Vital Signs Study Guide

Vital Signs

• The vital signs are body temperature, pulse, respirations and blood pressure.
• The signs reflect changes in function that otherwise might not be observed.
• Vital signs are checked to monitor the functions of the body.
• It should be evaluated with reference to the client's present and prior health
status and then compare to the client's usual and accepted normal standards.
• The four main vital signs that are monitored by health care providers are the
following:

A. body temperature

B. pulse rate

C. Respiration rate (rate of breathing)

D. Blood pressure

• Pain is also considered by many agencies as the fifth vital sign and pulse
oximetry is also measured together with the other 4 traditional vital signs.

I. Body temperature

It is the balance between heat produced and heat lost from the body and is
measured in heat units called degrees.

2 kinds of body Temperature:

1. Core temperature -It is the temperature of the deep tissues of the body such as
the abdominal and pelvic cavity.

2. Surface temperature- It is the temperature of the skin, subcutaneous tissue and

fat.

Factors that affect Body's heat production

A. Basal metabolic rate- Rate of energy utilization in the body. Metabolic rates
decrease with age. In general, the younger the person, the higher the BMR.
Metabolic rates increases with fever and disease

B. Muscle activity -It increases the metabolic rate e.g. shivering

 C. Thyroxine output- Hormone secreted into the bold stream by thyroid gland
which increases metabolic rate. Increased thyroxine output increases the rate
of cellular metabolism throughout the body.

D. Epinephrine, norepinephrine and sympathetic stimulation- These hormones

directly affects the liver and muscle cells, thereby increasing metabolism.

E. Fever- First sign of infection. Fever increases cellular metabolic rate and thus
increases the temperature

Processes involved in heat loss:

A. Radiation- is the loss of body heat directly to colder objects in the environment.
Because heat always travels from a warm object to a cooler one. Example: a person
standing in a cold room will lose heat by radiation. So, Radiation is the transfer of heat
from one surface to another with contact. Example: drop light for newborn.

B. Conduction- is the direct transfer of heat from a part of the body to a colder object.
For example, when a warm hand touches cold metal or ice, or when a person's hand is
immersed in water with a temperature below his body temperature. Heat passes
directly from the body to the colder object. So, Conduction, is the transfer from one
molecule to another with lower temperature or with contact. (ex: chair, hug).

C. Convection occurs when heat is transferred to circulating air, as when cool air
moves across the surface of a person's body. Example: A person who is standing
outside in windy winter weather and who is wearing lightweight clothing is losing heat
to the environment mostly by convection.

D. Evaporation-is the conversion of any liquid to a gas. The evaporation process

requires energy (heat). Evaporation is the natural mechanism by which sweating cools
the body. This is why swimmers coming out of the water feel a sensation of cold as the
water evaporates from their skin. Individuals who exercise vigorously in a cool
environment may sweat and feel warm at first, but later, as their sweat evaporates,
they can become exceedingly cool.

Factors affecting Body Temperature:

A. Age

A newborn has difficulty adjusting in his body temperature. By the time, the baby is
one year old, the parts of his body that control his body temperature are fully
developed and his normal body temperature has been established.

-An elderly person will usually have a low-normal body temperature. The lower
body temperature is caused by changes within his body and by a decrease in physical
activity. - Children’s temperature vary due to underdeveloped thermoregulatory center.
Older folks or client tends to have a low body temperature due to loss of
subcutaneous fat, inadequate diet, lack of activity, reduced thermo regulatory
efficiency.

B. Diurnal Variations

Time of Day Affects Body Temperature. A person's body temperature is usually lower
in the morning (4 – 6 am) than in the afternoon (4-6 pm). This change is mainly due to
warmer weather and more physical activity occurring later in the day.

C. Exercise

When a person exercises or does hard work, his muscles change stored energy
supplies in the body (mainly glucose and fat) into usable energy. When the body’s
muscles change stored energy into usable energy, heat is given off. This is why you
can warm up in cold weather by doing exercises.

