NCM 101:

Health Assessment

Group 1:
Vital Signs

Submitted by:
Leader: Jamisola, Maria Maristel G.
Members: Abdullah, Abdul Majid V.
Agbay, Kryshna Kaye B.
Cala, Rovan Jon Antony T.
Enriquez, Deborah Chloe B.
BSN1-C

Submitted to:
Ms. Nikki Rae Cayanan

December 9, 2019
 Cebu Doctors’ University
College of Nursing
Cebu,Philippines

Health Assessment

Vital Signs

Objectives: After 3 hours of lecture discussion and classroom demonstration,

the Level I students will be able to:

1. Define the following terms

1.1 Vital signs – the most frequent and routine measurements obtained by
health care providers are those of temperature, pulse, blood pressure (BP),
respiratory rate and oxygen saturation.

1.2 Temperature – difference between the amount of heat produced by body

processes and the amount lost to the external environment.
Normal Body Temperature:
For Adults : 37° C (97.6-99.6°F)
For Children : 36.4°C (95.9-99.5°F)
For Infants: 36.4°C (97.5°F)

• Hyperthermia – an elevated body temperature related to the inability of

the body to promote heat loss or reduce heat production.In humans,
hyperthermia is defined as a temperature greater than 37.5–38.3 °C.
• Malignant hyperthermia- hereditary condition of uncontrolled heat
production that occurs when susceptible individuals receive certain
anesthetic drugs.
• Hypothermia – heat loss during prolonged exposure to cold overwhelms
the ability of the body to produce heat. Hypothermia (hi-poe-THUR-me-
uh) occurs as your body temperature falls below 95 F (35 C)
• Convection – is the transfer of heat away by air movement. A fan
promotes heat loss through convection. The rate of heat loss increases
when moistened skin comes into contact with slightly moving air.
• Radiation –is the transfer of heat from the surface of one object to the
surface of another without direct contact between the two. As much as
85% of the surface area of the human body radiates heat to the
environment.
• Evaporation – is the transfer of heat energy when a liquid is changed to
a gas. The body continuously loses heat by evaporation.
• 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.
• Lysis – step ladder pattern when elevated body temperature scatter down
to normal. It is the subsidence of one or more symptoms of an acute
disease as, for example, the lysis of fever in pneumonia.
• Stadium – a stage of period in the progress of disease.
• Diaphoresis – is visible perspiration primarily occurring on the forehead
and upper thorax, through you can see it in other places on the body. A
range of conditions can cause diaphoresis, including the following:
Menopause, Hyperthyroidism, Diabetes, Pregnancy, and Obesity.
• Core temperature – is the temperature of the deep tissues of the body,
such as abdominal cavity and pelvic cavity.
• Surface temperature – is the temperature of the skin, the
subcutaneous tissue and fat.
1.3 Pulse – the throbbing sensation that can be palpated over a peripheral
artery or auscultated over the heat; result of a wave of blood pumped into
arterial circulation by the contradiction of the left ventricle.
Normal Pulse Rate:
Resting normal adult: 60-100 bpm
For children:
3-4 years old: 80-120 bpm
5-6 years old: 75-115 bpm
7-9 years old: 70-110 bpm
For infants: 80-140 bpm

• Pulse rate – the number of pulsing sensations occurring in 1 minute

period. It is the product of the heart rate and stroke volume of ventricle.
• Cardiac output – stroke volume x heart rate. The amount of blood that
is pumped from the heart during each contraction.
• Stroke volume output – amount of blood ejected by the ventricles with
each contraction. It can be affected by the amount of blood in the left
ventricle at the end of diastole, the resistance to left ventricular ejection,
and myocardial contractility.
• Peripheral output – the nurse recorded in the arteries in distal portion
of the limbs, either radial or pedal.
• Apical pulse – heartbeat as listened to with the bell or diaphragm of a
stethoscope placed on the apex of the heart.
• Tachycardia – an abnormally elevated HR, above 100 beats/min n
adults.
• Bradycardia – is a low rate, below 60 beats/min in adults
• Pulse rhythm – regular interval happens between each pulse/heartbeat.
• Dysrhythmia – an interval interrupted by an early or late beat or a
missed beat indicates an abnormal rhythm
• Intermittent – irregular periods of alternating pauses and regular cycles
of the pulse.
• Pulse volume - strength of pulse shows volume of blood ejected arterial
wall which every heart contraction.
1.4 Respiration – The mechanism the body uses to exchange gases between
the atmosphere and the blood and the blood and the cells.
The normal respiration rate for an adult at rest is 12 to 20 breaths per
minute.

