Nelia B.

Perez, RN, MSN

PCU – Mary Johnston College of
Nursing
 reflects changes in body functions that otherwise
might not be observed
 Temperature
 Pulse
 Respiration
 Blood pressure
 Pain
Vital Signs
 One of the most frequent assessments made as a nurse
 Nurse is
 Responsible for measuring, interpreting significance and
making decisions about care
 Knowing normal ranges
 Knowing history and other therapies that may affect VS
Vital Signs
 Nurse must
 Know environmental factors that affect vital signs
 Exercise, stress, etc.
 Use a systematic, organized approach
 Verify and communicate changes in vital signs
 Monitor VS regularly
 Frequency determined by
 MD order; nursing judgement, client condition and facility
standards
Vital Signs: Facility standards
 Hospital:
 Every 4-8 hours
 Home health:
 each visit
 Clinic:
 Each visit
 Skilled facility
 Daily and as needed
When to Assess Vital Signs
 Upon admission to any healthcare agency
 Based on agency institutional policy and procedures
 Any time there is a change in the patient’s condition
 Before and after surgical or invasive diagnostic
procedures
 Before and after activity that may increase risk
 Before administering medications that affect
cardiovascular or respiratory functioning
Special Nursing Interventions:
 Wash hands before and after a procedure
to maintain asepsis
 Gather equipment needed including
watch with a second hand to maximize
time and reduce effort
 Greet client and introduce oneself to
promote client’s sense of well-being
Special Nursing Interventions:
 Inform client what you will do to elicit cooperation and
allay anxiety
 Check for proper lighting and diminish noise when
necessary to obtain accurate baseline data
 Assist to a comfortable resting position, for a child, have
the parent remain close by and position the child
comfortably in the parent’s arm to ensure comfort
 Record/document appropriately and transfer readings
to TPR sheet
BODY
TEMPERATURE
Body Temperature
 the balance between the heat produced by the body
and the heat lost from the body
 Types:
 Core Temperature – temperature of the deep
tissues of the body measured by taking oral and
rectal temperature
 Surface Temperature – temperature of the skin,
subcutaneous tissue and fat measured by taking
axillary temperature
Maintenance of Body Temperature
 Thermoregulatory center in the
hypothalamus regulates temperature
 Center receives messages from cold and
warm thermal receptors in the body
 Center initiates responses to produce or
conserve body heat or increase heat loss
Heat Production
 Primary source is metabolism
 Hormones, muscle movements, and exercise
increase metabolism
 Epinephrine and norepinephrine are
released and alter metabolism
 Energy production decreases and heat
production increases
Factors affecting Heat Production
 Basal metabolic rate (BMR)
 Muscle activity
 Thyroxine output
 Epinephrine, norepinephrine and
sympathetic stimulation
 Increased temperature of the body cells
(fever)
Sources of Heat Loss
Skin (primary source)
Evaporation of sweat
Warming and humidifying
inspired air
Eliminating urine and feces
Processes involved in Heat Loss
 Radiation
 transfer of heat loss from the surface of one object to the
surface of another without contact between two objects
 Convection
 dissipation of heat by air currents
 Evaporation
 continuous vaporization of moisture from the skin, oral mucous,
respiratory tract; insensible heat loss
 Conduction
 Transfer of heat from one surface to another
 transfer of heat from one surface to another, which requires
temperature difference between two surfaces
Factors affecting TEMPERATURE
Age
Diurnal variations
Exercise
Hormones
Stress
TYPES of FEVER (pyrexia):
 Intermittent
 temperature fluctuates between periods of fever and periods of
normal/subnormal temperature
 Remittent
 temperature fluctuates within a wide range over the 24 hour period
but remains above normal range
 Relapsing
 temperature is elevated for few days, alternated with 1 or 2 days of
normal temperature
 Constant
 body temperature is consistently high
Decline of FEVER (pyrexia):
 Crisis/flush/defervescent stage
 sudden decline of fever which indicates
impairment of function of the
hypothalamus
 Lysis
 gradual decline of fever which indicates
that the body is able to maintain
homeostasis
Clinical Signs of FEVER (pyrexia):
Onset (cold or chill stage) of fever
Course of fever
Defervescence (fever abatement)
TEMPERATURE CONVERSION
 To change from Fahrenheit to Celsius:
 subtract 32 degrees from the Fahrenheit reading
 Multiply by 5/9 or divide by 9/5 (1.8)
 oC = (oF – 32) x 5/9
 To change from Celsius to Fahrenheit
 Multiply the Celsius reading by 9/5 or 1.8
 Add 32
 oF = (9/5 x oC) + 32 or (oC x 1.8) + 32
Special Nursing Interventions:
 Remove thermometer from its container and check the
temperature reading. Shake down the mercury as necessary
(until mercury is below 35 C) by holding the thermometer
between the thumb and forefinger at the end farthest from
the bulb. Snap the wrist downward.
 Wash/wipe the thermometer in a rotating manner before
use, from the bulb to the stem, after use, from the stem to
the bulb. This practice ensures medical asepsis.
Special Nursing Interventions:
 Hold the thermometer at
eye level, and rotate it until
the mercury column is
visible