D. Hormones

Menstrual Cycle Affects Body Temperature. A woman's body temperature drops

slightly before ovulation, rises about 1º F above normal during ovulation, because
progesterone is secreted and then returns to her normal level.

Pregnancy Affects Body Temperature. During pregnancy, a woman's body temperature

stays above her regular normal temperature.

E. Stress

A person that is excited (joyful, scared, angry, and so forth.) will have an increase in
body temperature. The excitement causes the body to increase the rate at which it
changes stored food (glucose and fat) into usable energy. As the energy output
increases, so does the amount of heat-produced by the body.

F. Environment

Extremes in environmental temperature, can affect the person's temperature

regulatory systems

ALTERATIONS IN BODY TEMPERATURE:

- Normal range: 96.8 ‘F to 99.5 ‘F (36 ‘C to 37.5 ‘C)

1. Pyrexia
• Other terms for pyrexia are: febrile, fever, hyperthermia, hyperpyrexia.
• A body temperature above the normal range .It is also known as hyperthermia
or (in lay terms) fever. A very high fever, such as 41 C is called hyperpyrexia.
• A client with fever is called FEBRILE, and a client without fever is called
AFEBRILE
Heat Exhaustion: - Result of excessive heat and dehydration (s/sx: paleness,
dizziness, nausea, vomiting, fainting and moderate temp (38.3’C to 38.9’C ).

- Elevated body temperature contributes to dehydration, which

leads to body tissues drying out and malfunctioning. Rehydrating by increasing fluid
intake, the client's tissues will allow the temperature to return to normal.

Heat Stroke - Result of people exercising in hot weather and often do not sweat.
(s/sx: Body temperature of 41’C or higher, delirious, unconscious, seizures)

4 common types of fever:

• Intermittent- the body temperature alternates at regular intervals between

periods of fever and periods of normal or subnormal temperatures. An example
is with the disease malaria.
• Remittent- such as with a cold influenza, a wide range of temperature
fluctuations (more than 2 C<3.6 F>) occurs over the 24-hour period, all of
which are above normal
• Relapsing- short febrile periods of a few days are interspersed with periods of 1
or 2 days of normal temperature. Example: Malaria
• Constant- the body temperature fluctuates minimally but always remains
above normal. This can occur with typhoid fever.
• Fever-spike- temperature that rises to fever level rapidly following a normal
temperature and then returns to normal within a few hours. Bacterial blood
infections often cause fever spikes.

2. Hypothermia
A core body temperature below the lower limit of normal .

3 Physiologic Mechanisms:

1. Excessive heat loss.

2. Inadequate heat production to counteract heat loss.
3. Impaired hypothalamic thermo regulation

Hypothermia Clinical Manifestations:

• Decreased body temperature, pulse, and respirations
• Severe shivering (initially)
• Feelings of cold and chills
• Pale, cool, waxy skin
• Frostbite (nose, fingers, toes)
• Hypotension
• Decreased urinary output
• Lack of muscle coordination
• Disorientation
• Drowsiness progressing to coma
Nursing Interventions for Clients with Hypothermia:
• Provide a warm environment
• Provide dry clothing
• Apply warm blankets
• Keep limbs close to the body
• Cover the client’s scalp with a cap
• Supply warm oral or intravenous fluids
• Apply warming pads

Types of Thermometer

A. Mercury -in-glass Thermometer:

• Oral - has a slender bulb designed to provide a long surface for exposure when it
is placed under the tongue.

• Rectal - has a pear-shaped bulb.

• Multi-use - has a blunt, stubby tip. (maybe used in rectal, oral, axillary site, and
is frequently used for children, as it is considered the safest).

B. Electronic Thermometers

These thermometers use a component called a thermistor at the end of a plastic and
stainless steel probe to sense the temperature. The temperature is read on a digital
display that resets itself when the probe is replaced in the body of the battery powered
recording device. It can provide a reading in only 2 to 60 seconds depending on the
model.
 • Chemical Dot Thermometer. Disposable and consists of a flat plastic device
holding many temperature sensing chemical "dots" that change color when they
reach a certain temperature, using a liquid crystal dots or bars or heat sensitive
tape applied to forehead.

