VITAL

SIGNS
VITA L SIGNS
The vital signs or cardinal signs are

Temperature Pulse Blood Pressure

Respiration Pain assesment

* These signs are the clearest indicators of overall health status

 Guidelines for Taking Vital Signs
Ø The Nurse caring for the client measures vital
signs
Ø Equipment is functional and appropriate
Ø The Nurse knows the normal range for all Vital
Signs
Ø The Nurse knows the client’s Medical History and Therapies
and Medications prescribed
Ø The Nurse knows the client’s normal range of Vital Signs
Ø The Nurse controls minimizes environmental factors that may affect
vital signs
Ø The Nurse and Physician decide the frequencyof vital signs
assessment on the basis of the client’s condition
Ø The Nurse analyzes the result of vital signs measurement
Ø The Nurse uses an organized, systematic approach when
takingvital signs
Ø The Nurse verifies and communicates significant changes in vitalsigns.
 BODY TEMPERA TURE
Ø The balance between the heat produced by the body and the
heat lost from the body

FACTORS INFLUENCING BODY TEMPERATURE:

Ø AGE
Ø DIURNAL VARIATIONS
Ø EXERCISE
Ø HORMONES
Ø STRESS
 BODY TEMPERA TURE

KINDS OF BODY TEMPERATURE:

C o r e Te m p e r a t u r e : T h e t e m p e r a t u r e o f t h e d e e p
tissues of the body. This remains relatively constant

Surface Temperature: Temperature of the skin, the

subcutaneous tissue and fat. In contrasts, it rises
and falls in response to the environment
FACTORS AFFECTING THE BODY’S HEAT PRODUCTION
1. BASAL METABOLIC RATE (BMR)
2. MUSCLE ACTIVITY (EXERCISE, SWIMMING, ETC).
3. THYROXINE OUTPUT
4. EPINEPHRINE, NOREPINEPHRINE AND SYMPHATHETIC
STIMULATION
5. INCREASED TEMPERATURE OF BODY CELLS (FEVER)
HEAT LOSS PROCESSES:
Radiation: the transfer of heat from the surface of one
object to the surface of another without contact between
the two objects
Conduction: the transfer of heat from one object to
another in direct contact
Convection: dispersion of heat by air currents.
Evaporation: continuous vaporization of moisture
from the skin, oral mucous,respiratory tract
TERMINOLOGY FOR BODY TEMPERATURE
HYPERTHERMIA - Elevated body temperature related to the inability
of the body to promote heat loss (higher than 38.0℃ or 100)
HYPOTHERMIA - heat loss during prolong exposure to cold
environment (lower than 36.5℃ or 96.0℉ )
Pyrexia - a body temperature above the usual range; aka
Hyperthermia/ fever
Hyperpyrexia - very high fever
Febrile - A client who has fever
Afebrile - a client who has no fever
TYPES OF FEVER:

Intermittent Fever: The temperature fluctuates between periods of fever

and periods of normal/subnormal temperature.

Remittent Fever: The temperature fluctuates within a wide range over

the 24 hour period but remains above normal range

Relapsing fever: The temperature is elevated for few days, alternated

with 1 or 2 days of normal temperature

Constant/Continuous fever: Body temperature is consistently high

Most Common Sites of Measuring Body Temperature:
No hot or cold drinks or
ORAL smoking 20mins prior to
temp. Leave in place 3 min
Posterior sublingual pocket-under tongue (close to carotid artery)
Must be awake and alert Not
for small children (bite down)

Non invasive- good for

AXILLARY
children Leave in place 5-10mins
Bulb in center of axilla
Less accurate (no major
Lower arm position across chest Measure 0.5C lower than oral oral temp.
blood vessels nearby)

RECTAL W hen unsafe or inaccurate

Side lying with upper leg flexed, insert lubricated bulb (1 1/2 inch adult and 1/2 inch by mouth (unconscious, lLeave in place 2-3min
infant) disoriented or irrational)
Measures 0.5C higher than oral
Side lying position- leg flexed

TYMPHANIC Rapid measurement

Close to hypothalamus- sensitive to core temp. changes Adult- pull Easy assesibility
pinna up & back Cerumen impaction distorts
reading 2-3 seconds
Child- pull pinna down & back
Otitis media can distort
reading
 PULSE RA TE
Ø Refers to the wave of blood or impulse created by the
contraction of the left ventricle during the cardiac cycle.

