Vital Signs

NRG 203
WEEK 1
VITAL SIGNS
• Body temperature, pulse, respirations, and Blood Pressure
• Monitor functions of the body
-Vital signs are a quick and efficient way of monitoring a patient's condition or identifying
problems and evaluating his or her response to intervention.
-Vital signs and other physiological measurements are the basis for clinical decision
making and problem solving.
-Measurement of vital signs provides data to determine a patient's usual state of health (baseline
data
When to Assess Vital Signs
• On admission
• Change in client’s health status
• Client reports symptoms such as chest pain, feeling hot, or faint
• Pre and post surgery/invasive procedure
• Pre and post medication administration that could affect CV system
• Pre and post nursing intervention that could affect vital signs
Body Temperature
• Reflects the balance between the heat produced and the heat lost
from the body
• Measured by heat units called degrees
Factors Affecting Body Temperature
● Age
• Exercise
• Hormones
• Stress
• Environment
Alterations in Body Temperature
• Pyrexia, Hyperthermia, Fever - body temperature above the

usual range
• Febrile - a client who has a fever
• Afebrile - a client who does not have fever
• Hypothermia - core body temperature below the lower limit
of normal
Pulse
• Is a wave of blood created by contraction of the left ventricle of

the heart
• Represents the amount of blood that enters the arteries with each
ventricular contraction
• Peripheral pulse- a pulse located away from the heart Ex. Foot or
wrist
• Apical pulse- is the central pulse that is located at the apex of the
heart
Factors Affecting Pulse
• Age
• Gender
• Exercise
• Fever
• Medications
• Hypovolemia
• Stress
• Position changes
• Pathology
Factors Affecting Respirations
• Exercise
• Stress
• Environmental temperature
• Medications
Factors Affecting Blood Pressure
• Age
• Exercise
• Stress
• Race
• Gender
• Medications
• Obesity
• Disease process
Temperature: Lifespan Considerations
Unstable Newborns must be kept warm to prevent hypothermia
Tympanic or temporal artery sites preferred
Tends to be lower than that of middle-aged adults

Pulse: Lifespan Considerations
Newborns may have heart murmurs that are not pathological
The apex of the heart is normally located in the fourth
intercostal space in young children; fifth intercostal space
in children 7 years old and older
Often have decreased peripheral circulation

Respirations: Lifespan Considerations
Some newborns display “periodic breathing”
Diaphragmatic breathers
Anatomic and physiologic changes cause
respiratory system to be less efficient

Blood Pressure: Lifespan Considerations
Arm and thigh pressures are equivalent under 1 year of age
Thigh pressure is 10 mm Hg higher than arm
Client’s medication may affect how pressure is taken

Sites for Measuring Body Temperature
• Oral
• Rectal
• Axillary
• Tympanic membrane
• Skin/Temporal artery
Types of Thermometers
• Electronic
• Chemical disposable
• Infrared (tympanic)
• Scanning infrared (temporal artery)
• Temperature-sensitive tape
• Glass mercury
Nursing Care for Fever
• Monitor vital signs
• Assess skin color and temperature
• Monitor laboratory results for signs of dehydration or infection
• Remove excess blankets when the client feels warm
•Provide adequate nutrition and fluid
• Measure intake and output
• Reduce physical activity
• Administer antipyretic as ordered
• Provide oral hygiene
• Provide a tepid sponge bath
• Provide dry clothing and bed linens

Nursing Care for Hypothermia
• Provide warm environment
• Provide dry clothing
• Apply warm blankets
• Keep limbs close to body
• Cover the client’s scalp
• Supply warm oral or intravenous fluids
• Apply warming pads
Pulse Sites
Readily accessible
When radial pulse is not accessible
During cardiac arrest/shock in adults

Determine circulation to the brain
Infants and children up to 3 years of age
Discrepancies with radial pulse
Monitor some medications
Pulse Sites
Blood pressure Cardiac arrest in infants
Cardiac arrest/shock
Circulation to a leg;
Circulation to a leg;
Circulation to lower leg
Circulation to the foot
Circulation to the foot

Characteristics of the Pulse
• Rate tachycardia- over 100 BPM
bradycardia- less than 60 BPM
• Rhythm dysrhytmia or arrhythmia- irregular pulse
• Volume force of blood with each beat absent to bounding
• Arterial wall elasticity •
Bilateral equality
Pulse Rate and Rhythm
Rate Rhythm
– Beats per minute – Equality of beats and intervals

between beats
– Tachycardia
– Dysrhythmias
– Bradycardia
– Arrhythmia
Characteristics of the Pulse
• Volume – Strength or amplitude – Absent to bounding
• Arterial wall elasticity – Expansibility or deformity
• Presence or absence of bilateral equality – Compare corresponding artery

Inhalation
• Diaphragm contracts (flattens)
• Ribs move upward and outward
• Sternum moves outward
• Enlarging the size of the thorax

Exhalation
● Diaphragm relaxes
• Ribs move downward and inward
• Sternum moves inward
• Decreasing the size of the thorax

Respiratory Control Mechanisms
• Respiratory centers
– Medulla oblongata
– Pons
Components of Respiratory Assessment
• Rate
• Depth
• Rhythm
• Quality
• Effectiveness
Respiratory Rate and Depth
• Depth
• Rate
– Normal
– Breaths per minute
– Deep
– Apnea
– Shallow
– absence of breathing
– Bradypnea abnormally slow respirations
– Tachypnea abnormally fast respirations

