ASSESSING VITAL SIGNS
RLE 10
@VITAL SIGNS
• Also known as Cardinal Signs
• Includes (1) TEMPERATURE, (2) PULSE, (3) RESPIRATION, and (4) BLOOD PRESSURE &
recently PAIN as the 5th V/S in some facilities
• A person’s physiologic status is reflected by these indicators of body function
• Checked to monitor the functions of the body, functions that might not be observed
• Should be evaluated with reference to the client’s present and prior health status, are compared to the
client’s usual (if known) and accepted normal standars
• When and where? Chiefly a nursing judgement or depending on facility or physician’s order
@Vital Signs are commonly assessed:
• Screenings at health fairs and clinics
• In the home
• Upon admission to a healthcare setting to obtain baseline data
• When certain medications are given (meds that could affect respi or cardio system ex. Digitalis)
• @Before and after diagnostic and surgical procedures (there might be internal bleeding)
• Before and after certain nursing interventions that could affect V/S (ex. Ambulating a client who has
been on bed rest, b/c he may have activity intolerance
• In emergency situations or when client has change in health status or reports symptoms such as chest
pain or feeling hot or faint
@Purposes of assessing Vital Signs
• To obtain baseline measurement of the patient’s vital signs
• To assess patient’s response to treatment or medication
• To monitor patient’s condition after invasive procedures
@I. ASSESSING TEMPERATURE
BODY TEMPERATURE
• heat of the body measured in degrees
• Difference between production of heat and loss of heat from the body
@PROCESS OF HEAT PRODUCTION OCCURS THROUGH:
• Food Metabolism and Activity – basal metabolic rate (BMR) or the rate of energy utilization in the body
• Increased thyroxin production - increased cellular metabolism is d/t inc thyroxine output from the
thyroid gland, this effect is called CHEMICAL THERMOGENESIS
• Chemical thermogenesis
• Epinephrine, norepi, SNS stimulation
• Fever = inc metabolic rate
• Muscle activity = inc metabolic rate
@PROCESS OF HEAT LOSS OCCURS THROUGH:
• Radiation – surface to surface by waves therefore no contact (ex. Nude person standing in room @
normal temperature)
• Conduction – contact between 2 surfaces; heat transfer to a surface of lower temperature (ex. immersion
in cold water)
• Convection – mov’t by air currents
• Evaporation – water to steam; continuous & unnoticed evaporation of moisture from the respiratory tract
& from mucosa of mouth & from skin
• Elimination – urination, defecation
@TYPES of TEMPERATURE
• Core Temperature
Temperature of the deep tissues of the body such as abdominal cavity & pelvic cavity; relatively
constant
measured thru tympanic and rectal routes
• Surface Temperature
Temperature of the skin, subcutaneous tissue & fats; rises and falls in response to the environment
measured thru oral and axillary routes
@FACTORS AFFECTING BODY TEMPERATURE – nurses should be aware so that they can recognize
normal temperature variations & understand the significance of the body temperature measurements that deviate
from normal
• Age – infant is greatly influenced by the temperature of environment and must be protected from
extreme changes; people 75 y.o & up are at risk for hypothermia (T < 36C or 96.8F) for a variety of reasons
such as inadequeate diet, loss of subcutaneous tissue, lack of activity & decreased thermo-regulatory efficiency
• Sex – d/t hormones; women > men hormone fluctuations; progesterone during ovulation rises body
temperature
• Exercise – can inc temp to as high as 38.3C to 40C (101-104F) rectally
• Time of day – also “diurnal variations” or “circadian rhythms”; @ 1C between early am and late pm;
highest @ 8pm and midnight; lowest @ sleep between 4-6 am
• Emotions/stress – stimulation of SNS
• Environment – extremes in environmental temp
• Others; food, drugs
@4 COMMON SITES FOR ASSESSING
BODY TEMPERATURE
1. Oral – most frequently used, least disruptive, most convenient, done for 3 minutes ; wait 30 mins if
client ate or drank cold or hot food/fluids
CONTRAINDICATIONS:
• Infants and very young children
• Patients with oral surgery
• Unconscious or irrational patients
• Seizure-prone patients
• Mouth breathers and pts. with oxygen
2. @ Rectal – most accurate route, but invasive and uncomfortable to patient; done for 2-3 mins
CONTRAINDICATIONS:
Rectal abnormalities – ex. Significant hemorroids
Diarrhea
