Vital

signs are measurements of the body's

most basic functions.
Refers to measurement of Clients:
ØBody temperature
ØPulse
ØRespiration
ØBlood Pressure
ØApex beat
ØPain
ØOxygen Saturation
Fundamental to evaluate health problems.
Accuracy is essential.
 VITAL SIGNS
• Are Indicators of the body’s response to physical
environment and psychological stressors.

• A baseline set of vital signs are important to:

Ø establish baseline values of the client’s overall
health status.

Ø identify changes in the patient’s health status in

response to medical & nursing therapy .
 VITAL SIGNS

Pain
Blood
temperature Pulse Respiration. Oxygen VITAL SIGNS
pressure.
saturation
 WHEN TO TAKE VITAL SIGN
1. On admission to hospital, clinic or
healthcare agency.
(Routine observation to obtain baseline data).

2. Changes in general condition eg, changes

in level of consciousness, loss of
consciousness, pain, patient complain…etc.
( to determine alteration in disease condition)
 WHEN TO TAKE VITAL SIGN
3. Before, during and after
surgery or invasive
procedure (Lumbar
puncture, CVP,
angiogram) .
-provide baseline data for
further evaluation &
maintain the
hemodynamic status.
 WHEN TO TAKE VITAL SIGN
4. Before, during and
after nursing
intervention eg:

- blood transfusion,
- chemotherapy
 WHEN TO TAKE VITAL SIGN
5. Before and after the
administration of
medication→ could
effect respiratory,
cardiovascular and
temperature control
function.
• FACTORS AFFECTING VITAL SIGN
 Factors Influencing Vital Signs
1. AGE
- Variation of vital sign is based on age
- In newborn – thermoregulation & resp. centre is
immature (Temperature fluctuates with
environment).
- A newborn loses 30% of body heat through the
head.
Ø Temperature
36°C in newborn.(ranges 36.6°C to 37.2°C)
37 °C in adult. (ranges between 36.5°C to 37.4°C )
 Normal Age –Related Variation in Body
Temperature

AGE SITE Celcius Fahrenheit

5 Years Oral 37° C 98.6° F

Adult Oral 37° C 98.6° F

Adult Axillary 36.4° C 97.6° F
Adult Rectal 37.6° C 99.6° F
Tympanic 37.6 ºC 99.6° F
(ear)
70 years & 0ral 36.0° C 96.8° F
above
 Factors Influencing Vital Signs
AGE – Cont:
ØPulse
newborn / infant : 120 - 160 beat/min
Adult : 60 – 100 beats/min

ØRespiration
Newborn : 30-50 breath/min
Adult : 12 – 20 breath/min

ØBlood Pressure
Newborn – 65-95 mm Hg (Systolic) Diastolic 30-60
mmHg
Adult – 120/80 mm Hg
 Factor Influencing Vital Signs
2. GENDER

Ø Women
greater temperature
fluctuation than men due to
hormonal changes.
- occurs during menstrual cycle
due to progesterone level.
- Menopause – instability of
vasomotor controls
 Factor Influencing Vital Signs
3. RACE
Some ethnic group are more
susceptible than others to
hemodynamic alteration.

-The incidence of hypertension is

higher in African-Americans than
European Americans.

4. Lifestyle
- smoking, alcoholism, substance
abuse, caffeinated drinks, stress can
affect cardio-respiratory function.
 Factor Influencing Vital Signs
5. MEDICATON
- Can directly or indirectly alter
the pulse, respiration and
blood pressure.
Ø effect respiratory and
cardiovascular function.
Ø narcotic analgesic→ depress
rate & depth of respiration &
lower blood pressure.
Ø Digitalis – decrease heart rate.
Ø Antipyretic / antihypertensive
 Factor Influencing Vital Signs

6. PAIN
Ø Acute pain
Ø (sympathetic stimulation)
- increases heart rate, blood
pressure, respiration rate

Ø Chronic pain
(parasympathetic
stimulation)
- decreases pulse rate.
 Factor Influencing Vital Signs
7. Anxiety & stress
(Stimulate symphatetic nervous
system)
- Increase production of
epinephrine &
norepinephrine – increasing
metabolic activity & heat
production.
- increasing heart rate & blood
pressure & resp. (increase in
CO and peripheral vascular
resistance).
 Factor Influencing Vital Signs
8.Exercise

Muscle activity increases metabolism – increases heat

production, heart rate and blood pressure.
Exercise increases body temperature to as high as 38°C –
40°C.
 Factor Influencing Vital Signs
9. Circadian Rhythm
(regulates the sleep-wake cycle)
a) Body temperature normally changes
0.5°C – 1°C degrees throughout the day.
Lowest : between 1 am – 4 am
Highest : 4 pm – 6 pm.

b) Pulse – Decrease during sleep.

c) Blood Pressure:
Lowest level – early morning.
Highest Level- late afternoon or early
evening.
•
 TEMPERATURE
• Temp: is the “hotness” or “coldness” of a substance.
• Refers to temperature inside the body or core body heat.
• represents the balance between heat gain and heat loss
from the body.

