sThese are indices of health, or signposts in

determining client’s condition. This is also

known as cardinal signs and it includes
body temperature, pulse, respirations,
and blood pressure and recently oxygen
saturation. These signs have to be looked at
in total, to monitor the functions of the body.
g client’s condition. This is also known as cardinal
signs and it includes body temperature, pulse,
Temperature
Pulse
Respiration
Blood pressure
Oxygen Saturation
 When to Assess Vital signs
1. Upon admission to any healthcare agency
2. Based on agency institutional policy and
procedures
3. Any time there is a change in the patient’s
condition
3. Before and after surgical or invasive diagnostic
procedures
4. Before and after activity that may increase risk
5. Before administering medications that affect
cardiovascular or respiratory functioning
Body Temperature
the balance between the heat produced by the body
and the heat lost from the body
Types:
Core Temperature – temperature of the deep tissues of
the body measured by taking oral and rectal
temperature (abdominal cavity, pelvic cavity)
Surface Temperature – temperature of the skin,
subcutaneous tissue and fat measured by taking
axillary temperature
Thermoregulatory
center in the
hypothalamus regulates
temperature
Factors affecting Heat Production
Heat is produced through the metabolism of food
(chemically). Food is used as energy by muscles and
glands to generate most of the heat in the body.
During exercise, the muscles become active and the
person feels warm. Increasing muscular tone
(shivering or gooseflesh) produces heat. The process
of digestion also increases body temperature.
When a person becomes angry or excited, the adrenal
glands become very active and the body warms as a
result of the action of certain body chemicals such as
epinephrine.
FACTORS WHICH INFLUENCE NORMAL BODY
TEMPERATURE
Body temperature is usually lowest in the morning and
highest in the late afternoon or evening.
c. Normal temperature for infants and children is usually
higher than the normal adult temperature. At birth, heat-
regulating mechanisms are not fully developed, so a marked
fluctuation in body temperature may occur during the infant's
first year of life.
d. In some women, ovulation may be signaled by a slight
drop in body temperature 12 to 24 hours before a
postovulation rise in temperature of about 0.4ºF to 0.8ºF.
Sources of Heat Loss
Skin (primary source)
Evaporation of sweat
Warming and humidifying
inspired air
Eliminating urine and feces
Processes involved in Heat Loss
1. Radiation is a form of heat loss through infrared rays. This
involves the transfer of heat from one object to another, with
no physical contact involved. For example, the sun transfers
heat to the earth through radiation.
2. Conduction is the process of losing heat through physical
contact with another object or body. For example, if you were
to sit on a metal chair, the heat from your body would transfer
to the cold metal chair.
3. Convection is the process of losing heat through the
movement of air or water molecules across the skin. The use
of a fan to cool off the body is one example of convection.
4. Evaporation is the process of losing heat through the
conversion of water to gas (evaporation of sweat).
Factors affecting
TEMPERATURE
Age
Diurnal variations
Exercise
Hormones
Stress
 •Pyrexia - is fever above the usual range
•Hyperpyrexia – very high fever; hyperthermia

Terminology
Febrile –is the term used for having fever
Afebrile - Without fever, denoting apyrexia; having a normal
body temperature.
Pyrexia - is fever above the usual range
Hyperpyrexia – very high fever; hyperthermia
Hypothermia - the condition of having an abnormally low
body temperature, typically one that is dangerously low.

