VITAL SIGN

KALSOOM NAZ (lecturer)

HIMS PESHAWAR

OBJECTIVES

1. Define Vital Signs.

2. Define terms related to Vital sign.
3. Describe the physiological concept of temperature, respiration, and blood pressure.
4. Describe the principles and mechanisms for normal thermoregulation in the body.
5. Identify ways that affect heat production and heat loss in the body.
6. Define types of body temperature according to its characteristics.
7. Identify the sign and symptoms of fever.
8. Discuss the normal ranges for temperature, pulse, respiration, and blood pressure.
9. List the factors affecting temperature, pulse, respiration.
10. Describe the characteristics of pulse and respiration.
11. List factors responsible for maintaining normal blood pressure.
12. Describe various methods and sites used to measure T.P & B.P.
13. Recognize the signs of alert while taking TPR and B.P.

Vital sign
Vital sign are the indicator of the body’s physiologic status and response to physical environment
and psychological stressor.
The vital sign or the cardinal sign are temperature, pulse, respiration, and blood pressure. The
findings are governed by the vital organs.

Vital signs are called cardinal signs because of their importance. These are the indicator of health
status, as these indicate the effectiveness of circulatory, respiratory, neural, & endocrine body
functions.
1. Temperature
2. Pulse
3. Respiration
4. Blood pressure
5. oxygen saturation
6. Pupillary reaction / pain

When to take vital sign

• Upon admission.
• On a routine basis.
• Before and after invasive procedure.
• Before and after administration of medication.
 • Any deterioration of patient’s general condition.
• Before and after nursing intervention that may influence vital sign.
• Prior to medical emergency

Temperature

it is the hotness or coldness of the body.

OR
It is balance between the heat produced by the body and heat lost from the body.
Heat produced – Heat lost = Body temperature

Types
There are two kinds of temperature.
1. Core Temperature
2. Surface Temperature

Core Temperature: is the temperature of the deep tissues of the body. It remains constant and
varies very little as + 1 F except when a person has a fever.
Surface Temperature: by contrast the temperature of the surface or skin, fluctuate (rises or fall)
in response to the environment.

Normal body temperature is not an exact point on a scale but a range of temperatures. When
measured orally for an adult, on an average it is between 36-38C (96.8 – 100 F).

Regulation of body temperature

The system that regulates body temperature has 3 main parts:
1. Sensors in the periphery and in the core,
2. An integrator in the hypothalamus, and
3. An effector system that adjusts the production and loss of heat.

Most sensors or sensory receptors are in the skin. The skin has more receptors for cold than
warmth. Therefore, skin sensors detect cold more efficiently than warmth.
When the skin becomes chilled over the entire body, three physiological processes to increase the
body temperature take place:
1. Shivering increases heat production.
2. Sweating is inhibited to decrease heat loss.
3. Vasoconstriction decreases heat loss.

Regulation of body temperature

Body temperature is regulated by balancing the amount of heat the body produces with the
amount of heat the body loses.

Body heat is produced as a by-product of metabolism, which is the sum of all biochemical and
physiological processes that take place in the body.
The hypothalamus, a gland located in the brain, acts as a thermoregulator

It can adjust body temperature that results in either increasing or decreasing heat production
throughout the day.

• The anterior Hypothalamus promotes heat loss through vasodilatation and sweating

• The posterior Hypothalamus promotes: – Heat conservation by vasoconstriction – Heat

production and maintains the core temperature

Thermoregulation

Balance between heat production and heat loss. When the amount of heat produced by
the body exactly equals the amount of heat lost, the person is in heat balance.
1. Heat production
2. Heat loss
Heat production in the body is called thermogenesis. Heat loss to the environment is
called thermolysis.

1. Heat production

Basal metabolic rate: Basal metabolic rate (BMR) is the total number of calories that
your body needs to perform basic, life-sustaining functions like breathing and circulation
etc.
Muscle activity: Body cells are constantly producing and breaking down ATP
(Adenosine triphosphate) and these chemical reactions produce heat during.

Thyroxin: Thyroid hormones stimulate diverse metabolic activities most tissues, leading to
an increase in basal metabolic rate

Epinephrine, nor epinephrine and sympathetic stimulation:

Epinephrine and nor epinephrine are released by the adrenal medulla and nervous
system respectively. They are the flight/fight hormones that are released when the
body is under extreme stress. During stress, much of the body's energy is used to
combat imminent danger.

