VITAL SIGNS

OBJECTIVES
At the completion of this unit learners will be able to:
• Define Vital Signs.
• Define terms related to Vital sign.
• Describe the physiological concept of temperature, respiration and blood pressure.
• Describe the principles and mechanisms for normal thermoregulation in the body.
• Identify ways that affect heat production and heat loss in the body.
• Define types of body temperature according to its characteristics.
• Identify the sign and symptoms of fever.
• Discuss the normal ranges for temperature, pulse, respiration and blood pressure.
• List the factors affecting temperature, pulse, respiration.
• Describe the characteristics of pulse and respiration.
• List factors responsible for maintaining normal blood pressure.
• Describe various methods and sites used to measure T.P & B.P.
• Recognize the signs of alert while taking TPR and B.P.
 VITAL SIGNS
• Vital or cardinal signs reflects changes in body functions that otherwise might not be
observed (TPR)
1. Body temperature
2. Pulse
3. Respirations
4. Blood pressure
5. Pain
• Monitor functions of the body
• Should be a thoughtful, scientific assessment
 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
 BODY TEMPERATURE
• Body temperature reflects the balance between the heat produced and the heat lost
from the body.
• Measured in heat units degrees.
Normal body temperature,measured orally, of an adult is
between 36.7C (98F) to 37C (98.6F)
 TWO TYPES OF BODY
TEMPERATURE
• Core temperature
Is the temperature of deep tissues of the body such as cranium, thorax, abdominal
cavity and pelvic cavity. Remains constant.
• Surface temperature
Is the temperature of the skin, the subcutaneous tissue and fat. It changes in
response to environment.
 FACTORS AFFECTING HEAT
PRODUCTION
• Basal metabolic rate (BMR)
• Muscle activity
• Thyroxine output
• Fever
• Sympathetic stimulation (Epinephrine, norepinephrine)
 PROCESSES INVOLVED IN HEAT
LOSS
• Radiation
transfer of heat loss from the surface of one object to the surface of another
without contact between two objects
• Convection
dissipation of heat by air currents
• Conduction
transfer of heat from one surface to another, which requires temperature difference
between two surfaces
• Evaporation
continuous vaporization of moisture from the skin, oral mucous, respiratory tract;
This continuous and unnoticed water loss is called insensible water loss, and the
accompanying heat loss is called insensible heat loss.
 REGULATION OF BODY
TEMPERATURE
The system that regulates body temperature has three main parts:

• sensors in the periphery(shell) and in the core,

• an integrator in the hypothalamus, and
• an effector system that adjusts the production and loss of heat.
 FACTORS AFFECTING
BODY TEMPERATURE
• Age
• Diurnal variations
(circadian rhythms)
• Exercise
• Hormones
• Stress
• Environment
 ALTERATIONS IN BODY
TEMPERATURE
The normal range for adults is considered to be between 36°C and 37.5°C (96.8°F to
99.5°F).

There are two primary alterations in body temperature:

• Pyrexia/Hyperthermia
• Hypothermia.
 PYREXIA
Pyrexia
A body temperature above the usual range is called pyrexia,
hyperthermia, or (in lay terms) fever. A very high fever, such as
41°C (105.8°F), is called hyperpyrexia.

The client who has a fever is referred to as febrile; the one who
does not is afebrile.
 TYPES OF FEVER (PYREXIA):
• Intermittent: temperature fluctuates between periods of fever and periods of
normal/subnormal temperature

• Remittent: temperature fluctuates within a wide range over the 24 hour period but
remains above normal range

• Relapsing: temperature is elevated for few days, alternated with 1 or 2 days of normal
temperature

• Constant: body temperature is consistently high

A temperature that rises to fever level rapidly following a normal temperature and then returns to
normal within a few hours is called a fever spike.
 ALTERATIONS IN BODY TEMPERATURE

In some conditions, an elevated temperature is not a true fever.

• Heat exhaustion: is a result of excessive heat and dehydration and a moderately
increased temperature (38.3°C to 38.9°C [101°F to 102°F]).