• Temperature control is regulated by a complex mechanism

involving the hypothalamus.
• Anterior Hypothalamus – control heat loss
• Posterior hypothalamus – control heat production.
• The temperature regulating centre the keeps the
temperature constant.
 Oral • Measurements
Tympanic
– Degrees Fahrenheit (°F)
– Degrees Celsius
(centigrade; °C)
Temperature
Routes
• Normal adult oral
temperature
Rectal
– 98.6°F
Axillary
Temporal – 37°C
 Centigrade & Fahrenheit Conversion
1. Centigrade to Fahrenheit Conversion:
• °F = (°C X 9/5) + 32. 40°C
• °F = (40 X 9/5) + 32
• = 104°F

2. Fahrenheit to Centigrade Conversion:

• °C = (°F – 32) x 5/9 104°F
e.g: 104°F
°C = (104 – 32) X 5/9
= 40 °C
Types of body temperature.

Core
temperature

Body
Temperature

Surface
Temperature
 CORE TEMPERATURE
• Core temperature.

Ø Temperature of the deep tissue

of the body such as abdominal &
pelvic cavity.

Ø is the exact temperature at

which all the bodily functions
works with optimal efficiency.

Ø Remains relatively constant at

37º C ( 98.6ºF).
Ø controlled by the hypothalamus
(control center in the brain) .
 Core Body Temperature

Ø death generally occurs

when the core
temperature exceeds
42ºC;
Ø cardiac arrhythmias occur
at 28ºC or below;
Ø asystole occurs at 20ºC
 SURFACE TEMPERATURE

• Surface temperature
ØTemperature of the
skin, subcutaneous
tissue & fat.
Ørise & fall in
response to
environmental
conditions.
 Temperature Measurement site
CORE Surface
• Rectum • Oral
• Tympanic Membrane • Skin
• Esophagus • Axilla
• Pulmonary Artery
• Urinary Bladder
 Factors Affecting Body’s
Heat Production
Heat loss

-Radiation
-Conduction
Heat Production: -Convection
-Evaporation
-Basal Metabolism
(Vaporization)
-Muscular activity
-Thyroxin & Epinephrine
-Fever
 Body Temperature
Body Temperature = Heat produced – Heat Loss.

Thermoregulation is the balance between heat

produced and heat loss.
 Heat Production
1. Basal Metabolic Rate (BMR)
• amount of energy necessary to maintain the vital
involuntary activities, including breathing, maintenance
of heat, heartbeat and blood circulation, and the
activities of the nervous system and internal organs.

• Varies with age, sex, size, state of nutrition & endocrine

functions.
• The BMR is higher in males than in females, in the
young.
• decreases as age advances
Heat Production

2. Muscle Activity
- physical activity
increases body
temperature.

--shivering activates
certain muscles to
increase metabolism
and thereby warms
the body.
 Heat Production
3. Thyroxine output
Increased thyroxine output – increases rate of cellular
metabolism throughtout the body.

- This effect is called Chemical Thermogenesis

- ( stimulation of heat production through increased
cellular metabolism).
 Heat Production
4. Symphathetic stimulation &
stress response.

-Increases the rate of cellular

metabolism

-5. Fever
-- increases cellular metabolic
rate – increases body
temperature.
 HEAT LOSS
1. Radiation

Transfer of heat from the surface of one object to another without

contact (Holtzclaw, 1998).
- Heat radiates from skin to environment or cooler surrounding.
- (through peripheral vasodilatation & constriction).

- 85% of human body’s surface area radiate heat to the

environment.
- Removing pt’s clothing or blanket increases heat loss through
radiation.

- Standing exposes a greater radiating surface area.

- Lying in fetal position – minimize heat radiation.
 HEAT LOSS
2. Conduction

ØIs the transfer of heat from one object to another with direct
contact.
ØHeat conducts through contacts with solid, Liquid and gases.
ØAccounts for 3% heat loss.

ØThe nurse increases conductive heat loss when applying ice-

packs, bathing patient.
ØWarm hand touches cool objects – heat is lost.

ØConductive heat loss is reduced by applying several layers of

clothing or Contact with warmer objects
 HEAT LOSS
3. Convection
-Is the transfer of heat by air movement
- e.g fan, wind blowing.