Heat loss

Radiation: The emission of energy as electromagnetic waves from the body.

Conduction: It is the transfer of heat from one surface to the other through direct contact.
Heat is transferred via solid material

Convection: Convection is the dispersion of heat by air currents

Conversion/Vaporization: Evaporation is the continuous evaporation of moisture from the

 respiratory tract and from the mucosa of the mouth as well as from the skin.
Normal ranges of body temperature

Factors affecting temperature

 Age Infants greatly influenced by the temperature, children more labile than adult and
elderly are extremely sensitive to environmental change due to decreased
thermoregulatory control.
 Diurnal variation Body temperature normally change throughout the day, varying as
much as 1.0 °C between early morning and late afternoon — The point of highest
body temperature is usually reached between 8pm and 12 midnight and the lowest
point is reached during sleep between 4 a.m. and 6 a.m.
 Exercise
 Hormones Women usually experience more hormone fluctuations than men,
progesterone secretion in women raises body temperature
 Stress Epinephrine and nor epinephrine increases metabolic activity and heat
production
 Environment

Alteration in body’s temperature

The normal range for adults is between 36°C and 37.5°C (96.8°F to 99.5°F).
There are two primary alterations in body temperature

1. Pyrexia or Hyperthermia
2. Hypothermia.

1. Pyrexia
A body temperature above the usual range is called pyrexia, hyperthermia, or (in lay terms) fever.
A very high fever, such as 41°C (105.8°F), is called hyperpyrexia.
Febrile: The client who has a fever is referred to as febrile.
Afebrile: The one who does not is called Afebrile.

 Low Pyrexia: The fever does not rise more than 99 to 100 F

 Moderate Pyrexia: Body temperature remain between 100–103-degree F

 High Pyrexia: Body temperature remain between 103- 105-degree F

 Hyperpyrexia: Temperature above 105-degree F

Common Types of Fever

1. Intermittent fever: The body temperature alternates at regular intervals between periods
of fever and periods of normal or subnormal temperature e.g., Malaria

2. Remittent fever: A wide range of temperature fluctuation (more than 2 0c) occurs over
the 24-hr. period, all of which are above normal e.g., a cold or influenza

3. Relapsing fever: Short febrile periods of a few days are interspersed with periods of 1 or
2 days of normal temperature.

4. Constant fever: The body temperature fluctuates minimally but always remains above
normal e.g., typhoid fever

Fever Spikes: A temperature that rises to fever level rapidly following a normal
temperature and then returns to normal within a few hours is called a fever spike.
Bacterial blood infections often cause fever spikes.
 Inverse Fever: The highest range of temperature is recorded in morning hours and
lowest in the evening.
Hypothermia
is a core body temperature below the lower limit of normal i.e., 95 F or 35 C. The three
physiological mechanisms of hypothermia are
(a) Excessive heat loss,
(b) Inadequate heat production to counteract heat loss,
(c) Impaired hypothalamic thermoregulation

If skin and underlying tissues are damaged by freezing cold, this results in frostbite. Frostbite
most commonly occurs in hands, feet, nose, and ears in which ice crystal forms inside the
cell and damage it.

Clinical manifestation of hypothermia

• Decreased body temperature, pulse, and respirations
• Severe shivering (initially)
• Feelings of cold and chills
• Pale, cool, waxy skin
• Frostbite (discolored, blistered nose, fingers, toes)
• Hypotension
• Decreased urinary output
• Lack of muscle coordination, Disorientation, drowsiness progressing to coma

Types of hypothermia
1. Induced hypothermia: is the deliberate lowering of the body temperature to decrease
the need for oxygen by the body tissues such as during certain surgeries.
2. Accidental hypothermia: can occur because of
o exposure to a cold environment,
o immersion in cold water, and
o lack of adequate clothing, shelter, or heat.
In older adults, the problem can be compounded by a decreased metabolic rate and the
use of sedative medications.

