Vital Signs- are body temperature, pulse,

respirations, and blood pressure.

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 2. Muscle activity. Muscle activity, including
that could affect the respiratory or cardiovascular
shivering, increases the metabolic rate.
systems; for example, before giving a digitalis
3. Thyroxine output. Increased thyroxine output
preparation
increases the rate of cellular metabolism throughout
 Before and after any nursing intervention that could
the body.
affect the vital signs (e.g., ambulating a client who has
been on bed rest).
4. Epinephrine, norepinephrine, and sympathetic
stimulation/ stress response. These hormones
immediately increase the rate of cellular metabolism
BODY TEMPERATURE- reflects the balance in many body tissues.
between the heat produced and the heat lost from the 5. Fever. Fever increases the cellular metabolic rate
body and is measured in heat units called degrees. and thus increases the body’s temperature further.

There are two kinds of body temperature: Heat is lost from the body through radiation,
Core temperature- is the temperature of conduction, convection, and evaporation.
the deep tissues of the body, such as the abdominal
Conduction is the transfer of heat from one molecule
cavity and pelvic cavity. It remains relatively
constant. to a molecule of lower temperature. Conductive
transfer cannot take place without contact between
Surface temperature- is the temperature of the skin, the molecules and normally accounts for minimal
the subcutaneous tissue, and fat. It, by contrast, rises heat loss except, for example, when a body is
and falls in response to the environment. immersed in cold water. The amount of heat
transferred depends on the temperature difference
Several factors affect the body’s heat production. and the amount and duration of the contact.
Radiation is the transfer of heat from
The most important are these five:
the surface of one object to the surface of another
1. Basal metabolic rate. is the without contact between the two objects, mostly in
rate of energy utilization in the body required to the form of infrared rays.
maintain essential activities such as breathing.
Convection is the dispersion of heat by air currents.
Metabolic rates decrease with age. In general, the
The body usually has a small amount of warm air
younger the person, the higher the BMR.
adjacent to it. This warm air rises and is replaced by
cooler air, so people always lose a small amount of
heat through convection.

Evaporation is continuous vaporization of moisture

from the respiratory tract and from the mucosa of the
mouth and from the skin.
This continuous and unnoticed water loss is called
insensible water loss, and the accompanying heat loss
is called insensible heat loss. Insensible heat loss
accounts for about 10% of basal heat loss. When the
body temperature increases, vaporization accounts
for greater heat loss.
Regulation of Body Temperature
The system that regulates body temperature has three
main parts:
sensors in the periphery and in the core, an
integrator in the hypothalamus, and an effector
system that adjusts the production and loss
of heat.

When the skin becomes chilled over the entire body,

three physiological processes to increase the body
temperature take place:
5. Stress. Stimulation of the sympathetic nervous
1. Shivering increases heat production. system can increase the production of epinephrine
2. Sweating is inhibited to decrease heat loss. and norepinephrine, thereby increasing metabolic
3. Vasoconstriction decreases heat loss. activity and heat production. Nurses should anticipate
that a highly stressed or anxious client
Factors Affecting Body Temperature could have an elevated body temperature for that
reason.
1. Age. Infants are greatly influenced by the
6. Environment. Extremes in environmental
temperature of the environment
temperatures can affect a person’s temperature
and must be protected from extreme changes.
regulatory systems. If the temperature is assessed in a
Children’s temperatures vary more than those of
very warm room and the body temperature
adults do until puberty. Many older people,
cannot be modified by convection, conduction, or
particularly those over 75 years, are at risk of
radiation, the temperature will be elevated. Similarly,
hypothermia (temperatures below 36°C, or 96.8°F)
if the client has been outside in cold weather without
for a variety of reasons, such as inadequate diet, loss
suitable clothing, or if a medical
of subcutaneous fat, lack
condition prevents the client from controlling the
of activity, and reduced thermoregulatory efficiency.
temperature in the environment (e.g., the client has
Older adults are also particularly sensitive to
altered mental status or cannot dress self), the body
extremes in the environmental
temperature may be low.
temperature due to decreased thermoregulatory
controls.
2. Diurnal variations (circadian rhythms). Body Alterations in Body Temperature
temperatures normally change throughout the day, The normal range for adults is between
varying as much as 1.0°C (1.8°F) between the early 36°C and 37.5°C (96.8°F to 99.5°F).
morning and the late afternoon. The
point of highest body temperature is usually reached There are two primary alterations in body
between 1600 and 1800 hours (4:00 pm and 6:00 temperature: pyrexia and hypothermia.
pm), and the lowest point is reached during sleep
between 0400 and 0600 hours (4:00 am and 6:00 am) 1. pyrexia, hyperthermia or (in lay terms) fever. –
(Figure 29–3 •). Older adults’ temperatures may vary A body temperature above the usual range
less than those of younger persons due to the changes 2. hyperpyrexia- A very high fever, such as 41°C
in autonomic functioning common in aging (105.8°F).
(Marigold, Arias, 3. febrile- The client who has a fever
Vassallo,Allen, & Kwan, 2011). 4. afebrile- the one who does not
3. Exercise. Hard work or strenuous exercise can
increase body temperature to as high as 38.3°C to
40°C (101°F to 104°F) measured rectally.
4. Hormones. Women usually experience more
hormone fluctuations than men. In women,
progesterone secretion at the time of ovulation raises Four common types of fevers;
body temperature by about 0.3°C to 0.6°C
(0.5°F to 1.0°F) above basal temperature. 1. intermittent fever- the body temperature
alternates at regular intervals between periods of
fever and periods of normal or subnormal
temperatures. An example is with the disease Persons experiencing heat stroke generally have
malaria. been exercising in hot weather, have warm, flushed
skin, and often do not sweat. They usually have a
2. remittent fever- such as with a cold or influenza, a temperature of 41.1°C (106°F) or higher, and may be
wide range of temperature fluctuations (more than delirious, unconscious, or having seizures.
2°C [3.6°F]) occurs over a 24-hour period, all of
which are above normal.

