Chapter 5

Vital Signs

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 Vital Signs

• Reveal changes in patient condition

• Include temperature, pulse, blood pressure,
respirations, oxygen saturation
• Sometimes pain is included
• Performed during routine physical
assessment

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 Patient-Centered Care
 Be culturally sensitive when taking vital sign
measurements
 Protect patient privacy
 Observe patient cultural norms
 Be considerate of patient anxiety

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 Evidence-Based Practice
 Measurement considerations
 Deep breathing during BP measurement
 Talking

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Safety Guidelines

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Safety Guidelines (Cont.)

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Safety Guidelines (Cont.)

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 Measuring Body Temperature
Skill 5-1
 Goal: to obtain a
representative
average temperature
of core body tissues
 Normal range: 36C
to 38C (96.8F to
100.4F)

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 Measuring Body Temperature
Skill 5-1 (Cont.)
 Core temperature measurement sites
 Tympanic membrane
 Urinary bladder
 Temporal artery
 Rectum
 Esophagus
 Pulmonary artery

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 Quick Quiz!
The nurse is checking the patient’s core
temperature. Which site is the nurse using?
A.Skin
B.Tympanic membrane

C.Axilla

D.Oral cavity

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 Delegation and Collaboration
 The task of temperature measurement can be
delegated to nursing assistive personnel (NAP)
 The nurse instructs NAP to:
 Communicate the appropriate route, device, and
frequency of temperature measurement
 Explain any rectal positioning precautions
 Review temperature values/significant changes to
report to the nurse

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 Recording and Reporting

• Record temperature and route on vital sign

flow sheet or in electronic health record
(EHR)
• Record temperature site on vital sign flow
sheet or in EMR or nurses’ notes

• Report abnormal findings to nurse in charge

or health care provider

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 Special Considerations
 Teaching
 Maintaining body temperature
 Risk factors for hypothermia, frostbite, and heatstroke
 Taking antibiotics as directed
 Pediatric
 Physiological differences

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 Special Considerations (Cont.)
 Gerontological
 Lower normal temperature
 Physiological differences
 Home care
 Environmental conditions that influence temperature
 Mercury-in-glass thermometers

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 Assessing Radial Pulse
Skill 5-2
 Goal: to assess the
integrity of the
cardiovascular
system
 Radial and carotid
arteries commonly
used

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 Delegation and Collaboration
 Radial pulse measurement task can be
delegated to NAP if patient is stable
 The nurse instructs NAP to:
 Communicate appropriate pulse rate site;
measurement frequency; and factors related to
patient history
 Review and report patient’s usual pulse rate and
significant changes
 Report specific abnormalities

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 Recording and Reporting

• Record pulse rate and assessment site

on vital sign flow sheet or in EHR or
chart
• Document in EHR or chart the
measurement of pulse rate after
administration of specific therapies
• Report abnormal findings to nurse in
charge or health care provider

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 Special Considerations
 Teaching
 Self-assessment of pulse rates
• Response to medications/exercise
 Pediatric
 Apical, femoral, or brachial pulse is best for young
children
 Sinus dysrhythmia
 Breath holding

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 Special Considerations (Cont.)
 Gerontological
 Reduced heart rate with exercise
 Slow cardiovascular response increase/decrease
 Peripheral vascular disease makes radial pulse
assessment difficult
 Home care
 Self-assessment of pulse rates

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 Assessing Apical Pulse
Skill 5-3
 Goal: to assess
cardiac function
 Each apical pulse is
the combination of
two sounds: S1 and S2

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 Delegation and Collaboration
 The task of apical pulse measurement can be
delegated to NAP if the patient is stable and is
not at high risk for acute or serious cardiac
problems
 The nurse instructs NAP to:
 Communicate measurement frequency and factors
related to patient history
 Review patient values and report to the nurse any
abnormalities

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 Recording and Reporting
• Record rate and rhythm on vital sign flow
sheet or in EMR or nurses’ notes
• Document in appropriate area of EMR apical
pulse rate measurement after administration
of therapies
• If apical pulse not found at fifth intercostal
space (ICS) and left midclavicular line
(LMCL), document location of point of
maximal impulse (PMI)
• Report abnormal findings
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 Special Considerations
 Teaching
 Caregivers of patients prescribed
cardiotonic/antidysrhythmic medications
 Pediatric
 PMI differences
 Count apical pulse for 1 full minute until age 2 years
 Breath holding affects pulse rate

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 Special Considerations (Cont.)
 Gerontological
 Physiological changes can make the PMI difficult to
palpate
 Lift sagging breast tissue if necessary
 Decreased resting heart rate
 Home care
 Quiet location for auscultation