• Temperature sensitive tape. It is also used to obtain the general indication of

the body surface temperature. When applied to the skin usually forehead or
abdomen, the temperature digits on the tape respond by changing color.

• Infrared thermometers. It senses the body’s heat in the form of infrared energy
given off by a heat source which is in the ear canal primarily the tympanic
membrane.

• Temporal artery thermometers. It determines the temperature using a

scanning infrared thermometer that compares arterial temperatures in the
temporal artery or the forehead to the room temperature the calculate the heat
balance to approximate the core temperature of the blood in the pulmonary
artery.

SITES FOR MEASURING BODY TEMPERATURE:

1. Oral - most accessible and convenient. BUT, may break when bitten, maybe
inaccurate if hot or cold food is ingested. Could injure the mouth following oral
surgery.
- Body temperature is frequently measured orally even if the client has
eaten or drank something cold or hot. One only needs to wait 30 minutes, and
then this site can be used.
- (thermometer placement) Place the tip on either side of the frenulum.

2. Rectal - this is a reliable measurement BUT, inconvenient or unpleasant, and

could injure the rectum. Presence of stool may interfere with thermometer
placement.

3. Axilla - Safe and non-invasive, BUT, longer to take an accurate measurement

A digital thermometer may be used to take an axillary temperature. It is a small
hand-held device with a “window” showing your temperature in numbers.

4. Tympanic - Readily accessible, reflects core temperature. Very fast, BUT, is

uncomfortable and involves the risk of injuring the membrane if the probe is
inserted too far. Repeated measurement may vary, and presence of cerumen
may affect the reading.

Skin/Temporal Artery - A temporal artery thermometer works by sliding to device

across the forehead. A fever may indicate the flu or a different viral infection. This
has been proven to be the most accurate non-invasive form of measuring body
temperature. The accuracy of this thermometer can be attributed to its use of the
Arterial heat balance method. Safe and easy to use, non-invasive, very fast. BUT,
instrument is expensive or sometimes unavailable.
 CONTRAINDICATION TO TEMPERATURE TAKING
Oral Temperature Rectal Temperature
a. Oral lesions or surgery a. Anal/rectal conditions or
b. Dyspnea surgeries.
c. Cough (anal fissure, hemorrhoids, hemorrhoidectomy)
d. Nausea and vomiting b. Diarrhea
e. Presence of oro-nasal contraptions c. Cardiac condition
(e.g. nasal pack, nasogastric tube, ndotrancheal tube)
f. Seizure-prone
g. Very young children
h. Unconscious
i. Restless, disoriented, confused

Conversion:

To convert from Fahrenheit to Celsius: C= ( F-32 ) x 5/9

Example: C = (F-32) x 5/9

= ( 100 – 32 ) x 5/9
= 68 x 5/9
= 340/9
= 37.77 or 37.8

To covert from Celsius to Fahrenheit: F= ( C x 9/5 ) + 32

Example: F = ( C x 9/5 ) + 32
= ( 38 x 9/5 ) + 32
= ( 342/5 ) + 32
= 68.4 + 32
= 100.4
 Reading: Cleaning:

Thermometer placement
Oral: Rectal:

II. Pulse

Definition of Pulse
Pulse is a wave of blood created by contraction of the left ventricle of the heart.
Pulse wave represents the stroke volume output or the amount of blood that enters
the arteries with each ventricular contraction.

Pulse is commonly assessed by palpation (feeling) or auscultation (hearing).

The middle three fingertips are used for palpating all pulse sites except the apex of the
heart. A stethoscope is used for assessing the apical pulse.
 A DOPPLER ULTRASOUND STETHOSCOPE (DUS) - is used for pulses that
are difficult to assess. The DUS detects movement of red blood cells through a blood
vessel. In contrast to the conventional stethoscope, it eliminates environmental
sounds.

