VITAL SIGNS MONITORING 4.
Hormones – during menstruation,
VITAL
- absolute; necessary; important; essential
VITAL SIGNS
- measurement of body functions
- has to fall on the normal values
- body temperature, pulse, respirations,
and blood pressure
BODY TEMPERATURE (T)
- reflects the balance between the heat
produced and the heat lost from the body
- measured in heat units called degrees
(°C or °F)
- normal range: 36.5 °C to 37.5 °C
 Core temperature – the temperature
of the deep tissues of the body, such
as the abdominal cavity and pelvic
cavity
 Surface temperature – the
temperature of the skin, the
subcutaneous tissue, and fat
 Heat balance – when the amount of
heat produced by the body equals the
amount of heat lost
FACTORS AFFECTING BODY
TEMPERATURE
1. Age
2. Diurnal variations (circadian rhythms)
3. Exercise
metabolism increases
5. Stress
6. Environment
7. Gender
ALTERATIONS IN BODY
TEMPERATURE
- The normal range for adults is
considered to be between 36°C and
37.5°C (96.8°F to 99.5°F)
PYREXIA
- body temperature above the usual range
- also called hyperthermia or fever
- hyperpyrexia: a very high fever above
40°C
 Febrile – client who has a fever
(above 37.5°C)
 Afebrile – client who does not
have fever (normal temperature)
TYPES OF FEVER
1. Intermittent fever
 the body temperature alternates
at regular intervals between
periods of fever and periods of
normal or subnormal
temperatures (ex: malaria)
 febrile to normal to febrile
2. Remittent fever
 a wide range of fluctuations
occurs over a 24-hour period (ex:
cold or influenza)
  temperature above normal
decreases but it is still above the
normal range
3. Relapsing fever
 short febrile periods of a few
days are interspersed with
periods of 1 or 2 days of normal
temperature
 afebrile after 1 to 2 days
4. Constant fever
 the body temperature fluctuates
minimally but always remain
above normal (ex: typhoid fever,
dengue)
 not increasing or decreasing in
temperature
 antipyretic – medication for fever /
pyrexia
 analgesic – medication for pain
HYPOTHERMIA
- core body temperature below the lower
limit of normal
COMMON SITES FOR MEASURING
BODY TEMPERATURE
1. Oral – under the tongue; accessible
 Wait for 30 minutes before
taking the temperature orally to
ensure that the temperature of the
mouth is not affected by the
temperature of the food, fluid, or
warm smoke
2. Rectal – considered to be very accurate
and reliable
 rectal for newborns – for
checking if there is a hole (anus)
3. Axillary – safe and noninvasive; often
preferred site for measuring
temperatures
 Some clinicians recommend
rechecking an elevated axillary
temperature with one taken from
another site to confirm the degree
of elevation
4. Tympanic Membrane – frequent site for
estimating core body temperature
 If the probe fits too loosely in the
ear canal, the reading can be
lower than the true value
5. Temporal Artery – very fast; safe and
non-invasive; measured on the forehead
using a chemical thermometer
TYPES OF THERMOMETER
1. Electronic thermometers (digital
thermometer) – can provide a reading in
only 2 to 60 seconds
2. Chemical disposable thermometers –
have liquid crystal dots or bars that
change color to indicate temperature
3. Tympanic thermometers
4. Infrared thermometers
TEMPERATURE CONVERSION
FACTORS
 °F to °C
5
° C= ( ° F−32 ) ×
9
 °C to °F
 (
° F= ° C ×
9
5)+32
 beta-blockers – medications to
slow down the heart rate
ex: metoprolol (those drugs with
PULSE a “-lol” suffix)
- wave of blood created by contraction of 11. Thyroid problems (hyperthyroidism)
the left ventricle of the heart
 Peripheral pulse – pulse located PULSE SITES
away from the heart
 Apical pulse – central pulse;
located at the apex of the heart

CARDIAC OUTPUT
- the volume of blood pumped into the
arteries by the heart and equals the result
of the stroke volume (SV) times the
heart rate (HR) per minute