Sites to measure temperature

 Oral
 Rectal
 Axillary
 Tympanic membrane
 Temporal artery

Advantage and disadvantage

 Temperature safety precautions

• Hold rectal and axillary thermometers in place

• Stay with resident when taking temperature
• Prior to use, shake liquid in glass down
• Shake thermometer away from resident and hard objects
• Wipe from end to tip of thermometer prior to reading
• Delay taking oral temperature for 10 - 15 minutes if resident has been smoking, eating, or
drinking hot/cold liquids
• Oral – most common, most convenient
• Rectal – registers one degree Fahrenheit higher than oral, most accurate
• Axillary – least accurate; registers one degree Fahrenheit lower than oral
• Tympanic – probe inserted into the ear canal

PULSE
The pulse is an index of the heart’s rate and rhythm. Pulse provides valuable data about
person’s cardiovascular status.

DEFINITIONS- “The pulse is a wave of blood created by contraction of the left

ventricle of the heart.”

PHYSIOLOGY OF PULSE

Blood flows through the body in a continues circuit. Electrical impulses originating from
the SA node travel through heart muscle to stimulate cardiac contraction.
Approximately 60 to 70 ml (stroke volume) of blood enters the aorta with each
ventricular contraction.

With each stroke volume ejection, the wall distends, creating a pulse wave that travels
 rapidly toward the distal ends of the arteries.
When a pulse wave reaches a peripheral artery, it can be felt by palpating the artery
lightly against underlying bone or muscles.

REGULATION OF PULSE
Pulse is regulated by the Autonomic Nervous System through the Sino-atrial node.( Often
called pacemaker.)
• Para sympathetic stimulation decreases the heart rate
• Sympathetic stimulates increase the heart rate.
•
The quantity of blood forced out of the left ventricle during each contraction is called
stroke volume.(70 ml for an average adult).
Cardiac output = Stroke volume × Pulse rate =70ml × 80 BPM
=5600 ml =5.6 L/min
The number of pulsing sensation occurring in 1minute is the pulse rate.
The volume of blood pumped by the heart for 1 minute is the Cardiac output.

Pulse rate X Stroke Volume = Cardiac out put

70 beats per minute X 70 ml / beat = 4.9 L/min
60 beats per minute X 85 ml / beat = 5.1 L/min

PULSE ASSESMENT

A pulse is commonly assessed by palpation (feeling) or auscultation using stethoscope. A

pulse is normally palpated by applying moderate pressure with the three middle fingers of
the hand.

The pads on distal aspects of the finger are the most sensitive areas for detecting a pulse with
gentle pressure. A stethoscope is used for assessing apical pulse. While palpating a pulse a nurse
should assess the followings…….

 Pulse Rate
 Pulse Rhythm
 Pulse Volume
 Character
 Bilateral Equality

Pulse Rate :- It is stated as number of pulses or beats per minute. Count the pulses for not less
than half minute. BPM
• Normal 60-100 b/min (80/min)
• Adult PR > 100 BPM is called tachycardia
• Adult PR < 60 BPM is called bradycardia

Pulse Volume, or force, refers to the strength of the pulse when the heart contracts. The pulse
volume is also called the pulse strength or quality, refers to the force of blood with each beat
It can be range from absent to bounding.
 • Bounding- Strong full force pulse.
• Thready / weak- Difficult to palpate, a pulse of diminished strength.
• Absent- No palpable pulse.
Volume is influenced by the forcefulness of the heartbeat, the condition of the arterial
walls, and hydration or dehydration.

Pulse Rhythm refers to the regularity, or equal spacing, of all the beats of the pulse. Normally,
the intervals between each heartbeat are of the same duration.
A pulse with an irregular rhythm is known as a dysrhythmia or arrhythmia.
• Equal time elapses between beat of a normal pulse; this steady beat is called Pulsus
regularis.
• A pulse with an irregular rhythm is referred to an Arrhythmia.

Bilateral Equality or Symmetry of Pulse

When assessing peripheral pulse to determine the adequacy of blood flow to a particular area of
the body.
To check the blood flow of bilateral is important.

TYPES OF PULSE

1. Peripheral pulse is a pulse located away from the heart, for example, in the foot or wrist.
Assessed via fingers

2. The apical pulse, in contrast, is a central pulse; that is, it is located at the apex of the
heart. It is also referred to as the point of maximal impulse (PMI) and is taken via
stethoscope.

