VITAL SIGNS ASSESSMENT
Introduction to Healthcare (Lecture 4)
12 HA-15 | Christine Sangil | SEM 1 (2ND QTR) 2022
VITAL SIGNS
● Objective measurement of one’s overall health
status
● Vital → provides important information on the
status of the patient
● Most common measurements obtained by
HCPs as they provide data about the
effectiveness of the body’s circulatory, respiratory,
and neuroendocrine functions.
● Person’s temperature, pulse, respiration, and
blood pressure (TPRBP)
● Types of Vital signs:
○ Cardinal
■ temperature, pulse,
respirations, and blood
pressure (T, P, R and BP)
■ Pulse oximetry, the noninvasive
measurement of arterial
oxyhemoglobin saturation of
arterial blood
○ 5th vital sign – Pain
■ standard of care for vital signs in
many health care settings
■ Problems that lead a patient to
seek healthcare
■ Helps in understanding the
patient’s clinical status and
progress
MEASURING VITAL SIGNS
● Many factors cause vital signs to change outside
the acceptable range.
○ Temperature of environment
○ Physical exertion
○ Medications
○ Effects of diagnostic tests and illness
● Doing so accurately provides data to determine a
patient’s usual state of health (baseline data),
response to physical and psychological stress,
and medical and nursing therapies.
● Change in vital signs = change in physiological
functioning/change in comfort, signaling the
necessity for medical/nursing intervention.
● Quick and efficient way of monitoring your
patient’s condition, identifying problems, and
evaluating a patient’s response to intervention.
● Backbone for clinical problem solving.
SIGNIFICANT ISSUES FOR HCPS
1. When and how often vital signs should be
obtained
2. Legal and ethical responsibilities of HCP in
relation to obtaining vital signs.
GENERAL GUIDELINES
1. The Health Care Provider (HCP) should know the
normal values of vital signs.
2. The HCP in charge of the client is responsible
for assessing vital signs.
3. Equipment for vital signs taking should be
functioning and appropriate for client’s age,
size and condition.
4. The HCP should be aware of the client’s
condition, therapies and medication.
5. The HCP should minimize environmental
factors that can alter vital signs results.
6. The HCP uses a calm and caring approach
towards the client when performing vital signs.
7. The HCP is systematic and organized when
measuring vital signs to ensure accuracy.
8. On the basis of a patient's condition, collaborate
with health care providers to decide the
frequency of vital sign assessment.
9. Use vital sign measurements to determine
indications for medication administration
10. Verify and communicate significant changes in
vital signs
WHEN TO ASSESS VITAL SIGNS
1. Upon admission and before discharge of the
client
2. At the start of every shift
3. Before, during and after an invasive procedure
■ surgery, liver biopsy, or paracentesis)
4. Before and after an intervention, therapy or
treatment
■ Antidysrhythmic – Pulse rate must be ≥
60
■ Antihypertensive – BP must be higher
than specified systolic/diastolic rate
5. Before and after medication administration
■ BP after a diuretic/antihypertensive
■ Temperature after antipyretic
■ Pulse rate & rhythm after antidysrhythmic
■ Respiratory rate, depth, and
characteristics after bronchodilator
■ BP & Respiratory rate after opioid
6. Whenever a client’s condition changes
■ When a patient reports pain/dizziness,
short of breath, or falls.
ASSESSING BODY TEMPERATURE
● Body Temperature – The result/balance
between the heat produced by the body and
the heat lost from the body.
VITAL SIGNS ASSESSMENT
Introduction to Healthcare (Lecture 4)
12 HA-15 | Christine Sangil | SEM 1 (2ND QTR) 2022
○ Purposes:
■ To obtain baseline information
■ To assess the progression of an
illness
■ To monitor a response to therapy
○ Types of Body Temperature:
■ Core Temperature
➢ inner parts of the body
(vital organs such as the
heart, liver and kidneys,
and the blood)
➢ Sites: rectum, tympanic
membrane, oral cavity
■ Surface Temperature
➢ Sites: skin, axillae
(armpit)
HYPOTHALAMUS AS TEMPERATURE CONTROL
CENTER
● Hypothalamus – Thermoregulating center of the
brain
● Anterior hypothalamus
○ Controls heat loss
■ AH-preoptic area contains cold
and heat-sensitive neurons
(central thermoreceptors).
○ Nerve sensors send out signals that
initiate sweating, peripheral
vasodilation and inhibition of heat
production.
■ Temperature sensory signals
from the central anterior
hypothalamic-preoptic area are
transmitted into the posterior
hypothalamic area.
■ When the preoptic area is
heated, the skin all over the body
immediately breaks out in a
profuse sweat, and the blood
vessels over the whole-body
surface become dilated.
■ Any excess body heat production
becomes inhibited.
● Posterior hypothalamus
○ Integrates the peripheral and central
temperature sensory signals
■ Temperature sensory signals
from the central AH-preoptic
area, and peripheral
thermoreceptors are transmitted
both into the posterior
hypothalamic/hypothalamus
area.
■ Signals are integrated to control
the heat-conserving and
heat-producing reactions of the
body
○ Controls heat production
■ Responsible for temperature
decreasing and increasing
mechanisms
○ Nerve sensors send out signals that
initiate shivering, vasoconstriction and
release of epinephrine.
FACTORS THAT PROMOTE HEAT PRODUCTION
1. Basal metabolic rate
● Rate of energy used by the body to
maintain crucial physiological activities,
such as breathing.
● Factors that increase the basal metabolic
rate include metabolism, activity, and
certain hormones.
2. Muscle activity
● Activity and exercise increase metabolic
rate. Vigorous exercise can increase
body temperature to as high as 104°F.
● Shivering, an involuntary physiological
trembling caused by the contraction of
muscles, can increase the rate of heat
production by four times normal.
○ is associated with the onset of a
fever and is a response to fear.
○ Contraction of the arrector pili
muscles cause hair to rise above
the skin (piloerection, also known
as gooseflesh or goosebumps)
and occurs in response to cold
exposure, but it is not a
significant heat-preserving
process in humans.
VITAL SIGNS ASSESSMENT
Introduction to Healthcare (Lecture 4)
12 HA-15 | Christine Sangil | SEM 1 (2ND QTR) 2022
○ During the first few months of life,
infants are unable to shiver and
instead metabolize brown fat to
produce heat.
3. Thyroxine production
● Thyroxine – hormone of thyroid gland;
increases cellular metabolism (which
increases BMR)
○ Increased BMR = increased heat
production
● Hyperthyroidism – excessive production
of hormone thyroxine. It increases cellular
metabolism, metabolic rate, and body
temperature
4. Epinephrine, norepinephrine and stress
response
● Epinephrine and norepinephrine –
hormones that quickly increase when the
sympathetic nervous system is stimulated
by emotional stress, excitement, or
anxiety (fight-or-flight response)
○ This increases cellular
metabolism, metabolic rate, and
body temperature.
● Generally, a significantly stressed or
highly anxious patient may have an
increased body temperature.
5. Fever
● Fever increases the cellular metabolic
rate and thus increases the body’s
temperature further.
FACTORS THAT PROMOTE HEAT LOSS
1. Vaporization (evaporation)
● As moisture on the skin or in the breath
on exhalation evaporates, heat loss
occurs. If the humidity in the environment
is high, less evaporation and heat loss
occur.
● (a) Insensible water loss is loss of
moisture via vaporization.
● (b) Insensible heat loss is heat loss
associated with insensible water loss.
● For example, perspiration that results
from a hot environment.
● a Necessary Cooling Mechanism at High
Air Temperatures
○ When the temperature of the
environment becomes greater
than that of the skin, the body
gains heat by both conduction
and radiation.
○ So, the evaporation is the only
way by which the body can rid
itself of heat under these
conditions.
● Therefore, anything that prevents
adequate evaporation when the
surrounding temperature is higher than
the skin temperature will result in a rise of
the internal body temperature.
● Inadequate perspiration occurs in
patients who are born with congenital
absence or malfunctioning of sweat
glands (Ectodermal dysplasia). These
patients are in danger of overheating in
hot environments.
●
●
2. Radiation
● Transfer of heat from a warm surface to a
cooler surface without direct contact; this
is responsible for nearly 50 percent of
body heat loss.
● For example, body heat is lost via the
skin in a room that is cooler than the skin.
3. Conduction
● Heat transferred from a warm to a cool
surface via direct contact.
● For example, a body is placed in a tub of
cool water or on a cool operating room
table.
4. Convection
● Transfer of heat via air or water by
movement of heated elements to a cooler
area of air or water.
● For example, body heat is transferred to
the air closest to the body and the air
surrounding the body is continually
replaced by circulating cooler air.
FACTORS AFFECTING BODY TEMPERATURE
1. Age
● Metabolic rate is higher in a younger
person and decreases with age.
● Infants and older adults are less able to
manage extreme environmental
temperatures.
● Infants.
○ The normal range of body
temperature in infants is 98.6°F
to 99.8°F.
○ Thirty percent of heat loss occurs
through the head of an infant,
which is proportionately larger
than the rest of the body when
compared to an adult.
VITAL SIGNS ASSESSMENT
Introduction to Healthcare (Lecture 4)
12 HA-15 | Christine Sangil | SEM 1 (2ND QTR) 2022

