VITAL SIGNS

VITAL SIGNS
 Also known as CARDINAL SIGNS
 TPR: Temperature, Pulse, Respiration. Blood pressure
 Some agencies have designated pain as a 5th V/S
 critical indicators of a client's physiologic functioning, effects of disease and effects of therapy. It
indicates changes in the vital organs (heart, lungs, brain)

REMINDERS WHEN TAKING THE VITAL SIGNS

1. Frequency of taking the vital signs
a) On admission in an institution.
 Serves as a baseline data in developing a care plan as a basis for comparison
b) When a client has a change in health status or reports symptoms such as chest pain or feeling hot or
faint.
c) Before and after surgery or an invasive procedure
d) Before and/or after the administration of a medication that could affect the respiratory or cardiovascular
systems
e) Before and/or after any nursing intervention that could affect the vital signs
f) Taken during a first home visit or first contact with the client
g) In cases of V/S abnormalities (high temp., irregular PR, or RR) and severe illness. Monitoring is more
frequent.
 Ex: every 15-30 min, every 1 hr. etc . . .
h) Before and after delivery, operation and blood transfusion
i) Before any laboratory or diagnostic tests
j) Dependent on the judgment of the nurse
2. Accurate taking, recording and reporting of V/S
 instruments to be used must be accurate and functional
 appropriate methods, routes, steps, and techniques must be followed
 use proper color of ink in recording
 T - black or blue
 P- red
 R- black or blue

I. TEMPERATURE
 Hotness or coldness of the body
 Balance between the heat produced and heat lost from the body and is measured in heat units called
degrees
 The Hypothalamus is the heat regulating center
 Body heat is primarily produced by metabolism (chemical processing of food to produce energy)

Types of Body Temperature

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1. Core temperature
 temp at the deep tissues, such as the abdomen and pelvic cavity.
 It remains relatively constant

2. Surface temperature
 temperature of the skin and subcutaneous tissue and fat.
 It, by contrast, rises and falls in response to the environment

FACTORS THAT AFFECT THE BODY’S HEAT PRODUCTION

1. Basal Metabolic Rate (BMR)
 Rate of energy utilization in the body required to maintain essential activities
 Metabolic rates decrease with age.
2. Muscle activity
 Muscle activity including shivering, increases metabolic rate
3. Thyroxine output
 Increased thyroxine output increases the rate of cellular metabolism throughout the body.
 Chemical thermogenesis
 The stimulation of heat production in the body through increased cellular
metabolism
4. Epinephrine, Norepinephrine and Sympathetic Stimulation/Stress response
 These hormones immediately I increase the ate of cellular metabolism in many body tissues
5. Fever
 Increases the cellular metabolic rate and thus increases the body’s temperature further

Processes Involved in Heat Loss

A. RADIATION
 transfer of heat from the surface of one object to the surface of another without contact between the
two objects, mostly in the form of infrared rays
Ex: a nude person standing naked in a room at normal room temp loses 60% of heat thru radiation
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B. CONDUCTION
 transfer of heat from one surface to another requiring contact between the 2
Ex: TSB, ice bath, cold compress
C. CONVECTION
 dispersion of heat thru air current
Ex: use of a fan or Aircon
D. VAPORIZATION
 Continuous evaporation of moisture from the skin, oral and respiratory tract.
 This continuous and unnoticed water loss is called insensible water loss, and the accompanying heat
loss is called insensible heat loss
Ex: TSB

3 PHYSIOLOGIC PROCESSES TO INCREASE/DECREASE THE BODY TEMPERATURE

1. Shivering
2. Sweating
3. Vasoconstriction

FACTORS AFFECTING TEMPERATURE

1. Age
 infants are greatly influenced by the temperature of the environment and must be protected from
extreme changes.
 The Elderly are also particularly sensitive to extremes in the environmental temperature due to
decreased thermoregulatory controls
2. Diurnal variations (circadian rhythm)
 body temp varies throughout the day.
 The point of highest body temp is usually reached between 4PM and 6PM, and the lowest point
is during sleep between 4AM and 6AM.
3. Exercise
 increases metabolism thus increasing temp
4. Hormones
 progesterone, thyroxine, norepinephrine, epinephrine increase body temp. Estrogen decreases
body temp
5. Stress
 stimulation of the sympathetic nervous system increases the production of norepinephrine and
epinephrine which increase metabolism
6. Environmental temperature
 temp extremes affect the thermoregulating system of the body

