VITAL SIGNS Normal Values of Body

Are used to measure the body's basic functions. Temperature

These measurements are taken to help assess the • 36°C – 37.5°C
general physical health of a person, give clues to • 96.8°F – 99.5°F
possible diseases, and show progress toward
recovery.
VITAL SIGNS TO BE MEASURED
• Body temperature
• Pulse rate
• Respirations
• Blood pressure
• Pain assessment
• Oxygen saturation
WHEN TO CHECK VITAL SIGNS?
Times to Assess Vital Signs
• On admission to a health care agency to
obtain baseline data
• When a client has a change in health
status or reports symptoms such as chest
pain or feeling hot or faint
• Before and after surgery or an invasive
procedure
• Before and/or after the administration of
a medication that could affect the
respiratory or cardiovascular systems; for
example, before giving a digitalis
preparation
• Before and after any nursing intervention FACTORS AFFECTING BODY’S
that could affect the vital signs (e.g.,
ambulating a client who has been on bed HEAT PRODUCTION
rest) 1. Basal metabolic rate.
• The basal metabolic rate (BMR) is the rate
of energy utilization in the body required
BODY TEMPERATURE
to maintain essential activities such as
Body temperature reflects the balance between
breathing.
the heat produced and the heat lost from the
2. Muscle activity.
body, and is measured in heat units called degrees.
• Muscle activity, including shivering,
(Celsius and Fahrenheit)
increases the metabolic rate.
3. Thyroxine output.
Two kinds of body • Increased thyroxine output increases the
temperature rate of cellular metabolism throughout
• Core temperature the body.
o is the temperature of the deep 4. Epinephrine, norepinephrine, and sympathetic
tissues of the body, such as the stimulation/stress response.
abdominal cavity and pelvic • These hormones immediately increase
cavity. It remains relatively the rate of cellular metabolism in many
constant. body tissues.
• Surface temperature 5. Fever.
o is the temperature of the skin, • Fever increases the cellular metabolic
the subcutaneous tissue, and rate and thus increases the body's
fat. It, by contrast, rises and falls temperature further.
in response to the environment.
FACTORS AFFECTING BODY • Mild to severe dehydration
TEMPERATURE • Drowsiness, restlessness, delirium, or
convulsions
1. Age
2. Diurnal Variations • Herpetic lesions of the mouth
3. Exercise • Loss of appetite (if the fever is prolonged)
4. Hormones • Malaise, weakness, and aching muscles
5. Stress DEFERVESCENCE (FEVER ABATEMENT/FLUSH
6. Environment PHASE)
• Skin that appears flushed and feels warm
PYREXIA • Sweating
• Decreased shivering
• A body temperature above the usual range is
called pyrexia, hyperthermia, or (in lay terms) • Possible dehydration
fever. A very high fever, such as 41°C (105.8°F), is
called Hyperpyrexia. HYPOTHERMIA
• The client who has a fever is referred to as Hypothermia is a core body temperature below
febrile; the one who does not is afebrile. the lower limit of normal. The three physiological
mechanisms of hypothermia are:
TYPES OF FEVER
• Intermittent fever - the body temperature (a) excessive heat loss,
alternates at regular intervals between periods of (b) inadequate heat production to counteract heat
fever and periods of normal or subnormal loss, and
temperatures. (c) impaired hypothalamic thermoregulation.
• Remittent fever - such as with a cold or
influenza, a wide range of temperature It can be induced or accidental.
fluctuations (more than 2°C [3.6°F]) occurs over a
24-hour period, all of which are above normal NURSING INTERVENTIONS FOR
• Relapsing fever - short febrile periods of a few CLIENTS WITH FEVER
days are interspersed with periods of 1 or 2 days
of normal temperature. • Monitor vital signs.
• Constant fever - the body temperature • Assess skin color and temperature.
fluctuates minimally but always remains above • Monitor white blood cell count,
normal. hematocrit value, and other pertinent
laboratory reports for indications of
CLINICAL MANIFESTATIONS infection or dehydration.
Fever • Remove excess blankets when the client
ONSET (COLD OR CHILL PHASE) feels warm, but provide extra warmth
• Increased heart rate when the client feels chilled.
• Increased respiratory rate and depth • Provide adequate nutrition and fluids
• Shivering (e.g., 2,500-3,000 mL/ day) to meet the
• Pallid, cold skin increased metabolic demands and
• Complaints of feeling cold prevent dehydration.
• Cyanotic nail beds • Measure intake and output.
• "Gooseflesh" appearance of the skin • Reduce physical activity to limit heat
• Cessation of sweating production, especially during the flush
COURSE (PLATEAU PHASE) stage.
• Absence of chills • Administer antipyretics (drugs that
• Skin that feels warm reduce the level of fever) as ordered.
• Photosensitivity • Provide oral hygiene to keep the mucous
• Glassy-eyed appearance membranes moist.
• Increased pulse and respiratory rates • Provide a tepid sponge bath to increase
• Increased thirst heat loss through conduction.
• Provide dry clothing and bed linens.
CLINICAL MANIFESTATIONS TYPES OF THERMOMETERS
Hypothermia Electronic Thermometers
• Decreased body temperature, pulse, and • Can provide a reading in only 2 to 60
respirations seconds, depending on the model. The
• Severe shivering (initially) equipment consists of an electronic base,
• Feelings of cold and chills a probe, and a probe cover, which is
• Pale, cool, waxy skin usually disposable.
• Frostbite (discolored, blistered nose, Chemical disposable thermometers
fingers, toes) • Are also used to measure body
• Hypotension temperatures. Chemical thermometers
• Decreased urinary output have liquid crystal dots or bars that
• Lack of muscle coordination change color to indicate temperature.
• Disorientation Some of these are single use and others
• Drowsiness progressing to coma may be reused several times.
Temperature-sensitive tape
NURSING INTERVENTIONS FOR • may also be used to obtain a general
indication of body surface temperature. It
CLIENTS WITH HYPOTHERMIA does not indicate the core temperature.
• Provide a warm environment. The tape contains liquid crystals that
• Provide dry clothing. change color according to temperature.
• Apply warm blankets. When applied to the skin, usually of the
• Keep limbs close to body. forehead or abdomen, the temperature
• Cover the client's scalp with a cap or digits on the tape respond by changing
turban. color
• Supply warm oral or intravenous fluids. Infrared thermometers
• Apply warming pads. • sense body heat in the form of infrared
ASSESSING THE BODY energy given off by a heat source, which,
TEMPERATURE in the ear canal, is primarily the tympanic
membrane. The infrared thermometer
• Orally - temperature is taken by mouth
makes no contact with the tympanic
• Rectal - temperature is taken by rectum
membrane.
• Axilla - temperature is taken in the armpit
Temporal artery thermometers
• Tympanic membrane - temperature is
• determine temperature using a scanning
taken nearby tissue in the ear canal
infrared thermometer.
TEMPERATURE SCALES
Sometimes a nurse needs to convert a body
temperature reading in Celsius (centigrade) to
Fahrenheit, or vice versa.