Components of Respiratory Assessment
• Rhythm • Effectiveness
– Regular
– Uptake and transport of O2
– Irregular
– Transport and elimination of CO2
• Quality
– Effort
– Sounds
Alteratered Breathing Patterns
• Rate • Volume
– Tachypnea -Hyperventilation
– quick, shallow breaths - overexpansion of the lungs
– Bradypnea- abnormally characterized by rapid and deep
shallow breathing breaths
– Apnea- absence or cessation of -Hypoventilation

breathing
- underexpansion of the lungs
characterized by shallow respirations
Alteratered Breathing Patterns
• Rhythm • Ease or Effort
– Cheyne- Stroke breathing – Dyspnea- difficult and labored
- rhythmic waxing and waning of breathing during which the
respirations, from very deep to very individual has a persistent,
shallow breathing and temporary unsatisfied need for air and feels
apnea distressed
– Orthopnea- ability to breathe

only in upright sitting or standing
positions
Alteratered Breath Sounds
• Stridor
– a shrill, harsh sound heard during inspiration with laryngeal obstruction
• Wheeze
- continuous, high pitched musical squeak or whistling sound occuring on expiration

Systolic and Diastolic Blood Pressure
• Systolic – Contraction of the ventricles
• Diastolic – Ventricles are at rest – Lower pressure present at all times
• Pulse Pressure = difference between systolic and diastolic pressures
• Measured in mm Hg
• Recorded as a fraction, e.g. 120/80
• Systolic = 120 and Diastolic = 80

Korotkoff’s Sounds
• Phase 1 – First faint, clear tapping or thumping sounds
– Systolic pressure
• Phase 2 – Muffled, whooshing, or swishing sound
• Phase 3 – Blood flows freely – Crisper and more
intense sound – Thumping quality but softer than in
phase 1
• Phase 4 – Muffled and have a soft, blowing sound
• Phase 5 – Pressure level when the last sound is heard –
Period of silence – Diastolic pressure
Measuring Blood Pressure
• Direct (Invasive Monitoring)
• Indirect – Auscultatory – Palpatory
• Sites – Upper arm (brachial artery) – Thigh (popliteal artery)

Video taking vital signs
https://www.youtube.com/watch?v=gUWJ-6nL5-8&t=100s
Resources • Audio Glossary • HyperHEART Shows the heart pumping and talks about
diastolic and systolic cycles. Has tutorials for atrial systole and others. Very fun site. •
Best Practice--Vital Signs Reviews research studies related to vital signs. Covers all
aspects of vital signs and even gives implications for practice and recommendations. •
The Medical Center--Vital Signs Provides an overview of vital signs. Nicely done.

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NRG 203

• Monitor functions of the body

problems and evaluating his or her response to intervention.

making and problem solving.

• Change in client’s health status

• Client reports symptoms such as chest pain, feeling hot, or faint

• Pre and post surgery/invasive procedure

• Pre and post medication administration that could aﬀect CV system

• Pyrexia, Hyperthermia, Fever - body temperature above the

• Is a wave of blood created by contraction of the left ventricle of

Tympanic or temporal artery sites preferred

Tends to be lower than that of middle-aged adults

The apex of the heart is normally located in the fourth

intercostal space in young children; ﬁfth intercostal space

in children 7 years old and older

Often have decreased peripheral circulation

Anatomic and physiologic changes cause

respiratory system to be less eﬃcient

Thigh pressure is 10 mm Hg higher than arm

Client’s medication may aﬀect how pressure is taken

• Assess skin color and temperature

• Monitor laboratory results for signs of dehydration or infection

• Remove excess blankets when the client feels warm

•Provide adequate nutrition and ﬂuid

• Measure intake and output

• Reduce physical activity

• Administer antipyretic as ordered

• Provide oral hygiene

• Provide a tepid sponge bath

• Provide dry clothing and bed linens

During cardiac arrest/shock in adults

Circulation to lower leg

Circulation to the foot

Circulation to the foot

bradycardia- less than 60 BPM

• Rhythm dysrhytmia or arrhythmia- irregular pulse

• Volume force of blood with each beat absent to bounding

• Arterial wall elasticity •

– Beats per minute – Equality of beats and intervals

• Arterial wall elasticity – Expansibility or deformity

• Presence or absence of bilateral equality – Compare corresponding artery

• Ribs move upward and outward

• Sternum moves outward

• Enlarging the size of the thorax

• Ribs move downward and inward

• Sternum moves inward

• Decreasing the size of the thorax

– Bradypnea abnormally slow respirations

– Tachypnea abnormally fast respirations

– Apnea- absence or cessation of -Hypoventilation

– Orthopnea- ability to breathe

– a shrill, harsh sound heard during inspiration with laryngeal obstruction

- continuous, high pitched musical squeak or whistling sound occuring on expiration

• Diastolic – Ventricles are at rest – Lower pressure present at all times

• Pulse Pressure = diﬀerence between systolic and diastolic pressures

• Recorded as a fraction, e.g. 120/80

• Systolic = 120 and Diastolic = 80

• Direct (Invasive Monitoring)

• Indirect – Auscultatory – Palpatory

• Sites – Upper arm (brachial artery) – Thigh (popliteal artery)