NCM 103A: FUNDAMENTALS OF NURSING (RLE)

Topic: Vital Signs

Activate Prior Knowledge

Properly identify and define the different parts of a patient’s chart.

Acquire New Knowledge

Learning Objectives:
At the end of lecture-discussion and demonstration, the students will be able to:
1. Define Vital Signs
2. Identify and describe the vital signs and its importance.
3. Identify the factors that can affect accurate vital signs taking
4. Efficiently perform the procedures in taking vital signs

VITAL SIGNS
Vital signs or cardinal signs
❖ reflect the physiological status of the body and provide information critical to
evaluating the body’s homeostatic balance.
❖ Vital signs are measurements of the body's most basic functions. The four main
vital signs routinely monitored by medical professionals and health care providers
include the following:

• Body temperature
• Pulse rate
• Respiration rate (rate of breathing)
• Blood pressure (Blood pressure is not considered a vital sign, but is often
measured along with the vital signs.)

❖ Vital signs are useful in detecting or monitoring medical problems. Vital signs can
be measured in a medical setting, at home, at the site of a medical emergency, or
elsewhere.
Vital
❖ is used because the information gathered is the clearest indicator for normal
patient status. These four signs form baseline evaluative data necessary for
ongoing evaluation of a patient’s condition.
1. Temperature
❖ Represents the balance between heat gain and heat loss and is regulated in the
hypothalamus of the brain.
❖ It is measured by a clinical thermometer.
❖ Variations in temperature indicate the health status of the body.
❖ This may be due to microorganisms, nervous system disease, or injury.
There are two kinds of body temperature:
1. Core temperature is the temperature of the deep tissues of the body, such as the
abdominal cavity and pelvic cavity. It remains relatively constant.
2. Surface temperature is the temperature of the skin, the subcutaneous tissue and fat.

Heat Production
Heat is produced in the body by metabolism, which is the chemical reaction in all body
cells. Food is the primary fuel source for metabolism. Activities requiring additional
chemical reactions increase the metabolic rate. As metabolism increases, additional heat
is produced. When metabolism decreases, less heat is produced.
Heat production occurs during:
1) rest = The body produces internal heat due to normal metabolic
processes. At rest or during sleep, metabolic heat production is
small however, during intense exercise, heat production is large
2) voluntary movements = Muscular exercise can result in large
amounts of heat production Because the body is at most 20% to

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 30% efficient. 70% to 80% of the energy expended during exercise
is released as heat
3) involuntary shivering = Shivering, heat production during exposure
to cold
4) non-shivering thermogenesis = Action of hormones. Thyroxine:
increase metabolic rate and Catecholamine’s: (epinephrine and
norepinephrine) can cause an increase in the rate of cellular
metabolism. The increase in heat production due to the combined
influences of thyroxine and catecholamine’s is called Non shivering
thermogenesis
Heat Loss
Heat is lost in the body through radiation, conduction, convection, and vaporization:
1. 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.
2. 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. The amount of heat transferred
depends on the temperature difference and the amount and duration of the contact.
3. 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, and
so people always lose a small amount of heat through convection.
4. Vaporization is continuous evaporation 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.

Factors affecting body temperature

Nurses should be aware of the factors that can affect a patient’s body temperature to be
able to recognize and understand the significance of body temperature measurements
that deviate from normal.
1. Age
❖ The infant is greatly influenced by the temperature of the environment and must
be protected from extreme changes.
❖ Children’s temperatures continue to be more variable than those of adults until
puberty.
❖ Older people, aged 75 and above, are particularly sensitive to extremes in
environmental temperature due to decreased thermoregulatory controls.
2. Diurnal variations (circadian rhythms)
❖ Body temperature normally change throughout the day, between the early morning
and the late afternoon.
❖ The point of highest body temperature is usually reached between 8:00pm and
midnight, and the lowest is reached during sleep between 4:00 and 6:00 am.
3. Exercise
❖ Hard work or strenuous exercise can increase body temperature.
4. Hormones
❖ Women usually experience more hormone fluctuations than men. In women,
progesterone secretion at the time of ovulation raises body temperature.
5. Stress
❖ Stimulation of the sympathetic nervous system can increase the production of
epinephrine and norepinephrine, that increases metabolic activity and heat
production.
6. Environment
❖ Extremes in environmental temperatures can affect a person’s temperature
regulatory systems.

