Vital Signs

Learning Outcomes
1. Describe factors that affect the vital signs and
accurate measurement of them.
2. Identify the variations in normal body
temperature, pulse, respirations, and blood pressure
that occur from infancy to old age.
3. Verbalize the steps used in:
 a. Assessing body temperature.
 b. Assessing a peripheral pulse.
 c. Assessing the apical pulse and the apical-
radial pulse.
 d. Assessing respirations.
 e. Assessing blood pressure.
 f. Assessing blood oxygenation using pulse
oximetry.
Learning Outcomes
4.Describe appropriate nursing care for alterations
in vital signs.
5. Identify nine sites used to assess the pulse and
state the reasons for their use.
6. List the characteristics that should be included
when assessing pulses.
7. Describe the mechanics of breathing and the
mechanisms that control respirations.
8. Recognize when it is appropriate to delegate
measurement of vital signs to unlicensed assistive
personnel.
9. Demonstrate appropriate documentation and
reporting of vital signs.
The traditional vital signs are body
temperature, pulse, respirations,
and blood pressure.

Pain to be assessed as the fifth

vital signs.
When and how often to assess a
specific client’s vital signs are
chiefly nursing judgments,
depending on the client’s
health status.
TEMPERATURE
BODY TEMPERATURE
Reflects the balance between the heat produced and the heat
lost from the body, and is measured in heat units called
degrees.

Hypothalamus – Regulates the body temperature.

Kinds of body temperature:

 Core temperature
 Surface temperature.
Core Temperature
The temperature of the deep tissues of the
body, such as the abdominal cavity,pelvic
cavity, chest cavity. It remains relatively
constant.

Our body must maintain an internal

temperature for us to stay alive.

Range: 36.5 - 37.5 degrees Celsius

Surface Temperature
The temperature of the skin,
the subcutaneous tissue, and
fat. It, by contrast, rises and
falls in response to the
environment.
 When the amount of heat produced by the
body equals the amount of heat lost, the
person is in heat balance.

Heat production Heat loss

• Basal metabolic • Radiation
rate • Conduction
• Exercise/Shivering • Convection
• Secretion of • Evaporation
thyroxine,
epinephrine, and
norepinephrine,
• Inflammation/Fever
Factors that affect body heat
production
1. Basal metabolic rate (BMR)
 Rate of energy utilization in the body required to maintain essential
activities such as breathing. Metabolic rates decrease with age. In
general, the younger the person, the higher the BMR.
2. Muscle activity.
 Muscle activity, including shivering, increases the metabolic rate.
3. Thyroxine output.
 Increased thyroxine output increases the rate of cellular metabolism
throughout the body.
4. Epinephrine, norepinephrine, and sympathetic
stimulation/ stress response.
 These hormones immediately increase the rate of cellular
metabolism in many body tissues.
5. Fever.
 Fever increases the cellular metabolic rate and thus increases the
body’s temperature
Factors contributing to heat
loss

Radiation
Conduction
Convection
Evaporation
Radiation
 Is the transfer of heat from the surface of one object to the
surface of another without contact between the two objects,
mostly in the form of infrared rays.
Conduction
 is the transfer of heat from one molecule to a molecule of
lower temperature. Conductive transfer cannot take place
without contact between the molecules and normally
accounts for minimal heat loss except, for example, when a
body is immersed in cold water.
Convection
 is the dispersion of heat by air currents. The body usually has
a small amount of warm air 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
 Continuous vaporization of moisture from the skin
Regulation of body temperature

The system that regulates body temperature

has three main parts:
 Sensors in the periphery
 Sensors in the core
 Effector system that adjusts the production and
loss of heat.

The skin has more receptors for cold than

warmth. Therefore, skin sensors detect cold
more efficiently than warmth.
Physiological processes to
increase the body temperature
1. Shivering increases heat
production.
2. Sweating is inhibited to
decrease heat loss.
3. Vasoconstriction decreases
heat loss.
Hypothalamus
When the Hypothalamus detects
heat, it sends out signals intended
to reduce the temperature, that is,
to decrease heat production and
increase heat loss.
 In contrast, when the cold sensors
are stimulated, the hypothalamus
sends out signals to increase heat
production and decrease heat
loss.
Hypothalamus
The signals from the cold-sensitive
receptors of the hypothalamus initiate
effectors, such as vasoconstriction,
shivering, and the release of epinephrine,
which increases cellular metabolism and
hence heat production.

When the warmth-sensitive receptors

in the hypothalamus are stimulated, the
effector system sends out signals that initiate
sweating and peripheral vasodilation.
 Or
al

Factors Affecting Body

te
m
pe
rat
ur

Temperature e
(°
C)

Age
Variations/Circadian rhythm
Exercise
Hormones
Stress
Environment
Alterations in Body
Temperature
The normal range for adults is considered
to be between 36°C and 37.5°C (96.8°F to
99.5°F).

