Vital Signs

Temperature
Pulse Rate

Joanna G. Llanos Dee MAN, RN

 Angelite Prayer
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Angelite Charism. We thank you for the gift of your
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bless you for the continuous guidance of the Holy
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give perpetual praise to you in whatever we do.
We ask this through Christ our Lord. Amen.

Oh, Holy Guardian Angels, guide us and protect us!

Laus Deo semper
Vital Signs (VS)
 Temperature, pulse, respiration, blood pressure (B/P),
oxygen saturation and pain assessment are the most
frequent measurements taken by a Nurse/ HCP.

 Because of the importance of these measurements they

are referred to as Vital Signs or Cardinal Signs. They
are important indicators of the body’s response to
physical, environmental, and psychological stressors.
Vital Signs
 VS may reveal sudden changes in a client’s condition in
addition to changes that occur progressively over time.
A baseline set of VS are important to identify changes in
the patient’s condition.

 VS are part of a routine physical assessment and are not

assessed in isolation. Other factors such as physical
signs & symptoms are also considered.

 Important Consideration:
 A client’s normal range of vital signs may differ from the standard
range.
Purposes

 1. to determine the course of illness

 2. to observe the general condition of the client

 3. to aid the physician in making diagnosis

 When to take vital signs
1. Upon admission

2. According to the physician’s order or the

institution’s policy or standard of practice

3. When assessing the client during home health

visit

4. Before & after a surgical or invasive diagnostic

procedure
When to take vital signs
5. Before & after the administration of meds or therapy
that affect cardiovascular, respiratory & temperature
control functions.

6. When the client’s general physical condition changes

decrease LOC, increase pain

7. Before, after & during nursing interventions

influencing vital signs

8. When client reports symptoms of physical distress

Factors Affecting Vital Signs
Age Medications

Gender Pain

Heredity Other Factors:

exercise and
Race metabolism, anxiety
and stress, postural
Lifestyle changes, diurnal
variations and
Environment hormones
General Considerations:
 Therapeutic Environment and Informed Consent

◦ “Hello, I am XXX (state first and last name). I am a XXX

(state designation, e.g., I am a registered nurse). Today, I
am here to take your vital signs. It will involve me touching
your arm, are you okay with that?”

◦ It is also important to ensure the client’s privacy by closing

the curtains or the door to the room.
General Considerations:
 Infection Prevention and Control

◦ Clean hands and clean equipment are essential to infection

prevention and control when measuring vital signs.

 Equipment
◦ Healthcare providers always inspect equipment before use to
ensure it is in good working condition.
General Considerations:
 Before vital signs are taken, be sure that the client has
rested and should not have consumed tobacco,
caffeinated drinks, or alcohol.

 The frequency of taking the TPR, BP depends on the

condition of the client and the policy of the institution.

 Inform the physician or head nurse promptly for any

significant change in the VS.
 TEMPERATURE
 Temperature
 the balance between the heat produced and the heat
lost from the body

 measured in heat units called

“degrees”.


 Hypothalamus- thermo- regulating center of the body

 Core temperature – temperature of the body tissues, is
controlled by the hypothalamus (control center in the brain) –
maintained within a narrow range.

 Skin temperature rises & falls in response to environmental

conditions & depends on blood flow to skin & amount of heat
lost to external environment

 The body’s tissues & cells function best between the range
from 36 deg C to 38 deg C

 Temperature is lowest in the morning, highest during the

evening.
  Shivering increases heat
production

 Sweating is inhibited to
decrease heat loss

 Vasoconstriction
decreases heat loss

Hypothalamic
Integrator
Factors that Affect Body Heat
Production:
 Age Basal Metabolic Rate (BMR)

 Sex Muscle activity

 time of day Thyroxin output

 activity level Epinephrine, nor-epinephrine and

sympathetic stimulation (stress
response)

Fever
Thermometers – 3 types
 Glass mercury – mercury expands or contracts in response to heat.
(just recently non mercury)

 Electronic – heat sensitive probe, (reads in seconds) there is a

probe for oral/axillary use (red) & a probe for rectal use (blue). There
are disposable plastic cover for each use. Relies on battery power
– return to charging unit after use.

 Infrared Tympanic (Ear) – sensor probe shaped like an otoscope in

external opening of ear canal. Ear canal must be sealed & probe
sensor aimed at tympanic membrane – ret’n to charging unit after
use.
Methods of Heat Loss
 Radiation
transfer of heat from the surface of one object to the
surface of the another without contact between the
two objects (heat exchange), mostly in the form of
infrared rays.

 Conduction
heat loss through contact with fluids or solids. (e.g.
body immersed in cold water)
Methods of Heat Loss
 Convection
 when air flows along the skin, it is usually cooler than the skin.
Heat will therefore be transferred from the skin to the air around
it.

