I. Answer the following questions as comprehensively as possible.

For answers that need

resources, cite them properly using the APA format (7th edition) available online.

1. What factors influence vital signs?

Several factors can cause changes in one or more of the vital signs and these include an
individual’s age, weight, gender and overall health.

2. What are the normal ranges of temperature (all sites), pulse, respirations and blood pressure
for different age groups?

Vital Signs Infant Children Adolescent Adults Elderly

0-12 months old 6-13 years old 14-17 years old 20+ years 60+ years old
old
Pulse rate 100 to 160 beats per 70 to 110 60-100 bpm. 60-100 bpm. 80-136 beats
minute (bpm) beats per per minute
minute
Respiration Rate 0 to 6 months 30 to 60 18–30 12 to 16 12-18
breaths per minute 12 to 16 breaths breaths
(bpm) 6 to 12 months 24
to 30 bpm
Blood Pressure 5 to 90/45 to 120/< 80 mm 120/< 80 mm Hg 120/< 80 mm 120/< 80 mm
65 millimeters of Hg Hg Hg
mercury (mm Hg)
Temperature:
36.8 96.4–99.5°F (
 Tympanic 35.8°C to 38°C (96.4°F 97.0–100.0°F 35.8°C to 38°C (9 ± 0.7°C (98.2 35.8–37.5°C)
to 100.4°F) (36.1–37.8°C)) 6.4°F to 100.4°F) F ±
1.3F) 37.5°C
 Oral 35.5°C to 37.5°C (95.9°F 95.9–99.5°F 35.5°C to 37.5°C  97.6–99.6°F 96.4–98.5°F (
to 99.5°F) (35.5–37.5°C) (95.9°F to 99.5°F 35.8–36.9°C)
)
 Axillary 36.5°C to 37.5°C (97.8°F 96.6–98.0°F 34.7°C 6.6° (35.9° C) 96.0–97.4°F (
to 99.5°F) (35.9–36.7°C) to 37.3°C (94.5°F and 98° F 35.6–36.3°C)
to 99.1°F) (36.7° C)
 Temporal 35.4 °C and 37.4 °C. 35.4 °C and 98.6°F (37°C) 98.6°F (37°C) 98.6°F (37°C).
37.4 °C. .
 Rectal 36.6°C to 38°C (97.9°F 97.9–100.4°F 36.6°C to 38°C (9 97.1–99.2°F ( 97.1–99.2°F (
to 100.4°F) (36.6–38°C) 7.9°F to 100.4°F) 36.2–37.3°C) 36.2–37.3°C)
3. In what situations should a nurse take oral, rectal, axillary and tympanic temperatures?

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.

The rectal procedure is normally used for an infant or young child, for a patient who is
unconscious or irrational, and for a patient that has difficulty breathing with his mouth closed.
The rectal route is used in the case of any suspected environmental injury such as heatstroke
or hypothermia

The axilla is the preferred site for measuring temperature in newborns because it is accessible
and safe. However, some research indicates that the axillary method is inaccurate when
assessing a fever.

The tympanic membrane, is a frequent site for estimating core body temperature. Like the oral
site, the tympanic membrane also has an abundant arterial blood supply, primarily from
branches of the external carotid artery.

4. Where are the sites for taking pulse located on the body?

The pulse is readily distinguished at the following locations:

(1) at the point in the wrist where the radial artery approaches the surface;
(2) at the side of the lower jaw where the external maxillary (facial) artery crosses it;
(3) at the temple above and to the outer side of the eye, where the temporal artery is near the
surface;
(4) on the side of the neck, from the carotid artery;
(5) on the inner side of the biceps, from the brachial artery;
(6) in the groin, from the femoral artery;
(7) behind the knee, from the popliteal artery;
(8) on the upper side of the foot, from the dorsalis pedis artery.

5. How do you measure temperature orally, rectally, axillary, and tympanic?

Axillary method (under the armpit)

The armpit method is usually used to check for fever in newborns and young children.

 Place the tip of the thermometer in the centre of the armpit

 Tuck your child’s arm snugly (closely) against their body
 Leave the thermometer in place for about 1 minute, until you hear the “beep”
 Remove the thermometer and read the temperature
Oral method (in the mouth)

The mouth method can be used for children who are older than 5 years of age. It is not
recommended for children younger than 5 years of age, because it is hard for them to hold the
thermometer under their tongue long enough.

 Carefully place the tip of the thermometer under your child’s tongue
 With your child’s mouth closed, leave the thermometer in place for about 1 minute until
you hear the “beep”
 Remove the thermometer and read the temperature

Tympanic method (in the ear)

The ear method is recommended for children older than 2 years old. Though quick to use, the
ear method can produce temperature readings that are incorrect, even when the
manufacturer’s directions are followed.