PULSE RATE (PR) / HEART RATE (HR)

- measured by bpm (beats per minute)
- use two or three middle fingertips to
locate the pulse
- normal range: 60 – 100 bpm

FACTORS AFFECTING THE PULSE

1. Age
2. Sex
3. Anxiety / Stress
4. Pain 1. Temporal artery- superior and lateral to
5. Disease the eye
6. Position 2. Carotid – at the side of the neck;
7. Hypovolemia / dehydration between the trachea and
8. Exercise sternocleidomastoid muscle
9. Fever 3. Apical – apex of the heart; located on the
10. Medications left side of the chest, to the left of the
sternum at the fifth intercostal space
 4. Brachial – inner aspect of the bicep
muscles; medially in the antecubital
space
5. Radial – the most accessible; on the
thumb side of the inner aspect of the
wrist
6. Femoral – alongside the inguinal
ligament
7. Popliteal – behind the knee
8. Posterior tibial – medial surface of the
ankle; behind the medial malleolus
9. Dorsalis pedis – over the bones of the
foot; between the big and second toes
ASSESSING THE PULSE
- commonly assessed by palpation or
auscultation
 Any medication that could affect the
heart rate.
 Whether the client has been physically
active. If so, wait 10 to 15 minutes until
the client has rested and the pulse has
slowed to its usual rate.
 Any baseline data about the normal heart
rate for the client. For example, a
physically fit athlete may have a resting
heart rate below 60 beats/min.
 Whether the client should assume a
particular position (e.g., sitting). In some
clients, the rate changes with the position
because of changes in blood flow
volume and autonomic nervous system
activity.
TERMINOLOGIES FOR PR / HR
 Pulse rhythm – the pattern of the beats
and the intervals between the beats
 regular rhythm
 irregular rhythm – dysrhythmia
or arrhythmia
 Pulse strength – the force of blood
exerted with each beat
 bounding or threading
GRADING FOR PULSE STRENGTH
0 – absent or o pulse
1 – weak / threading pulse
2 – normal pulse
3 – bounding pulse
 Tachycardia – an excessively fast heart
rate (over 100 bpm)
 Bradycardia – heart rate less than 60
bpm
RESPIRATIONS
- an act of breathing
- inspiration (inhalation) – the intake of air
into the lungs
- expiration (exhalation) – breathing out or
the movement of gases from the lungs to
the atmosphere
RESPIRATORY RATE (RR)
- measured by breaths per minute
- full respiration = 1 exhale & 1 inhale
- normal values: 12-20 breaths per minute
FACTORS AFFECTING RESPIRATIONS
1. Altitude
2. Stress
3. Temperature
4. Exercise
ASSESSING RESPIRATIONS
Before assessing client’s respirations, a
nurse should be aware of the following:
 The client’s normal breathing pattern
 The influence of the client’s health
problems on respirations
 Any medications or therapies that might
affect respirations
 The relationship of the client’s
respirations to cardiovascular function.
TERMINOLOGIES FOR RR
 Tachypnea – abnormally fast
respirations; polypnea
 Bradypnea – abnormally slow
respirations
 Eupnea – normal respirations
 Dyspnea – labored / difficulty in
breating
 Hyperventilation – deep, rapid
respirations due to decrease in carbon
dioxide
 Hypoventilation – very shallow
respirations
 Cheyne-Stokes respiration – decreased
respirations followed by apnea
 Apnea – the absence of breathing
 Kussmaul breathing – deep, rapid
breathing pattern due to increased tidal
volume
OXYGEN SATURATION
- measured using the device called pulse
oximeter
- normal values: 95-100%
BLOOD PRESSURE
- force exerted by the blood on the arterial
walls
- relationship between the cardiac output
& peripheral resistance
 Cardiac output – blood ejected
from heart each minute
 Peripheral resistance – resistance
of arteries to blood flow
- measured in units of millimeters of
Mercury (mmHg)
- standard BP: 120/80 mmHg
SYSTOLIC PRESSURE
- the pressure of blood as a result of
contraction of the ventricles
DIASTOLIC PRESSURE
- the pressure when the ventricles are at
rest
PULSE PRESSURE
- the difference between the diastolic and
the systolic pressures
- normal PP is about 40 mmHg
FACTORS AFFECTING BLOOD ASSESSING BLOOD PRESSURE
PRESSURE - measured with a blood pressure cuff, a
1. Age sphygmomanometer, and a stethoscope
2. Exercise NOTE: Ask first if the client is in pain as this
3. Stress may alter his or her blood pressure.
4. Race - blood pressure cuff consists of a bag,
5. Sex called a bladder, that can be inflated with
6. Medications air
7. Obesity - One tube connects to a bulb that inflate
8. Diurnal Variations the bladder
9. Medical Conditions - The other tube is attached to
10. Temperature sphygmomanometer