4. Evaporation
Is the transfer of heat energy when a liquid is changed to
gas.
-Body continuously losses heat through evaporation
-About 600 – 900 mls a day evaporates from the skin and
lungs resulting in water & heat lost.
-(insensible water loss does not play a major role in
temperature regulation).
-Sweat evaporates from skin – promoting heat loss.
 HEAT LOSS
Diaphoresis

Is visible perspiration occurring in the forehead,

upper thorax, palms, soles & other parts of the
body.

Sweat is released when body temperature rises

and evaporates from skin.

A lowered body temperature inhibits sweat

gland secretion.
An adult human has between 1.6 million and 4
million sweat glands.
 Temperature Alteration
Fever: a defense mechanism that inhibits the
growth of some bacteria and viruses

ØPyrexia
ØHyperpyrexia
ØHyperthermia
ØHypothermia
 Temperature Alteration
Pyrexia
- A body temperature above the usual range.
- Occurs when heat production exceeds heat loss.
-Client body temperature rises above 37.4° C orally and 38 °C
rectally. (febrile)

Hyperpyrexia – extremely high temperature (above 41°C )

Pyrexia of unknown origin (PUO) refers to fever whose etiology

cannot be determined.

Afebrile – absence of fever.

 PYREXIA

Low Grade Fever: 37.5°C - 38°C

Moderate Fever: 38.1°C - 39°C

High Fever: 39.1°C - 41°C

Hyperthermia fever > 41°C

 Temperature Alteration

Pyrogens (bacteria, virus, fungi and some antigen) are substance

that cause fever.

Pyrogens trigger the immune system to produce WBC & release of

hormone like substance to promote body’s defense against
infection.
 Patterns of Fever
Fever patterns differ depending on causative
pyrogens.

i. Intermittent

ii. Remittent

iii. Sustained

iv. Recurrent
 Patterns of Fever
1. Intermittent

Fever spikes interspersed with usual temperature.

Alternately rises and falls; can be normal, elevated, or
subnormal
The temperature returns to normal at least once in 24 hrs.
Associated with Gram-negative and gram-positive sepsis,
abscess & infective endocarditis .

522
 Patterns of Fever
2. Remittent
Fever spikes and falls without a return to normal
temperature until recovery.
Associated with viral URTI, legionella (severe form of
pneumonia) and mycoplasma infection.
 Patterns of Fever
3. Sustained

A constant body temperature continuously above 38 °C that

demonstrate little fluctuation (variation).

4. Recurrent (relapsing)

Ø fever that returns after several days of normal

temperature
Ø Febrile episodes with normothermia may be longer than
24 hrs.
Ø Caused by various infection including fungal.
 Alteration in Thermoregulation
Alteration Definition Characteristics
Hyperthermia An elevated body temp. Disease or trauma to hypothalamus
relates to body’s inability to can impair heat loss mechanism.
promote heat loss or
reduce heat production

Hypothermia A body temp. of 35°C or Uncontrolled shivering,

lesser due to exposure to Decrease in metabolism leads to
cold weather. impaired mental functioning (loss
of memory, depression & poor
judgment).
Temp below 34.4°C causes pulse,
resp. & blood pressure to drop.
Skin – cyanotic. Dysrhythmias
occurs – cardiac arrest if untreated.
 Alteration in Thermoregulation
Alteration Definition Characteristics
Heat an increase body temperature Loss of excessive water &
Exhaustion (38°C - 40°C ) due to sodium from perspiration.
environmental heat exposure, Leads to thirst, nausea,
which causes profuse vomiting, weakness &
diaphoresis. disorientation.
Heat Stroke A critical increase in body Dry hot skin (most imp. sign)
temperature (41°C -44°C) due The person becomes delirious,
to expose to sun / high confused, experience excess
temperature. thirst, abdominal cramps &
visual disturbances.
LOC if untreated.
Damage to all organs due to
high temp.
++immediate cooling procedure
must be undertaken.
 Alteration in Thermoregulation

Alteration Definition Characteristics

Frostbite Freezing of body’s surface area Circulatory impairment

(earlobes, nose, fingers & toes) followed by gangrene.
in extremely low temperature.

Ice crystal forming inside the

cell can produce permanent
circulatory and tissue damage.
 Common sites for temp.
measurement
• Measurements
Tympanic Oral – Degrees Fahrenheit (°F)
– Degrees Celsius
(centigrade; °C)
Temperature
Routes
• Normal adult oral
Rectal Axillary
temperature
– 98.6°F
Temporal
– 37°C
 Methods of Temp. Taking
• ORAL.

