Vital Signs

Vital Signs

Monitor functions of the body

Should be a thoughtful, scientific assessment
These are composed of body temperature, pulse, respirations and blood pressure. In
some agencies internationally, they assigned a fifth vital sign, which is pain
assessment.

When to Assess Vital Signs

On admission
Change in clients health status
Client reports symptoms such as chest pain, feeling hot, or faint
Pre and post surgery/invasive procedure
Pre and post medication administration that could affect CV system
Pre and post nursing intervention that could affect vital signs
Body Temperature
Is the balance between the heat produced and the heat lost from the body and it is measured
in heat units called degrees.
It is a balance between the internal and external environment of the body.
2 kinds of body temperature
Core temperature
It is the temperature of the deep tissues of the body.
This remains relatively constant (37C/98F)
E.g. abdominal cavity and pelvic cavity
Surface temperature
Temperature of the skin, the subcutaneous tissue and fat.
It constantly rises and falls in relation to the environment.
Mechanisms of heat production
1. Heat is produced through metabolism of food
BMR - Rate of energy utilization in the body required to maintain essentials activities such
as breathing, walking, speaking and others.
Metabolic rates decrease with age.
2. Heat is produced through body secretions
E.g. epinephrine, norepinephrine
3. Muscle activity increases metabolic rate.
E.g. shivering
4. Produced physically from the environment
Mechanisms of heat loss
Radiation
Transfer of heat between objects that are not in contact
Conduction
Heat exchange between atoms/molecules of objects in contact
Convection
Air next to the body is heated, moves away and replaced by cool air
Evaporation
Moisture and heat loss from the skin, response passages and mucous membranes of
the mouth
Types of fever
Intermittent - malaria
Remittent - influenza
1

 Relapsing Constant typhoid fever

Fever spike bacterial blood infections

Clinical Manifestations of Fever

ONSET OR CHILL PHASE
Increased heart rate
Increased respiratory rate and depth
Shivering
Pallid, cold skin
Complaints of feeling cold
Cyanotic nail beds
Gooseflesh
Cessation of sweating
COURSE OR PLATEAU PHASE
Absence of chills
Skin that feels warm
Photosensitivity
Glassy-eyed appearance
Increased pulse and respiratory rates
Increased thirst
Mild to severe dehydration
Drowsiness, restlessness delirium or convulsions
Herpetic lesions of the mouth
Loss of appetite
Malaise, weakness and aching muscles
DEFERVESCENCE OR FLUSH PHASE
Skin that appears flushed and feels warm
Sweating
Decreased shivering
Possible dehydration
Clinical signs of hypothermia
Decreased body temperature, pulse and respiratory rate
Severe shivering (initially)
Feelings of cold and chills
Pale, cool, waxy skin
Frostbite (nose, fingers and toes)
Hypotension
Decreased urinary output
Lack of muscle coordination
Disorientation
Drowsiness progressing to coma
Sites for Measuring Body Temperature
Oral
Rectal
Axillary
Tympanic membrane
Skin/Temporal artery
Factors Affecting Body Temperature
Age
Diurnal variations (circadian rhythms)
Exercise
Hormones
Stress
Environment
Types of Thermometers
Electronic

Chemical disposable
2

Infrared (tympanic)
Temperature-sensitive tape/strip

Scanning infrared (temporal artery)

Glass mercury

Pulse Rate
Refers to the wave of blood or impulse created by the contraction of the left ventricle during the
cardiac cycle.

Figure 29-12
Nine sites for assessing pulse.

Stroke volume is the amount of blood that enters the arteries with each ventricular contraction
Compliance- it is the ability of the arteries to contract and expand.
*when the heart is resting, the heart pumps 4 to 6 liters of blood per minute. This volume is
called cardiac output (CO).
CO = SVxHR
Pulse Site:
1. Temporal- it is where the temporal artery located, between the upper, lateral part of the eye
and upper medial part of the ear
2. Carotid- at the side of the neck, at the carotid triangle. Located between the Anterior/front of
SCM and below the angle of the mandible
3. Apical- at the apex of the heart.
In adult this is located on the left side of the chest, no more than 8 cm (3 in) to the left
sternum under the
4th, 5th or 6th intercostal space.
In Children 7 to 9 years old, the apical pulse is located between the 4th and 5th
intercostal space.
In Young Children below 4 years old , it is located at the left side of midclavicular line
and
In Children between 4 and 6 years old it is at the midclavicular line.
4. Brachial- at the anterior part of the arm in children and at the ante-cubital space (elbow
crease) in adult.
5. Radial located at the wrist (anterior part), along with the thumb. It is where the radial artery
is located
6. Femoral at the inguinal ligament, the femoral artery is located.
7. Popliteal- at the popliteal region, located at the back of the knee
8. Posterior Tibial- at the medial aspect of the ankle, it is where the posterior tibial artery is
located
3

 9. Dorsalis pedis- where the dorsalis pedis artery passes over the bones of the foot, at the
space between the big toe and the 2nd toe.
Assessing the Pulse
1. A pulse is commonly assessed by palpation or auscultation.
2. 3 middle fingers are used for palpating all pulse site, except for apical pulse.
3. Stethoscope is used in assessing apical pulse and fetal heart tones.
4. Doppler ultrasound is used for pulses that is to difficult to assess.
5. The pulse is normally palpated by applying are moderate pressure with the three fingers of
the hand.
6. The pads of the most distal aspect of the fingers are the most sensitive areas of detecting
the pulse.
7. When assessing the pulse, there is a need to take note of the following
a. rate
b. rhythm
c. volume
d. arterial wall elasticity
e. presence or absence of bilateral equality.
Rate- referred to tachycardia- (over 100 beats/ minute) bradycardia (60 beats/minute or
less)
Rhythm- is the patterns of beat and the interval between the beats.
Dysrhythmia or arrhythmia is an example of irregular rhythm.
Elasticity of the arterial wall
- It reflects the expansibility of the arterial wall.
- A healthy, normal artery feel straight, smooth, soft and pliable
- While, elderly people often have inelastic arteries that feels twisted or tortuous and
irregular upon palpation
Factors Affecting Pulse
1. Age
2. Sex- after puberty the mans pulse rate is slightly lower than the female
3. Exercise
4. Fever- pulse rate increases when metabolic rate increases
5. Medications
6. Hemorrhage- loss of blood increase pulse rate
7. Stress