3. relapsing fever- short febrile periods of a few days

are interspersed with periods of 1 or 2 days of normal
temperature.

4. constant fever- the body temperature fluctuates

minimally but always remains above normal. This
can occur with typhoid fever. A temperature that rises
to fever level rapidly following a normal
temperature and then returns to normal within a few
hours called a fever spike. Bacterial blood infections
often cause fever spikes.

An elevated temperature is not a true fever.

Two examples are:

Heat exhaustion- is a result of excessive heat and

dehydration. Signs of heat exhaustion include

HYPOTHERMIA- is a core body temperature

below the lower limit of normal.

three physiological mechanisms of hypothermia:

(a) excessive heat loss,
(b) inadequate heat production to counteract
heat loss,
(c) impaired hypothalamic thermoregulation.

Accidental hypothermia can occur as a result:

(a) exposure to a cold environment,
(b) immersion in cold water,
(c) lack of adequate clothing, shelter, or heat.

paleness, dizziness, nausea, vomiting, fainting, and a

moderately increased temperature (38.3°C to 38.9°C
[101°F to 102°F]).
 both inpatient and ambulatory care settings.

5. The temperature may also be measured on the

forehead using a chemical thermometer or a
temporal artery thermometer. Forehead
temperature measurements are most useful for infants
and children when a more invasive measurement is
not necessary.

TYPES OF THERMOMETERS
Assessing Body Temperature
most common sites for measuring body temperature: Electronic thermometers can provide a reading in
1. The body temperature may be measured orally. If
a client has been taking cold or hot food or fluids or
smoking, the nurse should wait 30 minutes before
taking the temperature orally to ensure that the
temperature of the mouth is not affected by the
temperature of the food, fluid, or warm smoke.

2. Rectal temperature readings are considered to be

very accurate. Rectal temperatures are
contraindicated for clients who are undergoing
rectal surgery, have diarrhea or diseases of the
rectum, are immunosuppressed,
have a clotting disorder, or have significant
hemorrhoids.