PULSE SITES

1. Radial – base of thumb

2. Temporal – side of forehead
3. Carotid – side of neck
4. Brachial – inner aspect of elbow
 5. Femoral – inner aspect of upper thigh
6. Popliteal - behind knee
7. Dorsalis pedis – top of foot
8. Posterior tibial
9. Apical pulse – over apex of heart
– taken with stethoscope
– left side of chest

REASONS FOR USING SPECFIC SITES FOR PULSE

VARIATION OF PULSE WITH AGE

Newborn 80-180beats/min
1 year 80-140beats/min
5-8 years 75-120beats/min
Teen 50-90beats/min
Adult 60-100beats/min
Old adult 60-100beats/min

FACTOR AFFECTINNG PULSE

• Age
• Sex
• Exercise or Physical training
• Body fluids
• Position
• Drugs
• Illness
• Emotions
• Temperature

Age
As age increases, the pulse rate gradually decreases overall. See Table 29–2 for specific
variations in pulse rates from birth to adulthood.

Sex
After puberty, the average male’s pulse rate is slightly lower than the females.

Exercise
The pulse rate normally increases with activity. The rate of increase in the professional athlete is
often less than in the average person because of greater cardiac size, strength, and efficiency.

Hypovolemia/dehydration
Loss of blood from the vascular system increases pulse rate. In adults, the loss of circulating
volume results in an adjustment of the heart rate to increase blood pressure as the body
compensates for the lost blood volume.

Stress
In response to stress, sympathetic nervous stimulation increases the overall activity of the heart.
Stress increases the rate as well as the force of the heartbeat. Fear and anxiety as well as the
perception of severe pain stimulate the sympathetic system.

Fever
The pulse rate increases (a) in response to the lowered blood pressure that results from peripheral
vasodilation associated with elevated body temperature and (b) because of the increased
metabolic rate.

Medications.
Some medications decrease the pulse rate, and others increase it. For example, cardiotonic (e.g.,
digitalis preparations) decrease the heart rate, whereas epinephrine increases it.

Position. When a person is sitting or standing, blood usually pools in dependent vessels of the
venous system. Pooling results in a transient decrease in the venous blood return to the heart and
a subsequent reduction in blood pressure and increase in heart rate.

Pathology. Certain diseases such as some heart conditions or those that impair oxygenation can
alter the resting pulse rate.

BREATHING/ RESPIRATION

Respiration: Respiration is the mechanism the body uses to exchange gases between the
atmosphere and the blood and the blood and the cell. Respiration involves the following
processes....

Ventilation: the movement of gases between in and out of the lungs (inspiration and expiration).

Diffusion: the movement of oxygen and carbon dioxide between the alveoli and the red blood
cells.
Perfusion: the distribution of red blood cells to and from the capillaries.

PHYSIOLOGICAL CONTROL

The respiratory center (medulla oblangata) in the brain stem regulates the involuntary (adults
normally breathe in a smooth, uninterrupted pattern, 12- 20 times / min) control of respiration.

Ventilation is regulated by CO2, O2, and hydrogen ion concentration (PH) in the arterial blood.
The most important factor in the control of ventilation is the level of CO2 in the arterial blood.

An elevation in the Co2 level causes the respiratory control system in the brain to increase the
rate and depth of breathing.

The increased ventilatory effort removes excess CO2 by increasing exhalation.

MECHANISM OF BREATHING

1.Inspiration/ inhalation
2. Expiration / exhalation
3. Pause

Inspiration/ inhalation
o During this phase the respiratory center sends impulses along the phrenic nerve,
causing the diaphragm to contract.
o Abdominal organs move downward and forward, increasing the length of the
chest cavity to move air into the lungs.
o The diaphragm moves approximately 1 cm, and the ribs retract upward from the
body’s midline approximately 1.2 - 2.5 cm.
o During a normal, relaxed breath, a person inhales 500ml of air. This amount is
referred as Tidal volume.

Expiration / Exhalation:

o During expiration the diaphragm relaxes, and the abdominal organs return to their
original position.
o The thorax decreases in size, and thus the lungs are compressed.
o The ribs move downward and inward
o The sternum moves inward

Pause:
o The relaxation time between inspiration and expiration.
o The normal (breath) rate and depth of ventilation is called Eupnea.

