VITAL SIGNS

• Taking of vital signs refers to measurement of

– body temperature (T),
– pulse (P) ,
– respiratory (R) rates, and
– blood pressure (BP).
• Vital signs are fundamental to physical
assessment (the first step in the physical
examination) .
• Baseline values establish the norm against which
subsequent measurements can be compared.
• Variations from normal may indicate problems
with the client’s health status.
• Frequency of vital sign measurements for
hospitalized client is determined by the client’s
health status and the established standards of
care for the institution.
• The sequence for recording vital signs
measurement in the nurses’ notes is T-P-R and
BP.
• Special graphic forms used to record vital signs
to facilitate data comparison at a glance
because the data are plotted on a graph.
 Thermoregulation
• Thermoregulation is the body’s physiological
function of heat regulation to maintain a
constant internal body temperature.
• The “core” internal temperature of 98.6°
Fahrenheit (F) (37° centigrade [C]) does not
vary more than 1.4°F (0.77°C) and is higher
than the skin and external temperature.
• Skin temperature rises and falls with changes
in environmental temperature.
• Heat is produced in the body’s cells through
food metabolism that results in the release of
energy.
• The body converts energy supplied by
metabolized nutrients to energy forms that
can be used directly by the body
• One form of this energy is thermal energy for
regulation of body temperature
• Body temperature is controlled by balancing
metabolic heat production with heat loss.
• Most heat production comes from the deep
tissue organs (brain, liver, and heart) and the
skeletal muscles.
• The skin, subcutaneous tissues, and fat of the
subcutaneous tissues serve as heat insulators .
• Sweat glands in the dermis are innervated by
sympathetic nerves of the autonomic nervous
system and are controlled by the anterior
hypothalamus to regulate sweating.
 Heat loss
• Skin’s surface through
– radiation,
– conduction,
– convection, and
– evaporation
• Insensible heat loss:
– heat lost through continuous, unnoticed water
loss that occurs with vaporization, accounting for
10% of basal heat production.
• Behavioral Control of Body Temperature
– Person makes appropriate environmental
adjustments to reestablish comfort
• e.g. putting on warm clothing.
 Respiration
• Act of breathing.
• Five physiological pulmonary functions
provide oxygen to the tissues and remove
carbon dioxide:
– Ventilation
• Inflow and outflow of air between the atmosphere and
the lung alveoli.
– Circulation
• Quantity of blood flowing through the lungs
• is approximately 4 to 6 L/min.
– Diffusion
• Exchange of oxygen and carbon dioxide between the
alveoli and the blood.
– Transport
• Carrying of oxygen and carbon dioxide in the blood to
and from the cells
– Regulation
• The neurogenic system that adjusts the rate of alveolar
ventilation to meet the demands of the body.
• Hemodynamic Regulation
– The physiological function of blood circulating to
maintain an appropriate environment in tissue
fluids.
– When the body’s circulatory needs change, the
heart rate either accelerates or decelerates.
– This is a compensatory mechanism under the
control of the cardiac centers that are located in
the medulla of the brain stem.
– Stroke volume :
• Blood that enters the aorta with each ventricular
contraction(60-70 ml)
– Cardiac output :
• Volume of blood pumped by the heart in 1 minute.
CO=HR X SV
 Pulse
• Is the bounding of blood flow in an artery that is
palpable at various points on the body.
• Is caused by stroke volume ejection and
distension of the walls of the aorta, which creates
a pulse wave as it travels towards the distal ends
of the arteries.
• Pulse pressure
– is a measurement of the ratio of stroke volume to
compliance (total distensibility) of the arterial system.
– Calculated as the difference btw systolic and diastolic
BP
• Pulse Points
– Temporal
– Carotid
– Brachial
– Apical
– Radial
– Femoral
– Popliteal
– Posterior tibial
– Dorsalis pedis
 Blood Pressure
• Is the measurement of pressure pulsations
exerted against the blood vessel walls during
systole and diastole.
• Blood pressure and pulse determine the
volume of ejected blood into the arterial
system with each ventricular contraction.
• In a healthy young adult, the pressure at the
height of each pulse (systolic pressure) is
approximately 120 mm Hg, and the pressure
at the lowest point of each pulse (diastolic
pressure) is approximately 80 mm Hg.
• The pulse pressure is the difference between
these pressures, which is 40 mm Hg.
• Four hemodynamic regulators for blood
pressure
– Blood volume
• Volume of blood in the circulatory system.
– Cardiac output
• Influences systolic pressure.
– Peripheral vascular resistance
• size and distensibility of arteries determines diastolic
pressure.
• Arterial resistance (decreased distensibility) is
encountered when the left ventricle pumps blood from
the heart under pressure during the systolic phase.
– Viscosity
• Thickness of blood based on the ratio of proteins and
cells to the liquid portion of blood.
• The greater the viscosity, the harder the heart must
work to pump blood, with a resultant increase in blood
pressure.
• Blood pressure is a result of the cardiac output and
peripheral vascular resistance.
• Arteries expand during systole and contract
during diastole, creating two distinct pressure
phases:
– Systolic blood pressure
• maximum pressure exerted against arterial walls during
systole (when myocardial fibers contract and tighten to
eject blood from the ventricles).
– Diastolic blood pressure
• pressure remaining in the arterial system during
diastole (period of relaxation i.e. the pressure
remaining in the blood vessels after the heart has
pumped).
 Factors influencing vital signs
• Age.
– Ventilation
• Bony changes in the thorax and vertebrae and the
decline in respiratory and abdominal musculature
reduce the ability of the lungs to distend.
– Circulation and diffusion
• The increase in dead air space in the respiratory tree
decreases the quantity of blood flowing through the
lungs and gaseous exchange
– Transport
• Atherosclerosis (plaques in the inner walls of arteries)
and dysrhythmia (irregular heartbeat) reduce the
amount of blood available to tissues.
– Regulation
• Inability of lung to function maximally reduces the rate
of alveolar ventilation to meet the demands of the
body.
 Normal age-related variations in body temperature
Age: Normal Range
Celsius Fahrenheit

