Vital Signs

CAROL MITCHELL, RN, MSN

 Learning Outcomes
At the end of the teaching session and demonstration of lab skills students will be able to:
 Define related terms
 Describe factors that affect the vital signs and accurate measuring
Identify normal ranges for each vital sign
Identify sites used to assess pulse
Explain how to measure apical pulse and apical-radial pulse
Identify components of respiratory assessment
Differentiate systolic from diastolic Blood pressure
Discuss measurement of blood oxygenation using pulse oximeter
Definition
Vital or cardinal sign: body temperature, pulse, respirations and blood pressure (TPR & BP)
Assess Pain as the 5th VS at the same time as each of the other four
Body Temperature
Reflects the balance between the heat produced and the heat lost from the body, measured in
heat units called degrees
2 kinds of body temperature:
1. core temperature: temp of the deep tissues of the body such as abdominal cavity, relatively
constant, a range of temperatures
2. surface temperature: temperature of the skin, subcutaneous tissue and fat. It rises and falls
in response to the environment
The body produces heat as a by-product of metabolism
FACTORS FFECTING BODY HEAT PRODUCTION:
Basal metabolic rate (BMR) – rate of energy utilization in the body required to maintain essential
activities such as breathing
Muscle activity – muscle activity such as shiver increases BMR
Thyroxine output
Epinephrine, norepinephrine and sympathetic stimulation – hormones increase rate of cellular
metabolism
Fever – increases cellular metabolic rate, thus increasing body temperatue
Heat loss
Heat is loss from the body through:
Radiation: the process whereby heat is transferred from one object to another without direct
contact between the two.
Conduction: the transfer of heat by direct contact between two objects. Heat passes from the
warmer object to the colder
Convection: heat is lost through convection when air currents pass over a warm object, carrying
its heat away with them.( e.g.. using fans)
Vaporization: process whereby a substance in liquid state is changed to a vapor state.
Factors affecting body temperature
Age – infant is influenced by the environment temperature; older people are at risk for hypothermia
Diurnal variations (circadian rhythms) – body temperature change throughout the day varying as much
as 1.0C (1.8F) between early morning and late afternoon
Exercise – strenuous exercise can increase body temp to as high as 38.3 to 40C 101 to 104F (rectally)
Hormones
Emotional states - Stress
Environment
Ingestion of hot/ cold liquids
Alterations in body temperature
1. Pyrexia/hyperthermia/Fever: elevation of body temperature above the normal range
2. Hypothermia: A condition in which core body temperature is abnormally lower than normal
Assessing Body Temperature
4 most common sites for measuring body temperature:
Oral: reflects changing body temperature more quickly than rectal temp
 rectal: considered to be very accurate
Axillary: Preferred site for newborns
tympanic membrane
The forehead may be used with electronic/chemical thermometers; most useful for infants and
children
Types of thermometers
Mercury-in-glass: can be hazardous when broken due to exposure to mercury
Electronic
Chemical disposable thermometers
Temperature sensitive tape
Infrared thermometers
Temperature scales
Body temperature is measured in degrees on 2 scales: Celsius (centigrade) and Fahrenheit
To convert from Fahrenheit to Celsius: C= (F -32 x 5/9;
EXAMPLE when Fahrenheit reading is 100; C= (100-32) X 5/9 = (68) X 5/9 = 37.7
To convert from Celsius to Fahrenheit , multiply the Celsius reading by 9/5 then add 32;
 F = (Celsius temp X 9/5) + 32
EXAMPLE: when the Celsius reading is 40: F= (40 X 9/5) +32 = 104
 Lifespan considerations
Infants:
Using axillary site, hold infants' arm against the chest
