Vital Signs

CHAPTER 11
Vital Signs
Slide 1
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
Which needs more assessment?
1. Regular sinus rhythm 96%
2. B/P of 120/86
3. Rectal Temp of 99.8
4. Respiratory rate of 30
4% 0% 0%
6 8 30
th
m /8 9.
h y 12
0
of
9 of
sr of p a te
si n u P em yr
r B/ l T t or
la cta ira
gu Re sp
Re Re
Slide 2
What’s most important for an
oral temp just after smoking?
1. Rinse mouth with 76%
water
2. Place thermometer
firmly under tongue
12% 8%
3. Wait 15 minutes to 4%
take temp
Shake down the
er .. ...
4. it h
w
at
er
fir
m
st
o
ta
k
er
m
.. .
w et e th
thermometer
t
th om nu th
e
ou rm m
i n
e m
t he 15 ow
ns e
ai
t d
Ri Pl ac W a ke
Sh
Slide 3
Which is the least accurate site
for body temperature?
82%
1. Oral
2. Rectal
3. Axillary
4. Tympanic
9% 9%
0%
l a l y c
Or
a
ct ar ni
Re ill p a
Ax m
Ty
Slide 4
Which statement by the patient
needs further investigation?
39%
36%
1. “I will request pain
25%
meds when I can no
longer stand the pain”
2. Distraction and
imagery techniques
help my pain. ed ... r y.
..
o s..
.
e p
m ag y
I need to change my i n im m
3. es
t pa
an
d
ch
a ng
e
qu on to
position regularly
re cti d
ill st
ra ee
w i n
“I D I
Slide 5
Which assessment relates directly
to pain? 25%
1. Blood Pressure 100/60
25%
2. Dilated pupils
25%
3. Pulse 80 beats per minute

25%
4. Respirations 14 per minute
Slide 6
The PT is teaching a client to take a core
temperature. Which sites would be used?
1. Skin
0%
2. Mouth
4%
3. Axilla
4%
4. Rectal
93%
Slide 7
A client having her B/P taken asks,
“What does B/P actually represent?
1. It’s
21%the wave of blood created by
contraction of the left ventricle of
the heart. 71%
7%
2. It’s a measurement of the pressure
exerted by the blood as it pulsates
through the arteries.
3. It’s a measure of the volume of

blood in the cardiac region. Slide 8
Pulse rate of 140 beats per
minute is known as
1. Bradycardia
2. Tachycardia 4%
3. Proxycardia 12%
4%
4. Extopicardia
81%
Bradycardia Tachycardia Proxycardia Extopicardia

Slide 9
A pedal pulse site is used to:
1. Determine discrepancies
with the radial pulse
2. Identify venous thrombus
3. Determine circulation to 14%
11%
the foot.
4%
4. As the primary means of
checking heart rate.
71%
Determine discrep... Identify venous t...

Determine circula... As the primary me... Slide 10
You arrive at bedside to take vital signs just
after client has had a cup of coffee. What do
you do?
1. Ask client to rinse mouth
to normalize temp
2. Ask client to not eat, 0%
drink, or smoke for 30 21%
4%
min, then take V/S.
3. Take all the V/S except
temp…do that later 75%
4. Proceed to take the v/s
according to Hospital
routine. Ask client to rin...
Take all the V/S ...
Ask client to not...
Proceed to take t... Slide 11
Which post surgery patient is in
most need of pain meds?
1. Patient with Pulse
120, R 22 ,b/p
140/92.
2. “I’m starving and 11%
have a dull ache in
7%
my back
3. Patient with pulse
81%
of 68, R 18 and
b/p 100/76
Patient with Puls... “I’m starving and... Patient withSlide
puls...
12
Which B/P in an adult is
considered hypertension
1. 110/70
2. 130/80
3. 140/90
4. 160/110 0% 11%
18%
71%
110/70 130/80 140/90 160/110 Slide 13

