Vital Signs

N200/200L
Spring 2013
02/23/22
 Guidelines for Measuring
Vital Signs
O Establish a baseline
O Understand and interpret values.
O Appropriately delegate
O Communicate findings.
O Ensure equipment is in working order.
O Accurately document findings.

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 Vital Signs
O Cardinal signs
O Body Temperature
O Pulse
O Respirations
O Blood pressure
O Pulse Oximeter
O Pain (considered a vital sign)

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 Vital Signs
How often should you assess vital signs?

O Change in client’s health status

O Client reports symptoms (baseline
changes)
O Pre and post procedures
O Pre and post medication administration
that may affect CV system
O Pre and post nursing intervention that
may vital signs
O Routine according to agency
O According to specific orders

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 Body Temperature
O Body temperature = balance between
heat produced and heat lost from
body. Measured in degrees.
O Temperature range:
O 98.6°F to 100.4°F or 36°C to 38°C
O Temperature sites:
O Oral, rectal, axillary, tympanic
membrane, temporal artery, esophageal,
pulmonary artery

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 Body Temperature
O Two kinds of body temperature:
O Core temperature
O Temperature of DEEP tissues of body, such
as abdominal cavity.
O Surface temperature
O Temperature of skin, subcutaneous tissue
and fat. Not as constant as core
temperature rises and falls in response to
the temperature

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Body Temperature Regulation
Neural and vascular Heat production
control

Heat loss Skin temperature

regulation

Behavioral control Thermoregulation

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 Body Temperature
O Heat Production
O Basal Metabolic Rate (BMR)
O Rate of energy utilization to maintain
essential physiological activities such as
breathing. Rates decrease with age.
O Muscle Activity
O Thyroxine output (Thyroid Gland)
O Increases cellular metabolic rates.
Chemical thermogenesis

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 Body Temperature
O Heat Production
O Epinephrine, Norepinephrine, and
sympathic stimulation
O All three increase the rate of
metabolism in many body tissues.
O Fever
O Increases cellular metabolic rate, thus
increasing body temperature (infectious
process)

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 Factors Affecting
Body Temperature
O Diurnal variations
O (circadian
rhythms)
O Age
O Exercise
O Hormones
O Stress
O Environment
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 Sites for Measuring
Body Temperature
O Oral
O Rectal
O Tympanic membrane
O Temporal artery
O Axillary

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 Types of Thermometers

O Electronic
O Chemical disposable
O Infrared (tympanic)
O Temperature-sensitive tape
O Glass mercury
O Scanning infrared (temporal artery) 02/23/22
 Nursing Care for Fever
O Monitor vital signs O Measure intake and
O Assess skin color and output
temperature O Reduce physical
O Monitor laboratory activity
results for signs of O Administer antipyretic
dehydration or
infection as ordered
O Remove excess O Provide oral hygiene
blankets when the O Provide a tepid sponge
client feels warm bath
O Provide adequate O Provide dry clothing
nutrition and fluid and bed linens
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Pulse, Physiology, and Regulation
O An indicator of circulatory status
O Electrical impulses originate from the sinoatrial
(SA) node
O Cardiac output, heart rate, stroke volume
O Mechanical, neural, and chemical factors
regulate ventricular contraction and stroke
volume.

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 Pulse
O Pulse – wave of blood created by contraction
of the left ventricle of heart.
O Peripheral Pulse – pulse located away from the
heart, i.e. radial.
O Apical Pulse – central pulse, located at the
apex of heart.

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 Pulse
O Sites (ALL arterial vessels)
O Temporal
O Carotid
O Apical (common)
O Brachial
O Radial (common)
O Femoral
O Popliteal (difficult)
O Posterior tibial (usually condition specific)
O Dorsalis pedis (usually condition specific)

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 Characteristics of the Pulse
O Assessment O Volume
O Rate O Strength or amplitude
O Rhythm O Absent to bounding
O Volume O Presence or absence of
O Arterial wall bilateral equality
elasticity O Compare corresponding
artery

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 Pulse

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SURFACE ANATOMY LANDMARKS & APICAL PULSE SITES

Measuring Apical Pulse

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 Respiration

O Ventilation
O Diffusion
O Perfusion
O Physiological
control
O Mechanics of
breathing

