Measuring Vital Signs

Measuring Vital Signs
Vocabulary
• Afebrile – temperature is within
normal range
• Febrile – temperature is elevated
• Hypothermia – temperature is below
normal
• Axillary – referring to the armpit
• Aural – pertaining to the ear
• Oral – referring to by mouth
• Rectal – referring to the end of the
large intestine just above the anus
Vocabulary continued…
• Calibration – standard measure
(each line on a thermometer or a
ruler is a calibration)
• Celsius – measure of heat;
abbreviated C
• Fahrenheit – measure of heat;
abbreviated F
Why are vital signs so
important?
• Indicate normal or abnormal
function
• Normal = homeostasis
(balance)
• Accuracy can mean the
difference between life and
death
Vital Signs
• One of the most frequent
assessments made as a nurse
• Nurse is
– Responsible for measuring,
interpreting significance and making
decisions about care
– Knowing normal ranges
– Knowing history and other therapies
that may affect VS
Vital Signs
• Nurse must
– Know environmental factors that affect vital
signs
• Exercise, stress, etc.
– Use a systematic, organized approach
– Verify and communicate changes in vital
signs
– Monitor VS regularly
– Frequency determined by
• MD order; nursing judgement, client condition
and facility standards
What are vital signs?
• TPR and BP where:
• T = body temperature (measure of
body heat)
• P = pulse rate (the rate at which the
heart is pumping blood through the
body)
• R = respiratory rate (the rate at which
the lungs are breathing air in and out)
• BP = blood pressure (the highest and
lowest amount of pressure placed on
the blood vessels of the body)
What is body heat
(temperature)?
• Heat is produced by muscle
activity, food oxidation, and
glands.
• Heat is “lost” through
respiration, perspiration, and
excretion.
• Shivering is an early response
for thermoregulation that
increases heat production.
Factors that increase body
temperature:
• Exercise
• Digestion of food
• Increase environmental temperature
• Illness
• Infection
• Excitement
• Anxiety
Factors that decrease body
temperature:
• Sleep
• Fasting
• Exposure to cold
• Depression
• Decreased muscle activity
• Certain illnesses
• Mouth breathing
Most common sites to measure
temperature:
• Mouth (Oral)
• Axilla (Underarm)
• Rectum
• Ear (Aural)
Types of thermometers:
• Glass
• Electronic digital
• Aural or tympanometer
• Chemically treated strips
Normal temperature readings:
• Oral = 98.6° F (37° C)
• Axillary = 97.6° F (36.4° C)
• Rectal = 99.6° F (38° C)
Variances in temperature
• Fever (pyrexia) aka afebrile
– Abnormally high body temperature
(>100.4 F)
– Occurs in response to pyrogens
(bacteria)
• Hyperpyrexia aka febrile
– Fever > 105.8
Pulse
• The number of times the heart
pumps or beats in a minute
• Indicates that blood is circulating
through the body
• Most common sites to measure
pulse – radial, antecubital (brachial),
apical (stethoscope on the chest
wall)
vocabulary
• Arrhythmia – irregular heart beats
• Apex – the top of the heart
• Bounding – extremely strong heart beat
• Bradycardia – slower than normal heart
beat
• Hemorrhage – bleeding
• Tachycardia – faster than normal heart
beat
When counting the pulse,
you feel the pressure of
blood against the artery as
the heart contracts. Pulse
rate varies for different ages
(faster in infants)
newborn = 120 – 160
teenagers = 75 - 110
adults = 72-80
Characteristics of a pulse:
• Rate – fast, slow
• Rhythm – regular, steady, irregular
• Arrhythmia – even or uneven
intervals between pulse
• Force of the beat / volume –
bounding, thready or weak; normal,
strong
• Pulse rates below 60 or above 100
should always be reported
• Athletes may have a pulse rate
under 60 due to excellent fitness
Factors that influence pulse
rate:
• Exercise (increases pulse rate)
• Hemorrhage (weakens, increases)
• Emotional excitement (increases)
• Elevated temperature (increases)
• Medication (increases or decreases)
• Age (increases)
• Aerobic fitness (decreases)
• Depression (decreases)
• Illness (increases or decreases)
• Shock (increases)
• The radial pulse is the most common site
for counting the pulse rate.
• Adult pulse rate may range from 60-80.
• The pulse oximeter is an electronic device
that determines pulse and oxygen
concentration in the hemoglobin of the
arterial blood.
• pO2 < 90% not enough oxygen in the
tissues to function normally
Respiration
• The process of taking in oxygen and
expelling carbon dioxide
• Helps regulate temperature and
eliminate all waste products
• 1 expiration / exhalation (breathing
out) + 1 inspiration / inhalation
(breathing in)
Respiration rate is assessed by
observing the client’s chest
movement upward and outward
for a complete minute.
Auscultation (listening with a

