Vital Signs

Shurouq Qadose
17/2/2008
Vital signs are temperature, pulse, respiration,
blood pressure and pain. A change in vital signs
may indicate a change in health.

Frequency of vital signs: vital signs are assessed at

least every 4 hours in hospitalized patients with
elevated temperatures, with low or high blood
pressures, with changes in pulse rate or rhythm or
with respiratory difficulty as well as in patients
who are taking medications that effect
cardiovascular or respiratory function or who had
a surgery.
Times to assess vital signs:
• On admission to a health care agency to obtain
baseline data
• When a client has a change in health status or
report symptoms such as chest pain or feelings
hot or faint.
• Before and after surgery or an invasive procedure
• Before and/or after the administration of a
medication that could affect the respiratory or
cardiovascular systems such as before giving
digitalis preparation
• Before and after any nursing interventions that
could affect the vital signs such as ambulating a
client who has been on bed rest.
 Body Temperature
Body temperature reflects the balance between the heat
produced and the heat lost from the body, and is
measured in heat units called degrees. There are two
kinds of body temperature:
Core temperature is the temperature of the deep
tissues of the body such as abdominal cavity and
pelvic cavity; it remains relatively constant. The
surface temperature is the temperature of the skin,
the subcutaneous tissue, and fat. It rises and falls in
response to the environment. When the amount of
heat produced by the body equals the amount of heat
loss, the person is in heat balance.
A number of factors affect the body's heat production:
• Basal metabolic rate "BMR" is the rate of energy
utilization in the body required to maintain essential
activities such as breathing.
• Muscle activity; including shivering, increases the
metabolic rate.
• Thyroxine output; increased thyroxine output increases
the rate of cellular metabolism throughout the body.
• Epinephrine, norepinephrene, and sympathetic
stimulation/stress response. These hormones
immediately increases the rate of cellular metabolism in
many body tissues
• Fever; fever increases the cellular metabolism rate and
thus increases the body's temperature further.
 Mechanism of heat loss:
Radiation; the transfer of heat from the surface
of one object to the surface of another without
contact between the two objects, mostly in the
form infrared rays.
Conduction; is the transfer of heat from one
molecule to a molecule of lower temperature
such as the body transfers heat to an ice pack
causing the ice to melt.
Vaporization; the conversion of a liquid to vapor
such as body fluid in the form of perspiration
and insensible loss is vaporized from the skin.
Convection is the dispersion of heat by air
currents. The body usually has a small amount
of warm air adjacent to it. This warm air rises
and is replaced by cooler air.
Factors affecting body temperature:

• Circadian Rhythms; predictable fluctuations in

measurement of body temperature and blood
pressure such as body temperature is usually
lower in the morning than in the evening.
• Age; the body temperature of infants and
children changes more rapidly in response to
both heat and cold.
• Hormones; women tend to have more
fluctuations in body temperature than men as a
result of hormones changes
• Stress; the body respond to both emotional and
physical stress as a threat increasing the
production of epinephrine and nor epinephrine
as a result the metabolic rate increases raising
the body temperature
• Environmental temperature; we are responding
to a change in environment either by wearing
or less clothes.
• Exercise, hard work or strenuous exercise can
increase body temperature.
 Alterations in body temperature
There are two primary alterations in body
temperature: pyrexia and hypothermia.

Pyrexia
A body temperature above the usual range is called
pyrexia, hyperthermia, or fever.
Hyperpyrexia; is a very high fever usually above 41
°C and survival is rare when the temperature
Reaches 44 °C and death due to damaging effects
on the respiratory center.
The client who has a fever is referred to as febrile;
the one who does not is afebrile.
The signs and symptoms of fever: loss of
appetite, headache, hot, dry skin, flushed face,
thirst and general malaise. Young children or
other people with high fevers may experience
periods of delirium or seizures.
 Nursing Interventions for Client's with
fever:
• Monitor vital signs
• Assess skin color and temperature
• Monitor WBC, HCT, and other laboratory reports for
indications of infection or dehydration
• Remove excess blanket when the client feels warm,
but provide extra warmth when the client feels
chilled.
• Measure intake and output
• Provide adequate nutrition and fluid
• Reduce physical activity to limit heat production.
• Administer antipyretic
• Provide oral hygiene to keep the mucous
membrane moist.
• Provide a tepid sponge bath to increase heat
loss through conduction.
• Provide dry clothing and bed linens.
Hypothermia; is a core body temperature below
the lower limit of normal. The three
physiologic mechanisms of hypothermia are:
• Excessive heat loss
• Inadequate heat production to counteract heat
loss
• Impaired hypothalamic thermoregulation
The clinical signs of hypothermia:
–Decreased body temperature, pulse, and
respiration
–Severe shivering
–Feelings of cold and chills
–Pale, cool skin
–Hypotension
–Decreased urinary output
–Lack of muscle coordination
–Disorientation
–Drowsiness progressing to coma
–Frostbite(nose, fingers, toes)
Nursing Interventions for Client's with Hypothermia
»Provide a warm environment
»Provide dry clothing
»Apply warm blanket
»Keep limbs close to body
»Cover the client's scalp with a cap
»Supply warm oral or intravenous
fluids
»Apply warming pads
Assessing Body Temperature