• Heat stroke: generally have been exercising in hot weather, have warm, flushed skin, and
often do not sweat. They usually have a temperature of 41.1°C (106°F)
 CLINICAL MANIFESTATION OF FEVER

ONSET (COLD OR CHILL PHASE)

■ Increased heart rate
■ Increased respiratory rate and depth
■ Shivering
■ Pallid, cold skin
■ Complaints of feeling cold
■ Cyanotic nail beds
■ “Gooseflesh” appearance of the skin
■ Cessation of sweating
COURSE (PLATEAU PHASE)
■ Absence of chills
■ Skin that feels warm
■ Photosensitivity
■ Glassy-eyed appearance
■ Increased pulse and respiratory rates
■ Increased thirst
■ Mild to severe dehydration
■ Drowsiness, restlessness, delirium, or convulsions
■ Herpetic lesions of the mouth
■ Loss of appetite (if the fever is prolonged)
■ Malaise, weakness, and aching muscles
DEFERVESCENCE (FEVER ABATEMENT/FLUSH PHASE)
■ Skin that appears flushed and feels warm
■ Sweating
■ Decreased shivering
■ Possible dehydration
 NURSING CARE FOR FEVER
• Monitor vital signs.
• Assess skin color and temperature.
• Monitor white blood cell count, hematocrit value, and
• other laboratory reports
• Remove excess blankets when the client feels warm, but provide extra warmth
when the client feels chilled.
• Provide adequate nutrition and fluids (e.g., 2,500–3,000 mL per day).
• Measure intake and output.
• Reduce physical activity
• Administer antipyretics (drugs that reduce the level of fever) as advised.
• Provide oral hygiene to keep the mucous membranes moist.
• Provide a tepid sponge bath
• Provide dry clothing and bed linens.
 HYPOTHERMIA
• Hypothermia is the core body temperature below the lower limit of normal.
• Three physiologic mechanisms are:
1. Excessive heat loss
2. Inadequate heat production
3. Impaired hypothalamic thermoregulation
 CLINICLAL SIGNS OF
HYPOTHERMIA
 Decreased body temperature, pulse and respiration
 Severe shivering initially
 Feeling of cold and chills
 Pale, cool and waxy skin
 Hypotension
 Decreased urinary output
 Lack of muscle coordination
 Disorientation
 Drowsiness progressing to coma
 TYPES OF HYPOTHERMIA
• Accidental hypothermia
1. Exposure to cold environmemt
2. Immersion in cold water
3. Lack of adequate clothing or heat
• Induced hypothermia
Deliberate lowering of the temperature to decrease the need for oxygen by the body
tissues.
 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
 ASSESSING BODY TEMPERATURE
The most common sites for measuring body
temperature are
• 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
 MERCURY-IN- GLASS
THERMOMETER
• Traditionally used thermometers, having long, slender tips or short rounded
tips.
• Glass thermometers can be hazardous due to exposure to mercury, which is
toxic to humans, and broken
glass should the thermometer crack
or break.
 ELECTRONIC THERMOMETER
• The electronic thermometer consists of a rechargeable battery-powered display unit, a thin
wire cord, and a temperature-processing probe covered by a disposable probe cover
 CHEMICAL DISPOSABLE
THERMOMETERS
• Single-use or reusable chemical dot thermometers are thin strips of plastic with a
temperature sensor at one end. The sensor consists of a matrix of chemically impregnated
dots that change color at different
temperatures
 TEMPERATURE-SENSITIVE TAPE
Temperature-sensitive tape may also be used to obtain a general indication of body
surface temperature.
It does not indicate the core temperature. The tape contains liquid crystals that change
color according to temperature
 INFRARED THERMOMETERS
• Infrared thermometers sense body heat in the form of infrared energy given off by a
heat source, which, in the ear canal, is primarily the tympanic membrane
 TEMPORAL ARTERY
THERMOMETERS
• Temporal artery thermometers determine temperature using a scanning infrared
thermometer that compares arterial temperature in the temporal artery of the forehead to
the temperature in the room and calculates the heat balance to approximate the core
temperature of the blood in the pulmonary artery.
 TEMPERATURE CONVERSION

✔To change from Fahrenheit to Celsius:

• Subtract 32 degrees from the Fahrenheit reading
• Multiply by 5/9
• 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
 SPECIAL NURSING INTERVENTIONS
• Remove thermometer from its container and check the temperature reading.

• Shake down the mercury as necessary (until mercury is below 35 C) by holding the
thermometer between the thumb and forefinger at the end farthest from the bulb.

• Snap the wrist downward.