Factors affecting the pulse

1. Age as age increases, the pulse rate gradually

decreases overall
2. Sex/Gender After puberty, the average male’s pulse rate is
slightly slower than the female’s
3. 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.
4. 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.
5. Medications Some medications decrease the pulse rate, and
others increase it. For example, cardiotonics (e.g.,
digitalis preparations) decrease the heart rate,
whereas epinephrine increases it.
6. Hemorrhage Loss of blood from the vascular system normally
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. Adults can
usually lose up to 10% of their normal circulating
volume without adverse effects.
7. 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 sever pain stimulate the
sympathetic system.
8. Position Changes When the 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 the heart rate.
9. Pathology Certain diseases such as some heart conditions or
those that impair oxygenation can alter the resting
pulse rate.
PRINCIPLES INVOLVING PULSE:

1. Compliance – Ability of the arteries to contract and expand. When a person’s

arteries lose their disability, as can happen with age, greater pressure is
required to pump the blood into the arteries.

2. Cardiac Output – Is the amount of blood the heart pumps through the
circulatory system in a minute. It is the product of the heart (HR) and stroke
volume (SV). Thus CO = HR x SV (Cardiac output = Heart rate x stroke
volume).

Normal adult has a CO of 4.7 liters (5 quarts) of blood per minute. Cardiac
output is usually denoted as L/min (liters per minute).

Heart Rate – is the number of heart beats per minute. The heart beats to
supply oxygenated clean blood from the left ventricle to the blood vessels of the
body via the aorta.

Stroke volume - is the amount of blood pumped or ejected from the left
ventricle with each heart beat or during contraction.

3. Peripheral Pulses - are those pulses that are palpable at the peripheries
which located away from the heart.

4. Apical Pulse - at the left midclavicular line (ICS) fifth intercostal space (ICS)
Pulse Sites and Reasons for using specific pulse sites

Location of Peripheral pulses:

1. Temporal. Used when radial pulse is not accessible. It is located over the
temporal bone of the head; superior and lateral to the lateral eye.

2. Carotid. Used during cardiac arrest / shock in adults. Used to determine

circulation to the brain. It is located at the lateral aspect of the neck; below the
ear lobe.

3. Apical. Routinely used for infants and children up to 3 years old of age. It is
located at the left midclavicular line (MCL) fifth intercoastal space (ICS). The
apical-radial pulse is used to assess the type of client with a history of
cardiovascular disorder due to feebleness of the wave of blood flow felt at the
peripheral sites.

4. Brachial. Used to measure blood pressure. Used during cardiac arrest for
infants. It is located at the inner aspect of the upper arm (biceps muscles) or
medially at the antecubital space.

5. Radial. It is located on the thumb side of the inner aspect of the wrist. Radial
site is most commonly used in adults. It is easily found in most people and
readily accessible.
 6. Femoral. Used in cases of cardiac arrest/shock. Used to determine circulation
to a leg. It is located alongside the inguinal ligament.

7. Popliteal. Used to determine circulation to the lower leg. It is located at the back
of the knee.

8. Posterior Tibial. Used to determine circulation to the foot. It is located at the

middle aspect of the ankle, behind the medial malleolus.

9. Pedal (dorsalis pedis). Used to determine circulation to the foot. It is located at

the dorsum of the foot. The dorsalis pedis pulse site is in the foot, so this is the
ideal site to assess the pulse for toes that are cool to touch.

When assessing the dorsalis pedis pulse of a client, you determine that the pulse
is absent, how do you explain this? - Too firm pressure on a pulse site will
obliterate that pulse because the dorsalis pedis pulse requires one to apply some
pressure over the dorsalis pedis artery, making contact with the cones in the foot.