Newborn Axillary 35.5–39.5°C 96.0–99.5°F

1 yr Oral 37.7°C 99.7°F

3 yr Oral 37.2°C 99.0°F

5 yr Oral 37.0°C 98.6°F

Adult Oral 37.0°C 98.6°F

Axillary 36.4°C 97.6°F

Rectal 37.6°C 99.6°F

70+ yr Oral 36.0°C 96.8°F

• Gender.
– Temperature variations occur during the menstrual cycle in
response to progesterone level.
– Males in general have higher blood pressure than females
of the same age.
• Heredity
– Hereditary factors linked to specific cardiovascular disease
occurrence.
• Race.
– Some ethnic groups are more susceptible to
hemodynamic alterations.
• Lifestyle
– Cigarette smoking, cause chronic changes in the lungs
leading to impaired ventilation.
– Stimulants like caffein and tobacco elevate heart rate.
• Environment
– Temperature and noise level can alter heart rate.
• Medications
– Digitalis preparations (cardiac glycosides) decrease
the pulse rate.
– Narcotic analgesics depress rate and depth of
respirations and lower the blood pressure
• Pain.
– With acute pain, sympathetic stimulation
increases the heart rate, which increases the
cardiac output and vasoconstriction, causing an
increased peripheral vascular resistance.
• Other factors
– Exercise
– Metabolism
– Anxiety
– Stress
– Postural changes
– Diurnal (daily) variations (also called
circadian)
MEASURING VITAL SIGNS
 Body Temperature
• Assess the client for the most appropriate site
and gather the necessary equipment