Crisis - sudden decline of fever which indicates impairment

of function of the hypothalamus
Lysis - gradual decline of fever which indicates that the body
is able to maintain homeostasis
Types of Fever
TEMPERATURE CONVERSION
To change from Fahrenheit to Celsius:
subtract 32 degrees from the Fahrenheit reading
Multiply by 5/9 or divide by 9/5 (1.8)
oC = (oF – 32) x 5/9
To change from Celsius to Fahrenheit
Multiply the Celsius reading by 9/5 or 1.8
Add 32
oF = (9/5 x oC) + 32 or (oC x 1.8) + 32
METHODS of Temperature Taking:
ORAL: most accessible and convenient method
Nursing Considerations:
Allow 15 minutes to elapse between client’s intake
of hot or cold food or smoking and the
measurement of oral temperature
METHODS of Temperature Taking:
ORAL: most accessible and convenient method
Nursing Consideration:
Place the thermometer under the tongue, directed
towards the side and instruct client to gently close
the lips not the teeth around the thermometer
Contraindications to Oral Temperature
Taking:
 oral lesions or oral surgery
 dyspnea
 cough
 nausea and vomiting
 presence of oro-nasal pack, nasogastric tube
 seizure prone
 very young children
 unconscious
 restless, disoriented, confused
Oral Thermometers
METHODS of Temperature Taking:
RECTAL: most accurate measurement of
temperature
Indications:
 When there is respiratory obstruction which prevents closure of the
mouth
 When the mouth is dry, parched and inflamed
 When there is oral/nasal surgery or disease
 For very young, restless and irrational children
 For mentally disturbed, unconscious, dyspneic, irrational, restless and
convulsive patients
 When a patient is mouth breather and with oxygen
METHODS of Temperature Taking:
RECTAL: most accurate measurement of
temperature
Nursing Considerations:
Assist client to assume lateral position/sims
position. To expose anal area
Lubricate thermometer about 1 inch above the
bulb with water soluble jelly before insertion. To
reduce friction and prevent trauma to the mucous
membrane in the anus
METHODS of Temperature Taking:
RECTAL: most accurate measurement of
temperature
Nursing Considerations:
Insert thermometer by 0.5 – 1.5 inches (1.5 – 4 cm) for
adults, 0.9 inch (2.5 cm) for a child and 0.5 inch (1.5 cm) for
an infant or insert beyond the internal anal sphincter
Instruct the client to take a deep breath during the
insertion of the thermometer. To relax the internal anal
sphincter
METHODS of Temperature Taking:
RECTAL: most accurate measurement of
temperature
Nursing Considerations:
Hold the thermometer in place for 2 minutes (for neonates,
5 minutes). To ensure recording of temperature
Do not force the insertion of thermometer. To prevent
trauma in the area
Normal value:
 98.6 o – 100.6 oF (37.0 o – 37.5 oC)
Contraindications to Rectal Temperature Taking

Anal/rectal conditions or surgeries, e.g. anal

fissure, hemorrhoids, hemorrhoidectomy
Diarrhea
Rectal Thermometers
METHODS of Temperature Taking:
AXILLARY: safest and most non-invasive method
Nursing Considerations:
 Pat dry the axilla. Rubbing causes friction and will increase
temperature in the area
 Place the thermometer in the client’s axilla
 Place the arm tightly across the chest to keep the
thermometer in place
Normal value:
 96.6 o – 98.6 oF (35.8 o – 37.0 oC)
Axillary Thermometers
METHODS of Temperature Taking:
Tympanic: readily accessible, reflects the core
temperature, very fast
Nursing Considerations:
 Can be very uncomfortable and involve risks of injuring the
membrane if the probe is inserted too far
 Repeated measurements may vary (right and left ears may
differ)
 Presence of cerumen can affect the reading
Normal value:
 98.2 o – 100.2 oF (36.8 o – 37.9 oC)
METHODS of Temperature Taking:
Tympanic Thermometers
Other Thermometers
 Normal Values

ORAL RECTAL AXILLARY

98.6o F 99.5o F 97.7o F

37.0o C 37.5o C 36.5o C

PULSE
• Wave of blood created by contraction of left
ventricle of the heart
• Regulated by the autonomic nervous system
• Pulse rate = number of contractions over a
peripheral artery in 1 minute
Factors affecting the PULSE rate
Age
Sex/Gender
Exercise
Fever
Medication
Hemorrhage
Stress
Position changes
PULSE sites:
Temporal
Carotid
Apical
Brachial
Radial
Femoral
Popliteal
Dorsalis Pedis
Pedal
PULSE site: TEMPORAL
PULSE site: CAROTID
PULSE site: APICAL
PULSE site: RADIAL/BRACHIAL
PULSE site: RADIAL
PULSE site: FEMORAL
PULSE site: POPLITEAL
PULSE site: POSTERIOR TIBIAL
PULSE sites: PEDAL/DORSALIS PEDIS
ASSESSMENT of the Pulse:
If pulse is regular, count for 30 seconds
and multiply by 2. If irregular, count for 1
minute. When obtaining baseline date,
count for the pulse for a full minute
Assess pulse rhythm by noting the
pattern and intervals of beat. Dysrhytmia
is irregular rhythm
ASSESSMENT of the Pulse:
Asses the pulse volume (amplitude) –
strength of the pulse
Normal pulse ca be felt with moderate
pressure
Full or bounding pulse can be
obliterated only by great pressure
Thready pulse can easily be obliterated
(weak or feeble)
ASSESSMENT of the Pulse:
Arterial wall elasticity: the artery feels
straight, smooth, soft and pliable