Certain heart conditions – ex. CHF; may result to vagal stimulation = bradycardia
Immunosuppressed - may inc risk of infection
Clotting disorder
3. @Axillary – safer than the oral method, non-invasive, least accurate; Done for 10 minutes; for clients
with oral problem( oral inflammation, wired jaws, oral surgery)
4. @Tympanic membrane – accessible, less invasive; has abundant arterial blood supply; Within two
seconds
Up/back for adult
Down/back for pedia
CONTRAINDICATIONS:
• Presence of ear ache
• Significant ear drainage
• Scarred tympanic membrane
@ASSESSING TEMPERATURE
(axillary route) Taylor’s p. 14
@Route vs Special Considerations (table)
ROUTE SPECIAL CONSIDERATIONS
• Done for 3 minutes
ORAL • Upon intake of hot/cold fluids, wait
30 minutes
• Done for 2-3 minutes
• Presence of fecal matter could
RECTAL result to a false reading
• Lubricate tip prior to inserting
• Done for 10 minutes
AXILLARY
• Within two seconds
TYMPANIC • Up/back for adult
• Down/back for pedia
@Unexpected Situations in assessing TEMPERATURE
• Temperature higher/lower than expected based on how skin feels
(re-assess with new thermometer)
• Feeling lightheaded or passes out during rectal temp assessment
(remove thermometer immediately, assess BP & HR, notify doctor, don’t take another rectal temp)
@ Assessment Findings
Pyrexia Elevated BT
Hyperpyrexia BT above 41˚C
Intermittent fever BT alternates regularly between
periods o fever, normal or subnormal
temperature
Remittent fever Fluctuations of several degrees
above normal, but not reaching
normal between fluctuations
Constant fever Consistently elevated and fluctuates
very little
Relapsing fever Returns to normal for at least a day
then the fever occurs
Resolution of Pyrexia by crisis Elevated BT returns to normal
suddenly
@Types of Thermometer
1. Tympanic Thermometer/infrared thermometer – senses body heat in form of infra red energy given off by the
heat source which is the ear canal (tympanic membrane)
2. Electronic or Digital Thermometer – can read temp in 2-60 sec depending on manufacturer
3. Glass Thermometer – traditional; “mercury-in-glass thermometers”
4. Temperature – sensitive Tape – does not indicate core temp; w/ liquid crystals that change color; placed at
forehead or abdomen
5. Chemical Thermometer – uses crystal dots/bars or sensitive tape applied @ forehead
@II. ASSESSING PULSE Taylor’s p. 16
PULSE
• A wave of blood being pumped into the arterial circulation by the contraction of the left ventricle
• Throbbing sensation palpated over a peripheral artery
• Assessed by palpation (feeling) or auscultation (hearing)
• Middle three fingertips are used for palpating all pulse sites except the apex of the heart; a stethoscope is
used for assessing apical pulses & FHT
@ASSESSMENT PARAMETERS / CHARACTERISTICS OF PULSE
• Rate – number of beats per minute
AGE GROUP PULSE RANGE
Newborn 80-180 bpm
Adults 60-100 bpm
Elderly 60-100 bpm
Assessment Findings: Tachycardia, bradycardia
• Rhythm – pattern or regularity of beats and interval between each beat
Term Meaning
Pulsus regularis Equal rhythm
Arrhythmia Irregular rhythm
Premature beat Beat that occurs between normal
beats
Heart rhythm Time interval between each
heartbeat
• @Volume/amplitude – also pulse strength; amount of blood pumped with each heartbeat
Normal pulse – can be felt w/ moderate pressure of the fingers & can be obliterated w/ greater pressure
Full or bounding pulse – forceful or full blood volume that is obliterated only with difficulty
Weak, feeble, thready – pulse that is readily obliterated w/ pressure from the fingers
Cardiac Output – 5-6 Liters of blood is forced out of the left ventricle per minute
Pulse Deficit – difference between the apical and radial counts taken simultaneously
@LOCATION OF PERIPHERAL PULSES
>temporal – superior and lateral to the eye
>carotid - @ side of cheek
>brachial – inner aspect of the bicep muscle of the arm or medially in the antecubital space
>radial - @ the thumb side of the inner aspect of the wrist
>femoral - @ inguinal ligament
>politeal – behind the knee
>posterior tibial – medial surface of the ankle
>dorsalis pedis/ pedal – over the bones of the foot
@Reasons for Using Specific Pulse Site
Pulse Site Reasons for Use
Radial Readily accessible
Temporal Used when radial pulse is not accessible
Carotid Used in cases of cardiac arrests
Used to determine circulation to the brain
Apical Routinely used for infants 7 children up to 3 yrs.
