VITAL SIGNS

Vital Signs

 The taking of vital signs refers to measurement

of the client’s body temperature (T), pulse (P)
rate, respiratory (R) rate, and blood pressure
(BP).
 Vital signs are the first step in the physical
examination.
Vital Signs

 Assessment of vital signs provides specific

data regarding the client’s current condition.
 Variations from baseline values may indicate
potential problems with the client’s health
status.
Vital Signs

 The sequence for recording vital sign

measurements in the nurses’ notes is T-P-R
and BP.
 Vital signs are plotted on graphic forms that
facilitate data comparison at a glance.
Factors Influencing Vital Signs

 Age
 Gender
 Heredity
 Race
 Lifestyle
 Environment
Factors Influencing Vital Signs

 Medications
 Pain
 Exercise
 Anxiety and Stress
 Postural Changes
 Diurnal (daily) Variations
Physiologic Function

 Thermoregulation
 The heat of the body is measured in units called
degrees.
 The core internal temperature of 98.6 degrees
Fahrenheit (F) does not vary more than 1.4 degrees
F.
 Core internal temperature is higher than the skin
and external temperature.
Thermoregulation

 The body’s physiological function of heat

regulation to maintain a constant internal body
temperature
Hypothalamus – heat-regulating center.

Two types:
1. CORE TEMPERATURE – the temperature of
the deep tissues of the body (internal organs).

2.SURFACE TEMPERATURE – the temperature

of the skin, subcutaneous tissue and fat.
Normal: Range: 36.7◦c – 37◦c (98.6◦F)

 Factors that affect the body’s heat production:

a.) Basal Metabolic Rate (BMR)
- the younger the person, the higher the BMR; the older person, the lower the
BMR.

b.) Muscle activity

- (exercise, swimming) increases the metabolic rate.

c.) Thyroxine Output

- increases cellular metabolic rate.

d.) Epinephrine, norepineprine, and sympathetic

stimulation.
Increased temperature of the body cells (fever)
Process involved in Heat Loss:

 Radiation
- the transfer of heat from the surface of one object to the surface of another
without contact between the two objects.
 Conduction
- the transfer of heat from one surface to another. It requires temperature
difference between the two objects.
 Convection
- the dissipation of heat by air currents.

 Evaporation
- the continuous vaporation of moisture from the skin, oral mucosa, heat
respiratory tract. (also insensible heat loss)
Factors Affecting Temperature:
1. Age
– the infant’s body temp is greatly affected by the temp of the environment.
Elder people are at risk of hypothermia due to decreased thermoregulatory
controls, decreased subcutaneous fat, inadequate diet and sedentary
activity.

2. Diurnal Variations
- highest temperature is usually reached between 8:00pm to 12mn; lowest
temp 4:00 – 6:00am

3. Exercise
Factors Affecting Temperature:

4. Hormones
- progesterone, thyroxine, norepineprine & epinephrine – increase body
temp
- estrogen – decreases body temp.

5. Stress
- SNS stimulation increases the production of epinephrine and
norepinephrine, thereby increasing metabolic rate and heat production.
Alteration in Body Temperature:

 Pyrexia body temp above the normal range

(Hyperthermia – Fever)
 Hyperpyrexia – very high fever, 41◦c (105.8◦F) and above.
 Hypothermia – subnormal core body
temp. caused by excessive heat loss,
inadequate heat production, impaired
hypothalamic fxn.
Types of Fever:
 Intermittent Fever
-temp fluctuates bet periods of fever and periods of normal/subnormal
temp.
 Remittent Fever
- temp fluctuates within a wide range over the 24 hrs period but remains
above normal range.
 Relapsing Fever
-temp is elevated for few days, alternated with 1 – 2 days of normal
temp.
 Constant Fever
- very high temp cause irreversible brain damage.
Decline of Fever

Crisis or flush or defervescent stage

- the sudden decline of fever – indicates impairment of function of
the hypothalamus.

