Vital Signs

• The taking of vital signs refers to measurement

of the client’s body temperature (T), pulse (P)
rate, respiratory (R) rate, and blood pressure
(BP).
• Health status indicators of vital body functions.
• A change in vital signs might indicate a change
in health.
• Vital signs are the first step in the physical
examination.

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 Vital Signs
• Assessment of vital signs provides
specific data regarding the client’s
current condition.
• Variations from baseline values may
indicate potential problems with the
client’s health status.

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 Vital Signs
• The sequence for recording vital sign
measurements in the nurses’ notes is T-P-
R and BP.
• Vital signs are plotted on graphic forms
that facilitate data comparison at a
glance.

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 Temperature
• Body temperature is the heat of the
body measured in degrees.
• Heat is generated by metabolic
processes in the core issues of the body,
transferred to the skin surface by
circulating blood, & then dissipated to
the environment.

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 • Thermoregulation
– Core body temperature is maintained within
a range of 36.0oC (97oF) to 37.5oC (99.5oF).
– Core temperatures are measured at tympanic
or rectal areas.
– Surface body temperatures are measured at
oral (sublingual) and axillary sites.

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 Conversion of Body
Temperature
• oC x 9 + 32 = oF
5
• oF - 32 x 5 = oC
9
Solve this: a. 37 oC to oF
b. 100 oF to oC

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 Heat Production
• Heat Production
1. Metabolism – primary source of heat in the
body
– Hormones (epinephrine/norepinephrine and
thyroid hormone), muscle movements, and
exercise increase body metabolism

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 2. Shivering, a response that increases the
production of heat, is initiated by
hypothalamus resulting to muscular
tremors.
3. Vasodilation and Vasoconstriction
3. Piloerection (goosebumps) – reduces
the size of the surface to minimize heat
loss.

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 Heat Loss
• Skin is the primary site of heat loss.
• “arteriovenous shunts” – remain open to
allow heat to dissipate or close and
retain heat in the body

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 Thermoregulation
• Mechanisms of Heat Transfer
– Radiation
– Conduction
– Convection
– Evaporation
• Insensible Heat Loss

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 Mechanisms of Heat Transfer
A. Convection – dissemination of
heat by motion between areas
of unequal density or the
transfer of energy between an
object and its environment,
due to fluid motion
• E.g. An oscillating fan blows
currents of air across the
surface of a warm body

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 B. Evaporation – The
conversion of a liquid to a
vapor
• E.g. Body fluid in the
form of perspiration and
insensible loss is
vaporized from the skin

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 C. Radiation – diffusion or
dissemination of heat by
electromagnetic waves
• E.g. The body gives off
waves of heat from
uncovered surfaces

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 • D. Conduction – Transfer of heat to
another object during direct contact.
• E.g. The body transfer heat to an ice
pack, causing the ice to melt.

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 Factors Affecting Body
Temperature
• A. Circadian Rhythms (events recurring
at 24-hour interval)
– E.g. Body temperature is 0.6oC (1-2oF) lower
in the EARLY MORNING than in the late
afternoon.
– PEAK elevation of body temp occurs in late
afternoon, between 4 and 7 p.m.

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 • B. Age & Sex – both the very young &
very old are more sensitive to changes in
environmental temperature
– Women tend to have more fluctuations in
body temperature than men because of the
increase in PROGESTERONE secretion
during ovulation as much as ½ - 1 degree
• C. Environmental Temperature
– Hypothermia – low body temperature
– Hyperthermia – high body temperature

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 Body Temperature
• Afebrile – a person with a normal body
temperature
• Febrile – a person with increased body
temperature
• Pyrexia (fever)- increased body temp
resulting from a response to bacterial or
viral infections and tissue injuries.