Common Sites for Measuring Body Temperature

1. Oral – most frequently used site
Advantages:

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 a. Accessible – requires no position change
b. Comfortable for client
c. Provides accurate surface temperature reading
d. Reflects rapid change in core temperature
Disadvantages:
a. Causes delay in measurement if client recently ingested hot/cold
fluids or foods, smoked, or receives oxygen by mask/cannula
b. Should not be used with clients who have had oral surgery, trauma,
history of epilepsy, or shaking chills
c. Should not be used with infants, small children, or confused,
unconscious, or uncooperative clients.
d. Risk of body fluid exposure.
2. Rectal – considered to give very accurate readings
Advantages:
a. More reliable when oral temperature cannot be obtained
Disadvantages:
a. May lag behind core temperature during rapid temperature
changes
b. Should not be used for clients with diarrhea, clients who have had
rectal surgery, a rectal disorder, or decreased platelets
c. May be source of client embarrassment and anxiety.
d. Risk of body fluid exposure.
e. Should not be used for routine vital signs in newborns.
3. Axilla – preferred site
Advantages:
a. Safe and noninvasive
b. Can be used with newborns and unconscious clients.
Disadvantages:
a. Long measurement time
b. Requires continuous positioning by nurse.
c. Measurement lag behind core temperature during rapid temperature
changes.
d. Not recommended in infants and young children
4. Tympanic membrane
Advantages:
a. Easily accessible site
b. Can be used for tachypneic clients
c. Provides accurate core reading
d. Very rapid measurement (2-5 seconds)
e. Temperature can be obtained without disturbing, waking, or
repositioning client.
f. Eardrum close to hypothalamus; sensitive to core temperature changes
g. Unaffected by oral intake of food or fluids or smoking
Disadvantages:
a. Hearing aids must be removed before measurement
b. Cerumen impaction can lower readings
c. Otitis media can distort readings
In addition to the four common sites for measuring temperature, the forehead may also
be used using a chemical thermometer. Forehead temperature measurements are most
useful for infants and children.
Advantages:
a. Inexpensive
b. Provides continuous reading
c. Safe and noninvasive
d. Can be used for neonates
Disadvantages:
a. Lags behind other sites during temperature changes, especially during
hyperthermia
b. Diaphoresis or sweat can impair adhesion
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 c. Unreliable during chill phase of fever
d. Can be affected by environmental temperature
It is generally accepted that rectal temperatures are usually 0.5oC (0.9oF) higher than oral
temperatures, and axillary and tympanic temperatures are usually 0.5 oC (0.9oF) lower
than oral temperatures. Sites reflecting core temperature are more reliable indicators of
body temperature than sites reflecting surface temperatures.
Several types of equipment and different procedures might be used to measure body
temperature. To obtain an accurate, you must choose the correct equipment, the best
site, and the appropriate tool based on the patient’s condition.

Types of thermometers:
1. Mercury-in-glass thermometers (standard glass thermometer)
❖ The mercury-in-glass thermometer consists of a glass tube sealed at one end with
a mercury-filled bulb at the other.
❖ Exposure of the bulb to heat causes the mercury to expand and rise in the enclosed
tube. The length of the thermometer is marked with either Fahrenheit or centigrade
calibrations.
❖ These types of thermometers were traditionally used to measure body
temperature.
❖ Glass thermometers can be hazardous due to exposure to mercury, which is toxic
to humans, and broken glass, should the thermometer crack or break. Some
hospitals no longer use this type of thermometers and their manufacture and sale
have been banned in some cities. The nurse may still encounter this type of
thermometer and must be well versed in its safe use.
❖ Three types of glass thermometers are the:
a. Oral or slim-tipped (or for axillary use)
b. Stubby (may be used for any site)
c. Pear-shaped – rectal use
2. Electronic thermometer
❖ This equipment consists of a battery-operated portable electronic unit, a probe that
the nurse attaches to the unit, and a probe cover.
❖ This type of thermometer can provide a reading in only 2 to 60 seconds, depending
on the model. The oral probe has a blue tip and the rectal probe has a red tip.
3. Tympanic thermometer (infrared thermometer)
❖ This type of thermometer senses body heat in the form of infrared energy given off
by a heat source, which in the ear canal is primarily the tympanic membrane.
❖ A sound signals when the peak temperature reading has been measured
4. Chemical dot thermometer
❖ This is a disposable thermometer and it consist of a flat plastic device holding many
temperature-sensing chemical “dots” that change color when they reach a certain
temperature.
❖ It is inexpensive and unbreakable.

Normal Values of Body Temperature

Age Site Normal Range

Newborn Axillary 36.5 – 37.5oC (96.0 – 99.5oF)
1 year Oral 37.7oC (99.7oF)
3 years Oral 37.2oC (99.2oF)
5 years Oral 37.0oC (98.6oF)
Adult Oral o
37.0 C (98.6oF)
Axillary 36.4oC (97.6oF)
Rectal o
37.6 C (99.6oF)
70+ years Oral 36.0oC (96.8oF)
If it is necessary to convert temperature readings, the following formulas can be used:

1. To convert Farenheit to Celsius:

C = (F – 32o) x 5/9
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2. To convert Celsius to Fahrenheit:
F = (9/5 x C) + 32o

Obtaining Temperature

Purposes:
1. To determine if temperature is within normal range.
2. To provide baseline data for further evaluation.
3. To determine alterations in disease conditions.
Contraindications:
1. Oral—Oral surgery or trauma, history of epilepsy, shaking, chills, age (infants and
small children), confusion, unconsciousness, and uncooperativeness.
2. Rectal—Diarrhea, rectal surgery or disorders, bleeding tendencies, and routine vital
signs in newborns. If the thermometer cannot be adequately inserted into the rectum, or
if you feel resistance during insertion, remove the thermometer and try using an
alternative route to measure the patient’s temperature.
3. Axillary—Age (infants and small children) and axillary lesions.
4.Tympanic—Cerumen in ear canal, tympanic membrane or other ear surgery,
exceptionally young age (infants and children younger than 3 years of age).
5. Temporal artery/skin—Allergy to adhesive.