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 Assessing Respirations
Skill 5-4
 Respiration: the
exchange of oxygen
(O2) and carbon
dioxide (CO2)
 Assess ventilation
by observing rate,
depth, and rhythm
of respiratory
movements

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 Delegation and Collaboration
 The task of counting respirations can be
delegated to NAP unless the patient is
considered unstable
 The nurse instructs the NAP to:
 Communicate measurement frequency and factors
related to patient history/risk for respiratory rate
changes
 Review and report unusual respiratory values and
significant changes

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 Recording and Reporting

• Record respiratory rate on vital sign flow

sheet or in EHR or chart
• Document respiratory rate measurement
after administration of specific therapies
• Record type and amount of oxygen
therapy, if used
• Report abnormal findings to nurse in
charge or health care provider

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 Special Considerations
 Teaching
 Deep-breathing and coughing exercises
 Pediatric
 Assess respiratory rates first, before other vital signs
 Be aware of physiological differences

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 Special Considerations (Cont.)
 Gerontological
 Restricted chest expansion
 Reduced depth of respirations
 Change in lung function
 Dependence on accessory muscles
 Home care
 Assess for environmental factors that influence
patient respiratory rate

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 Quick Quiz!
The nurse receiving the report is told that her
patient is having Cheyne-Stokes respirations.
What will the nurse expect to find when assessing
this patient?
A.Slow but normal breathing rate
B.Increased depth of respirations

C.Alternating periods of apnea and hyperventilation

D.Cessation of respirations for several seconds

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Assessing Arterial Blood Pressure
Skill 5-5
 Blood pressure (BP)
is commonly
assessed with a
sphygmomanometer
and a stethoscope
 Korotkoff phases: five
sounds heard over an
artery

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Assessing Arterial Blood Pressure
Skill 5-5 (Cont.)
 Hypertension
 Prehypertension
 Hypotension
 Orthostatic
 Blood pressure
equipment

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 Delegation and Collaboration
 The task of blood pressure measurement can be
delegated to NAP unless patient is unstable
 The nurse instructs NAP to:
 Explain the procedure
 Communicate frequency and factors related to patient
history
 Review and report blood pressure values, changes, or
abnormalities

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 Recording and Reporting

• Record blood pressure and site assessed on

vital sign flow sheet or in EHR or chart
• Document measurement of blood pressure
after administration of specific therapies
• Report abnormal findings to nurse in charge
or health care provider

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 Special Considerations
 Teaching
 Risks for hypertension
 Time and position to take blood pressure
 Pediatric
 Not routine for children younger than 3 years old
 Risk of anxiety
 Korotkoff sounds difficult to hear

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 Special Considerations (Cont.)
 Gerontological
 Susceptible to cuff pressure injury
 Increased systolic pressure
 Fall in blood pressure after eating
 Postural hypotension
 Home care
 Equipment/environment recommendations

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 Noninvasive Electronic Blood
Pressure Measurement
Procedural Guideline 5-1
 Used when frequent
assessment is
required
 Critically ill/potentially
unstable patients;
during/after invasive
procedures; therapies
requiring frequent
monitoring

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 Delegation and Collaboration
 The task of blood pressure measurement using
an electronic blood pressure machine can be
delegated to NAP unless the patient is
considered unstable
 The nurse instructs NAP to:
 Communicate measurement information
 Select appropriate blood pressure cuff
 Review and report patient information

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 Quick Quiz!
The nurse is preparing to assess the blood
pressure of an adult patient, using a thigh cuff on
an electronic BP monitor. The nurse should use a
cuff of what size for this patient?
A.17 to 25 cm
B.23 to 33 cm

C.31 to 40 cm

D.38 to 50 cm

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 Measuring Oxygen Saturation
(Pulse Oximetry)
Procedural Guideline 5-2
 Noninvasive measurement of arterial blood
oxygen saturation
 A probe with a light-emitting diode (LED)
measures oxygenated hemoglobin molecules
 Probes can be applied to the earlobe, finger,
toe, bridge of nose, or forehead
 Normal pulse oximetry (SpO2) is greater than
95%

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 Delegation and Collaboration
 The task of oxygen saturation measurement can
be delegated to NAP
 The nurse instructs NAP to:
 Explain to the patient factors that falsely lower O2
saturation
 Use specific sensor site, probe, and frequency of
oxygen saturation measurements for the patient
 Notify the nurse of low O2 saturation readings
 Not use pulse oximetry to assess heart rate

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