VITAL SIGNS

- baseline data for future assessment

- Measure of most basic function of the body

> Blood Pressure

> Body Temperature
> Respiratory Rate
> Pulse Rate

BODY TEMPERATURE
- indicates the difference between production of heat (body process) and loss of heat (external
environment)
- Measured in degrees

HEAT PRODUCTION

Heat Loss
• Evaporation - insensible water and heat loss
• Radiation
• Conduction
• Convection

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
Types of Body Temperature

1. Core Body Temperature

- High temperature (Deep Tissues)
- Regulated by Thermoregulatory center in the hypothalamus
- Tympanic, Rectal, Bladder, Esophagus, Pulmonary Artery, Oral

2. Surface Body Temperature

- Lower temperature
- Skin, subcutaneous tissue, and fats
- Axilla, Forehead

FACTORS AFFECTING BODY TEMPERATURE

AGE
- Infants and elderly are more sensitive to extreme temperature

SEX (Hormone Level)

 - Women tend to have more temperature fluctuation than men

- Circadian Rhythm
- Environment
- Exercise
- Stress

TEMPERATURE ALTERATIONS
- Hypothermia (Shivering)
- Hyperthermia (Perspiration)

SITES FOR MEASURING BODY TEMPERATURES

1. Oral
2. Rectal
3. Axillary
4. Tympanic Membrane
5. Skin/ Temporal Artery

Different Types of Thermometer

1. Electronic = 2- 60 seconds
2. Digital = Listen for a sound indicating that the maximum temperature has been reached
3. Tympanic= usually 2 seconds
4. Glass
5. Oral= 2-3 minutes
6. Rectal = 2 minutes
7. Axilla= 9 minutes
(for infants and children= 5 minutes)

* Temperature Sensitive Tape= 15 seconds

METHODS IN TEMPERATURE TAKING

* Oral
-most accessible and convenient method
-allow 15-30 minutes to elapse between intake of hot or cold food or smoking
-wash thermometer before use (bulb-to-stem) and after use (stem-to-bulb)

* Axillary
-safest and most non-invasive
-pat dry the axilla

COMMON INDICATION IN TAKING ORAL TEMPERATURE

X— oral lesion/ surgery, dyspnea, cough, nausea and vomiting

* Rectal
-most accurate measurement
-assume lateral position
-lubricate thermometer
-ask client to take a deep breath
- -insert thermometer as follows
— infant = 1.5 cm
 — children= 2.5 cm
— adult = 3.7 cm
-do not force to prevent anus perforation

X— anal/rectal conditions or surgeries, diarrhea, quadriplegic clients

AGE-RELATED VARIATIONS IN NORMAL TEMPERATURE

AGE TEMPERATURE SITE

Newborn 36.8 Axillary

1-3 y/o 37.7 Rectal

6-8 y/o 37.0 Orally

10 y/o 37.0 Orally

Teens 37.0 Orally

Adults 37.0 Orally

> 70 y/o 36.0 Orally

AVERAGE NORMAL TEMPERATURE FOR HEALTHY ADULTS AT VARIOUS EFFECT

SITE TEMPERATURE (CELSIUS) FAHRENHEIT

Oral 37.0 98.6

Rectal 37.5 99.5

Axilla 36.5 97.6

Tympanic 37.5 99.5

Forehead 34.4 94.0

TYPES OF FEVER
* Intermittent— alternates at regular intervals between periods of fever and periods of normal
* Remittent— fluctuations (above) 2 degrees Celsius over 24 hours all are above normal
* Relapsing— short febrile periods of a few days are interspered with periods of 1 or 2 days of normal
temperature
* Constant— fluctuates minimally but always above normal

PULSE
- wave of blood created by contraction of the left ventricle of the heart
- A throbbing sensation that can be palpated over the peripheral arteries or auscultated over the apex
of the heart

TWO TYPES OF PULSE

1. Apical Pulse= central pulse, located at the apex of the heart
Point of Maximal Impulse (PMI)—- where the apical pulse is best heard