TYPES OF BREATHING
 Costal (thoracic)
Observed by the movement of the chest upward and downward.
Commonly used for adults

2. Diaphragmatic (abdominal)
Involves the contraction and relaxation of the diaphragm, observed by the movement of
abdomen.
Commonly used for children.

FECTORS AFFECTING BREATHING

• Body position
• Exercise
• Acute pain
• Medications
• Smoking
• Hemoglobin function
• Anxiety
• Abdominal trauma
• Neurological Injury
BEAMS-HAAN

CHARACTERISTICS OF BREATHING
When the respiration rate is taken, several characteristics should be noted:
• Rate,
• Rhythm,
• Depth, and quality or characteristics of breathing.

Respiratory Rate: It is the number of respirations per minute. The normal respiration
rate for healthy adults at rest is 12 to 20 cycles per minute. Children have a more rapid
rate of breathing than adults. Respiratory Rate Ranges of Various Age Groups
• Newborn . 30–50
• 1–2 years old 20–30
• 3–8 years old 18–26
• 9–11 years old 16–22
• 12–Adult 12–20

 Tachypnea—quick, shallow breaths

 Bradypnea—abnormally slow breathing
 Apnea—cessation of breathing.

Respiratory Rhythm: It refers to the regular and equal spacing of breaths. In a regular
respiratory rhythm, the cycles of inspiration and expiration have about the same rate and depth.

With irregular breathing patterns, the depth and amount of air inhaled and exhaled and the rate
of respirations per minute will vary.
Respiratory Depth: The depth of respiration is the volume of air that is inhaled and exhaled. It
is described as either “shallow” or “deep.” Rapid but shallow respirations occur in some disease
conditions, such as high fever, shock, and severe pain.

Hyperventilation refers to deep and rapid respirations, and hypoventilation refers to shallow and
slow respirations.

Respiratory Quality: Respiratory quality or character refers to breathing patterns — both

normal and abnormal. Labored breathing refers to respirations that require greater effort from the
patient.

Dyspnea—difficult and labored breathing during which the individual has a persistent,
unsatisfied need for air and feels distressed

Orthopnea—ability to breathe only in upright sitting or standing positions

Breath Sounds: Normal respirations do not usually have any noticeable sounds. However,
certain diseases and illnesses can cause irregular respiration sounds.

ASSESSMENT OF RESPIRATORY RATE

• Eupnea ( 12 – 20/ min)

• Ventilatory depth: The depth of respiration is assessed by observing movement of chest

wall

A deep respiration involves a full expansion of the lungs with full exhalation.

• Ventilatory depth: Diaphragmatic breathing results from the contraction and relaxation
of the diaphragm and is best observed by watching abdominal movements.

Ventilatory diffusion and perfusion: The respiratory process of diffusion and perfusion can
be evaluated by measuring the oxygen saturation of the blood.
Color of skin
Capillary refill

ALTERATIONS IN RESPIRATION
 Apnea: Absence of breathing.
 Eupnea: Normal breathing
 Orthopnea: Only able to breathe comfortable in upright position (such as sitting in
chair), unable to breath laying down.
 Dyspnea: Subjective sensation related by patient as to breathing difficulty.
 Paroxysmal nocturnal dyspnea attacks of severe shortness of breath that wakes a person
from sleep
  Hyperpnea: Increased depth of breathing
 Tachypnea: Increased frequency without blood gas abnormality
 Bradypnea: is a respiratory rate that is lower than normal for age.
 Hyperventilation: Increased rate or depth, or combination of both.
 Hypoventilation: Decreased rate or depth, or some combination of both.
 Kussmaul's Respiration is a deep and labored breathing pattern often associated with
severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney
failure.

BLOOD PRESSURE

Blood pressure (BP) is one of the most important vital signs because it aids in diagnosis and
treatment, especially for cardiovascular health. Blood pressure readings are almost always taken
at every medical visit, even if it is the only vital sign obtained.

Definition: Blood pressure is the amount of force exerted on the arterial walls while the heart is
pumping blood— specifically when the ventricles contract.

Blood pressure is measured by gauging the force of this pressure through two specific readings:
Systolic and Diastolic.