 Rinse the thermometer in

tap water, dry it, shake it
down and return to its
container
METHODS of Temperature Taking:
 ORAL: most accessible and convenient method
 Nursing Considerations:
 Allow 15 minutes to elapse between client’s intake
of hot or cold food or smoking and the
measurement of oral temperature
METHODS of Temperature Taking:
 ORAL: most accessible and convenient method
 Nursing Consideration:
 Place the thermometer under the tongue, directed
towards the side and instruct client to gently close
the lips not the teeth around the thermometer
METHODS of Temperature Taking:
 ORAL: most accessible and convenient method
 Nursing Consideration:
 Wash the thermometer before use, from the bulb to
the stem, after use, from the stem to the bulb. This
practice ensures medical asepsis.
METHODS of Temperature Taking:
 ORAL: most accessible and convenient method
 Nursing Consideration:
 Take oral temperature for 2 – 3 minutes. This
ensures adequate time for recording of the
temperature
 Normal value:
 97.6 o – 99.6 oF (36.5 o – 37. 5 oC)
METHODS of Temperature Taking:
 Contraindications to Oral Temperature Taking:
 oral lesions or oral surgery
 dyspnea
 cough
 nausea and vomiting
 presence of oro-nasal pack, nasogastric tube
 seizure prone
 very young children
 unconscious
 restless, disoriented, confused
METHODS of Temperature Taking:
Oral Thermometers
METHODS of Temperature Taking:
 RECTAL: most accurate measurement of temperature
 Indications:
 When there is respiratory obstruction which prevents closure of the
mouth
 When the mouth is dry, parched and inflamed
 When there is oral/nasal surgery or disease
 For very young, restless and irrational children
 For mentally disturbed, unconscious, dyspneic, irrational, restless and
convulsive patients
 When a patient is mouth breather and with oxygen
METHODS of Temperature Taking:
 RECTAL: most accurate measurement of temperature
 Nursing Considerations:
 Assist client to assume lateral position/sims
position. To expose anal area
 Lubricate thermometer about 1 inch above the bulb
with water soluble jelly before insertion. To reduce
friction and prevent trauma to the mucous
membrane in the anus
METHODS of Temperature Taking:
 RECTAL: most accurate measurement of temperature
 Nursing Considerations:
 Insert thermometer by 0.5 – 1.5 inches (1.5 – 4 cm) for
adults, 0.9 inch (2.5 cm) for a child and 0.5 inch (1.5 cm) for
an infant or insert beyond the internal anal sphincter
 Instruct the client to take a deep breath during the insertion
of the thermometer. To relax the internal anal sphincter
METHODS of Temperature Taking:
 RECTAL: most accurate measurement of temperature
 Nursing Considerations:
 Hold the thermometer in place for 2 minutes (for neonates,
5 minutes). To ensure recording of temperature
