St.

Scholastica’s College Tacloban

Maharlika Highway, Brgy. Campetic, Palo, Leyte
COLLEGE OF NURSING

VITAL SIGNS

JERBIES E LLAMES, RN
 1 Objectives

2 Vital Signs: Discussion

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CONTENTS
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 o b j e c ti ve s
LEARNING OUTCOMES

At the end of discussion, the students should be able to

01 accomplish the following:

1. Explain the physiologic process involved in homeostatic

regulation of temperature, pulse, respirations, and blood pressure.

2.Identify the sites for assessing the vital signs

3. accurately assess the vital signs.

4. know the normal ranges of vital signs and determine abnormal

findings.
 What is the THERMOREGULATORY Center of the
body?

01 TEMPERATURE
 HEAT PRODUCTION
 Metabolism
 Hormones
 Muscle Movements
 Exercise

HEAT LOSS
01 TEMPERATURE  Skin
 Mechanism of Heat
Transfer
• Radiation
• Convection
• Evaporation
• Conduction
 Factors affecting the body temperature
 Circadian Ryhthms
 Age and Sex
 Environmental Temperature

01 TEMPERATURE
  PYREXIA
 FEBRILE
 AFEBRILE
 HYPOTHERMIA
 HYPERTHERMIA or HYPERPYREXIA
 NEUROGENIC FEVER
TEMPERATURE  FEVER OF UNKNOWN ORIGIN
01
 TYPESOF FEVER

 Intermittent
 Remittent
 Constant
 Relapsing
TEMPERATURE  Crisis
01  Lysis
 ASSESSING BODY TEMPERATURE

Equipments
 Electronic and Digital
 Tympanic Membrane
 Glass
TEMPERATURE  Disposable-Single Use
01  Temporal Artery
 Automated Monitoring Devices
 ASSESSING BODY TEMPERATURE

Equipments

01 TEMPERATURE
 SITES OF ASSESSING BODY TEMPERATURE

1. Tympanic Membrane Temperature

 core body temperature

 easy and safe, readily available
 not to be used: ear drainage, scars
01 TEMPERATURE
 SITES OF ASSESSING BODY TEMPERATURE

2. Oral Temperature

 able to follow instructions

 not for unconscious patient, irrational, seizure-
prone, infant and young children, disease of oral
01 TEMPERATURE cavity, surgery of mouth or nose
 if patient had either cold drinks or chew a gum,
must have rest 15 or 30 minutes prior taking
temperature
 SITES OF ASSESSING BODY TEMPERATURE

3. Rectal Temperature

 most accurate
 uncomfortable for patient
 provide privacy
01 TEMPERATURE  not for patient who undergone rectal surgery,
with heart disorder, or spinal cord injury
 What is a Pulse?

It is a throbbing sensation that can be palpated

over a peripheral artery or auscultated over the
apex of the heart.

02 PULSE
 PULSE RATE

Normal Rate: 60-100 in adults

 Tachycardia
 Bradycardia
 Dysrhythmia

02 PULSE
 How to describe a Pulse?

 Absent
 Thready
 Weak
 Normal
PULSE  Bounding
02
 ASSESSING THE PULSE

Equipment: Stethoscope
Doppler UTZ Stethoscope

02 PULSE
 ASSESSING THE PULSE- place the 3
middle fingers over the artery and lightly
compress

 Peripheral Artery Pulse

 Radial Pulse
 Temporal
02 PULSE
 Carotid
 Brachial
 Popliteal
 Femoral
 Posterior Tibial
 Dorsalis pedis
 ASSESSING THE PULSE

 Apical Pulse
 between the 5th and 6th ribs,
about 8cm to the left of the medial
line and slightly below the nipple
02 PULSE
 INHALATION

EXPIRATION

EXTERNAL RESPIRATION

INTERNAL RESPIRATION
03 RESPIRATIONS
 Normal Rate: 12-20 cpm EUPNEA

Increased RR- Tachypnea

Decreased RR- Bradypnea

Apnea- absence of breathing

03 RESPIRATIONS
Dyspnea- difficulty of breathing

Orthopnea- a condition wherein a person can

breath easily in an upright position
 What are the respiratory centers of the body?

03 RESPIRATIONS
 Medull and pons

 activated or stimulated by the chemoreceptors

in the aortic arch and carotid arteries from the
irritant receptors in the lungs

 Carbon dioxide- powerful stimulant

03 RESPIRATIONS
 PATTERNS OF RESPIRATIONS

 Normal
 Tachypnea- > 24 breaths per minute; shallow
 Bradypnea- < 10 breaths per minute; regular
 Hyperventilation- increased rate and depth
 Hypoventilation- decreased rate and depth
03 RESPIRATIONS  Cheyne-Strokes- alternate: deep, rapid, then apnea;
regular
 Biot's- varying depths and rate then apnea; irregular
  Refers to the force of blood against the arterial
walls

04  Normal Value- 120/80mmHg

BLOOD
PRESSURE
  Systolic BP

 Diastolic BP

 Pulse Pressure

04 BLOOD  Peripheral Resistance and Compliance

PRESSURE  Neural and Humoral Mechanisms

 Cardiac Output= Stroke Volume x Heart
Rate
 Factors Affecting the Blood Pressure

 Age
 Circadian Rhythm
 Sex
 Food Intake
04 BLOOD  Exercise
 Weight
PRESSURE  Emotional state
 Body position
 Race
 Drugs/Medications
  Hypertension
 Hypotension
 Orthostatic Hypotension

04 BLOOD
PRESSURE
 ASSESSING THE BLOOD PRESSURE

Equipment

 Sphygmomanometer
 Noninvasive BP Monitor
04 BLOOD  Doppler UTZ
 Sthetoscope
PRESSURE
 ASSESSING THE BLOOD PRESSURE

Sites and Methods

 Korotkoff Sounds
 Brachial Artery BP
04 BLOOD  Popliteal Artery- SBP is usually 10-40 mmHg
higher than brachial artery
PRESSURE  Palpating the blood pressure- sensory
detection method
 How to get the MAP?

MAP (Mean Arterial Pressure)

-is the average pressure in a patient's arteries

during one cardiac cycle. it is considered as the
04 BLOOD better indicator of perfusion to vital organs

PRESSURE MAP = SBP+2 (DBP)

3
THANK YOU
 Exercise #1
STUDENT NURSE: ______________________
DATE OF ASSESSMENT: __________________
PATIENT'S NAME: ________________________ AGE______ SEX______

VITAL SIGNS SITE RESULT REMARKS

Indicate if Normal
or Not Normal
TEMPERATURE
PULSE RATE
RESPIRATORY
RATE
BLOOD
PRESSURE