Presence/absence of bilateral equality:

absence of bilateral equality indicates
cardiovascular disorder
ASSESSMENT of the Pulse:
Pulse pressure:
Systolic pressure MINUS diastolic pressure
Pulse deficit
Apical pulse MINUS peripheral pulse
Pulsus paradoxus
Systolic pressure falls by more than 15 mmHg during
inhalation
Pulsus alternans
Alternating strong and weak pulses
 ASSESSMENT of the Pulse:
Age Normal Pulse Rate
Newborn to 1 month 80 – 180 beats/min
1 year 80 – 140 beats/min
2 years 80 – 130 beats/min
6 years 75 – 120 beats/min
10 years 60 – 90 beats/min
Adult 60 – 100 beats/min
Tachycardia – pulse rate above 100 beats/min
Bradycardia – pulse rate below 60 beats/min
Respiration
the act of breathing
Pulmonary ventilation — movement of air in and
out of lungs
Inhalation: breathing in
Exhalation: breathing out
Respiration
Two Types of Breathing:
Costal (thoracic)
Diagphragmatic (abdominal)
Respiratory Centers:
Medulla Oblongata – primary center for
respiration

Pons – (1) Pneumotaxic center; responsible

for rhythmic quality of breathing (2)
Factors Affecting Respiratory
Rate:
Exercise
Pain/Stress/Anxiety
Environment
Increased altitude
Medication
Respiratory and cardiovascular disease
Alterations in fluid, electrolyte, and acid balances
Trauma
Infection
Assessment of Respiration:
With fingers still in place, after taking pulse rate,
note the rise and fall of patient’s chest with
respiration. You may place the client’s arm across
the chest and observe chest movement and for
infants, observe the movement of the abdomen,
these observes for depth of respiration
Observe rate. Count for 30 seconds if
respirations are regular and multiply by 2. If
irregular, count for 60 seconds.
Assessment of Respiration:
Observe the respiration (inhalations and
exhalations) for regular or irregular rhythm

Observe the character or quality of

respiration – the sound of breathing and
respiratory effort
Assessment of Respiration:
Normal rate in adult
12 – 20 breaths/minute
Normal rate in infant
20 – 40 breaths/minute
Normal rate in preschool
20 – 30 breaths/minute
 Assessment of Respiration:
Types of Description
Breathing
Eupnea Normal respiration that is quiet, rhythmic and effortless
Tachypnea Rapid respiration, above 20 breaths/min in an adult
Bradypnea Slow breathing, less than 12 breaths/minute in an adult
Hyperventilation Deep rapid respiration, carbon dioxide is excessively exhaled (resp. alkalosis)
Hypoventilation Slow, shallow respiration, carbon dioxide is excessively retained (resp.
acidosis)
Dyspnea Difficult and labored breathing
Orthopnea Ability to breathe only in an upright position
Apnea Absence/cessation of breathing
Biot’s respiration Quick, shallow inspiration followed by regular or irregular periods of apnea
Kussmaul Very deep and labored breathing; acetone breath (metabolic acidosis)
respiration
Apneustic Deep, gasping inspiration with a pause at full inspiration followed by
Physiology of Blood Pressure
Force of the blood against arterial walls
Controlled by a variety of mechanism to maintain
adequate tissue perfusion
Pressure rises as ventricle contracts and falls as
heart relaxes
Highest pressure is systolic
Lowest pressure is diastolic
Physiology of Blood Pressure:
..\Pictures\3DScience_Human_Heart.jpg

systolic pressure – pressure of blood as a

result of contractions of the ventricles (100 –
130 mmHg); systole (contraction of the heart);
numerator in BP reading
diastolic pressure – pressure exerted when

the ventricles are at rest (60 – 90 mmHg);

diastole (relaxation of the heart);
denominator in BP reading
Physiology of Blood Pressure
pulse pressure – difference between the
systolic and diastolic pressures, normal is 30 –
40 mmHg
hypertension is an abnormally high blood

pressure for at least two consecutive readings

hypotension is an abnormally low blood

pressure, systolic pressure below 100/60

mmHg
Determinants of Blood Pressure
Blood volume
Peripheral resistance
Cardiac output
Elasticity or compliance
of blood vessels
Blood viscosity
Factors Affecting Blood Pressure:
Age, gender, race
Circadian rhythm
Food intake
Exercise
Weight
Emotional state
Body position
Drugs/medications
Disease process
Sphygmomanometers
Sphygmomanometers
Parts of the Stethoscope: stethoscopebasics.pdf