Converting a Celsius reading to Fahrenheit or Vice versa

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FORMULA:
Fahrenheit to Celsius:
0
C = (0F 32) X 5 Celsius to Fahrenheit:
0
9 F = 0C X 9 + 32

ALTERATIONS IN BODY TEMPERATURES

1. PYREXIA/HYPERTHERMIA/FEVER
 Body temp above normal
 The condition of having a fever is called febrile
 A person without fever is called afebrile
 HYPERPYREXIA
 Very high fever ranging from 410 C (105.8 0F) and above. This causes irreversible brain cell damage
and death
 Probable causes: infection, damage to heat-regulating center

4 Common Types of FEVER

1. Intermittent fever
 Body temp alternates at regular intervals between periods of fever and periods of normal or
subnormal temperatures
2. Remittent fever
 A wide range of temp fluctuation (more than 2 0C (3.60F) occurs over the 24 hr period, all of
which are above normal
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
 Body temperature fluctuates minimally but always remain above normal

2. HYPOTHERMIA
Core body temperature below the lower limit of normal

3 Physiologic Mechanisms of Hypothermia

1. excessive heat loss
2. inadequate heat production
3. impaired hypothalamic function

COMMON SITES FOR MEASURING BODY TEMPERATURE

1. ORAL ROUTE/METHOD
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Advantages:
 Accessible and convenient
Disadvantages:
 Not used for pts. who could be possibly injured by the thermometer and those who are unable to hold the
thermometer in place:
 infants or small children
 confused or unconscious pts
 those who had oral surgery
 clients experiencing pain
 mouth-breathers, those with difficulty of breathing, cough,
 with oronasal contraptions, Ex: NGT, ET ,nasal pack
 pts with history of convulsion or seizures
 those experiencing chills
 inaccurate if client has just ingested hot or cold food or fluid or smoked
*there is a need to wait for 30 minutes before taking the oral temp of pts who had just took in hot or cold
beverages, or had been smoking

2. AXILLARY ROUTE/METHOD
Advantage:
 safe and non-invasive
Disadvantage:
 the thermometer must be left in place a long time to obtain an accurate measurement

3. RECTAL ROUTE/METHOD
Advantage:
 reliable and very accurate
Disadvantage:
 inconvenient and more unpleasant for clints, difficult for clint who cannot turn to side.

4. TEMPORAL ARTERY
Advantage:
 Safe and non-invasive
 Very fast
Disadvantage:
 Requires electronic equipment that may be expensive or unavailable
 Variation in technique needed if the client has perspiration on the forehead

5. TYMPANIC MEMBRANE
Advantage:
 Readily accessible
 reflects the core temp
 very fast
Disadvantage:
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 can be uncomfortable and involves risk of injuring the membrane if the probe is inserted too far.

Types of Thermometers
1. Mercury-in-glass thermometer
2. Electronic thermometer
3. Chemical disposable thermometer
4. Infrared thermometer
5. Temporal artery Thermometer

II. PULSE RATE

Pulse
 A wave of blood created by the contraction of the Left Ventricle of the heart and is transmitted into the
different pulse sites away from the heart
 Generally the pulse wave represents the stroke volume output or the amount of blood that
enters the arteries with each ventricular contraction
Cardiac output
 amount of blood pumped into the arteries by the heart per minute, 5-6 liters of blood/minute

 In a healthy person, the pulse reflects the heartbeat; that is, the pulse rate is the same as the rate of the
ventricular contractions of the heart