3. The axillary is often the preferred site for

measuring temperature in newborns because it is
accessible and safe. Axillary temperatures
are lower than rectal temperatures. Some clinicians
recommend rechecking an elevated axillary
temperature with one taken from another only 2 to 60 seconds, depending on the model. The
site to confirm the degree of elevation. Nurses should equipment consists of an electronic base, a probe, and
check agency protocol when taking the temperature a probe cover, which is usually disposable. Some
of newborns, infants, toddlers, and children. Adult institutional models have a different circuit and probe
clients for whom the axillary method of temperature for oral and rectal measurement.
assessment is appropriate include those for whom
other temperature sites are contraindicated. Two special types of oral thermometers are basal
and hypothermia.
4. The tympanic membrane, or nearby tissue in the A basal thermometer is calibrated with 0.1°F
ear canal, is a frequent site for estimating core body intervals and is for fertility purposes, indicating the
temperature. However, tympanic temperature rise that is associated with ovulation.
temperature measurements have been shown to be Hypothermia thermometers have a greater low
imprecise (Rubia-Rubia, Arias, Sierra, & Aguirre- range than everyday thermometers, usually
Jaime, 2011). If the probe fits measuring temperatures from 27.2°C to 42.2°C (81°F
too loosely in the ear canal, the reading can be lower to 108°F).
than the true value. Electronic tympanic
thermometers are found extensively in
Chemical disposable thermometers are also used to
measure body temperatures. Chemical thermometers To convert from Celsius to Fahrenheit, multiply the
have liquid crystal dots or bars Celsius reading by the fraction 9/5 and then add 32;
that change color to indicate temperature. Some of that is:
these are single use and others may be reused several
times. One type that has small chemical F = (Celsius temperature x 9/5) +32
dots at one end.
To read the temperature, the nurse notes the highest For example, when the Celsius reading is 40:
reading among the dots that have changed
color. These thermometers can be used orally, F = (40 x 9/5) = 72 +32 = 104
rectally, or in the axilla.
Temperature-sensitive tape may also be used to PULSE
obtain a general indication of body surface The pulse is a wave of blood created by contraction of
temperature. It does not indicate the core the left ventricle of the heart. Generally, the pulse
temperature. The tape contains liquid crystals that wave represents the stroke volume output or the
change color according to temperature. When applied amount of blood that enters the arteries with each
to the skin, usually of the forehead or abdomen, the ventricular contraction.
temperature digits on the tape respond by changing Compliance of the arteries is their ability to
color. The skin area should be dry. After the length of contract and expand. When a person’s arteries lose
time specified by the manufacturer (e.g., 15 seconds), their distensibility, as can happen with age, greater
a color appears on the tape. This method is pressure is required to pump the
particularly useful at home and for infants whose blood into the arteries.
temperatures are to be monitored. Cardiac output is the volume of blood pumped into
Infrared thermometers sense body heat in the form the arteries by the heart and equals the result of the
of infrared energy given off by a heat source, which, stroke volume (SV) times the heart rate (HR) per
in the ear canal, is primarily minute. For example, 65 mL x 70 beats per minute 5
the tympanic membrane. The infrared thermometer 4.55 L per minute. When an adult
makes no contact with the tympanic membrane. is resting, the heart pumps about 5 liters of blood
Temporal artery thermometers determine each minute. In a healthy person, the pulse reflects
temperature using a scanning infrared thermometer the heartbeat; that is, the pulse rate is the same as the
that compares the arterial temperature in the temporal rate of the ventricular contractions of the
artery of the forehead to the temperature in the heart. However, in some types of cardiovascular
room and calculates the heat balance to approximate disease, the heartbeat and pulse rates can differ. For
the core temperature example, a client’s heart may produce
of the blood in the pulmonary artery. The probe is very weak or small pulse waves that are not
placed in the middle of the forehead and then drawn detectable in a peripheral pulse far from the heart. In
laterally to the hairline. If the client has perspiration these instances, the nurse should assess the
on the forehead, the probe is also touched behind the heartbeat and the peripheral pulse. A peripheral pulse
earlobe so the thermometer can compensate for is a pulse located away from the heart, for example,
evaporative cooling. in the foot or wrist. The apical
pulse, in contrast, is a central pulse; that is, it is
TEMPERATURE SCALES located at the apex of the heart. It is also referred to
Sometimes a nurse needs to convert a body as the point of maximal impulse (PMI).
temperature reading in Celsius (centigrade) to
Fahrenheit, or vice versa. Although the
conversion can be accomplished using several Factors Affecting the Pulse
different formulas, the most common is described The rate of the pulse is expressed in beats per minute
here. To convert from Fahrenheit to Celsius, deduct (beats/min). A pulse rate varies according to a
32 from the Fahrenheit reading and then multiply by number of factors. The nurse should
the fraction 5/9; that is: consider each of the following factors when assessing
a client’s pulse:
• Age. As age increases, the pulse rate gradually
C = (Fahrenheit temperature -32) x 5/9
decreases overall. See Table 29–2 for specific
For example, when the Fahrenheit reading is 100: variations in pulse rates from birth to adulthood.
• Sex. After puberty, the average male’s pulse rate is
C = (100-32) = (68)x 5/9 = 37.8 slightly lower than the female’s.
• Exercise. The pulse rate normally increases with age, the apex is left of the midclavicular line (MCL);
activity. The rate of increase in the professional between 4 and 6 years, it is at the MCL . For a child 7
athlete is often less than in the average person to 9 years of age, the apical pulse is located at the
because of greater cardiac size, strength, and fourth or fifth
efficiency. intercostal space.
• Fever. The pulse rate increases (a) in response to the 4. Brachial, at the inner aspect of the biceps muscle
lowered blood pressure that results from peripheral of the arm or medially in the antecubital space.
vasodilation associated with elevated body 5. Radial, where the radial artery runs along the
temperature and (b) because of the increased radial bone, on the thumb side of the inner aspect of
metabolic rate. the wrist.
• Medications. Some medications decrease the pulse 6. Femoral, where the femoral artery passes
rate, and others increase it. For example, cardiotonics alongside the inguinal ligament.
(e.g., digitalis preparations) decrease the heart rate, 7. Popliteal, where the popliteal artery passes behind
whereas epinephrine increases the knee.
it. 8. Posterior tibial, on the medial surface of the ankle
• Hypovolemia/dehydration. Loss of blood from the where the posterior
vascular system increases the pulse rate. In adults, the tibial artery passes behind the medial malleolus.
loss of circulating volume 9. Dorsalis pedis, where the dorsalis pedis artery
