01

Vital
Signs
NURSING

Presented by Kristine Marie A. Ylaya

 02

REPORTER'S PROFILE

N A M E : K R I S T I N E M A R I E A . Y L AYA
Course & Year: Bachelor of Science in Nursing, 2nd Year
Home Address: Purok 13, Malungay Street, Poblacion, Bayugan,
Agusan del Sur
Email Address: kmylaya@gmail.com
LEARNING
03

OBJECTIVES
After completing this chapter, you will be able to:
1. Describe factors that affect the vital signs and accurate
measurement of them.
2. Identify the variations in normal body temperature, pulse, respirations, and blood pressure

NURSING
that occur from infancy to old age.
3. Describe appropriate nursing care for alterations in vital signs. 
4. Identify nine sites used to assess the pulse and state the reasons for their use. 
5. List the characteristics that should be included when assessing pulses.
6. Describe the mechanics of breathing and the mechanisms that control respirations.
7. Recognize when it is appropriate to delegate measurement of vital signs to unlicensed
assistive personnel.
8. Demonstrate appropriate documentation and reporting of vital signs.
 04
Introduction
Body Temperature
PRESENTATION Pulse

OVERVIEW Respirations
Blood Pressure
Oxygen Saturation

KE Y TOP IC S Nursing • March 2020

 05
INTRODUCTION

W HAT ARE VI TAL SI GNS ?

are the evidence of the current physical

functioning of the body. They provide
critical that is 'vital' for life, and so they are
called vital signs. The traditional vital
signs are body temperature, pulse,
respi?rations, and blood pressure. Nursing • March 2020
 06

BODY
TEMPERATUR
E
re fl e cts th e ba l a nce
be twe en th e h e at pro du ce d
and the h e at l o s t fro m th e
bod y, a nd i s m e as ur e d i n
he at uni ts ca l l e d
d eg r ee s .

Nursing • March 2020

 07

CORE Two SURFACE

TEMPERATUR Kinds TEMPERATUR
r e fl ec ts th e E
ba l a nce of E
i s th e te m p e ra ture o f th e
b et we e n th e h ea t s k i n, th e s ub cuta ne o us
p rod uce d a nd th e h e a t
l o s t from the bo d y, a nd i s
Body ti s s ue , a nd fa t. It, b y
c o ntra s t, r i s e s a nd fal l s i n
me a s ure d i n h e a t uni ts r e s p o ns e to th e
c alle d d e g re e s .
Temperatur e nvi ro nm e nt
e:

Nursing • March 2020

 A NUMBER OF FACTORS AFFECT 08
THE BODY’S HEAT PRODUCTION.
TH E M O ST I M PO RTAN T A R E TH E SE F I V E:

B A S A L M E TA B O L I C RAT E MUSCLE ACTIVITY

(BMR)

is the rate of energy utilization in the body Muscle activity, including

Nursing • March 2020

required to maintain essential activities shivering, increases the
such as breathing. Metabolic rates metabolic rate.
decrease with age. In general, the younger
the person, the higher the BMR.
 EPINEPHRINE, NOREPINEPHRINE, AND 09
S Y M PAT H E T I C S T I M U L AT I O N / S T R E S S
RESPONSE

These hormones immediately increase the rate of cellular

metabolism in many body tissues.

T H Y R OX I N E O U T P U T FEVER

Nursing • March 2020

Increased thyroxine output Fever increases the cellular
increases the rate of cellular metabolic rate and thus increases
metabolism throughout the body. the body’s temperature further.
 10
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.

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 except, for example, when a
body is immersed in cold water.
CONVECTION 11

is the dispersion of heat by air currents. This warm air rises

and is replaced by cooler air, so people always lose a small
amount of heat through convection.

EVAPORATION
is continuous vaporization of moisture from the respiratory
tract and from the mucosa of the mouth and from the skin.
•Insensible Water Loss
continuous and unnoticed water loss
•Insensible Heat Loss
the accompanying heat loss
The system that regulates body temperature has three main parts: 12

sensors in the periphery and in the core, an integrator in the

hypo?thalamus, and an effector system that adjusts the
production and loss of heat.