• Inspiration – An active process of the respiratory center sending

impulses along the phrenic nerve, which causes the diaphragm to
contract. During inspiration, the abdominal organs move downward and
forward, increasing the length of the chest cavity to move air into the
lungs.
• Expiration – is a passive process. During expiration the diaphragm
relaxes, the lung and chest wall return to a relaxed position, and the
abdominal organs return to their original positions.
• Internal respiration – the exchange of oxygen and carbon dioxide
between the capillaries and body tissue cells.
• External respiration – the exchange of oxygen and carbon dioxide
between the alveoli of the lungs and the pulmonary blood system.
• Hyperventilation – Respiratory rate in excess of that required to
maintain normal carbon dioxide levels in the body tissues.There are many
factors that can lead to hyperventilation. This condition most commonly
results from anxiety, panic, nervousness, or stress. It often takes the form
of a panic attack.
Other causes include: bleeding, use of stimulants, drug overdose (aspirin
overdose, for example), severe pain, pregnancy, infection in the lungs

• Hypoventilation – Respiratory rate is abnormally low and insufficient to

prevent carbon dioxide retention. The causes Hypoventilation include the
following:
-Chronic obstructive pulmonary disease (COPD), which includes
emphysema and bronchitis
-Chest wall deformities
-Central respiratory drive depression, which can be caused by alcohol and
certain drugs, such as narcotics
-Obesity
• Costal breathing – occur when the external intercostal muscles and the
other accessory muscle are used to move the chest upward and outward
• Diaphragmatic – Respiration in which the abdomen moves out while the
diaphragm descends on inspiration.
• Respiratory rate – Observe a full inspiration and expiration when
counting respiratory rate. The usual respiratory rate varies with age and
declines throughout life.
• Eupnea – Normal respirations that are quiet, effortless, and rhythmical.
• Apnea – Respirations cease for several seconds.
• Deep respiration – Involves a full expansion of the lungs with full
exhalation.
• Shallow breathing – Only a small quantity of air passes through the
lungs and ventilatory movement is difficult to see.
• Respiratory volume – the amount of hair inhaled, exhaled and stored
within the lungs at any given of time
• Respiratory quality – can be normal and abnormal quality. Normal-
does not require conscious effort, even and regular. Abnormal- may
experience pain and have labored breathing.
• Diffusion – The process for the exchange of respiratory gases in the
alveoli of the lungs and the capillaries of the body tissues.
• Perfusion – The ability of the cardiovascular system to pump oxygenated
blood to the tissues and return deoxygenated blood to the lungs.
1.5 Blood pressure – The force exerted on the walls of an artery by the pulsing
blood under pressure from the heart.

Patient Systolic BP (mmHg) Diastolic BP (mmHg)

Infants (0-3 months) 85-90 35-65
Infants (3 months– 1 year) 90-100 60-67

Children (1-4 years old) 100-108 60

Children (4-12 years old) +2 per year to 100 60-70
Adolescents 100-120 65-75
Adults <120 <80
Elderly (>65 years old) 120-140 80-90

• Systolic blood pressure – The pressure when the heart beats pumping
blood.
• Diastolic blood pressure – The pressure when the heart is at rest
between beats
• Pulse pressure – The difference between systolic and diastolic pressure.
• Hypertension – Disorder characterized by an elevated blood pressure.
• Hypotension – Abnormal lowering of blood pressure that is inadequate
for normal perfusion and oxygenation of tissues. (less than 90/60).
• Orthostatic hypotension – Abnormally low blood pressure occurring
when a person stands. Dehydration, blood loss, and anemia are the most
common reasons to develop low blood pressure when standing.
• Arterial blood pressure – The blood pressure in the system of arteries
in the body.
• Korotkoff’s sound – Sound heard during the taking of blood pressure
using a sphygmomanometer and stethoscope.
• Auscultatory gap – Disappearance of sound when obtaining a blood
pressure; typically occurs between the first and second Korotkoff sounds.
• Mean blood pressure – mean actual pressure = 2 x diastolic + systolic /
3 ex. BP of 130/80 : 130 + 160 = 290 / 3 = 96.7MAP
• Vasodilatation – Increase in the diameter of a blood vessel caused by
inhibition of its vasoconstrictor nerves or stimulation of dilator nerves.
2)Enumerate the importance of taking vital signs.
1.Provides baseline data of usual health of patient
2.Provides data for nursing interventions, and evaluation of the outcome
of care.
3.Understand risk to patient’s health and wellness.
4.Useful in establishing presence of disease, and monitoring of chronic
disease.
5.Basis for clinical decision making and problem solving.

3) State the indications in taking vital signs.

1.Initial evaluation of patient during admission to health care facility.
2.On a routine schedule in a hospital setting according to health care
provider orders.
3. Before and after transfusion of blood products, and administration of
medication/therapies.
4. Change in patients status or condition.

4)Explain the Scientific principles in taking vital signs.

1. Anatomy and Physiology

Knowledge of the different arteries to measure pulse.

2.Physics
Knowledge of the correct amount of pressure the Bp Cuff needs to place
on the arm in order to correctly close/open the brachial artery.

3. Pharmacology
Knowledge of guidelines on medication allows the medical team to analyze
the vital signs data, in order to determine whether or not the patient is
suitable/ is in need for certain medications.
4. Psychology
Use of various techniques to make the patient less anxious, so that they
aren’t producing variability to their normal values.