results in an adjustment of the heart rate to increase passes over the bones of the foot, on an imaginary
blood pressure as the body compensates for the lost line drawn from the middle of the ankle to the space
blood volume. between the big and second toes.
• Stress. In response to stress, sympathetic nervous The radial site is most commonly used in adults. It is
stimulation increases the overall activity of the heart. easily found in most people and readily accessible.
Stress increases the rate as Assessing the Pulse
well as the force of the heartbeat. Fear and anxiety as A pulse is commonly assessed by palpation (feeling)
well as the perception of severe pain stimulate the or auscultation (hearing). The middle three fingertips
sympathetic system. are used for palpating all pulse sites except the apex
• Position. When a person is sitting or standing, blood of the heart. A stethoscope is used for assessing
usually pools in dependent vessels of the venous apical pulses. A Doppler ultrasound stethoscope is
system. Pooling results in a transient decrease in the used for pulses that are difficult to assess. The DUS
venous blood return to the heart and a subsequent headset has earpieces similar to standard stethoscope
reduction in blood pressure and increase in heart rate. earpieces, but it has a long cord attached to a volume-
• Pathology. Certain diseases such as some heart controlled audio unit and an ultrasound transducer.
conditions or those that impair oxygenation can alter The DUS detects movement of red blood cells
the resting pulse rate. through a blood vessel. In contrast to the
Pulse Sites conventional stethoscope, it eliminates environmental
A pulse may be measured in nine sites: sounds.
1. Temporal, where the temporal artery passes over A pulse is normally palpated by applying moderate
the temporal bone of the head. The site is superior pressure with the three middle fingers of the hand.
(above) and lateral to (away The pads on the most distal
from the midline of) the eye. aspects of the finger are the most sensitive areas for
2. Carotid, at the side of the neck where the carotid detecting a pulse. With excessive pressure, one can
artery runs between the trachea and the
sternocleidomastoid muscle. the left side of the chest,
about 8 cm (3 in.) to the left of the sternum
(breastbone) at the fifth intercostal space (area
between the ribs). In older adults, the apex may be
further left if conditions are present that have led to
an enlarged heart. Before 4 years of
obliterate a pulse, whereas with too little pressure one expansibility or its deformities. A healthy, normal
may not be able to detect it. Before the nurse assesses artery feels straight, smooth, soft, and
the resting pulse, the client should assume a pliable. Older adults often have inelastic arteries that
comfortable position. feel twisted (tortuous) and irregular on palpation.
The nurse should also be aware of the following: When assessing a peripheral pulse to determine the
• Any medication that could affect the heart rate. adequacy of blood flow to a particular area of the
• Whether the client has been physically active. If so, body (perfusion), the nurse
wait 10 to 15 minutes until the client has rested and should also assess the corresponding pulse on the
the pulse has slowed to its usual rate. other side of the body. The second assessment gives
• Any baseline data about the normal heart rate for the nurse data with which to compare
the client. For example, a physically fit athlete may the pulses. For example, when assessing the blood
have a resting heart rate below 60 beats/min. flow to the right foot, the nurse assesses the right
• Whether the client should assume a particular dorsalis pedis pulse and then the left dorsalis pedis
position (e.g., sitting). In some clients, the rate pulse. If the client’s right and left pulses are
changes with the position because of changes in the same volume and elasticity, the client’s dorsalis
blood flow volume and autonomic nervous system pedis pulses are bilaterally equal. The pulse rate does
activity. When assessing the pulse, the nurse collects not need to be counted when
the following data: the rate, rhythm, volume, arterial assessing for perfusion and equality. When a
wall elasticity, and presence or peripheral pulse is located, it indicates that pulses
absence of bilateral equality. An excessively fast more proximal to that location will also be present.
heart rate (e.g., over 100 beats/min in an adult) is For example, if the dorsalis pedis, the most distal
referred to as tachycardia. A heart rate in an adult of pulse of the lower extremity, cannot be felt, the nurse
less than 60 beats/min is called bradycardia. If a next palpates for the posterior tibial pulse. If it is not
client has either tachycardia or bradycardia, the felt, the popliteal pulse must be assessed. If the
apical pulse should be assessed. popliteal pulse is found, it is
The pulse rhythm is the pattern of the beats and the not necessary to assess the femoral pulse since it
intervals between the beats. Equal time elapses must also be present in order for the more distal pulse
between beats of a normal pulse. A pulse with an to exist.
irregular rhythm is referred to as a dysrhythmia Or
arrhythmia. It may consist of random, irregular beats Apical Pulse Assessment
or a predictable pattern of irregular beats Assessment of the apical pulse is indicated for
(documented as “regularly irregular”). When a clients whose peripheral pulse is irregular or
dysrhythmia is detected, the apical pulse should be unavailable and for clients with known
assessed. An electrocardiogram (ECG) is necessary cardiovascular, pulmonary, and renal diseases. It is
to define the dysrhythmia further. commonly assessed prior to administering
Pulse volume, also called the pulse strength or medications that affect heart rate. The apical
amplitude, refers to the force of blood with each beat. site is also used to assess the pulse for newborns,
Usually, the pulse volume is the same with each beat. infants, and children up to 2 to 3 years old.
It can range from absent to bounding. A normal pulse
can be felt with moderate pressure of the fingers and APICAL-RADIAL PULSE ASSESSMENT
can be An electrocardiogram (ECG) is necessary to
define the dysrhythmia An apical-radial pulse may need to be assessed for
further. clients with certain cardiovascular disorders.
Pulse volume, also called the pulse strength or Normally, the apical and radial rates are identical.
amplitude, refers to the force of blood with each An apical pulse rate greater than a radial pulse rate
beat. Usually, the pulse volume is the same with each can indicate that the thrust of the blood from the heart
beat. It can range from absent to bounding. A normal is too weak for the wave to be felt at the peripheral
pulse can be felt with moderate pressure of the pulse site, or it can indicate that vascular disease is
fingers and can be obliterated with greater pressure. preventing impulses from being transmitted. Any
A forceful or full blood volume that discrepancy between the two pulse rates is called a
is obliterated only with difficulty is called a full or pulse deficit and needs to be reported promptly. In no
bounding pulse. instance is the radial pulse greater than the apical
A pulse that is readily obliterated with pressure from pulse.
the fingers is referred to as weak, feeble, or thready.
The elasticity of the arterial wall reflects its
An apical-radial pulse can be taken by two nurses or (H+) in the arterial blood
one nurse, although the two-nurse technique may be
more accurate.