C = (Fahrenheit temperature – 32) x 5/9

To convert from Celsius to Fahrenheit, multiply the

Celsius reading by the fraction 9/5 and then add
32; that is:

F = (Celsius temperature X 9/5) + 32

IMPLEMENTATION
Preparation
• Check that all equipment is functioning
normally.
Performance
1. Prior to performing the procedure,
introduce self and verify the client’s
identity using agency protocol. Explain to
the client what you are going to do, why
it is necessary, and how he or she can
participate. Discuss how the results will
be used in planning further care or
treatments.
2. Perform hand hygiene and observe
appropriate infection prevention
procedures. Apply gloves if performing a
rectal temperature.
3. Provide for client privacy.
4. 4. Position the client appropriately (e.g.,
lateral or Sims’ position for inserting a
rectal thermometer).

PULSE
• Pulse refers to a pressure wave that
expands and recoils the artery when the
heart contracts/beats. It is palpated at
many points throughout the body.
• An excessively fast heart rate (e.g., over
100 beats/min in an adult) is referred to
as tachycardia.
• A heart rate in an adult of less than 60
beats/min is called bradycardia.
• If a client has either tachycardia or
bradycardia, the apical pulse should be
assessed.
FACTORS AFFECTING THE Position.
PULSE • When a person is sitting or standing,
blood usually pools in dependent vessels
• Age.
of the venous system. Pooling results in a
o As age increases, the pulse rate
transient decrease in the venous blood
gradually decreases overall.
return to the heart and as subsequent
• Sex.
reduction in blood pressure and increase
o After puberty, the average in heart rate.
male’s pulse rate is slightly lower Pathology.
than the females.
• Certain diseases such as some heart
• Exercise.
conditions
o The pulse rate normally
increases with activity. The rate
of increase in the professional
athlete is often less than in the
average person because of
greater cardiac size, strength,
and efficiency.
• Fever.
o The pulse rate increases (a) in
response to the lowered blood PULSE SITES
pressure that results from Temporal
peripheral vasodilation • where the temporal artery passes over
associated with elevated body the temporal bone of the head. The site is
temperature and (b) because of superior (above) and lateral to (away
the increased metabolic rate. from the midline of) the eye.
• Medications.
o Some medications decrease the Carotid
pulse rate, and others increase • at the side of the neck where the carotid
it. For example, cardiotonics artery runs between the trachea and the
(e.g., digitalis preparations) sternocleidomastoid muscle.
decrease the heart rate,
whereas epinephrine increases Apical
it.
• at the apex of the heart. In an adult, this
is located on the left side of the chest,
FACTORS AFFECTING THE about 8 cm (3 in.) to the left of the
PULSE sternum (breastbone) at the fifth
Hypovolemia/dehydration. intercostal space (area between the ribs).
• Loss of blood from the vascular system In older adults, the apex may be further
increases the pulse rate. In adults, the left if conditions are present that have led
loss of circulating volume results in an to an enlarged heart. Before 4 years of
adjustment of the heart rate to increase age, the apex is left of the midclavicular
blood pressure as the body compensates line (MCL); between 4 and 6 years, it is at
for the lost blood volume. the MCL. For a child 7 to 9 years of age,
the apical pulse is located at the fourth or
Stress. fifth intercostal space.
• In response to stress, sympathetic
nervous stimulation increases the overall Brachial
activity of the heart. Stress increases the • at the inner aspect of the biceps muscle
rate as well as the force of the heartbeat. of the arm or medially in the antecubital
Fear and anxiety as well as the perception space.
of severe pain stimulate the sympathetic
system.
Radial
• where the radial artery runs along the
radial bone, on the thumb side of the
inner aspect of the wrist.