ØMost accessible and

convenient.
ØComfortable for patient
ØProvides accurate surface temp.
reading
Methods of Temp. Taking

ORAL.

ØInaccurate if client has taken

hot/cold liquid / smoke or showered
15-30 minutes prior to taking
temperature.

ØAffected by oxygen delivery. (rare)

ØThermometer can break/ if bitten –

risk of mercury poisoning.(Glass
Thermometer)
 METHODS OF TEMPERATURE TAKING.

• Indication (Oral) :
Ø Alert, conscious and co-
operative patients.

Must place thermometer tip in left

or right mouth pocket under
tongue

Digital Thermometer: Remove once it Beeps

 METHODS OF TEMPERATURE TAKING.

CONTRAINDICATION: (ORAL)

ØChildren under 6 years old.

ØPatients with seizures, delirious,

confused, disoriented patients.

ØTachypneic or mouth breathing

patients.
ØPatient with oral inflammatory
disease.
Øundergone oral surgery / Oral trauma
ØPt who are vomiting or nauseated.
 METHODS OF TEMPERATURE TAKING.
• Axilla.
Ø The least accurate but safe.
Ø thermometer in place for 5-10
minutes.
Ø Pt. must be still/no movement
Ø Must document as an axillary
temp and NOT an oral temp

• Indication :
Ø Newborn and infants.
Ø Unconscious or uncooperative
patients.

Digital Thermometer: Remove once it Beeps

 METHODS OF TEMPERATURE TAKING.
• Rectal.
Ø most accurate and reliable
measurement.

Disadvantages:
Ø Needs lubrication
Ø Inconvenient, unpleasant
ØMay cause rectal trauma /
perforation

ØPresence of stool may interfere

with thermometer placement.
(thermometer may be embedded in
stool rather than rectal wall).
 METHODS OF TEMPERATURE TAKING.
• Rectal:
• Indication :
Ø Comatose or uncooperative patient
• Avoid : immediately after activity, a bowel
movement or a hot bath or shower.
 METHODS OF TEMPERATURE TAKING.
•Contraindication (Rectal)

Ø Newborns
Ø Pts. With Diarrhea or disease of the rectum
Ø Patients undergone rectal surgery or bleeding
Ø Hematological disorder
Ø Hemorrhoids.
ØØ Contraindicated on patient with myocardial infarction-
stimulate vagal response leading to cardiac
dysrhythmias.
 METHODS OF TEMPERATURE TAKING.

ØPatient need be positioned left lateral, upper leg flexed.

ØLubricate with lubricant jelly.
Øinsert lubricated bulb in anus 2-3 mins.
Ø1-1 1/2 inch adult
Ø1/2 inch infant.

Digital Thermometer: Remove

once it Beeps
 TYPES OF THERMOMETER
BULB

1) Mercury
thermometer.
• Widely used in
hospitals, clinic and
healthcare facilities.
• Consist of mercury in
a glass tube.
• (Currently NOT in
Use)
Rectal
Thermometer
 TYPES OF THERMOMETER

• Calibrated marks on the tube

allow temperature to be
read by the length of the
mercury within the tube.

• a bulb of mercury at the end

of the thermometer contains
most of the mercury which
the volume can expand and
contract in response to heat.
 TYPES OF THERMOMETER
2) Electronic/digital
thermometer.
• Widely used.
• Accurate, fast, easy to read
• Comfortable for the patient
• disposable plastic covers for
each usage to reduce
infection.
• Probe for
oral/axillary/rectal.
 Types of Thermometer
• Electronic Thermometer
• Consist of a battery powered
portable electronic unit, a
probe covered by a plastic
sheath. (prevent cross
contamination).

• records the temperature in

seconds.
• Probe for oral/axillary/rectal.
 TYPES OF THERMOMETER
3) Infrared Tympanic (Ear)

• Sense body heat in the form of infrared energy

given off by a heat source in the ear canal
(tympanic membrane).

• sensor probe shaped like an otoscope in

external opening of ear canal.

• The tympanic has an abundant arterial blood

supply.
(close proximity to the internal carotid artery)

• Ear canal sealed & probe sensor aimed at

tympanic membrane.

• Relies on battery power- return to charging

unit after use.
 TYPES OF THERMOMETER
•Tympanic thermometer
•Can be affected by heat & cold:
– Heating & cooling measures
• Hot packs, ice packs, heating
blankets
– Extreme outside and inside
temperatures
• Air conditioners, overheated rooms
• Very hot or very cold days
– Bathing or swimming
– Should NOT be used if patient had ear
surgery
– Ear infection / cerumen
 Types Of Thermometer
Tympanic thermometer
Proper technique essential
Adult – pull ear up and back
Child – pull ear down and back

Rapid measurement – 2 to 5
seconds!

