VITAL SIGNS

RYAN MANGUNAY AMIGO, RN. RM. MSN. MAN. DIPHM. CHA. DPCHA. FRIN.
ASSISTANT PROFESSOR
VITAL SIGNS OF LIFE

Lecture Objective:
1. To gain accurate knowledge related to
assessment of 4 vital signs of life.
2. To master the skills needed in determining /
monitoring the 4 vital signs of life.
3. To prepare the students in the application of
skills necessary in assessing vital signs of life.
VITAL SIGNS
Vital signs are indicators of health, measures that
indicates the effectiveness of circulatory,
respiratory, neural and endocrine body functions.

Assessment of vital signs provides data to identify

nursing diagnoses, implement planned
interventions, and evaluate outcomes of care.

An alteration in vital signs signals a change in

physiological function and the need for medical or
nursing intervention.
GUIDELINES FOR MEASURING VITAL SIGNS

1. Measuring vital sign is your responsibility.

2. Assess equipment to ensure that it is working
correctly and provides accurate findings.
3. Select equipment on the basis of patient’s
condition and characteristics.
4. Know the patient’s usual range of vital signs.
5. Know your patient’s medical history, therapies,
and prescribed medications.
GUIDELINES FOR MEASURING VITAL SIGNS (CONT.)

6. Control or minimize environmental factors that

affect vital signs.
7. Used an organized, systematic approach when
taking vital signs.
8. On the basis of patient’s condition, collaborate
with health care providers to decide frequency of
vital sign assessment.
GUIDELINES FOR MEASURING VITAL SIGNS (CONT.)

9. Use vital signs measurements to determine

indications for medication administrations.
10. Analyze the results of vital sign measurements
on the basis of patient’s condition and past medial
history.
11. Verify and communicate significant changes in
vital signs.
WHEN TO MEASURE VITAL SIGNS
1. On admission to a health care facility
2. When assessing a patient during home care visits
3. In a hospital on a routine schedule according to the
health care provider’s order or hospital standards of
practice before, during and after, and after a surgical
procedure or invasive diagnostic procedure.
4. Before, during, and after a transfusion of blood
products
5. Before, during, and after administration of
medication or therapies that affect cardiovascular,
respiratory, or temperature-control functions.
WHEN TO MEASURE VITAL SIGNS

6. When patient’s general physical condition changes.

7. Before, during, and after nursing intervention
influencing a vital sign.
8. When a patient reports nonspecific symptoms of
physical distress.
10. Analyze the results of vital sign measurements on
the basis of patient’s condition and past medial history.
11. Verify and communicate significant changes in vital
signs.
THERE ARE FOUR VITAL SIGNS WHICH ARE STANDARD
IN MOST MEDICAL SETTINGS:

1. Body Temperature
2. Pulse (Heart / Cardiac Rate)
3. Respiratory Rate
4. Blood Pressure
BODY TEMPERATURE
RYAN MANGUNAY AMIGO, RN. RM. MSN. MAN. DIPHM. CHA. DPCHA. FRIN.
ASSISTANT PROFESSOR
BODY TEMPERATURE

✔Is the amount of heat produced by the body and

heat loss by the body.
TYPES
• Core Temperature. The temperature of the deep
tissues of the body. Measured by taking oral and
rectal temperature.
• Surface temperature. The temperature of the
skin, subcutaneous tissue and fat. Measured by
taking axillary temperature.
HEAT PRODUCTION / CONTROL
✔ Body heat is primarily produced by metabolism. The
heat regulating center is found in the hypothalamus.
Thermogenesis
• Is the process of heat production in organisms. It occurs
mostly in warm-blooded animal
• Depending on whether they are initiated through
locomotion and intentional movement of the muscles,
thermogenic methods can be classified as one of the
following:
i. Exercise-associated thermogenesis (EAT)
ii. Non-exercise-associated thermogenesis (NEAT)
iii. Diet- induced thermogenesis (DIT)
FACTORS AFFECTING THE BODY’S HEAT PRODUCTION
ARE AS FOLLOWS:
1. Muscle Activity. (exercise, swimming). Increases
cellular metabolic rate. Therefore, exercise increases
body heat production
2. Thyroxine Output. Increases cellular metabolic rate
(chemical thermogenesis). Hyperthyroidism is
characterized by increased body tempertature.
3. Epinephrine, norepinephrine and sympathetic
stimulation. Increases the rate of cellular
metabolism. These in turn, increase body
temperature.
FACTORS AFFECTING THE BODY’S HEAT PRODUCTION
ARE AS FOLLOWS:

4. Increased temperature of body cells (fever). Increases

the rate of cellular metabolism. “Fever further causes
fever.”
5. Basal Metabolic Rate (BMR). The younger the person,
the higher the BMR; the older the person, the lower the
BMR. Therefore, the older persons have lower
temperature than the younger persons.
FACTORS AFFECTING TEMPERATURE ARE AS
FOLLOWS:
1. Age The infant’s body temperature is greatly
affected by the temperature 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 8:00 PM to 12:00 MN; and the
lowest temperature is reached between 4:00 and
6:00AM.
FACTORS AFFECTING TEMPERATURE ARE AS
FOLLOWS:

3. Exercise Strenuous exercise increases metabolic

rate thus, the body temperature.
4. Hormones (e.g progesterone, thyroxine,
norepinephrine, and epinephrine increase body
temperature; estrogen decreases body temperature.
5. Stress Sympathetic nervous system stimulation
increases the production of epinephrine and
norepinephrine, thereby increasing the metabolic
rate and heat production.
ALTERATIONS IN BODY TEMPERATURE
1. Pyrexia(Hyperthermia or fever) Body
temperature above normal range. (also
hyperthermic fever)
2. Hyperpyrexia Very high fever, 41° C ( 105.8 F)
and above.
3. Hypothermia Subnormal core body
temperature. This may be caused by excessive
heat loss, inadequate heat production or
impaired hypothalamic function.
BODY TEMPERATURE
Patterns of Fever
1. Sustained: A constant body temperature
continuously above 38’C that has little fluctuation
2. Intermittent: Fever spikes interspersed with usual
temperature levels (temperature returns to
acceptable value at least once in 24 hours)
3. Remittent: Fever spikes and falls without a return
to acceptable temperature levels.
4. Relapsing: Periods of febrile episodes and periods
with acceptable temperature values (Febrile
episodes and periods of normothermia are often
longer than 24 hours)
CLINICAL SIGNS OF FEVER
• Onset (cold or chill stage)
• Increased heat rate
• Increased respiratory rate 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
• Course (Plateau stage)
• Absence of chills
• Skin that feels warm
• Photosensitivity
• Glass-eyed appearance
• Increased RR and HR
• Increased thirst, malaise, weakness and aching
muscles
• Drowsiness, restlessness, delirium or
convulsions
• Mild to severe dehydration, loss of appetite
CLINICAL SIGNS OF FEVER

• Defervescence (Fever abatement/flush stage)

• Skin that appears flushed and feels warm
• Sweating
• Decreased shivering
• Possible dehydration
INTERVENTIONS IN CLIENTS WITH FEVER

✔Monitor V.S
✔Assess skin color and temperature.
✔Monitor WBC,Hct and other pertinent laboratory
records.
✔Elevated wbc levels indicate presence of infection
✔Elevated Hct indicated dehydration.
✔Remove excess blankets when the client feels
warm; provide extra warmth when the client feels
chilled.
INTERVENTIONS IN CLIENTS WITH FEVER

• Provide adequate foods and fluids. To provide

additional calories and prevent dehydration.
• Measure intake and output.
• Maintain prescribed IV fluids as ordered by the
physician.
• Promote rest. To reduce body heat production.
• Provide good oral hygiene. To prevent herpetic
lesions of the mouth.
INTERVENTIONS IN CLIENTS WITH FEVER

• Provide cool, circulating air using a fan. To dissipate

heat by convection.
• Administer antipyretics as ordered. Temperature of
38.5°C and above usually require administration of
antipyretic.
• Provide dry clothing and bed linens. To ensure
comfort.
• Provide TSB (Temperature of water 80-98°F). To
enhance heat loss by evaporation and conduction.
NORMAL ADULT TEMPERATURE RANGES

Methods of Temperature Taking Ranges

1. Oral 96.6 ° - 99.6 °F

(36.5 ° - 37.5°C)
2. Axillary 96.6° - 96.6 °F
(35.8° - 37.0°C)
3. Rectal 98.6°- 100.6°F
(37.0° - 38.1°C)
4. Tympanic 98.2° - 100.2°F
(36.8° - 37.5°C)
TYPES OF THERMOMETER

I. Digital Thermometer
II. Tympanic Thermometer
III. Film Thermometer
IV. Infrared Thermometer
V. Chemical Thermometer
 PULSE
RYAN MANGUNAY AMIGO, RN. RM. MSN. MAN. DIPHM. CHA. DPCHA. FRIN.
ASSISTANT PROFESSOR
PULSE
• 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).
• It can be felt in any place that allows an artery
to be compressed against a bone, such as at the
neck (carotid artery), at the wrist (radial artery),
behind the knee (popliteal artery), on the inside
of the elbow (brachial artery), and near the
ankle joint (posterior tibial artery).
• The pulse rate can also be measured by
measuring the heart beat directly (auscultation),
usually using a stethoscope.
FACTORS AFFECTING THE PULSE RATE ARE AS
FOLLOWS:

• Age. Younger persons have higher rate than older

persons.
• Sex/Gender. After puberty, females have higher
pulse rate than the males.
• Exercise. Increases metabolic rate, thereby
increasing the pulse rate.
• Fever. Increases metabolic rate, therefore the
pulse rate increases.
FACTORS AFFECTING THE PULSE RATE ARE AS
FOLLOWS:

• Medications. Digitalis, beta blockers decrease

pulse rate, epinephrine, atropine sulfate increase
pulse rate.
• Hemorrhage. Increases pulse rate as
compensatory mechanism for blood loss.
• Stress. Sympathetic nervous stimulation increases
the activity of the heart.
• Position changes. In sitting or standing position
there is decreased venous return to the heart,
decrease BP, therefore increase in the heart rate.
PULSE SITES
• Temporal. Over the temporal bone of the head;
superior and lateral to the eye.
• Carotid. At the lateral aspect of the neck; below
the ear lobe.
• Apical. At the left midclavicular line (MCL) fifth
intercostals space (ICS), use stethoscope.
• Brachial. At the inner aspect of the upper arm
(Biceps muscles) or medially at the antecubital
space.
• Radial. On the thumb side of the inner aspect of
the wrist.
PULSE SITES

• Femoral. Along side the inguinal ligament.

• Posterior Tibial. At the medial aspect of the ankle,
behind the medial malleolus.
• Popliteal. At the back of the knee.
• Pedal. (Dorsalis Pedis). At the dorsum of the foot.
• Use the middle two to three fingertips to palpate
the pulse. Do not use the thumb. The normal
pulse is detected readily, obliterated by strong
pressure.
PULSE VARIATIONS BY AGE
AGE PULSE AVERAGE(and
ranges)
Newborn 130(80-180)
1 year 120(80-140)
5-8 years 100(75-120)
10 years 70(50-90)
Teen 75(50-90)
Adult 80(60-100)
Older adult 70(60-100)
REASONS FOR USING SPECIFIC PULSE SITE
Pulse Site Reasons Pulse Site Reasons
Radial Readily accessible Brachial Used to measure
blood pressure
Used for cardiac
arrest in infants
Temporal Used when radial Femoral Used in cases of
pulse is not cardiac
accessible arrest/shock
Used to determine
circulation to a leg
Carotid Used during Popliteal Used to determine
cardiac circulation to the
arrest/shock in lower leg
adults
Used to determine
circulation to brain
Apical Used for infants Posterior tibial Used to determine
and children up to circulation at foot
3 years of age
Dorsal pedial Used for
circulation at foot
CHARACTER OF THE PULSE
1. Rate –beats per minute
❑Common Abnormality
❖Tachycardia- elevated HR more than 100 bpm
❖Bradycardia- decreased HR less than 60bpm
• Pulse Deficit- inefficient contraction of the heart
failing to transmit wave to the peripheral pulse site.
It is usually associated with abnormal rhythms.
Infant 120-160 bpm Toddler 90-140 bpm
Preschooler 80-110 bpm School-age child 75-100 bpm
Adolescent 60-90 Adult 60-100
CHARACTER OF THE PULSE

2. Rhythm- normal, regular interval that occurs

between each pulse or heartbeat.
• Dysrhythmia- an interval interrupted by an early or
late beat or missed beats.
3. Strength- or amplitude of a pulse reflects the
volume of blood ejected against the arterial wall each
heart contraction
4. Equality-symmetrical pulses simultaneously except
carotid pulse.
 RESPIRATION
RYAN MANGUNAY AMIGO, RN. RM. MSN. MAN. DIPHM. CHA. DPCHA. FRIN.
ASSISTANT PROFESSOR
RESPIRATION
• The act of breathing
• Primary function is to obtain oxygen for use by
body's cells & eliminate carbon dioxide that cells
produce
• Includes respiratory airways leading into (& out of)
lungs plus the lungs themselves
• Pathway of air: nasal cavities (or oral cavity) >
pharynx > trachea > primary bronchi (right & left)
> secondary bronchi > tertiary bronchi >
bronchioles > alveoli (site of gas exchange)
THREE PROCESS OF VENTILATION

1. Ventilation- the movement of gases in and out of

the lungs
• The movement of gases in and out of the lungs
which is composed of 2 cycles:
❖Inhalation (inspiration)- Movement of air onto
the lungs.
❖Exhalation (expiration)- Movement of air
going out of the lungs.
Inhalation (inspiration) + Exhalation (expiration) =
1 respiratory cycle
THREE PROCESS OF VENTILATION

2. Diffusion- the movement of oxygen and carbon

dioxide between alveoli and the red blood cells
3. Perfusion- the distribution of red blood cells to
and from the pulmonary capillaries.
FACTORS INFLUENCING CHARACTER OF
RESPIRATIONS