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 Respiratory Control
Mechanisms
O Respiratory centers
O Medulla oblongata
O Pons
O Chemoreceptors
O Medulla
O Carotid and aortic bodies
O Both respond to O2, CO2, H+
in arterial blood

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 Mechanics of Breathing
O Ratio is 1:2 (inhale:exhale)
O Inhalation
O Diaphragm contract; Ribs move upward and
outward; Sternum moves outward (Active Phase).
O Exhalation
O Diaphragm relaxes; Ribs move downward and
inward; Sternum moves inward (Passive Phase)

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Ventilatory Rate, Rhythm,
Depth
O Two phases
O Inhalation (inspiration)
O Exhalation (expiration)
O = One Complete Breath
O Two Types
O Costal (thoracic) Breathing
O Diaphragmatic (abdominal) Breathing

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Assessment of Ventilation

O Easy to assess
O Respiratory rate
O Ventilatory depth
O Ventilatory rhythm
O Diffusion and perfusion
O Arterial oxygen saturation

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 Components of Vent/Resp
Assessment
O Rate O Rhythm
O Breaths per minute O Regular
O Eupnea O Irregular

O Bradypnea O Quality
O Tachypnea O Effort
O Sounds
O Depth
O Effectiveness
O Normal
O Uptake and
O Deep transport of O2
O Shallow O Transport and
elimination of CO2

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 Respirations
O Recognizing Inadequate Breathing
O Labored breathing
O Use of accessory muscles
O Pale or blue skin
O Cool, clammy skin
O Irregular respirations
O Abnormal lung sounds

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 Pulse Oximetry
O Noninvasive
O Estimates arterial blood
oxygen saturation
(SpO2)
O Normal SpO2 85-100%; <
70% life threatening
O Detects hypoxemia
before clinical signs and
symptoms
O Sensor, photodetector,
pulse oximeter unit
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 Pulse Oximetry
O Factors that affect accuracy include:
O Hemoglobin level
O Circulation
O Activity
O Carbon
monoxide
poisoning

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 Systolic and Diastolic Blood
Pressure
O Systolic O Measured in mm Hg
O Contraction of the O Recorded as a
ventricles fraction, e.g.
O Diastolic 120/80
O Ventricles are at rest O Systolic = 120 and
O Lower pressure Diastolic = 80
present at all times
O Pulse Pressure =
difference between
systolic and diastolic
pressures
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Diastole Systole

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 Arterial Blood Pressure
and Physiology
O Force exerted on walls of an artery
O Systolic and diastolic
O Cardiac output
O Peripheral resistance
O Blood volume
O Viscosity
O Elasticity

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Factors Influencing Blood Pressure
O Age
O Stress
O Ethnicity
O Gender
O Daily Variation
O Medications
O Activity, weight
O Smoking
O Assessment of blood pressure and pulse evaluates
the general state of PERFUSION and cardiovascular
health
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 Korotkoff’s Sounds

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Hypertension and Hypotension

 Hypertension  Hypotension
 More common than  90 mm Hg
hypotension  Dilation of arteries

 Thickening of walls  Loss of blood

 Loss of elasticity volume

 Family history  Decrease of blood

 Risk factors flow to vital organs

 Orthostatic/postural

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 Measurement of Blood
Pressure
O Equipment
O Auscultation
O Children
O Ultrasonic stethoscope
O Palpation
O Lower extremity
O Electronic blood pressure

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 Important Concepts
O Hypertension
O Hypotension
O Orthostatic hypotension
O Narrow/wide pulse pressures

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 Delegation of Measurement
of Vital Signs
O General O T, P, R & B/P
considerations prior O Routine
to delegation measurement may
O Nurse assesses to be delegated to UAP
determine stability O UAP reports
of client abnormal
O Measurement is temperatures
considered to be O Nurse interprets
routine abnormal
O Interpretation rests temperature and
with the nurse determines response

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 Oxygen Saturation
Delegation
O Application of the pulse oximeter sensor
and recording the Sp02 may be delegated
to UAP
O Nurse interprets oxygen saturation value
and determines response

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