VITAL SIGNS

Vital signs are used to measure the body's basic functions. These measurements are
taken to help assess the general physical health of a person, give clues to
possible diseases and show progress toward recovery.

Vital signs to be measured

Body temperature
Pulse rate
Respirations
Blood pressure
Pain assessment
Oxygen saturation

When to check vital signs???

BODY 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. (Celcius and Fahrenheit)

Two kinds of body temperature

Core temperature is the temperature
of the deep tissues of the body, such as the abdominal cavity and pelvic
cavity. It remains relatively constant.

Surface temperature
is the temperature of the skin, the subcutaneous tissue, and fat. It, by contrast,
rises and falls in response to the environment.

Normal values of body temperature

36 °C – 37.5 °C
96.8°F – 99.5 °F

FACTORS AFFECTING BODY’S HEAT PRODUCTION

1. Basal metabolic rate. The basal metabolic rate (BMR) is the rate of energy
utilization in the body required to maintain essential activities such as
breathing.
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 further.

FACTORS AFFECTING BODY TEMPERATURE

Age
Diurnal variations
Exercise
Hormones
Stress
Environment

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 FEVER
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
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.

HYPOTHERMIA
Hypothermia is a core body temperature below the lower limit of normal. The three
physiological mechanisms of hypothermia are (a) excessive heat loss, (b) inadequate
heat production to counteract heat loss, and (c) impaired hypothalamic
thermoregulation. It can be induced or accidental.

ASSESING BODY TEMPERATURE

Orally – temperature is taken by mouth
Rectal - temperature is taken by rectum
Axilla – temperature is taken in the armpit
Tympanic membrane – temperature is taken nearby tissue in the ear canal

TYPES OF THERMOMETER
Electronic thermometers can provide a reading in
only 2 to 60 seconds, depending on the model.
The equipment consists of an electronic base, a probe,
and a probe cover, which is usually disposable

Chemical disposable thermometers are also used to measure body#temperatures.

Chemical thermometers have liquid crystal dots or bars#that change color to
indicate temperature. Some of these are single use#and others may be reused several
times.

Temperature-sensitive tape may also be used to obtain a

General indication of body surface temperature. It does
not indicate the core temperature. The tape contains
liquid crystals that change color according to temperature.
When applied to the skin, usually of the forehead or
abdomen, the temperature digits on the tape respond by
changing color

Infrared thermometers sense body heat in the form

of infrared energy given off by a heat source, which,
in the ear canal, is primarily the tympanic membrane .
The infrared thermometer makes no contact with the
tympanic membrane.

Temporal artery thermometers determine

 temperature using a scanning infrared thermometer

TEMPERATURE SCALES
Sometimes a nurse needs to convert a body temperature reading in Celsius
(centigrade) to Fahrenheit, or vice versa.

C = (Fahrenheit temperature - 32) X 5/9

For example, when the Fahrenheit reading is 100:
C = (100-32) X 5/9 = (68) X 5/9 = 37.8

To convert from Celsius to Fahrenheit, multiply the Celsius reading by the fraction
9/5 and then add 32; that is:

F = (Celsius temperature X 9/5) + 32

For example, when the Celsius reading is 40:
F = (40 3 X9/5) + 32 = (72 + 32) = 104

IMPLEMENTATION
Preparation
Check that all equipment is functioning normally.
Performance
1. Prior to performing the procedure, introduce self and verify the client’s
identity using agency protocol. Explain to the client what you are going to do, why
it is necessary, and how he or she can participate. Discuss how the results will be
used in planning further care or treatments.
2. Perform hand hygiene and observe appropriate infection prevention procedures.
Apply gloves if performing a rectal temperature.
3. Provide for client privacy.
4. Position the client appropriately (e.g., lateral or Sims’ position for inserting
a rectal thermometer).

PULSE
Pulse refers to a pressure wave that expands and recoils the artery when the heart
contracts/beats. It is palpated at many points throughout the body.
An excessively fast heart rate (e.g., over 100 beats/min in an adult) is referred
to as tachycardia.
A heart rate in an adult of less than 60 beats/min is called bradycardia.
If a client has either tachycardia or bradycardia, the apical pulse should be
assessed.