 Do not force the insertion of thermometer. To prevent
trauma in the area
 Normal value:
 98.6 o – 100.6 oF (37.0 o – 38.1 oC)
METHODS of Temperature Taking:
 Contraindications to Rectal Temperature
Taking
 Anal/rectal conditions or surgeries, e.g. anal
fissure, hemorrhoids, hemorrhoidectomy
 Diarrhea
 Quadriplegic clients. Vagal stimulation may
occur, causing bradycardia and syncope
METHODS of Temperature Taking:
Rectal Thermometers
METHODS of Temperature Taking:
 AXILLARY: safest and most non-invasive method
 Nursing Considerations:
 Pat dry the axilla. Rubbing causes friction and will increase
temperature in the area
 Place the thermometer in the client’s axilla
 Place the arm tightly across the chest to keep the
thermometer in place for 9 minutes (for infants and children,
5 minutes
 Normal value:
 96.6 o – 98.6 oF (35.8 o – 37.0 oC)
METHODS of Temperature Taking:
Axillary Thermometers
METHODS of Temperature Taking:
 Tympanic: readily accessible, reflects the core
temperature, very fast
 Nursing Considerations:
 Can be very uncomfortable and involve risks of injuring the
membrane if the probe is inserted too far
 Repeated measurements may vary (right and left ears may
differ)
 Presence of cerumen can affect the reading
 Normal value:
 98.2 o – 100.2 oF (36.8 o – 37.9 oC)
METHODS of Temperature Taking:
 Tympanic Thermometers
METHODS of Temperature Taking:
 Other Thermometers
PULSE
PULSE
 wave of blood created by contraction of left ventricle
of the heart
 Regulated by the autonomic nervous system through
cardiac sinoatrial node
 Parasympathetic stimulation — decrease heart rate
 Sympathetic stimulation — increases heart rate
 Pulse rate = number of contractions over a peripheral
artery in 1 minute
Factors affecting the PULSE rate
 Age
 Sex/Gender
 Exercise
 Fever
 Medication
 Hemorrhage
 Stress
 Position changes
PULSE sites:
 Temporal
 Carotid
 Apical
 Brachial
 Radial
 Femoral
 Popliteal
 Dorsalis Pedis
 Pedal
PULSE site: TEMPORAL
PULSE site: CAROTID
PULSE site: APICAL
PULSE site: RADIAL/BRACHIAL
PULSE site: RADIAL
PULSE site: FEMORAL
PULSE site: POPLITEAL
PULSE site: POSTERIOR TIBIAL
PULSE sites: PEDAL/DORSALIS PEDIS
ASSESSMENT of the Pulse:
 If pulse is regular, count for 30 seconds and
multiply by 2. If irregular, count for 1
minute. When obtaining baseline date,
count for the pulse for a full minute
 Assess pulse rhythm by noting the pattern
and intervals of beat. Dysrhytmia is
irregular rhythm
ASSESSMENT of the Pulse:
 Asses the pulse volume (amplitude) –
strength of the pulse
 Normal pulse ca be felt with moderate
pressure
 Full or bounding pulse can be
obliterated only by great pressure
 Thready pulse can easily be obliterated
(weak or feeble)
ASSESSMENT of the Pulse:
 Arterial wall elasticity: the artery feels
straight, smooth, soft and pliable

