VITAL SIGNS

Module C
 objectives
• • Define the key terms and key
abbreviations in this chapter.
• • Explain why vital signs are measured.
• • List the factors affecting vital signs.
• • Identify the normal ranges for each
temperature site.
• • Explain when to use each temperature site.
• • Explain how to use thermometers.
• • Identify the pulse sites.
• Describe a normal pulse and normal
respirations.
• • Describe the practices to follow when
measuring blood pressure.
• • Perform the procedures described in this
chapter.
• • Know the normal vital signs for the
different age-groups
 What are Vital Signs?
• Temperature
• Pulse
• Respirations
• Blood Pressure
• Pain (considered the 5th vital sign)
 When to measure vital signs?
• On admission to health care facility
• In a hospital on regular hosp schedule or as
MD ordered (q8hours, q4 hours, etc)
• Before and after procedures (surgery,
invasive diagnostic procedures)
• Before, during, and after blood transfusions
• When patient’s general condition changes
(nursing judgment)
 GUIDELINES FOR
ASSESSMENT
• Taken by nurse giving care
• Equipment should be in good
condition
• Know baseline VS and normal
range for pt and age group
• Know pt’s medical history
• Minimize environmental factors
GUIDELINES CONTINUED
• Be organized in approach
• Increase frequency of VS as
condition worsens
• Compare VS readings with the
whole picture
• Record accurately
• Describe any abnormal VS
 VS MUST BE ACCURATE
• Both measuring and recording
• VS vary according to pt’s
illness/condition
• Compare results with pt’s normal
• Results are used to determine
treatments, medications,
diagnostic work, etc
REPORTING ABNORMAL VS
• WHEN—grossly abnormal, return to
normal, noted change for that pt
• WHY—indicates change in metabolism or
physiological function within the body
• WHO—student reports to instructor, then
TL, RN, Dr (follow chain of command)
• HOW—orally to appropriate person, then
document on chart
 Body Temperature
• Difference between heat produced by body
processes and the heat lost to the external
environment
• Range 96.8 – 100.4 F (36 – 38 degree C)
• Average for healthy young adults 98.6F or
37degrees C
• No single temp is normal for all people
 HEAT IS PRODUCED BY:

• Metabolism
• Increased muscle
activity
• Vasoconstriction
• External sources
HEAT IS LOST BY:
• Vasodilation
• Convection
• Radiation
• Conduction
• Evaporization
 TEMP or FEVER?
• TEMPERATURE—the
measurement of heat in
the body
• FEVER—the
measurement of heat in
the body that is above
normal for the individual
TYPES OF THERMOMETERS
READING A THERMOMETER
 Normal Range Throughout Life
Cycle
• Adults- 96.8- 100.4 • Newborn range –
degree F 95.9- 99.5F
• Adult Avg 98.6 F Oral • Infants and children –
• Adult Avg 99.5 F same as adults
Rectal • Elderly – Avg 96.8F
• Adult Avg 97.7 F Ax
 Frequently used terms:
• Pyrexia or fever
• Febrile
• Hyperthermia
• Hypothermia
• Afebrile
FEVER—A DEFENSE
MECHANISM
• Indicator of disease in body
• Pathogens release toxins
• Toxins affect hypothalamus
• Temperature is increased
• Rest decreases metabolism and
heat production by the body
 PATTERNS OF FEVER
• SUSTAINED- remains above normal with
little change
• RELAPSING – periods of febrile episodes
interspersed with acceptable temp values
• INTERMITTENT—varies from normal to
above normal to below normal (may have a
fairly predictable pattern)
• REMITTENT—fever spikes and falls w/o a
return to normal temp values
 Factors Affecting Body Temp
• Age ( newborn- temp • Stress
control mechanism
immature, elderly-
• Environment
sensitive to temp changes)
• Exercise
• Hormonal level
• Circadian rhythm (temp
normally changes 0.9 to
1.8 degree F /24hr Lowest
1-4AM Max-6PM )
 ORAL TEMPERATURE
• Accessible
• Dependable
• Accurate
• Convenient
RECTAL TEMPERATURE