○ Infants and children should wear ● Due to SNS stimulation >> increase
hats and adequate clothing when cellular metabolism and increase heat
the environment is cool or cold. production
Hats are placed on the heads of
newborns in a hospital to help TYPES OF THERMOMETERS
retain body heat.
● Older adults. PAPER STRIP THERMOMETER
○ (1) The range of body ● Advantages:
temperature difference in older ○ Easy to use; some go under the tongue
adults is 0.3°F to 1.2°F less than or axillae, others are topical (forehead or
younger adults, depending on the abdomen).
site of measurement. ○ Disposable.
○ (2) Have problems maintaining ○ Inexpensive.
body heat because they ● Disadvantages
experience decreased ○ Less accurate than other thermometers;
thermoregulatory efficiency and should not be used if very accurate
have less subcutaneous fat, monitoring of temperature is essential.
slower metabolism, and ○ Indicates only body surface temperature.
decreased vasomotor control. Results may be difficult to read
2. Diurnal variations for some people.
● Cyclical repetitions of various ● Considerations
physiological processes throughout 24 ○ Oral strips (A): Read results immediately
hours; body temperature may increase or after removal because colors change
decrease by as much as 1.8°F quickly when removed from the mouth.
throughout this time frame. ○ Skin strips (B): Ensure that the skin is dry
● The highest temperature is between 4 before placement; hold the strip firmly
and 6 p.m.; the lowest temperature is against the skin for 15 to 60 seconds,
between 4 and 6 a.m. according to the manufacturer’s
3. Environment instructions.
● Increased environmental temperature:
High environmental temperature, high GLASS OR PLASTIC NON MERCURY THERMOMETER
humidity, and a hot bath or immersion in ● Advantages
a hot tub can cause an increase in body ○ Accurate
temperature. ○ Can be used for oral, rectal, or axillary
● Decreased environmental temperature: temperatures.
Lack of adequate clothing, lack of shelter, ○ Easily cleaned and disinfected.
submersion in cold water, or an illness ○ Less costly than electronic thermometers.
that prevents the body from ● Disadvantages
physiologically raising the body ○ Takes 3 to 8 minutes to provide results,
temperature when cold can lead to depending on the site.
hypothermia. A cold environmental ○ Results may be difficult to read for some
temperature compounded by a strong air people.
current can cause greater heat loss than ○ May be easily broken (glass
that which is expected based on the thermometers).
environmental temperature alone; this is ● Considerations
called the wind chill factor. ○ Use an appropriate probe for the route:
4. Exercise ■ oral/axillary thermometer has an
● Due to SNS stimulation >> increase elongated tip and is indicated by
cellular metabolism and increase heat a blue dot on the opposite end
production (A).
5. Hormones ■ Rectal thermometer has a bulb at
● Catecholamines, thyroxine, progesterone the tip and is indicated by a red
affect body temperature dot on the opposite end (B).
6. Stress ○ Use a new plastic sheath between uses.
VITAL SIGNS ASSESSMENT
Introduction to Healthcare (Lecture 4)
12 HA-15 | Christine Sangil | SEM 1 (2ND QTR) 2022
○ Shake the temperature down below 95°F
before use.
○ Leave in place for length of time
recommended for route.
○ Read at eye level while rotating the
device until marks are visible; each short
line is 2 tenths of a degree; use the
higher degree if the mark is between two
lines.
○ Clean with soap and water and soak it in
a disinfectant according to the
manufacturer’s instructions; it if is
dedicated to a specific patient, clean, dry,
and store it in a thermometer case in the
patient’s bedside table.
TEMPORAL SCANNER THERMOMETER (INFRARED
SENSOR)
● Advantages
○ Easy to use and read.
○ Provide results within 2 to 5 seconds.
○ Noninvasive, comfortable.
○ Unaffected by eating, drinking, smoking,
and oxygen administration.
○ Can be used for infants, people who are
sleeping, and those who have difficulty
breathing.
● Disadvantages
○ Expensive to purchase.
○ Less accurate than glass, plastic, or
electronic thermometers.
○ Requires recharging of batteries and
regular maintenance to guarantee
accuracy.
○ Must be cleaned between patients.
○ Influenced by perspiration and head
coverings, hair, or temporal area against
a mattress or pillow that retains surface
heat, resulting in inaccurately high
results.
● Considerations
○ Ensure that the machine is charged
before use, and return the device to the
charger after use.
○ Clean the probe before and after use
○ Avoid this route if the area has been
covered by a hat or hair or if the patient’s
temporal area has been against a
mattress or pillow.
○ Press and hold the button while the probe
is placed flat on the forehead between
the eyebrow and hairline and slide
laterally across the forehead to the
opposite hairline.
○ Continue to hold the button and touch
probe just below the mastoid behind the
ear lobe.
○ Release the button and read the result.
TYMPANIC THERMOMETER (INFRARED SENSOR)
● Advantages
○ Convenient.
○ Provide results within 3 seconds.
○ Unaltered by eating, drinking, smoking,
and oxygen administration.
○ Can be used for infants and patients who
are sleeping or have difficulty breathing.
● Disadvantages
○ Expensive to purchase.
○ Can be uncomfortable.
○ Requires a new probe cover for each
patient to prevent cross-contamination.
○ Requires recharging of batteries and
regular maintenance to guarantee
accuracy.
○ Contraindicated for patients with an ear
infection or ear surgery.
○ Ear wax (cerumen), incubators, and
radiant heaters can influence results.
● Considerations
○ Ensure that the machine is charged
before use, and return the device to the
charger after use.
○ Use a new probe cover for each ear;
discard the cover in an appropriate
receptacle.
○ Point the probe gently and firmly directly
at the tympanic membrane for an
accurate result; be cautious with the
small ear canals of children.
○ Straighten the ear canal in children
younger than age 3 years by pulling the
pinna (auricle) of the ear down and back.
○ Straighten the ear canal of older children