Adult- 5th intercostal space mid clavicular line

Children- 4th intercostal space mid clavicular line
Infants- Mid clavicular line or line with the nipple

2. Peripheral Impulse= pulse located away from the heart

* Temporal — the site is superior (above) and lateral to (away from the midline of the eye)
* Carotid— at the side of the neck
* Brachial— at the inner aspect of the biceps muscle of the armor medially in the ante cubital space
* Radial— on the thumb side of the inner aspects of the wrist
* Femoral— alongside the inguinal ligament
* Popliteal— behind the knee
* Posterior Tibial— on the medial surface of the ankle
* Pedal (dorsalis pedis) — imaginary line drawn from the middle of the ankle to the space between
the big ad second toes

FACTOR AFFECTING PULSE

- Age
- Gender
- Exercise
- Fever
- Medications
- Hypovolemia
- Stress
- Position changes
- Pathology

PULSE

Take note of the following:

1. Rate— beats per minute (Normal= 60-100 bpm)

> Tachycardia— more than the normal pulse rate
> Bradycardia— less than the pulse rate

2. Rhythm— pattern of the beats and the intervals between them

> Dysrhythmia or arrythmia— pulse with irregular rhythm
> Regular or irregular

3. Pulse Volume/Force— also called pulse strength or amplitude, refers to the force of blood with
each beat
> Absent Pulse— no pulse felt
 > Thready Pulse— pulse not easily felt, disappears on slight palpation
> Weak Pulse— stronger than thready, disappears on light palpation
> Normal Pulse— pulse felt easily, disappears on moderate pressure
> Bounding Pulse— pulse is strong and does not disappear on moderate pressure

Measuring Apical Pulse

= locate the apical pulse by palpating for the fifth (5th) intercostal space, left mid clavicular
line (MCL)
= auscultate the apical pulse using a stethoscope with both a bell-shaped and flat disc of the
stethoscope. Count the apical pulse for 1 full minute.

Respirations
- Pulmonary ventilation/ Respiration
> other term for breathing
> the movement of air in and out of the lungs

TYPES OF BREATHING

*Costal (thoracic breathing)—- can be observe through the movement of the chest
*Diaphragmatic Breathing—- can be observed through the movement of the abdomen

TWO MECHANISMS OF BREATHING

1. Inhalation/ Inspiration= act of breathing in

2. Exhalation/ Expiration= act of breathing out

Respiratory System— the primary respiratory center is medulla oblongata

FACTORS THAT AFFECT RESPIRATION

1. Age= the respiratory rate decreased with age
2. Gender= In males, respiratory movements are primarily diaphragmatic. In females,
there is greater intercostals muscle movement
3. Exercise= causes an increase in rate and depth
4. Acid-Base Balance= alterations in acid-base balance commonly result in increased
rate and depth in respiration (hyperventilation)
5. Brain Lesions= lesions of the brain (e.g. hemorrhage and tumors) on brain stem can
likewise cause a change in depth and rate of respirations; most commonly manifested in
Cheyne-Strokes respirations
6. Increased Altitude= it may also increase respiratory rate and depth prior to
adaptation by increase hemoglobin levels
7. Respiratory Disease= any alteration in the normal respiratory structures may result in
changes in respiratory rate, depth, and patterns, which is most
manifested as difficult breathing, using accessory muscles where the
depth may be shallower.
“Smoking can also alter the pulmonary airways.”