When the skin becomes chilled over the entire body, three phys?iological
processes to increase the body temperature take place:
1. Shivering increases heat production.
2. Sweating is inhibited to
decrease heat loss.
3. Vasoconstriction decreases REGULATION OF
heat loss.
BODY
TEMPERATURE
Nursing • March 2020
 FACTORS
13

AGE
AFFECTING Many older people, particularly those over
75 years, are at risk of hypothermia
BODY (temperatures below 36°C, or 96.8°F) for a

TEMPERATURE variety of reasons, such as inadequate

diet, loss of subcutaneous fat, lack of
activity, and reduced thermoregulatory
efficiency. Older adults are also
particularly sensitive to extremes in the
environmental temperature due to
decreased thermoregulatory controls.

N UR SI N G
 14

D I U R N A L VA R I AT I O N S
( C I RC A D I A N R H Y T H M S )
Body temperatures normally change
throughout the day, varying as much as
1.0°C (1.8°F) between the early morning
and the late afternoon. The point of
highest body temperature is usually
reached between 1600 and 1800 hours
(4:00 pm and 6:00 pm), and the lowest
point is reached during sleep between
0400 and 0600 hours (4:00 am and 6:00
am)
N UR SI N G
 15

E X E RC I S E
Hard work or strenuous exercise can
increase body temperature to as high as
38.3°C to 40°C (101°F to 104°F) measured
rectally.

HORMONES
Women usually experience more hormone
fluctuations than men. In women,
progesterone secretion at the time of
ovulation raises body temperature by
about 0.3°C to 0.6°C (0.5°F to 1.0°F) above
N UR SI N G basal temperature.
 16
STRESS
Stimulation of the sympathetic nervous
system can increase the production of
epinephrine and norepinephrine, thereby
increasing metabolic activity and heat
production.

ENVIRONMENT
Environment. Extremes in environmental
temperatures can affect a person’s
temperature regulatory systems.
N UR SI N G
ALTERATIONS IN BODY 17

TEMPERATURE
PYREX IA /H YP ERT H ER M IA

A body temperature above the usual range.

FEVER SPIKE
A temperature that rises to fever level rapidly following a normal
temperature and then returns to normal within a few hours.

H E AT E X H A U S T I O N
a result of excessive heat and dehydration.
FOU R COM MON TYPES OF FEVERS:
18

•Intermittent Fever
the body temperature alternates at regular intervals between periods of fever
and periods of normal or subnormal temperatures.
•Remittent Fever
a wide range of temperature fluctuations (more than 2°C [3.6°F]) occurs over a
24-hour period, all of which are above normal.
•Relapsing Fever
short febrile periods of a few days are interspersed with periods of 1 or 2 days of
normal temperature.
•Constant Fever
the body temperature fluctuates minimally but always remains above normal.
 19
HY P O T HE RM I A

is a core body temperature below the lower limit of normal.

T H E T HR E E PH Y S I OLOG I C A L M E C HA NI S M S
O F H YPOT H E R M I A A R E :

(a) excessive heat loss

(b) inadequate heat production to counteract heat loss, and (c)
impaired hypothalamic thermoregulation
I NDU C E D H Y PO TH E R M I A 20

is the deliberate lowering of the body temperature to

decrease the need for oxygen by the body tissues such as
during certain surgeries.

ACC I DE N TA L H Y POT HE R M I A

can occur as a result of:

(a) exposure to a cold environment,
(b) immersion in cold water, and
(c) lack of adequate clothing, shelter, or heat.
21
 TYPES OF 22

ELECTRONIC THERMOMETERS
THER MOMETER

c an p rovi d e a re a d i ng i n on l y 2 to 6 0   se co nd s , d ep e nd i ng o n
th e m od el . T h e eq u i p m ent c on si s ts of an el ec t ro ni c b as e, a
p ro b e, a nd a p ro b e c over, w h i c h i s u su al l y d i sp o sab l e

BASAL THERMOMETER
i s ca l i b ra ted w i t h 0 .1 ° F i n ter val s an d i s f or fe r ti l i ty
p u rp os es , i nd i c a ti n g th e t em p erat ure ri s e th at i s
as s oc i at ed w i t h ovu l a ti o n.