and adults by pulling the pinna up and
back.
ELECTRONIC THERMOMETER
● Advantages
○ Convenient and easy to use.
○ Can be used for oral, rectal, and axillary
temperatures.
○ Provides results within 2 to 60 seconds.
● Disadvantages
○ Expensive to purchase.
○ Requires a new probe cover for each
patient to prevent cross-contamination.
VITAL SIGNS ASSESSMENT
Introduction to Healthcare (Lecture 4)
12 HA-15 | Christine Sangil | SEM 1 (2ND QTR) 2022
○ Requires recharging of batteries and
regular maintenance to guarantee
accuracy.
○ Affected by intake of hot and cold foods
or liquids, smoking, and oxygen
administration if the oral route is used.
● Considerations
○ Ensure that the machine is charged
before use, and return the device to the
charger after use.
○ Use an appropriate probe for the route:
blue probe for an oral or axillary
temperature; red probe for a rectal
temperature.
○ Use a new probe cover for each patient;
eject the probe cover into an appropriate
receptacle.
○ Hold the probe in the patient’s mouth so
that the patient does not touch it and
contaminate the probe; hold a rectal
probe in the patient’s rectum to prevent
trauma if the patient should move; clean
the handle of the probe if touched by the
patient and after use.
METHODS OF TEMPERATURE-TAKING
1. Oral route – 97.5°F to 99.5°F
● Advantage:
○ most accessible and convenient
○ reflects rapid change in core
temperature
○ Can be used for those who have
rectal problems/severe diarrhea
● Disadvantages:
○ contraindicated in children below
3 y/o
○ Seizure-prone client
○ confused, irrational and
unconscious clients
○ clients who experience nausea
and vomiting
○ contraindicated after oral and
nasal surgery.
● Client care consideration:
○ Ensure that the client has not
smoke or ingested hot or cold
foods or liquids for 9 minutes
before measurement and
capable of sealing the lips around
the thermometer.
○ Insert the thermometer under the
tongue in the posterior sublingual
pocket.
○ Hold the thermometer in place
until temperature is obtained.; 3-5
minutes for a glass or plastic
thermometer.
○ Wash the thermometer
■ Bulb to stem (before use)
■ Stem to bulb (after use)
2. Rectal route – 98.5°F to 100.5°F
● Advantage:
○ most accurate and reliable
measurement of temperature
○ Can be used for patients who are
unable to follow instructions
(confused, disoriented, or
unconscious)
● Disadvantages:
○ inconvenient and difficult to
clients who are unable to turn to
sides
○ presence of stool may interfere
with thermometer placement
○ may cause ulcerations and rectal
perforations in children and
infants
○ diarrhea, after rectal and/or
prostatic surgery or injury, recent
myocardial infarction and post
head injury
○ may embarrass the client;
requires privacy
○ contraindicated for newborns;
clients with hemorrhoids, or a
fragile rectal mucosa and those
underwent colon and rectal
surgery, clients with heart
conditions
VITAL SIGNS ASSESSMENT
Introduction to Healthcare (Lecture 4)
12 HA-15 | Christine Sangil | SEM 1 (2ND QTR) 2022
● Considerations
○ Draw the curtain and position the
patient in a lateral position with
knees flexed or Sims position to
access the anus.
○ Wash hands, and then don clean
gloves.
○ Lubricate the tip of the
thermometer with a water-soluble
gel.
○ Raise the upper buttock with one
hand, and instruct patient to take
a deep breath while inserting the
thermometer into the anus
beyond the rectal sphincter:
■ 1 to 1.5 inches for an
adult
■ 0.5 to 0.9 inches for a
child
■ 0.5 inches for an infant.
○ Hold the thermometer in place
until it is time for removal: 2
minutes (adult) & 5 minutes
(infants).
○ Remove, clean and read the
thermometer.
○ Remove any gel from the
patient’s perianal area after
thermometer removal.
○ Remove and discard your gloves
in an appropriate trash
receptacle; wash your hands.
3. Axillary route – 96.5°F to 99°F
● Advantage
○ safest and non-invasive;
accessible
○ can be used for newborns and
uncooperative clients
● Disadvantages:
○ thermometer must remain in
place for long periods; approx. 8
minutes.
○ not as accurate as rectal route
● Client care considerations:
○ Pat dry the axilla if moist.
○ Place the thermometer in the
middle of the axilla and instruct to
position the arms across the
chest.
○ Leave the thermometer for 8-10
minutes.
○ Remove the thermometer and
wipe with rotating motion from
stem to bulb.
○ Hold the thermometer at eye
level.
○ Read the temperature.
○ Clean the thermometer with soap
and water (if mercurial glass).
○ Use same thermometer for
repeat temperature taking to
ensure accuracy.
4. Tympanic route – 97°F to 100.4°F
● Advantages:
○ easily accessible
○ reflects results within seconds
○ unaltered by eating, smoking,
drinking, and oxygen
administration
○ can be used for infants,
unconscious and dyspneic
clients.
● Disadvantages:
○ equipment is expensive
○ can be uncomfortable
○ contraindicated for clients with
ear infection and those who
underwent ear surgery
○ earwax may result to inaccurately
low result
● Client care considerations:
○ Clean the lens under the probe
before use.
○ Straighten the ear canal.
■ Pull the pinna UP and
BACK (adult).
■ Pull the pinna DOWN
and BACK (children 3
years and younger).
○ Insert the probe into the ear
canal firmly but gently towards
tympanic membrane.
○ Push the button to take the
temperature.
○ Remove the device when it
beeps.
○ Eject the probe cover into an
appropriate trash receptacle.
○ Repeat procedure for the other
ear using a new probe cover.
5. Temporal artery – 97.4°F to 100°F
VITAL SIGNS ASSESSMENT
Introduction to Healthcare (Lecture 4)
12 HA-15 | Christine Sangil | SEM 1 (2ND QTR) 2022
● Advantages:
○ Easily accessible.
○ Provides results within several
seconds.
○ Is more accurate than the
tympanic route.
○ Is unaffected by eating, drinking,
smoking, and oxygen
administration.
○ Can be used for infants, people
who are unconscious, and those
who have difficulty breathing.
● Disadvantages:
○ Head covering, hair or temporal
area against a pillow or mattress
can cause inaccurately high
results.
○ Influenced by perspiration
● Client care considerations:
○ Determine that the site is not
influenced by hair, a hat or lying