30 – 35 cm (12-14 inches) long

0.3 cm (1/8 inch) internal diameter
Stethoscope
 ASSESSING Blood Pressure:
Ensure that the client is rested
Allow 30 minutes to pass if the
client had engaged in exercise or
had smoked or ingested caffeine
before taking the BP (might tend to
increase BP)
Use appropriate size of the BP cuff.
Too narrow cuff causes high false
reading and too wide cuff causes
false low reading.
Position the client in sitting or
 ASSESSING Blood Pressure:
Position the arm at the level of the
heart, with the palm of the hand
facing up. The left arm is preferably
used because it is nearer the heart
Apply/wrap the deflated cuff
snugly in upper arm, the center of
the bladder directly over the
medial aspect or 1 inch above the
antecubital space or at least 2 – 3
fingers above the elbow
 ASSESSING Blood Pressure:
Determine palpatory BP before
auscultatory BP to prevent
auscultatory gap
Use the bell of the stethoscope
since the BP is a low frequency
sound
Inflate and deflate BP cuff
slowly, 2 -3 mmHg at a time
Wait 1 -2 minutes before
making further determinations
 ASSESSING Blood Pressure:
Palpate the brachial artery
with your fingertips
Close the valve on hand
pump by turning the knob
clockwise
Insert the ear attachment of
the stethoscope in your ears
so they tilt slightly forward
an ensure it hangs freely from
the ear to the diaphragm
 ASSESSING Blood Pressure:
Place the diaphragm of stethoscope
over brachial pulse and hold with
the thumb and index finger
Pump out the cuff until the
sphygmomanometer registers about
30 mmHg above the point where the
brachial pulse disappeared
Release the valve on the cuff
carefully so that the pressure
decreases at the rate of 2 – 3 mmHg
per second
 ASSESSING Blood Pressure:
As the pressure falls, note
the first sound, muffling,
and last sound heard

Deflate the cuff rapidly

and completely after
noting the last sound
 ASSESSING Blood Pressure:
Read lower meniscus of the
mercury level of the
sphygmomanometer at eye
level to prevent error of parallax
Error of parallax happens if
the eye level is higher than
the lever of the lower
meniscus of the mercury,
this causes false low reading,
if the eye level is lower, this
causes false high reading
DIGITAL SPHYGMOMANOMETER
 Oxygen Saturation

Over the past decade,

Oxygen Saturation
measurement of gas
exchange and red
blood cell oxygen
carrying capacity has
become available in all
hospitals and many
clinics.
 Oxygen Saturation
Oxygen Saturation
provides important
information about
cardio-pulmonary
dysfunction and is
considered by many to
be a fifth vital sign.
Oxygen Saturation
Oxygen Saturation
For those suffering
from either acute or
chronic cardio-
pulmonary disorders,
Oxygen Saturation
can help quantify the
degree of impairment.
Pulse oximetry is a noninvasive monitoring
technique used to estimate the measurement
of arterial oxygen saturation (Sao2) of
hemoglobin.

Oxygen saturation is an indicator of the

percentage of hemoglobin saturated with
oxygen at the time of the measurement .
Pulse Oximetry
Introduced in early
1980s.
Non-invasive
measurement of
oxygen saturation.
Safe
Inexpensive
What Does it Mean?
SpO2 READING (%) INTERPRETATION

95 – 100 Normal

91 – 94 Mild Hypoxemia

86 – 90 Moderate Hypoxemia

< 85 Severe Hypoxemia

Interventions
SpO2 INTERPRETATION INTERVENTION
READING
(%)
95 – 100 Normal Change FiO2 to maintain saturation.

91 – 94 Mild Hypoxemia Increase FiO2 to increase saturation.

86 – 90 Moderate Increase FiO2 to increase saturation.

Hypoxemia Assess and increase ventilation.
< 85 Severe Hypoxemia Increase FiO2 to increase saturation.
Increase ventilation.
PaO2/FiO2 ratio.
The ratio of partial
pressure arterial oxygen
and fraction of inspired
oxygen, sometimes
called the Carrico index,
is a comparison between
the oxygen level in the
blood and the oxygen
concentration that is
breathed.