Equipment:
Thermometer
Tissue paper
Wrist watch
Container with disinfectant
Procedure and Rationale: (oral and axillary temperature)
PROCEDURE RATIONALE
1. Wash hands. To prevent the spread of
microorganisms.
2. Rinse thermometer in cold water if kept Chemical taste is bitter. Chemical
in a disinfectant solution. solution may irritate the mucous
membrane.
3. Wipe dry with tissue moving from bulb Prevents transfer of microorganisms
to stem using a firm twisting motion. from fingers to bulb where there are a
few or no organisms to an area where
organisms may be present. Twisting
helps to contact the entire surface.
4. Grasp thermometer with thumb and This facilitates lowering down the
forefinger and shake vigorously by mercury level to 35.5oC or lower.
snapping wrist in downward motion to
lower mercury level to below 95-960F
(35.50C)
5. a. For axillary temperature: To dry perspiration from the axilla.
Pat dry axilla of client. Place To allow the bulb to rest against the
thermometer in the center of the axilla superficial blood vessels; minimal
and lower patient’s arm down across exposure to environmental heat/cold,
the chest. arms help hold thermometer in place.
There are several superficial blood
b. For oral temperature: vessels under the tongue so that
Place thermometer in client’s mouth measurement of temperature is
under the tongue in a slanting obtained satisfactorily. Air may cool
position and ask client to close his the mouth and give a false low reading.
lips.
6. Leave in place for 8-10 minutes. Allow sufficient time for the
thermometer to reach its maximum
temperature.

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7. Remove thermometer and wipe it once To minimize the spread of
with tissue from fingers down the bulb, microorganisms by cleaning from an
using a firm twisting motion. area where there are few organisms to
an area where there are more
organisms. Wiping down toward bulb
reduces contamination of nurse’s
fingers with patient’s bacteria. Friction
helps loosen matter from a surface.
8. Read temperature by rotating To get accurate reading.
thermometer until the mercury level is
clearly visible and at eye level. Shake
thermometer down, cleanse and return
to storage container.
9. Dispose used tissue wipes in a To minimize spread of
container for contaminated items. microorganisms.

10. Wash hands. To minimize spread of

microorganisms.
11. Document temperature reading. Documentation provides information
for assessment and diagnosis.

Procedure and Rationale: (rectal temperature)

PROCEDURE RATIONALE
1. Same as oral method from nos. 1-4.

5. Screen client. Instruct and assist
client to turn on his side facing away
from you with knees slightly flexed
(adults: side-lying or prone; infants:
prone or supine)
6. Lubricate bulb of thermometer with
lubricant. Insert into the anal canal
through the rectum. Allow sufficient
time for the rectal thermometer to
reach its maximum temperature.
7. Same as in oral temperature, nos. 6-
11.
Provide privacy. Reposition client for
clear visualization of rectal opening.
Lubricant will reduce friction facilitating
insertion of thermometer and minimizing
irritation of the mucous membrane of the
anal canal. Length of insertion increases
with age. For infants, insert thermometer
1.2 cm (0.5 in) and for adults, 3.5 cm (1.5
in). Unexpected movements by the client
may advance the thermometer to an
unsafe depth if not held in place.

Procedure and Rationale: Oral Temperature Using Electronic Thermometer

PROCEDURE RATIONALE
1. Remove the electronic unit from the Electronic unit must be taken into the
charging unit, and remove the probe client’s room to assess the client’s
from within the recording unit. temperature.
2. Cover thermometer probe with Using a cover prevents
disposable probe cover and slide it into contamination of the thermometer
place until it snaps into place. probe.

3. Place the probe beneath the patient’s When the probe rests deep in the
tongue in the posterior sublingual posterior sublingual pocket, it is in
pocket. Ask the client to close his/her contact with blood vessels lying
lips around the probe. close to the surface.

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 4. Continue to hold the probe until beeps If left unsupported, the weight of the
are heard. Note the temperature probe tends to pull it away from the
reading. correct location. The signal indicates
the measurement is completed. The
electronic thermometer provides a
digital display of the measured
temperature.
5. Remove the probe from the client’s Disposing of the probe cover
mouth and dispose of the probe cover ensures that it will not be reused
by holding the probe over an accidentally on another client.
appropriate receptacle and pressing
the probe release button.
6. Return the thermometer probe to the The thermometer needs to be
storage place within the unit and return recharged for future use.
the electronic unit to the charging unit
to make sure it is fully charged.