Respiratory Rate
The act of breathing, intake of oxygen and output of carbon dioxide
Types
1. External respiration- the interchange of O2 and CO2 between the alveoli and the pulmonary
blood
2. Internal respiration- takes place throughout the body; it is the interchange of gases between
the circulating blood and the cells of the body tissues.
Terminologies:
Inhalation or inspiration- the act of intake of air into the lungs
Exhalation or expiration- the act of breathing out of gases from the lungs to the environment
Ventilation- movement of air in and out the lungs
Hyperventilation- refers to very deep and rapid ventilation
Hypoventilation- refers to very shallow respiration
Types of Breathing
1. Costal or thoracic breathing - It involves the external intercostal muscle and other intercostal
muscle. It can be observed by the movement of the chest upward and outward or downward
2. Diaphragmatic or abdominal breathing - It involves the contraction and relaxation of the
diaphragm, it is observed by the movement of the abdomen.
Control Centers of Respiration:
4

1. Medulla oblongata and Pons

2. Chemoreceptors located centrally in the medulla and peripherally in the carotid and aortic
bodies
NOTE: These centers and receptors respond to changes in the concentration of O2, CO2 and
Hydrogen in arterial blood.
Increased CO2 concentration in the blood triggers chemoreceptors thus stimulates respiration
Assessing Respiration:
1. The client normal breathing pattern is assessed therefore the client should be at resting
mode.
2. Identify behavior/ activities of the patient as well as medication or therapies because these
will affect the respiration taking.
3. Identify if there are any health problems such as heart problems and others
Respiratory Rate:
- is normally described in breaths per minute
Types:
Eupnea- Normal Breathing
Bradypnea- Abnormally slow
Tachypnea or polypnea- Abnormally fast
Apnea- cessation of breathing
Respiratory depths
is established by watching the movement of the chest.
It is generally describe as normal, deep or shallow, deep respiration are those in which a large
volume of air is inhaled and exhaled. Shallow respiration involve the exchange of small volume
of air
NOTE: in normal inspiration and expiration, an adult takes in about 500ml of air. This volume is
called Tidal volume
Respiratory rhythm/ pattern
It refers to regularity of expiration and inspiration
Types
Regular
Irregular
Dsypnea- difficulty in breathing
Orthopnea- ability to breath in an upright position
Inhalation
Diaphragm contracts (flattens)
Ribs move upward and outward
Sternum moves outward
Enlarging the size of the thorax
Exhalation
Diaphragm relaxes
Ribs move downward and inward
Sternum moves inward
Decreasing the size of the thorax

Blood Pressure - Force exerted by the blood against a vessel wall

Heart Sound
1. First Sound-occurs at the beginning of ventricular systole. It is caused by the closure of the
tricuspid and mitral valves
2. Second Sound- marks the beginning of ventricular diastole and is caused by the closure of
aortic and pulmonary valves.
5

Arterial blood Pressure

is a measure of the pressure exerted by the blood as it flows through the arteries.
Two blood pressure measurements
1. Systolic pressure- is the maximum pressure developed on the ejection of blood from the left
ventricle into the arteries
- Contraction of the ventricles
2. Diastolic Pressure-is the lowest pressure and is a measure of the peripheral resistance.
- Ventricles are at rest
- Lower pressure present at all times

Pulse Pressure = difference between systolic and diastolic pressures

Measured in mm Hg
Recorded as a fraction, e.g. 120/80
Systolic = 120 and Diastolic = 80

In measuring the BP
By means of auscultation- the systolic pressure is taken at the point when beats becomes
audible. As the mercury continues to fall, the sound of the beats becomes louder, then
gradually diminishes until a point is reached at which there is a sudden, marked diminution in
intensity.
The average BP is about 120/80 at 20 yrs old and at the age of 60 is 160/90
Korotkoffs Sounds
Phase 1
First faint, clear tapping or thumping sounds
Systolic pressure
Phase 2
Muffled, whooshing, or swishing sound
Phase 3
Blood flows freely
Crisper and more intense sound
Thumping quality but softer than in phase 1
Phase 4
Muffled and have a soft, blowing sound
Diastolic pressure
Phase 5
Pressure level when the last sound is heard
Period of silence

Measuring Blood Pressure

Direct (Invasive Monitoring)
Indirect
Auscultatory
Palpatory
Sites
Upper arm (brachial artery)
Thigh (popliteal artery)

Mercury manometer and cuff

Aneroid manometer and cuff

2 types of sphygmomanometer
Aneroid and mercury manometer
Aneroid is a calibrated dial with a needle that points to the calibrations while the other is a
calibrated cylinder filled with mercury.
Other types
Electric sphygmomanometer
Doppler stethoscope
Variations in BP cuff
If the bladder is too narrow, the obtained BP reading is erroneously elevated; if it is too wide the
reading will be erroneously low
The width should be 40% of the circumference or 20% wider than the diameter of the midpoint
of the limb on which it is used
The length of the bladder should be sufficiently long almost to encircle the limb and to cover at
least 2/3 of its circumference