Peripheral pulse
 pulse located in the periphery of the body,
 ex: foot or wrist

Apical pulse
 central pulse, located at the apex of the heart
 point of maximal impulse (PMI)

FACTORS AFFECTING PULSE RATE

1. Age. As age increases, the pulse rate decreases

2. Gender. After puberty, females have a slightly higher pulse rate than males

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3. Stress. The sympathetic nervous stimulation increases the overall activity of the heart.Stress increases the
rate, and force of the heart beat. Fear and anxiety as well as the perception of severe pain stimulate the
sympathetic system
4. Exercise. Pulse rate increases with activity
5. Fever. Pulse rate increases in response to lowered Bp because of vasodilation associated with temperature
and because of increased metabolic rate
6. Medication. Digitalis, beta blockers decrease the pulse rate, while epinephrine and atropine sulfate increase
PR
7. Position changes- When a person assumes a sitting or standing position, blood pools in dependent vessels of
the venous system. Pooling results in a transient decrease in the venous return to the heart and results to a
decrease in BP and an increase in the PR.
8. Pathology. Certain diseases such as heart condition or those that impair oxygen can alter the resting pulse
rate

PULSE SITES
* When locating for the pulse in any of these sites, use the middle 2 to 3 fingers to palpate. Do not use the
thumb because it has its own pulsation, thus yielding inaccurate results

1. Temporal
 found over the temporal bone of the head, superior and lateral to the eyes
 used when radial pulse is not accessible
2. Carotid
 lateral aspect of the neck, below the earlobes, where the carotid artery runs between the trachea
and sternocleidomastoid muscle
 used during cardiac arrest/shock in adults
 used to determine circulation to the brain
3. Apical
 located at the 5th ICS, MCL, Left. This is where the Cardiac Rate is taken.
 In elders, the apex may be further left if there are no conditions that have led to an enlarged
heart.
 Before 4 years of age, the apex is left of the MCL
 Between 4 and 6 years, it is at the MCL
 For a child 7-9 years, the apical pulse is located at the 4th or 5th ICS
 Routinely used for infants and children up to 3 y/o
 Used to determine discrepancies with radial pulse
 Used in conjunction with some medications
4. Brachial
 inner aspect of the biceps muscle, medially in the antecubital fossa.
 Used when taking the blood pressure
 Used during cardiac arrest for infants
5. Radial
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 Where the radial artery runs along the radial bones, on the thumb-side of the inner aspect of the
wrist
 Readily accessible
 common site for taking the pulse rate, and also used when taking the blood pressure
6. Femoral
 Where the femoral artery passes alongside the inguinal ligament
 Used in cases of cardiac arrest/shock
 Used to determine circulation to a leg
7. Popliteal
 Where the popliteal artery passes behind the knee
 Used to determine circulation to a lower leg
8. Posterior tibial
 medial aspect of the ankle, behind the medial malleolus
 Used to determine circulation to the foot
9. Pedal/Dorsalis pedis
 Dorsum (upper surface of the foot) , found on an imaginary line drawn from the middle of the
ankle to the space between the big and second toe
 Used to determine circulation to the foot

ASSESSING THE PULSE

 A pulse is commonly assessed by palpation (feeling) or auscultation (hearing)
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 A pulse is normally palpated by applying moderate pressure with 2-3 middle fingers of the hand.
 The nurse should be aware of the following:
1) Any medication that could affect the heart rate
2) Whether the client has been physically active. If so, wait 10-15 min until the client has rested and
the pulse slowed to its usual rate
3) Any baseline data about the normal heart rate.
4) Whether the client should assume a particular position

1. Rate

Abnormal Pulse Rates

Tachycardia - pulse rate above normal
Bradycardia - pulse rate below normal

2. Rhythm
 pattern and interval of beats
 equal time elapses between beats of a normal pulse

Regular rhythm - pattern and intervals are similar throughout the entire minute
Dysrhythmia/Arrythmia - irregular rhythm or the pattern and intervals of beats are not the same throughout the
entire minute