Procedure and Rationale: Tympanic Membrane Temperature

PROCEDURE RATIONALE
1. Place client in Sim’s position. Facilitates easy access to the ear.
2. Push the “on” button and wait for For proper function, thermometer must
the “ready” signal on the unit. be turned on and warmed up.
3. Attach tympanic probe covering. Use of the covering deters the spread of
microorganisms.
4. Insert the probe snugly into the If the probe is not inserted correctly, the
external ear, using gentle but firm client’s temperature will be noted as
pressure, angling the thermometer lower than normal.
toward the client’s jaw line. Pull
pinna up and back to straighten
ear canal in an adult.
5. Activate the unit by pushing the The digital thermometer must be
trigger button. The reading is activated to record the temperature.
immediate (usually 2 seconds).
Note the reading.
6. Discard the probe cover in an Discarding the cover ensures that it will
appropriate receptacle by pushing not be reused accidentally on another
the probe cover release. And client. The thermometer must stay on
replace the thermometer in its the charger so that it is ready to use at
charger. all times.
7. Record reading and indicate site. Promotes accurate documentation for
data comparison.

2. Pulse
❖ The pulse is described as a throbbing sensation that can be palpated over a
peripheral artery or auscultated over the apex of the heart.
❖ It is the rhythmic expansion of an artery produced by the wave of blood forced into
the blood vessel when the left ventricle of the heart contracts.
❖ The pulse is caused by the contraction of the left ventricle which forces a bolus of
blood into the aorta. The aorta distends to accommodate the surge of blood and
then recoils as the ventricles relax and the blood moves down the artery.
❖ Characteristics of the pulse, including rate, quality, rhythm, and volume, provide
information about the effectiveness of the heart as a pump and the adequacy of
peripheral blood flow.

Factors Affecting the Pulse

The rate of the pulse is expressed in beats per minute. A pulse rate varies according to
a number of factors and these should be considered when assessing a client’s pulse.
1. Age. As age increases, the pulse rate gradually decreases.
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2. Gender. After puberty, the average male’s pulse rate is slightly lower than the
female’s.
3. Exercise. The pulse rate normally increases with activity.
4. Fever. The pulse rate increases (a) in response to the lowered blood pressure that
results from peripheral vasodilatation associated with elevated body temperature and (b)
because of the increased metabolic rate.
5. Medications. Some medications decrease the pulse rate, and others increase it.
6. Hypovolemia. Loss of blood from the vascular system normally increases 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.
7. 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.
8. Position changes. 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 a subsequent reduction in blood pressure and
increase in heart rate.
9. Pathology. Certain diseases such as some heart conditions or those that impair
oxygenation can alter the resting pulse rate.

Pulse Sites
1. Temporal pulse.
❖ Feel for the superficial temporal artery, which passes upward just in front of the
ear.
❖ Palpate gently, using the tips of two or three fingers.
❖ This pulse is often used in infants or when the radial pulse is not accessible.
2. Carotid pulse.
❖ Feel for the carotid pulse by locating the larynx (voice box) and sliding two or three
fingers off into the groove beside it.
❖ The carotid artery should only be compressed for a short time to avoid impeding
blood flow to the brain.
❖ The carotid pulse is used during adult CPR and to assess cardiac function and
circulation to the head.
3. Apical pulse, at the apex of the heart.
❖ The apical pulse is measured by listening over the apex of the heart on the left
side of the chest, using a stethoscope.
❖ The apex is usually found at the fifth intercostal space just inside the midclavicular
line.
❖ The apical pulse is used in infants or the elderly, whose pulse rates are often
difficult to determine using peripheral sites.
4. Brachial pulse.
❖ The brachial artery is located near the center of the antecubital space, toward the
little finger. Have the patient rest the arm palm upward, and use two or three
fingers to locate the pulse.
❖ This pulse is commonly used to measure blood pressure.
5. Radial pulse.
❖ The radial artery runs along the radial bone, on the thumb side of the inner aspect
of the wrist.
❖ Feel for the pulse with the patient’s arm positioned alongside the body, palm
downward.
❖ Curl two or three of your fingers around the wrist on the thumb side, and palpate
gently.
❖ This site is used routinely to measure the pulse rate because of its convenience
and accessibility.
6. Femoral pulse.
❖ The femoral artery passes alongside the inguinal ligament.
❖ To locate the femoral pulse, press harder halfway between the anterior superior
iliac spine and the symphysis pubis, below the inguinal ligament.
❖ Respect the patient’s privacy when attempting to locate this pulse.
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 ❖ It is commonly used to assess circulation to the leg and may be used to evaluate
chest compressions during CPR.
7. Popliteal pulse.
❖ The popliteal artery passes behind the knee.
❖ With the patient’s leg in a flexed position, the popliteal pulse can be felt behind the
knee in the popliteal fossa.
❖ Press more deeply to be able to locate the pulse.
❖ This is useful when assessing circulation to the lower leg and when measuring the
blood pressure using the leg.
8. Posterior tibial pulse.
❖ This pulse can be felt by curving the fingers behind and a little below the medial
malleolus of the ankle.
❖ This pulse is often difficult to feel in obese patients or in those with considerable
edema.
9. Pedal (dorsalis pedis) pulse.
❖ 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.
❖ This pulse is easily obliterated so it should be palpated gently.
❖ This is used to determine circulation to the foot.