Lysis
- the gradual decline of fever. – indicates
that the body is able to maintain
homeostatis.
Clinical Signs of Fever:
a.) Onset
- increased HR
- increased RR and depth
- shivering
- pale, cold, skin
- cyanotic nail bed
- complaints of feeling cold
- “goose Flesh” appearance of the skin
- cessation of sweating
- rise in body temperature
Clinical Signs of Fever:
b.) Course
- absence of chills
- skin that feels warm
- feeling of being neither hot or cold
- increased pulse and respiratory rates.
- increased thirst
- mild to severe dehydration
- simple, drowsiness, restlessness, or delirium
and convulsions.
- loss of appetite to eat
- malaise, weakness, and aching muscles.
Clinical Signs of Fever:
c.) Defervescence (Fever abatement)
- skin that appears flushed and feels warm
- sweating
- decrease shivering
- possible dehydration
Nursing Intervention:
Nursing Intervention:
a.) monitor vita signs
b.) assess skin color and temperature
c.) Monitor WBC, hematocrit value and other
pertinent lab records.
d.) remove excess blankets when the client feels
warms; provide extra warm when client feels
chilled.
e.) provide adequate food and fluid
f.) measure I & O
g.) Maintain prescribed IV fluids
h.) promote rest
i.) provide good oral hygiene
j.) provide cool, circulating air by using a fan.
k.) provide dry clothing and bed linens.
l.) provide TSB
m.) administer antipyretics as ordered.
a.) ORAL (36.8◦c – 37.1◦c)
- Most accessible and convenient.
- Allow 15 minutes to elapse between a client’s intake of
hot or cold food or smoking.
- Place the thermometer under the tongue, directed
toward the side.
- Wash the thermometer before use, from bulb to the
stem, after use, from stem to the bulb.
- Take oral temperature 2 -3 minutes.
Contraindications:
1. Oral lesions or surgery
2. Dyspnea
3. Cough
4. Nausea & vomiting
5. Presence of oro-nasal contraptions, e.g. nasal pack,
nasogastric tube, endotracheal tube, etc.
6. Seizure – prone
7. Very young children
8. Unconscious / comatose
9. Restless, disoriented, confused, with mental problems
b.) Rectal (37.6◦c)
- Most accurate measurement.
- Assist client to assume lateral position.
- lubricate thermometer before insertion.
- Insert thermometer by 05 – 1.5 in (1.5 – 4cm)
- Instruct the client to take a deep breath during
insertion of the thermometer to relax the internal
sphincter.
- Hold the thermometer in place for 2 minutes. (for
neonates, 5 minutes).
- Do not force insertion of the thermometer into a
newborn.
Contraindication:
1. Surgeries (hemorrhoids, hemorrhoidectomy,
anal fissure).
2. diarrhea
c.) Axillary (36.5 – 37.2◦c)
- Safest and most non-invasive
- Pat dry thee axilla
- Place the thermometer in the client’s axilla
- Place the arm tightly across the chest to keep
the thermometer in place for 7 – 10 mins;
max 10 mins.
Nursing Diagnoses:
 Clients with Altered Body Temperature:
a.) High risk for altered body temperature r/t
- illness or trauma affecting temp regulation.
- medication causing vasoconstriction,
vasodilation, altered metabolic state, or sedation
- inactivity or vigorous activity.
b.) Hyperthermia r/t
- exposure to excessively warm environment
- Increase metabolic rate
- dehydration
Nursing Diagnoses:
c.) Hypothermia r/t
- exposure to excessively cool environment.
- debilitating illness or trauma
- lack of adequate clothing and shelter.

d.) Ineffective thermoregulation r/t

- decreased basal metabolism secondary to
aging
- trauma or illness
Hemodynamic Regulation

 Pulse
 The pulse is caused by the stroke volume ejection
and distension of the walls of the aorta.
 The bounding of blood flow in an artery is palpable
at various points in the body (pulse points).

- It is a wave of blood created by contraction of the left

ventricle of the heart . The pulse rate is regulated by the
autonomic nervous system ( ANS ) .
Blood Vessel Structure: Arteries,
Veins
Factors Affecting Pulse Rate
 Age
 Sex / gender
 Exercise
 Fever
 Medications
 Hemorrhage
 Stress
 Position changes
Pulse Sites:
Pulse Sites:
 Temporal
 Carotid
 Apical
 Brachial
 Radial
 Femoral
 Popliteal
 Pedal
 Assessment of Pulse
A.) Rate
• Tachycardia – pulse rate above 100
• Bradycardia - pulse rate less 6o
Age Normal Ranges
Newborn to 1 month 80 – 180 beats / min
1 years 80 – 140 beats / min
2 years 80 - 130
6 years 75 - 120
10 years 50 - 90
adult 60 - 100
B.) Rhythm
– patterns and interval of beats.
- Dysrhythmia – is irregular rhythm

C.) Volume (Amplitude) – the strength of

pulse.
• A normal can be felt with moderate pressure
• Full or bounding pulse – it can be obliterated
only by great pressure.
• Thready pulse – (weak or feeble)
D.) Arterial wall elasticity
- the artery feels straight, smooth soft and
pliable.

E.) Presence / Absence of bilateral equality

Respiration

 Respiration is the act of breathing.