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 • When the set point is increased, the
hypothalamus initiates shivering &
vasoconstriction
• Most fevers are self-limiting, after factors
causing it are controlled.
• Hyperpyrexia – a high fever, usually
above 41oC
• Hyperthermia is different from pyrexia in
that the hypothalamic set point is not
changed

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 • Neurogenic fever – usually the result of
damage to the hypothalamus from
intracranial trauma/bleeding or
increased ICP.
– This does not respond to antipyretic

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 TYPES OF FEVER
• Intermittent – body temp alternates
regularly between a period of fever & a
period of normal temp.
• Remittent – body temp fluctuates
several degrees >2 oC above normal but
does not reach normal between
fluctuations
• Constant – remains consistently elevated

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 • Relapsing – body temp returns to
normal for at least a day but then the
fever recurs.
• Crisis – fever returns to normal suddenly
• Lysis – fever returns to normal gradually

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 Physical Effects of Fever
• Hot, dry skin Other Nursing
• Flushed face Observations
• Thirst • Dehydration
• General malaise • Decreased urine
• Loss of appetite output
• In children, seizures• Rapid Heart Rate
•

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 Thermoregulation
• Behavioral Control of Body Temperature
– The person makes appropriate
environmental adjustments in response to
the body’s signaling conditions of either
being overheated or too cold.

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 Some Nursing Interventions to
Reduce Fever
• Administer a tepid sponge bath as
appropriate
• Encourage increased intake of oral fluids
• Encourage or give oral hygiene as
appropriate
• Administer anti-pyretic medications, as
appropriate

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 Body Temperature
• Temperature Scales
– Centigrade or Fahrenheit scales are used to
measure temperature.
– Glass or electronic thermometers are used.
• Sites
– Oral – best site
– Rectal – fastest site
– Axillary – safest site
– Tympanic

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 Body Temperature
• In assessing, the nurse must know what
equipment to use, which site to choose,
what method is appropriate.
• Assessing Body Temperature Orally
– No consumption of hot or cold food or
beverage
– No smoking for 15 to 30 minutes before the
measurement

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 Nursing Considerations
• Heat exhaustion
– Place patient in a cool environment
• Heat stroke
– No perspiration
– Emergency measures to lower temperature
• Hypothermia
– Heating blankets and warm fluids

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 Documentation
• Record the temperature measurement
and the site on the designated medical
record form.
• Temperature measurements are usually
plotted on a graph.

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 Respiration
• Respiration is the act of breathing.
• Terms related to respiratory function are:
– External respiration – exchange of O2 and
CO2 between alveoli of the lungs
– Internal respiration - exchange of O2 and CO2
between circulating blood & tissue cells
– Inspiration/ Inhalation – act of breathing in
– Expiration/ Exhalation – act of breathing out
– Vital capacity

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 • Pulmonary Ventilation/ Respirations –
movement of air in and out of the lungs
• This is the part that is being measured as
a vital sign

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 Respiration Physiology
• Respiratory centers – Medulla Oblangata
and Pons
• Increased in CO2 is the MOST POWERFUL
respiratory stimulant, causing an Increase
in respiratory rate and depth
• Rate & depth can change in response to
body demands
• Cerebral cortex – allows voluntary control
of breathing (e.g. Singing)

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 Respiratory Rate
• Healthy adults breathe about 12 to 20
times each minute.
• Infants & Young children breathe faster
• EUPNEA – normal respiration
• Normally smooth, effortless, & without
conscious effort

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 • Tachypnea – increased respiratory rate
• Bradypnea – decreased respiratory rate
• Apnea – periods during which there is NO
breathing
– If >4-6 minutes, brain damage & death might
occur
• Dyspnea – difficulty/ labored breathing
• Usually has rapid, shallow respirations
• Hyperventilation – Increased rate & depth
• Hypoventilation - decreased rate & depth

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 Description Pattern Associated Features

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 ORTHOPNEA
• A condition wherein dyspneic people
can breathe more easily in an upright
position
• While sitting/standing, gravity lowers
organs in the abdominal cavity away
from diaphragm giving more room for
lungs to expand within the chest

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 Factors Influencing Respirations
• Age – 30-60 breaths/min in newborn &
12-20 breaths/min in adult
• Exercise – increases respiratory rate &
depth
• (Any condition causing an in CO2 & O2
in the blood increases rate & depth in
respirations)

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 Factors Influencing Respirations
• Increased altitude
• Respiratory Diseases – e.g. PTB,
Pneumonia
• Anemia
• Anxiety
• Medications – e.g. Narcotics slow
respiratory rate & depth
• Acute pain
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 Respirations
• Sites
– Observation of chest wall expansion and
bilateral symmetrical movement of the
thorax
– Placement of back of hand next to client’s
nose and mouth to feel expired air

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 Assessing Respirations
• Rate is counted by number of breaths
taken per minute.
– Normal range is 12 to 20 breaths per minute.

