ELIEZER V.

GELLIDO
‘EZER’
C H A P T E R 29:
VITAL SIGNS

Eliezer V. Gellido
 VITAL SIGNS
Indicators of health status,
these measures indicate the
effectiveness of circulatory,
respiratory, neural, and
endocrine body functions.
 VITAL SIGNS
•Temperature,
•Pulse,
•Blood Pressure (BP),
•Respiratory rate, and oxygen
saturation.
•Pain
 Measurement of vital
signs provides data to
determine a patient’s usual
state of health.
 FACTORS AFFECTING
VITAL SIGNS
The temperature of the
environment, the patient’s physical
exertion, and the effects of illness
cause vital signs to change,
sometimes outside an acceptable
range.
 An alteration in vital
signs signals a change in
physiological function
and the need for
medical or nursing
intervention.
 When you learn the
physiological variables influencing
vital signs and recognize the
relationship of their changes to
other physical assessment findings,
you can make precise
determinations about a patient’s
health problems.
 Vital signs and other
physiological measurements
are the basis for clinical
decision making and
problem solving.
 WHEN TO MEASURE VITAL
SIGNS
• On admission to a health care facility
• When assessing a patient during home
care visits
• In a hospital on a routine schedule
according to the health care provider’s
order or hospital standards of practice
 WHEN TO MEASURE VITAL
SIGNS
•Before and after a surgical
procedure or invasive diagnostic
procedure
•Before, during, and after a
transfusion of blood products
 WHEN TO MEASURE VITAL
SIGNS
• Before, during, and after the administration of
medication or therapies that
affect cardiovascular, respiratory, or
temperature-control functions
• When a patient’s general physical condition
changes (e.g., loss of consciousness or
increased intensity of pain).
 WHEN TO MEASURE VITAL
SIGNS
• Before and after nursing interventions
influencing a vital sign (e.g., before a patient
previously on bed rest ambulates or before a
patient performsrange-of-motion exercises)
• When a patient reports nonspecific symptoms
of physical distress (e.g.,
feeling “funny” or “different”)
 GUIDELINES FOR
MEASURING VITAL SIGNS
Vital signs need to measure them
correctly, and at times you appropriately
delegate their measurement. You also
need to know expected values , interpret
your patient’s values, communicate
ffindings appropriately, and begin
interventions as needed.
 ACCEPTABLE RANGES
FOR ADULTS
Temperature Range: 36° to Respirations
38° C (96.8° to 100.4° F) 12 to 20 breaths/min
Average oral/tympanic: 37° C
(98.6° F)
Average rectal: 37.5° C (99.5°
F)
Average axillary: 36.5° C (97.7°
F)
Pulse Blood Pressure
60 to 100 beats/min Average: <120/<80 mm Hg
Pulse pressure: 30 to 50 mm Hg
 GUIDELINES FOR MEASURING VITAL
SIGNS
• The nurse caring for the patient is responsible for
measurement of vital signs.
• Ensure that equipment is functional and appropriate
for the size and age of
the patient.
• Determine the patient’s medical history, therapies,
and prescribed medications. Some illnesses or
treatments cause predictable changes in vital signs.
Some medications affect one or more vital signs.
 GUIDELINES FOR MEASURING VITAL
SIGNS
• Use an organized, systematic approach when
taking vital signs. Each procedure requires a
step-by-step approach to ensure accuracy.

• Based on the patient’s condition, collaborate

with healthcare providers to decide the
frequency of vital sign assessment.
 GUIDELINES FOR MEASURING VITAL
SIGNS
• Use vital sign measurements to determine
indications for medication administration.

• Analyze the results of vital sign measurement. Vital

signs are not interpreted in isolation. You need to
also know related physical signs or symptoms and
be aware of the patient’s ongoing health status.
 GUIDELINES FOR MEASURING VITAL
SIGNS
• Communicate significant changes in vital signs
to the patient’s health care provider or the
charge nurse. Document findings and
compare with baseline measurements to
identify significant changes. When vital signs
appear abnormal, have another nurse or
health care provider repeat the measurement
to verify readings.
 GUIDELINES FOR MEASURING VITAL
SIGNS
• Instruct the patient or family
caregiver in vital sign
assessment and the
significance of findings.
 BODY TEMPERATURE
Body temperature is the
difference between the amount of
heat produced by body processes
and the amount of heat lost to the
external environment.
 BODY TEMPERATURE