 Evaporation
 Due to your body's ability to sweat, moisture appearing on
your skin can evaporate and large amounts of heat can escape
from your body.

moisture from the respiratory tract and from the mucosa of the
mouth
Sites
Oral
Posterior sublingual pocket – under
tongue (close to carotid artery)
Axillary
Bulb in center of axilla
Lower arm position across chest
Rectal
Side lying with upper leg flexed,
insert lubricated bulb (1-11/2 inch
adult) (1/2 inch infant)
Ear
Close to hypothalmus – sensitive to
core temp. changes
Adult - Pull pinna up & back
Child – pull pinna down & back
No hot or cold drinks or smoking 20 Leave in place 3 min
min prior to temp. Must be awake &
alert.
Not for small children (bite down)
Non invasive – good for children. Leave in place 5-10 min.
Less accurate (no major bld vessels
Measures 0.5 C lower than oral temp.
nearby)
When unsafe or inaccurate by mouth Leave in place 2-3 min.
(unconscious, disoriented or
Measures 0.5 C higher than oral
irrational)
Side lying position – leg flexed
Rapid measurement 2-3 seconds
Easy assessibility
Cerumen impaction distorts reading
Otitis media can distort reading
Oral temperature
 ● reflects changing body temperature more quickly than
rectal method; most common site.

 ● Contraindicated to clients who:

 ○ are under age 6
 ○ are irrational or unconscious persons
 ○ have wired jaw, wound in the mouth or have had oral
surgery
 ○ cannot breathe through their nose and uses the mouth
for breathing

 ○ are mouth breathers or with O2 inhalation.

Rectal Temperature
● considered to be one of the most accurate

● Contraindicated to clients:
○ undergoing rectal surgery
○ with diarrhea or diseases of the rectum
○ are immuno-suppressed
○ with a clotting disorder
○ have significant hemorrhoids
○ with heart diseases
Axillary
 ● preferred site for measuring temperature in
newborns

 ○ See to it that the axilla/armpit is dry and the

thermometer is placed within the hollow of the
axilla.
Continuation …
Tympanic Membrane

 ● one of the most accurate non-invasive

measurements of core body temperature

 ● the tympanic membrane shares the same

blood supply as the hypothalamus
Continuation …
Skin Thermometer Sheaths

Skin thermometer sheaths

Alterations in Body
Temperature
 Pyrexia/Hyperthermia – fever

◦ Febrile
◦ Afebrile

 Hyperpyrexia – a very high fever 41oC

 Hypothermia – core body temperature below the lower

limit
Normal Body Temperature
 Excessive heat loss
Three
physiologic
mechanisms Inadequate heat
production to
of counteract heat loss
hypothermia
are:
Impaired hypothalamic
thermoregulation
Common Types of Fever

 Intermittent
 The body temperature alternates regularly between a period of
fever and a period of normal or subnormal temperature
 Remittent
 The body temperature fluctuates several degrees more than 2
deg C above normal but does not reach normal between
fluctuations (cold or influenza)
 Constant

 The body temperature remains consistently elevated and

fluctuates less than 20C (typhoid fever)
Common Types of Fever

• Relapsing
• Short febrile periods of a few days are interspersed with periods
of 1-2 days of normal temperature.

• Fever spike
• A temperature that rises to fever level rapidly following a normal
temperature and then returns to normal within a few hours.

• (bacterial blood infection)

Assessing Body Temperature

● Clinical signs/manifestations Clinical signs/manifestations of

of hypothermia: hyperthermia:
Assessing Body
Temperature
 Instructional Video
(Temperature assessment by oral route)

https://www.youtube.com/watch?v=AVHR485
DHmA
Conversion
The temperature T in degrees Celsius (°C) is
equal to the temperature T in degrees Fahrenheit
(°F) minus 32, times 5/9:

 T(°C) = (T(°F) - 32) × 5/9

 or
 T(°C) = (T(°F) - 32) / (9/5)
 or
 T(°C) = (T(°F) - 32) / 1.8
Conversion Fahrenheit to Celsius
 Example

 Convert 68 degrees Fahrenheit to degrees

Celsius:

 T(°C) = (68°F - 32) × 5/9 = 20 °C

Conversion Celsius to Fahrenheit
0 degrees Celsius is equal to 32 degrees
Fahrenheit:
 0 °C = 32 °F
 The temperature T in degrees Fahrenheit (°F) is
equal to the temperature T in degrees Celsius
(°C) times 9/5 plus 32:
 T(°F) = T(°C) × 9/5 + 32
 or
 T(°F) = T(°C) × 1.8 + 32
Conversion Celsius to
Fahrenheit
 Example

 Convert 20 degrees Celsius to degrees

Fahrenheit:
 T(°F) = 20°C × 9/5 + 32 = 68 °F
Special Considerations:
 Stay with the client while the thermometer is in
place.

 Provide individual thermometer for each client.

 Use separate thermometer for each route.