• Wash/wipe the thermometer in a rotating manner before use, from the bulb to the stem,
after use, from the stem to the bulb. This practice ensures medical asepsis
• Hold the thermometer at eye level, and rotate it until the mercury column is
visible

• Rinse the thermometer in tap water, dry it, shake it down and return to its
container
 PROCEDURE FOR MEASURING BODY
TEMPERATURE
1. Prepare the client.
2. Prepare the equipment ( remove the packaging, check temperature reading.)
3. Shake down the mercury by holding the thermometer.
4. Take the temperature
• For oral temperature place the thermometer or probe at base of the tongue. Ask the
client to close the lips, not the teeth. Place the thermometer for 2-3 secs.
• For rectal temperature place some lubricant on thermometer. Insert the thermometer
into anus. Hold thermometer for 3 mins.
• For axillary temperature place the thermometer in the center of the axilla. Assist the
client to place the arm tightly across the chest to keep the thermometer in place.
Leave thermometer in place for 9 mins according to agency.
5. Remove the thermometer. Wipe the thermometer in a rotating manner towards the
bulb.
6. Read the temperature.
7. Clean and shake down the thermometer.
8. Document the reading.
PULSE
 PULSE
wave of blood created by contraction of left ventricle of the heart

Pulse rate = number of contractions over a peripheral artery in 1 minute

The pulse wave represents the
Stroke Volume Output: the amount of blood that enters the arteries with each
ventricular contraction.
• Compliance Of The Arteries: is their ability to contract and expand.
• Cardiac Output: is the volume of blood pumped into the arteries by the heart and equals
the result of the stroke volume (SV) times the heart rate (HR) per minute.
CO=SV*HR
• 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.
It is also referred to as the point of maximal impulse (PMI)
 FACTORS AFFECTING THE PULSE
RATE
• Age
• Sex/Gender
• Exercise
• Fever
• Medication
• Hypovolemia/dehydration
• Stress
• Position changes
• Pathology
 PULSE SITES
• Temporal
• Carotid
• Apical
• Brachial
• Radial
• Femoral
• Popliteal
• Posterior tibial
• Dorsalis Pedis
 TEMPORAL
Slightly anterior to the external auditory meatus
 CAROTID
Lateral to the thyroid cartilage
 BRACHIAL
Medial o the bicep tendon
 RADIAL
Just lateral to the flexor carpi
radialis tendon
 APICAL
left side of the chest, about 8 cm (3 in.) to the left of the sternum (breastbone)
at the fifth intercostal space (area between the ribs).
 POPLITEAL
Inferior portion of the popliteal fossa
 DORSALIS PEDIS
Just lateral to extensor hallicus longus tendon
 ASSESSING THE PULSE
 A pulse is commonly assessed by palpation or auscultation.

 3 middle fingers are used for palpating all pulse site, except for apical pulse.

 Stethoscope is used in assessing apical pulse and fetal heart tones.

 Doppler ultrasound is used for pulses that is to difficult to assess.

 ASSESSING THE PULSE
7. When assessing the pulse, there is a need to take note of the following
1. rate
2. rhythm
3. volume
4. arterial wall elasticity
5. presence or absence of bilateral equality.
 PULSE CHARACTERISTICS
• Rate: number of beats
• Rhythm: pattern of beats
• Volume: force of beats
• Arterial wall elasticity
• Bilateral equality
 CHARACTERISTICS OF THE PULSE
Rate
• tachycardia- over 100 BPM
• bradycardia- less than 60 BPM

Rhythm
• Equality of beats and intervals between beats
• dysrhythmia or arrhythmia- irregular pulse
Arterial wall elasticity
• Expansibility or deformity

Presence or absence of bilateral equality

• Compare corresponding artery

Volume
is the pulse strength or the amplitude, refers to the force of blood with each beat. E.g.
bounding/full; weak/feeble/thready pulse
 PULSE ASSESSMENT

Pulse pressure:

Systolic pressure MINUS diastolic pressure

Pulse deficit

Apical pulse MINUS peripheral pulse

Respiration
 RESPIRATION
• the act of breathing

• carbon dioxide is the primary chemical stimulus of breathing; when carbon dioxide level in
the blood is high, there is stimulation for breathing