1. Exercise
2. Acute pain
3. Anxiety
4. Smoking
5. Body positions
6. Medications
7. Neurological injury
8. Hemoglobin functions
CHARACTERISTICS OF RESPIRATION

1. Respiratory rate- observe a full respiration and

expiration when counting ventilation or
respiration rate. The usual rate declines
throughout life.
2. Ventilatory depth- assess the depth of
respirations by observing the degree of excursion
or movement in the chest wall.
3. Ventilatory rhythm- determine breathing pattern
by observing the chest or abdomen.
OTHER MUSCLE OF BREATHING
 BLOOD PRESSURE
RYAN MANGUNAY AMIGO, RN. RM. MSN. MAN. DIPHM. CHA. DPCHA. FRIN.
ASSISTANT PROFESSOR
BLOOD PRESSURE

• Is the measure of the pressure exerted by the blood

as is pulsates through the arteries (Arterial Blood
Pressure)
• BP=Cardiac Output x Total Peripheral Resistance or
C.O x TPR
• Systolic Pressure. Is the pressure of blood as a result
of contraction of the ventricles (100 – 140 mmmHg).
• Diastolic pressure. Is the pressure when the
ventricles are at rest (60 – 90 mmHg).
DETERMINANTS OF BLOOD PRESSURE

• Peripheral Vascular resistance

• Cardiac output
• Blood volume
• Viscosity
• Elasticity
FACTORS AFFECTING BLOOD PRESSURE

• Age. Older people have higher BP due to decreased

elasticity of blood vessels.
• Exercise. Increases cardiac output; hence the BP.
• Stress. Sympathetic nervous system stimulation causes
increased BP.
• Race. Hypertension is one of the 10 leading causes of
death among Filipinos.
• Obesity. BP generally is elevated among overweight
and obese people.
FACTORS AFFECTING BLOOD PRESSURE

• Sex/Gender. After puberty and before age 65 years,

males have higher BP. after age 65 years, females have
higher BP due to hormonal variations in menopause.
• Medications. Some medications may increase or
decrease BP.
• Diurnal Variations. BP is lowest in the morning and
highest in the late afternoon or early evening.
• Diseases Process. Diabetes Mellitus, Renal Failure,
Hyperthyroidism, Cushing’s Disease cause increase in
BP.
CLASSIFICATION OF BLOOD PRESSURE FOR ADULTS
AGES 18 AND OLDER
Category Systolic Diastolic

Normal <120 <80

Prehypertension 120-139 80-89
Stage 1 >140 >90
hypertension
Stage 2 >160 >90
hypertension
ALTERATIONS IN BLOOD PRESSURE

• Hypertension- BP of greater than 140/90mm Hg

• Hypotension-systolic BP falls to <90 mm Hg
• Orthostatic or Postural hypotension- a decrease of 20
mm Hg of the diastolic or systolic BP
COMMON ERRORS IN BLOOD PRESSURE
MEASUREMENT
Error Effect
Cuff to wide False-low reading
Cuff to narrow or too short False-high reading
Cuff wrapped too loosely or unevenly False-high reading
Deflating cuff to slowly False-high diastolic reading
Deflating cuff too quickly False-low systolic and
false-high diastolic reading
Arm below heart level False-high reading
Arm above heart level False-low reading
Arm not supported False-high reading
Stethoscope applied firmly against antecubital fossa False-low diastolic reading
Inflating too slowly False-high diastolic reading
Repeating assessments too quickly False-high systolic reading
Inadequate inflation level False-low systolic reading
IMPORTANT NOTE’S (DONT YOU FORGET)

• Determine palpatory BP before auscultatory BP to

prevent auscultatory gap.
• inflate and deflate BP cuff slowly 2-3 mm Hg at a
time.
• Wait 1-2 minutes before making further
determinations.
• The sound during BP taking is Korotkoff sound.
 ALTERATION IN READING

• The systolic pressure in the popliteal

artery is usually 10-40 mmHg higher
than that in the brachial artery; the
diastolic pressure is usually the same.
OXYGEN SATURATION
RYAN MANGUNAY AMIGO, RN. RM. MSN. MAN. DIPHM. CHA. DPCHA. FRIN.
ASSISTANT PROFESSOR
OXYGEN SATURATION

• A Pulse Oximeter is a noninvasive device that

estimates a client’s arterial blood oxygen
saturation (SaO2) by means of a s sensor attached
to the client’s finger, toe,nose, earlobe or
forehead. (N: 95-100%) (70%: life threatening)
Factors affecting the Oxygen Saturation:
1. Hemoglobin
2. Circulation
3. Activity
4. Carbon monoxide poisoning
THANK YOU!