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.
There are basically two types of breathing: costal
(thoracic) breathing and diaphragmatic (abdominal)
breathing.
Costal breathing involves the external intercostal
muscles and other accessory muscles, such as the
sternocleidomastoid muscles. It can be observed by
the movement of the chest upward and outward. By
contrast, diaphragmatic breathing involves the
contraction and relaxation
of the diaphragm, and it is observed by the movement
of the abdomen, which occurs as a result of the
diaphragm’s contraction and
downward movement.

Mechanics and Regulation of Breathing

During inhalation, the following processes
normally occur: The diaphragm contracts (flattens),
the ribs move upward and outward, and the sternum
moves outward, thus enlarging the thorax and
permitting the lungs to expand. During exhalation,
the diaphragm relaxes, the ribs move downward and
inward, and the sternum moves inward, thus Assessing Respirations
decreasing the size of the thorax as the lungs are Resting respirations should be assessed when the
compressed. Normal breathing is automatic and client is relaxed because exercise affects respirations,
effortless. A normal adult inspiration lasts 1 to 1.5 increasing their rate and depth.
seconds, and an expiration lasts 2 to 3 seconds. Anxiety is likely to affect respiratory rate and depth
Respiration is controlled by (a) respiratory centers as well. Respirations may also need to be assessed
in the medulla oblongata and the pons of the brain after exercise to identify the client’s
and (b) chemoreceptors tolerance to activity. Before assessing a client’s
located centrally in the medulla and peripherally respirations, a nurse should be aware of the
in the carotid and aortic bodies. These centers and following:
receptors respond to changes in the concentrations of • The client’s normal breathing pattern
oxygen (O2), carbon dioxide (CO2), and hydrogen • The influence of the client’s health problems on
respirations
• Any medications or therapies that might affect
respirations
• The relationship of the client’s respirations to
cardiovascular function.
The rate, depth, rhythm, quality, and effectiveness of
respirations should be assessed. The respiratory rate
is normally described in
breaths per minute. Breathing that is normal in rate Respiratory quality or character refers to those aspects
and depth is called eupnea. Abnormally slow of breathing that are different from normal, effortless
respirations are referred to as bradypnea, breathing. Two of these aspects are the amount of
and abnormally fast respirations are called tachypnea effort a client must exert to breathe and the sound of
or polypnea. breathing. Usually, breathing does not require
Apnea is the absence of breathing. noticeable
effort. Sometimes, however, clients can breathe only
Factors Affecting Respirations with substantial effort—this is referred to as labored
Several factors influence respiratory rate. Those breathing. The sound of breathing is also significant.
that increase the rate include exercise (increases Normal breathing is silent, but a number of abnormal
metabolism), stress (readies the body for “fight or sounds such as a wheeze are obvious to the nurse’s
flight”), increased environmental temperature, and ear. Many sounds occur as a result of the presence of
lowered oxygen concentration at increased altitudes. fluid in the lungs and are most clearly heard with a
Factors that may decrease stethoscope. See
the respiratory rate include decreased environmental Chapter 30 for methods used to assess lung sounds.
temperature, certain medications (e.g., narcotics), and For details about altered breathing patterns and terms
increased intracranial pressure. The depth of a used to describe various
person’s respirations can be established by watching patterns and sounds, see Box 29–5.
the movement of the chest. Respiratory depth is The effectiveness of respirations is measured in part
generally described by the uptake of oxygen from the air into the blood
as normal, deep, or shallow. Deep respirations are and the release of carbon dioxide from the blood into
those in which a large volume of air is inhaled and expired air. The amount of hemoglobin
exhaled, inflating most of the lungs. Shallow in arterial blood that is saturated with oxygen can be
respirations involve the exchange of a small volume measured indirectly through pulse oximetry. A pulse
of air and often the minimal use of lung tissue. oximeter provides a digital readout of both the
During a normal inspiration and expiration, an adult client’s pulse rate and the oxygen saturation.
takes in about 500 mL of air. This
volume is called the tidal volume. For further BLOOD PRESSURE
information about pulmonary volumes and Arterial blood pressure is a measure of the pressure
pulmonary capacities, see Chapter 50 . exerted by the blood as it flows through the arteries.
Body position also affects the amount of air that can Because the blood moves in waves, there are two
be inhaled. People in a supine position experience blood pressure measurements.
two physiological processes
that suppress respiration: an increase in the volume of The systolic pressure is the pressure of the blood as a
blood inside the thoracic cavity and compression of result of contraction of the ventricles, that is, the
the chest. Consequently, pressure of the height of the blood wave.
clients lying on their back have poorer lung aeration, The diastolic pressure is the pressure when the
which predisposes them to the stasis of fluids and ventricles are at rest. Diastolic pressure, then, is the
subsequent infection. Certain lower pressure, present at all times within the
medications also affect the respiratory depth. For arteries. The difference between the diastolic and
example, narcotics such as morphine and large doses the systolic pressures is called the pulse pressure. A
of barbiturates such as pentobarbital normal pulse pressure is about 40 mmHg but can be
depress the respiratory centers in the brain, thereby as high as 100 mmHg during
depressing the respiratory rate and depth. exercise. Blood pressure is measured in millimeters
Hyperventilation refers to very deep, rapid of mercury (mmHg) and recorded as a fraction:
respirations; hypoventilation refers to very shallow systolic pressure over the diastolic pressure. A typical
respirations. blood pressure for a healthy adult is 120/80 mmHg