•Can be used with all age groups &

most patients:
ØNewborns , infants & small
children
ØUseful with confused &
uncooperative patients
 TYPES OF THERMOMETER

4) Heat sensitive tape.

• A chemical strip tape applied
to the skin.
• color changes indicates the
temperature level.
• tapes are disposable and not
breakable.
• Most appropriate-small
children.
 TYPES OF THERMOMETER

5. Temporal artery
thermometer.
– Temporal scanner
– Noninvasive, quick
– Stroke scanner across
forehead, crossing over the
temporal artery
ØAssessment
ØPlanning
ØImplementation
ØEvaluation
 ASSESSMENT.
1. The purpose of taking temperature.

2. Assess the previous body temperature (a baseline data).

3. Identify the appropriate method of taking body

temperature. (oral, axilla or rectal)

4. Assess factors that influences body temperature.

• - Ask if patient has been eating, drinking or showered.

• Wait 15-30 minutes before taking the temperature as
these factors will influence the temperature reading.
 PLANNING
• Oral Digital thermometer.
• Dry swab
• Spirit swab
• Receiver
• Watch (seconds)
• Clinical chart
• Pen and ruler
• Lubricant, Glove & tissue (rectal)
 Equipments
Ø Trolley (top)

Oral Digital Pen &

Thermometer Dry Swab Ruler

Watch
Spirit swab
Thermometer
Cover Clinical Chart

72
 Equipments
ØTrolley (Bottom)

Receiver clinical waste

73
 IMPLEMENTATION
1. Greet patient and inform
procedure. (allay
anxiety).

2. Take the thermometer

out from the container.
 IMPLEMENTATION

3. Hold
thermometer
using your thumb
and index finger.
 IMPLEMENTATION
4.Rinse tip of thermometer
under running water.

5.Dry thermometer with

dry cotton from bulb’s end
to stem.
(circular motion)
 IMPLEMENTATION:
Oral Temperature
6) Place the thermometer
cover.
7) Place the thermometer
under the tongue.
(oral sublingual pocket).
-contact with large blood
vessels under the
tongue.

8). Instruct the patient to

open the mouth & lift
the tongue up.
 IMPLEMENTATION: Oral
Temperature
9. Have the patient hold
lips closed.
- Instruct patient not to
bite the thermometer.
10. leave thermometer in
place until it beeps.

11. Then instruct patient

to open the mouth &
remove thermometer
 IMPLEMENTATION:
Oral Temperature
12. Remove the cover.

13. Read the temperature.

14. Inform patient the

reading.
 IMPLEMENTATION
15. Record in the clinical
chart.
Ø Using pen : red and
blue/black.
Ø Write the time, date and
make sure it’s the
correct patient.
• Indicate the method

16. Discard thermometer in

receiver.
 IMPLEMENTATION

17. Wash thermometer with soap and water.

18. Wipe thermometer with spirit swab.

Allow thermometer to dry and keep in closed

container.
 EVALUATION

• Temperature is within normal range.

• Compare the reading to the previous to
detect abnormality.
• inform the result to doctor if the reading is
abnormal so that appropriate action can be
taken.
Digital (oral)
 Axillary Temperature
1. Repeat action 1-6.

2. Expose patient’s arm.

- Ensure axilla is dry. (Pat dry with
clean towel).

3. Place tip of thermometer in the

center of axilla. (Probe must
touch skin on all sides.)

4. Fold the patients arm and place

arms across client’s chest.
5. Leave until it beeps.
6. Repeat action 12- 18.
Axilla
 Rectal Temperature
1. Greet & inform procedure.
2. Provide privacy .
3. Repeat action 1-6. (RECTAL THERMOMETER)
4. Place patient in lateral position with upper knee flexed.
5. Adjust sheet to expose anal area.
6. Place tissue in easy reach.
7. Apply gloves.
8. Lubricate tip of rectal thermometer.
(Easier insertion & prevent irritation to rectum)
 Rectal Temperature
9. Separate buttock to expose anus.
-Instruct patient to take deep breath.
-(This will help to relax the sphincter
muscle that controls the opening and
closing of the anus.)