HYPOTHERMIA THERMOMETER
Hyp ot he rmi a th erm om et ers have a g r eater l ow ra ng e
t han every d a y th erm om ete rs , u s ual l y mea su ri ng
t em p erat ures f ro m 2 7 .2 ° C to 4 2 .2 ° C (8 1 ° F to 1 0 8 ° F ).
 23

CHEMICAL DISPOSABLE
T HERM
Chemical O M E T E Rhave liquid crystal dots or bars that change
thermometers
color to indicate temperature. To read the temperature, the nurse
notes the highest reading among the dots that have changed color.
These thermometers can be used orally, rectally, or in the axilla.
 24
T E M P E RAT U R E - S E N S I T I V E TA P E
may also be used to obtain a general indication of
body surface temperature. It does not indicate the
core temperature. The tape contains liquid crystals
that change color according to temperature.

I N F RA R E D T H E R M O M E T E R
sense body heat in the form of infrared energy
given off by a heat source, which, in the ear canal,
is primarily the tympanic membrane
 25

T E M P O RA L A RT E RY T H E R M O M E T E R
determine temperature using a scanning infrared
thermometer that compares the arterial temperature in
the temporal artery of the forehead to the temperature
in the room and calculates the heat balance to

NURSING
approximate the core temperature of the blood in the
pulmonary artery
 26
FAHRENHEIT TO CELSIUS
C = (Fahrenheit temperature - 32) x 5/9

CELSIUS TO
F FAHRENHEIT 
= ( C e l s i u s t e m p e ra t u r e x 9/5) + 32

TEMPERATURE SCALES

Nursing • March 2020

N UR S I N G 27
 29

P U L S E
is a wave of blood created by
contraction of the left ventricle of the
heart. The pulse wave represents the
stroke volume output or the amount of
blood that enters the arteries with
each ventricular contraction.
Nursing • March 2020
 30

CARDIAC PERIPHERAL
OUTPUT i s a p u l s e l o cPULSE
ated away from the hear t,
for example, in the foot or wrist.
is the volume of
blood pumped into
the arteries by the
heart and
the result of the
equals APICAL PULSE
stroke volume (SV) i s a c e n t ra l p u l s e ; t h a t i s , i t i s l o c a t e d a t
t i m e s t h e h e a r t ra t e the apex of the heart. It is also referred
(HR) per minute. to as the point of maximal impulse (PMI).
 FACTORS 32

AGE
As age increases, the pulse rate gradually
AFFECTING THE
decreases overall. PULSE
SEX
After puberty, the average male’s pulse
rate is slightly lower than the female’s.

E X E RC I S E
The pulse rate normally increases with
activity.
N UR SI N G
 33
FEVER
The pulse rate increases (a) in response to
the lowered blood pressure that results
from peripheral vasodilation associated
with elevated body temperature and (b)
because of the increased metabolic rate.

M E D I C AT I O N S
Some medications decrease the pulse
rate, and others increase it. For example,
cardiotonics (e.g., digitalis preparations)
decrease the heart rate, whereas
epinephrine increases it.
N UR SI N G
 34
H Y P O V O L E M I A / D E H Y D RAT I O
Loss of blood from the vascular system N
increases the pulse rate.
STRESS
In response to stress, sympathetic
nervous stimulation increases the overall
activity of the heart.
POSITION
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. N UR SI N G
 35
POSITION
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.

PAT H O LO GY
Certain diseases such as some heart
conditions or those that impair
oxygenation can alter the resting pulse
rate.
N UR SI N G
PULSE SITES
ASSESSING
THE
PULSE
When assessing the pulse, the nurse collects the following data: 39

the rate, rhythm, volume, arterial wall elasticity, and presence or

absence of bilateral equality.