Reasons for using specific pulse sites:

Pulse site Reasons

Radial Readily accessible
Temporal Used when radial pulse is not accessible
Carotid Used during cardiac arrest/shock in adults
Used to determine circulation to the brain
Apical Routinely used for infants and children up to 3 years old
of age
Brachial Used to measure blood pressure
Used during cardiac arrest for infants
Femoral Used in cases of cardiac arrest/shock
Used to determine circulation to a leg
Popliteal Used to determine circulation to the lower leg
Posterior tibial Used to determine circulation to the foot
Dorsal pedal Used to determine circulation to the foot

Normal Pulse rates by age

Age Pulse average(beats per minute or bpm)
Newborn 130 bpm(120-160)
1 year 120 bpm(100-140)
5-8 years old 100 bpm(75-120)
10 years 70 bpm(60-90)
Teen 75 bpm(60-100)
Adult 80 bpm(60-100)
Older adult 70 bpm(60-100)
Types of Pulse:

1. Bigeminal- a pulse in which beats occur as two in rapid succession separated

from the following pair by a longer interval; it is usually related to regularly
occurring ventricular premature beats
2. Collapsing-pulse with fast upstroke and fast downstroke
3. Corrigan’s or the Water Hammer pulse- a jerky pulse with a full expansion,
followed by a sudden collapse, occurring in aortic regurgitation. Called also
cannonball, collapsing, pistol-shot, trip-hammer, or water-hammer p.
4. Dicrotic-a pulse whose tracing has two peaks instead of the usual one, the
second one coming during diastole as an exaggeration of the dicrotic wave.
5. Labile- a pulse that is normal when the patient is resting but increased by
sitting, standing, or exercise
6. Wiry-small, tense pulse

Characteristics of pulse:

1. Rate Number of beats per minute.

2. Rhythm The pattern and interval of beats.
3. Volume The strength of the pulse.
• Normal Pulse
• Full or Bounding Pulse
• Imperceptible Pulse
• Thready or Feeble (weak) Pulse
4. Tension Compressibility of the arterial wall.
• High tension Pulse Tension is either high or low.
• Low tension

REGULAR - This is when intervals between beats are constant.

TACHYCARDIA - Is a condition that makes your heart beat more than 100 times per
minute or above normal range. The heart normally beats at a rate of 60 – 100 times
per minute for adult.

BRADYCARDIA - Is a condition typically defined wherein an individual has a resting

heart rate of under 60 beats per minute in adults or below normal range.
BOUNDING - a bounding pulse is when a person feels their heart beating harder or
more vigorously than usual. One of the most common causes of a bounding pulse, as
participating in strenuous activity forces the heart to work harder than it is used to,
beating faster to circulate more blood.

WEAK (THREADY) - A thready pulse is also known as WEAK pulse. When the pulse
cannot be feel with the mild pressure on arteries, then it is a thready pulse. Thready
pulse is associated with low blood pressure or bradycardia.
IRREGULAR – This is when intervals between beats are not constant.
Procedure:

Assessment
Assess for clinical signs of cardiovascular alterations such as dyspnea, fatigue,pallor
and cyanosis.

Planning
Assemble equipments to organize things and facilitate smooth flow of procedure. Watch
with second hand and a stethoscope.

Implementation
• Check that all items is functioning normally and gather equipments. It will save
time and will facilitate a smooth flow of procedure.
• Introduce self and identify the client’s identity. Explain the procedure to the client
to gain cooperation from the client.
• Wash hands or don gloves if performing a rectal temperature to reduce
transmission of microorganisms.
• Provide privacy
• Select the site.
• Assist the client in a comfortable position. Client’s arm should rest alongside of
the body or the forearm can rest at 90 degree angle across the chest with palm
facing down.
• Locate Pulse. Put the tips of your index finger and middle finger together and feel
for the pulse by pressing down moderately with your fingertips on the site
• Count Pulse Beats and Note Abnormalities. Count the pulse beats felt during a
60-second period. Use the clock or watch. As you count the beats, note the
strength and regularity (rhythm) of the beats.
• Record Pulse Rate.
• Record any Abnormalities. If you noticed anything about the patient's pulse that
is not normal (irregular, intermittent, thready, bounding, and so forth), record
your observations on the form or piece of paper
• Take Pulse at Other Sites, if Needed.