The four most common sites for measuring body

temperature are oral, rectal, axillary, and the
tympanic membrane and the skin.

Orally: It reflects changing body temperature more

quickly than the rectal method. Oral thermometers
may have long, short, or rounded tips
Contra indication of oral temperature:
• Breathing is difficult or rapid
• Can't close mouth for any reason
• Breathing through mouth
• Mouth is inflamed
• Confused or comatose
• Infant or young children
• Oral surgery/ broken jaw
• Unconscious/agitated people
Rectally; are considered to be very accurate.

Contra indication of rectal temperature

• Diarrhea
• Rectal surgery
• Clotting disorders
• Hemorrhoids "pile"
Axillary; is the preferred site for measuring
temperature newborn because it is accessible
and offers no possibility rectal perforation.
Contraindication of axillary temperature
• Thin patient
• Local inflammation
• Unconsciousness, shocked patients
• Constricted peripheral blood vessels.
Tympanic membrane; nearby tissue in the ear
canal because the membrane has an
abundant arterial blood supply.
Temporal artery thermometer are most useful
for infants and children where a more invasive
measurement is not necessary.
 Advantages and disadvantages of four sites for body
temperature measurement

Temperature scales
The body temperature is measure in degreed on
two scales: Celsius (centigrade) and
Fahrenheit.
C= (Fahrenheit temperature – 32) * 5/9
F = (Celsius temperature * 9/5) +32
 Pulse

Pulse; is a wave of blood created by contraction

of the left ventricle of the heart.
Cardiac output; is the volume of blood pumped
into the arteries by the heart and equals the
result of the stroke volume times the heart rate.
A peripheral pulse; is a pulse located away from
the heart such as in the foot, wrist neck.
Apical pulse; is a central pulse; that is, located at
the apex of the heart.
 Factors affecting pulse:
• Age; as age increases, the pulse rate gradually
decreases.
• Gender, male’s pulse rate is slightly lower than the
female’s.
• Exercise; the pulse rate normally increase with
activity
• Fever; the pulse rate increases in response to the
lowered blood pressure that results from peripheral
vasodilatation associated with elevated temperature
and because of the increased metabolic rate.
• Medications; some medications decrease the pulse
rate, and others increase it such as digitalis decrease
the heart rate.
• Hypovolemia; loss of blood from the vascular
system normally increase pulse rate. Stress; in
response to stress, sympathetic nervous system
stimulation increases the overall activity of the
heart.
• Position change; when the person is sitting or
standing, blood usually pools in dependent
vessels of the venous system.
• Pathology; certain diseases such as some heart
conditions or those with impair oxygenation
can alter the resting pulse rate.
 Pulse Sites

– Temporal; passes over the temporal bone of the

head. The site is superior and lateral to the eye.
– Carotid; at the side of the neck between the
trachea and the sternocleiodomastoid muscle.
– Apical; at the apex of the hearty. About 8cm to the
left of the sternum and at the fourth and sixth
intercostals space.
– Brachial; at the inner aspect of the biceps muscle
of the arm
Pulse Sites
– Radial; on the thumb side of the inner aspect of
the wrist
– Femoral; alongside the inguinal ligaments
– Popliteal; behind the knee
– Posterior tibial; on the medial surface of the ankle
– Pedal “dorsalis pedis”; over the bones of the feet
Assessing the Pulse
A pulse is normally palpated by applying
moderate pressure with the three middle
fingers of the hand. A pulse is commonly
assessed by palpation “feeling’ or auscultation
“hearing”.
Apical pulse; if the peripheral pulse is difficult to
assess accurately because it is irregular. The
apical pulse located at 5-6 intercostals rib.
A Doppler ultrasound stethoscope (DUS) is used for
pulses that are difficult to assess.