3. Pulse Volume/Amplitude
 strength of the pulse

Scale Description of the Pulse

3+ Bounding- it is difficult to obliterate the artery with fingertips
2+ Normal- requires moderate pressure to obliterate the pulse
1+ Feeble, Weak, Thready- easy to obliterate, usually rapid
0 Absent- no pulse

4. Arterial wall elasticity

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 reflects expansibility or deformities; a normal, healthy artery feels smooth, straight, soft and
pliable
 elders often have inelastic arteries that feel twisted (tortuous) and irregular upon palpation
5. Bilateral equality
 rate, rhythm, amplitude

APICAL-RADIAL PULSE ASSESSMENT

 may need to be assessed for clients with certain cardiovascular disorders
 normally the apical and radial rates are identical
 an apical pulse rate greater than the radial pulse can indicate that the thrust of the blood from the heart is
too weak for the wave to be felt at the peripheral pulse site or it can indicate that vascular disease is
preventing impulses from being transmitted

Pulse Deficit
 any discrepancy between two pulse rates

III. RESPIRATORY RATE

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RESPIRATION
 act of breathing
Inhalation/Inspiration
 intake of air into the lungs
Exhalation/Expiration
 breathing out or the movement of gases from the lungs to the atmosphere
VENTILATION
 movement of air in and out of the lungs

2 TYPES OF BREATHING
1. Costal (Thoracic) breathing
 Involves the external intercostal muscles and other accessory muscles, such as the
sternocleidomastoid muscle.
 It can be observed by the movement of the chest upward and outward
2. Diaphragmatic (Abdominal) breathing
 Involves the contraction and relaxation of the diaphragm
 Observed by the movement of the abdomen, which occurs as a result of the diaphragm’s
contraction and downward movement.

MECHANICS AND REGULATION OF BREATHING

 Inhalation diaphragm contracts (flattens), the ribs move upward and outward, and the sternum moves
outward  enlarging the thorax and permitting the lungs to expand.
 Exhalation  diaphragm relaxes, the ribs move downward and inward, and the sternum moves inward
 decreasing the size of the thorax as the lungs are compressed.
 Normally breathing is carried out automatically and effortlessly
 Inspiration – 1-1.5 sec
 Expiration – 2-3 sec

Respiratory Centers
1. Medulla Oblongata - primary respiratory center
2. Pons
a. pneumotaxic center-responsible for rhythmic quality of breathing
b. apneustic center- responsible for deep, prolonged inspiration
3. Chemoreceptors located centrally in the medulla and peripherally in the carotid and aortic bodies- respond to
changes in the concentration of 02 ,CO2 and hydrogen in the arterial blood, they respond by increasing or
decreasing the RR

FACTORS AFFECTING RR
1. Exercise and stress - increase RR by increasing metabolism
2. Environment- increase in environmental temp will increase RR, decrease in environmental temp will
decrease RR
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3. Increased altitude will increase RR
4. Medications- narcotics will decrease RR, ex: morphine, valium

ASSESSING RESPIRATIONS
1. Rate- speed, fastness or slowness of respiration
Eupnea- normal rate and depth, quiet, effortless, rhythmic

Tachypnea- rapid respiration, marked by quick shallow breaths, above normal

Bradypnea- slow breathing, below the normal
Apnea- absence of breathing

2. Depth- how deep or shallow the chest movements are during inspiration and expiration
 During normal inspiration and expiration, an adult takes in about 500ml of air. This volume is called
tidal volume
Hyperventilation- prolonged and deep breaths,
Hypoventilation- slow, shallow respiration
Kussmauls- very deep with normal rhythm, Air hunger

3. Quality or Character- refers to respiratory effort and sound of breathing

Dyspnea- difficult and labored breathing
Orthopnea- ability to breathe only in an upright position
Apnea- absence or cessation of breathing