Normal Values of Pulse

Age Normal Range Average Rate/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

Obtaining the Pulse Rate

Purposes:
1. To establish baseline data for subsequent evaluation.
2. To identify whether the pulse rate is within normal range.
3. To determine whether the pulse rhythm is regular and the pulse
volume is appropriate.
4. To compare the equality of corresponding peripheral pulses on
each side of the body.
5. To monitor and assess changes in the client’s health status.
6. To monitor clients at risk for pulse alterations.
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Equipment:
Watch with a second hand
Stethoscope – for apical pulse auscultation
Procedure and Rationale:
Taking a radial pulse:
PROCEDURE
1. Assess the patient’s condition.
Determine the client’s activity
schedule.
2. Place patient in a comfortable
position. Ask about activity within the
last half hour.
3. Palpate over the pulsing artery (radial Most pulses are taken at the radial site
or peripheral) using pads of the three
middle fingers.
4. Apply light but firm pressure.
5. Count pulse for one whole minute.
6. Note rhythm and volume of the pulse. Indicative of possible problem with
7. Leave the patient in a comfortable
position.
8. Document findings.
Taking an apical pulse:
PROCEDURE
1. Place the patient in a supine or left-
sided position.
2. Warm diaphragm with hands.
3. Place stethoscope on the apex of the
heart. The apex is normally located in
the fifth intercostal space just below
the nipple and three inches to the left
of the sternum.
4. Count the heartbeat for one minute
using a watch with second hand.
5. Assess rhythm and any unusual
sounds.
6. Leave the patient in a comfortable
position.
7. Document findings.
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RATIONALE
To determine factors that may alter
pulse rate.
Pulse rate increases with activity.
on the wrist. This minimizes exposure
of the patient and is usually very easy
to palpate. The pads of the fingers are
used because the thumb has a pulse
of its own which may confuse the
measurement of the patient’s pulse.
Pulse is more accurately assessed
with light, firm pressure. Too much
pressure occludes pulse and impairs
blood flow.
Sufficient time is necessary to study
the rate, volume, and quality of the
pulse. Degree of error is reduced by
counting the pulse for longer times.
cardiovascular system and tissue
perfusion.
Promotes comfort and sense of well-
being.
Communicates data for further
assessment, legal responsibility,
verifies competent nursing care.
RATIONALE
Provides for patient’s comfort.
Warming the diaphragm promotes
patient comfort.
This is the point of maximum impulse,
where the heartbeat is heard.
Counting for a full minute increases
the accuracy of assessment.
Indication of possible cardiac
problems.
Promotes comfort and sense of well-
being.
Documents data for further
assessment, legal responsibility,
verifies competent nursing care.
3. Respiration
❖ It is the act of bringing oxygen into the body and removing carbon dioxide. When
there is an alteration of the pattern of respiration, ongoing evaluation will yield
important cause to a patient’s changing condition.
❖ It is the part that is measured as a vital sign is pulmonary ventilation
❖ The respiratory rate is determined by counting the number of breaths per minute.
If respirations are very shallow and difficult to visually detect, observe the sterna
notch, where respirations are more apparent.
❖ With an infant or young child, assess respirations before taking the temperature so
the child is not crying, which would alter the respiratory status.
❖ The respiratory depth can be established by watching the movement of the chest.
It is generally described as normal, deep, or shallow.
❖ Deep respirations are those in which a large volume of air is inhaled and exhaled,
inflating most of the lungs.
❖ Shallow respirations involve the exchange of a small volume of air and often the
minimal use of lung tissue.

Factors Affecting Respirations

Factors that increase respiratory rate include:
1. exercise (increases metabolism)
2. stress (readies the body for “fight” or “flight”)
3. increased environmental temperature
4. lowered oxygen concentration at increased altitudes

Factors that may decrease the respiratory rate include:

1. decreased environmental temperature
2. certain medications (e.g., narcotics)
3. increased intracranial pressure

Normal Values of Respiration

Age Normal Range Average Rate/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

Obtaining the Respiratory Rate

Purposes:
1. To establish baseline data for subsequent evaluation.
2. To monitor abnormal respirations and respiratory patterns and
identify changes.
3. To assess respirations before the administration of certain
medications.
4. To compare if respiratory rate is within normal range with pulse
and blood pressure readings.
Equipment:
Watch with second hand
Stethoscope if respirations are to be auscultated.
Procedure and Rationale:
PROCEDURE RATIONALE
1. Assess client’s condition. Determine Allows nurse to accurately assess
the client’s activity schedule. presence and significance of
respiratory alterations.