The nurse should aware of the following:

• Any medications that could affect the heart rate.
• Whether the client has been physically active.
• Whether the client should assume a particular
position.
When assessing the pulse the nurse collect the following data:

1. Rate, an excessively fast heart rate over 100 BPM in an adult is

called Tachycardia. A heart rate in an adult of less than 60BPM
is called Bradycardia.
2. Rhythm is the pattern of the beats and the intervals between the
beats. A pulse with an irregular rhythm is referred to as a
dysrhythmia or arrhythmia.
3. Volume is called pulse strength or amplitude, refers to the force of
blood with each beat. It can range from absent to bounding.
4. Elasticity of the arterial wall reflects its expansibility or its
deformities. A healthy, normal artery feels straight, smooth, soft,
and pliable. Elders often have inelastic arteries that feel twisted
and irregular upon palpation.
Apical-Radial Pulse Assessment
It may need to be assessed for clients with
certain cardiovascular disorders. Normally the
apical pulse and radial are identical.
Pulse deficit; the discrepancy between the radial
pulse and apical pulse.
Mechanics and regulation of breathing
During inhalation, the diaphragm contracts the
ribs move upward and outward, and the
sternum moves outward, thus enlarging the
thorax and permitting the lungs to expand.
During exhalation. The diaphragm relaxes, the
ribs move downward and inward, and the
sternum moves inward, thus decreasing the
size of the thorax as the lungs are compressed.
Respiration is controlled by (a) respiratory
centers in the medulla oblongata and the pons
of the brain and (b) by chemo receptors located
centrally in the medulla and peripherally in the
carotid and aortic bodies.
External respiration; the interchange of oxygen
and carbon dioxide between the alveoli of the
lungs and the pulmonary blood. Internal
respiration; the interchange of these same
gases between the circulating blood and the
cells of the body tissues.
Assessing Respiration
• Nurses should be aware of the following
before having respiration rate:
• The client’s normal breathing pattern
• The influence of the client’s health problems
on respirations
• Any medications or therapies that might affect
respirations
• The relationship of the client’s respiration to
cardiovascular function
The respiratory rate is normally described in
breaths per minute, normal in depth and rate
called eupnea. Bradypnea; abnormally slow
respirations. Tachypnea; abnormally fast
respirations. Apnea; the absence of breathing.
Factors affecting Respirations
Factors increase the rate:
• Exercise
• Increase metabolism
• Stress
• Increased environmental temperature
• Lowered oxygen concentration
 Factors decrease respiration rate:
• Decreased environmental temperature
• Certain medications such as narcotics
• Increased intra cranial pressure
Respiration depth; is generally described as
normal, deep, or shallow. Deep respirations;
large volume of air is inhaled and exhaled,
inflated most of the lungs.
Shallow breathing involve the exchange of a
small volume of air and often the minimal use
of a lung tissue
Hyperventilation; refers to very deep, rapid
respiration.
Hypoventilation; refers to very shallow
respirations
Respiratory rhythm refers to the regularity of
the expirations and the inspirations .An
respiratory rhythm can be described as regular
or irregular.
- Cheyne-stokes breathing, from very deep to
very shallow breathing and temporary apnea.
Kussmaul …….. Increased rate and depth of
respiration above 20bpm
Respiratory quality, usually breathing does not
require noticeable effort. Dyspnea, difficult
and labored breathing. Orthopnea, ability to
breath only in upright sitting or standing
positions.
Breath sounds
- Stridor, harsh sound heard during inspiration
with laryngeal obstruction
- Stertor, snoring respiration usually due to a
partial obstruction of the upper airway.
- Wheeze, continuous, high pitched musical
sound occurring on expiration when air moves
through narrowed or partially obstructed air
way.
Secretions and coughing
- Hemoptysis, the presence of blood in the
sputum
- Productive cough, a cough accompanied by
expectorated secretions
- Nonproductive cough, a dry, harsh cough
without secretions
 Blood Pressure
Blood pressure is referred to the force of the
blood against arterial walls. Maximum blood
pressure is exerted on the walls of arteries
when the left ventricles of the heart pushes
blood through the aortic valve into the aortas
during contraction, the highest pressure thus
called systolic pressure.
Diastolic pressure is the pressure when the
ventricles are at rest. Diastolic pressure, then,
is the lower pressure present at all times within
the arteries. The differences between the two
called the pulse pressure
 Determination of blood pressure
• Pumping action of the heart; when the
pumping action of the heart is weak, less blood
is pumped into arteries "lower cardiac output",
and the blood pressure decreases.
• Peripheral vascular resistance; peripheral
vascular can increase blood pressure. The
diastolic pressure especially is affected. Some
factors that create resistance in the arterial
system are the capacity of the arterioles, the
compliance of the arteries, and the viscosity of
the blood
• Blood volume; when the blood volume
decreases as a result of hemorrhage, the blood
pressure decreases because of the decreased
fluid in the arteries.
• Blood viscosity; blood pressure is higher when
the blood is highly viscous "thick" that is,
when the proportion of RBC to the blood
plasma is high.
 Factors affecting Blood Pressure

