VITAL SIGNS THE 4 CARDINAL SIGNS OF VITAL SIGNS

1. Body Temperature
● Is the baseline procedure. It reflects the body’s physiological
2. Pulse Rate
status and ability to regulate temperature, maintain local and 3. Respiratory rate
systematic blood flow and oxygenated tissues 4. Blood Pressure
● Changes in vital signs can indicate sudden or gradual changes
in clients’ status. Significant changes should be reported
immediately to the charge nurse and physician. A. BODY TEMPERATURE

WHEN TO TAKE VITAL SIGNS ● Normal body temperature is maintained through a

● On the client’s admission to hospital or extended care facility.
● In a hospital on a routine frequency according to a physician
order.
● During a client visit to a clinic or toa physician’s office.
balance between heat production and heat loss in
affected largely by the central nervous system control
by Centre located in the hypothalamus (Located below
the thalamus of the midbrain nearest to the pituitary
gland).
● Rise and fall of the body temperature

● Before and after surgical procedure. PURPOSES OF THE BODY TEMPERATURE

● Before and after any invasive diagnostic procedure. 1. To obtain baseline data on admission to the hospital
2. To guard against hyperthermia or hypothermia
● Before and after administration of medication that affects 3. To monitor the client’s response to procedure or therapy
cardiovascular and respiratory functions. 4. To detect and follow the cause of febrile illness.
● Whenever the client’s general physical condition suddenly 5 PRIMARY FACTORS THAT AFFECTS HEAT PRODUCTION IN THE
worsens. BODY
● Before nursing interventions that may influence any one of 1. Basal Metabolic Rate
the vital signs (ambulating after a week of bed rest). ● Amount of energy release in the body requires to
● Whenever the client reports to the nurse any none specific maintain essential activity.
symptoms of physical distress. ● BMS vary with age and sex (the younger the
● Whenever client’s presents symptoms of confusion and person, the higher is the BSM. Male has higher
disorientation. BMS than female)
2. Muscular Activities
 ● Muscles exercises increases heat production.
3. Thyroxin
● A hormone secreted by the thyroid gland, essential
for normal growth and metabolism. Increase in
Thyroxin output increases the rate of cellular
metabolism. Increases heat production.
4. Epinephrine, nor epinephrine and Sympathetic Activity
● Epinephrine and norepinephrine – chief hormone
of normal adrenal medulla. Increase in these FACTORS
hormones immediately increases the rate of REGULATION
cellular metabolism in many body tissues. (e.g liver
and muscle tissues)
● Sympathetic stimulation of brown fats cells
stimulated they produce a large amount of heat.
5. Body Temperature
● Fever increases metabolic rate. The presence of
fever increases the body’s temperature further.
4 PHYSICAL PROCESS OF HEAT LOSS
1. Radiation
● Is the transfer of heat from the surface of one
object to the surface of another without contact
with two objects. Example. UV rays of the sun, 60%
heat loss by a nude person standing in a room at a
normal room temperature.
2. Evaporation
● Or vaporation is the process by which water is
converted into steam.
3. Convection
● Is the movement of heat from one another by
current of heat or fluids. Transfer of heat form the
hotter to the colder part. Ex. Electric Fan
4. Conduction
● Is the transfer of heat from any substance like air,
water and clothing which comes in contact with the
body. Ex. Sponge bath.
AFFECTING TEMPRATURE MAINTENANCE AND
a. Environmental Temperature
● Brief exposure to extreme cold stimulates the body
to produce more heat.
● Too much exposure to the sun by the use of warm
clothing heat regulates.
b. Diurnal Variations
● The body temperature generally lowest in the early
morning and highest in the afternoon and early
evening following the day’s activity.
c. Exercise
● Heat production is increase by exercise due to
increased cell activity
d. Specific Dynamics action of blood
● The oxidation and combustion of food released heat
producing energy covertly in starvation.
e. Hormonal activity
 COMMON SITES FOR BODY TEMPERATURE
● Any factors that increase activities consequently raises
heat production. Ex. Progesterone secretion at the a. Mouth (oral)
time of ovulation raises the body temperature. ● Place in the posterior sublingual pocket of the tongue