• Inhalation: breathing in
• Exhalation: breathing out
Three processes
• Ventilation: movement of gases in and out of the lungs
• Diffusion: exchange of gases from an area of higher pressure to an area of lower
pressure and occurs in the alveolo-capillary membrane
• Perfusion: the availability and movement of blood for transport of gases, nutrients and
metabolic waste products
 TYPES OF BREATHING
Costal breathing
• Involves the external intercostal muscles and other accessory muscles, such as the
sternocleidomastoid muscles.
• Movement of the chest upward and outward.
Diaphragmatic breathing
• Involves the contraction and relaxation of the diaphragm,
• the movement of the abdomen, which occurs as a result of the diaphragm’s contraction
and downward movement.
 MECHANICS AND REGULATION OF
BREATHING
During Inhalation:
• The diaphragm contracts (flattens),
• The ribs move upward and outward,
• The sternum moves outward,
• Enlarging the thorax and
• Permitting the lungs to expand.
During exhalation
• The diaphragm relaxes,
• The ribs move downward and inward,
• The sternum moves inward,
• Decreasing the size of the thorax

Normal adult inspiration lasts 1 to 1.5 seconds,

and an expiration lasts 2 to 3 seconds.
 MECHANICS AND REGULATION OF
BREATHING
• Respiratory centers
• Medulla oblongata
• Pons
• Chemoreceptors
• Medulla
• Carotid and aortic bodies
• Both respond to O2, CO2, H+ in arterial blood
Respiratory Centers:
• Medulla Oblongata –
primary center for respiration
• Pons –
(1) Pneumotaxic center; responsible for rhythmic quality of breathing
(2) Apneustic center; responsible for deep, prolonged inspiration
• Carotid and aortic bodies –
contain peripheral chemoreceptors, which take up the work of breathing when central
chemoreceptors in the medulla are damaged, oxygen level concentration is low and
respond to pressure.
• Muscle and joints contain proprioreceptors, e.g. exercise
 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
 SPECIAL INTERVENTIONS
Before assessing a client’s respirations, a nurse
should be aware of the following:
■ client’s normal breathing pattern
■ client’s health problems on respirations
■ medications or therapies that might affect respirations
■ relationship of the client’s respirations to cardiovascular function.
 ASSESSING RESPIRATION
Rate: regulated by blood levels of O2, CO2 and ph
• Chemical receptors detect changes and signal CNS (medulla)
• Normal: 12-20 breaths per minute
• Apnea: no breathing
• Bradypnea: abnormally slow
• Tachypnea: abnormally fast
• Observe for one full minute
Depth
• Normal: diaphragm moves ½ inch
• Deep
• Shallow

Hyperventilation
• refers to very deep, rapid respirations;
Hypoventilation
• to very shallow respirations.
Rhythm
• refers to the regularity of the expirations and the inspirations.
• Respirations are evenly spaced.
• Assessment of the pattern
• Abnormal: Cheyne stokes, Kussmaul,

Quality Or Character:

• Work of breathing
• Dypsnea: labored breathing
• Orthopnea: inability to breath when horizontal
• Observe for retractions, nasal flaring and restlessness
 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 the respiration (inhalations and exhalations) for regular or irregular rhythm
• Observe the character or quality of respiration – the sound of breathing and respiratory
effort
 ARTERIAL BLOOD PRESSURE

“Arterial blood pressure is a measure of the pressure exerted by the blood as it flows
through the arteries” There are two blood pressure measures.
The systolic pressure is the pressure of the blood as a result of contraction of the
ventricles, that is, the pressure of the height of the blood wave.

The diastolic pressure is the pressure when the ventricles are at rest. Diastolic pressure,
then, is the lower pressure, present at all times within the arteries.

The difference between the diastolic and the systolic pressures is called the pulse pressure.
• A normal pulse pressure is about 40 mmHg but can be as high as 100 mmHg during
exercise.
• Mean arterial pressure (MAP) is the average arterial
pressure throughout one cardiac cycle