on a pillow or mattress.
○ Dry the site if there is
perspiration.
○ Ensure the device is charged.
○ Remove the protective cap &
clean the probe following the
manufacturer’s instructions.
○ Place probe with gentle pressure
on the center of the forehead,
halfway between the hairline and
eyebrows.
○ Depress and hold the start button
while dragging the probe laterally
across the forehead to the
opposite hairline.
○ Continue to depress the start
button and touch the probe
behind the ear lobe on the soft
area below the mastoid process.
○ Release the button and read the
result.
○ Clean the probe.
6. Skin – 2°F to 4°F less than core temperature.
● Advantages
○ Easily accessible: Forehead or
abdomen.
○ Available in disposable strips.
● Disadvantages
○ Less accurate and reliable than
other routes; should not be used
if accurate monitoring of
temperature is essential.
○ Indicates body surface
temperature only.
○ Perspiration interferes with
measurement.
● Client care considerations
○ Draw the curtain and position the
patient if the abdomen, rather
than the forehead, is being used.
○ Ensure that the skin is dry.
○ Place the strip directly on skin,
holding its edges firmly to the
skin so that the entire strip is in
contact with the skin.
○ Observe for color changes as the
strip reacts to the skin
temperature.
○ Read the result while the strip is
still in contact with the skin.
○ Remove the strip from the skin
and discard it in an appropriate
trash receptacle.
○ Use another type of thermometer
if the result is not within the
normal range.
ALTERATIONS IN BODY TEMPERATURE
A. Decreased Body Temperature (Hypothermia)
● Hypothermia – body temperature less
than 98.6°F (36°C).
● Severe hypothermia – body temperature
less than 82.4°F (28°C).
● When body temperature decreases to
less than 77°F (25°C), cardiac and
respiratory functions cease, cells may still
be viable, and death is possible.
● Three physiological mechanisms of
hypothermia:
○ excessive heat loss
○ inadequate heat production to
counteract heat loss
VITAL SIGNS ASSESSMENT
Introduction to Healthcare (Lecture 4)
12 HA-15 | Christine Sangil | SEM 1 (2ND QTR) 2022
○ impaired hypothalamic
thermoregulations
● Clinical indicators:
○ Shivering initially
○ Decreased, irregular pulse
○ Decreased respirations
○ Hypotension
○ Reports of feeling cold and chilly
○ Pale, cool skin
○ Oliguria
i. urinary output less than
400 ml per day or less
than 20 ml per hour
○ Reduced muscle coordination
○ Disorientation
○ decreased level of
consciousness, progressing to
coma.
● Interventions
○ Monitor vital signs.
○ Monitor pulse oximetry, but do
not apply a pulse oximeter probe
to an appendage (e.g., finger,
toe, ear lobe) that exhibits
vasoconstriction because the
result will be inaccurately low and
may compromise skin integrity.
○ Increase the environmental
temperature.
○ Ensure that clothing and linen are
dry.
○ Cover the patient with warm
blankets, and put a hat on the
patient.
○ Position extremities close to the
body.
○ Provide warm oral fluids.
○ Administer warm IV fluids as
ordered.
○ Administer ordered procedures.
i. Provide a warm bath,
apply an electric blanket,
or position a temperature
management blanket
over and/or under the
patient.
ii. Avoid using an electric
blanket or temperature
management blanket if
the patient has severe
hypothermia because it
may burn skin that has
peripheral
vasoconstriction.
B. Increased Body Temperature
Hyperthermia
● Core body temperature is more than
105°F (40.5°C).
● Heat exhaustion: caused by excessive
environmental heat and dehydration
Clinical indicators:
○ Weakness
○ Muscle aches
○ Headache
○ Syncope
○ Nausea
○ Vomiting
○ Paleness
○ Dizziness
○ Diaphoresis
○ Temperature between 98.6°F to
103°F.
● Heat stroke: caused by exercise in hot
weather
Clinical indicators:
○ flushed, hot, dry skin
○ throbbing headache
○ rapid, strong pulse;
○ Temperature of 103°F or more
○ WOF: impaired judgment,
dizziness, delirium,
unconsciousness, and seizures.
Fever (Pyrexia, Febrile)
● Temperature of 37.8°C (orally) or 38.3°C
(rectally).
● Fever up to 38.9°C enhances immune
response, promote phagocytosis, hinder
reproduction of pathogens.
● Hyperpyrexia
○ Core body temperature of
105.8°F (41.0°C) or more
○ extremely dangerous condition
requiring medical intervention to
avoid cell damage especially to
delicate brain tissues.
Clinical indicators
○ Agitation
○ Confusion
○ Stupor
○ May progress to coma.
PULSE
● Pulse
○ Wave of blood created by contraction of
the left ventricle of the heart
○ Regulated by the autonomic nervous
system
VITAL SIGNS ASSESSMENT
Introduction to Healthcare (Lecture 4)
12 HA-15 | Christine Sangil | SEM 1 (2ND QTR) 2022
● Physiology Related to Pulse
○ Apical pulse: Central pulse auscultated
over the apex of heart; reflects heart rate.
○ Peripheral pulse: Rhythmic expansion of
an artery that is palpated when a surge of
blood occurs in response to contraction of
the heart; reflects heart rate and
adequacy of circulation to a part of the
body beyond the heart, such as an
extremity.
○ Pulse deficit: Difference between apical
and radial rates (apical rate minus radial
rate).
○ Stroke volume: Amount of blood that
exits the left ventricle with each
contraction of the heart; about 70 mL in a
healthy adult.
○ Cardiac output: Volume of blood that is
pumped from the heart in 1 minute; about
5.6 L/minute; it is the product of the
stroke volume multiplied by the heart rate
per minute.
FACTORS AFFECTING PULSE RATE
● Age
○ As age increases, heart rate gradually
decreases.
○ Variations by age
■ (1) Newborns: 120 to 160
beats/minute.
■ (2) 1 to 2 years of age: 90 to 120
beats/minute.
■ (3) 3 to 18 years of age: 80 to
100 beats/minute.
■ (4) Adults: 60 to 100
beats/minute.
● Sex
○After puberty, the heart rate of males
generally is slightly slower than the heart
rate of females.
● Exercise
○ Rate increases because of the increase
in the metabolic rate and the increased
demand for oxygen and nutrients at the
cellular level; stroke volume and cardiac
output increase.
○ Rate of increase in athletes may be less
than the average adult because of larger
cardiac size, strength, efficiency, and
endurance.
● Fever