TA C H YC A R D I A
an excessively fast heart rate (e.g., over 100 beats/min in an
adult)

B RA DYC A R D I A
a heart rate in an adult of less than 60 beats/min
PULSE RHYTHM
40
is the pattern of the beats and the intervals between the beats

DY S R H Y T H M I A O R A R R H Y T H M I A
pulse with an irregular rhythm.
it may consist of random, irregular beats or a predictable pattern
of irregular beats.

P U L S E V O LU M E
also called the pulse strength or amplitude, refers to the force of
blood with each beat. Usually, the pulse volume is the same with
each beat. It can range from absent to bounding.
 41

FULL OR BOUNDING PULSE

forceful or full blood volume that is obliterated only with
difficulty

W E A K , F E E B L E , O R T H R E A DY
pulse that is readily obliterated with pressure from the fingers
APICAL PULSE 42

ASSESSMENT

indica ted for c lients whose peripheral

pulse is irregula r or unava ilable and for
clients with known ca rdiovascular,
pulmona ry , a nd rena l d isea ses. Also used
to a ssess th e pulse for newborns, infants,
and c hild ren up to 2 to 3 y ea rs old.

MARCH 2020
NURSING
 APICAL-RADIAL 43

PULSE ASSESSMENT
as s e s s ed fo r cl i e n ts wi th ce r tai n ca r di ova s cul a r d i s o r d e rs .
Api c a l p ul s e rate g re a te r th a n a ra di al pu l s e rate ca n
ind i ca te th a t th e th r us t o f th e b lo o d fro m th e he a r t i s to o
we a k fo r th e wave to b e fe l t a t th e p e ri p h e ra l p ul s e s i te, o r
it ca n i n di ca te th a t va s cul a r d i s e a s e i s p r eve nti ng
im p ul s e s fro m be i ng trans m i tte d .

PULSE

NURSING
DEFdICIT
i s c r ep a n cy be t we en t h e two puls e
ra t e s i s ca l led a puls e de fi cit
 44

RESPI RAT ION S

is the act of breathing.

NURSING • MARCH 2020

 45

INHAL AT ION/INS PIRAT I ON

refers to the intake of air into the lungs.
VENTI L ATI O N
used to refer to the
movement of air in
EX H AL AT IO N / EXP IRAT ION and out of the lungs
refers to breathing out or the movement
of gases from the lungs to the
atmosphere
 46
TWO TYPES OF
C O S TA L
BREATHING:
( T H O RA C I C ) B R E AT H I N G
involves the external intercostal muscles and other accessory muscles,
such as the sternocleidomastoid muscles. It can be observed by the
movement of the chest upward and outward.

D I A P H RA G M AT I C ( A B D O M I N A L ) B R E AT H I N G
diaphragmatic breathing involves the contraction and relaxation of the
diaphragm, and it is observed by the movement of the abdomen, which occurs
as a result of the diaphragm’s contraction and downward movement.
MECHANICS AND REGULATION OF BREATHING 47

INHAL ATIO N
diaphragm contracts (flattens), the ribs move upward and outward,
and the sternum moves outward, thus enlarging the thorax and
permitting the lungs to expand.

NURSING
 48
EXHAL ATI ON
diaphragm relaxes, the ribs move downward and inward, and
the sternum moves inward, thus decreasing the size of the
thorax as the lungs are compressed.

NURSING
 49

RE S P I RATI O N I S C O NTR OL LE D BY:

(a) respiratory centers in the medulla oblongata and the pons of the
brain 
(b) chemoreceptors located centrally in the medulla and peripherally in
the carotid and aortic bodies

These centers and receptors respond to changes in the

concentrations of oxygen (O2), carbon dioxide (CO2), and hydrogen

NURSING
(H+) in the arterial blood
 ASSESSING RESPIRATIONS 50

• T h e cl i e nt ’s no rm a l b rea thing pa tte rn

• T h e i nfl ue nce o f the c lie nt’s he alt h pro ble m s o n re spi ra tio ns
• A ny m ed i c at i o ns o r the rap ie s that m ig ht af fe ct resp irati o ns
• T he r e l a t i o ns h i p o f the cli ent’s re sp iratio ns to card iovascul ar
f unct i o n.