5. Immunology/ Microbiology
Pyrogens, acting as antigens, trigger immune system response, altering
patient’s temperature.
5. Guidelines for Taking Vital Signs
Guidelines
The nurse caring for the client is
responsible for vital signs
measurement.
Asses and select equipment on the
basis of the patient's condition and
characteristics
The nurse should know the client’s
normal range of vital signs.
The nurse should know the client’s
medical history, therapies, and
prescribed medications.
The nurse should control or
minimize environmental factors that
may affect vital signs.
The nurse should use a systematic
approach when taking vital signs.
On the basis of patient's condition,
the nurse should collaborate with
other health care providers
Following surgery or treatment
intervention, the nurse may measure
vital signs more often.
The nurse may use vital sign
assessment to determine indications
for medication administration.
The nurse should analyze the results
of vital sign measurement on the
basis of patient's condition and past
medical history.
The nurse should verify and
communicate significant changes in
vital signs.
Rationale
To review vital sign data, interpret
their significance, and critically think
through decisions about intervention
To ensure that it is working correctly
and to provide accurate findings.
The client’s usual values serve as a
baseline for comparison with findings
taken later to detect a change in
condition over time
Because some illnesses or treatments
cause predictable vital sign changes.
Measuring the pulse after the client
exercises may yield a value that is not
a true indicator of the client’s
condition.
To ensure accuracy
The nurse is responsible for judging
whether more frequent assessments
are necessary
To detect complications.
The nurse should know the acceptable
ranges for the patient before
administering medications.
The nurse is often in the best position
to assess all clinical findings about a
client.
When vital signs appear abnormal, it
may help to have another nurse
or a physician repeat the
measurement.
6.1 TEMPERATURE
6.1.1 Physiology

• Body temperature is the difference between the amount of heat produced by

body processes and the amount lost to the external environment.

Heat Produced - Heat Lost = Body Temperature

Despite extremes in environmental conditions and physical activity, temperature-

control mechanisms of humans keep body core temperature (temperature of the
deep tissues) relatively constant.

● Body Temperature Regulation

Physiological and behavioral mechanisms regulate the balance between heat lost
and heat produced, or thermoregulation.

● Neural and Vascular Control

The Hypothalamus, located between the cerebral hemispheres controls the body
temperature. The anterior part controls heat loss thus posterior part controls heat
production.
Set point - refers to a comfortable temperature at which a heating system
operates.
anterior > set point = reduced temp.
posterior < set point = increased temp.

● Heat Production
Temperature regulation depends on normal heat production processes. Heat
produced by the body is a by-product of metabolism - chemical reaction in all
body cells. Food is the primary fuel source for metabolism.
Heat production occurs during:
➢ rest
➢ Voluntary movements
➢ Involuntary shivering
➢ Nonshivering thermogenesis
➢

● Heat Loss
The structure of the skin and exposure to the environment result in constant
normal heat loss through:
➢ Radiation - the transfer of heat from the surface of one object to the
surface of another without direct contact between the two.
➢ Conduction - the transfer of heat from one object to another with direct
contact. Solid, liquid, gases conduct heat through contact.
➢ Convection - the transfer of heat away by air movement.
➢ Evaporation - the transfer of heat energy when a liquid is changed to
gas.
 ➢ Diaphoresis - visible perspiration primarily occurring on the forehead and
upper thorax, although can be seen in other places of the body.
● Skin
Skin regulates temperature through insulation of the body, vasoconstriction,
temperature sensation. The skin, subcutaneous tissue, and fat keep heat inside
the body.

● Behavioral Control
Healthy individuals are able to maintain comfortable body temperature when
exposed to temperature extremes. The ability of a person to control body
temperature depends on:
➢ The degree of temperature extreme
➢ The person’s ability to sense feeling comfortable or uncomfortable
➢ Thought processes or emotions, and
➢ The person’s mobility or ability to remove or add clothes.
➢ Individuals are unable to control body temperature if any if these abilities
are lost.

6.1.2 Factors Affecting Body Temperature

● Age - the temperature-control mechanism of a child and an adult differ on how

they respond to changes in the environment.

● Exercise - any form of exercise increases metabolism and heat production and
thus body temperature.

● Hormone Level - women generally experience greater fluctions in body

temperature than men. Hormonal variations during the menstrual cycle cause
body temperature fluctuations.

● Circadian Rhythm - the expression of circadian rhythm is modified by the

thermoregulatory mechanism controlling heat production and heat loss, which
also show circadian rhythms.

● Stress - Individuals dealing with chronic stress may experience a sudden spike in
body temperature. This fever is a biological reaction to an emotional event or
ongoing trauma. The condition is typically treated with anti-anxiety medications
and therapy.

● Environment - The temperature and humidity of the environment affect body

temperatures by requiring additional heating or cooling of a body to maintain a
temperature suitable to the required cellular processes and life.

● Temperature alterations - it includes fever, hyperthermia, heatstroke, heat

exhaustion, and hypothermia.
~ 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.
 ~ Hyperthermia - an elevated body temperature related to the inability of
the body to promote heat loss ore reduce heat production
~ Heatstroke - a dangerous heat emergency with a high mortality rate.
Prolonges exposure to the sun ir a high environmental temperature
overwhelms the heat-loss mechanisms of the body.
~ Heat Exhaustion - occurs when profuse diaphoresis results in excess
water or electrolyte loss. Caused by environmental heat exposure, a
patient exhibits signs and symptoms of deficient fluid volume.
~ Hypothermia - heat loss during prolonged exposure to cold
overwhelms teh ability of the body ro produce heat.

6.1.3 Types of Fever

● Sustained - a constant body temperature continuously above 38oC (100.4oF)
that has little fluctuation.

"
● Intermittent - fever spikes interspersed with usual temperature levels
(Temperature returns to acceptable value at least once in 24 hours.