○ Increased body temperature: With a
fever, each degree of Fahrenheit
increases the heart rate by 10
beats/minute to compensate for the
decreased blood pressure associated
with vasodilation and increased BMR.
○ Decreased body temperature: When the
body cools, each degree of Fahrenheit
decreases the heart rate by 10
beats/minute because BMR slows.
● Medication
○ Some medications increase the heart rate
(e.g., epinephrine, theophylline, and
atropine).
○ Some medications decrease the heart
rate (e.g., digoxin, antihypertensives, and
opioids).
● Blood Volume
○ Increased blood volume (hypervolemia).
■ (1) Pulse is full and bounding;
rate may increase.
■ (2) Commonly caused by fluid
volume excess or excess IV
fluids.
○ Decreased blood volume (hypovolemia).
■ (1) Pulse is weak or thready; rate
increases to transport more
oxygen to body cells.
■ (2) Commonly caused by
decreased fluid volume related to
dehydration or hemorrhage.
● Stress, Emotions, and Hormones
○ Sympathetic nervous system releases
epinephrine and norepinephrine, resulting
in constriction of peripheral blood vessels
and an increase in the metabolic rate,
force of cardiac contractions, and heart
rate.
○ Increased thyroid hormones
(hyperthyroidism) increase the heart rate
and decreased thyroid hormones
(hypothyroidism) decrease the heart rate.
● Pathological Processes
○ Any condition that influences cardiac,
respiratory, or neurological functioning
may alter the heart rate.
VITAL SIGNS ASSESSMENT
Introduction to Healthcare (Lecture 4)
12 HA-15 | Christine Sangil | SEM 1 (2ND QTR) 2022
○ For example, obstructive pulmonary
diseases and hypoxia increase the heart
rate; increased intracranial pressure
(ICP) decreases the heart rate and may
make it irregular; cardiovascular disease
may increase or decrease the heart rate
or make it irregular.
● Ingested or Inhaled Substances
○ Ingestion of food increases the heart rate
slightly for several hours.
○ Caffeine, nicotine, and illegal drugs, such
as cocaine, increase the heart rate.
● Circadian Rhythm (Diurnal Variations)
○ Rate is slowest from predawn to dawn
hours and progressively increases toward
evening.
● Rest, Sleep, and Biofeedback Activities
○ These activities decrease the body’s
metabolic rate and subsequently the
heart rate.
PULSE SITES
● Radial
○ Common site used to assess character of
pulse peripherally
○ Assesses of status of circulation to hand
● Brachial
○ Assesses upper extremity BP
○ Used during infant CPR
● Carotid
○ Easily accessible site used to assess in
patients with physiological shock or used
during adult CPR when other sites are
not palpable
● Femoral
○ Used to assess in patients with
physiological shock or used during adult
CPR when other sites are not palpable;
○ Assesses status of circulation to leg
● Apical
○ Used to auscultate for apical pulse
● Ulnar
○ Used to assess status of circulation to
ulnar side of the hand; used to perform
Allen test
● Politeal
○ Used to auscultate lower extremity BP
○ assesses status of circulation to lower leg
● Tibial
○ Used to assess status of circulation to
foot
● Dorsalis Pedis
○ Used to assess status of circulation to
foot
TECHNIQUES IN PULSE ASSESMENT
● By palpation
○ Select the pulse site.
○ Place the client in a comfortable resting
position.
○ Place two or three fingertips and apply
moderate pressure. Do not use thumb to
palpate arterial pulsation.
VITAL SIGNS ASSESSMENT
Introduction to Healthcare (Lecture 4)
12 HA-15 | Christine Sangil | SEM 1 (2ND QTR) 2022
○ Count for 1 full minute to obtain accurate
picture of rate and irregularities.
● By auscultation
○ Use the diaphragm of the stethoscope to
count the apical pulse at Left 5th ICS
MCL for adult and Left 4th ICS MCL for
children.
○ Make sure the tubing extends straight as
kinks can distort sound transmission.
● Normal Pulse Rates
○ Ensure patient is doing the calming
method (inhale through nose, exhale
through mouth)
RESPIRATION
● Respiration
○ Act of breathing
○ Movement of gases into and out of the
lungs, promoting an exchange of gases
between the atmosphere and the
capillary beds in the alveoli.
○ Involves inhalation and exhalation.
■ Inhalation or inspiration refers
to the intake of air into the lungs.
■ Exhalation or expiration refers
to breathing out or the movement
of gases from the lungs to the
atmosphere.
● Types of Breathing
i. Costal (thoracic) breathing:
○ external intercostal muscles and
other accessory muscles, such
as the sternocleidomastoid
muscles
ii. Diaphragmatic (abdominal) breathing:
○ the contraction and relaxation of
the diaphragm, and it is observed
by the movement of the abdomen
FACTORS AFFECTING RESPIRATION
● Increases Respiratory rate:
○ Exercise (increases metabolism)
○ Stress (prepares the body for “fight or
flight”),
○ Increased environmental temperature
○ Lowered oxygen concentration at
increased altitudes
● Decreases Respiratory rate:
○ Decreased environmental temperature,
○ Certain medications (e.g., narcotics), and
○ Increased intracranial pressure
ASSESSING RESPIRATIONS
● Count respiration with the client in a
comfortable position. Place the client's arm in a
relaxed position across the abdomen or lower
chest.
○ One respiration = one inhalation and one
exhalation.
○ Observe them by the rise and fall of the
chest or abdomen or palpate them with
the palm of the hand on the chest,
diaphragm, or abdomen.
○ Count respirations for a minimum of 30
seconds and multiply the result by 2.
○ Assess the respiratory rate.
● Discreetly observe the rise and fall of the chest.
○ Respirations are under both involuntary
and voluntary control.
○ Assess respirations without the patient’s
awareness to ensure that the respirations
counted are under involuntary control.
■ Position the patient’s arm across
the diaphragm and palpate over
the patient’s radial pulse site at
the same time respirations are
being assessed. The patient will
assume you are obtaining a
pulse and not feel self-conscious
and voluntarily alter the
respiratory rate.
● Observe the character of respirations.
○ Identify the Depth of Respirations
VITAL SIGNS ASSESSMENT
Introduction to Healthcare (Lecture 4)
12 HA-15 | Christine Sangil | SEM 1 (2ND QTR) 2022