The acceptable temperature

of humans ranges from 36° to
38° C (96.8° to 100.4° F). Bodily
tissues and cells function best
within the relatively narrow
temperature range.
 BODY TEMPERATURE

For healthy young adults the

average oral temperature
is 37° C (98.6° F).
 BODY TEMPERATURE

• In addition, the temperature

value obtained often differs,
depending on the
measurement site.
 BODY TEMPERATURE

Thermoregulation, physiological
and behavioral mechanisms regulate
the balance between heat lost and
heat produced.
 BODY TEMPERATURE

The hypothalamus senses minor

changes in body temperature. The
anterior hypothalamus controls
heat loss, and the posterior
hypothalamus controls heat
production.
 HEAT PRODUCTION.

Heat produced by the body

is a by-product of metabolism,
which is the chemical reaction
in all body cells.
A number of factors affect
the body’s heat
production. The most
important are these five:
1. Basal metabolic rate.
2. Muscle activity
3. Thyroxine output.
4. Epinephrine, norepinephrine, and
sympathetic stimulation/ stress
response.
5. Fever.
 HEAT LOSS.
Heat loss and heat production
occur simultaneously. Skin structure
and exposure to the environment result
in constant, normal heat loss through
radiation, conduction, convection, and
evaporation.
 RADIATION
Radiation is the transfer of
heat from the surface of one
object to the surface of another
without direct contact between
the two.
 CONDUCTION
Conduction is the transfer of heat
from one object to another with direct
contact. Solids, liquids, and gases
conduct heat through contact. When
the warm skin touches a cooler object,
heat is lost.
 CONVECTION
Convection is the transfer of heat
away by air movement. A fan
promotes heat loss through
convection. Convective heat loss
increases when moistened skin comes
into contact with slightly moving air.
 EVAPORATION
Evaporation is the transfer of
heat energy when a liquid
ischanged to a gas.
 FACTORS AFFECTING BODY
TEMPERATURE
Nurses should be aware of the
factors that can affect a client’s body
temperature so that they can
recognize normal temperature
variations and understand the
significance of body temperature
measurements that deviate from
normal.
 FACTORS AFFECTING BODY
TEMPERATURE
• 1. AGE
• 2. Exercise.
• 3. Hormone Level.
• 4. Circadian Rhythm.
• 5. Stress.
• 6. Environment.
 TEMPERATURE ALTERATIONS .
Fever, or pyrexia, occurs because
heat-loss mechanisms are unable to
keep pace with excessive heat
production, resulting in an abnormal
rise in body temperature.
 In addition to physical signs and
symptoms of infection, fever
determination is based on several
temperature readings at different times
of the day compared with the usual
value for that person at that time.
 Pyrogens such as bacteria
and viruses elevate body
temperature. Pyrogens act as
antigens, triggering immune
system responses.
Febrile- presence of fever

Afebrile- absence of fever

 The term fever of
unknown origin (FUO) refers
to a fever with an
undetermined cause.
 Malignant hyperthermia, is a
hereditary condition of uncontrolled
heat production that occurs when
susceptible people receive certain
anesthetic drugs.
 Hypothermia. Heat loss
during prolonged exposure to
cold overwhelms the ability of
the body to produce heat.
1. To convert Fahrenheit to Celsius, subtract
32 from the Fahrenheit reading and
multiply the result by 5/9.
C = (F − 32) × 5/9