"
● Remittent - fever spikes and falls without a return to acceptable temperature
levels

"

● Relapsing - periods of febrile episodes and periods with acceptable temperature

values (Febrile episodes and periods of normothermia are often longer than 24
hours)

"
6.1.4 Different Sites in Taking Temperature and its normal body temperature range

Normal Body Temperature: 97-99o F (36.1-37.2o C)

SITE TEMPERATURE (oF/ oC)

Oral 97.6 - 99.6oF (36.4 - 37.6oC)
Tympanic Membrane 98.6 - 100.6oF (37.0 - 38.1oC)
Rectal 98.6 - 100.6oF (37.0 - 38.1oC)
Axillary 96.6 - 98.6oF (35.9 - 37.0oC)

6.1.5 Equipment used in Taking Temperature

● Digital thermometers

! Digital thermometers are regarded as the fastest and most

accurate type of thermometer. Readings are taken from under the tongue, from
the rectum or under the armpit. They are easily found in local pharmacies and
can be used at home or in the hospital.

● Electronic ear thermometers

! These use infrared technology to get their temperature

reading. Electronic ear thermometers are less accurate as if there is too much
wax in the ear it can give an incorrect reading. Despite being expensive, they are
a lot easier to use on babies and young children, as it can be hard to get
children to sit still for long enough while using digital thermometers.
● Forehead thermometers
 ! These thermometers also read heat using infrared, and
are placed on the temporal artery. Forehead thermometers are also not as
reliable as digital thermometers

● Plastic strip thermometers

! These thermometers can detect the presence of a

fever in a patient, however, they do not give an exact temperature reading. They
simply act as an indication that something might be wrong. To use them, you just
place the strip on the forehead.

● Pacifier thermometer

! These thermometers are used predominantly in babies

older than three months. They require the baby to be still for a couple of minutes
and this can be a struggle. This means that sometimes the temperature can be
inaccurate.

● Glass and mercury thermometers

 ! These thermometers are the old school way to take a
temperature. You normally would place it under your tongue and watch the
mercury rise. Once it stops, that would be your temperature. Unfortunately, due to
the risk of mercury poisoning, this means of taking a temperature is not a good
idea and you are highly recommended to consult with a healthcare body to
discard any you might have.

6.2 PULSE


6.2.1 Physiology
The pulse is the palpable bounding of blood flow generated by the opening and
closing of the aortic valve in the heart. Blood flows through the body in a
continuous circuit. The pulse is an indirect indicator of circulatory status which
can be felt by applying firm fingertip pressure to the skin at sites where the
arteries travel near the skin’s surface; it is more evident when surrounding
muscles are relaxed.

● Cardiac output - refers to the volume of blood pumped by the heart during 1
minute and the product of Heart Rate (HR) and Stroke Volume (SV) of the
ventricle.
CO = HR x SV
● Heart Rate - is the speed of the heartbeat measured by the number of
contractions (beats) of the heart per minute (bpm) and the most common way to
change cardiac output.
● Stroke Volume - volume of blood pumped by each ventricle in one contraction
and is usually remains relatively constant.
6.2.2 Factors Influencing Pulse Rates
FACTOR INCREASES PULSE RATE DECREASE PULSE
RATE
Exercise Short-term exercise H conditioned by long-
term exercise, resulting
in lower resting pulse
and quicker return to
resting level after
exercise

Temperature Fever and heat Hypothermia

Emotions Sympathetic stimulation
increased by acute pain and
anxiety, affecting heart rate;
effect of chronic pain on heart
rate varies
Parasympathetic
stimulation increased by
unrelieved severe pain
affecting heart rate;
relaxation

Medications Positive chronotropic drugs Negative chronotropic

such as epinephrine drugs such as digitalis

Hemorrhage Sympathetic stimulation -

increased by loss of blood
Postural changes Standing or sitting Lying down
Pulmonary Diseases causing poor -
conditions oxygenation such as asthma,
chronic obstructive pulmonary
disease (COPD)

6.2.3 Character of the Pulse

The pulse rate, rhythm, strength, and equality are assessed when palpating
pulses.
● Rate. Pulse rates refers to the number of pulsing sensations occuring in 1
minute. It is exactly equal to the heartbeat, as the contractions of the heart cause
the increases in blood pressure in the arteries that lead to a noticeable pulse.
Taking the pulse is, therefore, a direct measure of heart rate. The pulse rate is
counted by starting at one, which correlates with the first beat felt by your fingers.
Count for thirty seconds if the rhythm is regular (even tempo) and multiply by two
to report in beats per minute. Count for one minute if the rhythm is irregular.

● Rhythm. The normal pulse rhythm is regular, meaning that the frequency of the
pulsation felt by your fingers follows an even tempo with equal intervals between
pulsations.
 ● Strength. The pulse force is the strength of the pulsation felt when palpating the
pulse. The force is important to assess because it reflects the volume of blood,
the heart’s functioning and cardiac output, and the arteries’ elastic properties.
Remember, stroke volume refers to the volume of blood pumped with each
contraction of the heart (i.e., each heart beat). Thus, pulse force provides an idea
of how hard the heart has to work to pump blood out of the heart and through the
circulatory system.
Pulse force is recorded using a four-point scale:
➢ 3+ Full, bounding
➢ 2+ Normal/strong
➢ 1+ Weak, diminished, thready
➢ 0 Absent/non-palpable

● Equality. Pulse equality refers to whether the pulse force is comparable on both
sides of the body. For example, palpate the radial pulse on the right and left wrist
at the same time and compare whether the pulse force is equal. Pulse equality is
assessed because it provides data about conditions such as arterial obstructions
and aortic coarctation.