 Use a clean probe tip each time, and follow the manufacturer’s instructions carefully
 Gently tug on the ear, pulling it back. This will help straighten the ear canal, and make a
clear path inside the ear to the ear drum
 Gently insert the thermometer until the ear canal is fully sealed off
 Squeeze and hold down the button for 1 second
 Remove the thermometer and read the temperature

Rectal method (in the rectum)

The rectal method can be used to check for fevers in newborns and young children. Use a rectal
thermometer only if you are comfortable doing so and a health care provider has shown you
how to do it safely.

 Cover the silver tip with petroleum jelly (such as Vaseline)

 Place your baby on their back with their knees bent
 Gently insert the thermometer in the rectum, about 2.5 cm (1 inch), holding it in place
with your fingers
 Leave the thermometer in place for about 1 minute until you hear the “beep”
 Remove the thermometer and read the temperature

6. What steps are used in taking pulse and respiration?

As the heart forces blood through the arteries, you feel the beats by firmly pressing on the
arteries, which are located close to the surface of the skin at certain points of the body. The
pulse can be found on the side of the neck, on the inside of the elbow, or at the wrist. For most
people, it is easiest to take the pulse at the wrist. If you use the lower neck, be sure not to press
too hard, and never press on the pulses on both sides of the lower neck at the same time to
prevent blocking blood flow to the brain. When taking your pulse:

 Using the first and second fingertips, press firmly but gently on the arteries until you feel
a pulse.
 Begin counting the pulse when the clock's second hand is on the 12.
 Count your pulse for 60 seconds (or for 15 seconds and then multiply by four to
calculate beats per minute).
 When counting, do not watch the clock continuously, but concentrate on the beats of
the pulse.
 If unsure about your results, ask another person to count for you.

The respiration rate is the number of breaths a person takes per minute. The rate is usually
measured when a person is at rest and simply involves counting the number of breaths for one
minute by counting how many times the chest rises. Respiration rates may increase with fever,
illness, and other medical conditions. When checking respiration, it is important to also note
whether a person has any difficulty breathing.

Normal respiration rates for an adult person at rest range from 12 to 16 breaths per minute.

7. How do you measure blood pressure?

 To begin blood pressure measurement, use a properly sized blood pressure cuff.

The length of the cuff's bladder should be at least equal to 80% of the
circumference of the upper arm.
 Wrap the cuff around the upper arm with the cuff's lower edge one inch above
the antecubital fossa.
 Lightly press the stethoscope's bell over the brachial artery just below the cuff's
edge. Some health care workers have difficulty using the bell in the antecubital
fossa, so we suggest using the bell or the diaphragm to measure the blood
pressure.
 Rapidly inflate the cuff to 180mmHg. Release air from the cuff at a moderate rate
(3mm/sec).
 Listen with the stethoscope and simultaneously observe the dial or mercury
gauge. The first knocking sound (Korotkoff) is the subject's systolic pressure.
 When the knocking sound disappears, that is the diastolic pressure (such as
120/80).
 Record the pressure in both arms and note the difference; also record the
subject's position (supine), which arm was used, and the cuff size (small, standard
or large adult cuff).
 If the subject's pressure is elevated, measure blood pressure two additional
times, waiting a few minutes between measurements

8. How and where do you record vital signs?

All vital signs should be taken when the individual is “at rest.” You should wait 30 minutes to take a
temperature, pulse, respiration, or blood pressure if a person has just eaten, drank a hot or cold
beverage, just smoked, or exercised. Vital signs can be measured in a medical setting, at home, at the
site of a medical emergency, or elsewhere.

REFERENCES:

Kozier & Erb's Fundamentals of Nursing : Concepts, Process, and Practice. Upper Saddle River,
N.J. :Pearson Prentice Hall, 2008.

Lockwood, C., Conroy‐Hiller, T., & Page, T. (2004). Vital signs. JBI reports, 2(6), 207-230.

Fever and temperature taking (2020) Canadian Paediatric Society

https://www.caringforkids.cps.ca/handouts/health-conditions-and-
treatments/fever_and_temperature_taking

 Mia A. What Is the Normal Body Temperature Range? (2020)

https://www.healthline.com/health/what-is-normal-body-temperature

Sphygmomanometer. Definition, How to Use (2020) Clinical Skills Education LLC

https://www.practicalclinicalskills.com/sphygmomanometer

HOW TO TAKE AN AXILLARY TEMPERATURE (2015)

https://brooksidepress.org/vitalsigns/lessons/lesson-2-temperature/2-24-how-to-take-an-
axillary-temperature/