2. To convert Celsius to Fahrenheit, multiply

the Celsius reading by 9/5 and add 32 to
the product.
F = (9/5 × °C) + 32
 PULSE
The pulse is the palpable
bounding of blood flow noted at
various points on the body. Blood
flows through the body in a
continuous circuit. The pulse is an
indicator of circulatory status.
 PULSE SITES
Temporal - Over temporal bone of
head, above and lateral to eye
Carotid - Along medial edge of
sternocleidomastoid muscle in
neck
 PULSE SITES
Apical - Fourth to fifth intercostal
space at left midclavicular line
Brachial - Groove between biceps
and triceps muscles at antecubital
fossa
 PULSE SITES
Radial - Radial or thumb side of
forearm at wrist
Ulnar - Ulnar side of forearm at
wrist
 PULSE SITES
Femoral - Below inguinal ligament,
midway between symphysis pubis and
anterior superior iliac spine, when other
pulses are not palpable; used to assess
status of circulation to leg
Popliteal - Behind knee in popliteal
fossa
 PULSE SITES
Posterior - tibial Inner side of
ankle, below medial malleolus
Dorsalis pedis - Along top of
foot, between extension
tendons of great and first toe
 FACTORS INFLUENCING PULSE RATE
1. Exercise
2. Temperature
3. Emotions
4. Drugs
5. Hemorrhage
6. Postural changes
7. Pulmonary conditions
 ASSESSMENT OF PULSE
You can assess any artery for pulse rate,
but you typically use the radial artery because
it is easy to palpate. When a patient’s condition
suddenly worsens, the carotid site is
recommended for quickly finding a pulse. The
heart continues delivering blood through the
carotid artery to the brain as long as possible.
 When cardiac output
declines significantly,
peripheral pulses weaken and
are difficult to palpate
 The apical pulse
provides a more accurate
assessment of heart
function.
•Use of a Stethoscope. Assessing the
apical rate requires a stethoscope.
 EARPIECE

Binaurals

tubings

Chest
Bell
piece
diaphragm
 ACCEPTABLE RANGES OF
HEART RATE
AGE BEATS PER MINUTE
Infant 120-160
Toddler 90-140
Preschooler 80-110
School-age child 75-100
Adolescent 60-90
Adult 60-100
 CHARACTER OF THE PULSE
Assessment of the radial pulse
includes measuring the rate,
rhythm, strength, and equality.
When auscultating an apical
pulse, assess rate and rhythm
only.
 RATE.
Some practitioners prefer to make
baseline measurements of the pulse
rate as a patient assumes a sitting,
standing, and lying position. The HR
temporarily increases when a person
changes from a lying to a sitting or
standing position.
 When assessing the pulse,
consider the variety of factors
influencing the pulse rate. A single
factor or a combination of these
factors often causes significant
changes. If you detect an
abnormal rate while palpating a
peripheral pulse, the next step is to
assess the apical rate.
 Assess the apical rate by listening to
heart sounds. Identify the first and second
heart sounds (S1 and S2). At normal slow
rates S1 is low pitched and dull, sounding
like a “lub.” S2 is higher pitched and
shorter, creating the sound “dub.” Count
each set of “lub-dub” as one heartbeat.
Using the diaphragm or bell of the
stethoscope, count the number of lub-
dubs occurring in 1 minute.
TWO COMMON ABNORMALITIES
IN PULSE RATE ARE
Tachycardia is an abnormally
elevated HR above 100 beats/min
in adults.
Bradycardia is a slow rate,
below 60 beats/min in adults.
 An inefficient
contraction of the heart
that fails to transmit a
pulse wave to the
peripheral pulse site
creates a pulse deficit.
 RHYTHM.
Normally a regular
interval occurs
between each pulse or
heartbeat.
 DYSRHYTHMIA.
• An interval interrupted by an early
or late beat or a missed beat
indicates an abnormal rhythm or
dysrhythmia. You identify a
dysrhythmia by palpating an
interruption in successive pulse waves
or auscultating an interruption
between heart sounds.
 STRENGTH.
The strength or amplitude of a
pulse reflects the volume of blood
ejected against the arterial wall
with each heart contraction and the
condition of the arterial vascular
system leading to the pulse site.
 EQUALITY.
Assess radial pulses on both sides of
the peripheral vascular system, comparing
the characteristics of each. A pulse in one
extremity is sometimes unequal in strength
or absent in many disease states (e.g.,
thrombus [clot] formation, aberrant blood
vessels, cervical rib syndrome, or aortic
dissection).
 Assess all symmetrical pulses
simultaneously except for the
carotid pulse. Never measure
the carotid pulses
simultaneously.
 RESPIRATION
Respiration is the mechanism
the body uses to exchange
gases between the atmosphere
and the blood and the blood
and the cells.
 Respiration involves ventilation (the
movement of gases in and out
of the lungs), diffusion (the movement
of oxygen and carbon
dioxide between the alveoli and the
red blood cells), and perfusion
(the distribution of red blood cells to
and from the pulmonary
capillaries).
 Breathing is generally a passive
process. Normally a person thinks
little about it. The respiratory center
in the brainstem regulates the
involuntary control of respirations.
Adults normally breathe in a
smooth, uninterrupted pattern 12 to
20 times a minute.
 TERMINOLOGIES