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 Nursing Considerations
• Cyanosis
– Bluish appearance in the nail beds, lips, and
skin
– Reduced oxygen levels in the arterial blood

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 Nursing Considerations
• Clients with respiratory alterations
require additional nursing assessment.
– Pulse oximetry
– Apnea monitor
• Documentation
– Rate, depth, rhythm, and character

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 Hemodynamic Regulation
• The circulatory system transports
nutrients to the tissues, removes waste
products, and carries hormones from one
part of the body to another.

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 Hemodynamic Regulation
• Systemic Circulation
– Arteries
– Arterioles
– Capillaries
– Veins
– Venules

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 Hemodynamic Regulation
• Pulse
– The pulse is caused by the stroke volume
ejection and distension of the walls of the aorta.
– Results as a wave of blood is pumped into an
already full aorta, the arterial walls in the
cardiovascular system expand to compensate
for the increase in pressure of the blood
– The bounding of blood flow in an artery is
palpable at various points in the body (pulse
points).

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 Pulse Physiology
• It is regulated by the autonomic nervous
system through the sinoatrial node (aka
Pacemaker)
• Parasympathetic Nervous System –
decreases pulse rate
• Sympathetic Nervous System – increases
pulse rate

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 • Pulse rate is the number of pulsations
felt over a peripheral artery or head over
the apex of the heart in 1 minute
• This rate normally corresponds to the
same rate at which the heart is beating.

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 The Heart: Regulation of Heart
Rate
 Starling’s law of the heart – the more
that the cardiac muscle is stretched, the
stronger the contraction
 Changing heart rate is the most
common way to change cardiac
output

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Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings 59 Slide 11.20
 Pulse
 Monitored at
“pressure
points” where
pulse is easily
palpated

Figure 11.16
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Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings 60 Slide 11.35
 • The normal pulse rate ranges from 60 to
100 beats per minute.
• Rate, quality, & rhythm of pulse provide
information about the effectiveness of
the heart to pump & the adequacy of
peripheral blood flow.

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 Increased Pulse Rate
• Tachycardia – increased heart rate
• Factors Contributing to Tachycardia
– A decrease in Blood Pressure
– An elevated temperature (7-10 bpm)
– Exercise
– Pain
– Any condition resulting in poor blood
oxygentaion
– Strong emotions
– Some medications

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 Decreased Pulse Rate
• Bradycardia – pulse rate below
60beats/min
• Pulse rate is normally slower during
sleep, in men, & those who are thin

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 Pulse Rhythm
• It is the pattern of the pulsations and the
pauses between them
• This pattern is normally regular
• An irregular pattern of heartbeats is
called Dysrhythmia.

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 Pulse Amplitude & Quality
• Pulse Amplitude – describes the quality
of the pulse in terms of its fullness &
reflects the strength of left ventricular
contraction
• It is assessed by the feel of the blood
flow through the vessel

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 Pulse
• Sites
– The most accessible peripheral sites
are the radial and carotid sites.
– The carotid site should always be used
to assess the pulse in a cardiac
emergency.

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 Assessing Pulse Rate
• A peripheral pulse is palpated by placing
the first two fingers on the pulse point
with moderate pressure.
• A Doppler ultrasound stethoscope is used
on superficial pulse points.

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 Assessing Pulse Rate

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 Blood Pressure
• Blood Pressure
– It refers to the force of the blood against
arterial walls
– Maximum blood pressure is exerted on the
walls of arteries when the left ventricle
pushes blood through the aortic valve into
the aorta at the beginning of systole
– Pressure rises as the ventricle contracts &
falls as the heart relaxes.

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 Blood Pressure
• Systolic Pressure
– Maximum/ highest pressure exerted against
arterial walls during systole
• Diastolic Pressure
– Lowest pressure in the arterial system when
the heart rests between beats during diastole
• Pulse Pressure
– Difference between systolic and diastolic
pressure

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 Measurement
• BP is measured in millimeters of mercury
(mmHg) and is recorded as Fraction
• Numerator = systolic pressure
• Denominator = diastolic pressure
• E.g. 120/ 80
– 120 – systolic
– 80 – diastolic
– 40 – pulse pressure