Factors affecting pulse rate:

Ø AGE
Ø SEX/GENDER
Ø EXERCISE
Ø FEVER
Ø MEDICATIONS
Ø HEMORRHAGE
Ø STRESS
Ø POSITION CHANGES
 9 PULSE SITES

1. CAROTID ARTERY
2. RADIAL ARTERY
3. FEMORAL
4. POPLITEAL
5. POSTERIOR TIBIAL ARTERY
6. DORSALIS PEDIS ARTERY
7. BRACHIAL ARTERY
8. TEMPORAL
9. APICAL
VARIATIONS IN PULSES BY AGE
 A SSESS: RA TE, RHY TY M, STRENGHT
A ND TENSION

AMPLITUDE Rate- N- 60-100 average 80bpm

Tachycardia- greater than 100 bpm
0 - absent Bradycardia- less than 60 bpm
1+ - weak, thready
2+ - normal Rhythm- the pattern of the beats (regular or irregular)

3+- Full, bounding Strength - or amplitude, the volume of blOOd pushed against
the wall of an artery during the ventricular contraction
weak or thready (lack fullness)
full bounding (vol higher than normal)
imperciptible (cannot be felt of heard)
PULSE: LIFESPAN CONSIDERATIONS:
Infants: Newborns may have heart murmurs that are not
pathological
Children: The apex of the heart is normally located in the
fourth intercostal space in young children; fifth intercostal
space in children 7 years old and older.
Elders: Often have decreased peripheral circulation
Stethoscope
Diaphragm- high pitched sound, lowest, lung and heart sounds- tight
seal
Bell- low pitched sound, heart and vascular sounds, apply belllightly
(hint think of Bell with the "L' for Low)
 RESPIRATIONS

Ø The act of breathing

Three Processes of Respiration

üVentilation- the movement of gases in and out of the lungs
-Inhalation (Inspiration)
-Exhalation (Expiration)
üDiffusion- the exchange of gases fron an area of higher pressure to an
lower pressure. it occurs at the alveolo-capillary membrane.
üPerfusion- the availability and movement of blood for transport of
gases, nutrients and metabolic waste produucts.
Two Types of Breathing
1.Costal (thoracic)- involves movement of the chest
2. Diaphragmatic (Abdominal)- Involves movement of the abdomen

Respiratory Centers
1. Medulla Oblongata- is the primary respiratory center
2. Pons- Contains the following:
üPneumotaxic Center- responsible for the rhythmic quality of
breathing.
üApneustic Center- Responsible for deep, prolonged inspiration.
 Major Factors Affecting
Respiratory Rare (RR)

1.Exercise
2.Stress
3.Environment
4.Increased altitude
5.Medications
 ASSESSING RESPIRATION

RATE - Normal is 12-20/minute in adult

DEPTH - Observe the movement of the chest. May be normal, deep
or shallow
RHYTHM - Observe for regularity of exhalations and inhalations
Quality or character - Refers to respiratory effort and sound of
breathing
TERMINOLOGIES:

EUPNEA - Normal respiration that is quiet, rhythmic, and effortless

TACHYPNEA - Rapid respiration, above 20 breaths/minute in an adult
BRADYPNEA - Slow breathing, less than 12 breaths/minute in an adult
HYPERVENTILATION - Deep rapid respiration. Carbon dioxide is
excessively exhaled (respiratory alkalosis)
HYPOVENTILATION - Slow, shallow respiration. Carbon dioxide is
excessively retained (respiratory acidosis)
DYSPNEA - Difficult and labored breathing
ORTHOPNEA - Ability to breath only in upright position
APNEA - Absense of respiration
RESPIRATIONS: LIFESPAN CONSIDERATIONS
Infants: Some newborns display
“periodic breathing”
Children: Diaphragmatic breathers
Elders: Anatomic and physiologic changes cause
respiratory systemto be less efficient.
 BLOOD PRESSURE
Ø Force exerted on the walls of arteries under the pressure from the
heart. Measured in millimeters of mercury (mmHg)