III. Respiration
• The act of breathing. It includes the intake of oxygen and the output of carbon
dioxide.
• External respiration refers to the interchange of oxygen and carbon dioxide
between the alveoli of the lungs and pulmonary blood.
• Refers to a person’s breathing and the movement of air and out of the lungs.
The respiratory system provides oxygen to body tissues for cellular respiration,
removes the waste product carbon dioxide, and helps maintain acid-base
balance.
• It is also the process by which organisms exchange gases, especially oxygen
and carbon dioxide, with the environment. In air-breathing vertebrates,
respiration takes place in the lungs. In fish and many invertebrates,
respiration takes place through the gills. Respiration in green plants occurs
during photosynthesis.
 • Respiration is the biochemical process in which the cells of an organism obtain
energy by combining oxygen and glucose, resulting in the release of carbon
dioxide, water and ATP. (TP – Adenosine Triphosphate, which is the energy-
carrying molecule used in cells because it can release energy very quickly).

Processes involved in respiration

1. Ventilation-Basically, breathing is ventilation. Ventilation is the mechanical act of

moving air in and out of your lungs.
a) Inspiration or breathing-in phase – also called Inhalation, wherein the
Diaphragm contracts (flatten); ribs move upward and outward; sternum move
outward;; size of the thorax enlarged.
b) Expiration or breathing-out phase – also called Exhalation, wherein the
diaphragm relaxes; ribs move downward and inward; sternum moves inward; size of
the thorax decreased.
2. Diffusion- Diffusion is the movement of molecules from an area of higher
concentration (the air) to an area of lower concentration (the blood cells).
3. Perfusion-passing out of fluid through body tissues.

2 types of breathing:

1. Costal (thoracic) – Involves external intercostal muscle and other necessary

muscle.
2. Diaphragmatic (abdominal) – Involves contraction and relaxation of diaphragm.

Factors affecting respiration:

1. Age As you grow from infant to an adult, you have a larger

lung capacity. As lung capacity increases, there is a
lower respiration rate
2. Sex
3. Stress Increase the rate and depth of respirations
4. Environment In High environmental temperature, respiration rate
decreases.
5. Increased altitude altitude-Increase respiratory rate and depth because
oxygen concentration decreases at high elevation
6. Medications Narcotics decrease respiratory rate and depth.
Albuterol dilates bronchioles and increase air into
and out of the lungs
7. Ingestion of food Increases the rate and depth
and exercise

Characteristics of respiration:

1. Rate Normal is 12-20/min (adult). The unit of

measurement of rate is beats per minute or BPM.
Rate also determines whether it is in a BRADYPNEA
(below normal range, or decreased respiratory rate),
 TACHYPNEA 9above the normal range, or increased
respiratory rate), APNEA (NOT BREATHING, is the
absence of breathing)
2. Depth Observe the movement of the chest. Whether it is
normal, deep, or shallow or hyperventilation (refers
to very deep, rapid respirations), hypoventilation
(refers to very shallow respiration.
3. Rhythm Refers to the regularity of the expirations and the
inspirations. Observe for regularity of exhalations.
4. Quality or character Refers to respiratory effort and sound of breathing.

Respiratory rates by age

Age Repiratory rate (breaths per minute or bpm)
Newborn 35 bpm(30-60)
1 year 30 bpm(20-40)
5-8 years old 20 bpm(15-25)
10 years 19 bpm(15-25)
Teen 18 bpm(15-20)
Adult 16 bpm(12-20)
Older adult 16 bpm(12-20)

Procedure:
Asessment

• Assess color of skin and mucous membrane

• Assess position assumed for breathing
• Assess chest movements ,chest pain and dyspnea

Planning
Assemble equipments:
Watch with second hand. Make sure that equipments are functioning normally to
organize things and facilitate smooth flow of procedure.