Systolic blood pressure is the highest pressure that occurs as the left ventricle of the heart is
contracting.
Diastolic blood pressure is the lowest pressure level that occurs when the heart is relaxed, and
the ventricle is at rest and refilling with blood.
o Blood pressure is read in millimeters (mm) of mercury (Hg), or “mmHg”. Blood pressure
is recorded using just the systolic (highest pressure) reading over the diastolic (lowest
pressure), like writing a fraction.

o For example, 120/80 would indicate a systolic pressure of 120 (mmHg) and a diastolic
reading of 80 (mmHg).

Pulse pressure: PP is the difference between the systolic and diastolic readings and
calculated by subtracting the diastolic reading from the systolic reading. If the blood pressure
is 120/80, the pulse pressure is 40.

In general, a pulse pressure that is greater than 40 mmHg is considered widened, and one that
is less than 30 mmHg is narrowed.

Pulse pressure
A widened pulse pressure may be an indicator for cardiovascular disease and anemia

A narrowed pulse pressure may be an indicator for congestive heart failure (CHF), stroke, or
shock. Although pulse pressure is useful in predicting cardiovascular risk in patients, it
should not be used alone and depends on various other factors, such as the patient’s BP and
age.

NORMAL BLOOD PRESSURES

FACTOR AFFECTING BLOOD PRESSURE

• Race
• Exercise
• Age
• Diurnal variation
• Stress
• Gender
• Medications

BLOOD PRESSURE ASSESSMENT

Equipment used are
blood pressure cuff, a sphygmomanometer, and a stethoscope.

Types of sphygmomanometers:
• Mercury
• Aneroid
• Electronic

1. Direct (invasive, arterial blood pressure monitoring)

2. Indirect /Noninvasive
Auscultatory method
Palpatory method

Direct method- A monitor is used for this method. This is a continuous method which
measures mean pressures. A needle or catheter is inserted into the brachial, radial, or
 femoral artery and a monitor displays arterial pressure in wave form.

Direct (invasive) blood pressure monitoring is recommended in sick and compromised

patients, those who are at risk of developing major blood loss during surgery or for whom
abnormal blood gases are anticipated (patients with respiratory disease or thoracotomies).

Indirect method- Taking blood pressure by using sphygmomanometer

.
Palpatory method
In the palpatory method of blood pressure determination, instead of listening for the
blood flow sounds, the nurse uses light to moderate pressure to palpate the pulsations of
the artery as the pressure in the cuff is released. The pressure is read from the
sphygmomanometer when the first pulsation is felt

The auscultatory method is most used in hospitals, clinics, and homes. External
pressure is applied to a superficial artery and the nurse reads the pressure from the
sphygmomanometer while listening with a stethoscope. When carried out correctly, the
auscultatory method is relatively accurate.

When taking a blood pressure using a stethoscope, the nurse identifies phases in the
series of sounds called Korotkoff’s sounds. The systolic pressure is the point where the
first tapping sound is heard while the diastolic pressure is the point where the sounds
become inaudible .

SITES
 Upper arm
 Thigh
 Leg
 Forearm
 Upper arm (using brachial artery (commonest)
 Thigh around popliteal artery
 Forearm using radial artery
 Leg using posterior tibial or dorsal pedis

ALTERATIONS IN BP

1.Hypertension
2.Hypotension:
3. Orthostatic Hypotension or Postural Hypotension

1. Hypertension:
It is an often a symptomatic disorder characterized by persistently elevated blood pressure. The
diagnosis of hypertension is made when an average of two or more diastolic readings on at least
two visits is 90 mm Hg or higher. Or
when the average of multiple systolic blood pressures on two or more subsequent visits is
consistently higher than 135 mm Hg.
2. Hypotension: is generally considered present when the systolic blood pressure falls 90
mm Hg or below.

3. Orthostatic Hypotension or Postural Hypotension: It occurs, when a normotensive

person develops symptoms of and low blood pressure when
rising to an upright position. Or change his position from lying to sitting and to standing
position.

REFERENCES
Kozier & Erb’s Fundamental of Nursing ,8th edition
( Audrey Berman ,Shirlee J. Synder).

Fundamentals of Nursing: Standards & Practice, 2nd Edition

( Sue C. DeLaune Patricia K. Ladner.)

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