Respiratory rhythm refers to the regularity of the (pulse pressure of 40). Because blood pressure can
expirations and the inspirations. Normally, vary considerably
respirations are evenly spaced. Respiratory among individuals, it is important for the nurse to
rhythm can be described as regular or irregular. An know a specific client’s baseline blood pressure. For
infant’s respiratory rhythm may be less regular than example, if a client’s usual blood
an adult’s. See Chapter 50 for details about abnormal pressure is 180/100 mmHg, and it is assessed
respiratory rhythms. following surgery to be 120/80 mmHg, this
significant drop in pressure may indicate
complications and must be reported to the primary When the blood volume decreases (for example, as a
care provider. A consistently elevated pulse pressure result of a hemorrhage or dehydration), the blood
occurs in arteriosclerosis. pressure decreases because of decreased
A low pulse pressure (e.g., less than 25 mmHg) fluid in the arteries. Conversely, when the volume
occurs in conditions such as severe heart failure. increases (for example, as a result of a rapid
Sometimes, it is useful to also determine the mean intravenous infusion), the blood pressure increases
arterial pressure (MAP) because this represents the because of the greater fluid volume within the
pressure actually delivered to the body’s organs. The circulatory system.
MAP can be calculated
in several different ways, one of which is to add two- BLOOD VISCOSITY
thirds of the diastolic pressure to one-third of the Blood pressure is higher when the blood is highly
systolic pressure. A normal viscous (thick), that is, when the proportion of red
MAP is 70 to 110 mmHg. blood cells to the blood plasma is high. This
Determinants of Blood Pressure proportion is referred to as the hematocrit. The
Arterial blood pressure is the result of several factors: viscosity increases markedly when the hematocrit is
the pumping action of the heart, the peripheral more than 60% to 65%.
vascular resistance (the resistance
supplied by the blood vessels through which the Factors Affecting Blood Pressure
blood flows), and the blood volume and viscosity. Among the factors influencing blood pressure are
age, exercise, stress, race, gender, medications,
PUMPING ACTION OF THE HEART obesity, diurnal variations, medical conditions,
When the pumping action of the heart is weak, less and temperature.
blood is pumped into arteries (lower cardiac output), • Age. Newborns have a systolic pressure of about 75
and the blood pressure decreases. mmHg. The pressure rises with age, reaching a peak
When the heart’s pumping action is strong and the at the onset of puberty, and then tends to decline
volume of blood pumped into the circulation somewhat. In older adults, elasticity of
increases (higher cardiac output), the blood pressure the arteries is decreased—the arteries are more rigid
increases. and less yielding to the pressure of the blood. This
produces an elevated systolic pressure. Because the
walls no longer retract as flexibly with decreased
pressure, the diastolic pressure may also be high.
PERIPHERAL VASCULAR RESISTANCE • Exercise. Physical activity increases the cardiac
Peripheral resistance can increase blood pressure. output and hence the blood pressure. For reliable
The diastolic pressure especially is affected. Some assessment of resting blood pressure,
factors that create resistance in the arterial system are wait 20 to 30 minutes following exercise.
the capacity of the arterioles and capillaries, the • Stress. Stimulation of the sympathetic nervous
compliance of the arteries, and the viscosity of the system increases cardiac output and vasoconstriction
blood. The internal diameter or capacity of the of the arterioles, thus increasing
arterioles and the capillaries the blood pressure reading; however, severe pain can
determines in great part the peripheral resistance to decrease blood pressure greatly by inhibiting the
the blood in the body. The smaller the space within a vasomotor center and producing vasodilation.
vessel, the greater the resistance. • Race. African Americans older than 35 years tend to
Normally, the arterioles are in a state of partial have higher blood pressures than European
constriction. Increased vasoconstriction, such as Americans of the same age although
occurs with smoking, raises the blood pressure, the exact reasons for these differences are unclear
whereas decreased vasoconstriction lowers the blood (Covelli, Wood, & Yarandi, 2012).
pressure. • Sex. After puberty, females usually have lower
If the elastic and muscular tissues of the arteries are blood pressures than males of the same age; this
replaced with fibrous tissue, the arteries lose much of difference is thought to be due to hormonal
their ability to constrict and dilate. This condition, variations. After menopause, women generally have
most common in middle-aged and older higher blood pressures than before.
adults, is known as arteriosclerosis. • Medications. Many medications, including caffeine,
may increase or decrease the blood pressure.
• Obesity. Both childhood and adult obesity
BLOOD VOLUME predispose to hypertension.
• Diurnal variations. Pressure is usually lowest early of less than 90 mmHg. For all other individuals, the
in the morning, when the metabolic rate is lowest, goal is less than 140/90 mmHg (James et al., 2014).
then rises throughout the day and peaks in the late
afternoon or early evening.
• Medical conditions. Any condition affecting the
cardiac output, blood volume, blood viscosity, and/or
compliance of the arteries has a direct effect on the Hypotension
blood pressure. Hypotension is a blood pressure that is below normal,
• Temperature. Because of increased metabolic rate, that is, a systolic reading consistently between 85 and
fever can increase blood pressure. However, external 110 mmHg in an adult whose normal pressure is
heat causes vasodilation and decreased blood higher than this. Orthostatic
pressure. Cold causes vasoconstriction and
elevates blood pressure.
Hypertension
A blood pressure that is persistently above normal is
called hypertension. A single elevated blood pressure
reading indicates the need for reassessment.
Hypertension cannot be diagnosed unless an
elevated blood pressure is found when measured
twice at different
times. It is usually asymptomatic and is often a
contributing factor to myocardial infarctions (heart
attacks). An elevated blood pressure
of unknown cause is called primary hypertension.