10. Insert rectal thermometer gently into

anus.
ØInfant: 0.5 inches (1.2 cm)
ØAdult: 1.5 inches (3.5 cm).
 Rectal Temperature
11. Release your hold on the patient's upper buttock

Hold thermometer in place while temperature is

taken

(prevent it from going in or out)

ØDo not force insertion if resistance felt.
12. Leave until it beeps.
Repeat action 12-18.
 RETURN
DEMONSTRATION
PULSE
 PULSE.
• Pulse is the bounding of blood flow
in an artery that is palpable at
various points of the body.
• Is caused by stroke volume ejection
& distensions of the walls of aorta.
• This create a pulse wave which
travels rapidly toward distal end of
arteries.
• As the wave reaches superficial
peripheral artery, the pulse can be
palpated by applying gentle
pressure at pulse point.
 Purpose
1.To establish baseline data for subsequent evaluation.
(monitor changes in client’s health status).

2. To monitor clients at risk for pulse alteration

Øhistory of heart disease or experiencing cardiac arrhythmias
ØHaemorrhage, acute pain, fluid resuscitation, fever etc.

3. To evaluate blood perfusion to the extremities.

(determine equality of peripheral pulse)
NORMAL AGE-RELATED VARIATIONS
IN RESTING PULSE
AGE NORMAL AVEREAGE RATE
RANGE / MINUTE
Newborn 100 – 170 140
1 Year 80 - 170 120
3 Years 80 - 130 110
6 Years 75 - 120 100
10 Years 70 - 110 90
14 Years 60 - 110 90
Adult 60 - 100 80
Athletes 40 - 60
 Factor Influencing Pulse
Ø Age
Ø Body Temperature
Ø Exercise
Ø Medication- digitalis / opioid decreases heart rate,
epinephrine (increase)
Ø Hypovolemia – Blood or fluid loss from vascular system
(Increases heart rate)
Ø Emotions - fear, anger, anxiety, excitement, etc
Ø Pain
Pulse points
 PULSE SITES

1. Temporal

Ø over temporal bone

of the head .

ØUsed to assess pulse

in children.
 PULSE SITES
2. Carotid.

Øside of the neck where

carotid artery runs between
trachea & sternocleidomastoid
muscle.

ØUse during cardiac arrest /

shock
ØUsed to determine
circulation to the brain
 PULSE SITES
3.Radial.

Ø Inner and lateral aspect of the

wrist (thumb side)
Ø (where radial artery runs along
the radial bone).

Ø Common site to assess

peripheral pulse & assess
circulation of the hand.
 PULSE SITES
4. Brachial.

At antecubital fossa

ØSite to access status of

circulation to lower arm.

ØSite to measure B/P

ØUsed during cardiac arrest

in children
 PULSE SITES
5. Femoral.

ØWhere the femoral artery

passes alongside the inguinal
ligament.

ØUsed to assess circulation

to leg.

Ø used in cases of cardiac

arrest & shock
 PULSE SITES
6.Popliteal.

Ø Popliteal artery passes

behind the knee (popliteal
fossa)
Used to determine circulation
to the lower leg.
 PULSE SITES
7. Dorsalis pedis/pedal.

Ø Where dorsalis pedis

artery passes over the
bones of the foot.

Ø middle of the ankle to the

space between the big
and second toes.

Ø Determine circulation to
the foot
 PULSE SITES

8.Posterior tibial.

ØWhere posterior tibial

artery passes behind the
medial malleolus.

ØDetermine circulation to
the foot
 CHARACTERISTICS OF A PULSE.
1) Pulse Rate

Ø number of pulse beats per minute.

Ø Tachycardia – pulse rate over 100 beats /min
Ø Bradycardia- pulse rate below 60 beats/min
(*Assess apical pulse: Bradycardia & Tachycardia )
- Detect any pulse deficit
(the difference in a minute's time between the number of
beats of the heart and the number of beats of the pulse)
 CHARACTERISTICS OF A PULSE.

2) Pulse Rhythm.

Ø pattern of the beats and the intervals between the

beats.
Ø May be regular or irregular
Ø normal pulse : equal time elapse between beats
Ø Pulse with irregular rhythm → dysrhythmia or
arrhythmia. (**Assess apical pulse)
 CHARACTERISTICS OF A PULSE.

3) Pulse volume (amplitude)

Ø Refers to the force of blood with each beat.
(degree of pulsation)
Ø Is a measurement of the force by the ejected
blood against arterial wall with each contraction.
Ø Range from absent to bounding.
Ø Normal pulse can be felt with moderate pressure
of the fingers.
 Pulse Volume scale
SCALE Description

0 Absent Pulse

+1 Weak & Thready pulse

+2 Normal Pulse

+3 Bounding Pulse
 Pulse Volume scale
• If a pulse is noted to be weaker during inhalation and
stronger during exhalation (pulsus paradoxus), this could
indicate either greater reduction in the flow of blood to
the left ventricle than is normal:
Ø pericarditis
Ø Pericardial effusion
Ø Asthma
 CHARACTERISTICS OF A PULSE.