■ observed amount of chest occurs more often in infants and

expansion; it is directly related to children.
the volume of air inhaled. ○ Closed glottis immediately before
■ can be described as shallow, exhalation, causing grunting; a
normal, or deep closed glottis promotes exchange
■ a somewhat subjective of gases in alveoli.
observation by the HCP. ○ Exhaling through the mouth with
■ Amount of air inhaled in one lips shaped like a small O to
breath is between 300 and 500 lengthen exhalation (pursed-lip
mL (tidal volume). breathing); helps keep airways
○ Identify the Rhythm and Pattern of open and prevents trapping of air
Respirations in the alveoli.
■ Rhythm is determined by ○ Wide-eyed, startled look or other
identifying the length of intervals signs of fear related to an inability
between respirations. to breathe.
➢ a. Regular rhythm: ○ Dyspnea relieved by assuming
Evenly spaced intervals an upright position (orthopnea).
between respirations. ○ Leaning forward while in a sitting
➢ b. Irregular rhythm: position (orthopneic position).
Unevenly spaced ● Rate
intervals between ○ Eupnea: Normal respiratory rate of 12 to
respirations. 20 breaths/minute.
■ Assess irregular rhythms for a full ○ Bradypnea: Less than 12
minute. breaths/minute.
■ Assess irregular rhythms further ○ Tachypnea: More than 20
to identify patterns associated breaths/minute.
with Cheyne-Stokes, Biot, and ○ Apnea: Absence of breathing
Kussmaul respirations. ○ Hyperpnea: Labored respiration normally
○ Identify the Degree of Respiratory occurring during exercise
Effort ● Effort – Amount of work required to breathe.
○ act of breathing should be ○ Dyspnea: Difficulty in breathing
effortless. ○ Orthopnea: Ability to breathe only in
○ Difficulty breathing (dyspnea) can upright, sitting or standing position.
be observed by another; the
feeling of not being able to catch
BLOOD PRESSURE
your breath (shortness of breath)
is a subjective symptom that only ● Blood Pressure
the patient can describe. ○ Indirect measurement of the force of
○ Clinical indicators of respiratory blood against arterial walls during cardiac
distress: contraction and cardiac relaxation.
■ Use of accessory ○ Numerous factors (determinants)
muscles of respiration, influence blood pressure, including
such as intercostal, physiological factors, such as:
trapezius, and abdominal ■ Cardiac output
muscles, to help expand ■ Blood volume
the thoracic cavity. ■ Peripheral vascular resistance
○ Sinking of intercostal, ■ Viscosity of the blood
supraclavicular, and subcostal and personal factors, such as:
tissues during inspiration ■ Age
(retractions). ■ Activity
○ Widening of the nares during ■ Body weight
inhalation (nasal flaring) to ■ Medications
reduce resistance to airflow; ■ Lifestyle behaviors.
VITAL SIGNS ASSESSMENT
Introduction to Healthcare (Lecture 4)
12 HA-15 | Christine Sangil | SEM 1 (2ND QTR) 2022

○ HCP must not only know how to perform

the skill of obtaining a blood pressure
measurement but also understand the
physiological and personal determinants
that influence blood pressure.
● Systolic pressure – ventricular contraction
● Diastolic pressure – ventricular relaxation
● Pulse pressure – difference between systolic
and diastolic pressure.

PHYSIOLOGICAL DETERMINANTS OF BLOOD

PRESSURE
● Cardiac Output
○ The volume of blood that is pumped from
● Age
the heart in 1 minute (about 5.6 L).
○ Infants have a mean systolic blood
○ It increases as a result of an increase in
pressure (SBP) of approximately 75 mm
heart rate, an increase in heart
Hg.
contractility, and an increase in circulating
○ Blood pressure increases with age and
blood volume.
arrives at the expected adult values at
● Blood Volume
puberty; continues to rise slightly during
○ The amount of blood within the
adulthood.
intravascular compartment.
○ Both systolic and diastolic blood
○ When the amount of circulating blood
pressures increase in older adults
increases within the intravascular
because of decreased arterial wall
compartment, the pressure in that space
elasticity.
also increases because the blood exerts
● Sex/Gender
more pressure against the vessel walls.
○ After puberty, women tend to have lower
○ As the amount of circulating blood
blood pressures than men of the same
decreases, blood pressure decreases.
age.
● Peripheral Vascular Resistance
○ After menopause, blood pressure may
○ The amount of friction between blood flow
increase due to a decrease in estrogen.
and vessel walls.
● Ethnicity/Race (men in the United States).
○ It is influenced by the thickness of the
○ Evidence supports the fact that people of
blood (viscosity), elasticity of arterial
specific ethnicities may have a higher or
walls, and width of arterial lumens.
lower risk of developing certain illnesses;
○ Decreased elasticity of arterial walls,
whether this difference is caused by
decreased width of arterial lumens, and
some genetic component or due to
increased blood viscosity all increase
cultural circumstances is unclear.
blood pressure.
○ For example, some believe that the
○ Increased elasticity of arterial walls,
higher rate of hypertension among men
increased width of arterial lumens, and
of African American heritage (43 percent)
decreased blood viscosity all decrease
versus men of white European heritage
the blood pressure.
(27.8 percent) may be due to a
genetically based salt sensitivity. In
addition, men of African American
heritage have a higher rate of kidney
disease, which can increase blood
pressure. American men of Asian or
Pacific Islander heritage have a 9.7
percent rate of hypertension. These
statistics hold constant across
independent research, suggesting a
genetic component.
● Sympathetic stimulation
VITAL SIGNS ASSESSMENT
Introduction to Healthcare (Lecture 4)
12 HA-15 | Christine Sangil | SEM 1 (2ND QTR) 2022

