Chapter 32

Vital Signs
NRS 102

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General Survey

Physical appearance

Age
Sex
Level of consciousness
Skin color
Facial features

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General Survey

Body structure

Stature
Nutrition
Symmetry
Posture
Position
Body build, contour

Mobility

Gait
Range of motion
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General Survey

Behavior

Facial expression
Mood and affect
Speech
Dress
Personal hygiene

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Guidelines for Measuring

Vital Signs

Establish a baseline for future

assessments.
Be able to understand and interpret
values.
Appropriately delegate measurement.
Communicate findings.
Ensure equipment is in working order.
Accurately document findings.
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Body Temperature
Physiology

Body temperature:

Temperature range:

Heat produced
Heat lost
98.6 F to 100.4 F or 36 C to 38 C

Temperature sites:

Oral, rectal, axillary, tympanic membrane,

temporal artery, esophageal, pulmonary artery

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Body Temperature Regulation

Neural and vascular
control

Heat production

Heat loss

Skin temperature
regulation

Behavioral control

Thermoregulation

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Factors Affecting Body

Temperature
Age

Exercise

Hormonal level

Circadian rhythm

Environment

Temperature alterations

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Abnormal Body Temp

Hypothermia

Heat loss during prolonged exposure to cold

Classified by core temp (mild-severe)
May be intentional (surgery)
Early signs- uncontrolled shivering, loss of
memory, poor judgment
Later signs- Cyanosis, decreased VS, cardiac
dysrhythmias, loss of consciousness
Frostbite- body exposure to subnormal temps

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Abnormal Body Temp

Hyperthermia

Elevated body temp related to bodys inability

to promote heat loss or reduce heat
production
Heatstroke- prolonged exposure to sun or
high environmental temp. Heat depresses
hypothalamus function
Heat Exhaustion- profuse diaphoresis result
in fluid & electrolyte loss

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Nursing Process
and Temperature

Assessment
Diagnosis
Planning
Implementation
Evaluation

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Pulse, Physiology, and Regulation

The indicator of circulatory status

Electrical impulses originate from the
sinoatrial (SA) node.
Cardiac output, heart rate, stroke volume
Mechanical, neural, and chemical factors
regulate ventricular contraction and stroke
volume.

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Assessment of Pulse

Sites
Use of stethoscope
Character of pulse
Nursing process and pulse determination

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Knowledge check!
Which patient would be most likely to present
with a pulse rate that is lower than normal?
A. A 70-year-old telephone salesman presenting
with dehydration.
B. A 20-year-old runner who had surgery 4 days
ago for a fractured leg.
C. A 67-year-old who presented with an
exacerbation of his COPD

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Respiration

Ventilation
Diffusion
Perfusion
Physiological control
Mechanics of breathing

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Assessment of Ventilation

Easy to assess
Respiratory rate
Ventilatory depth
Ventilatory rhythm
Diffusion and perfusion
Arterial oxygen saturation

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Assessing Respirations

Assessing rate- observe full inspiration &

expiration
Assess for full minute
Normal adult 12 20 breaths/minute
Varies with age, rate declines throughout life
Apnea Monitor

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Normal & Abnormal Respirations

Eupnea- normal respirations

Bradypnea- abnormally slow < 12
Tachypnea- abnormally fast >20
Hyperpnea- labored, after exercise
Hyperventilation/Hypoventilation
Cheyne-Stokes

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Nursing Process and Respiratory

Vital Signs

Measurements include:

Respiratory rate, pattern, depth, SpO2,

ventilation, diffusion, perfusion

Nursing diagnosis
Interventions
Planning
Evaluation

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Arterial Blood Pressure

and Physiology

Force exerted on walls of an artery

Systolic and diastolic
Cardiac output
Peripheral resistance
Blood volume
Viscosity
Elasticity

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Factors Influencing Blood Pressure

Age
Stress
Ethnicity
Gender
Daily Variation
Medications
Activity, weight
Smoking
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Hypertension and Hypotension

Hypertension
More common than
hypotension
Thickening of walls
Loss of elasticity
Family history
Risk factors

Hypotension
90 mm Hg
Dilation of arteries
Loss of blood volume
Decrease of blood flow
to vital organs
Orthostatic/postural

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Factors controlling Blood

Pressure

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Measurement of Blood Pressure

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Vital Signs

Blood pressure

Systolic pressure
Diastolic pressure
Pulse pressure
Mean arterial pressure

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Slide 9-29

Measurement of Blood Pressure

Equipment
Auscultation
Children
Ultrasonic stethoscope
Palpation
Lower extremity
Electronic blood pressure

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Nursing Process and Blood

Pressure Determination

Assessment of blood pressure and pulse

evaluates the general state of
cardiovascular health.
Hypertension, hypotension, orthostatic
hypotension, or narrow/wide pulse
pressures define nursing diagnoses.

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Knowledge check!
Significant elevation in blood pressure
measurements from one day to the next
could be attributed to:
A. A decrease in cuff size
B. An increase in cuff size
C. New onset of pain or anxiety
D. A and C

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Measurement of Arterial Oxygen

Saturation

Pulse oximeter
Allows indirect measurement of oxygen
saturation
SpO2 is a reliable estimate of SaO2
Measurement is affected if extremity is cold,
edematous or if nail polish is present
(interference with light transmission)

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Slide 9-35

Health Promotion and Vital Signs

Monitor vital signs.

Include age-related factors.
Include environmental and activity factors.

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