4. Equality
Pulses on both side of the peripheral vascular system
should be assessed.
- Eg radial pulse – characteristics of both side must be
checked & compared.

- Unequal or absent pulse may indicate thrombus

formation or vascular problem)
- ***The carotid pulse must NEVER be assessed
simultaneously – excessive pressure may occlude
blood supply to brain.
Examples of some pulse patterns are illustrated in figure 3-1.

pulse patterns
 Assessment
Ø General condition of patient.
Ø Sign & Symptom of Cardiovascular alteration..(chest
pain, weak, irregular or fast heart rate, difficulty in
breathing)
Ø Asses factors that influence the pulse rate.
(medication, activity, pain etc)
Ø Purpose of taking pulse
Ø Identify appropriate location for taking pulse.
Ø Previous data as baseline
 PLANNING

Prepare the equipment

• Watch (second)
• Clinical chart
• Pen and ruler
 IMPLEMENTATION

• Greet patient and inform procedure.

• Wash hands – Medical asepsis

 IMPLEMENTATION

1) Choose the suitable site

for the pulse checking.

Ø Place fingertips of first 2

or middle 3 fingers over
the radial pulse area or
appropriate artery.

( finger tips are sensitive

enough to feel the pulse).
 IMPLEMENTATION

2. Press fingers gently until the

pulse can be felt.
Ø Count for 1 minute using
the watch with second.

Ø Assess for the rate, rhythm

and volume of the pulse.
•Do NOT use your thumb
– Thumbs have a pulse, which
can be mistaken for a
patient’s pulse
 Pulse : Brachial

•Used for infants and

small children.
•Place fingertips of first 2
or middle 3 fingers over
the brachial pulse area
•Lightly press your
fingertips on the pulse
area
 IMPLEMENTATION

3. Record the reading in

the clinical chart.
Ø Using pen : red and
blue/black.
Ø Write the time, date
and make sure it’s the
correct patient.
Ø Inform patient the
reading.
 EVALUATION

•Inform staff nurse or doctor if pulse is:

– Difficult to feel or count
– Very fast or very slow
– Irregular or skipping
• Compare the reading to the previous to
detect abnormality.
 EVALUATION
• Automated BP machines can take pulse readings
• Accurate with strong, normal pulses.

• Inaccurate with:
– Very fast or very slow pulses
– Weak, skipping or irregular pulses
– Arm movement or agitation
• When in doubt – count it yourself!
 DEFINITION OF RESPIRATION

• The act of bringing the oxygen into the

body and removing carbon dioxide.
• The respiratory rate is the number of
breath taken per minute.
 BREATHING
• Inspiration-
• Active process
• initiated by the contraction
of the diaphragm & external
intercostals muscle.. Chest
expands to allow air to
move into the lungs.
• Expiration-
• Is a passive process
involving relaxation of the
diaphragm & elastic recoil
of tissues.
 Muscle Groups of Inhalation
1. Diaphragm:
– contraction draws air into lungs
– 75% of normal air movement
2. External intracostal muscles:
– assist inhalation
– 25% of normal air movement
3. Accessory muscles assist in elevating ribs:
Ø sternocleidomastoid
Ø serratus anterior
Ø pectoralis minor
Ø scalene muscles
 Factors Influencing Respiration
Factors Effects
Exercise Increases rate & depth to meet body’s need for
additional oxygen & to rid the body of CO2.
Acute pain Increases rate of respiration.

Anxiety Increases rate & depth as a result of

sympathetic stimulation.

Smoking Increases rate of respiration.

Medication Narcotic analgesic, GA & sedative depress rate

& depth
 Factors Influencing Respiration
Factors Effects
Neurological Injury to brain stem impairs the resp. centre –
Injury Inhibits resp. rate & rhythm.

Hemoglobin Anemia – reduce oxygen carrying capacity of the

Function blood: increases resp. rate.

Increased Altitude – lowers the amount of

saturated oxygen – increases resp. rate & depth.

Sickle cell disease – reduces ability of hemoglobin

to carry oxygen- increases resp. rate & depth.
 Normal Age variation in respiration
AGE Normal Range Average Rate /
(Breath per minute Minute
Newborn 30 – 50 40
1 year 20 - 40 30
3 Years 20 – 30 25
6 Years 16 - 22 19
14 Years 14 – 20 17
Adult 12 – 20 18
 CHARACTERISTIC OF NORMAL RESPIRATION.

• Healthy adult normally takes between 12 to 20 breaths per

minute.
• Check respirations: Look, listen, and feel for movement of air
• Breathing normal in rate → eupnoea.