Femoral
• where the femoral artery passes
alongside the inguinal ligament.

Popliteal
• where the popliteal artery passes behind
the knee.

Posterior tibial
• on the medial surface of the ankle where
the posterior tibial artery passes behind
the medial malleolus.

Dorsalis pedis Assessing the Pulse

• where the dorsalis pedis artery passes
• A pulse is commonly assessed by
over the bones of the foot, on an
palpation (feeling) or auscultation
imaginary line drawn from the middle of
(hearing). The middle three fingertips are
the ankle to the space between the big
used for palpating all pulse sites except
and second toes.
the apex of the heart. A stethoscope is
used for assessing apical pulses.
• A normal pulse can be felt with moderate
pressure of the fingers and can be
obliterated with greater pressure. A
forceful or full blood volume that is
obliterated only with difficulty is called a
full or bounding pulse. A pulse that is
readily obliterated with pressure from
the fingers is referred to as weak, feeble,
or thready.

IMPLEMENTATION
Preparation
• If using a DUS, check that the equipment
is functioning normally.
Performance
1. Prior to performing the procedure, introduce
self and verify the client’s identity using agency
protocol. Explain to the client what you are going
to do, why it is necessary, and how he or she can
participate. Discuss how the results will be used in
planning further care or treatments.

2. Perform hand hygiene and observe appropriate

infection prevention procedures.

3. Provide for client privacy.

4. Select the pulse point. Normally, the radial pulse
is taken, unless it cannot be exposed or circulation
to another body area is to be assessed.

5. Assist the client to a comfortable resting

position. When the radial pulse is assessed, with
the palm facing downward, the client’s arm can
rest alongside the body, or the forearm can rest at
a 90-degree angle across the chest. For the client
who can sit, the forearm can rest across the thigh,
with the palm of the hand facing downward or
inward.

6. Palpate and count the pulse. Place two or three

middle fingertips lightly and squarely over the
pulse point.

7. Assess the pulse rhythm and volume

8. Document the pulse rate, rhythm, and volume

and your actions in the client record

RESPIRATIONS
• Respiration is the act of breathing.
Inhalation or inspiration refers to the
intake of air into the lungs. Exhalation or
expiration refers to breathing out or the
movement of gases from the lungs to the
atmosphere.
• Ventilation is also used to refer to the
movement of air in and out of the lungs.
• A person's respiratory rate is the number
of breaths you take per minute. The
normal respiration rate for an adult at
rest is 12 to 20 breaths per minute.

Types of Breathing

Costal (thoracic)Breathing
• Costal breathing involves the external
intercostal muscles and other accessory
muscles, such as the sternocleidomastoid
muscles.

Diaphragmatic abdominal
breathing
• diaphragmatic breathing involves the
contraction and relaxation of the
diaphragm
Assessing Respirations Deep respirations
• Resting respirations should be assessed • are those in which a large volume of air is
when the client is relaxed because inhaled and exhaled, inflating most of the
exercise affects respirations, increasing lungs.
their rate and depth. Shallow respirations
• Anxiety is likely to affect respiratory rate • respirations involve the exchange of a
and depth as well. small volume of air and often the minimal
• Before assessing a client’s respirations, a use of lung tissue.
nurse should be aware of the following: Tidal volume
o The client’s normal breathing • 500 mL of air
pattern Hyperventilation
o The influence of the client’s • Very deep, rapid respirations
health problems on respirations Hypoventilation
o Any medications or therapies • very shallow respirations
that might affect respirations. Respiratory rhythm
o he relationship of the client’s • rhythm refers to the regularity of the
respirations to cardiovascular expirations and the inspirations.
function. Normally, respirations are evenly spaced.
Should be assessed: • Respiratory rhythm can be described as
• The rate, regular or irregular.
• depth, Respiratory quality or character
• rhythm, • Refers to those aspects of breathing that
• quality, and are different from normal, effortless
• effectiveness of respirations breathing.
• Two aspects:
The respiratory rate o the amount of effort a client
• is normally described in breaths per must exert to breathe
minute. o the sound of breathing.
Eupnea
• Breathing that is normal in rate and depth
Bradypnea
• Abnormally slow respirations
Tachypnea or polypnea
• Abnormally fast respirations
Apnea
• Absence of breathing.

