By.

Nova Gerungan
Vital Signs
 The nurse caring for the patient is
responsible for measurement of vital signs.
Although you sometimes delegate
measurement of selected vital signs (i.e., in
stable patients), as a nurse you need to analyze
them to interpret their significance and make
decisions about interventions.
 Ensure that equipment is functional and
appropriate for the size and age of the patient.
Equipment used to measure vital signs (e.g., a
thermometer) needs to work properly to
obtain accurate findings.
Vital Signs
• Various determinations that provide information
about the basic body conditions of the patient
• 4 main vital signs:
• Temperature
• Pulse
• Respirations
• Blood Pressure
Vital Signs
Other important vital signs that provide information
about the patient’s condition include:
Color of the skin
Size of the pupils and their reaction to light
Level of consciousness
Patient’s response to stimuli
Vital Signs
• Accuracy is essential
• Abnormal vital signs are often the first indication of a disease
of abnormality
• Never guess or report an inaccurate reading
• If you note any abnormality or change in a vital sign,
report it immediately to your supervisor or doctor
• If you have difficulty obtaining a correct reading for
any vital sign, ask for help
DEVICES FOR OBTAINING A VITAL SIGN
When to take vital signs
• On a client’s admission
• According to the physician’s order or the institution’s policy or
standard of practice
• When assessing the client during home health visit
• Before & after a surgical or invasive diagnostic procedure
• Before & after the administration of meds or therapy that affect
cardiovascular, respiratory & temperature control functions.
• Before, after & during nursing interventions influencing vital signs
• When client reports symptoms of physical distress
Temperature
The normal body temperature of a person varies
depending on age, recent activity, food and fluid
consumption, stress, time of day, and in women the
stage of the menstrual cycle.
Variations in Body Temp
• Time of day affects body temp
• Usually lower in morning after body has rested
• Higher in evening after muscular activity and food intake with
metabolism
• Parts of the body where temp is measured can also
lead to variations
• Painful procedures and exercise should not have
occurred within one hour
• Patient should have been sitting quietly for about 5
minutes
Factors Causing an Increase in
Body Temperature

 Illness and infection, Exercise

 High temperatures in the environment
Factors Causing a Decrease in
Body Temperature

• Starvation or fasting
• Sleep
• Decrease in muscle activity
• Cold temperatures in the
environment
Factors That Could Alter Temp
• Eating, drinking hot or cold liquids and/or smoking
can alter oral temp
• Make sure the pt has had nothing to eat, drink or
smoke for at least 15 minutes prior to taking temp
• If so, wait 15 minutes before taking temp
Temperature

• Homeostasis is a constant state of fluid balance

• Ideal health state in the human body
• Rate of chemical reactions in body is regulated by
the temperature
• If temperature is too high or too low, body’s fluid
balance is also affected
• The anterior hypothalamus controls heat loss, and the posterior
hypothalamus controls heat production.
• When nerve cells in the anterior hypothalamus become heated
beyond the set point, impulses are sent out to reduce body
temperature.
• Mechanisms of heat loss include sweating, vasodilation (widening)
of blood vessels. The body redistributes blood to surface vessels to
promote heat loss.
• If the posterior hypothalamus senses that body temperature is
lower than the set point, the body initiates heat conservation
mechanisms.
• Vasoconstriction (narrowing) of blood vessels reduces blood
flow to the skin and extremities.
• Compensatory heat production is stimulated through voluntary
muscle contraction and muscle shivering. When
vasoconstriction is ineffective in preventing additional heat
loss, shivering begins.
• Radiasi ialah emisi energi panas dari permukaan tubuh
dalam bentuk gelombang elektromagnetik melalui suatu
ruang.
• Konduksi ialah perpindahan panas antara obyek yang
berbeda suhunya melalui kontak langsung obyek tersebut.
• Konveksi ialah perpindahan panas melalui aliran udara/air.
• Evaporasi ialah perpindahan panas melalui ekskresi air dari
permukaan kulit dan saluran pernapasan saat bernapas.
Temperature

• Oral
• Axilary
• Tympanic
• Rectal
Temperature
Oral Temperatur
• Taken in the mouth
• Thermometer left in for 3-5
minutes
• Most common, convenient,
comfortable way to take
temperature
• Check for eating/drinking
anything hot/cold exercising
or smoking a cigarette 15
minutes prior
Rectal Temperatur
• Taken in the rectum
• Thermometer left in for 3-5 minutes
• Most accurate
• Insert 1-1 ½ inches, hold in place and screen patient
for privacy
Axillary Temperatur
• Taken under the armpit or in the groin fold
• Thermometer left in for 8-10 minutes
• Dry armpit/groin, place in center and hold in place
Tympanic Temperatur

• Taken in the ear

• Measures the thermal infrared energy
radiating from the blood vessels in
the eardrum
• Position and ear wax can affect
readings
• left in until it beeps
• Temperature is calculated into an
equivalent by mode
Tanda Klinis Hipertermi

• Pulse meningkat dan RR cepat & dalam

• Menggigil karena meningkatnya ketegangan otot dan
kulit terasa dingin karena vasokontriksi
• Kedinginan dan suhu tubuh meningkat
Tanda Klinis Hipotermi

• Suhu tubuh turun – merasa sangat kedinginan

• Hipotensi dan koordinasi otot berkurang
• Disorientasi, mengantuk -> KOMA
Respiration
• Seat the patient in a quiet
comfortable environment
• Count the number of times the
chest rises and falls in 60 seconds
• Bradypnea – Slower that
12/minute
• Tachypnea - Persistent over
20/minute
Pulse

• Palpate the radial artery

• Use the middle and index fingers
• Count the pulses for 1 minute
Palpate the radial artery
• Push lightly at first, adding pressure if there is a lot of
subcutaneous fat or you are unable to detect a pulse.
If you push too hard, you might occlude the vessel
and mistake your own pulse for that of the patient.
Normal Pulse Rate

• The normal pulse rate for adolescents and adults

ranges from 60 to 100 beats/min.
• The pulse rate increases and decreases in response to
a variety of physiologic mechanisms. It also might be
altered by activity, medications, emotions, pain, heat
and cold, and disease processes.
• Normal pulse rates change across the life span,
gradually diminishing from birth to adulthood
Physiology of the Pulse

• The quantity of blood forced out of the left ventricle

with each contraction is called the stroke volume (SV).
• The cardiac output (CO) is the amount of blood
pumped per minute, and averages from 3.5 L/min to
8.0 L/min in a healthy adult.
• This volume is determined by using the following for-
mula: Cardiac Output = Stroke Volume x Heart Rate
• Heart rate increases, cardiac output usually also
increases.
Blood Pressure
Blood pressure is the force in the
arteries when the heart
beats(systolic), and when the
heart is at rest(diastolic)
Blood pressure is measured in
millimeters of mercury(mmHg)
oSystolic – Pressure at which the
sounds first appear
oDiastolic – Pressure at which the
sounds are no longer audible
METHOD FOR TAKING A BP

SEAT THE PATIENT IN A COMFORTABLE POSITION

Inflate the BP cuff
• Palpate and locate the brachial artery
• Position the cuff so the bladder is over the artery and
the cuff is 1-2cm above the antecubital fossa
• Note this level and inflate the cuff 20 -30 mm Hg more
to overcome an ausculatory gap (until the radial pulse
disappears)
Record the systolic and diastolic readings

• First sounds heard will be the

systolic
• Continue deflating the cuff until
the last sound is heard the
diastolic