○ Pain, anxiety, fear, and stress may trigger

BP elevation.
○ The sympathetic nervous system
response to stress increases cardiac
output and constricts blood vessels;
therefore, blood pressure increases.
○ Acute pain increases blood pressure;
however, chronic pain might not.
● Daily Variations / Circadian Rhythm / Diurnal
Rhythms
○ Blood pressure usually is lowest in the
morning, increases during the day, and is
highest in the late afternoon or evening.
○ These changes are related to the body’s
metabolic rate.
● Medications and Treatment
○ May decrease with use of opioids,
antihypertensives, antidysrhythmics, and SPHYGMOMANOMETER
diuretics.
○ May increase with use of some
over-the-counter medications, herbal
preparations, and illicit drugs.
● Activity/Exercise
○ Increases metabolic rate and cardiac
output, thereby increasing blood
pressure.
● Weight
○ Obesity: An additional vascular supply is
necessary to perfuse excessive body
mass, resulting in increased peripheral
resistance; thus, blood pressure
increases. ASSESSING BLOOD PRESSURE
● Diet and Smoking (Lifestyle behaviors)
○ Excessive dietary sodium, smoking
tobacco, and three or more alcoholic
beverages a day may increase blood
pressure.
● Diseases
○ Any condition that affects the circulatory
system or any major organ of the body
(e.g., kidneys, thyroid gland, and brain)
may affect the blood pressure.
● Body Position
○ Higher when a person is standing rather
than sitting or lying; when the arm being
used for measurement is held higher than
the heart; when sitting, when the feet are
dangling rather than on the floor; and
when the legs are crossed at the knees
when sitting.

BLOOD PRESSURE APPARATUS

● Steps to Ensure Accurate Blood Pressure
Readings
VITAL SIGNS ASSESSMENT
Introduction to Healthcare (Lecture 4)
12 HA-15 | Christine Sangil | SEM 1 (2ND QTR) 2022
○ No smoking or drinking of caffeinated
beverages for 30 min before BP is taken
○ Examining room is quite and comfortably
warm.
○ Arm is free of clothing
■ NO arteriovenous fistulas for
dialysis, scarring from prior
brachial artery cutdowns, or signs
of lymphedema (seen after
axillary node dissection or
radiation therapy).
○ Viable pulse (i.e. brachial artery)
○ Arm position at the heart level
■ Roughly level with the 4th
interspace at its junction with the
sternum.
○ Well-supported arm a little above client’s
waist
● Contraindications to Upper limb extremity
BP measurement:
○ The shoulder, arm, or hand (or the hip,
knee, or ankle) is injured or diseased.
○ A cast or bulky bandage is on any part of
the limb.
○ The client had surgical removal of breast
or axillary (or inguinal) lymph nodes on
that side.
○ The client has an intravenous infusion or
blood transfusion in that limb.
○ The client has an arteriovenous fistula
(e.g., for renal dialysis) in that limb.
○ upper or lower amputation of the
extremity,
○ presence of edema, capillary refill more
than 3 seconds, and
○ any inflammation, infection, lesions, or
trauma in the leg.
Therefore, in this case, BP should be taken using
the upper limb extremity.
BLOOD PRESSURE MEASUREMENT
● Prepare and position the client appropriately.
Health Care Provider:
○ Perform hand hygiene.
○ Collect appropriate equipment for
measuring blood pressure (BP):
Sphygmomanometer, BP Cuff,
Stethoscope
○ Ensure that equipment is working
properly before using it with a patient and
charged if it is an electronic device.
○ Introduce yourself, identify the patient,
explain what you are going to do, and
provide privacy by closing the door or
pulling the curtain.
Client:
○ NO SMOKING, NO CAFFENAITED
BEVERAGES, NO PHYSICAL ACTIVITY
within 30 minutes
○ The width of the inflatable bladder of the
cuff should cover at least 40% of the
upper arm circumference
○ The length of inflatable bladder should
cover at least 80% of the upper arm
circumference.
○ Position: sitting with arm slightly bent
and palm is facing upward and forearm is
supported at heart level.
○ BP is similar: sitting, standing, supine
○ Arm below heart level: falsely high BP
○ Arm above heart level: falsely low BP
● Wrap the deflated cuff evenly around the
upper arm.
○ Place the lower border of the cuff approx.
2.5 cm (1inch) above the elbow crease.
● Perform a preliminary palpatory determination
of SBP in initial examination.
○ Palpate the brachial artery with the
fingertips.
○ Close the valve clockwise.
○ Pump the cuff until the pulse is no longer
felt.
○ Note the palpatory systolic pressure
■ The mean ESTIMATE of the
maximum pressure required to
measure the systolic pressure.
■ Technique that prevents
erroneously underestimating the
systolic BP by beginning the BP
measurement during an
auscultatory gap.
VITAL SIGNS ASSESSMENT
Introduction to Healthcare (Lecture 4)
12 HA-15 | Christine Sangil | SEM 1 (2ND QTR) 2022

● An auscultatory gap =
the temporary loss of
sound when the cuff
pressure is high followed
by the return of sounds
at a lower level.
● Occurs more often in
patients with excessively
high blood pressures.
○ Release the pressure completely and
WAIT for 1-2 min.
● Position the stethoscope appropriately.
○ Clean the earbuds first with cotton balls
socked in alcohol. Then warm the
bell/diaphragm of the steth by gently
rubbing it against your palm. before
contact with the client’s brachial area.
○ Ear attachments should be tilted slightly
forward. ○ Deflate the cuff completely after
○ Place the bell over the brachial pulse and disappearance of the sounds.
hold with thumb and index finger. ○ Wait for 1-2 min. (before reinflating a cuff
● Auscultate client’s BP if a second assessment is necessary to
○ determine both the SBP and the DBP. prevent a falsely elevated diastolic result
○ Place the bell or diaphragm of the due to venous congestion)
stethoscope over the artery without ○ Repeat the steps ONLY until 3 times on
touching the cuff and ensure that the the SAME ARM. Otherwise, remove the
tubing of the stethoscope and cuff and allow 5-15 min rest period before
sphygmomanometer are not touching getting the BP on the same arm.
anything; these actions eliminate ○ Repeat the procedure on the opposite
interfering sounds. Recall the palpatory arm if this is the client’s initial
SBP obtained during the palpatory examination. (for comparison)
method earlier. ○ Remove the cuff.
○ Pump the cuff 30 mm Hg above the level ■ There should be a difference of
of the palpated systolic BP (palpatory no more than 5 to 10 mmHg
SBP + 30mm Hg). between the arms.
■ Ensures that the first sound ■ The arm with higher BP reading
associated with a BP will be should be used for subsequent
heard accurately. examinations.
○ Release the pressure within the cuff ○ Analyze, record and report the BP
slowly (2 to 3 mm Hg per second) measurement results.
○ As pressure falls, listen for a variety of
sounds (Korotkoff sounds).