EUPNEA TA C H Y P N E A O R P O LY P N E A
breathing that is normal in rate and abnormally fast respirations
depth 

B RA DY P N E A APNEA
abnormally slow respirations is the absence of breathing
 51

D E EP RE SPIRAT ION S
which a large volume of air is inhaled
and exhaled, inflating most of the lungs.
TI DAL VOLUM E
During a normal
inspiration and
expiration, an adult takes
SH A L LO W R ESP IRAT IONS in about 500 mL of air

exchange of a small volume of air and

often the minimal use of lung tissue

H Y P E RV E N T I L AT I O N
very deep, rapid respirations
R E S P I RAT O RY R H Y T H M
regularity of the expirations and the
inspirations. Respiratory rhythm can
be described as regular or irregular.
L A B O R E D B R E AT H I N G
breathe only with substantial effort
52
H Y P O V E N T I L AT I O N
very shallow respirations
R E S P I RAT O RY Q U A L I T Y O R
C H A RAC T E R
aspects of breathing that are different from
normal, effortless breathing. 
• amount of effort a client must exert to
breathe
• the sound of breathing
 54

B LOOD
PR ESSU R E
a measure of the pressure
exerted by the blood as it
flows through the arteries

NURSING • MARCH 2020

 55

S YS TOLIC PR E SS UR E P U LS E
PRE S S U R E
pressure of the blood as a result of
contraction of the ventricles, that is, the difference between
pressure of the height of the blood wave
the diastolic and the
systolic pressures.
normal pulse
D IAS T OL IC PR ESSU R E pressure is about 40
pressure when the ventricles are at rest, mmHg but can be as
that is, the lower pressure, present at all high as 100 mmHg
times within the arteries
during exercise.
 56

MEAN ARTERIAL PRESSURE

(MAP)
r e p r e s e n t s t h e p r e s s u r e a c t u a l l y d e l i v e r e d t o t h e b o d y ’s
organs
c a n b e c a l c u l a t e d i n s e v e ra l d i f f e r e n t w a y s , o n e o f w h i c h i s t o
add two-thirds of the diastolic pressure to one-third of the
systolic pressure.
normal MAP is 70 to 110 mmHg
 DETERMINANTS OF BLOOD 57

PRESSURE
P U M P I N G A C T I O N O F T H E H E A RT

Wh en t he p um p i n g a ct i on of t he he ar t i s w eak, l es s b l oo d i s
p um p ed i nto a r te ri es (l o w er c ard i ac ou tp u t) , an d th e b l oo d
p ress u re d e c rea s es
Wh en th e h ea r t ’s p um p i ng ac ti on i s s tron g an d t he vol u me of
b l ood p um p ed i nto t he c i rc u l ati o n i nc reas es (hi g h er c ard i ac
ou tp ut ), th e b l o od p res s u re i n c reas es
P E R I P H E R A L VA S C U L A R R E S I S TA N C E
c an in c rea s e b l o od p re ss ure . So me fac tors that c reat e
resi s t anc e i n t he a r te ri al s ys tem are th e c ap ac i t y o f th e
ar t eri ol es a nd ca p i l l a ri es , t he c o m p l i anc e o f th e ar t eri es , an d
th e vi sc o s i ty o f th e b l o od .
B LO O D V O LU M E 58

Wh en t he b l o od vo l um e d ec re ase s (f or exa mp l e , as a res ul t of

a h em orrh a g e o r d ehy d rati o n) , th e b l o od p ress ure d ec re ase s
b ec aus e o f d ec rea s ed fl u i d i n th e ar teri e s.
Wh en t he b l o od vo l um e d ec re ase s (f or exa mp l e , as a res ul t of
a h em orrh a g e o r d ehy d rati o n) , th e b l o od p ress ure d ec re ase s
b ec aus e o f d ec rea s ed fl u i d i n th e ar teri e s.