6.2.4 Pulse Normal Range

AGE HEART RATE (bpm)

Infant 120-160 bpm
Toddler 90-140 bpm
Preschooler 80-110 bpm
School-age child 75-100 bpm
Adolescent 60-90 bpm
Adult 60-100 bpm

6.2.5 Sites in Taking a Pulse Rate

SITE LOCATION
Temporal Over temporal bone of head, above and lateral to eye
Carotid Along medial edge of sternocleidomastoid muscle in
neck
Apical Fourth to fifth intercostal space at left midclavicular
line
Brachial Groove between biceps and triceps muscles at
antecubital fossa
Radial Radial or thumb side of forearm at wrist
Ulnar Ulnar or little finger side of forearm at wrist
 Femoral Below inguinal ligament, midway between symphysis
pubis and anterior superior iliac spine
Popliteal Behind knee in popliteal fossa
Posterior tibial Inner side of ankle, below medial malleolus
Dorsalis pedis Along top of foot, between extension tendons of great
and first toe

6.2. 6 Various Pulse Rates and Rhythms

● Tachycardia
Tachycardia means that your heart is beating too fast. For example, a normal
heart beats 60 to 100 times per minute in adults. Tachycardia is any resting heart
rate over 100 beats per minute (BPM).

There are three subtypes of tachycardia:

➢ Supraventricular tachycardia occurs in the upper chambers of your heart

known as the atria.
➢ Ventricular tachycardia occurs in the lower chambers known as the
ventricles.
➢ Sinus tachycardia is a normal increase in the heart rate that may occur
when you’re sick or excited. With sinus tachycardia, your heartbeat
returns to normal once you get better or become calm.

● Bradycardia
If you’re bradycardic, it means you have a slow heart rate (less than 60 BPM).
Bradycardia generally occurs when the electrical signals traveling from the atria
to the ventricles become disrupted. Some athletes have slower heart rates
because they are in excellent physical condition, and this isn’t usually the result
of a heart problem.
6.3 RESPIRATION
6.3.1 Physiology

• Respiration is the mechanism the body uses to exchange gases between

the atmosphere and the. blood, and the blood and cells.

• Physiological control . Breathing is a passive process. Normally a person

thinks a 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. The body
regulates ventilation using levels of CO2, O2 , and hydrogen ion
concentration (pH) in the arterial blood. The most important factor in
ventilation is the level of CO2 . An elevation of CO2 level causes the
increase rate and depth of breathing. The increased ventilatory effort
removes excess CO2 by increasing exhalation.

• Mechanics of breathing. During inspiration, the diaphragm contracts.

Abdominal organs move downward and forward., increasing the length of
chest cavity to move air into the lungs. The diaphragm moves approx. 1
cm and ribs retract approximately 1.2-2.5 cm. During normal relaxed
breath, a person inhales 500mL or the tidal volume. During respiration,
the diaphragm relaxes, and the abdominal organs return to their original
positions. Inspiration is active while expiration is a passive process.
6.3.2 process of respiration
• VENTILATION- The movement of gases in and out of the lungs.

• DIFFUSION- The movement of carbon dioxide and oxygen between

the alveoli and the red blood cells; the process whereby gases
move from an area of high pressure to low pressure

• PERFUSION- The distribution of red blood cells to and from the

pulmonary capillaries; refers to the blood flow to tissues and
organs
 6.3.3 Assessment of respiration

Assessment of ventilation
• Respiration is the easiest to assess yet needs to be accurately measured.
• Do not let the patient know that you are assessing respirations. Keep in mind
the patient’s usual ventilatory rate and pattern
• The objective measurements are the rate and depth of breathing, and rhythm
of ventilatory movements.
• The respiratory rate varies with age. RR above 27 breaths/min is an important
risk for cardiac arrest.

Acceptable Ranges of Respiratory Rate

Age Rate(breaths/min)
Newborn 30-60
Infant (6 months) 30-50
Toddler (2 years) 25-32
Child 20-30
Adolescent 16-20
Adult 12-20

• Ventilatory depth. Observe the degree of excursion or movement in the chest

wall. Describe the movements as deep or shallow, normal or labored. A
deep respiration involves a full expansion of lungs with full exhalation.

• Ventilatory Rhythm. Observe the chest or abdomen. Healthy men and children
usually demonstrate diaphragmatic breathing while women use thoracic
muscles. longer expiration phase is evident when the outward flow of air
is obstructed. With normal breathing, a regular interval occurs after
every respiratory cycle. Infants tend to breathe less regularly. Estimate
the time interval after each respiratory cycle.
Assessment of diffusion and perfusion
Evaluate the respiratory process of diffusion and perfusion by
measuring the oxygen saturation of blood. Blood flow through the
pulmonary capillaries delivers red blood cells for oxygen attachment. The
percentage of hemoglobin that is bound with oxygen in the arteries is the
percent of saturation on hemoglobin or SaO2 . It is usually 95-100%.