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 2. Place the client in a comfortable
position. Lying down with the head of
the bed at 45-60o angle.
3. Place a hand against the client’s chest
or position the patient’s arm over the
abdomen.
4. While supposedly taking the radial
pulse, count respirations by observing
the rise and fall of the client’s chest for
one whole minute.
5. Note rate, depth, rhythm, and
character.
6. Document findings.
7. Wash hands.
Position of discomfort may cause client
to breathe more rapidly.
Client’s or nurse’s hand rises and falls
during respiratory cycle.
Counting the respirations while
presumably still counting the pulse
helps to keep the patient from
becoming conscious of his breathing
and possible altering his breathing
efforts. Accuracy is increased when
rate is counted over a longer time (one
minute)
Indicates possible problems with
ventilation on oxygen supply to
tissues.
Documentation provides information
for assessment and diagnosis.
Prevent spread of microorganisms.

4. Blood pressure
❖ Refers to the force of the blood against the arterial walls in the body.
❖ Blood pressure readings provide information about the condition of the heart,
arteries, arterioles, vessel resistance, and the cardiac output.
❖ It is the force exerted by the blood against the walls of the arteries of the body.
Because the blood in waves, there are two blood pressure measures: the systolic
pressure, which is the pressure of the blood as a result of contraction of the
ventricles; and the diastolic pressure, which is the pressure when the ventricles
are at rest.
❖ Pulse pressure is the difference between the diastolic and the systolic pressure.
It is an indication of adequate cardiac stroke volume. In shock, the systolic blood
pressure tends to fall before the diastolic pressure, and this decreases the pulse
pressure, indicating an inadequate volume of blood being pumped from the heart.
❖ Perfusion of the tissue with blood is dependent in the blood pressure to move the
blood through the capillaries and back to the heart. If pressure drops too low,
some of the body tissues will be inadequately perfused and hypoxia will result. If
blood pressure is too high, tissue and capillary damage can occur.
❖ The effectiveness of the pumping action of the heart and the amount of resistance
to blood offered by the vascular system will determine blood pressure. As the
vessels constrict, blood pressure rises, and as the vessel relax and dilate, blood
pressure goes down.

Factors Affecting Blood Pressure

1. Age.
❖ Newborns have a mean systolic pressure of about 75 mmHg. The pressure rises
with age, reaching a peak at the onset of puberty, and then tends to decline.
❖ In older people, elasticity of the arteries is decreased – arteries are more rigid and
this produces an elevated systolic pressure, and the diastolic pressure is also
elevated because the walls no longer retract with decreased pressure.
2. Exercise.
❖ Physical activity increases cardiac output thus increasing blood pressure.
❖ 20 to 30 minutes of rest is indicated before the resting blood pressure can be
assessed.
3. Stress.
❖ Stimulation of the sympathetic nervous system increases cardiac output and
vasoconstriction of the arterioles, thus increasing the blood pressure; however,

Renalyn_Pilloc_NCM103a_Fundamentals_Skills
 sever pain can decrease blood pressure greatly by inhibiting the vasomotor center
and producing vasodilatation.
4. Gender.
❖ After puberty, females usually have lower blood pressures than males of the same
age possibly due to hormonal variations. After menopause, women generally have
higher blood pressures than before.
5. Medications.
❖ Many medications may increase or decrease the blood pressure.
6. Obesity.
❖ Both childhood and adult obesity predispose to hypertension.
7. Diurnal variations.
❖ Pressure is usually lowest early in the morning, when the metabolic rate is lowest,
then rises throughout the day and peaks in the late afternoon or early evening.
8. Disease process.
❖ Any condition affecting the cardiac output, blood volume, blood viscosity, and/or
compliance of the arteries has a direct effect on the blood pressure.

Blood Pressure Equipment

Blood pressure is measured with a blood pressure cuff, a sphygmomanometer, and a
stethoscope.
Types of sphygmomanometers:
1. Aneroid sphygmomanometer – it is a calibrated dial with a needle that points
to the calibrations.
2. Mercury sphygmomanometer – this is a calibrated cylinder filled with mercury.
3. Electronic sphygmomanometer – this eliminates the need to listen to the
sounds of the client’s systolic and diastolic blood pressures through a
stethoscope.

Blood Pressure Sites

The blood pressure is usually assessed in the client’s arm using the brachial artery and
a standard stethoscope. Assessing the blood pressure on a client’s thigh is usually
indicated in these situations:
1. The blood cannot be measured on either arm due to burns or other
trauma
2. The blood pressure in one thigh is to be compared with the other thigh
Blood pressure is not measured on a client’s arm or thigh in the following situations:
1. The shoulder, arm, or hand (or the hip, knee or ankle) is injured or
diseased.
2. A cast or bulky bandage is on any part of the limb.
3. The client has had a removal of axilla (or hip) lymph nodes on that side.
4. The client has an intravenous infusion in that limb.
5. The client has an arteriovenous fistula (as in renal dialysis) in that limb.