FACTORS AFFECTING THE PULSE

• 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. The rate of increase
in the professional athlete is often less than in the average person because of
greater cardiac size, strength, and efficiency.
• Fever. The pulse rate increases (a) in response to the lowered blood pressure
that results from peripheral vasodilation associated with elevated body temperature
and (b) because of the increased metabolic rate.
• Medications. Some medications decrease the pulse rate, and others increase it.
For example, cardiotonics (e.g., digitalis preparations) decrease the heart rate,
whereas epinephrine increases it.

FACTORS AFFECTING THE PULSE

• Hypovolemia/dehydration. Loss of blood from the vascular system increases the
pulse rate. In adults, the loss of circulating volume results in an adjustment of
the heart rate to increase blood pressure as the body compensates for the lost
blood volume.
• Stress. In response to stress, sympathetic nervous stimulation increases the
overall activity of the heart. Stress increases the rate as well as the force of
the heartbeat. Fear and anxiety as well as the perception of severe pain stimulate
the sympathetic system.
• Position. When a person is sitting or standing, blood usually pools in dependent
vessels of the venous system. Pooling results in a transient decrease in the venous
blood return to the heart and as ubsequent reduction in blood pressure and increase
in heart rate.
• Pathology. Certain diseases such as some heart conditions

PULSE SITES
1. Temporal, where the temporal artery passes over the temporal
bone of the head. The site is superior (above) and lateral to (away
from the midline of) the eye.
2. Carotid, at the side of the neck where the carotid artery runs between
the trachea and the sternocleidomastoid muscle.
3. Apical, at the apex of the heart. In an adult, this is located on 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 age, the apex is left of the midclavicular line (MCL); between 4 and 6
years, it is at the MCL For a child 7 to 9 years of age, the apical pulse is
located at the fourth or fifth
intercostal space.
4. Brachial, at the inner aspect of the biceps muscle of the arm or
medially in the antecubital space.
5. Radial, where the radial artery runs along the radial bone, on the
thumb side of the inner aspect of the wrist.
6. Femoral, where the femoral artery passes alongside the inguinal
ligament.
7. Popliteal, where the popliteal artery passes behind the knee.
8. Posterior tibial, on the medial surface of the ankle where the posterior
tibial artery passes behind the medial malleolus.
9. Dorsalis pedis, where the dorsalis pedis artery passes over the bones of the
foot, on an imaginary line drawn from the middle of the ankle to the space between
the big and second toes.

Assessing the Pulse

A pulse is commonly assessed by palpation (feeling) or auscultation (hearing). The
middle three fingertips are used for palpating all pulse sites except the apex of
the heart. A stethoscope is used for assessing apical pulses.
A normal pulse can be felt with moderate pressure of the fingers and can be
obliterated with greater pressure. A forceful or full blood volume that is
obliterated only with difficulty is called a full or bounding pulse. A pulse that
is readily obliterated with pressure from the fingers is referred to as weak,
feeble, or thready.

IMPLEMENTATION
Preparation
If using a DUS, check that the equipment is functioning normally.
Performance
1. Prior to performing the procedure, introduce self and verify the client’s
identity using agency protocol. Explain to the client
what you are going to do, why it is necessary, and how he or she can participate.
Discuss how the results will be used in planning further care or treatments.
2. Perform hand hygiene and observe appropriate infection prevention procedures.
3. Provide for client privacy.
4. Select the pulse point. Normally, the radial pulse is taken, unless it cannot be
exposed or
circulation to another body area is to be assessed.
5. Assist the client to a comfortable resting position. When the radial pulse is
assessed, with the palm facing downward, the client’s arm can rest alongside the
body or the forearm can rest at a 90-degree angle across the chest. For the client
who can sit, the forearm can rest across the thigh, with the palm of the hand
facing downward or inward.
6. Palpate and count the pulse. Place two or three middle fingertips lightly and
squarely over the pulse point.
7. Assess the pulse rhythm and volume
8. Document the pulse rate, rhythm, and volume and your actions in the client
record
IMPLEMENTATION#

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.
A person's respiratory rate is the number of breaths you take per minute. The
normal respiration rate for an adult at rest is 12 to 20 breaths per minute.
RESPIRATIONS

Types of Breathing
Costal (thoracic)Breathing - Costal
breathing involves the external intercostal muscles
and other accessory muscles, such as the
sternocleidomastoid muscles.

Diaphragmatic (abdominal) breathing-

diaphragmatic breathing involves the
contraction and relaxation of the diaphragm