4. Rhythm- regularity of exhalation and inhalation

Cheyne-Stokes breathing – rhythmic waxing and waning of respiration, from very deep to shallow breathing
and temporary apnea.
Kussmauls- very deep with normal rhythm, Air hunger

5. Breath Sounds
Normal Breath Sounds
1. Vesicular
 Soft-intensity, low pitched, “gentle sighing” sounds created by air moving through smaller airways
(bronchioles and alveoli)
 Over peripheral lung, best heard at base of lungs
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 Best heard on inspiration.
2. Broncho-vesicular
 Moderate-intensity and moderate-pitched “blowing” sounds created by air moving through larger airway
(bronchi)
 Between the scapulae and lateral to the sternum at first and second intercostal spaces
 Equal inspiratory and expiratory phases
3. Bronchial (tubular)
 High pitched, loud, “harsh” sounds created by air moving through the trachea
 Anteriorly over the trachea, not normally heard over the lung tissue
 Louder than vesicular sounds, have short inspiratory phase and long expiratory phase

ABNORMAL BREATH SOUNDS AND OTHER FINDINGS

1. Audible without amplification
 Stridor- shrill, harsh sound heard during inspiration with laryngeal obstruction
 Stertor- snoring or sonorous respiration, usually due to a partial obstruction of the upper airway
 Wheeze- continuous, high pitched musical squeak or whistling sound occurring on expiration and
sometimes on inspiration when air moves through a narrowed or partially obstructed airway
 Bubbling- gurgling sounds heard as air posses through moist secretions in the respiratory tract

2. Audible by stethoscope
 Crackles (Rales)
 fine, short, interrupted crackling sounds, alveolar rales are high pitched.
 Sound can be simulated by rolling a lock of hair near the ear.
 Best heard inspiration but can be heard on both inspiration and expiration
 Cause: air passing through fluid or mucus in any air passage
 Location: most commonly heard in the bases of the lower lung lobes
 Gurgles (rhonchi)
 Continuous, low-pitched, coarse, gurgling, harsh, louder sounds with moaning or snoring quality
 Best heard on expiration but can be heard on both inspiration and expiration
 May be altered by coughing
 Cause: air passing through narrowed air passages as a result of secretions, swelling, tumors
 Location: over most lung areas but predominate over the trachea
 Pleural friction rub
 Superficial grating or creaking sounds heard during inspiration and expiration.
 Not relieved by coughing.
 Cause: rubbing together of inflamed pleural surfaces
 Location: in areas of greatest thoracic expansion

3. Chest Movements
 Intercostal retractions - indrawing between ribs
 Substernal retraction - indrawing beneath the breastbone
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 Suprasternal retraction – indrawing above the clavicles

4. Secretions and Coughing

 Hemoptysis - blood in the sputum
 Productive cough - cough accompanied by expectorated secretions
 Nonproductive cough - dry, harsh cough without secretions

IV. BLOOD PRESSURE ( BP )

 refers to the force of blood against the arterial walls
 pressure exerted by the blood as it pulsates through the arteries
 measured in milliliters of mercury (mm Hg) and recorded as a fraction

2 Blood Pressure Measures

1. Systolic pressure - pressure as a result of contraction of the ventricles
2. Diastolic pressure- pressure when the ventricles are at rest, lower pressure that is constantly present in
the arterial walls

Pulse pressure
 difference between the systolic and diastolic pressure;
 the normal difference is 40 mmHg but can be as high as 100 during exercise.