An elevated blood pressure of known cause is called

secondary hypertension.
Hypertension is a widespread health problem.
Individuals with diastolic blood pressures of 80 to
89 mmHg or systolic blood pressures of 120 to 139
Hypotension is a blood pressure that decreases when
mmHg should be considered prehypertensive and,
the client sits or stands. It is usually the result of
without intervention, may develop cardiac disease.
peripheral vasodilation in which
Hypertension is when either the systolic BP is higher
blood leaves the central body organs, especially the
than 140 mmHg or when the
brain, and moves to the periphery, often causing the
diastolic blood pressure (BP) is 90 mmHg or higher
person to feel faint. Hypotension
(see Table 29–4). The stage of hypertension is
can also be caused by analgesics such as meperidine
determined by the higher of the two values. For
hydrochloride (Demerol), bleeding, severe burns, and
example, if either of the systolic or diastolic values
dehydration. It is important
falls in the stage 2 range, stage 2 hypertension is
to monitor hypotensive clients carefully to prevent
assigned. Factors associated
falls. When assessing for orthostatic hypotension:
with hypertension include thickening of the arterial
• Place the client in a supine position for 10 minutes.
walls, which reduces the size of the arterial lumen,
• Record the client’s blood pressure.
and inelasticity of the arteries
• Assist the client to slowly sit or stand. Support the
as well as such lifestyle factors as cigarette smoking,
client in case of faintness.
obesity, heavy alcohol
• Immediately recheck the blood pressure in the same
consumption, lack of physical exercise, high blood
sites as previously.
cholesterol levels, and continued exposure to stress.
• Repeat the pulse and blood pressure after 3 minutes.
The national guidelines for high blood pressure
• Record the results. A drop in blood pressure of 20
management recommend that hypertensive
mmHg systolic or 10 mmHg diastolic indicates
individuals age 60 years or older receive treatment
orthostatic hypotension
toward a goal of less than 150/90 mmHg and
(Mager, 2012).
hypertensive individuals age 30 through 59 years
have a diastolic goal
Assessing Blood Pressure
Blood pressure is measured with a blood pressure
cuff, a sphygmomanometer, and a stethoscope. The
blood pressure cuff consists of a bag, called a
bladder, that can be inflated with air (Figure 29–18 •).
It is covered with cloth and has two tubes attached to
it. One tube connects to a bulb that inflates the
bladder. A small valve on the side of
this bulb traps and releases the air in the bladder.
The other tube is attached to a sphygmomanometer.
The sphygmomanometer indicates the pressure of the
air within the
bladder. There are two types of sphygmomanometers:
aneroid and digital. The aneroid sphygmomanometer
has a calibrated dial with a needle that points to the
calibrations (Figure 29–19 •). Many agencies use
digital (electronic) sphygmomanometers (Figure 29–
20 •), which eliminate the need to listen for the (McFarlane, 2012). Blood pressure cuffs are made of
sounds of the client’s systolic and diastolic blood nondistensible material so that an even pressure is
pressures through a stethoscope. Electronic blood exerted around the limb. Most cuffs are held in place
pressure devices should be calibrated by hooks, snaps, or hook-and-loop fabric. Others
periodically to check accuracy. All health care have a cloth bandage that is long enough to encircle
facilities should have manual blood pressure the limb several times;this type is closed by tucking
equipment available as backup. Doppler ultrasound the end of the bandage into one of the bandage folds.
stethoscopes are also used to assess blood pressure
(see Figure 29–15). These are of particular value
when blood pressure sounds are difficult to hear, such
as in infants, obese clients,
and clients in shock. Systolic pressure may be the
only blood pressure obtainable with some ultrasound
models. Blood pressure cuffs come in various sizes
because the bladder
must be the correct width and length for the client’s
arm (figure 29–21 •). If the bladder is too narrow, the
blood pressure reading will be erroneously elevated;
if it is too wide, the reading
will be erroneously low. The width should be 40% of
the circumference, or 20% wider than the diameter of
the midpoint, of the limb on which it is used. The arm
circumference, not the age of the client, should
always be used to determine bladder size. The nurse
can determine whether the width of a blood pressure
cuff is appropriate:
Lay the cuff lengthwise at the midpoint of the upper
arm, and hold the outermost side of the bladder edge
laterally on the arm. With the
other hand, wrap the width of the cuff around the
arm, and ensure that the width is 40% of the arm
circumference (Figure 29–22 •). The length of the
bladder also affects the accuracy of measurement.
The bladder should be sufficiently long to cover at
least two-thirds of the limb’s circumference. For
obese clients, a standard sized bladder in an extra-
long cuff may be the most appropriate
 The blood pressure is usually assessed in the client’s
upper arm using the brachial artery and a standard
stethoscope. Assessing the blood
pressure on a client’s thigh is indicated in these
h situations:
• The blood pressure cannot be measured on either
arm (e.g., because of burns or other trauma).
• The blood pressure in one thigh is to be compared
with the blood pressure in the other thigh. Blood
pressure is not measured on a particular client’s limb
in the following
situations:
• The shoulder, arm, or hand (or the hip, knee, or
ankle) is injured or diseased.
• A cast or bulky bandage is on any part of the limb.
• The client has had surgical removal of breast or
axillary (or inguinal) lymph nodes on that side.
• The client has an intravenous infusion or blood
transfusion in that limb.
• The client has an arteriovenous fistula (e.g., for
renal dialysis) in that limb.