Implementation
• Introduce self and identify the client’s identity. Explain the procedure to the client
to gain cooperation from the client.
• Wash hands or don gloves if performing a rectal temperature to reduce
transmission of microorganisms.
• Provide privacy.
• Observe and palpate and count the respiratory rate.
Client’s awareness that the Nurse is counting the respiratory rate could cause
the client purposefully alter the respiratory pattern.
• Observe the characteristics respiration
• Document the findings.
Evaluation
1. Relate respiratory rate to other vital signs, in particular the pulse rate. Note
the characteristics of breathing.
2. Report to the primary care provider any significant findings and above or
below the Normal range.

IV. Blood Pressure

Blood Pressure

A measure of the pressure exerted by the blood as it pulsates through the arteries. The
brachial is the most common artery used to access a blood pressure reading because it
is the most accessible.

Systolic Pressure The pressure of the blood as a result of contraction of

the ventricles.
Diastolic Pressure The pressure when ventricles are at rest.
Pulse Pressure Is the difference between the systolic and diastolic
pressures.
Hypertension Is an abnormally high blood pressure over 140 mm
Hg systolic and or 90 mm Hg diastolic for at least two
consecutive readings.
Hypotension Is an abnormally low blood pressure, systolic
pressure below 100 mm Hg.

Determinants of Blood Pressure:

1. Blood Volume
2. Peripheral Resistance
3. Cardiac Output
4. Elasticity or compliance of blood vessels

Factors affecting blood Pressure:

1. Age Newborns have a mean systolic pressure of about

75 mmHg. The pressure rises with age, reaching a
peak at the onset of puberty, and then tends to
decline somewhat. In elders, elasticity of the
arteries is decreased—the arteries are more rigid
and less yielding to the pressure of the blood. This
produces an elevated systolic pressure. Because
the walls no longer retract as flexibly with
decreased pressure, the diastolic pressure may
also be high.
2. Exercise Physical activity increases the cardiac output and
hence the blood pressure; thus 20 to 30 minutes
 of rest following exercise is indicated before the
resting blood pressure can be reliably assessed.
3. Stress Stimulation of the sympathetic nervous system
increases cardiac output and vasoconstriction of
the arterioles, thus increasing the blood pressure
reading; however, severe pain can decrease blood
pressure greatly by inhibiting the vasomotor
center and producing vasodilation
4. Race African American males over 35 years have higher
blood pressure than European American males of
the same age
5. Obesity Both childhood and adult obesity predispose to
hypertension
6. Sex/Gender After puberty, females usually have lower blood
pressures than males of the same age; this
difference is thought to be due to hormonal
variations. After menopause, women generally
have higher blood pressures than before.
7. Medications Many medications, including caffeine may
increase or decrease the BP
8. Diurnal Variations Pressure is usually lowest early in the morning,
when the metabolic rate is lowest, then rises
throughout the day and peaks in the late
afternoon or early evening.
9. Pathology Any condition affecting the cardiac output, blood
volume, blood viscosity, and/or compliance of the
arteries has direct effect on the blood pressure.

Classification of Blood pressure

Category Systolic BP (mmHg) Diastolic BP (mmHg)
Normal <120 <80
Prehypertension 120-139 80-89
Hypertension,stage 1 140-159 90-99
Hypertension,stage 2 >160 >100

Blood Pressure sites:

❖ Indications for Assessing Blood pressure on the Client’s thighs:

• Burns or other trauma
• For Comparison purposes (both thighs)

❖ Indications for not using the limb in Assessing Blood pressure:

• The shoulder, arm or hand is injured or diseased
• A cast or bulky bandage is on any part of the limb
• The client have a surgical removal of axilla lymph nodes on that side
• The client has an intravenous infusion or arteriovenous fistula in that
limb.
Common errors in Assessing Blood Pressure

Selected sources of Errors in Blood pressure Assessment

Error
Erroneously low
Bladder cuff too wide
Deflating cuff too quickly
Arm above the level of the heart
Failure to identify auscultatory gap
Note:
Failure to use the same arm
consistently would result to
inconsistent measurements
Effects
Erroneously high
Bladder cuff too narrow
Arm unsupported
Insufficient rest before assessment
Repeating assessment too quickly
Cuff wrapped too loosely or unevenly
Deflating Cuff too slowly
Assessing immediately after a meal
or while the client smokes or in pain

Procedure
Assessment
• Assess signs and symptoms of hypertension such as headache, ringing on the
ears and nosebleeds.
• Assess signs and symptoms of hypotension such as tachycardia, dizziness,
mental confusion and restlessness.