Factors Affecting Respirations

Increase
• Exercise (increases metabolism),
• Stress (readies the body for “fight or
flight”)
• increased environmental temperature
• lowered oxygen concentration at
increased altitudes.
Decrease
• decreased environmental temperature
• Certain Medications
• increased intracranial pressure.
Respiratory Depth
• Normal, deep, or shallow
 pumping action is strong and the volume
of blood pumped into the circulation
increases (higher cardiac output), the
blood pressure increases.
PERIPHERAL VASCULAR RESISTANCE
• Peripheral resistance can increase blood
pressure. The diastolic pressure
especially is affected. Some factors that
create resistance in the arterial system
are the capacity of the arterioles and
capillaries, the compliance of the arteries,
BLOOD PRESSURE and the viscosity of the blood.
Arterial blood pressure Arteriosclerosis
• A measure of the pressure exerted by the • If the elastic and muscular tissues of the
blood as it flows through the arteries. arteries are replaced with fibrous tissue,
the arteries lose much of their ability to
Two blood pressure measurements: constrict and dilate.
• Systolic Pressure BLOOD VOLUME
o pressure of the blood as a result • When the blood volume decreases, the
of contraction of the ventricles, blood pressure decreases because of de-
that is, the pressure of the creased fluid in the arteries. Conversely,
height of the blood wave. when the volume increases, the blood
• Diastolic Pressure pressure increases because of the greater
o the pressure when the ventricles fluid volume within the circulatory
are at rest. system.
o the lower pressure, present at all BLOOD VISCOSITY
times within the arteries. • Blood pressure is higher when the blood
is highly viscous (thick),that is, when the
Pulse Pressure proportion of red blood cells to the blood
• The difference between the diastolic and plasma is high. This proportion is referred
the systolic pressures to as the hematocrit.
• A normal pulse pressure is about 40 • The viscosity increases markedly when
mmHg but can be as high as 100 mmHg the hematocrit is more than 60% to 65%.
during exercise.
Factors Affecting Blood
Blood Pressure
Pressure
• Blood pressure is measured in millimeters
• Age
of mercury (mmHg) and recorded as a
fraction: systolic pressure over the • Exercise
diastolic pressure. • Stress
• typical blood pressure for a healthy adult • Race
is 120/80 mmHg (pulse pressure of 40). • Sex
• Medications
Determinants of Blood Pressure • Diurnal Variations
Arterial blood pressure • Medical Conditions
• the result of several factors: the pumping • Temperature
action of the heart, the peripheral
vascular resistance Hypertension
PUMPING ACTION OF THE HEART • A blood pressure that is persistently
• When the pumping action of the heart is above normal
weak, less blood is pumped into arteries Primary hypertension
(lower cardiac output), and the blood • An elevated blood pressure of unknown
pressure decreases. When the heart’s cause
Secondary hypertension OXYGEN SATURATION
• An elevated blood pressure of known pulse oximeter
cause • noninvasive device that estimates a
client’s arterial blood oxygen saturation
Hypotension (SaO2) by means of a sensor attached to
• blood pressure that is below normal, that the client’s finger
is, a systolic reading consistently between • Consists of:
85 and 110 mmHg in an adult whose o an inlet connection for the
normal pressure is higher than this. sensor cable, and a faceplate
• Can be caused by: that indicates:
o Analgesics such as meperidine ▪ the oxygen saturation
hydrochloride (Demerol) measurement
o Bleeding ▪ the pulse rates.
o Severe burns Hypoxemia
o hydration • Low oxygen saturation

Orthostatic hypotension
Factors Affecting Oxygen
• a blood pressure that decreases when the
client sits or stands. Saturation Readings
• Hemoglobin
Assessing Blood Pressure • Circulation
Blood pressure is measured with: • Activity
• Carbon Monoxide Poisoning
• Blood pressure cuff
o cuff consists of a bag, called a
bladder, that can be inflated
with air.
• Sphygmomanometer
o indicates the pressure of the air
within the bladder.
o Aneroid or Digital
• Stethoscope.
o Doppler ultrasound steth are
also used to assess blood
pressure