f. Age
● Contraindicated in infant and children below 6 years
● New born and children normally have higher body
old, unconscious patient and those receiving O 2
temperature than adult’s period. Normally ranges from
therapy, confuse and with convulsive disorder.
97.7 to 99.9 oF to 36.5 to 37.5 oC.
● Taken 5 to 7 minutes
● For old age 95 oF or 35 oC. 75 years are at risk for
b. Rectum (rectal or anal)
hypothermia due to inadequate diet, less activity and
loss of subcutaneous fats. ● Most accurate but inconvenient and unpleasant.
g. Stress
● Taken 3 minutes
● Highly stresses or anxious client could have an
c. Axilla (armpit)
elevated body temperature. Stress can stimulate
sympathetic nervous system leading to the increase in ● Preferred in children and safest
production of epinephrine and norepinephrine d. Ear
h. Food, fluid and smoking
3 TYPES OF THERMOMETER
a. Mercury fluids
b. Electronic
● Battery operated unit
c. Disposable Chemical
● Thermometer is inserted in the client’s tongue and left
TWO SCALES OF MEASURING BODY TEMPERATURE
in place for the time recommended by the
a. Fahrenheit Scale (oF) – is named after Gabriel Daniel manufacture. Ex. 45 sec.
Fahrenheit, a German Physicist who invented the mercury
thermometer in 1714. In these scale water freezes at 32 oF and PARTS OF THE THERMOMETER
boils at 212 oF a. Bulb or mercury bulb
b. Celsius Scale or Centigrade (oC) – is named after a Swedish b. Stem of the body
Scientist Anders Celsius who proposed the scale at which the c. Mercury
freezing point of water is oC and the boiling is 100 oC.
TERMS:
a. PYREXIA – in lay term “FEVER” an elevated body temperature
results higher than the normal value of 39.5 oC.
b. HYPOTHERMIA – an abnormally low body temperature. Body
temperature falls below 34.5 oC and could lead to death.
c. HYPERTHERMIA – an abnormally high body temperature. A
very high fever about 41 oC.
B. PULSE RATE
Pulse
● The ventricular contraction approximately 60-100 ml of
blood enters the aorta, distending the aortic walls and
creating the pulse wave.
● Pulse wave of blood created by the contraction by the
left ventricle of the heart.
● Client’s pulse can be felt (palpitated) peripherally or
heard (auscultator) each time the heart’s left ventricles
contracts and forces blood into aorta.
● Pulse rate is regulated by the autonomic nervous
system.
PURPOSE OF PULSE ASSESSMENT
1. To obtain a baseline measure of the client’s heart rate and
rhythm
2. To monitor changes in the client’s cardiovascular status.
3. To monitor the hearts response to a disease, procedure or
therapy.
4. To assess blood flow to a specific body part.
● Infant rates range from 100-160 beats per minute
● 4 years of age ranges from 80-120 beats per minutes
● Adolescent and adults ranges from 60 -100 beats per
minutes.
PULSE SITE
a. Apical - apex of the heart (central pulse)
b. Temporal pulse – temporal bone (superior and lateral to the
eye)
c. Carotid Pulse – side of the neck, below the lobe of the ear.
d. Radial pulse – palpated at the thumb side of the inner aspect
of the wrist.
e. Brachial pulse – antecubital space (medially)
f. Femoral Pulse – palpated between the anterior iliac spines.
g. Popliteal Pulse - palpated in the popliteal Forsa (knee crease)
h. Dorsalis Pedis – palpated along the top of the foot pedal
i. Posterior Tibialis – palpated on the inner side of each ankle.
TERMS
a. TACHYCARDIA – increase beats about 100
b. BRADYCARDIA – beats lower than 60
c. BOUNDING PULSE – a pulse that reaches higher level than
normal then disappears quickly.
d. FEEBLE, WEAK, THREAD PULSE – terms use for a pulse whose
volume is small and can bew readily literated. Very weak but
rapid.
e. RUNNING PULSE – a pulse rate that is too fast to counted
sometimes difficult to count.
 C. RESPIRATION e. TACHYPNEA – fast shallow breathing there is an increase of
respiratory rate
Respiration
f. KUSSMAUL RESPIRATION – air hunger. A rapid or intense
respiration.
● Act of breathing which include the intake of oxygen
g. ORTHOPNEA – breathing easier when person sit or stand
and output of carbon dioxide. h. BIOT’S RESPIRATION – irregular in rate and depth without
● Process of oxygen intake and carbon dioxide output by emerging patterns
the lungs i. HYPERVENTILATION – refers to very deep, rapid respiration.
j. HYPOVENTILLATION – refers to very shallow respiration.
● Normal respiration rate 12-20 breaths per minutes.