NEW BP GUIDELINES (2017)

VITAL SIGNS ASSESSMENT
Introduction to Healthcare (Lecture 4)
12 HA-15 | Christine Sangil | SEM 1 (2ND QTR) 2022
● HYPERTENSIVE CRISIS – SBP of 180mmHg or
higher, and a DPB of 120 mmHg or higher.
Consult your physician immediately.
● Primary prevention
○ DIET (DASH)
○ Exercise
○ Weight reduction- most effective
according to recent studies.
○ Stress management
○ Lifestyle modification
OTHER VITAL SIGNS
● Pain assessment (5th Vital Sign)
● Oxygen Saturation (commonly measured
together with TPRBP)
PAIN
● an unpleasant and highly personal experience
that maybe imperceptible to others, while
consuming all parts of the person’s life.
● Subjective
● Assessing Pain
○ Check the temperature, pulse rate,
respiration, and blood pressure. If the
client is in pain, proceed to the
succeeding steps.
○ Ask the patient to point to the pain
(location).
○ Determine the severity. Three scales are
commonly used:
■ Visual Analog scale
■ Numeric rating scale (1-10)
■ Faces pain scale
○ Ask the patient to describe the pain and
how it started (associated features).
Pursue the seven (7) features/attributes
of pain, as you would with any symptom:
■ Location.
■ Quality.
■ Quantity or severity.
■ Timing.
■ Setting in which it occurs. Include
environmental factors, personal
activities, emotional reactions, or
other circumstances that may
have contributed to the illness.
■ Remitting or exacerbating
factors. Does anything make it
better or worse?
■ Associated manifestations. Have
you noticed anything else that
accompanies it.
○ Refer to the primary care provider as
necessary.
OXYGEN SATURATION
● Oxygen Saturation
○ Percentage of all hemoglobin binding
sites that are occupied by oxygen.
● Pulse Oximeter
○ a noninvasive device that estimates a
client’s arterial blood oxygen saturation
(SaO2) by means of a sensor attached to
the client’s finger.
● Factors That Affect Oxygen Saturation and
Related Nursing Care
○ Amount of RBCs/hemoglobin: Oxygen
saturation measurement will be within the
normal range when the circulating
hemoglobin is fully saturated.
○ However, if the patient has a low RBC
count (anemia), all the hemoglobin may
be saturated, but the patient may have
inadequate oxygen reaching body
tissues. Consider the patient’s laboratory
value for RBCs when analyzing results.
○ If the circulation under the sensor is
impaired, the reading will be inaccurately
low; distal appendages that have
thickened nails, edema, or a capillary
refill more than 3 seconds should not be
used for placement of the sensor.
VITAL SIGNS ASSESSMENT
Introduction to Healthcare (Lecture 4)
12 HA-15 | Christine Sangil | SEM 1 (2ND QTR) 2022

○ Patient activity: Excessive movement or ➢ Alcohol wipe

shivering interferes with accurate
readings; place the probe on an ear lobe,
nose, or forehead instead of a finger or
toe.
○ Acrylic nails and dark nail polish interfere
with an accurate assessment; remove
nail polish or use an alternate placement
site for the sensor.
○ Moisture and oils on the skin: Excessive
perspiration can interfere with accurate
readings; clean the site with alcohol and
dry it before sensor placement.
● Patient Factors Indicating the Need for
Monitoring Oxygen Saturation
○ Acute or chronic impaired respiratory or
cardiac functioning.
○ Recovery from any type of anesthesia or
conscious sedation.
○ Any trauma, including surgery.
○ Ventilatory dependency.
○ Receipt of supplemental oxygen.
● Clinical Manifestations of Altered Oxygen
Saturation
○ Altered respiratory rate, depth, or rhythm.
○ Dyspnea and use of accessory muscles
of respirations.
○ Adventitious breath sounds.
○ Pallor or cyanosis of the lips, mucous
membranes, nail beds, and skin.
○ Restlessness, irritability, confusion, and
decreased level of consciousness.
● Assessing Oxygen Saturation
○ ASSESS:
■ The best location for a pulse
oximeter sensor based on the
client’s age and physical
condition. Unless
contraindicated, the finger is
usually selected for adults.
■ The client’s overall condition
including risk factors
development of hypoxemia (e.g.,
respiratory or cardiac disease)
and hemoglobin level
■ Vital signs, skin color and
temperature, nail bed color, and
tissue perfusion of extremities as
baseline data
■ Adhesive allergy
■ Assemble the necessary
equipment:
➢ Nail polish remover as
needed
➢ Sheet or towel
➢ Pulse oximeter
■ Check if the pulse oximeter is
functioning normally
○ IMPLEMENTATION:
■ Perform hand hygiene and
observe appropriate infection
control procedures.
■ Provide for client privacy.
■ Prepare the site. Remove nail
polish with acetone or polish
remover if there is, as it may
interfere with accurate
measurement.
■ Once sensor is in place, turn on
oximeter by activating power.
Observe pulse
waveform/intensity display and
audible beep.
➢ Correlate oximeter pulse
rate with patient’s radial
pulse.
■ Leave sensor in place until
oximeter readout reaches
constant value and pulse display
reaches full strength during each
cardiac cycle.
➢ Inform patient that
oximeter alarm will sound
if sensor falls off or
patient moves sensor.
➢ Read SpO2 on digital
display.
■ Assess skin integrity every 2
hours under sensor. Routinely
relocate sensor at least every 24
hours or more frequently.
■ Clean the surface of a reusable
sensor between patients with
70% Isopropyl alcohol solution or
for solution recommended by
manufacturer.
■ Discuss findings with patient as
needed.
■ Perform hand hygiene.
■ Record SpO2 on vital signs flow
sheet.
➢ Normal Sp02: 96-100%
VITAL SIGNS ASSESSMENT
Introduction to Healthcare (Lecture 4)
12 HA-15 | Christine Sangil | SEM 1 (2ND QTR) 2022