8. Anemia= decrease in oxygen-carrying hemoglobin may result in an increase rate of

respiration
9. Anxiety= can cause sighing type of respiration and increase respiratory rate
10. Medication= narcotics, sedatives, and anesthetic agents slow respiratory rate and
depth
11. Acute Pain= it increases respiratory rate but may decrease respiratory depth

Assessing Respiration

1. Rate (breaths/cycles per minute)

2. Depth- observe the movement of the chest. Maybe normal, shallow, or deep
3. Rhythm- regular/irregular
4. Quality or Character- refers to respiratory effort and sound of breathing

Patterns of Respiration

- Normal/ Eupnea- characterized by 12-20 breaths/min; regular

- Tachypnea- >24 breaths/min; regular
- Bradypnea- <10 breaths/min; regular
- Apnea- cessation of breathing
- Dyspnea- difficulty of breathing
- Hyperventilation- increased rate and depth
- Hypoventilation- decreased rate and depth

Lifespan Consideration
Infants= newborns display “periodic breathing”
Children= diaphragmatic breathers
Elders= anatomic and psychologic changes cause respiratory system to be less efficient

Blood Pressure
- a measure of the pressure exerted by the blood as it flows through the arteries

*Systolic— the pressure of the blood as a result of contraction of the ventricles, that is
the pressure of the height of the blood wave
*Diastolic— which is the pressure when the ventricles are at rest

— The difference between the diastolic and the systolic pressure is called the PULSE PRESSURE

DETERMINANTS OF BLOOD PRESSURE

1. Blood Volume- hypovolemia lowers BP
hypervolemia raises BP

2. Cardiac Output- when the pumping action of the heart is weak (decreased CO),
BP decreases

3. Elasticity or Compliance of Blood Vessels- in older people, elasticity of blood vessels

decreases thereby BP.

4. Peripheral Resistance- vasoconstriction elevates BP, vasolidation lowers BP

5. Blood Viscosity- viscosity increases markedly when the Hematocrit is more than
60-65 % increase blood viscosity raises BP

FACTORS AFFECTING BLOOD PRESSURE

1. Age— older people have higher BP due to decreased elasticity of blood vessel
2. Exercise— increase CO hence increase the BP
3. Stress— sympathetic nervous system stimulation causes increased BP
4. Race— hypertension is one of the ten leading causes of death among Filipinos
5. Obesity— BP generally is elevated among overweight and obese people
6. Medication— some medications may increase or decrease BP
7. Sex/Gender— after puberty and before age 65 years old, males have higher BP. After 65 years,
females have higher BP due to hormonal variations in menopause
8. Diurnal Variations— BP is lowest in the morning and highest in the late afternoon or early
evening
9. Disease Process— diabetes mellitus, renal failure, hyperthyroidism, Cushing’s disease cause
increase in BP

ALTERATION IN BLOOD PRESSURE

=Hypertension: a blood pressure that is persistently above normal. Usually asymptomatic

Types (2)
* Essential or Primary Hypertension- hypertension of unknown causes
* Secondary Hypertension- hypertension secondary to disease process

=Hypotension: blood pressure that is below normal. Orthostatic hypotension is a blood pressure that
falls when the client sits or stands

*Korotkoff’s Sound— the sound heard over the stethoscope when taking blood pressure, it comprises
5 phases in the series of sounds

TWO TYPES OF MANOMETER

1. Aneroid
2. Mercurial
- Cuff— the cuff must fit the client to avoid erroneous BP reading
> Too Narrow— false high BP reading
> Too Wide— false low BP reading

PARTS OF SPHYGMOMANOMETER
- Cuff
- Bladder
- Connecting tubes
- Valve
- Bulb

Assessing Blood Pressure

1. Ensure that the client is rested
2. Allow 30 minutes to pass if the client had engaged in exercise or had smoked or ingested caffeine
before taking the BP. These factors tend to increase BP
3. Use appropriate size BP cuff. Too narrow cuff causes false high reading. Too wide cuff causes
false low reading.
4. Position the client in sitting or supine position
5. Position the arm 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
6. Apply BP cuff snugly 1 inches above the antecubital fossa
7. Determine palpatory BP before auscultatory BP to prevent auscultatory BP
8. Use the bell of the stethoscope since the blood is a low frequency sound
9. Inflate and deflate BP cuff slowly 2-3 mmHg at a time
10. Wait 1-2 minutes before making further determination
11. The sound during the BP taking is Korotkoff sound