● Respiratory center located at the medulla or brain

D. BLOOD PRESSURE
stem.
Blood Pressure
PURPOSE OF RESPIRATION ASSESSMENT
1. To obtain baseline data on respiratory rate and characteristics ● Is force exerted by the blood against the arterial walls.
2. To monitor effect by pathogenic condition such as infection on
● Consists of systolic and diastolic pressure. Systolic is the
the client respiration
3. To monitor the client’s response to a specific therapy. pressure of the blood as a result of the contraction of
ventricles. Diastolic is the pressure when the ventricles are at
4 INTERRELATED PROCESS OF RESPIRATION rest.
1. Ventilation – the movement of air into and out of the lungs ● 120/80 mmHg normal for adult
2. Conduction – the movement of air through lung airways
3. Diffusion – the movement of oxygen and carbon dioxide ● 105/65 mmHg for children
between the alveoli and red blood cells.
● Pulse pressure – the difference between the systolic and
4. Perfusion – the distribution of blood flow through pulmonary
capillaries diastolic pressure
● Reflect to the output of blood volume, peripheral blood,
TERMS
viscosity, arterial (effect the blood pressure)
a. EUPNEA – normal breathing. Inspiration is 1.5 sec. expiration
2-3 secs. ● Viscosity- the sticky of the blood.
b. APNEA - absence of breathing
c. BRADYPNEA – decrease of respiratory rate
d. DYSPNEA – difficulty and painful breathing PURPOSE OF THE BLOOD PRESSURE ASSSESSMENT
 1. To obtain baseline blood pressure measurements a. Cuff
2. To assess the client’s cardiovascular status b. Scale/mercury scale/ manometer
3. To assess thew client’s response to blood or fluid volume loss c. Pump/bulb
after surgery, childbirth, trauma, or burns. d. Regulator/Valve
4. To evaluate the client’s response to charges in his condition
TERMS
after treatment with fluids. Medication, or other therapies.
a. HYPERTENSION – abnormally high BP over 140 mmHg systolic
KOROTKOFF’S Sounds
and 90 mmHg diastolic confirmed by minimum of 2
consecutive visits.
● The sound than can hear. Gradually lowered. When taking a
blood pressure using a stethoscope, the nurse identifies five b. HYPOTENSION – abnormally low BP with systolic below 100
phases in the series of sounds called KOROTKOFF. mmHg.
1st - systolic – pressure of blood as a result of contraction of the 1. What is the importance of taking vital signs?
ventricles. Faint, clear and tapping sounds are hears. (identify at least
two consecutive tapping sounds). The importance of taking vital signs lies in their ability to provide critical
information about a person's health status, helping healthcare providers to
2nd - Murmuring sounds or swishing, soft blowing sound assess, diagnose, and monitor various medical conditions.

3rd – More crisper Vital signs help to identify potential medical problems, to monitor the
progress of treatment, to evaluate the effectiveness of medications, to
4th – Maffled. detect medical emergencies.

5th – disappearing sounds.

2. What are the do’s and don’ts in taking vital signs?
PARTS OF THE STETHOSCOPE
Do’s:
a. Diaphragm  Ensure that the equipment used for measuring vital signs is clean
b. Earpiece and in good working condition.
c. Tube or Stem  Explain the procedure to the patient and obtain their consent.
 Use the correct technique for measuring each vital sign.
Instrument Used – Sphygmomanometer  Record the vital signs accurately, including the time and date of
measurement.
2 types of Sphygmomanometers
 Monitor the patient’s response during the procedure and take
a. Aneroid appropriate action if necessary.
b. Mercury Don'ts:
Parts of Sphygmomanometer  Don't take vital signs immediately after the patient has engaged in
physical activity, as this can affect the accuracy of the readings.
  Don't take vital signs over clothing, as this can interfere with the makes use of vaccine which is suspension of killed or living organism
accuracy of the readings. (ex. Mmr, opv, bcg)
 Don't use equipment that is outdated, damaged, or not properly
calibrated. Passive- when what has been introduced to the body is already
 Don't ignore abnormal vital sign readings, as they may indicate a antibodies that provide immediate protection against
serious medical condition. microorganisms.
 Don’t perform vital sign measurements in a noisy or distracting
environment, as this can interfere with the accuracy of the readings.  Naturally acquired passive immunity-
exhibited by the transfer of antibodies from mother’s placenta to the
Immunity fetus and transfer of antibodies from breast milk to the baby.

This is the total property of an individual to protect himself from an • Artificially acquired passive immunity-
infectious agent. injection of artificially prepared substance like immune serum of
Two types of immunity gamma globulin. These two are antibodies preparation (ex. Anti-
tetanus antibodies, diphtheria antitoxin)
• Nonspecific resistance- present at the time of birth or
has developed during maturation. THE ENVIRONMENTAL FACTORS OF DISEASE

• Specific resistance- acquired as a result of prior exposure Environment-

with a foreign substance. sum total of an organism's external surrounding conditions and
TWO FOLDS OF SPECIFIC RESISTANCE influences that affect its life and development.

Active- what has been introduced to the individual is the antigen and • Physical environment
the body makes the antibody.
• Climate- certain disease have seasonal distribution.
 Naturally acquired active immunity-
• Geography and location
when we get sick the infective agent will gain entry to the body, act as
stimulant for antibody formation because the organism acts as
• Biologic environ ment-
antigen. living environment of man consist of plant s , animals, and fellow
human beings.
The immunity is lifelong (ex. Measles, chicken pox, hepatitis A)
• Socio-economic environ men t
 Artificially acquired active immunity-
when the antigen has been deliberately introduced like injecting
vaccines, they act as antigen to stimulate antibody formation. It • The occurrence of disease follows biologic laws
 which apply to both communicable and non__
communicable diseases.
• Disease results from imbalance between the forces of the
agent and host
• The nature and extent of imbalance depends on the
nature and characteristics of host and agen t

• The characteristics of two are influenced

considerably the condi tion of the environment.