical
¨ Brachial
¨ Radial
¨ Femoral
¨ Popliteal
¨ Posterior Tibial
¨ Dorsalis Pedis
Key Points - Pulse
¨ Apical – Place stethoscope over the apex of the heart
¨ Radial – Locate the groove below the thumb on the
inside of the wrist to find the radial pulse
¨ Carotid – Place two fingers on the thyroid cartilage
Slide to the side into the groove, appox. 2 inches
Count for a full minute
VITAL SIGN: RESPIRATION
¨ Is the mechanism the body uses to exchange gases
between the atmosphere and the blood and the
blood and the cells.

¤ Ventilation
¤ Diffusion

¤ Perfusion
TYPES OF BREATHING

¨ Thoracic (Costal) – movement of chest

¨ Diaphragmatic (Abdominal) – involves movement of the

abdomen
RESPIRATORY CENTERS
¨ Controlled by a group of neurons in the brainstem: respiratory center
v Medulla Oblongata = “rhythmicity area”

v Pons = “pneumotaxic area”

¨ Neurons in the PONS transmit impulses to the medulla oblongata

continuously and regulate the duration of inspiratory bursts (control of
rate)
Factors Affecting Respiratory Rate

¨ Exercise
¨ Stress

¨ Environment

¨ Increased Altitude

¨ Medications
Characteristics of Respiration

¨ Rate
¨ Depth

¨ Rhythm

¨ Quality
Acceptable Range of Respiratory Rate
AGE RATE (breaths/ minute)
Newborn 30 -60

Infant (6 months) 30 - 50

Toddler (2 years) 25 - 32

Child 20 - 30

Adolescent 16 - 20

Adult 12 - 20
Breathing Patterns
¨ Eupnea
¨ Tachypnea
¨ Bradypnea
¨ Hyperventilation
¨ Hypoventilation
¨ Dyspnea
¨ Orthopnea position
¨ Apnea
¨ Hypoxemia
Key Points - Respirations
(12 – 20 breaths per minute)

¨ Count one full minute

¨ Do NOT tell the patient you are counting their breaths –
they’ll breath differently
¨ After counting the pulse for a full minute, continue
holding pulse but count respirations for another full
minute
VITAL SIGN: BLOOD PRESSURE

¨ Force exerted on the walls of

an artery by the pulsing blood
under pressure from the heart.

¤ Blood flows from an area of

high pressure to one of low
pressure
Blood Pressure
¨ Unit of measurement: millimeters of mercury (mm Hg),
recorded as a fraction.
¨ Systolic Pressure (N : 100 to 140 mm Hg)

¨ Diastolic Pressure (N : 60 to 90 mm Hg)

¨ Pulse Pressure (N: 30 to 50 mm Hg)

Blood Pressure
¨ Listen for the Korotkoff Sound

¨ Phases of Korotkoff Sound

PHASE DESCRIPTION
1 Clear, soft tapping that increases to a thud or loud tap (systolic sound)
2 Tapping changes to a soft whishing sound
3 Clear tapping sound returns
4 Muffled, blowing sound
(diastolic sound in children and physically active adults)
5 Disappearance of muffled blowing sound (second diastolic sound)
Factors Affecting Blood Pressure
¨ Age
¨ Exercise
¨ Stress
¨ Race
¨ Obesity
¨ Sex/ Gender
¨ Medication
¨ Circadian Rhythm
¨ Disease Process
Classification of Blood Pressure for Adults
( 18 years old and older)
CATEGORY SYSTOLIC DIASTOLIC
(mm Hg) (mm Hg)
Normal Less than 120 Less than 80
Prehypertension 120 - 139 80 - 89
Stage 1 Hypertension Greater than or equal to 140 Greater than or equal to 90

Stage 2 Hypertension Greater than or equal to 160 Greater than or equal to 90

Errors resulting to FALSE HIGH reading
¨ Cuff that is too narrow
¨ Cuff that is wrapped too loosely or unevenly
¨ Arm below level of the heart
¨ Arm not supported
¨ Measuring immediately after meal
¨ Client is in pain, anxious, with full bladder
¨ Cold hands/ stethoscope
¨ Deflating cuff too slowly
¨ Back unsupported, legs dangling
¨ Viewing meniscus below the level of the eye
Errors resulting to FALSE LOW reading
¨ Environmental noise
¨ Hearing Deficit
¨ Ear piece fitting poorly
¨ Stethoscope tubing too long
¨ Failing to pump cuff high enough
¨ Cuff too wide
¨ Arm below the level of the heart
¨ Releasing valve too rapidly.
Key Points – Blood Pressure
¨ Normal Reading: <120/ < 80 mmHg

¨ Equipment required – stethoscope, cuff,

sphygmomanometer

¨ Position patient – sitting, legs uncrossed, arm at heart level

¨ Ensure proper sizing of cuff (follow range lines on cuff)

Steps for manual blood pressure:
¨ Feel for brachial pulse
¨ Wrap cuff around upper arm, leaving room for 2 fingers under cuff
¨ Place diaphragm of stethoscope over the brachial artery/ pulse
¨ Tighten the valve on the bulb inflator
¨ Inflate the cuff until unable to hear brachial pulse (160 -180 mm Hg)
¨ Slowly release the air from the cuff by opening the valve
¨ Listen for “boof” sound of pulse
¨ Pulse sound will begin to fade
¨ Do not watch the bouncing of the arm on the meter
¨ Document Systolic BP/ Diastolic BP
VITAL SIGN: SpO2 (Pulse Oximetry)
¨ Normal : 95 – 100%
¨ Ensure fingernail free of polish, warm
hands with a warm towel if needed to
improve circulation
¨ Place probe with UV light on top of the
fingernail. Result will show within 3 to 5
seconds
¨ Special probes are also available for
ears, noses, and foreheads
VITAL SIGN: PAIN
¨ Subjective – what the patient say it is

¨ Use appropriate pain scale to quantify the

patient’s pain

¨ Use PQRST to assess more details about the pain

THERAPEUTIC MANAGEMENT
¨ Note trends in vital signs

¨ Report abnormal vitals to health care providers

¨ Treat cause
PATIENT EDUCATION
¨ Purpose of vital signs

¨ Frequency of vital signs

TAKING VITAL SIGNS – Articles Needed
TAKING VITAL SIGNS – Articles Needed
¨ Cotton balls
¨ Alcohol

¨ Wristwatch with a
second hand
¨ Notebook

¨ Pen
TAKING VITAL SIGNS – Methods

¨Inspect
¨Palpation

¨Auscultation
TAKING VITAL SIGNS
STEP
Identify the normal anatomical sites
Discuss the normal function of each part
Cite the purpose of vital signs taking
Wash hands
Ask the patient to void
Position the client comfortably
RATIONALE
To prevent the spread of infection
To promote client comfort throughout the procedure.
To prevent interruption while performing vital sign’s
taking
To facilitate accurate taking of vital signs
TAKING VITAL SIGNS
STEP
Explain the procedure and the need to
take vital signs
Encourage client’s participation
throughout the procedure
Provides proper draping/ privacy
Prepares environment conducive to the
procedure
RATIONALE
An explanation encourages cooperation and
prevents apprehension.
This prevents unnecessary exposure of client’s body
part
Different environmental factors (e.g. excessive noise
or temperature extremes can greatly affect client’s
vital signs)
NCM 103
FUNDAMENTALS OF NURSING PRACTICE
01 HOUR Part II: Demonstration: Vital Signs
RLE Evaluation Tool
 “Time for
Worksheet 1!”
THANK YOU!