Eupnea- the normal rate and depth

of ventilation.
Hypercarbia or Hypercapnia –
elevated carbon dioxide in the
blood
 TERMINOLOGIES
Hypoxemia, or low levels of arterial
O2
Hypoxia - low oxygen supply at the
body/tissue/ region
Apnea- Absence of breathing
 MECHANICS OF BREATHING

During INSPIRATION the respiratory

center sends impulses along the
phrenic nerve, causing the diaphragm
to contract. Abdominal organs move
downward and forward, increasing the
length of the chest cavity to move air
into the lungs.
 MECHANICS OF BREATHING
During EXPIRATION the
diaphragm relaxes, and the
abdominal organs return to their
original positions. The lung and
chest wall return to a relaxed
position.
 The accurate assessment of
respirations depends on the
recognition of normal thoracic
and abdominal movements.
During quiet breathing the
chest wall gently rises and falls.
 ASSESSMENT OF VENTILATION
Respirations are the easiest of all
vital signs to assess, but they are
often the most haphazardly
measured. Do not estimate
respirations. Accurate measurement
requires observation and palpation of
chest wall movement.
 PLSSSSSSS!!!!!!
Do not let a patient know
that you are assessing
respirations. A patient aware
of the assessment can alter
the rate and depth of
breathing.
 When assessing a patient’s
respirations, keep in mind the
patient’s usual ventilatory rate and
pattern, the influence any disease
or illness has on respiratory
function, the relationship between
respiratory and cardiovascular
function, and the influence of
therapies on respirations.
 RESPIRATORY RATE.
Observe a full inspiration and
expiration when counting ventilation or
respiration rate. The usual respiratory
rate varies with age (Table 29-5). The
usual range of respiratory rate declines
throughout life.
 ACCEPTABLE RANGES OF
RESPIRATORY RATE
AGE RATE (BREATHS/MIN)

Newborn 35-40
Infant (6 months) 30-50
Toddler (2 years) 25-32
Child 20-30
Adolescent 16-20
Adult 12-20
 FACTORS INFLUENCING CHARACTER
OF RESPIRATIONS
Exercise
Acute Pain
Anxiety
Smoking
FACTORS INFLUENCING CHARACTER
OF RESPIRATIONS
Body Position
Medications
Neurological Injury
Hemoglobin Function
 ALTERATIONS IN BREATHING
PATTERN
Bradypnea Rate of breathing is regular
but abnormally slow (less than 12
breaths/min).
Tachypnea Rate of breathing is regular
but abnormally rapid (greater than 20
breaths/min).
 ALTERATIONS IN BREATHING
PATTERN
Hyperpnea Respirations are labored,
increased in depth, and increased in rate
(greater than 20 breaths/min) (occurs
normally during exercise).
Hyperventilation Rate and depth of
respirations increase. Hypocarbia
sometimes occurs.
 ALTERATIONS IN BREATHING
PATTERN
Hypoventilation Respiratory- rate is abnormally
low, and depth of ventilation is depressed.
Hypercarbia sometimesoccurs.
Kussmaul’s respiration - Respirations are
abnormally deep, regular, and increased in rate.
Biot’s respiration - Respirations are abnormally
shallow for two to three breaths followed by
irregular period of apnea.
 ALTERATIONS IN BREATHING
PATTERN
Cheyne-Stokes respiration
Respiratory rate and depth are irregular,
characterized by alternating periods of apnea
and hyperventilation. Respiratory cycle begins
with slow, shallow breaths that gradually
increase to abnormal rate and depth. The
pattern reverses; breathing slows and becomes
shallow, climaxing in apnea before respiration
resumes.
 ASSESSMENT OF DIFFUSION AND
PERFUSION
Evaluate the respiratory processes of
diffusion and perfusion by measuring the
oxygen saturation of the blood.
The percent of hemoglobin that is
bound with oxygen in the arteries is the
percent of saturation of hemoglobin (or
SaO2). It is usually between 95% and 100%.
 BLOOD PRESSURE
Blood pressure is the force
exerted on the walls of an
artery by the pulsing blood
under pressure from the
heart.
 BLOOD PRESSURE
The contraction of the heart forces the
blood under high pressure into the aorta.
The peak of maximum pressure when
ejection occurs is the SYSTOLIC PRESSURE.
When the ventricles relax, the blood
remaining in the arteries exerts a minimum
or DIASTOLIC PRESSURE.
 BLOOD PRESSURE
The standard unit for measuring
BP is millimeters of mercury (mm
Hg).
The difference between systolic
and diastolic pressure is the PULSE
PRESSURE.
 AVERAGE OPTIMAL BLOOD PRESSURE
FOR AGE
AGE BLOOD PRESSURE (mm Hg)