METHODS
Blood pressure can be assessed directly or indirectly.
Direct (invasive monitoring) measurement involves
the insertion of a catheter into the brachial, radial, or
femoral artery. Arterial pressure is represented as
wavelike forms displayed on a monitor. With correct
placement,
this pressure reading is highly accurate.
Two noninvasive indirect methods of measuring
blood pressure are the auscultatory and palpatory
methods. The auscultatory method is most commonly
used in hospitals, clinics, and homes. External
pressure is applied to a superficial artery and the
nurse reads the pressure from the
sphygmomanometer while listening with a
stethoscope. When carried out correctly, the
auscultatory method is relatively accurate.
BLOOD PRESSURE ASSESSMENT SITES
When taking a blood pressure using a stethoscope, made based on blood pressure. It is an important
the nurse identifies phases in the series of sounds indicator of the client’s condition and is used
called Korotkoff’s sounds (Figure 29–23 •). Five phases extensively as a basis for nursing interventions.
occur but may not always be audible Two possible reasons for blood pressure errors are
(Box 29–6). The systolic pressure is the point where hurrying on the part of the nurse and subconscious
the first tapping sound is heard (phase 1). In adults, bias in which a nurse may
the diastolic pressure is the point be influenced by the client’s previous blood pressure
where the sounds become inaudible (phase 5). The measurements or diagnosis and “hear” a value
phase 5 reading may be zero; that is, the muffled consistent with the nurse’s expectations.
sounds are heard even when there is
no air pressure in the blood pressure cuff. For
complete accuracy, the phase 4 and 5 readings should
be recorded. The palpatory method is sometimes used OXYGEN SATURATION
when Korotkoff ’s sounds cannot be heard and A pulse oximeter is a noninvasive device that
electronic equipment to amplify the estimates a client’s arterial blood oxygen saturation
sounds is not available, or to prevent misdirection (SaO2) by means of a sensor attached to the client’s
from the presence of an auscultatory gap. An finger (Figure 29–25 •), toe, nose, earlobe,
auscultatory gap, which occurs particularly in or forehead (or around the hand or foot of a neonate).
hypertensive clients, is the temporary disappearance The oxygen saturation value is the percent of all
of sounds normally heard over the brachial artery hemoglobin binding sites that
when the cuff pressure are occupied by oxygen. The pulse oximeter can
is high followed by the reappearance of the sounds at detect hypoxemia (low oxygen saturation) before
a lower level. This temporary disappearance of clinical signs and symptoms, such as a dusky color to
sounds occurs in the latter skin and nail beds, develop. The pulse oximeter’s
part of phase 1 and phase 2 and may cover a range of sensor has two parts: (a) two light-emitting diodes
40 mmHg. If a palpated estimation of the systolic (LEDs)—one red, the other infrared—that transmit
pressure is not made prior to auscultation, light through nails, tissue, venous blood, and arterial
the nurse may begin listening in the middle of this blood; and (b) a
range and underestimate the systolic pressure. In the photodetector placed directly opposite the LEDs
palpatory method of blood pressure determination, (e.g., the other side of the finger, toe, or nose).
instead of listening for the blood flow sounds, the Because the photodetector measures the
nurse uses light to moderate pressure to palpate the amount of red and infrared light absorbed by
pulsations of the artery as the pressure in the cuff is oxygenated and deoxygenated
released. The pressure hemoglobin in peripheral arterial blood, it is reported
is read from the sphygmomanometer when the first as SpO2. Normal oxygen saturation is 95% to 100%,
pulsation is felt. A single whiplike vibration, felt in and below 70% is
addition to the pulsations, identifies the point at life threatening. Pulse oximeters with various types
which the pressure in the cuff nears the diastolic of sensors are available from
pressure. This vibration is no longer felt when the several manufacturers. The oximeter unit consists of
cuff pressure is below the diastolic pressure. an inlet connection for the sensor cable, and a
faceplate that indicates (a) the oxygen
saturation measurement and (b) the pulse rate.
Cordless units are also available (Figure 29–26 •). A
preset alarm system signals high and
low SpO2 measurements and a high and low pulse
rate. The high and low SpO2 levels are generally
preset at 100% and 85%, respectively,
for adults. The high and low pulse rate alarms are
usually preset at 140 and 50 beats/min for adults.
These alarm limits can, however, be
changed using the manufacturer’s directions.
Common Errors in Assessing
Blood Pressure
The importance of the accuracy of blood pressure
assessments cannot be overemphasized. Many
judgments about a client’s health are
Factors
Affecting
Oxygen
Saturation
Readings
Among the
factors
influencing
oxygen
saturation
readings are
hemoglobin levels, circulation, activity, and exposure
to carbon monoxide.
• Hemoglobin. If the hemoglobin is fully saturated
with oxygen, the SpO2 will appear normal even if the
total hemoglobin level is low. Thus, the client could
be severely anemic and have inadequate
oxygen to supply the tissues but the pulse oximeter
would return a normal value.
• Circulation. The oximeter will not return an
accurate reading if the area under the sensor has
impaired circulation.
• Activity. Shivering or excessive movement of the
sensor site may interfere with accurate readings.
• Carbon monoxide poisoning. Pulse oximeters
cannot discriminate between hemoglobin saturated
with carbon monoxide versus
oxygen. In this case, other measures of oxygenation
are needed.