Instructional Video

(How How to Take a Temperature: Under

Arm, Oral, Ear, Rectum, Skin, Temporal -
YouTube
Pulse
● expansion of the arterial
walls occurring with each
ventricular contraction
which causes a wave of
blood.

● can be felt when the finger

is placed over an artery

● equal to heartbeat (rate

of ventricular
contraction)
Purpose
 to obtain information regarding condition of the heart,
it’s action and the patient’s general condition (clues to
cardiac function and peripheral tissue perfusion)
Nine sites where pulse is commonly taken:

● Temporal ● Radial

● Carotid ● Popliteal

● Apical ● Posterior Tibial

● Femoral ● Dorsalis Pedis / Pedal

Pulse
● Brachial
Instructional Video

(9 Pulse Points Assessment)

https://www.youtube.com/watch?v=UBnlYGl3T2k
9 pulse point
Assessing the Pulse
● A pulse is commonly assessed by palpation (feeling) or
auscultation (hearing).
● 2 Pulse locations:

○ Peripheral pulse – away from the heart

○ Apical pulse – apex of the heart

● - point of maximal impulse (PMI)
● Moderate pressure is applied, pads being the most sensitive
areas. Excessive pressure may obliterate a pulse, too little may
not be able to detect it.
Terms used to describe the
Character of Pulse
● Rate
● Bradycardia- very slow pulse rate; (less than 60 bpm)
● Tachycardia- pulse rate above normal; excessively fast HR
(over 100 bpm)
Terms used to describe the
Character of Pulse
● Rhythm - pattern of the beats and the interval between the
beats
● Arrhythmia or dysrhythmia - a pulse with irregular rhythm;
random irregular beats
● assess apical pulse
 EKG or ECG may be necessary
Terms used to describe the
Character of Pulse
● Volume – aka. pulse strength or amplitude
● (force of blood with each beat)
● Full or bounding pulse – strong pulse rate
● Weak, feeble or thready – pulse that is readily obliterated
with pressure from the fingers; pulse of diminished strength
Amplitude
Normal Values(Kozier & Erbs)
 Normal Heart Rate

Age Heart Rate (Beats/min)

Infants 120-160

Toddlers 90-140

Preschoolers 80-110

School agers 75-100

Adolescent 60-90

Adult 60-100
Assessing Radial Pulse
 Left ventricle contracts causing a wave of bld to surge through
arteries – called a pulse. Felt by palpating artery lightly against
underlying bone or muscle.
 Carotid, brachial, radial, femoral, popliteal, posterior tibial,
dorsalis pedis
 Assess: rate, rhythm, strength – can assess by using palpation
& auscultation.

 Pulse deficit – the difference between the radial pulse and the apical
pulse – indicates a decrease in peripheral perfusion from some
heart conditions ie. Atrial fibrillation.
Procedure for Assessing Pulses
 Peripheral – place 2nd, 3rd & 4th fingers lightly on skin where an
artery passes over an underlying bone. Do not use your thumb (feel
pulsations of your own radial artery). Count 30 seconds X 2, if
irregular – count radial for 1 min. and then apically for full minute.

 Apical – beat of the heart at its apex or PMI (point of maximum

impulse) – 5th intercostal space, midclavicular line, just below lt.
nipple – listen for a full minute “Lub-Dub”
 Lub – close of atrioventricular (AV) values – tricuspid & mitral
valves
 Dub – close of semilunar valves – aortic & pulmonic valves
Assess: rate, rhythm,
strength & tension
 Rate – N – 60-100, average 80 bpm
 Tachycardia – greater than 100 bpm

 Bradycardia – less than 60 bpm

 Rhythm – the pattern of the beats (regular or irregular)

 Strength or size – or amplitude, the volume of bld pushed against the wall of an
artery during the ventricular contraction
 weak or thready (lacks fullness)

 Full, bounding (volume higher than normal)

 Imperceptible (cannot be felt or heard)

0----------------- 1+ -----------------2+--------------- 3+ ----------------4+

Absent Weak NORMAL Full Bounding
Assessment
 Tension – or elasticity, the compressibility of the
arterial wall, is pulse obliterated by slight
pressure (low tension or soft)

 Stethoscope
 Diaphragm – high pitched sounds, bowel, lung & heart sounds
– tight seal
 Bell – low pitched sounds, heart & vascular sounds, apply bell
lightly (hint think of Bell with the “L” for Low)
Special Considerations:
● One complete rise and fall of the arterial wall is considered as one beat or
one count.
● Take the pulse at a convenient site for the comfort of the patient and the
nurse.
● When taking the pulse, note the rate, rhythm, volume and quality of the
beats.
● Do not take pulse when the client is restless or when the child is crying.
● If peripheral pulse is difficult to obtain, take the apical pulse.
Instructional Video
 (Pulse Assessment)

 https://www.youtube.com/watch?v=nhAz84srBvg
Thank You