• Most reliable
• MUST hold
thermometer
in place
 AXILLARY
TEMPERATURE
• Safe
• Non-invasive
• Least
accurate
 TYMPANIC
TEMPERATURE
• Non-invasive
• Safe
• Accurate
• Disadvantages
– Excessive
cerumen
– Improper
technique
 AXILLARY TEMPERATURE
IMPORTANT POINTS
• AXILLA MUST HAVE
ADEQUATE TISSUE &
BE FREE OF
PERSPIRATION
• Not good method for
persons with elevated
temp
• Used when cannot get
oral or tympanic
• Leave in place 10
minutes
ORAL TEMPERATURES
• Wait 15-30 minutes
after eating,
drinking, chewing
gum or smoking
• If mouth breather-do
not take orally
• Leave in place 2 – 4
minutes with glass
thermometer
 TYMPANIC
TEMPERATURES
• Oral & tympanic readings
will be same/ similar
• Must direct probe toward
TM (eardrum)
• Follow instructions
• Keep plugged in and on
charger when not in use
• Usually preferred method
• Adults –pull pinna of ear
up & back
• Children under 3y/o-pull
pinna of ear down & back
RECTAL TEMPERATURES
• MOST accurate
• MUST hold thermometer in
place
• Very high temp
• Unconscious
• Do not take rectal temp on
clients with heart conditions
• Leave in place 2-3 min with
glass thermometer
• Lubricate thermometer
• DO Not take hand from
thermometer while rectal in
progress
NURSING DIAGNOSIS
Hyperthermia>
100.4F
Hypothermia
<96.8F
Risk for altered
body temperature
Ineffective
Thermoregulation
 Temperature Conversion
• Temperature can be measured in Fahrenheit
(F) or centigrade or Celsius (c)
• To convert F to c, subtract 32 from F
reading and multiply times 5/9. Ex.
(104 F – 32) x 5/9 = 40 degree c
• To convert c to F, multiply the c reading by
9/5 and add 32 to the product. Example
(40 x 9/5) + 32 =104 F
 Pulse
• Pulse- is the palpable bounding of the blood
noted at various points on the body. It is an
indicator of circulatory status.
TERMS RELATED TO PULSE

• Pulse—Rate, Rhythm, Quality

• Pulse Deficit
• Auscultate
• Palpate
• Tachycardia, Bradycardia
 Pulse Sites
• Temporal • Radial
• Carotid • Ulnar
• Apical • Femoral
• Brachial • Popliteal
• Dorsalsis Pedis
• Posterior Tibial
(Pedal)
• Radial and Apical are
most common pulse
sites used!
 PULSE RANGES
AGE RANGE

ELDERLY (65+) 60-100

AVERAGE ADULT 60-100 (50 or below if

extremely athletic)
NEWBORN 120-160
0-24 HOURS
INFANT 100-120
1 MONTH – 1 YEAR
CHILDREN (varies with age)
 TECHNIQUE
• Feel over BONY area
• DO NOT use thumb
• Use 2-3 fingers
• DO NOT squeeze
• Count 30 seconds if regular
x2
• Note Rate, Rhythm, Quality
• If irregular, count for 1 full
minute or take apical pulse
for 1 minute.
 APICAL-RADIAL PULSE
• Requires 2 nurses
• 1 nurse counts apical
heart rate
• 1 nurse counts radial
pulse
• BOTH count during
the same 60 seconds
• 1 nurse acts as
timekeeper for both
nurses
 PULSE DEFICIT
• Count apical-radial pulse
• The difference is the PULSE DEFICIT
• Apical pulse will always be the same or
higher than the radial pulse if both are
counted correctly
• If the radial pulse is higher, one or both
nurses counted incorrectly
 Factors Affecting Pulse Rates
• Exercise
• Temperature
• Emotions
• Drugs
• Hemorrhage
• Postural Changes
• Pulmonary Conditions
 Variations of Pulse Rates
• Tachycardia – Abnormally elevated pulse
rate. (above 100 beats/ min)
• Bradycardia – Abnormally slow pulse rate
(less than 60 beats / min)
 Pulse Rhythm
• Regular – A regular interval of time occurs
between each heartbeat or pulse felt.
• Irregular – Interval interrupted by early,
late, or missed beat.
 Strength and Quality of Pulse
• Pulse strength may be described as weak, strong,
bounding, or thready.
• PULSE GRADING (0-4 rating scale)
• 0 – absent, not palpable
• 1+ - diminished, barely palpable
• 2+- easily palpable, normal pulse
• 3+ - full, increased strength
• 4+ - bounding, cannot be obliterated
 Respirations
• Mechanism the body uses to exchange
gases between the atmosphere, blood, and
the cells. Involves three processes:
• Ventilation
• Diffusion
• Perfusion
 PROCESS OF RESPIRATION
• EXTERNAL RESPIRATION
– Inhaled air enters lungs, at alveoli O2 crosses over
to bloodstream
– CO2 and other wastes cross over from
bloodstream to alveoli and are exhaled
• INTERNAL RESPIRATION
– O2 carried in bloodstream crosses over to body
cells
– CO2 and other wastes from body cells cross over
to the bloodstream
 RESPIRATION
• Chest Cavity—airtight vacuum with
negative pressure
• INSPIRATION—diaphragm contracts
and pulls down, ribs move up, lungs fill
with air
• EXPIRATION—diaphragm relaxes and
moves up, ribs move down, lungs
expel air
NORMAL RESPIRATION RANGE
AGE RANGE