Planning
Assemble Equipments to facilitate smooth flow of procedure and to save time.

Equipments:
Stethoscope
Appropriate blood pressure cuff
Sphygmomanometer.

Implementation
• Ensure that equipments are functioning normally. Check for leaks in the tubing.
• Make sure that a client has not smoked or ingested caffeine 30 minutes prior to
measurement. Rationale: smoking constricts the blood vessels and caffeine
increases pulse rate .Both causes temporary increase in blood pressure.
• Introduce self and identify the client’s identity. Explain the procedure to the client
to gain cooperation from the client.
• Wash hands or don gloves if performing a rectal temperature to reduce
transmission of microorganisms.
• Provide privacy and place the client in appropriate position.
• Adult client should sit unless otherwise specified with feet flat on the floor.
Rationale: Legs crossed at the knee may result to elevated systolic and diastolic
pressures.
• Elbow should be slightly flexed with palm of the hand facing up and forearm
supported at heart level. Rationale: The blood pressure increases when the arm is
below heart level and decreases when it is above heart level.
 • Apply BP cuff snugly, 1 in. above the antecubital space. Rationale: The bladder
inside the cuff must be directly over the artery to be compressed if the reading is
to be accurate.
• Determine palpatory BP before auscultatory BP if this is the client’s initial
examination to prevent auscultatory gap. Rationale: The initial estimate tells the
nurse the maximal pressure to which the manometer needs to be elevated in
subsequent determination.
• Palpate the brachial artery and close the valve. Rationale: This gives an estimate
if systolic pressure.
• Position stethoscope appropriately. Rationale: Sounds are heard more clearly
when ear attachments follow the direction of the ear canal.
• Use bell shaped diaphragm of the stethoscope Rationale: The blood pressure is a
low frequency sound and it is best heard with a bell shaped diaphragm.
• Inflate and deflate BP cuff slowly, 2-3 mm Hg at a time. Rationale: If the rate is
faster or slower, an error in measurement may occur.
• Wait 1-2 min. before making further determination. Rationale: This permits blood
trapped to be released.
• Remove the cuff and wipe with approved disinfectant. Rationale: Cuffs can become
significantly contaminated.
• Document data and report pertinent information according to agency policy.

Evaluation
• Relate blood pressure to other vital signs, to baseline data and to health status.
• Report any significant change in the client’s blood pressure

Equipments:

Parts of a Bp set Parts of a stethoscope

REFERENCES

Ellis, Janice R., et al. Basic Nursing Skills. Fifth Edition, Philadelphia, 1992, J. B.
Lippincott Company.

Heirserman,David L.Taking Vital signs. .Sweet Haven publishing

services,2006.http://www.waybuilder.net/sweethaven/MedTech/Vitals/default.asp?i
Num=0205

Kaplan, The RN Course Book 11th ed., Kaplan, Inc: USA, 2008.

Kozier, et. al., Fundamentals of Nursing (Concepts, Process and Practice) 8th ed., vol
1&2, Pearson Education South Asia: Singapore, 2008.

Lippincott, Williams & Wilkins, Fundamentals of Nursing (The Art and Science of
Nursing) 6th ed., Vol. 1. Wolters Kluwer: USA, 2008.

Luage Cynthia. Temperature, Pulse, and Respiration. Manila, 1987, National Teacher
Training Center for Health Professions, UP Manila.

Saunders, Comprehensive Review for NCLEX-RN Examination, Elsevier, Inc.: USA,

2008.

Udan, Josie Quiambao (2004). Mastering Fundamentals of Nursing. Educational

Publishing House, Manila, Philippines