Unit II

Taking the Vital Signs

Vital Signs
The balance between the heat produced and heat lost from the
body and is measured in Celsius or Fahrenheit.

The body continually produces heat as a by-product of

metabolism. When the amount of heat produced by the
body equal the amount of heat lost, the person is in heat
balance.
 Factors affecting the body’s heat production
1. Basal Metabolic Rate (BMR)

It is the rate of energy utilization in the body required to

maintain body essentials (breathing, digestion).
BMR decreases with age. In general, the younger the
person, the higher the BMR.
2. Muscle Activity

Increases metabolic rate up to

2000 times and heat
production can increase up to
50 times than the normal.
3. Thyroxine Output
Increased thyroxine output increases the rate of
cellular metabolism throughout the body.
This effect is called thermogenesis, the stimulation of
heat production in the body through increased cellular
metabolism.
4. Strong Emotions
Fight/Flight and stress
hormones will be
stimulated

Increases the rate of

cellular metabolism
5. Presence of disease/illness fever

Increases the cellular

metabolic rate
6. Change in atmospheric temperature
Increased levels of carbon dioxide
and other greenhouse gases in
the atmosphere

Increased temperature of the earth’s

atmosphere
Factors affecting the body’s heat loss
1. Through skin
* Radiation is the transfer
of heat from the surface
of another without
contact between two
objects.
* Conduction is the transfer
of thermal energy through
direct contact.
* Convection is the transfer
of heat energy in a gas or
liquid by movement of
currents like the heat of
the stove while cooking,
the breeze .
* Evaporation is the
process of losing heat
through the conversion of
water to gas (evaporation
of sweat).
2. Through lungs
* Breathing out of air

3. Through kidneys
* Excretion of urine
which is warmed by
heat from the body
4. Through bowel
* Feces absorbs heat
from the body
Physiologic explanation of increase temperature

When the hypothalamus
detect that the client is febrile
* Shivering increases
heat loss
* Sweating is inhibited
to decrease heat loss
* Vasoconstriction
decreases heat loss

• Infection
• Climate change
• Bacterial invasion
Factors affecting body temperature
1. Age
2. Diurnal variations

Body temperatures normally change throughout the day.

The point of highest body temperature is usually between
8pm and midnight.

The lowest point is usually between 4am and 6am.

3. Exercise or Activity
4. Stress
5. Hormones

Women experience more hormone fluctuations than men.

In women, progesterone rises during ovulation.
6. Environment
Sites for measuring body temperature and
thermometers used
1. Oral Obtained by placing the thermometer (mercury
bulb or digital) under the patient's tongue with
lips closed for 3 minutes or when the beep is
heard.

Digital Thermometer
Glass or Mercury Thermometer
Pacifier Thermometer

Ensure that patient has not taken any hot

or cold food or fluids or smoked in 15 –
30 minutes prior to the procedure

Instruct the client to close the lip firmly

around the stem.
Contraindications for oral thermometers
2. Rectal

For this site, the nurse can either use digital

or mercury bulb thermometers
Indications in taking rectal temperature
Contraindications in taking rectal temperature
3. Axillary
Obtained by placing in the apex of the axilla with the arm
pressed closely to the side of the body for at least 5 – 10
minutes of until the beep is heard.
4. Tympanic membrane Obtained by placing an electronic probe
in the ear canal.
5. Skin/Temporal artery
6. Peripheral Refers to the temperature of the peripheral compartment,
which consists of extremities (arms and legs), the skin, and peripheral
tissues.
Advantages and Disadvantages of the Different Sites of
Temperature Taking:
Route Advantages Disadvantages
Oral Accessible * Inaccurate if client has just ingested
Convenient hot or cold drinks or foods
* Thermometers can break if bitten.
* Could injure the mouth following oral
surgery
Rectal Reliable * Inconvenient and unpleasant
* Could injure the rectum
* Presence of stool may interfere with
thermometer placement
 Route Advantages Disadvantages
Temporal Safe * Requires electronic equipment that may be
Noninvasive expensive or unavailable
Very fast * Client has perspiration on the forehead
Axillary Safe The thermometer may need to be in place a long
Non-invasive time to obtain an accurate measurement.
Tympanic Readily accessible Reflects * Can be uncomfortable and involves risk
the core temperature of injuring the membrane if the probe is
Very fast inserted too far.
* Repeated measurements may vary
right and left measurements
* Can differ presence of cerumen
Pyrexia. A temperature above the normal range.
Hyperthermia or fever. A very high temperature above
40°C.
Hypothermia. Temperature below 34°C.
 Common Types of Fever
1. Intermittent fever
A fever where temperature is elevated for several hours
followed by an interval when temperature drops back to
normal. Occurs in malaria, PTB
2. Remittent fever
Sustained fever is a pattern in which there is little change
(0.3°C or less) in the elevated temperature during a 24-hour
period. In sepsis, RHF.
3. Relapsing fever
A variant of the intermittent pattern, fever spikes are
separated by days or weeks of intervening normal
temperature like in lymphoma.
4. Continuous fever
A type or pattern of fever in which temperature does not
touch the baseline and remains above normal throughout
the day like in viral pneumonia.
5. Fever Spikes
A sudden sharp increase in temperature usually up as high
as 105°F like in borreliosis (Lyme disease, is transmitted to
humans by the bite of infected ticks).
6. Resolution of pyrexia by crisis