 Presence/absence of bilateral equality:

absence of bilateral equality indicates
cardiovascular disorder
ASSESSMENT of the Pulse:
 Pulse pressure:
 Systolic pressure MINUS diastolic pressure
 Pulse deficit
 Apical pulse MINUS peripheral pulse
 Pulsus paradoxus
 Systolic pressure falls by more than 15 mmHg during
inhalation
 Pulsus alternans
 Alternating strong and weak pulses
 ASSESSMENT of the Pulse:
Age Normal Pulse Rate
Newborn to 1 month 80 – 180 beats/min
1 year 80 – 140 beats/min
2 years 80 – 130 beats/min
6 years 75 – 120 beats/min
10 years 60 – 90 beats/min
Adult 60 – 100 beats/min
Tachycardia – pulse rate above 100 beats/min
Bradycardia – pulse rate below 60 beats/min
RESPIRATION
Respiration
 the act of breathing
 carbon dioxide is the primary chemical stimulus of
breathing; when carbon dioxide level in the blood
is high, there is stimulation for breathing
 Pulmonary ventilation — movement of air in and
out of lungs
 Inhalation: breathing in
 Exhalation: breathing out
Respiration
 Three processes
 Ventilation: movement of gases in and out of
the lungs
 Diffusion: exchange of gases from an area of
higher pressure to an area of lower pressure and
occurs in the alveolo-capillary membrane
 Perfusion: the availability and movement of
blood for transport of gases, nutrients and
metabolic waste products
Respiration

 The exchange of oxygen and carbon dioxide in the

body

 Two separate process

 Mechanical
 chemical
 respiration

 Mechanical
 Pulmonary ventilation; breathing
 Ventilation:
 Active movement of air in and out of the respiratory system
 Conduction
 Movement through the airways of the lung
Respiration

 Chemical
 Exchange of oxygen and carbon dioxide
 Diffusion
 Movement of oxygen and CO2 between alveoli and RBC
 Perfusion
 Distribution of blood through the pulmonary capillaries
Mechanics of ventilation
 Inspiration
 Drawing air into the lung
 Involves the ribs, diaphragm
 Creates negative pressure-allows air into lung
 Expiration
 Relaxation of the thoracic muscles and diaphragm
causing air to be expelled
Variations in assessment of respirations

 Rate: regulated by blood levels of O2, CO2 and ph

 Chemial receptors detect changes and signal CNS
(medulla)
 Normal: 12-20 breaths per minute
 Apnea: no breathing
 Bradypnea: abnormally slow
 Tachypnea: abnormally fast
 Observe for one full minute
Variations in assessment findings

 Depth
 Normal: diaphragm moves ½ inch
 Deep
 Shallow
 Rhythm
 Assessment of the pattern
 Abnormal
 Cheyne stokes, Kusmaul,
Variations in assessment of respirations

 Effort
 Work of breathing
 Dypsnea: labored breathing
 Orthopnea: inability to breath when horizontal
 Observe for retractions, nasal flaring and restlessness
Variations in breath sounds
 Wheeze
 High pitched continuous musical sound; heard on
expiration
 Rhonchi
 Low pitched continuous sounds caused by secretions in
large airways
 Crackles
 Discontinuous sounds heard on inspiration; high
pitched popping or low pitched bubbling
Variations in breath sounds

 Stridor
 Piercing, high pitched sound heard during inspiration
 Stertor
 Labored breathing that produces a snoring sound
oxygenation
 Hyperventilation
 Rapid and deep breathing resulting in loss of CO2
(hypocapnea); light headed and tingly
 Hypoventilation
 Rate and depth decreased; CO2 is retained
 Cheyne Stokes
 Irregular, alternating periods of apnea and
hyperventilation
Tools to measure oxygenation
ABG
directly measures the partial pressures of oxygen,
carbon dioxide and blood ph
normal= paCO2 80-100)
Pulse oximetry
non invasive method for monitoring respiratory status;
measures O2 saturation
normal= >95%
Respiration
Two Types of Breathing:
Costal (thoracic)
Diagphragmatic (abdominal)
Respiratory Centers:
 Medulla Oblongata – primary center for respiration
 Pons – (1) Pneumotaxic center; responsible for rhythmic
quality of breathing (2) Apneustic center; responsible for
deep, prolonged inspiration
 Carotid and aortic bodies – contain peripheral
chemoreceptors, which take up the work of breathing
when central chemoreceptors in the medulla are
damaged, oxygen level concentration is low and respond
to pressure.
 Muscle and joints contain proprioreceptors, e.g. exercise
Factors Affecting Respiratory Rate:
 Exercise
 Pain/Stress/Anxiety
 Environment
 Increased altitude
 Medication
 Respiratory and cardiovascular disease
 Alterations in fluid, electrolyte, and acid balances
 Trauma
 Infection
Assessment of Respiration:
 With fingers still in place, after taking pulse rate,
note the rise and fall of patient’s chest with
respiration. You may place the client’s arm across
the chest and observe chest movement and for
infants, observe the movement of the abdomen,
these observes for depth of respiration
 Observe rate. Count for 30 seconds if
respirations are regular and multiply by 2. If
irregular, count for 60 seconds.
Assessment of Respiration:
 Observe the respiration (inhalations and
exhalations) for regular or irregular rhythm