Tympanic route is fast and convenient
Avoid tympanic route with active ear infection
Rectal route is least desirable
Children:
Tympanic or axillary sites are commonly preferred
Avoid tympanic route with active ear infections
Oral route may be used for children >3 yrs., non-breakable , electronic thermometers are recommended
 PULSE
Pulse: a perceptible throbbing sensation as a wave of blood is pumped into the arteries by the
contraction of the left ventricle of the heart.
Pulse rate: the number of pulsations felt over a peripheral artery or heard over the apex of the
heart in 1 minute. This rate normally corresponds to the same rate at which the heart is beating
Pulse rate changes as individuals age, gradually diminishing from birth to adulthood
 Factors Affecting Pulse
Age: as age increases, pulse decreases
Gender: after puberty, the average male’s PR is slightly lower than females
Exercise: normally increases with exercise
Fever
Medications: some medications increase PR, others decrease it
Hypovolemia; Loss of blood from the vascular system decreases the PR
Stress
Position changes
Pathology: certain diseases such as heart conditions or those that impair oxygenation can alter the resting PR
 Pulse sites
A pulse may be measured in 9 sites:
Temporal
Carotid
Apical
Brachial
Radial
Femoral
Popliteal
Posterior tibial
Pedal (dorsalis pedis)
Assessing the Pulse
A pulse is commonly assessed by palpation (feeling) or auscultation (hearing).
The middle 3 fingertips are used for palpating all pulse except the apex of the heart. A
stethoscope is used to assess apical pulses and fetal heart tones
A pulse is normally palpated by applying moderate pressure with the 3 middle fingers
The pads on the most distal aspect of the finger are the most sensitive areas for detecting pulse
Ensure the client is comfortable
Assessing the Pulse cont
When assessing the pulse, the nurse collects the following data:
The rate
The rhythm
Volume
Arterial wall elasticity
Presence or absence of bilateral equality
Terms
Tachycardia: excessively fast HR; over 1oobets per minute (BPM) in an adult
Bradycardia: HR in an adult of 60 BPM
Pulse rhythm: Pattern of beats and the intervals between the beats
Dysrhythmia or Arrythmia: Irregular rhythm; may be random irregular beats or a predictable
patter of irregular beats
Pulse volume: also referred to as pulse strength or amplitude: the force of blood with each beat,
usually the same with each beat
Apical pulse assessment
Indicated for clients whose peripheral pulse is irregular or unavailable as well as for clients with
known cardiovascular, pulmonary and renal disease
Commonly assessed prior to administering medications that affect heart rate such as Digoxin
Also used to assess pulse for newborns, infants and children up to 2 to 3 years old
Apical-Radial Pulse Assessment
An apical-radial pulse may need to be assessed in clients with certain cardiovascular disorders.
An apical-radial pulse rate is assessed by counting at the apex of the heart and at a radial artery
simultaneously, may be taken by one nurse or two nurses
Pulse deficit: The difference between the apical and radial pulse rate
RESPIRATIONS
Respiration: The act of breathing
Inhalation/inspiration: the intake of air into the lungs
Exhalation/expiration: Breathing out or the movement of gases from the lungs to the
atmosphere
Ventilation: also used to refer to the movement of air in and out of the lungs
Types of breathing
2 types of breathing:
A) costal (thoracic) breathing – involves the external intercostal muscles and other accessory
muscles, observed by movement of the chest upward and outward
B) diaphragmatic (abdominal breathing) – contraction and relaxation of the diaphragm,
observed by movement of the abdomen
 Assessing respirations
Resting respirations should be assessed when the client is relaxed