Vital Signs
► They are called vital signs because they are
important.
► They include:
 Temperature
 Pulse
 Respirations
 Blood pressure
► Vitalsigns and other physiologic measurements
can be the bases for problem solving.
► Many facilities have developed a fifth vital
signpain level/comfort level.
Slide 14
Guidelines for Obtaining Vital
Signs
► The Psych Tech must be able to do all of
the following:
 Measure vital signs correctly
 Understand and interpret the values
 Communicate/document findings accurately
 Begin interventions as needed
Slide 15
Oximetry
►A non-invasive device that measures the
level of oxygenation in the blood.
► An excellent addition to information
received via vital signs.
► Will have a lesson on the operation and
values of oximetry in the nursing lab.
► Peg try to get a picture or example
Slide 16
Temperature
► Many factors can cause body temperature
variances.
 Environment
 Time of day
 Patient’s state of health
 Activity levels
 Stage of monthly menstrual cycle
Slide 17
Temperature
► Temperature is a relative measure of
sensible heat or cold.
► The body strives to maintain a
temperature of 98.6° F (37° C), which is
considered normal.
► Normal range is 97° to 99.6° F (36.1° to
37.5° C).
► The hypothalamus helps maintain a
balance between heat lost and heat
produced by the body. Slide 18
Temperature
► Two Types of Body Temperature
 Core Temperature
►Temperature of the deep tissues of the body
►Remains relatively constant unless exposed to
severe extremes in environmental temperature
►Assessed by using a thermometer device
 Surface Temperature
►Temperature of the skin
►May vary a great deal in response to the environment
►Assessed by touching the skin
Slide 19
Temperature
► Temperature measurements are obtained by
several methods.
 Heat-sensitive patches
►Patch placed on the skin; color changes on the patch
indicate temperature readings
 Electronic thermometers
►Consist of a rechargeable battery-powered display unit, a
thin wire cord, and a temperature processing probe
 Tympanic thermometer
►Special form of electronic thermometer; inserted into
auditory canal
Slide 20
Figure 11-2
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
Disposable, single-use thermometer strip.

Slide 21
Figure 11-3
Electronic thermometer.
Slide 22
Figure 11-4
Tympanic thermometer with probe cover inserted into auditory canal.

Slide 23
Temperature
Pyrexia, Febrile, or Hyperthermia
 When the temperature is above normal
 Fever is actually a body defense; it will destroy invading
bacteria.
► Classification of Fevers
 Constant: remains elevated consistently
 Intermittent: rises and falls
 Remittent: temperature never returns to normal until
the patient becomes well
► Hypothermia
 An abnormally low body temperature
Slide 24
Temperature
► Oral temperature is not obtained in the
comatose or disoriented patient or in small
infants.
► Rectal temperatures are contraindicated
for patients with recent rectal surgery or
certain conditions of the perineum.
► Axillary temperature is considered the
least accurate method.
► Rectal readings are normally 1° F higher
than oral, and axillary readings are 1° F
lower than oral.
Slide 25
Auscultating Using the
Stethoscope
► When assessing the apical heart rate, the
PT uses a stethoscope.
Slide 26
Using a stethoscope
► video
Slide 27
Figure 11-6
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St.
Louis: Mosby.)
Parts of a stethoscope.
Slide 28
Auscultating Using the
Stethoscope
► Chestpiece
 Diaphragm: circular, flat-surfaced portion of the
chest piece covered with a thin plastic disk
 Transmits high-pitched sounds created by the
high-velocity movement of air and blood
 Bell: bowl-shaped chestpiece, usually
surrounded by a rubber ring.
Transmits low-pitched sounds created by the
low-velocity movement of blood.
Slide 29
Pulse
► There is a rhythmic beating or vibrating
movement.
► The pulse is the regular, recurrent
expansion and contraction of an artery
produced by waves of pressure caused by
the ejection of blood from the left ventricle
of the heart as it contracts.
► The PT notes the rate, rhythm, and
volume of the pulse.
► Adult pulse rate is normally between 60
and 100 beats per minute.
Slide 30
Figure 11-7
Pulse sites.
Slide 31
Pulse
► Tachycardia
 The pulse is faster than 100 beats per minute.
 It may result from shock, hemorrhage, exercise,
fever, acute pain, and drugs.
► Bradycardia
 The pulse is slower than 60 beats per minute.
 It may result from unrelieved severe pain,
drugs, resting, and heart block.
Slide 32
Pulse
► Dysrhythmia
 Any disturbance or abnormality in a normal
rhythmic pattern, specifically irregularity in the
normal rhythm of the heart
► Any artery can be assessed for pulse rate, but
the radial and carotid arteries are peripheral
pulse sites that are easily palpated.
► The radial and apical locations are the most
common sites for pulse rate assessment.
Slide 33
Figure 11-9
Louis: Mosby.)
A, Point of maximum impulse is at fifth intercostal space. B,