BLOOD PRESSURE MEASURES:

Systolic Pressure: pressure of the blood as a result of contraction of the ventricles, that
is, the pressure of the height of the blood wave
Diastolic Pressure: pressure when the ventricles are at rest

PULSE PRESSURE: the difference between the Systolic pressure and the
Diastolic Pressure
- normal PP is 40mm Hg (at rest)
↑ Pulse Pressure – arteriosclerosis
↓ Pulse Pressure– Severe heart failure
 DETERMINANTS OF BLOOD PRESSURE
CARDIAC OUTPUT - The amount of blood the heart pumps through the circulatory
system in a minute
BLOOD VISCOSITY - Thickness of the blood
STROKE VOLUME - The amount of blood pumped by the left ventricle of the heart
in one contraction
BLOOD VOLUME - Normal blood volume is 5L (5000ml)
ELASTICITY OF VESSELS WALLS - Expandation of arterial walls
PERIPHERAL VASCULAR RESISTANCE - Constriction (vasoconstriction)/dilation of
blood vessels

Blood circulates through a network of:

• Veins
• Capillaries
• Arteries
• Arterioles
• Venules
HYPERTENSION is an abnormally high blood pressure over 140
mm Hg and or above 90 mm Hg diastolic for at least two
consecutive readings.

HYPOTENSION - is an abnormally low blood pressure, systolic

pressure below 100/60 mm Hg

ORTHOSTATIC HYPOTENSION - is a drop in systolic pressure more

than 20 mm Hg.
3 LAYERS OF VEINS
FACTORS CONTRIBUTING TO
BLOOD PRESSURE
CONT.
CONT.
 FACTOR AFFECTING BLOOD PRESSURE

1.AGE
2.EXERCISE
3.STRESS
4.RACE
5.OBESITY
6.SEX/GENDER
7.MEDICATIONS
8.DAILY VARIATIONS
9.ENVIRONMENT
KOROTKOFF’S SOUNDS:
Phase 1: First faint, clear tapping or thumping
sounds; SYSTOLIC PRESSURE
Phase 2: Muffled, whooshing, or swishing sound
Phase 3: Blood flows freely;Crisper and more
intense sound;Thumping quality but softer than in
phase 1
Phase 4: Muffled and have a soft, blowingsound
Phase 5: Pressurelevel when the last sound is
heard; Period of silence; DIASTOLIC PRESSURE
 PA IN A SSESSMENT
- An unpleasant sensory and emotional experience,
which we primarily associate with tissue damage or in
terms of such damage or both.
PHYSIOLOGIC PROCESSES: CLASSIFICATION OF PAIN
1. transduction 1. acute pain
2. nociceptors 2. chronic non-malignant pain
3. transmission 3. cancer pain
4. nodulation 4. visceral pain
5. perception 5. deep somatic pain
6. intractable pain
7. neuropathic pain
8. phantom pain
DIMENSIONS OF PAIN
- physical dimension, behavioral [dimension, sociocultural
dimension, congnitive dimension, and sensory dimension,
affective dimension and spiritual dimension

Pain Assessment
Tools
1. ABCDE MNEMONICS (Pain interview)

a - ask about the pain regularly

b - believe the patient and family in their reports of pain
c - choose pain control options appropriate for the patient’s family and setting
d - deliver interventions in a timely, logical and coordinated fashion
e - empower patients and their families
2. PQRST (Pain interview)

p - pallative
q - quality
r - radiate
s - severity
t - temporal factors

3. UNIVERSAL PAIN ASSESSMENT TOOLS

- verbal descriptor’s scale
- wong baker facial grimace scale
- activity tolerance scale
- FLACC scale (face, leg, activity, cry, consolability
- visual analog scale