Normal Values of Blood Pressure

Age Systolic (mm Hg) Diastolic (mmHg) Average

Newborn 65 – 95 30 – 60 80/60
Infant 65 – 115 42 – 80 90/61
3 years 76 – 122 46 – 84 99/65
6 years 85 – 115 48 – 64 100/56
10 years 93 – 125 46 – 68 109/58
14 years 99 – 137 51 – 71 118/61
Adult 100 – 140 60 – 90 120/80
Elderly 100 – 160 60 – 90 139/80

Renalyn_Pilloc_NCM103a_Fundamentals_Skills
 Obtaining a Blood Pressure

Purposes:
1. To establish a baseline for further evaluation.
2. To determine if arterial blood pressure reading is within normal range.
3. To assess the condition of the heart, arteries, blood vessel resistance, and
stoke volume.
4. To identify alterations in blood pressure reading from a change in disease
condition.
5. To compare blood pressure readings with pulse and respiration.
Equipment:
Sphygmomanometer
Stethoscope
Procedure and Rationale:

PROCEDURE RATIONALE
1. Wash hands. Clean off the Decreases the spread of
stethoscope diaphragm or bell with microorganisms.
antiseptic wipes.
2. Determine which extremity is most Cuff inflation can temporarily
appropriate for reading. Do not take a interrupt blood flow and can further
blood pressure reading on an injured compromise circulation in an
or painful extremity or one in which an extremity that already has an
intravenous line is running. impaired blood flow.

3. Select a cuff size that completely Provides equalization of pressure

encircles the upper arm without on the artery to ensure accurate
overlapping. The bladder must measurement.
encircle at least two-thirds of the arm.

4. Explain procedure to the patient. Patient has the right to obtain

5. Place the patient in a relaxed reclining
or sitting position with arm at the level
of the heart and with the palm of hand
facing upward. Expose the upper part
of patient’s arm. Blood pressure
should not be taken over clothes.
Renalyn_Pilloc_NCM103a_Fundamentals_Skills
information to gain his
cooperation.
Factors such as emotional upset,
exercise, and pain will alter BP
readings. If arm is above the level
of the heart, the blood pressure
reading will be lower than normal,
and if the below the level of the
heart, the blood pressure reading
 will be higher than normal. This
position places the brachial artery
on the inner aspect of the elbow so
that a stethoscope also can rest on
it conveniently. Prevent sounds
from being distorted and also
prevent missing sounds.
6. Palpate the brachial artery. To locate site for placement of
stethoscope.
7. Wrap cuff snugly and smoothly To allow maximum compression of
around the upper part of the arm artery, a smooth cuff wrapping
(about one inch above the antecubital produces equal pressure and this
space) with the center of the bladder helps give an accurate reading.
over the brachial artery.
8. Place the gauge at eye level, close For accurate reading of aneroid or
enough to read. (Not more than three mercury manometer.
feet away from the manometer).
9. Palpate the brachial artery, close the To locate the placement of
valve and compress bulb to inflate cuff stethoscope. Pumping the cuff up
to 30 mmHg above the point where to a pressure significantly above
palpated pulse disappears, then slowly the patient’s normal BP is needed
release the valve to deflate cuff. to detect elevations from normal;
pumping the cuff more than 30 mm
Hg over normal BP is usually
unnecessary and is uncomfortable
for the patient.
10. Place diaphragm or bell of Proper placement of stethoscope
stethoscope on the medial antecubital ensures optimal sound reception.
fossa where brachial artery is felt.
11. Place the stethoscope ear pieces in Each earpiece should follow angle
your ears, tighten the screw valve and of ear canal to facilitate hearing.
inflate the cuff rapidly (7 sec or less) by Tightening the valve prevents air
pumping up bulb until manometer leak during inflation. As bulb is
registers 30 mmHg above the pumped, air is forced into the cuff
diminished pulse point or at which and compresses arm at the
pulsations are no longer heard. pressure indicated on the gauge.
Compression should be done
quickly to reduce time for
development of venous
congestion.
12. Loosen valve slightly to release air at Too rapid or slow release of air can
a rate of 2-4 mmHg per second for cause inaccurate readings.
normal adult.
13. Listen for a faint, clear tapping sound The first sound when blood enters
(Korotkoff sound) that appears and the artery indicates the systolic
increases in intensity. pressure.

Korotkoff Sounds
• Nikolai Korotkoff, a Russian surgeon, was the first to describe arterial
sounds in 1905.
• When taking a blood pressure using a stethoscope, there are 5 phases of
sounds (Korotkoff’s sounds) heard:
• Phase I – the first faint, clear, repetitive tapping sounds heard; onset of the
sound corresponds to the systolic pressure.
• Phase II – a swishing or murmur is heard; this appears as the cuff is further
deflated. As the artery distends, there is a turbulence of blood flow.
• Phase III – sounds are crisper and increase in intensity.