7. Resolution of pyrexia by lysis

Obvious mechanisms for
increasing body temp-
shivering

Fever is sustained

Temperature
returns to
normal

Nonspecific symptoms
before temp rises
Conversion Formulas
Celsius to Fahrenheit : Multiply by 9, then divide by
5, then add 32

F = [(9/5) °C]+ 32)

Lorna has a body temperature of 38.7°C. Convert the
client’s temperature to Fahrenheit.
= [(9/5)38.7°C]+ 32)

= [(1.8)38.7°C]+ 32)

= 69.66 + 32)

= 101.66°F or 101.7°F
 Nursing Process applied to a Client with Fever
1. Assessment
A. Nursing history
* Ask for any occurrence of recent infection
* Verify whether the client had contact of
person/s with infectious disease
* Observe any temperature changes within
client’s environment
 * Note for recent strenuous activity
B. Physical Exam
* Take client’s vital signs and compare to
normal baseline
* Observe for shivering, flashes of face,
fatigue, eye redness and restlessness
* Palpate forehead if warm to touch
 C. Diagnostics
* Look for any abnormal results on the
following lab results: CBC, urinalysis,
fecalysis or chest X-ray.
2. Nursing diagnosis
Hyperthermia related to infection in the _______ as
evidenced by temperature of 39°C, loss of appetite,
weakness, and dehydration.
3. Goal and Outcome criteria
After 2 hours of my nursing interventions client’s
temperature will decrease to 37.5°C as manifested with
temperature of 37°C, able to consume diet served and
moist skin.
4. Nursing intervention
* Remove excess clothes and manipulate room
temperature by opening windows, putting on
electric fan or AC.
* Increase fluid intake (specify how many glasses)
* Refer to dietitian for client’s diet
* Perform cold or tepid sponge bath
* Administer antipyretic as ordered.
5. Evaluation
Client’s present temperature is 37°C, able to consume
diet served and moist skin.
 It is the wave of blood created by contraction of
the left ventricle of the heart.

The pulse wave represents the SV output and

the amount of blood that enters the arteries with
each ventricular contraction.

In healthy person, the pulse reflects the heartbeat, that is, the PR is the same as
the rate of the ventricular contractions of the heart.
 A person’s arteries loss their
distensibility

Greater pressure or effort is required to

pump the blood into the arteries.

Old Client When the client’s HR produce a weak or small pulse waves,
Client with COPD the nurse should assess and compare the heartbeat and the
peripheral pulse.
Peripheral pulse is a pulse located
away from the heart, like in the foot,
wrist or neck etc.

Apical pulse is located at the

apex of the heart.
The different pulse sites and their specific locations
Pulse Site Locations
Temporal pulse Temple directly in front of the ear
Carotid pulse Neck below the jaw and lateral to the larynx/trachea
Apical pulse Fifth intercostal space immediately to the left of the sternum using a
stethoscope.
Brachial pulse Anterior aspect of the elbow
Radial pulse Palpated immediately above the wrist joint near the base of the thumb
Femoral Ventral thigh between the pubic symphysis and anterior superior iliac
pulse spine
 Pulse Site Locations
Popliteal pulse Posterior knee
Posterior tibial pulse Posterior and inferior to the medial malleolus
Dorsalis pedis pulse groove between the first and second toes slightly medial on the dorsum
of the foot
Factors affecting pulse
1. Age Specific variations in pulse rates from birth to
adulthood.
2. Gender
The average adult male heart rate is between 70 and
72 beats per minute, while the average for
adult women is between 78 and 82 beats.