• Measurement of Arterial Oxygen Saturation

A pulse oximeter permits the indirect measurement of oxygen saturation.
The pulse oximeter is a probe with light-emitting diode connected by cable
to an oximeter. A photodetector in the probe detects the amount of
oxygen bound to hemoglobin molecules, and the oximeter calculates the
pulse saturation(SpO2) which is a reliable estimate of SaO2.

6.3.4 Factors influencing respiration

Exercise
-increases rate and depth to meet the need of the body for
additional oxygen and to rid the body of carbon dioxide.

Acute pain
-Pain alters rate and rhythm of respirations; breathing becomes
shallow.
-Patient inhibits chest wall movement when the pain is in the chest
area of chest or abdomen.

Anxiety
-Anxiety increases respiration rate and depth as a result of
sympathetic stimulation.

Smoking
-Chronic smoking changes pulmonary airways, resulting in
increased rate of respirations at rest when not smoking
 Body position
-A straight, erect posture promoted full chest expansion.
-A stooped or slumped position impairs ventilatory movement.
-Lying flat prevents full chest expansion.

Medications
-Opioid analgesics, general anesthetics, and sedative hypnotics
depress rate and depth
- Amphetamines and coccaine sometimes increase rate and depth.
- Bronchodilators slow rate by causing airway dilation.

Neurological Injury
- Injury to brainstem impairs respiratory center and inhibits
respiratory rate and rhythm.

Hemoglobin function
-Decreased hemoglobin levels (anemia) reduce oxygen-carrying
capacity of the blood, which increases respiratory rate
-Increased altitude lowers amount of saturated hemoglobin, which
increases respiratory rate and depth.

6.3.5 Alterations in respiration

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)

Hyperpnea
- Respirations are labored, increased in dephy, and increased in rate
(occurs normally during exercise)

Apnea
-Respirations cease for several seconds. Persistent cessation results
in respiratory arrest.
 Hyperventilation
-Rate and depth of respirations increase.

Hypoventilation
-Respiratory rate is abnormally low, and depth of ventilation is
depressed.

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.

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.

6.4 BLOOD PRESSURE

6.4.1 Physiology

• Cardiac output
The BP depends on the cardiac output. When the blood volume
increases, the pressure rises. Cardiac output increases due to an
increase in :HR, heart muscle contraction, and increase in blood
volume.

• Peripheral Resistance
The BP depends on the peripheral vascular resistance. The size of
the arteries and arterioles changes to adjust blood flow to the
needs of local tissues. The smaller the lumen, the greater the
peripheral vascular resistance. As resistance rises, BP rises.
 • Blood volume
An increase in blood volume exerts more pressure in the arterial
walls. When the blood volume falls, the BP falls.

• Viscosity
Hematocrit determines blood viscosity. When hematocrit rises and
blood flow slows, arterial BP rises. The heart contracts more
forcefully to move viscous blood through the system

• Elasticity
As pressure within the arteries increases, vessel walls diameter
increases. However, in certain diseases such as arteriosclerosis, the
vessels lose their elasticity which results in greater resistance.

6.4.2 Factors affecting blood pressure

Age
-Normal BP levels vary throughout life. BP increases during
childhood. Evaluate the BP level with respect to body size and age.
The heavier or taller the children, the higher BP they obtain.

Stress
-Anxiety, fear, pain, and emotional stress result in sympathetic
stimulation, which increases HR, cardiac output, and vascular
resistance. Anxiety increases BP as much as 30 mmHg.

Ethnicity
- Genetic and environmental factors are often contributing factors.
Hypertension-related deaths are also higher among African-
Americans.

Gender
-After puberty, males tend to have higher BP readings. After
menopause, women tend to have higher BP than men of similar
age. Yet, there is no clinically significant difference in BP levels
between boys and girls.
 Daily variation
-BP varies throughout the day, with lower during sleep between
midnight and 3 am. Between 3am and 6am, there is a slow and
steady rise in BP. When the patient awakens, there is an early-
morning surge.

Medications
-Before BP assessment, ask whether the patient is receiving
antihypertensive, diuretic, or other cardiac medications, which
lower BP. Vasoconstrictors and excess volume of IV fluids increase
it.

Activity and weight

-A period of exercise can reduce BP for several hours afterwards.
An increase in oxygen demand during activity increases it.
Inadequate exercise contributes to weight gain, and obesity is a
factor in the development of hypertension.

Smoking
-Smoking results in vasoconstriction, a narrowing of blood vessels.

6.4.3 Normal ranges

Average Optimal Blood Pressure for Age

Age Blood Pressure (mmHg)
Newborn 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

Classification of BP for adults ager 18 and older

Category Systolic(mmHg) Diastolic(mmHg)
Normal <120 <80
Prehypertension 120-139 or 80-89
Stage 1 hypertension ≥140 or ≥90
Stage 2 hypertension ≥160 or ≥90
6.4.4 Methods in assessing blood pressure

Arterial BP measurements are obtained either (invasively) or

indirectly (non invasively). The direct method requires the insertion of a
thin catheter in an artery. Tubing connects the catheter with electronic
hemodynamic monitoring equipment. The monitor displays a constant
arterial pressure waveform and reading. The common indirect method
requires a sphygmomanometer and a stethoscope. Auscultation is the
most widely used technique.