Primary alterations in
body temperature:
1. Pyrexia
2. Hypothermia.
Pyrexia
A body temperature above the usual range
is called pyrexia, hyperthermia, or (in lay
terms) fever.

A very high fever, such as 41°C (105.8°F),

is called hyperpyrexia.

The client who has a fever is referred to as

febrile;
The one who does not is afebrile.
Types of fevers

Intermittent
Remittent
Relapsing
Constant.
Types of fevers
Intermittent fever
 the body temperature alternates at regular
intervals between periods of fever and
periods of normal or subnormal
temperatures.
Remittent fever
such as with a cold or influenza, a wide
range of temperature fluctuations (more
than 2°C [3.6°F]) occurs over a 24-hour
period, all of which are above normal.
Types of fevers
Relapsing fever
Short febrile periods of a few days
are interspersed with periods of 1 or
2 days of normal temperature.

Constant fever
 The body temperature fluctuates
minimally but always remains above
normal.
 °F °C

Death
107.6 42

Hyperpyrexia
105.8 41

104.0 40

Pyrexia
102.2 39

100.4 38

98.6 37 Normal Average

range
36
96.8

95.0 35
Hypothermia

93.2 34 Death
Clinical Signs of Fever
May vary with the onset, course, and
abatement stages of the fever.

Under normal conditions, whenever the

core temperature rises, the rate of heat loss
is increased, resulting in a fall in
temperature toward the set-point level.
When the core temperature falls, the rate of
heat production is increased, resulting in a
rise in temperature toward the set point.
Clinical Signs of Fever
ONSET (COLD OR CHILL PHASE)
Increased heart rate
Increased respiratory rate and depth
Shivering
Cold skin
Complaints of feeling cold
Cyanotic nail beds
Cessation of sweating
Clinical Signs of Fever
COURSE (PLATEAU PHASE)
Absence of chills
Skin that feels warm
Photosensitivity
Increased pulse and respiratory rates
Increased thirst
Mild to severe dehydration
Drowsiness, restlessness, delirium, or
convulsions
Loss of appetite (if the fever is prolonged)
Malaise, weakness, and aching muscles
Clinical Signs of Fever
DEFERVESCENCE
(FEVER ABATEMENT/FLUSH PHASE)
Skin that appears flushed and feels warm
Sweating
Decreased shivering
Possible dehydration
Nursing Interventions for client with
Fever
 Monitor vital signs.
 Assess skin color and temperature.
 Monitor white blood cell count, hematocrit value,
and other pertinent laboratory reports for
indications of infection or dehydration.
 Remove excess blankets when the client feels
warm, but provide extra warmth when the client
feels chilled.
 Provide adequate nutrition and fluids (e.g., 2,500–
3,000 mL/ day) to meet the increased metabolic
demands and prevent dehydration.
Nursing Interventions for client with
Fever
 Measure intake and output.
 Reduce physical activity to limit heat production,
especially during the flush stage.
 Administer antipyretics (drugs that reduce the level
of fever) as ordered.
 Provide oral hygiene to keep the mucous
membranes moist.
 Provide a tepid sponge bath to increase heat loss
through conduction.
 Provide dry clothing and bed linens.
HYPOTHERMIA
A core body temperature below the
lower limit of normal.

Three physiological mechanisms

 excessive heat loss,
 inadequate heat production to
counteract heat loss, and
 impaired hypothalamic
thermoregulation.
Clinical Manifestations of
Hypothermia
 Decreased body temperature, pulse, and
respirations
 Severe shivering (initially)
 Feelings of cold and chills
 Pale, cool, waxy skin
 Frostbite (discolored, blistered nose, fingers, toes)
 Hypotension
 Decreased urinary output
 Lack of muscle coordination
 Disorientation
 Drowsiness progressing to coma
Nursing Interventions for client with
Hypothermia
Provide a warm environment.
Provide dry clothing.
Apply warm blankets.
Keep limbs close to body.
Cover the client’s scalp with a cap or
turban.
Supply warm oral or intravenous fluids.
Apply warming pads.
 Site Advantages Disadvantages

Oral Accessible and convenient - Thermometers can break if bitten.

- Inaccurate if client has just ingested hot
or cold food or fluid or smoked. Could
injure the mouth following oral surgery

Rectal Reliable measurement - Inconvenient and more unpleasant for

clients; difficult for client who cannot turn to
the side.
- Could injure the rectum.
- Presence of stool may interfere with
thermometer placement.

Axillary Safe and noninvasive -The thermometer may need to be left in

place a long time to obtain an accurate
measurement.

Temporal artery Safe and noninvasive; very - Requires electronic equipment that may
be expensive or unavailable.
- Variation in technique needed if the
client has perspiration on the forehead.