Used to determine discrepancies with radial pulse
Used in conjunction with some medications
Brachial Used to measure blood pressure
Used during cardiac arrest for infants
Femoral Used in cases of cardiac arrest
Used for infants and children
Used to determine circulation to the leg
Popliteal Used to determine circulation to the lower leg
Posterior tibial , Used to determine circulation to the foot
Pedal
@Factors Affecting Pulse Rate
1. Age – inc age, dec PR
2. Sex/gender – after puberty male’s pulse is slightly lower than femlae’s
3. Exercise – inc exercise, inc PR
4. Emotions/stress – SNS stimulation (fear, anxiety, perception of pain)
5. Prolonged heat application – inc metabolic rate, inc PR
6. Body positions- when sitting or standing, blood usually pools in dependent vessels of venous system
transient dec in venous return to the heart inc HR to compensate
7. Pain – d/t SNS stimulation
8. Decreased BP – inc HR as compensatory mechanism
9. Increased temperature – inc metabolic rate
10. Any conditions resulting to poor oxygenation of blood ex. CHF – inc HR to compensate
@ASSESSING PULSE Taylor’s p. 17
@Respiration – act of breathing
Pulmonary ventilation –(breathing) movement of air in and out of the lungs
Inspiration –(inhalation) act or breathing in
Expiration –(exhalation) act of breathing out
External respiration – exchange of O2 and CO2 between alveoli and blood
Internal respiration – exchange of O2 and CO2 between blood and tissue cells
@III. ASSESSMENT PARAMETERS / CHARACTERISTICS OF RESPIRATION
1. Rate – number of breaths per minute
AGE GROUP RESPIRATORY RANGE
Newborn 30 – 60 bpm
Adults 12-20 bpm
2. @Rhythm – regularity of respiration, inhalation and exhalation are evenly spaced;
AF – regular, irregular
Regular Effortless, quiet
Irregular Abnormal
3. @Depth – assessed by watching the movement of the chest
AF – normal, deep or shallow
4. ease & effort
AF – dyspnea, orthopnea
5. breath sounds
AF – stridor, bubbling, rales
6. volume – AF: hyperventilation (overexpansion of lungs), hypoventilation (underexpansion of lungs)
@2 TYPES OF BREATHING
1. Costal/thoracic breathing – involves external intercostal muscles and other accessory muscles; Observed
thru upward and outward movement of the chest
2. diaphragmatic (abdominal) breathing – involves contraction & relaxation of the diaphragm
@FACTORS AFFECTING RESPIRATION
3. Exercise – inc RR
4. Certain medications – eg. Narcotics
5. Age
6. Emotions – inc RR
7. Cardiac illness
8. Stress – inc RR
9. inc ICP = dec RR
@ASSESSMENT FINDINGS REGARDING RESPIRATION
Eupnea Normal, effortless breathing
Tachypnea RR > 24 bpm
Bradypnea RR < 10 bpm
Apnea Absence of breathing
Hyperpnea Deeper respiration with normal rate
Cheyne stokes Resp. becomes faster and deeper then
slower with alternate periods of apnea(20-
60sec)
Biot’s Faster and deeper than normal with abrupt
pauses in between each breath
@A.F. REGARDING RESPIRATION
• Kussmaul’s Faster and deeper respiration without pauses in between panting
• Apneustic Prolonged grasping followed by extremely short insufficient exhalation
• Dyspnea difficulty of breathing
• Orthopnea DOB unless sitting
• Wheezing narrowing of airways, causing whistling or sighing sounds
• Stridor high-pitched sounds heard on inspiration
@Rales - sound caused by air passing thru fluid or mucus in the airways usually heard on
inhalation
• Rhonchi sound caused by air passing thru airways narrowed by fluids, edema, muscle spasm usually
heard during exhalation
@ASSESSING RESPIRATION P 20 TAYLOR’S
IV. BLOOD PRESSURE
- Force of the blood against the
arterial walls
- Measured in millimeters of mercury
(mmHg)
Since blood moves in waves, there are 2 BP measures:
1. Systole – the highest pressure; pressure of the blood as a result of contraction of ventricles
2. Diastole – the lowest pressure; pressure of the blood when ventricles are at rest
Pulse pressure – difference between the systole and diastole
@AF:
• Hypertension – above 140/90 mmHg
• Hypotension – below 90/60 mmHg
• Orthostatic Hypotension –
decrease in Bp when changing
position
@Korotkoff’s sound –schematic diagram
@Factors that control Blood Pressure
1.Cardiac Output – amount of blood ejected from the heart per contraction
2. Blood Volume – adult has about 5-6 liters of circulating blood
3. Elasticity of arterial walls – yields upon systole and retracts upon diastole
@Factors affecting Blood pressure
– Age – newborns systolic = 75mmHg; BP rises w/ age
– Emotions/stress – SNS stimulation = inc BP
– Exercise – inc cardiac output = inc BP
– Drugs – dopamine, dobutamine, epinephrine
– Obesity – predispose to hypertension
– Disease process – any dse affecting C.O., blood volume, blood viscosity and compliance of the arteries
Assessment Findings:
1. hypertension – dx made when the ave of 2 or more diastolic readings on 2 visits subsequent to initial
assessment is 90 mmHg or higher or ave of multiple systolic BP readings is higher than 140mmHg
2. hypotension = systolic pressure is consistently between 85-110 mmHg
To ensure accuracy in taking the BP, you must:
Let the patient rest for a minimum of 5 minutes for routine assessment
2. Should not have ingested caffeine or nicotine 30 minutes before
3. Delay assessing if patient is:
a. in pain
b. emotionally upset, or
c. have just exercised.
Parts of BP apparatus
Assessing BP Taylor’s p. 23
The End