Assessing apical pulse.
Slide 34
Pulse
► Pulses on both sides of the peripheral
vascular system should be assessed.
► Pulses are palpated using the pads of the
index and middle fingers; only slight
pressure is applied over the artery to avoid
obliterating the pulse.
► Apical pulse represents the actual beating of
the heart.
Slide 35
Pulse
► When auscultated, the “lubb-dubb” heard
represents one cardiac cycle, or heartbeat.
► Pulse deficit: difference between the radial
and apical rates; signifies that the pumping
action of the heart is faulty.
Slide 36
Figure 11-8
(From Sorrentino, S.A. [2004]. Mosby’s textbook for nursing assistants. [6th ed.]. St. Louis: Mosby.)
Taking an apical/radial pulse.

Slide 37
Respirations
► The taking in of oxygen, its utilization in the
tissues, and the giving off of carbon dioxide;
the act of breathing.
 Internal Respirations
►The exchange of gas at the alveolar level
 External Respirations
►Breathing movements that can be observed by the
nurse; inspiration and expiration
Slide 38
Respirations
► Assessmentincludes the rate, depth,
rhythm, and quality.
 The normal rate for an adult is between 12
and 20 per minute.
►Tachypnea
 Rapid respiratory rate; exercise and fever increase
respiratory rate
►Bradypnea
 A slow respiratory rate, below 12 per minute
 The depth of respiration is determined by the
amount of air taken in with inhalation.
Slide 39
Figure 11-10
Patterns of respirations.
Slide 40
Respirations
► Assessment includes the rate, depth, rhythm,
and quality. (continued)
 The rhythm of respiration should be regular and
uninterrupted.
► Dyspnea
 Breathing with difficulty
► Apnea
 A lack of spontaneous respirations
► Cheyne-Stokes respirations
 An abnormal pattern of respiration; alternating
patterns of apnea and deep, rapid breathing.
Slide 41
Blood Pressure
► The pressure exerted by the circulating volume
of blood on the arterial walls, veins, and
chambers of the heart.
 Systolic
►The higher number; represents the ventricles contracting
 Diastolic
►The second number; represents the pressure within the
artery between beats
 Pulse Pressure
►Difference between the systolic and diastolic
Slide 42
Blood Pressure
► Normal blood pressure in the adult is 120/80 mm
Hg.
► Hypertension
 Sustained elevated blood pressure is above 140/90
mm Hg.
► Hypotension
 Blood pressure is below normal.
► Orthostatic Hypotension
 A drop of 25 mm Hg in systolic pressure and a drop
of 10 mm Hg in diastolic pressure when moving from
lying to sitting or sitting to standing.
Slide 43
Blood Pressure
► Sphygmomanometer
 A device for measuring the arterial blood pressure
 Consists of an inflatable cuff and a gauge
 The cuff is inflated around the patient’s arm to
compress the artery; then it is slowly deflated
while the nurse listens at the brachial artery with
a stethoscope and hears pulsating sounds.
►Korotokoff sounds: The first sound heard is the systolic
pressure; the point at which the last sound is heard is
the diastolic pressure.
Slide 44
Figure 11-11
(From Sorrentino, S.A. [2004]. Mosby’s textbook for nursing assistants [6th ed.]. St. Louis: Mosby.)
Aneroid manometer and cuff.

Slide 45
Figure 11-12
Wall-mounted aneroid sphygmomanometer.

Slide 46
Figure 11-17
Electronic sphygmomanometer.
Slide 47
Figure 11-14
Louis: Mosby.)
Doppler stethoscope over brachial artery to measure blood pressure.
Slide 48
Figure 11-13
The sounds during blood pressure measurement can be

differentiated into five Korotkoff phases.
Slide 49
Blood Pressure
► Assessment of Blood Pressure in the Lower
Extremities
 Occasionally, the upper extremities may be
inaccessible, so blood pressure must be measured in
the lower extremities.
 The popliteal artery, located behind the knee, is the
site for auscultation.
 The cuff must be wide and long enough to allow for
the larger girth of the thigh and is positioned with the
bladder over the posterior aspect of the midthigh.
Slide 50
Figure 11-15, A
(A, From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.].
St. Louis: Mosby.)
A, Lower-extremity blood pressure cuff positioned above popliteal