BLOOD VISCOSITY
Bl oo d p res s ure i s hi g h er w h en th e b l o od i s h ig hl y vi s c ou s
(th i c k), t ha t i s , w he n t he p ro p or t i on of re d b l o od c el l s to th e
b l ood p l a s m a i s hi g h . Thi s p rop o r ti on i s refer red to as th e
hem ato c ri t. T he vi s c o si t y i n c rease s m ark ed l y w hen th e
hem ato c ri t i s m ore th a n 6 0 % to 6 5 % .
 AGE
FACTORS 59

pressure rises with age, reaching a peak at

the onset of puberty, and then tends to
AFFECTING THE
decline somewhat. In older adults, PULSE
elasticity of the arteries is decreased—the
arteries are more rigid and less yielding to
the pressure of the blood

E X E RC I S E
Physical activity increases the cardiac
output and hence the blood pressure
For reliable BP result, wait 20 to 30
minutes following exercise
N UR SI N G
 60
STRESS
Stimulation of the sympathetic nervous
system increases cardiac output and
vasoconstriction of the arterioles, thus
increasing the blood pressure. Severe pain
can decrease blood pressure greatly by
inhibiting the vasomotor center and
producing vasodilation.
RA C E
African Americans older than 35 years
tend to have higher blood pressures than
European Americans of the same age

N UR SI N G

T E M P E RAT U R E
External heat causes vasodilation and
decreased blood pressure. Cold causes
vasoconstriction and elevates blood
pressure.
61
SEX
After puberty, females usually have lower
blood pressures than males of the same
age; this difference is thought to be due to
hormonal variations. After menopause,
women generally have higher blood
pressures than before.
M E D I C AT I O N S
Many medications, including caffeine, may
increase or decrease the blood pressure
N UR SI N G

MEDICAL CONDITIONS
Any condition affecting the cardiac output,
blood volume, blood viscosity, and/or
compliance of the arteries has a direct
effect on the blood pressure.
62
D I U R N A L VA R I AT I O N S
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.
OBESITY
Both childhood and adult obesity
predispose to hypertension.
N UR SI N G
 HYPERTENSION 63

• bl o o d pr e s s ur e t h a t i s p ersiste ntly a bove no rm al

• usua l l y a s ym p to m ati c a nd is o fte n a c o ntri buting fa cto r to
m y o ca rd i a l i nf a rct io ns (hea r t atta cks)

P R I M A RY H Y P E RT E N S I O N S E C O N D A RY H Y P E RT E N S I O N
elevated blood pressure of unknown elevated blood pressure of known cause
cause
 DETERMINANTS OF BLOOD 65

PRESSURE
P U M P I N G A C T I O N O F T H E H E A RT

Wh en t he p um p i n g a ct i on of t he he ar t i s w eak, l es s b l oo d i s
p um p ed i nto a r te ri es (l o w er c ard i ac ou tp u t) , an d th e b l oo d
p ress u re d e c rea s es
Wh en th e h ea r t ’s p um p i ng ac ti on i s s tron g an d t he vol u me of
b l ood p um p ed i nto t he c i rc u l ati o n i nc reas es (hi g h er c ard i ac
ou tp ut ), th e b l o od p res s u re i n c reas es
P E R I P H E R A L VA S C U L A R R E S I S TA N C E
c an in c rea s e b l o od p re ss ure . So me fac tors that c reat e
resi s t anc e i n t he a r te ri al s ys tem are th e c ap ac i t y o f th e
ar t eri ol es a nd ca p i l l a ri es , t he c o m p l i anc e o f th e ar t eri es , an d
th e vi sc o s i ty o f th e b l o od .
 HYPOTENSION 66

• a bl o o d pr e s s ure t hat is b el o w no rma l

• s ys to l i c r e ad i ng co nsist ently be twe e n 8 5 a nd 1 10 m mH g
• al so b e ca us ed by a nalg e sics such a s m e pe ri d ine
h yd ro c hl o ri de ( De me ro l ), b le e di ng , sev ere burns, a nd
d eh y dra ti o n

O RT H O S TAT I C H Y P O T E N S I O N
• a blood pressure that decreases when the client sits or stands.
• usually the result of peripheral vasodilation in which blood leaves the central body
organs, especially the brain, and moves to the periphery, often causing the person to
feel faint
 ASSESSING ORTHOSTATIC 67