ELDERLY (65+) 12-20

AVERAGE ADULT 12-20

NEWBORN 30-60
0-24 HOURS
INFANT 30-50
1 MONTH – 6 Months
CHILDREN (varies with
age)
 COUNTING RESPIRATIONS
• Count pulse first, then
count respirations while
holding wrist
• Note rate, rhythm,
quality, and character
• Observe a full
inspiration and
expiration
• Respiratory rates below
12 or greater than 20
require further
assessment.
 Counting Respirations cont.
• If respirations regular, count respirations for 30
seconds and multiply times 2.
• If irregular, less than 12 or greater than 20, count
for 1 full minute.
• Quality of respirations- assess movement of chest
or abdominal wall- deep, normal, shallow
• Deep- full expansion of lungs
• Normal- normal
• Shallow- limited expansion of lungs
 Factors Influencing
Characteristics of Respirations
• Exercise • Medications
• Acute Pain • Neurological injury
• Anxiety • Age
• Smoking • Environmental Temp
• Body position • Hemoglobin Function
 Blood Pressure
• Force exerted on the walls of the artery. Created by
the pulsing blood under pressure of the heart.
• Systolic- Peak and maximum pressure of ejection of
blood from the heart into the aorta. This is the top
number.
• Diastolic- The minimal pressure remaining the heart
when the heart relaxes. This is the bottom number.
• Recorded as a ratio Ex. 120/80
• Pulse pressure- Difference between the systolic and
diastolic. ( 120/80 – Pulse pressure 40)
EQUIPMENT FOR BP
“DOPPLER” OR ELECTRONIC
BP READINGS
ALTERNATIVE SITES
MEASURING BP
 MEASURING BLOOD
PRESSURE
• Cuff must be appropriate
size
• Cuff should be snug, not
loose
• Do not put stethoscope
under cuff ( place cuff 1-2
inches above elbow)
• Make mental note of
systolic and diastolic
numbers
MEASURING BP CONT’D
• If unsure of reading,
wait 30 seconds and
recheck-if unsure,
have someone else
check with you
• Loosen cuff even if to
be checked q 15
minutes
• Make sure all air is out
cuff before applying
 MEASURING BP
• False high if cuff too
small, false low if cuff is
too loose
• Auscultatory gap-
temporary disappearance
of sound between first
sound and next sound.
• Don’t take BP on arm
with IV, sling, surgery,
mastectomy, renal dialysis
shunt, etc.
MEASURING BP CONT’D

• Pt should be sitting or
lying with arm at the
level of the heart
• Distinguish Korotkoff
sounds (sounds heard
when taking BP) from
artifact
 ASSESSMENT OF BP IN
BOTH ARMS
• Heart disease
• 1st time BP
• 5-10 mm Hg
difference-use reading
that is highest
• Difference of 10mm
Hg should be reported
HOW and WHY BP TAKEN BY
PALPATION
• HOW-apply cuff over
brachial artery
• Pump up to 20-30 points
above last systolic reading
• Feel with 2 fingers for
systolic pressure; will not
feel diastolic pressure
• WHY- unable to hear
weak BPs
 FACTORS AFFECTING BP
• Exercise-increases
• Arteriosclerosis (loss
of vessel elasticity) &
Atherosclerosis (build
up of plaque)-
increases
• Transfusions-
increases
• Emotions -increases
FACTORS CONT’D
• Drugs
• Medications
• Diurnal variations
 FACTORS CONT’D

• PAIN-increases
• Hemorrhage –decrease
• Sex/Gender
• RACE-Blacks more prone
increase
• Age
• Heredity-increased chance
if immediate family
history
 Alterations in Blood Pressure
• Hypertension – most common alteration in
BP. Most often asymptomatic.
Characterized by persistently elevated BP.
Noted when diastolic is greater than 90
mm/Hg and systolic is greater than
140mm/Hg. Optimal BP for 18 y/o and
older is less than 120/80mm/Hg.
 Alterations In BP cont
• Hypotension- When systolic blood pressure
falls to 90 or below.
• Orthostatic (Postural) Hypotension- Occurs
when a normotensive person develops
symptoms and low blood pressure when
rising to an upright position.
 Common Mistakes in Blood
Pressure Assessments
• Cuff too wide or too • Arm above or below heart
narrow level or not supported
• Repeating assessment too
• Cuff wrapped too
quickly
loose or unevenly
• Inaccurate inflation level
• Inflating cuff too • Poorly fitting stethoscope
slowly • Impairment of examiners
• Deflating cuff too hearing
slowly or too quickly
 Documentation of Vital Signs
• Graphic sheets
• Flow sheets
• Nurses notes
• Computerized
 Pain – Fifth Vital Sign
• Process of measuring pain:
• Verbal and nonverbal
• Characteristic of pain- onset, duration, location,
quality, intensity, variations
• Factors affecting pain – culture, developmental
stage, gender, anxiety, previous experience
• Pain scale- numerical (0-10), verbal (descriptive),
visual analog( faces pain rating scale)