Respiratory rate is described in breaths per minute.

The rate, depth, rhythm, and quality of respirations should be assessed

Depth of respirations can be established by watching the chest movement. Generally described as normal, deep or
shallow.

During a normal inspiration and adult takes in 500mL of air, this volume is called tidal volume

Respiratory quality or character: Aspects of breathing different from normal

Eupnea: normal rate and depth of breathing

Dyspnea: difficult, labored breathing

Preparation
 Equipment: Watch with a second hand or indicator.
Determine the client's activity schedule and choose a suitable time to monitor the respiration.
Factors affecting Respirations
May Increase: exercise, stress, increased environmental temperature, lowered oxygen
concentration at increased altitudes, pain, anxiety
May decrease: decreased environmental temperature, certain medications (e.g. narcotics),
increase intracranial pressure
Depth of respirations can be established by watching the chest movement. Generally described
as normal, deep or shallow.
During a normal inspiration and adult takes in 500mL of air, this volume is called tidal volume
Respiratory quality or character: Aspects of breathing different from normal
Altered breathing patterns and sounds
Breathing Patterns
Rate:
Bradypnea: Abnormally slow respirations
Tachypnea: abnormally fast respirations
Apnea: absence of breathing
Volume:
Hyperventilation: very deep, rapid respirations
Hypoventilation: very shallow respirations
Altered breathing patterns and sounds
cont
Rhythm:
Cheyne-stokes breathing: rhythmic waxing and waning of respirations; from very deep tp very
shallow and temporary apnea
Ease of effort:
Dyspnea: difficult, labored breathing
Orthopnea – ability to breathe only in the upright, sitting or standing positions
Implementation
Hand washing, provide for client’s privacy
Place hand on chest or observe chest rise and fall and count the respirations rate.
Note relationship of inspiration to expiration; also note depth and effort of breathing
Count respirations for one minute or 30 seconds and multiply by 2
Observe the respiration for depth by watching the movement of the chest
Blood Pressure
Arterial Blood pressure: a measure of the pressure exerted by the blood as it flows through the arteries
Because the blood moves in waves, there are 2 blood pressure measures:
1. Systolic pressure – pressure of the blood due to contraction of the ventricles (height of the blood
wave)
2. Diastolic pressure – pressure when the ventricles are at rest
Pulse pressure: Difference between diastolic and systolic pressure
BP is measured in milliliters of mercury (mm Hg) and recorded as a fraction; systolic over
diastolic(SBP/DPB)
Average BP for an adult is 120/80mm Hg
Determinants of Blood Pressure
Arterial Bp is the result of:
The pumping action of the heart ; when the pumping action is weak, less blood is pumped into
arteries (low cardiac output) and BP decreases
The peripheral vascular resistance: increased vasoconstriction raises BP, decrease
vasoconstriction lowers BP
Blood volume and viscosity: blood volume decreases, BP decreases and vice versa. BP I higher
when blood is highly viscous
 Factors affecting Blood Pressure
Age
Exercise
Stress
Race
Gender
Medications
Obesity
Diurnal variations: pressure usually lower early in the morning
Disease process: conditions affecting cardiac output, blood volume, blood viscosity
 Hypertension
A BP that is persistently above normal
Primary HTN : elevated BP of unknown cause
Secondary HTN: elevated BP of known cause
Factors associated with HTN:
 thickening of the arterial walls
Cigarette smoking
Obesity
High blood cholesterol
Continued exposure to stress
Lack of physical exercise
heavy alcohol consumption
Hypotension
A BP that is below normal
orthostatic hypotension: BP that falls when the client sits or stands, associated with weakness
or fainting. It is the result of peripheral vasodilation in which blood leaves the central body
organs (brain) and moves to the periphery
Assessing Blood Pressure
Equipment
▪ Aneroid sphygmomanometer
▪ Cloth or disposable vinyl pressure cuff of appropriate size for patient’s extremity
▪ Stethoscope
▪ Alcohol swab
▪ Pen and vital sign flow sheet or electronic health record (EHR)
 Assessing
Blood Pressure
BP is monitored with a blood
pressure cuff, a
sphygmomanometer, and a
stethoscope
BP cuff consist of a rubber
bag that can be inflated with
air; called the bladder
 Assessing
Blood Pressure
cont
2 types of
Sphygmomanometer:
1. Aneroid: a calibrated dial
with needle that points to the
calibration
2. Mercury: calibrated cylinder
filled with mercury
Some agencies use electronic
sphygmomanometers
Assessing Blood Pressure cont
BP cuffs come in various sizes; bladder must be the correct width and length for the client’s
arm
If cuff is too narrow, BP will be too high, if too wide, BP will be too low
Width should be 40% of the circumference, or 20% wider than the diameter of the mid-point of
the limb on which it is used
Arm circumference used to determine the bladder size
Blood Pressure Sites and Methods
BP is usually assessed in the client’s arm using the brachial artery and a standard stethoscope
Methods used: auscultatory (use of stethoscope) and palpatory methods
When taking a BP using the stethoscope, the nurse identifies 5 phases in the series of sounds
called Korotkoff's sounds
 Korotkoff’s
Sounds
These are the arterial sounds
heard when taking blood
pressure. They are caused by
turbulence in the blood flow
caused by compression of the
artery
 Oxygen
Saturation
A pulse oximeter is a
noninvasive device that
measures a client’s blood
oxygenation (SaO2) by means
of a sensor attached to the
client’s finger, toe, earlobe, or
forehead
Pulse oximeter can detect
hypoxemia before other clinical
signs such as dusky skin color
Factors affecting Oxygen Saturation
Readings
Hemoglobin
Circulation
Activity (shivering or excessive movement)
Purpose
Measure oxygenation of blood
Assess the effectiveness of oxygen administration
Assess effectiveness of any other airway or breathing interventions
Assessment
The best location for a pulse oximetry sensor based on the client's age and physical condition
The client's overall condition including risk factors for development of hypoxemia and
hemoglobin
Vital signs ,skin and nail bed color, and tissue perfusion of extremities as baseline data.
Adhesive tape allergy.
Readings of pulse Oximetry
Readings are measured in SpO2; e.g.. SpO2 is 98%
Average reading is 95-99%
Oximetry will also give a pulse reading
References
Kozier, B., Erb, G., Berman, A. & Snyder, S. (2004). Fundamentals of Nursing: Concepts, Process
and Practice. (7th ed.). Pearson Education Inc. Upper Saddle River: New Jersey