stethoscope) is another method
to assess respiratory rate.
Abnormal respirations (lung
sounds) include:
• Dyspnea – difficulty breathing
(diminished lung sound)
• Apnea – stopped breathing (no lung
sound)
• Cheynes-Stokes – periods of labored
breathing followed by apnea
• Rales – bubbling or rattling sounds
caused by mucus
Factors that affect respiration:
• Anxiety
• Respiratory rate
• Relaxation
• Depression
• Head injury
• Age (newborn 40/minute; adult 12-
20/minute)
• Exercise
• Pain
• Fever
• Heart disease; congestive heart failure
• medication
• Hyperventilation – increase in the
respiratory rate may be caused by:
• -physical / mental stress such as
infection, exercise, or anxiety
• - increase in body temperature
• -lack of oxygen or low blood
pressure
• Hypoventilation – decrease in
respiratory rate may be caused by:
• -pain medications and alcohol
• - decrease body temperature
• - severe lack of oxygen and no blood
pressure
Blood Pressure:
• the force of the blood pushing against the

walls of the blood vessels.
– Systolic – greatest force exerted on the
arteries when the heart is contracting causing
a beat to be heard. This is the higher
number.
– Diastolic – least force exerted on the arteries
when the heart relaxes.
Blood Pressure depends on:
• Volume of blood in the circulatory system

• Force of the heartbeat
• Condition of the arteries
Factors that
Increase Blood Pressure:
• Loss of elasticity in the arteries
• Exercise
• Eating
• Stimulants (medication, coffee)
• Anxiety
Factors that
Decrease Blood Pressure
• Hemorrhage
• Inactivity
• Fasting
• Suppressants (medications that lower B/P)
• Depression
• Expected B/P readings
– Systolic between 100 – 140 mm
– Diastolic between 60 – 90 mm
– Written as a fraction with systolic over
diastolic
• Systolic between 120-140 mm and
diastolic between 80-90 mm is
considered Prehypertension
• Hypertension – blood pressure above
normal (high blood pressure)
• Hypotension – blood pressure below
normal (low blood pressure)
Equipment used:
• Sphygmomanometer – instrument used to

measure blood pressure (also called a
blood pressure cuff)
– Three types:
• Aneroid – calibrated dial
• Electronic – digital display
(does not require a stethoscope)
• Mercury – calibrated cylinder with mercury
• stethoscope
Figure 11-11
(From Sorrentino, S.A. [2004]. Mosby’s textbook for nursing assistants [6th ed.]. St. Louis: Mosby.)
Aneroid manometer and cuff.

Figure 11-12
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
Wall-mounted aneroid sphygmomanometer.

Figure 11-17
Electronic sphygmomanometer.
Figure 11-14
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St.
Louis: Mosby.)
Doppler stethoscope over brachial artery to measure blood pressure.
Figure 11-15, A
(A, From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.].
St. Louis: Mosby.)
A, Lower-extremity blood pressure cuff positioned above popliteal

artery at midthigh.
Figure 11-15, B
(A, From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.].
St. Louis: Mosby.)
B, Location of the popliteal artery and placement of

the cuff.
Measuring Blood Pressure
1. Roll up client’s sleeve above elbow,

being careful that it’s not too tight.
Support client’s arm on a firm surface.
2. Wrap wide part of cuff around client’s
arm directly over brachial artery.
Lower edge of cuff should be 1 or 2
inches above the bend of elbow.
3. Clean earpieces of stethoscope.
4. Locate brachial artery.
5. Tighten thumbscrew on valve.
6. Hold stethoscope in place.
7. Inflate cuff to 170 mm.
8. Open valve; if systolic sound is
heard immediately, reinflate the
cuff to 30 mm above systolic
sound.
9. Note systolic at first beat.
10. Note diastolic.
11. Open valve and release air.
12. Record blood pressure reading
correctly.
13. Clean earpieces on
stethoscope.
14. Put equipment away.
When Vital Signs Are Assessed
• The more ill the patient, the more
frequently vital signs are taken.
• Vital signs are interrelated.
– A rise in temperature of 1° F may cause an
increase in pulse rate of 4 beats per minute.
– Respiratory rate and blood pressure readings
increase with a rise in temperature.
– Blood pressure falls because of hemorrhage,
the pulse and respirations increase and the
temperature usually decreases.
Recording Vital Signs
• Graphic/Flow Sheet
– Used for charting vital signs
– R indicates a rectal temperature
– Ax indicates an axillary temperature
– Blood pressures are always written with the
systolic first and the diastolic beneath.
• Example: 120/80
– Apical pulse is indicated with an “ap” after
next to the number.
• Example: 78 ap
Recording Vital Signs
• Any abnormal findings are reported to your
clinical instructor, charge nurse or
telephone the physician immediately.
• Any accompanying or precipitating signs
and symptoms such as chest pain, vertigo,
shortness of breath, flushing, and
diaphoresis should be recorded as well.
• The nurse documents any interventions
initiated as a result of vital sign
measurement, such as tepid sponging.
• Assessment
– Normal daily fluctuations
– Factors likely to interfere with accuracy of vital
sign reading
– Medications that may influence vital signs
– Factors that influence vital signs
– Conditions that precipitate fever, such as
infections
– Pertinent laboratory values
– Previous baseline vital signs from patient’s
record

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Measuring Vital Signs

Auscultation (listening with a

• the force of the blood pushing against the

• Volume of blood in the circulatory system

• Sphygmomanometer – instrument used to

Aneroid manometer and cuff.

Wall-mounted aneroid sphygmomanometer.

A, Lower-extremity blood pressure cuff positioned above popliteal

B, Location of the popliteal artery and placement of

1. Roll up client’s sleeve above elbow,

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