Blood Pressure Equipment

• Make sure that you are comfortable with the sphygmomanometer
and stethoscope
• The sphygmomanometer includes pressure manometer, occlusive
cuff, inflatable rubber bladder, and pressure bulb
• Make sure the needle points to zero and that the manometer is
correctly calibrated
• The size of the cuff differs as the size of the limb circumference.
Ideally, the cuff width is 40% of the midpoint of the limb.
• Place the lower edge of the cuff above the antecubital fossa,
allowing room for the stethoscope bell
• The release valve of the sphygmomanometer must be clean and
freely movable for easy regulation.

Auscultation
• The best environment is a quiet room and comfortable
temperature.
• Sitting is the preferred position, although the patient may lie or
stand.
• Before obtaining BP, attempt to control facotrs for artificially high
reading such as pain, anxiety, or exertion.
• During the initial assessment, obtain and record the BP in both
arms. Normally there is a difference of 5-10 mmHg
between the arms. In subsequent assessments, measure
the arm with the higher pressure.
• Ask the patient to state his or her usual BP, inform him after
measuring. This is a good opportunity to educate the
patient about the optimal values of BP and risk factors.
 • The first onset of the sound corresponds to the systolic pressure.
• The second sounds is a blowing sound, while the third is more
intense tapping.
• The fourth becomes muffled and low pitched; this sound is the
diastolic pressure in infants and children
• In adolescents and adults, the fifth silent sound corresponds to
the diastolic pressure.
• Note the arm used in measuring (e.g., right arm [RA] 130/70)
and the patient’s position (e.g., sitting)

Assessment in children
-Children 3 years of age through adolescence need to have BP
checked atleast annually because of the changes in growth and
development. Help parents understand the importance of this routine
screening to detect children who are at risk of hypertension. They are
difficult to measure due to different arms sizes, restlessness, and low
amplitude of sound.

Ultrasonic stethoscope
-allows you to hear low frequency systolic sounds.

Palpation
-This method is useful for patients whose arterial pulsations are too
weak to create sounds. You can assess the systolic BP by palpation. The
diastolic is difficult to determine.

Lower-Extremity Blood Pressure

-Dressings, casts, IV catheters, or shunts make the upper
extremities inaccessible. The popliteal artery, behind the knee in the
popliteal space, is the site for auscultation. Placing the patient in prone
position is the best. The procedure is identical to brachial artery
auscultation. Systolic pressure in the legs is usually higher by 10 to 40
mmHg.

Electronic Blood Pressure Devices

-These machines rely on electronic sensor to detect vibrations of
blood. These devices are easy and efficient to use. However, automatic
 devices are not recommended for hypertensive patients because they are
unable to process low sounds of BP.

Self measurement of Blood Pressure

-improved technology allows individuals to measure own BP with
the push of a button. Aneroid sphygmomanometer and electronic digital
readout devices do not require the use of stethoscope. They are easier to
manipulate but require frequent recalibration and are sensitive.

7. Enumerate the different materials/equipment used in taking vital

signs
• Thermometry
• Stethoscopes
• Blood Pressure Devices
• Combo Kits (Stethoscope + Sphygmomanometer)
• Pulse Oximetry
• ECG
• Penlights
8. Demonstrate beginning skills in:

8.1 Taking and assessing the vital signs

8.1.1 Temperature

Assessment
• Assess for signs and symptoms of temperature alterations and factors that
accompany body temperature alterations.

• Determine previous activity that interferes with accuracy of temperature

measurement. When taking oral temperature, wait 20-30 minutes before
measuring temperatures if patient has smoked or ingested hot or cold
liquids or foods.
• Assess pertinent laboratory values, including complete blood count.
• Identify any medications or treatments that may influence body
temperature.
• Determine appropriate temperature site and device for patient.
• Obtain previous baseline temperature and measurement site from
patient's medical record.

Planning
• Identify patient using two identifiers (e.g., name and birth date, or medical
record number)
• Explain route by which temperature will be taken and importance of
maintaining proper position until reading is complete

Implementation
Equipment and Supplies

• Electronic thermometer
• appropriate probe (blue oral probes are used for axillary temperatures);
disposable probe cover
• paper and pen
• patient’s medical record
• tissue
• waste container

Method
• Perform hand hygiene.
• Greet and identify the patient.
• Explain the procedure. If the patient is a child, explain the procedure to
both the parent and child.

• Remove the electronic thermometer from its charging base, select the
appropriate probe, and attach a disposable probe cover.
• Ask the patient to expose the axilla (under the arm).
• Using a tissue, pat the axilla dry of any perspiration. Do not rub the area.
• Place the probe with cover into the axillary space.
 • Ask the patient to remain still and to hold the arm tightly next to the body
while the temperature registers.
• When the thermometer signals completion, remove the thermometer and
discard the probe cover in a waste container.
• Record the temperature in the patient’s medical record, making sure to
note that the temperature was obtained via the axillary route (AX) and
which side was used.
• Return the thermometer probe to its appropriate storage location, and
then return the entire unit to the rechargeable base.
• Perform hand hygiene.

Evaluation
• If temperature is assesses for the first time, establish temperature as
baseline if it is within normal range.

• Compare temperature reading with patient's previous baseline and

acceptable temperature range for his or her age-group.