 Observe the character or quality of

respiration – the sound of breathing and
respiratory effort
Assessment of Respiration:
Normal rate in adult
 12 – 20 breaths/minute
Normal rate in infant
 20 – 40 breaths/minute
Normal rate in preschool
 20 – 30 breaths/minute
 Assessment of Respiration:
Types of Breathing Description
Eupnea Normal respiration that is quiet, rhythmic and effortless
Tachypnea Rapid respiration, above 20 breaths/min in an adult
Bradypnea Slow breathing, less than 12 breaths/minute in an adult
Hyperventilation Deep rapid respiration, carbon dioxide is excessively exhaled (resp. alkalosis)
Hypoventilation Slow, shallow respiration, carbon dioxide is excessively retained (resp.
acidosis)
Dyspnea Difficult and labored breathing
Orthopnea Ability to breathe only in an upright position
Apnea Absence/cessation of breathing
Biot’s respiration Quick, shallow inspiration followed by regular or irregular periods of apnea
Kussmaul Very deep and labored breathing; acetone breath (metabolic acidosis)
respiration
Apneustic Deep, gasping inspiration with a pause at full inspiration followed by
respiration insufficient release
BLOOD
PRESSURE
Physiology of Blood Pressure
 Force of the blood against arterial walls
 Controlled by a variety of mechanism to maintain
adequate tissue perfusion
 Sound of Korotkoff
 Pressure rises as ventricle contracts and falls as
heart relaxes
 Highest pressure is systolic
 Lowest pressure is diastolic
Physiology of Blood Pressure:
..\Pictures\3DScience_Human_Heart.jpg

 systolic pressure – pressure of blood as a

result of contractions of the ventricles (100 –
140 mmHg); systole (contraction of the heart);
numerator in BP reading
 diastolic pressure – pressure exerted when
the ventricles are at rest (60 – 90 mmHg);
diastole (relaxation of the heart); denominator
in BP reading
Physiology of Blood Pressure
 pulse pressure – difference between the
systolic and diastolic pressures, normal is 30 –
40 mmHg
 hypertension is an abnormally high blood
pressure for at least two consecutive readings
 hypotension is an abnormally low blood
pressure, systolic pressure below 100/60
mmHg
Determinants of Blood Pressure
 Blood volume
 Peripheral resistance
 Cardiac output
 Elasticity or compliance
of blood vessels
 Blood viscosity
Factors Affecting Blood Pressure:
 Age, gender, race
 Circadian rhythm
 Food intake
 Exercise
 Weight
 Emotional state
 Body position
 Drugs/medications
 Disease process
Sphygmomanometers
Sphygmomanometers
Parts of the Stethoscope: stethoscopebasics.pdf