 Hypertension – a blood pressure that is STETHOSCOPE

persistently above the normal range - diaphragm: high-pitch sounds
 Hypotension – a blood pressure that is - bell: low-pitch sounds
below normal
KOROTKOFF’S SOUNDS
CLASSIFICATION OF BLOOD - a thumping sound
PRESSURE - The systolic pressure is the point where
the first tapping sound is heard (phase 1)
Blood Pressure Systolic Diastolic
- The diastolic pressure is the point where
Category
the sounds become inaudible (phase 5)
Normal < 120 mmHg < 80 mmHg
Prehypertension 120 – 139 80 – 89
mmHg mmHg
High Blood 140 – 159 90 – 99
Pressure mmHg mmHg
(Hypertension
Stage 1)
Hypertension ≥ 160 mmHg ≥ 100 mmHg
Stage 2
Hypertensive > 180 mmHg > 120 mmHg
Crisis
 - The palpatory method is sometimes used
when Korotkoff’s sounds cannot be
heard and electronic equipment to
amplify the sounds is not available
TYPES OF PAIN
AUSCULTATORY GAP
- the temporary disappearance of sounds
normally heard over the brachial artery
when the cuff pressure is high followed
by the reappearance of the sounds at a
lower level
COMMON ERRORS IN ASSESSING
BLOOD PRESSURE
- too loose = underestimated values
- too tight = overestimated values
 To check the cuff, insert two fingers
under the inserted cuff in order to assess
if it is fitted into the patient’s arm
 After the palpatory method, rest for
about 20 seconds before starting to
measure the blood pressure.
PAIN
- unpleasant sensory and emotional
experience arising from actual or
potential tissue damage
PAIN MANAGEMENT
PAIN ASSESSMENT GUIDE
- the alleviation of pain or a reduction in
pain to a level of comfort that is
acceptable to the client
1. Referred pain – appear to arise in
different areas of the body
2. Visceral pain – pain arising from organs
or hollow viscera; perceived in an area
remote from the organ causing the pain
3. Acute pain – pain that lasts only through
the expected recovery period; sudden or
slow onset
4. Chronic pain – persistent pain;
prolonged, usually recurring or lasting 3
months or longer, and interferes with
functioning (ex: arthritis)
5. Nociceptive pain – sharp, achy,
throbbing pain; experienced when an
intact, properly functioning nervous
system sends signals that tissues are
damaged, requiring attention and proper
care
6. Somatic pain – originates in the skin,
muscles, bone or connective tissue
7. Neuropathic pain – associated with
damaged or malfunctioning nerves due
to illness, injury, or undetermined
reasons; CNS & PNS
8. Radicular pain – compression of spinal
nerves; radiates on back and hips
1. Describe the pain
  aching, shooting, sharp, dull,
numb, tender, etc.
2. Location of the pain
3. Duration of the pain
4. Aggravating factors and alleviating
factors

TYPES OF PAIN SCALE INTENSITY

1. 1-10 pain scale –usually for adults

 0 – no pain
 10 – worst pain
2. Face Pain Scale (Wong-Baker Faces
Rating Scale)
 for children
 includes a number scale along
with an illustrated facial
expression so that pain intensity
can be documented