• Age; the pressure rises with age, reaching a

peak at the onset of puberty, and then tend to
decline.
• Exercise; physical activity increases the cardiac
output and hence in blood pressure; thus 20-
30 minutes of rest following exercise is
indicated before the resting blood pressure
can reliably assessed.
• Stress; stimulation of the nervous system
increases cardiac output and vasoconstriction
of the arterioles, however severe pain can
decrease blood pressure greatly by inhibiting
the vasomotor center and provide
vasodilatation
• Race (African American males over 35 years
have higher BP than European American
males)
• Gender; after puberty, female usually have
lower blood pressure than males at the same
age. After menopause the female has higher
blood pressure than males
• Medications
• Obesity; predispose to high blood pressure
• Diurnal variations; pressure is usually lowest
early in the morning when metabolic rate is
low.
• Disease process; any condition affecting the
cardiac output, blood volume, blood viscosity,
and compliance of the arteries has a direct
effect on the blood pressure.
 Hypertension
Hypertension; an abnormally high blood
pressure, over 140mm Hg systolic and 90 mm
Hg diastolic.
Factors associated with hypertension
• Thickening of the arterial walls, which reduces
the size of the arterial lumen
• Elasticity of the arteries
• Lifestyle as cigarette smoking
• Obesity
• Lack of physical exercise
• High blood cholesterol level
• Continued exposure to stress
Hypotension; blood pressure below normal that
is systolic reading between 85-110mm Hg. It
occurs as a result of peripheral vasodilatation
in which blood leaves the central body organs
especially the brain and moves to the periphery

Factors associated with hypotension

• Analgesics
• Bleeding
• Severe burn
• Dehydration.
It is important to monitor hypotensive clients
carefully to prevent falls. When assessing the
orthostatic hypotension:
– Place the client in a supine position for 2-3
minutes
– Record the client's pulse and blood pressure
– Assist the client to slowly sit or stand. Support the
client in case of faintness
– After one minute in the upright position, check the
pulse and blood pressure in the same site as
previously
– Record the results, a rise in pulse of 40 beats per
minute or a drop in blood pressure of 30mm Hg
indicates abnormal vital signs.
Equipments used to assess pulse and blood
pressure
• Stethoscope; is used to auscultated and assess
body sounds including the apical pulse and the
blood pressure
• Sphygmomanometer; is used to assess blood
pressure consist of cuff, good selection of the
cuff in order to obtain accurate blood pressure.
Blood pressure sites
Assessing the blood pressure on a client’s thigh
is indicated in these situations:
– The blood pressure can not be measured on either
arm due to burn or other trauma
– The blood pressure on one thigh is to be compared
with the blood pressure in the other thigh
Blood pressure is not measured on a particular
clients’ limb in the following situations:
1) Avoid having blood [pressure in injured or an
area with cast
2) The client has had removal of axilla lymph
node on that site
3) The client has intravenous line in that limb
4) The client has an arteriovenous fistula for
dialysis in that limb
Oxygen Saturation
A pulse oximeter; is a non invasive device that
measures a client's arterial blood oxygen
saturation by means of a sensor attached to the
client's finger, toe, nose, earlobe, or forehead.
The pulse oximeter can detect hypoxemia
before clinical signs and symptoms such as
dusky skin color and dusky nailbed color.
Factors affecting oxygen saturation reading
• Hemoglobin; if the hemoglobin is fully
saturated with oxygen, the saturation will
appear normal even if the total hemoglobin
level is low
• Circulation
• Activity; shivering or excessive movement of
the sensor site may interfere with accurate
reading.
• Carbon monoxide poisoning.