• Normal respiration must be :

ØAlmost invisible (Slightly observable)
Ø Effortless.
ØQuiet.
ØAutomatic.
ØRegular.
• Assessed by observing chest wall expansion & bilateral
movement of the thorax.
 BREATHING PATTERN

1. Rate

• Tachypnea → rapid respiration( above 24/min)

• Occurs in fever, acute asthma, pulmonary oedema etc.

• Bradypnea → slow breathing (below 10/min)

• Occurs in opiod toxicity, hypothyroidism, hypercapnia,
raised intracranial pressure (ICP)

• Apnea – Cessation of breathing

 Quality of breathing
Quality of breathing is determined as well as the rate
of breathing.

1. Depth (normal, shallow or deep)

2. Clarity of breath sounds
3. Difficulty breathing
(use of accessory muscles – sternocleidomastoid and
intercostal muscles)
 BREATHING PATTERN

2) Ease or effort

Normal breathing - Effortless

•Dyspnea – difficult and painful breathing, persistent,

unsatisfied need for air and feel distressed.

•Orthopnea – ability to breathe only and upright sitting or

standing positions.
 BREATHING PATTERN
3. Rhythm
Normal breathing - regular

•Cheyne-Stokes respirations
•William Stokes (Irish Physician:1804-1878) described this respiratory
pattern.

ØCyclically increasing rate & depth of breathing, followed by diminishing

respiratory effort and rate, ending in period of apnoea (10-60 seconds).

ØStrokes, severe head injuries, brain tumors, congestive heart failure,

overdose of narcotic drug.

ØOccurs more during sleep.

 BREATHING PATTERN
4. Volume

Hyperventilation – over expansion of the lungs

characterized by rapid & deep breaths.

Hypoventilation – under expansion of the lungs,

characterized by shallow respiration.
 Breathing pattern
5. Chest movement

i) Intercostal retraction – inward movement of

the intercostal muscles.
- usually a sign of difficulty with breathing due to
airway obstruction.

When the upper airway (trachea) or (bronchioles)

become partially blocked, air flow is restricted.
As a result, the intercostal muscles are sucked
inward, between the ribs.

ii) Substernal retraction – inward movement of

the muscles below the sternum.

iii) Suprasternal retraction – indrawing above

the clavicles
 BREATHING PATTERN
4) Breath sounds – refer You tube
• Stridor – harsh, croaking inspiratory sound, high pitched &
resemble the blowing of the wind due to obstruction of air
passages.
• Occurs in laryngeal obstruction, foreign body, tumor partially
occluding the larynx, trachea or main bronchus.

• Wheezing –whistling sound occurring on expiration when air

moves through partially obstructed airway.

• Bubbling (rales) – gurgling sounds heard on auscultation during

inspiration as air passes through moist secretions in the
respiratory tract. Pneumonia, bronchitis, asthma, or other
pulmonary disease

• (congestive cardiac failure, bronchitis, asthma, Pneumonia, TB)

PROSEDUR
 ASSESSMENT
• General condition→ to identify the needs to take the
respiration.

• Determine any sign and symptom of respiratory disturbance→

tachypnoeic, dyspnoea, cyanotic appearance of nail beds,
mucous membrane & skin; restlessness, confusion, reduced
level of consciousness etc.

• Assess factors that influences breathing.

• Determine previous baseline resp. rate.
• Ensure the client is comfortable position either lying or sitting
and well rested to get accurate reading. ***Cardiac
 PLANNING
Prepare the equipment
ØWatch (seconds)
ØClinical chart /
observation chart
ØPen and ruler
 REMEMBER
ØAFTER TAKING THE PULSE RATE FOR ONE
MINUTE, DO NOT LET GO OF YOUR HAND AT
THE WRIST.
(If patients are aware that you are counting
respirations, they may unintentionally alter
their breathing).
ØBreathing is controlled by both voluntary &
involuntary muscle
 IMPLEMENTATION
1. Wash hand.
2. Greet patient explain
procedure.
3. Assist patient to a
comfortable & relaxed
position.
(Position patient for clear view
of chest movement)
 IMPLEMENTATION
4. Observe patient’s chest movement and count
respiration for 1 minute.
(1 breath equal to 1 full cycle of inspiration
& expiration).

5. Observe the characteristics of the breathing :

ØRate
ØRhythm
ØDepth
ØSound
 IMPLEMENTATION
6. Record in the clinical chart
- Write the time, date and make sure it’s the
correct patient.

7. Wash hand
 EVALUATION
ØRespiratory rate, rhythm and depth are within
normal range.
• inform abnormal breathing pattern:
Ø Shallow
Ø Bradipnea
Ø Tachypnea
Ø Wheezing / stridor
Ø Poor effort