Renalyn_Pilloc_NCM103a_Fundamentals_Skills
 • Phase IV – a distinct, abrupt muffling or change of sound is heard. Cuff
pressure falls below the pressure of the vessel walls. This sound is the
diastolic pressure in infants and children.
• Phase V – the last sound is heard. In adolescents and adults, this
corresponds with the diastolic pressure.
14. Continue to deflate cuff (sounds will Sound is created where blood flow
change in quality). Record diastolic is completely unobstructed and
BP as the sound disappears vessel open during entire cardiac
(Korotkoff’s V sound). If sounds are cycle, muffling occurs when artery
continuously heard at a very low first stays open, but artery is still
reading, record the abrupt muffling of partially occluded by the cuff.
sound, phase IV (muffling is often
recorded for children)
15. Release air from cuff after sound Maintaining pressure in the cuff is
ceases. Wait 2 minutes before taking uncomfortable for the patient and
a second reading. obstructs venous return from the
lower arm. Waiting for a few
minutes before another reading will
allow normal circulation to return
to the limb.
16. Leave the patient in a comfortable Communicates respect and
position. promotes comfort.
17. Clean the diaphragm and bell of the Decreases spread of
stethoscope with antiseptic wipes. microorganisms from patient to
Wash hands. patient and patient to nurse.
18. Record and report findings. Provides communication among
health team. Legal responsibility
and verification of competent
nursing care.

Intake and Output

Measuring and recording intake and output (I & O) during a 24-hour periods helps to
complete the assessment data base for fluid and electrolyte balance. The nurse is
responsible for monitoring and recording all intake and all output. It may be an
independent or a dependent nursing intervention. General monitoring of I & O should be
evaluated for all clients, although measuring and documentation on the chart is not
required in some situations.

Intake – refers to all fluids entering the client’s body, such as:
a. Liquids with meals, gelatin, custards, ice cream, popsicles, sherbets, ice chips
(50% of measurable volume
b. Liquid medicines
c. Tube feedings
d. Parenteral fluids, blood components, and total parenteral nutrition

Output – refers to all fluids that leaves the client’s body, such as:
a. Urine
o Urine leakage on a pad can be weighed (1mL of urine weighs 1 gram
and the number of pads used in 24 hours can be counted)
b. Excessive perspiration and exhalation (water vapor exhaled) – it is not
recorded, since it cannot be accurately measured. Normally an adult
loses about 500 mL a day.
c. Diarrhea
d. Vomiting
e. Drainage from all tubes
f. Bleeding

Renalyn_Pilloc_NCM103a_Fundamentals_Skills
Purposes:
1. It helps to evaluate the client’s fluid and electrolyte balance.
2. To recognize significant fluid losses.
3. Helps in the diagnosis of a certain illness.
4. It influences the choice of fluid therapy.
5. To document the client’s ability to tolerate oral fluids.

Clinical DO’s and DON’Ts when monitoring I & O:

DO’s
1. Identify whether your patient has undergone surgery or if he has a medical
condition or takes medications that can affect fluid intake or loss.
2. Measure and record all intake and output. If you delegate this task, make sure
you know the totals and the fluid sources.
3. At least every 8 hours, record the type and amount of all fluids he's received and
describe the route as oral, parenteral, rectal, or by enteric tube.
4. Record ice chips as fluid at approximately half their volume.
5. Record the type and amount of all fluids the patient has lost and the route.
Describe them as urine, liquid stool, vomitus, tube drainage (including from
chest, closed wound drainage, and nasogastric tubes), and any fluid aspirated
from a body cavity.
6. If irrigating a nasogastric or another tube or the bladder, measure the amount
instilled and subtract it from total output.
7. For an accurate measurement, keep toilet paper out of your patient's urine.
8. Measure drainage in a calibrated container. Observe it at eye level and take the
reading at the bottom of the meniscus.
9. Evaluate patterns and values outside the normal range, keeping in mind the
typical 24-hour intake and output.

10. When looking at 8-hour urine output, ask how many times the patient voided, to
identify problems.
11. Regard intake and output holistically because age, diagnosis, medical problem,
and type of surgical procedure can affect the amounts. Evaluate trends over 24
to 48 hours.

DON’Ts
1. Don't delegate the task of recording intake and output until you're sure the person
who's going to do it understands its importance.
2. Don't assess output by amount only. Consider color, color changes, and odor too.
3. Don't use the same graduated container for more than one patient.

Application:
1. Vital Signs Return Demo

Assessment:
1. Graded Recitation
2. Pre-test or Post Test

Renalyn_Pilloc_NCM103a_Fundamentals_Skills
References:
1. Books
• Kozier & Erb’s (2007).Fundamentals of nursing (8th ed.)Pearson Education South
Asia Pte.Ltd.
• Berman, A., Snyder, S. J., Levett-Jones, T., Dwyer, T., Hales, M., Harvey, N., …
& Stanley, D. (2018). Kozier and Erb’s Fundamentals of Nursing [4th Australian
edition].
• Rosdahl, C. B., & Kowalski, M. T. (Eds.). (2008). Textbook of basic nursing.
Lippincott Williams & Wilkins.

2. Online

• https://www.youtube.com/watch?v=H68Sa04s_1s
• https://nurseslabs.com/vital-signs/
• https://www.hopkinsmedicine.org/health/conditions-and-diseases/vital-signs-
body-temperature-pulse-rate-respiration-rate-blood-pressure

Prepared by:
NCM 103a Instructors

Renalyn_Pilloc_NCM103a_Fundamentals_Skills