Tympanic membrane Readily accessible; - Can be uncomfortable and involves risk of

injuring the membrane if the probe is
inserted too far.
- Repeated measurements may vary.
- Right and left measurements can differ.
- Presence of cerumen can affect the
reading
PULSE
PULSE

The pulse is a wave of blood

created by contraction of the
left ventricle of the heart.
The pulse reflects the
heartbeat
 Factors Affecting the Pulse
The rate of the pulse is expressed in beats per minute (beats/min).

Age.
 As age increases, the pulse rate gradually decreases overall.

Sex.
 After puberty, the average male’s pulse rate is slightly lower than the female’s.

Exercise.
 The pulse rate normally increases with activity.
Fever.
 The pulse rate increases in response to the lowered blood pressure that results
from peripheral vasodilation associated with elevated body temperature and
because of the increased Metabolic rate.
Medications.
 Some medications decrease the pulse rate, and others increase it.
Variations in Pulse rate by age
AGE Pulse Average
Newborn 130 (80–180)
1 year 120 (80–140)
5–8 years 100 (75–120
10 years 70 (50–90)
Teen 75 (50–90)
Adult 80 (60–100)
Older adult 70 (60–100)
Pulse Sites
 Reason for using specific pulse
sites
Pulse site Reasons for use
Radial Readily accessible.
Temporal Used when radial pulse is not accessible.
Carotid Used during cardiac arrest/shock in adults.
Used to determine circulation to the brain.
Apical Routinely used for infants and children up to 3
years of age.
Used to determine discrepancies with radial
pulse.
Brachial Used to measure blood pressure.
Used during cardiac arrest for infants.
Femoral Used in cases of cardiac arrest/shock
Used to determine circulation to a leg
Popliteal Used to determine circulation to the lower leg

Posterior tibial Used to determine circulation to the foot

Dorsalis pedis Used to determine circulation to the foot
Rate and Rhythm
Tachycardia
 Heart rate/ Pulse rate above normal.
 Over 100 beats/min in adult

Bradycardia
 Heart rate/ Pulse rate below normal.
 Below 60 beats/min in adult

The pulse rhythm is the pattern of the beats

and the intervals between the beats.
 A pulse with an irregular
rhythm is referred to as a
dysrhythmia or arrhythmia. It
may consist of random,
irregular beats or a predictable
pattern of irregular beats.
RESPIRATION
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.
Mechanics and Regulation of
Breathing
 During inhalation, 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
decreasing the size of the thorax as the lungs are
compressed.
 Normal breathing is automatic and effortless. A normal
adult inspiration lasts 1 to 1.5 seconds, and an expiration
lasts 2 to 3 seconds.
Mechanics and Regulation of
Breathing

 Respiration is controlled by respiratory centers in the

medulla oblongata and the pons of the brain and
chemoreceptors located centrally in the medulla and
peripherally in the carotid and aortic bodies.

 These centers and receptors respond to changes in the

concentrations of oxygen (O2), carbondioxide(CO), and
hydrogen(H+) in the arterial blood.
Respiration
Respiration
 Assessing Respirations
• Resting respirations should be assessed when the client is relaxed
because exercise affects respirations, increasing their rate and depth.

• Anxiety is likely to affect respiratory rate and depth as well.

• Respirations may also need to be assessed after exercise to identify

the client’s tolerance to activity.

Before assessing a client’s respirations, a nurse should be aware of the

following:
•The client’s normal breathing pattern
•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.
Rate, Rhythm, Quality
 The respiratory rate is normally described in
breaths per minute.
 Breathing that is normal in rate and depth is called
eupnea.

 Abnormally slow respirations are referred to as

bradypnea,
 Abnormally fast respirations are called tachypnea
or polypnea.
 Apnea is the absence of breathing.
Variations in Respiration rate by
age
AGE Respiration Average
Newborn 35 (30-60)
1 year 30 (20-40)
5–8 years 20 (15-25)
10 years 19 (15-25)
Teen 75 18 (15-20)
Adult 80 16 (12-20)
Older adult 16 (15-20)
Rhythm
Respiratory rhythm refers to the regularity of
the expirations and the inspirations.

Normally, respirations are evenly spaced.

Respiratory rhythm can be described as
regular or irregular.

An infant’s respiratory rhythm may be less

regular than an adult’s.
Quality
Respiratory quality or character refers to
those aspects of breathing that are different
from normal, effortless breathing.
Two of these aspects are the amount of
effort a client must exert to breathe and
the sound of breathing.
However, clients can breathe only with
substantial effort—this is referred to as
labored breathing.
BLOOD PRESSURE
Blood Pressure
Arterial blood pressure is a measure of the pressure
exerted by the blood as it flows through the arteries.
Systolic pressure is the pressure of the blood as a
result of contraction of the ventricles, that is, the
pressure of the height of the blood wave.
Diastolic pressure is the pressure when the
ventricles are at rest. Diastolic pressure is the lower
pressure.
 The difference between the diastolic and the
systolic pressures is called the pulse pressure.
 A normal pulse pressure is about 40 mmHg.
 Blood pressure is measured in millimeters of
mercury (mmHg)