30 – 35 cm (12-14 inches) long

0.3 cm (1/8 inch) internal diameter
Stethoscope
 ASSESSING Blood Pressure:
 Ensure that the client is rested
 Allow 30 minutes to pass if the
client had engaged in exercise or
had smoked or ingested caffeine
before taking the BP (might tend to
increase BP)
 Use appropriate size of the BP cuff.
Too narrow cuff causes high false
reading and too wide cuff causes
false low reading.
 Position the client in sitting or
supine position
 ASSESSING Blood Pressure:
 Position the arm at the level of the
heart, with the palm of the hand
facing up. The left arm is preferably
used because it is nearer the heart
 Apply/warp the deflated cuff snugly
in upper arm, the center of the
bladder directly over the medial
aspect or 1 inch above the
antecubital space or at least 2 – 3
fingers above the elbow
 ASSESSING Blood Pressure:
 Determine palpatory BP before
auscultatory BP to prevent
auscultatory gap
 Use the bell of the stethoscope
since the BP is a low frequency
sound
 Inflate and deflate BP cuff
slowly, 2 -3 mmHg at a time
 Wait 1 -2 minutes before
making further determinations
 ASSESSING Blood Pressure:
 Palpate the brachial artery
with your fingertips
 Close the valve on hand pump
by turning the knob
clockwise
 Insert the ear attachment of
the stethoscope in your ears
so they tilt slightly forward an
ensure it hangs freely from
the ear to the diaphragm
 ASSESSING Blood Pressure:
 Place the diaphragm of stethoscope
over brachial pulse and hold with the
thumb and index finger
 Pump out the cuff until the
sphygmomanometer registers about
30 mmHg above the point where the
brachial pulse disappeared
 Release the valve on the cuff carefully
so that the pressure decreases at the
rate of 2 – 3 mmHg per second
 ASSESSING Blood Pressure:
 As the pressure falls, note
the first sound, muffling,
and last sound heard

 Deflate the cuff rapidly

and completely after
noting the last sound
 ASSESSING Blood Pressure:
 Read lower meniscus of the
mercury level of the
sphygmomanometer at eye
level to prevent error of parallax
 Error of parallax happens if
the eye level is higher than
the lever of the lower
meniscus of the mercury,
this causes false low reading,
if the eye level is lower, this
causes false high reading
Tools
 Indirect
 Equipment
 Sphygomanometer and stethescope
 Korotkoff’s sounds
 1st
 2nd
 3rd
 4th
 5th
Korotkoff’s sounds
 1st
 As you deflate the cuff; occurs during systole
 2nd
 Further deflation of the cuff; soft swishing sound
 3rd
 Begins midway through; sharp tapping sound
 4th
 Similar to 3rd sound but fading
 5th
 Silence, corresponding with diastole
Other BP issues
 Orthostatic or postural hypotension
 Sudden drop in BP on moving from lying to sitting or
standing position
 Primary or essential hypertension
 Diagnosed when no known cause for increase
 Accounts for at least 90% of all cases of hypertension
Vital signs
 Combination of skills which provide an indication of
state of health and body functionality
 Nurses can delegate the activity of VS, but are
responsible for interpretation, trending and decisions
based on the findings
Pain
 5th vital sign
 It is what the client says it is
 Nurse must know
 how to assess for it
 Establish acceptable comfort levels
 Follow up within appropriate time frame after
intervention
Pain
 Data collection
 Location (place and position)
 Intensity
 1-10
 Strength and severity
 What is your pain at present? What makes it worse? What is
the best that it gets?
Pain data collection
 Describe
 Aching, stabbing, tender, tiring, numb,……..
 Duration
 When did it start? Is is always there?
 Aggrevate/alleviate
 What makes it better/worse?
How does the pain affect…
 Energy
 Appetite  Nurse checks for
 Sleep  VS
 Activity  Knowledge of pain

 Mood  Med history

 Relationships  Side effects of meds

 Use of non
 Memory
pharmacological
 concentration therapies
References:
Fundamentals of Nursing, Kozier, Erb et al
Lippincott William and Wilkins

END
Fundamental of Nursing, Udan
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