This difference is largely accounted for by the size of

the heart, which is typically smaller in females than
males.
3. Exercise
4. Fever
Peripheral vasodilation associated with elevated
temperature plus the increased metabolic rate

Lowered blood pressure resulting to increased

pulse rate
5. Medications
Some medications decrease the pulse, and others
increases it.
Cardiotonics (digitalis) decrease the heart rate,
whereas epinephrine increases the PR.
6. Hypovolemia
Loss of blood from the vascular system normally
increases pulse rate.
7. Stress
Stimulation of the sympathetic nervous system
increasing the overall activity of the heart

Increases the PR as the force of the heartbeat

increases.
8. Position changes

Pooling result in decrease venous blood return to

the heart and subsequent reduction in BP and
increase in HR.

When a person is sitting or

standing, blood usually pools in
dependent vessels.
9. Pathology
Certain diseases such as heart conditions or those that
impair oxygenation can alter the PR of a person.
Description of a pulse
1. Volume – is the force or strength of the pulse.
Terms used to describe the volume (force) of
the pulse are weak, thready, or feeble for a pulse that
lacks strength, and strong, full, or bounding for
a pulse that feels forceful.
2. Rhythm – is the pattern of long and short sounds
in every beat.
Pulse is a steady beat like a ticking clock or of
a heartbeat. It can be measured in time by counting the
number of beats per minute (BPM).
Stating the pulse characteristics

Pulse rate reading is 70 bpm. Pulse is in regular beating,

appears to be strong, regular rhythm and bounding
equally between beats.
How would you describe a pulse on a physical exam?
Palpation should be done using the fingertips and intensity of
the pulse graded on a scale of 0 to 4 +.
0 = no palpable pulse
1+ = faint, but detectable pulse;
2+ = slightly more diminished pulse than
normal
3+ = normal pulse
4+ = bounding pulse
Terminologies
Tachycardia is the medical term for a heart rate over 100
beats per minute.
Bradycardia is a slower than 60 bpm or normal heart
rate.
Pulse deficit--the difference between the apical and
peripheral pulse rates.
Pulse pressure is the difference between systolic and
diastolic blood pressure.
The normal range of pulse pressure is between 40 and
60 mm Hg. Pulse pressure tends to increase after the
age of 50.
Measuring the pulse pressure help the medical
and nursing team to predict an impending
heart attack or stroke and presence of a
cardiovascular disorder.
It is the act of breathing. This involves
external and internal respiration.
Factors that may increase the respiratory rate
1. Exercise
2. Stress
3. Fever or increased environmental temperature
4. Lowered O2 concentration at increased altitude
At high altitude, there is less oxygen in the air.
Meaning there is relatively short on oxygen or hypoxic.
Factors that may decrease the respiratory rate
1. Decreased environmental temperature
2. Medications: Narcotics
3. Increased intracranial pressure
An increased intracranial pressure leads to HR
increase and breathing will became shallow, periods of
apnea, and blood pressure will begin to fall.
Eupnea – normal breathing
https://www.youtube.com/watch?v=VtnMRG0ORLs

https://www.youtube.com/watch?v=WfkWMfE9VTY
https://www.youtube.com/watch?v=E9iNwFF6R1Y

https://www.youtube.com/watch?v=e-inf2RkFW0
Altered Breathing Patterns and Sounds
1. Breathing Patterns Rate
Tachypnea is a condition that
refers to rapid breathing. The
normal breathing rate for an
average adult is 12 to 20 breaths
per minute.
Bradypnea is an abnormally slow
breathing rate. The normal breathing rate
for an adult is typically between 12 and
20 breaths per minute.