artery at midthigh.
Slide 51
Figure 11-15, B
(A, From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.].
St. Louis: Mosby.)
B, Location of the popliteal artery and placement of

the cuff.
Slide 52
Blood Pressure
► Automatic Measurement Devices
 Many automatic devices can determine blood
pressure automatically.
 Once the cuff is applied, the nurse can program
the device to obtain and record blood pressure
readings at preset intervals.
► Self-Measurement
 Portable home devices
 Stationary automated machines
Slide 53
Height and Weight
► Helps assess normal growth and
development
► Aids in proper drug dosage calculation
► May be used to assess the effectiveness of
drug therapy, such as diuretics
► Significantloss of weight may be a sign of
an underlying disease
Slide 54
Height and Weight
► Height
 Patient should remove shoes and stand erect.
 A measuring stick or tape may be attached
vertically to the weight scales or wall.
 Standing scales may have a metal rod, which
is attached to the back of the scale and
swings out over the top of the patient’s head.
Slide 55
Height and Weight
► Weight
 Types of scales
►Standing scales
►Chair scales; lift scales
 Used for patients who cannot stand
 Patients should be weighed at the same time
of day, on the same scale, and in the same
type of clothing to allow an objective
comparison of subsequent weighing.
 Patient should void before weighing.
Slide 56
Figure 11-18
(From Sorrentino, S.A. [2004]. Mosby’s textbook for nursing assistants. [6th ed.]. St. Louis: Mosby.)
Types of scales. A, Standing scale. B, Chair scale. C, Lift scales.

Slide 57
When Vital Signs Are Assessed
► Temperature, pulse, respirations, and
blood pressure are usually assessed at the
same time at set intervals.
►A set of vital signs is taken when the
patient is admitted to the facility and then
as prescribed by the physician or as policy
dictates.
► Example: every 4 hours; once a shift;
weekly
Slide 58
When Vital Signs Are Assessed
► The more ill the patient, the more
frequently vital signs are taken.
► Vital signs are interrelated.
 A rise in temperature of 1° F may cause an
increase in pulse rate of 4 beats per minute.
 Respiratory rate and blood pressure readings
increase with a rise in temperature.
 Blood pressure falls because of hemorrhage,
the pulse and respirations increase and the
temperature usually decreases.
Slide 59
Recording Vital Signs
► Graphic Flow Sheet
 Used for charting vital signs
 R indicates a rectal temperature
 Ax indicates an axillary temperature
 Blood pressures are always written with the systolic
first and the diastolic beneath.
►Example: 120/80
 Apical pulse is indicated with an “ap” after next to
the number.
►Example: 78 ap
Slide 60
Recording Vital Signs
► Anyabnormal findings are reported to the
nurse-manager or physician immediately.
► Anyaccompanying or precipitating signs
and symptoms such as chest pain, vertigo,
shortness of breath, flushing, and
diaphoresis should be recorded as well.
► The nurse documents any interventions
initiated as a result of vital sign
measurement, such as tepid sponging.
Slide 61
Nursing Process
► Assessment
 Normal daily fluctuations
 Factors likely to interfere with accuracy of vital
sign reading
 Medications that may influence vital signs
 Factors that influence vital signs
 Conditions that precipitate fever, such as infections
 Pertinent laboratory values
 Previous baseline vital signs from patient’s record
Slide 62
Nursing Process
► Nursing Process
 Fluid volume deficient
 Hyperthermia
 Hypothermia
 Body temperature, risk for imbalance
 Gas exchange, impaired
Slide 63

Vital Signs

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CHAPTER 11

3. Pulse 80 beats per minute

4. Respirations 14 per minute

3. It’s a measure of the volume of

Bradycardia Tachycardia Proxycardia Extopicardia

Determine discrep... Identify venous t...

110/70 130/80 140/90 160/110 Slide 13

Disposable, single-use thermometer strip.

Tympanic thermometer with probe cover inserted into auditory canal.

A, Point of maximum impulse is at fifth intercostal space. B,

Taking an apical/radial pulse.

Aneroid manometer and cuff.

Wall-mounted aneroid sphygmomanometer.

The sounds during blood pressure measurement can be

A, Lower-extremity blood pressure cuff positioned above popliteal

B, Location of the popliteal artery and placement of

Types of scales. A, Standing scale. B, Chair scale. C, Lift scales.

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