DETERMINANTS OF BP
1. Blood volume - too much blood circulating increases blood volume, too little blood circulating will
decrease Bp
2. Peripheral vascular resistance - vasoconstriction elevates Bp, vasodilatation decreases BP
3. Cardiac output - when the pumping action of the heart decreases, Bp decreases
4. Elasticity or Compliance of Blood vessels - in older people, elasticity of blood vessels decreases, thus
increasing Bp
5. Blood-viscosity - An increased Hematocrit, more than 60-65% raises Bp

FACTORS AFFECTING BLOOD PRESSURE

1. Age - older people have higher BP bec. of decreased b.v. elasticity
2. Exercise - increases cardiac output  increasing BP
3. Stress – stimulation of the sympathetic nervous system increases cardiac output and vasoconstriction of
the arterioles  increase in BP
4. Race - African American males over 35 years have higher blood pressures than European American
males of the same age
5. Obesity - Both childhood and adult obesity predispose to hypertension
6. Gender - after puberty, females usually have lower BP than males of the same age. After menopause,
women generally have higher BP.
7. Medications - anti-hypertensive drugs lower BP, antihistamines increase BP
8. Diurnal variations - lowest in the morning and highest in the late afternoon and early evening
9. Disease process

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ASSESSING BLOOD PRESSURE
 BP is measured with:
1. Blood pressure cuff
2. Sphygmomanometer
A. Aneroid
B. Digital
3. Stethoscope

METHODS (Non-invasive)
1. Auscultatory
 Most commonly used in the hospitals, clinics and homes
 When carried out correctly, it is relatively accurate
 The nurse identifies phases in the series of sounds called Korotkoff’s sounds
2. Palpatory
 Sometimes used when Korotkoff’s sounds cannot be heard and electronic equipment to amplify
the sounds is not available or to prevent misdirection from the presence of auscultatory gap
 Auscultatory gap
 Temporary disappearance of sounds normally heard over the brachial artery
when the cuff pressure is high followed by the reappearance of sounds at alower
level
 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.

Selected Sources of Errors in BP Assessment

ERROR EFFECT
Bladder cuff too narrow Erroneously high
Bladder cuff too wide Erroneously low
Arm unsupported Erroneously high
Insufficient rest before the assessment Erroneously high
Repeating assessment too quickly Erroneously high systolic or low diastolic
Cuff wrapped too loose or unevenly Erroneously high
Deflating cuff too quickly Erroneously low systolic and high diastolic
Deflating cuff too slowly Erroneously high diastolic
Failing to use the arm consistently Inconsistent measurements
Arm above level of the heart Erroneously low
Assessing immediately after a meal of while client Erroneously high
smokes or has pain
Failure to identify auscultatory gap Erroneously low

Considerations:
a) slightly higher among elderly
b) there is a normal difference in BP between both arm which is 5-10 mmHg
c) from lying to standing, Bp normally falls by 10-15 mmHg systolic and 5 mmHg diastolic

Abnormal Findings
1. Hypertension
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 abnormally high Bp over 140 mmHg systolic and 90 mmHg diastolic for at least 2 consecutive readings

2. Hypotension
 abnormally low blood pressure, that is a systolic reading consistently between 85 and 110 in an adult
whose normal pressure is higher than this.
 Orthostatic Hypertension
 blood pressure that falls when the client sits or stands.

TAKE NOTE
1. Allow the client to rest for several minutes before taking the BP if the client had smoked, ingested
caffeine, had been working or exercising
2. The lower border of the cuff should be 1 inch above the antecubital fossa
3. Use appropriate size of cuff. A too small cuff will produce false high readings
4. If using a mercurial Bp app, read the mercury at eye level.

Oxygen Saturation
 a measure of how much hemoglobin is currently bound to oxygen compared to how much hemoglobin
remains unbound.
Pulse Oximeter
 non-invasive devices that estimates a client’s arterial blood oxygen saturation
 can detect hypoxia before clinical signs and symptoms develop

Factors Affecting Oxygen Saturation Level

1. Hemoglobin – if hbg is fully saturated with O2, the SO2 will appear normal even if the total hgb level is low
2. Circulation – the oximeter will not return an accurate reading if the area under has impaired circulation
3. Activity – shivering or excessive movement of the sensor site may interfere with accurate readings
4. Carbon Monoxide poisoning – pulse oximeters cannot discriminate between hgb saturated with carbon
monoxide versus oxygen

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