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 Blood Pressure
 Measurements by health professionals
are made on the pressure in large
arteries
 Systolic – pressure at the peak of
ventricular contraction
 Diastolic – pressure when ventricles relax
 Pressure in blood vessels decreases as
the distance away from the heart
increases

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Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings 72 Slide 11.36
 Blood Pressure Physiology
• Peripheral Resistance
– Compliance – ability of the arteries to
stretch & distend
– Elasticity of the arterial walls
– With age, the walls become less elastic thus
rising blood pressure
– Blood viscosity

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 • Cardiac Output – amount of blood
pumped every minute
• Stroke Volume - quantity of blood forced
out of the left ventricle with each
contraction
• Cardiac Output (CO)
– CO= Stroke Volume x Heart Rate

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 Blood Pressure: Effects of
Factors
 Neural factors
 Autonomic nervous system
adjustments (sympathetic division)
 Renal factors
 Regulation by altering blood volume
(i.e. Antidiuretic Hormone (ADH)/
Vasopressin)
 Renin-Angiotensin-Aldosterone System
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Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings 75 Slide 11.39a
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 Atrial natriuretic peptide (ANP)
• is a powerful vasodilator, and a protein
hormone secreted by heart muscle cells
(right atrium)
• It is released by muscle cells in response
to high blood pressure.
• ANP acts to reduce the water, sodium
and adipose loads on the circulatory
system, thereby reducing blood
pressure.
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 Blood Pressure: Effects of Factors

 Temperature
 Heat has a vasodilation effect
 Cold has a vasoconstricting effect
 Age – lose elasticity of vessel walls

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Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings 78 Slide 11.39b
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  Diet
 Exercise
 Emotional State

• Body position – lower in a prone or

supine position than when sitting or
standing position

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 Cardiac Output Regulation

Figure 11.7

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Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings 81 Slide 11.19
 Blood Pressure
• Blood pressure can be within a wide
range and still be normal
• AHA recommends that Blood Pressure
readings be averaged on two or more
subsequent occasions before diagnosing
high blood pressure
• A rise or fall of 20 to 30 mmHg is
significant

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 Categories for Blood Pressure
Levels in Adults
(Ages 18 Years and Older)         

  Blood Pressure Level (mmHg)

Category Systolic   Diastolic
Normal < 120 and < 80

Prehypertension 120-139 or 80-89

High Blood Pressure  

Stage 1 Hypertension 140–159 or 90–99

Stage 2 Hypertension 160 or 10

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Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings 83 Slide 11.41
 Blood Pressure
• The direct method of measuring blood
pressure requires an invasive procedure.
• The indirect method requires use of the
sphygmomanometer and stethoscope
for auscultation and palpation as needed.

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 • Measurements should be taken after the
patient rests for at least 1 minute and
has not consumed caffeine or smoked
for 30 minutes before the measurement.

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 Sites
• The most common site for indirect
measurement is the client’s arm over the
brachial artery.
• Accurate measurement requires the
correct width of the blood pressure cuff
as determined by the circumference of
the client’s extremity (40%) .

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 Auscultation
• Korotkoff sounds are five distinct phases
of sound heard with a stethoscope during
auscultation.

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 Measuring Arterial Blood Pressure

Figure 11.18

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Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings 91 Slide 11.37
 Palpation
• The forearm or leg sites can be palpated
to obtain a systolic reading when the
brachial artery is inaccessible.
• Palpatory Blood Pressure or Sensory
Detection Method

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 Hypotension
• Hypotension refers to a systolic blood
pressure less than 90 mm Hg or 20 to 30
mm Hg below the client’s normal systolic
pressure.
• Orthostatic Hypotension (postural
hypotension)
– Sudden drop in systolic pressure when client
moves from a lying to a sitting to a standing
position

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 Hypertension
• Hypertension refers to a persistent
systolic pressure greater than 135 to 140
mm Hg and a diastolic pressure greater
than 90 mm Hg.

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 Some Nursing Interventions for
Hypertension
• Low-fat diet
• Losing excess weight
• Limiting alcohol intake
• Eliminating smoking
• Reducing salt intake
• Having regular physical activity

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 Nursing Considerations
• False Readings
– Recently eaten, ambulated, or experienced
an emotional upset
– Improper cuff width
– Improper technique in deflating cuff
– Improper positioning of extremity
– Failure to recognize an auscultatory gap
• Documentation
– Record on appropriate form

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