CENTIGRADE AND FAHRENHEIT CONVERSION FORMULAS

• Centigrade to Fahrenheit conversion:
– multiply the centigrade reading by 9/5 and add 32:
°F = (°C × 9/5) + 32
• Fahrenheit to centigrade conversion:
– deduct 32 from the Fahrenheit reading and multiply
by 5/9:
°C = (°F – 32) × 5/9
• Sites
– oral,
– Rectal
– Axillary
– Advanced :
• pulmonary artery temperature and infrared
thermometers for ear canal temperature .
• When heat production exceeds heat loss and
body temperature rises above the normal
range pyrexia occurs.
• When the body’s temperature rises above
37.4°C (101°F) orally or 38°C (100.4°F) rectally,
the client is said to be febrile.
• Temperature measurements usually plotted
on a graph to identify alteration patterns.
A. Insert thermometer into center of
axilla.
B.Place client’s arm across chest.
 Place the tip of thermometer under client’s
tongue in posterior sublingual pocket lateral to
center of lower jaw.
Preparation for the Insertion of a
Rectal Thermometer
 Pulse
• Pulse assessment is the measurement of a
pressure pulsation created when the heart
contracts and ejects blood into the aorta.
• pulse characteristics provides clinical data
regarding the heart’s pumping action and the
adequacy of peripheral artery blood flow.
• most accessible peripheral pulses
– Radial
– carotid.
• Assessing Pulse Rate
– Note any medications that could affect heart rate
– Physical activity increases heart rate, ensure that
client rests 5 to 10 minutes before assessing
pulse.
– Palpate a peripheral pulse by placing the first two
fingers on the pulse point with moderate
pressure.
– Normal radial and apical pulses are identical in
rate.
– Pulse deficit exists when the apical pulse rate is
greater than the radial pulse rate.
– Results from the ejection of a volume of blood
that is too small to initiate a peripheral pulse
wave.
• Pulse Characteristics
– Rate
– Rhythm
– Volume/strength
– Pulse rate :
• Number of times that you can feel a pulse wave passing
a point in one minute.
• Since a pulse wave occurs whenever the heart beats,
the pulse rate equals the heart rate.
• Normal pulse rates
– Adults: 60-100 beats/minute (average 72)
– Children 70-120
– Toddlers 90-150
– Newborns 120-160
• Bradycardia
– heart rate less than 60 beats per minute in an adult.
• Tachycardia
– heart rate in excess of 100 beats per minute in an adult.
– Pulse rhythm
• Regularity of the heartbeat.
• Regular
– beats are evenly spaced
• Irregular
– beats are not evenly spaced.
– Intermittent/Dysrhythmia (arrhythmia) is an irregular rhythm
caused by an early, late, or missed heartbeat
– Pulse volume:
• Strength /force of pulse is determined by amount of
blood forced into the artery by the heart beat.
• Normal
– full, easily palpable
• Weak/feeble/thready
– heart pumping a small amount of blood with each heart
beat; usually rapid
• Bounding
– heart pumping a large amount of blood with each heart beat;
could be due to exercise, anxiety etc
• Strong
– stronger than normal but less than bounding e.g. severe
bleeding
• Pulse volume scale
Scale Description of Pulse
• 0 Absent pulse
• 1+ Weak and thready pulse
• 2+ Normal pulse
• 3+ Bounding pulse
Place index and middle finger on inner aspect of
client’s wrist over the radial artery.
Palpating the Apical Pulse
Place diaphragm of stethoscope over the PMI to
auscultate for sounds.
• Point of maximal impulse (PMI)
– The area between fourth intercostal space left of
the sternal border and the fifth intercostal space,
left of the mid-clavicular line.
– Place diaphragm of stethoscope over the PMI
and auscultate for sounds S1 and S2 to hear lub-
dub sound.
 Respirations
• Respiratory assessment is the measurement of
the breathing pattern.
• Assessment of respirations provides clinical
data regarding the pH of arterial blood.
• Normal breathing is observable, effortless,
quiet, automatic, and regular.
• Assessed by observing chest wall expansion
and bilateral symmetrical movement of the
thorax.
• Assessing Respirations
– Assess rate, depth, and rhythm of respiration.
– Rate :
• Count number of breaths taken per minute.
• Normal respiratory rate 12 to 20 breaths per minute.
• One inspiration and expiration cycle is counted as one
breath.
– Depth & rhythm