8.1.2 Pulse

Assessment
• Determine need to assess radial or apical pulse:

• Assess pertinent laboratory values, including serum potassium and

compete blood count.

• Determine patient's previous baseline pulse rate if available in his or her

medical record.

• Determine if patient has latex allergy

Planning
• Identify patient using two identifiers (e.g., name, medical record number)

• Explain that you will assess pulse rate or heart rate. Encourage patient to
relax and not speak. If patient was active, wait 5 to 10 minutes before
assessing pulse.

Implementation

Equipment and Supplies

Paper and pen; patient’s medical record; watch with second hand

Method (Radial Pulse)

• Perform hand hygiene.

• Greet and identify the patient.
 Explain the procedure.
• Ask if the patient has recently smoked or performed ph
• Ask the patient to sit down and place the arm in a comfortable, supported
position. The hand should be at or below chest level with the palm facing
up.
Place fingertips on the radial artery on the thumb side of the wrist.
• Check the characteristics of the pulse for volume and rhythm.
• Start counting pulse beats when the second hand on the watch is at 3,
6,9,12 Count the pulse for 1 full minute (60 seconds).
• Perform hand hygiene.
• Record the pulse beats per minute in the patient’s medical record,
describing any characteristics or abnormalities in pulse rate.

Evaluation
• Compare readings with previous baseline and/or acceptable ranges of
heart rate for patient's age.
• Compare peripheral pulse rate with apical rate and note discrepancy.
• Compare radial pulse equality and note discrepancy.
• Correlate pulse rate with the data obtained from blood pressure and
related signs and symptoms (palpitations, dizziness)

8.1.3 Respiration rate

Assessment
• Determine need to assess patient's respirations:
• Assess pertinent laboratory values:
• Assess for factors that influences respirations.
• Determine previous baseline respiratory rate (if available) from patient's
record.

Planning
• Identify patient using two identifiers (e.g. name and birth date or name
and medical record number)
• Plan to assess respirations after measuring pulse in adult.

Implementation
To take respiration rate:

Equipment and Supplies

Patient’s medical record; watch with sweeping second hand; paper and pen

Method
• Perform hand hygiene.
• Greet and identify the patient.
• Assist the patient into a comfortable position.
• Place your hand on the patient’s wrist in position to take the pulse, or
place your hand on the patient’s chest or back.
• Count each breathing cycle by observing or feeling the rise and fall of the
 chest, back, or upper abdomen. Count breaths (inhale + exhale = 1
respiration) for one minute.
• Count for 1 full minute (60 seconds) using a watch with a second hand. If
the rate is a typical or unusual in any way, count respirations again for
another minute.
• Record the respiratory rate in the patient’s medical record, noting any
abnormality in rate, rhythm, and depth.
• Perform hand hygiene.

Evaluation
• If assessing respirations for the first time, establish rate, rhythm, and
depth as baseline if within normal range.
• Compare respiratory rate, depth, and rhythm with data obtained from
pulse oximetry and ABG measurements of available.

8.1.4 Blood Pressure

Assessment
• Determine need to assess patient's BP
• Asses for factors that affect BP
• Determine best site for BP assessment.
• Determine previous baseline BP (if available) from patient's record.
• Determine if patient has latex allergy.

Planning
Identify patient using two identifiers

• Explain to the patient that you will assess BP.

• Be sure that patient has not ingested caffeine or smoked 20 to 30 minutes
before BP measurement.
• Help patient to sitting position with legs uncrossed at knees if appropriate.
Be sure that room is warm, quiet and relaxing.
• Select appropriate cuff size.

Implementation
To take blood pressure:

Equipment and Supplies: Sphygmomanometer; stethoscope; 70 percent isopropyl

alcohol; alcohol sponges or cotton balls; paper and pen; patient’s medical record

Method

• Perform hand hygiene.

• Assemble the equipment. Using an alcohol wipe or cotton ball with 70
percent isopropyl alcohol, thoroughly cleanse the earpieces, bell, and
diaphragm pieces of the stethoscope. Allow the alcohol to dry.
• Greet and identify the patient, and explain the procedure.
• Assist the patient into a comfortable position. BP may be taken with the
patient in a sitting or supine (lying-down) position.
 • Uncover the patient’s arm 5 inches above the elbow. If the sleeve
becomes constricting when rolled back, ask the patient to slip the arm out
of the sleeve.
• Locate the brachial artery within the antecubital space (bend in the elbow)
by palpating with your fingertips. If the pulse is stronger in one arm than
the other, use the arm with the stronger brachial artery pulse.
• Have the patient straighten the arm with palm up and apply the proper-
size cuff of the sphygmomanometer over the brachial artery 1 to 2 inches
above the antecubital space.
• With the fingertips of your non-dominant hand, palpate the pulse in the
radial artery. Then, with your dominant hand, tighten the thumbscrew on
the hand bulb and pump air into the cuff quickly and evenly. Pump 20–30
mmHg above the point at which the radial pulse is no longer palpable.
Make note of this point.
• Rapidly deflate the cuff and wait 60 seconds before continuing.

Evaluation
• Compare reading with previous baseline and or/ acceptable value of BP for
patient's age.
• Compare BP in both arms and both legs.
• Correlate BP with data obtained from pulse assessment and related
cardiovascular signs and symptoms.