 Terms related to respiratory function are:
 External respiration
 Internal respiration
 Inspiration
 Expiration
 Vital capacity
Assessing Respiration:

 Rate: Normal is 16 – 20 breaths per min.

(adult)
 Depth: observe the movement of the chest.
May be normal, deep and shallow.
 Rhythm. observe the regularity of exhalation
and inhalations.
 Quality or character – refers to the
respiratory effort and sound of breathing.
 Respiration: the act of breathing
Three Processes:
a.) Ventilation –the movement of gases in and out of the lungs
Inhalation (Inspiration)
Exhalation (Expiration)

b.) Diffusion – the exchange of gases from an area of higher pressure

to an area of lower pressure – it occurs at the alveolo-capillary
membrane

c.) Perfusion – the availability and movement of blood for

transport of gases, nutrients and metabolic waste products.
Two types of Breathing
a.) Costal (thoracic) involves movement of the chest.
b.) Diaphragmatic (Abdominal) involves movement
of the abdomen.
Respiratory Centers:
 Medulla Oblongata – primary center
 Pons – contains the following:
* pneumotaxic center – responsible for the
rhythmic quality of breathing
* Apneustic center – responsible for deep,
prolonged inspiration.
• Carotid and aortic bodies
– Peripheral chemoreceptor's - respond to low
concentration in the blood
• Muscle and joints
- Proprioceptors – example: exercise – inc RR
Assessing Respiration:
 Rate – Normal is 16 – 20/min (adult)
 Depth – observes the movement of the chest
 Rhythm – observe for regularity of
exhalations and inhalations.
 Quality or character – refers to respiratory
effort and sound of breathing.
Major Factors Affecting Respiratory
Rate
 Exercise
 Stress
 Environment
 Increased altitude
 Medications (narcotic)
 Terminologies:
 Eupnea – normal respiration that is quiet,
rhythmic, effortless.
 Tachypnea – rapid respiration (quick, shallow
breaths)
 Bradypnea – slow breathing
 Hyperventilation – prolonged and deep breaths
(CO2 is excessively exhaled (respiratory acidosis)
* Hypoventilation - slow shallow respiration
(CO2 is excessively retained (respiratory acidosis)
• Dyspnea – difficult and labored breathing
• Orthopnea – ability to breath only in upright
position.
Blood Pressure

 The direct method of measuring blood

pressure requires an invasive procedure.
 The indirect method requires use of the
sphygmomanometer and stethoscope for
auscultation and palpation as needed.
Blood Pressure:
- Measurement of pressure pulsations exerted
against the blood vessel walls during systole
and diastole.

- Systolic Pressure - is the pressure of blood as a result of

contraction of the ventricles.
- Diastolic Pressure – is the pressure when the ventricles are
at rest. (60-90 mmHg)
- Pulse Pressures (S – D = P.P) Normal is 30 – 40mmHg
- The average BP of healthy adult is 120/80mmHg.
Sites

 The most common site for indirect

measurement is the client’s arm over the
brachial artery.
 Accurate measurement requires the correct
width of the blood pressure cuff as determined
by the circumference of the client’s extremity.
 Determinants of Blood Pressure:
a) Blood Volume
b) Peripheral Resistance
c) Cardiac Output
d) Elasticity or compliance
e) Blood viscosity (hct – 60 – 65%)
 Normal Vital Signs

AGE NORMAL RR NORMAL PR NORMAL BP

NEWBORN 30-50 per min 120-140 per min 60-80/40-50mmHg

May go 220 when
crying

1-4 Y 20-40 per min 80-140bpm 90-99/60-65mmHg

5-12 15-25 per min 70-115bpm 100-110/56-60mmHg

ADULT 12-20 per min 60-100bpm 90-140/60-90mmHg

Auscultation

 Korotkoff sounds are five distinct phases of

sound heard with a stethoscope during
auscultation.
Palpation

 The forearm or leg sites can be palpated to

obtain a systolic reading when the brachial
artery is inaccessible.
Hypotension

 Hypotension refers to a systolic blood pressure

less than 90 mm Hg or 20 to 30 mm Hg below
the client’s normal systolic pressure.
 Orthostatic Hypotension (postural
hypotension)
 Sudden drop in systolic pressure when client
moves from a lying to a sitting to a standing
position
Hypertension

 Hypertension refers to a persistent systolic

pressure greater than 135 to 140 mm Hg and a
diastolic pressure greater than 90 mm Hg.
Nursing Considerations

 False Readings
 Recently eaten, ambulated, or experienced an
emotional upset
 Improper cuff width
 Improper technique in deflating cuff
 Improper positioning of extremity
 Failure to recognize an auscultatory gap
 Documentation
 Record on appropriate form
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