HYPOTENSION
• Place the client in a supine position for 10 minutes.
• Record the client’s blood pressure.
• Assist the client to slowly sit or stand. Support the client in case of faintness. 
• Immediately recheck the blood pressure in the same sites as previously.
• Repeat the pulse and blood pressure after 3 minutes.
• Record the results. A drop in blood pressure of 20 mmHg systolic or 10 mmHg
diastolic indicates orthostatic hypotension
68
 BLOOD PRESSURE ASSESSMENT SITES 69

usually assessed in the client’s upper arm using

the brachial artery and a standard stethoscope

A S S E S S I N G T H E B LO O D P R E S S U R E O N A C L I E N T ’ S
T H I G H I S I N D I C AT E D I N T H E S E S I T U AT I O N S :
• The blood pressure cannot be measured on either arm (e.g., because of burns or
other trauma).
• The blood pressure in one thigh is to be compared with the blood pressure in the

NURSING
other thigh.
 B LO O D P R E S S U R E I S N O T M E A S U R E D O N A
70
PA RT I C U L A R C L I E N T ’ S L I M B I N T H E F O L LO W I N G
The
S•I T shoulder,
U AT I O N arm,
S : or hand (or the hip, knee, or ankle) is injured or diseased. 
• A cast or bulky bandage is on any part of the limb.
• The client has had surgical removal of breast or axillary (or inguinal) lymph nodes on
that side.
• The client has an intravenous infusion or blood transfusion in that limb.
• The client has an arteriovenous fistula (e.g., for renal dialysis) in that limb.

DI RECT (I NVAS IVE

MONI TOR IN G)
MEASUREMENT

NURSING
involves the insertion of a catheter into
the brachial, radial, or femoral artery
 NONINVASIVE INDIRECT METHODS
71

PALPATORY
AUS CULTATORY METH ODS
ME THOD
External pressure is used when
applied to a Korotkoff’s sounds
cannot be heard and
superficial artery and
electronic equipment
the nurse reads the
to amplify the sounds
pressure from the
is not available, or to
sphygmomanometer
prevent misdirection
while listening with a
from the presence of
stethoscope. an auscultatory gap.
 73

OXYGEN
S ATURAT ION
is the percent of all
hemoglobin binding sites that
are occupied by oxygen

NURSING
 PULSE OXIMETER 74

a no ni nva s i ve d evi ce tha t e stim a tes a cli ent’s ar te rial b lo o d

ox yge n s a t ura t i o n ( S aO2) by m ea ns o f a senso r a ttache d to the
c l i e nt ’s fi ng e r, to e, no se , ea rl o be , o r fo rehe a d (o r aro und the
h a nd o r f o o t o f a ne o nate ).
N o rm a l ox yg en s at urati o n i s 9 5% to 1 00 %, a nd be lo w 7 0% is life
t h r e at e ni ng
P U L S E OX I M E T E R ’ S S E N S O R H A S T W O PA RT S :
(a) two light-emitting diodes (LEDs)—one red, the other infrared—that
transmit light through nails, tissue, venous blood, and arterial blood;
and
(b) a photodetector placed directly opposite the LEDs (e.g., the other
side of the finger, toe, or nose).
 75

FACTORS AFFECTING H E M O G LO B I N
OXYGEN SATURATION If the hemoglobin is fully saturated with
oxygen, the SpO2 will appear normal even
READINGS if the total hemoglobin level is low. Thus,
the client could be severely anemic and
have inadequate oxygen to supply the
tissues but the pulse oximeter would
return a normal value.

C I RC U L AT I O N
The oximeter will not return an accurate
reading if the area under the sensor has
impaired circulation
N UR SI N G
 76

ACTIVITY
The pulse rate normally increases with
activity.

C A R BO N M O N OX I D E
POISONING
Pulse oximeters cannot discriminate
between hemoglobin saturated with
carbon monoxide versus oxygen.

N UR SI N G
 77

REFERENCE
B e r m a n , A . , F ra n d s e n , G . , & S n y d e r, S
( 2 0 1 6 ) . K o z i e r a n d E r b 's
N UR S I N G

fundamentals of nursing textbook