• The MAP can be calculated in several different ways, one of which is to add
two-thirds of the diastolic pressure to one-third of the systolic pressure. A
normal MAP is 70 to 110 mmHg.
 DETERMINANTS OF BLOOD
PRESSURE
• Pumping Action of the Heart
• Peripheral Vascular Resistance
• Blood Volume
• Blood Viscosity
 PUMPING ACTION OF THE HEART
• When the pumping action of the heart is weak, less blood is pumped into
arteries (lower cardiac output), and the blood pressure decreases. When the
heart’s pumping action is strong and the volume of blood pumped into the
circulation increases (higher cardiac output), the blood pressure increases.
 PERIPHERAL VASCULAR
RESISTANCE
• Some factors that create resistance in the arterial system are the capacity of
the arterioles and capillaries, the compliance of the arteries, and the
viscosity of the blood.
 BLOOD VOLUME
• When the blood volume decreases (for example, as a result of a hemorrhage
or dehydration), the blood pressure decreases because of decreased fluid in
the arteries.
• Conversely, when the volume increases (for example, as a result of a rapid
intravenous infusion), the blood pressure increases because of the greater
fluid volume within the circulatory system.
 BLOOD VISCOSITY
• Blood pressure is higher when the blood is highly viscous (thick), that is,
when the proportion of red blood cells to the blood plasma is high.

The proportion of RBCs to the blood plasma is referred to as the hematocrit.

• The viscosity increases markedly when the hematocrit is more than 60% to
65%.
 FACTORS AFFECTING BLOOD
PRESSURE
• Age
• Exercise
• Stress
• Race
• Gender
• Medications
• Obesity
• Diurnal Variations
• Medical Conditions
• Temperature
STETHOSCOPE
SPHYGMOMANOMETERS
 HYPERTENSION
A blood pressure that is persistently above normal is called hypertension.

A single elevated blood pressure reading indicates the need for reassessment.

Hypertension cannot be diagnosed unless an elevated blood pressure is found

when measured twice at different times.
• A blood pressure that is persistently above normal is called hypertension.

• A single elevated blood pressure reading indicates the need for reassessment.
Hypertension cannot be diagnosed unless an elevated blood pressure is found when
measured twice at different times.
• It is usually asymptomatic and is often a contributing factor to myocardial infarctions
(heart attacks).
 An elevated blood pressure of unknown cause is called primary hypertension.

 An elevated blood pressure of known cause is called secondary hypertension.

• Individuals with diastolic blood pressures of 80 to 89 mmHg or systolic blood pressures of
120 to 139 mmHg should be considered prehypertensive and, without intervention, may
develop cardiac disease.

• Hypertension is when either the systolic BP is higher than 140 mmHg or when the diastolic
blood pressure (BP) is 90 mmHg or higher.

• The stage of hypertension is determined by the higher of the two values. For example, if
either of the systolic or diastolic values falls in the stage 2 range, stage 2 hypertension is
assigned (>160 or >100).
 HYPOTENSION
Hypotension is a blood pressure that is below normal, that is, a systolic reading consistently
between 85 and 110 mmHg in an adult whose normal pressure is higher than this.

Orthostatic hypotension is a blood pressure that decreases when the client sits or stands. It is
usually the result of peripheral vasodilation in which
blood leaves the central body organs, especially the brain, and moves to the periphery, often
causing the person to feel faint.
When assessing for orthostatic hypotension:
• Place the client in a supine position for 10 minutes.
• Record the client’s blood pressure.
• Assist the client to slowly sit or stand.
• Support the client in case of faintness.
• Immediately recheck the blood pressure in the same sites as previously.
• Repeat the pulse and blood pressure after 3 minutes.
• Record the results. A drop in blood pressure of 20 mmHg systolic or 10
mmHg diastolic indicates orthostatic hypotension
• 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 supine position
• 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/warp 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
• 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
• 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
• 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
• As the pressure falls, note the first sound, muffling, and last sound heard
• Deflate the cuff rapidly and completely after noting the last sound
• 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 level of the
lower meniscus of the mercury, this causes false low reading, if the eye
level is lower, this causes false high reading
 KOROTKOFF’S SOUNDS
Phase 1: The pressure level at which the first faint, clear tapping or thumping sounds
are heard. These sounds gradually become more intense.

Phase 2: The period during deflation when the sounds have a muffled, whooshing, or
swishing quality.

Phase 3: The period during which the blood flows freely through an increasingly open
artery and the sounds become crisper and more intense and again assume a thumping
quality but softer than in phase 1.

Phase 4: The time when the sounds become muffled and have a soft, blowing quality.

Phase 5: The pressure level when the last sound is heard. This is followed by a period
of silence.