Newborn (3000 g [6.6 lb]) 40 (mean)

1 month 85/54
1 year 95/65
6 years* 105/65
10-13 years* 110/65
14-17 years* 119/75
18 years and older <120/<80
From National High Blood Pressure Education
Program (NHBPEP); National Heart,
Lung, and Blood Institute; National Institutes of
Health: The seventh report of the
Joint National Committee on Detection, Evaluation,
and Treatment of High Blood
Pressure, JAMA 289(19):2560, 2003.
 FACTORS INFLUENCING BLOOD
PRESSURE
1. Age.
2. Stress.
3. Ethnicity. The incidence of hypertension (high BP) is higher
in African Americans than in European Americans.
4. Gender.
5. Daily Variation.
6. Medications.
7. Activity and Weight.
8. Smoking.
 COMMON TERMS
Hypertension - Diastolic readings greater
than 90 mm Hg and systolic readings greater
than 140 mm Hg (NHBPEP, 2003) define
hypertension.
• Hypotension is present when the systolic BP
falls to 90 mm Hg or below. Although some
adults have a low BP normally, for most people
low BP is an abnormal finding associated with
illness.
 COMMON TERMS
Orthostatic hypotension, also
referred to as postural hypotension,
occurs when a normotensive person
develops symptoms and low BP when
rising to an upright position.
 MEASUREMENT OF BLOOD PRESSURE
Blood Pressure Equipment
• A sphygmomanometer includes a
pressure manometer, an occlusive
cloth or vinyl cuff that encloses an
inflatable rubber bladder, and a
pressure bulb with a release valve that
inflates the bladder
 During the initial assessment obtain
and record the BP in both arms. Normally
there is a difference of 5 to 10 mm Hg
between the arms. In subsequent
assessments measure the BP in the arm
with the higher pressure. Pressure
differences greater than 10 mm Hg
indicate vascular problems and are
reported to the health care provider or
nurse in charge.
 Guidelines for proper blood
pressure cuff size. Cuff width 20%
more than upper-arm diameter or
40% of circumference and two
thirds of arm length.
 COMMON ERRORS IN BLOOD
PRESSURE ASSESSMENT
ERROR EFFECT
Bladder or cuff too wide False-low reading
Bladder or cuff too narrow False-high reading
or too short
Cuff wrapped too loosely False-high reading
or unevenly
Deflating cuff too slowly False-high diastolic
reading
 COMMON ERRORS IN BLOOD
PRESSURE ASSESSMENT
ERROR EFFECT
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
 COMMON ERRORS IN BLOOD
PRESSURE ASSESSMENT
ERROR EFFECT
Stethoscope that fits poorly or False-low systolic and
impairment of examiner’s false-high diastolic reading
hearing,
causing sounds to be muffled
Stethoscope applied too False-low diastolic reading
firmly against
antecubital fossa
Inflating too slowly False-high diastolic reading
Repeating assessments too False-high systolic reading
 COMMON ERRORS IN BLOOD
PRESSURE ASSESSMENT
ERROR EFFECT
Inadequate inflation False-low systolic
level reading
Multiple examiners False-high systolic and
using different false-low diastolic
Korotkoff sounds for reading
diastolic readings
 Palpation. Indirect measurement of
BP by palpation is useful for patients
whose arterial pulsations are too weak
to create Korotkoff sounds. Severe
blood loss and decreased heart
contractility are examples of
conditions that result in BPs too low to
auscultate accurately.
 Auscultatory gap. It typically
occurs between the first and
second Korotkoff sounds. The gap
in sound covers a range of 40 mm
Hg and thus causes an
underestimation of systolic pressure
or overestimation of diastolic
pressure
THANK YOU