Apnea is an breathing repeatedly stops

and starts again or cessation of breathing.
2. Volume
Hyperventilation is an
overexpansion of the lungs
characterized by rapid and deep
breathing.
Hypoventilation is an
underexpansion of the lungs
characterized by shallow
respirations.
3. Rhythm
4. Ease or Effort
Dyspnea is difficult and labored breathing.
Orthopnea is the ability to breathe only on upright
position.
Video on Bronchial, Crackles (coarse and fine), Diminished breath sounds
Wheezes, Pleural rub, Rhonchi and Stridor Breath Sounds

https://www.youtube.com/watch?v=KRtAqeEGq2Q
5. Secretions and Coughing
Hemoptysis is presence of blood in the sputum.

Productive cough a cough accompanied by

expectorated secretions.
Nonproductive cough a dry, harsh cough without
secretions.
BP is recorded as fraction, where the numerator is the
systolic pressure and the denominator is the diastolic
pressure.
110 Results from the ventricular
___ contraction

90 Results from ventricular

relaxation
Korotkoff’s Sound
Are the "tapping" sounds heard with a stethoscope as the
cuff is gradually deflated. These are classified
into five different phases. (K-1, K-2, K-3, K-4, K-5).
This is due to blood turbulence
occurring in the brachial artery
under the stethoscope
diaphragm.
Factors affecting blood pressure
Parts of the Stethoscope
There are two sides of the stethoscope
that the nurse may use with
auscultation: the bell and the
diaphragm.

The bell side is used to hear low-

pitched sounds. The bell is used to
assess the S3 and S4 heart sound, as
these are low-pitched sounds.

The diaphragm is used for high-

pitched sounds like S1 and S2.
Proper Technique for Blood Pressure Measurement
1. In general, blood pressure should be measured:
* Before taking any morning doses of
antihypertensive drugs
* No less than 1 hour after exercising, smoking,
or consuming caffeine
* After allowing 10 min to adjust to the
temperature in the examining room
2. Choose the proper cuff for every client
Determination of Cuff Size Based on Arm
Circumference
Arm Circumference Cuff Size
9.0 to 14.0 cm infant
> 14 to 21 cm child
> 21 to 29 cm Regular adult
> 29 to 40 cm Large adult
> 40 to 52 cm Thigh
3. Choose the proper cuff for every client
BP should be measured while seated
4. Multiple readings should be taken
5. Follow correct technique
Four major types of pain
1. Nociceptive pain – pain as a result to tissue or
muscle injury
Examples include sprains, bone fractures, burns, bumps, bruises,
inflammation (from an infection or arthritic disorder), obstructions, and
myofascial pain (which may indicate abnormal muscle stresses).
2. Inflammatory pain – an abnormal inflammation
caused by inappropriate response by the body’s
immune system.
It is the spontaneous response to pain when there is tissue
damage and inflammation (e.g., postoperative pain, trauma,
arthritis).
3. Neuropathic pain – is pain caused by damage or
disease affecting the somatosensory nervous
system.
Examples include neuralgia (pain in the nerve pathway), cancer
pain, phantom limb pain, carpal tunnel syndrome, and peripheral
neuropathy (widespread nerve damage).
4. Functional pain – pain without obvious physiologic
origin, but can cause pain.
• Attitudes of health care providers and nurses
affect interaction with patients experiencing pain.
Competing demands, lack of privacy, and background noise are all
potential barriers to effective communication between nurses and
patients.

acute care, patient requests, chronic illnesses, psychosocial

problems, screening, counseling for behavioral change, and
administration and management of patient care,
• Many patients are reluctant to report pain related to the following
reasons:
> the patient’s desire to be a good patient
> their fear of addiction
> fear of the adverse effects like dizziness, nauseated,
or not feeling well after taking the treatment.
Terminologies
Addiction is defined as a chronic, relapsing disorder
characterized by compulsive drug seeking, continued use
despite harmful consequences, and long-lasting changes in the
brain.

Tolerance happens when a person no longer responds to a

drug in the way they did at first. So it takes a higher dose of
the drug to achieve the same effect as when the person first
used it.
Physical dependence to a drug can be demonstrated
by the presence of withdrawal symptoms when the
drug is not taken.

Withdrawal or abstinence
syndrome are clinical manifestations
like nausea and vomiting, abdominal
cramps, muscle twitching, profuse
perspiration, delirium and
convulsions.
Nursing Assessment in Client with Pain
FLACC pain scale assess the level of pain in children who are too young to cooperate
verbally. It can also be used in adults who are unable to communicate.