• Note the depth and rhythm of ventilatory movements
by observing for the normal thoracic and abdominal
movements and symmetry in chest wall movement.
• Characteristics of Normal and Abnormal Breath
– Eupnea
• refers to easy respirations with a normal rate that is age-
specific.
– Bradypnea
• Rate of 10 or fewer breaths per minute.
– Hypoventilation
• Shallow respirations.
– Tachypnea
• Rate greater than 24 breaths per minute.
– Hyperventilation
• Deep, rapid respirations.
 – Costal (thoracic) breathing
• When intercostal muscles and the other accessory
muscles are used in breathing.
– Diaphragmatic /abdominal/deep breathing
• Diaphragm contracts; abdomen expands instead of the
chest.
– Dyspnea
• Difficulty in breathing as observed by labored or forced
respirations through the use of accessory muscles in
the chest and neck to breathe.
• Respiratory alterations may lead to cyanosis
 Blood Pressure
• Pressure exerted by circulating blood on the
walls of arteries.
• measured by either a direct or an indirect
technique.
• The direct method requires an invasive
procedure.
• indirect method requires use of the
sphygmomanometer and stethoscope.
• Most common site for indirect blood pressure
measurement is the client’s arm over the
brachial artery.
• Others - forearm, leg.
• Contraindications for brachial artery blood
pressure measurement
– Venous access devices like branula
– Surgery involving the breast, axilla, shoulder, arm,
or hand
– Injury or disease to the shoulder, arm, or hand,
such as trauma, burns, or application of a cast or
bandage
The popliteal artery, can be used if the upper
extremities arteries are not accessible.
• Assessing Blood Pressure
– Use the correct width of the blood pressure cuff as
determined by the circumference of the client’s extremity.
– Inflate the cuff to a little over 180mm hg to collapse the
major arteries of the arm
– Slowly release air by turning the air valve and watch the
pressure drop.
– When you first hear a sound that will be the systolic
pressure.
– It means blood is now flowing in the artery of the arm
because now the systolic pressure is higher than the
pressure in the cuff.
– When you no longer hear any sound that will be the
diastolic pressure
– Bilateral readings should be done with the initial
blood pressure assessment.
– A pressure variance of 5 to 10 mm Hg normally
exists between arms.
– The arm with the higher reading should be used
for routine measurements.
Wrap the blood pressure cuff on the arm 1 inch above
client’s brachial pulsation, with bladder centered over
brachial artery.
Palpate the brachial artery with fingertips below
the pressure cuff.
Place bell chest piece over brachial artery below
blood pressure cuff.
• Hypotension
– Systolic blood pressure less than 90 mm Hg or 20
to 30 mm Hg below the client’s normal systolic
pressure; and a diastolic pressure below 60
– Causes:
• Decreased blood volume
– (e.g., hemorrhage)
• Decreased cardiac output
– (e.g., myocardial infarction [heart attack])
• Decreased peripheral vascular resistance (vascular
dilation)
– (e.g., shock)
– If the falling pressure is untreated, the body’s
compensatory mechanisms will fail and the client
will go into shock:
• cool, clammy skin;
• fast, thready pulse;
• Gradual decrease in urinary output
• disruption to cerebral blood flow that causes confusion,
progressing to coma.
– Orthostatic/postural hypotension
• Sudden drop of 25 mm Hg in systolic pressure and 10
mm Hg in diastolic pressure when the client moves
from a lying to a sitting or a sitting to a standing
position.
• Hypertension
– Persistent systolic pressure greater than 140 mm
Hg and a diastolic pressure greater than 90 mm
Hg.
– Causes of false high BP
• A cuff too narrow
• A cuff not well fitting around the extremity
• A cuff that is deflated too slowly
• When the mercury column in the manometer is not
positioned flat on a firm surface or is read above eye
level
• The extremity is below the heart’s apex level.
– causes of false low BP
• Extremity is above the heart’s apex level,
• Cuff is too wide for the extremity,
• Mercury column in the manometer is read below eye
level.
– Documentation
• If the brachial artery is not used for the measurement,
indicate the site when recording the results.
Thank you.