Al-Zaytoonah University of Jordan

Faculty of Nursing

Course name :Fundamental Nursing

Lecture 3
Vital signs
1
 Unit 7
Assessing Health:
Vital Signs
Body temperature.
Pulse.
Respiration.
Blood pressure.
PILOs CILOs topic
PILO #1: Understand and comprehend the 2-Knows the nursing care practices How to differentiate between
basic nursing knowledge needed to to provide evidence-based, normal and abnormal reading s
provide a safe and effective care
comprehensive nursing care for Temperature
environment, and comprehensive nursing
care based on research and scientific adult patients with various health Pulse
evidence. conditions Respiration
Blood pressure
Oxygen Saturation
Pain assessment
PILO # 5: Demonstrate the ability to 1-Promote physical health and Provide effective nursing care
maintain the physiological integrity wellness by providing care and based on the VS reading and
of patients while providing high comfort for adult patients with describe the pharmacological
quality nursing care. various health conditions. treatment for each
3-Utilize nursing implication for the
pharmacological administration by
considering the safety measures

3
Learning outcomes
• Describe factors that affect the vital signs and accurate measurement
of them.
• Identify the variations in normal body temperature, pulse, respiration,
and blood pressure that occur from infancy to old age.
• Verbalise the steps used in Assessing body temperature, peripheral
pulse, apical pulse, respirations, blood pressure,and blood
oxygenation using pulse oximetry.
* Describe appropriate nursing care for alterations in vital signs.
* Identify nine sites used to assess the pulse and state the reasons for
their use.
* List the characteristics that should be included when assessing pulses.
* Describe the mechanics of breathing and the mechanisms that control
respirations.
* Recognize when it is appropriate to assign or delegate measurement
of vital signs to assistive personnel.
* Demonstrate appropriate documentation and reporting of vital
signs.
 Basic Nursing Skills
Vital /cardinal signs(VS)
VS measurements reflect the function of three body processes
essential for life.
1.Regulation of body temperature
2.Heart function
3.Breathing
Abbreviations:

1-T Temperature 3-P Pulse

2-R Respirations 4-BP Blood Pressure

2. When a client has a change in health status

3. According to a nursing or medical order.

4. Pre-post operation or an invasive procedure.

5. Before / after the administration of a medication affect respiratory or

6. Before / after any nursing intervention affect the vital signs (e.g. ambulating the
client who has been on bed rest)
 1. Body Temperature
• It reflects the balance between the heat produced by body and
heat lost from the body.
Heat production by muscles, glands and oxidation of food
Heat loss by respiration, perspiration (sweat), excretion
(elimination)
Heat Balance is when the amount of heat produced the body
exactly equals the amount of heat loss.
Factors Affecting Temperature
•Exercise •Infection
•Illness •Emotions
•Hydration
•Age
•Clothing
•Time of day •Environmental
•Medications temperature/air movement
 Kinds of Body Temperature:
1- Core temperature
➢Temp of deep tissues of the body, such as cranium, thorax,
abdominal cavity, and pelvic cavity.
➢The normal core temperature is a range between 36.7 C (98F)
and 37 C (98.6F).
2- Surface temperature:
• Temp of skin, subcutaneous tissue, and fat.
• It rises and falls in response to the environment.
• It can vary from 20 C to 40 C.
 Alterations in Body
Temperature
I. Pyrexia , hyperthermia, or fever :
• A body temperature above the usual range is
• A very high fever, 41C, is hyperpyrexia.
• Febrile: is client who has a fever
• Afebrile is client who does not have fever
 Types of Fever
-Intermittent:
Body temperature alternates at regular intervals between periods of
fever and periods of normal or subnormal temperature.
-Remittent:
A wide range of temperature fluctuations (more than 2C) occurs over
the 24-hour period, all of which are above normal.
-Relapsing
Short febrile periods of a few days are interspersed with periods of 1 or
2 days of normal temperature.
-Constant:
Body temperature fluctuates minimally but always remains above
normal.
 Clinical Signs of Fever
1) Onset (cold or chill stage)
• Increased heart rate, temperature, erespiratory rate and depth
• Shivering
• Pallid, cold skin
• Complaints of feeling cold
• Cyanotic nail beds
• Gooseflesh appearance of the skin
• Cessation of sweating
 Clinical Signs of Fever
2) Course stage
➢Absence of chills
➢Skin that feels warm
➢Feelings of being neither hot nor cold
➢Photosensitivity
➢Increased pulse, respiratory rates and thirst
➢Mild to severe dehydration
➢Drowsiness, restlessness, or delirium, and convulsions
➢Herpetic lesions of the mouth
➢Loss of appetite
➢Malaise, weakness, and aching muscle
 Clinical Signs of Fever
3) Defervescence (Fever abatement) stage
▪Skin that appears flushed and feels warm
▪Sweating
▪Decreased shivering
▪Possible dehydration
 Alterations in Body Temperature
II- Hypothermia
•It is a core body temp below lower limit of
normal.
•Physiologic mechanisms of hypothermia are:
a) Excessive heat loss,
b) Inadequate heat production to counteract heat
loss,
c) Impaired hypothalamic regulation.
 Clinical Signs of Hypothermia
• Decreases body temp, pulse, respirations Blood pressure
• Severe shivering (initially) feelings of cold& chills.
• Pale, cool, waxy skin.
• Decreased urinary output.
• Lack of muscle coordination.
• Disorientation.
• Drowsiness progressing to coma
 Sites for Measuring Body Temperature
1- Oral.
• It reflects changing body temperature quickly
• It is the most accessible and convenient method.
• If a client has been taking cold or hot food or fluids or smoking, the
nurse should wait 30 minutes before taking the temperature.
• Time for leaving thermometer in the mouth is 2-3 minutes.
2- Rectal.
• It is the most accurate and reliable measurement.
• The time for leaving thermometer in rectum is 3-5 minutes
• Recently it is forbidden in children
 Sites for Measuring Body
Temperature
3- Axilla.
It is the safest, most non-invasive measurement.
The time for leaving thermometer under axilla is 5-9
minutes (5 minutes for infants and children)
4-Tympanic membrane, or nearby tissue in the ear canal.
5- Skin: overhead 1-3 second
 Types of Thermometers
1- Mercury-in-glass thermometers.
2- Electronic thermometers.
read in 2- 60 seconds
3- Skin thermometers; applied to forehead
4- Temperature-sensitive tape. It may be used to obtain
a general indication of body surface temperature. The
tape contains liquid crystals that change color according
to temperature.
5- Infrared thermometers. ‫األشعة تحت الحمراء‬
It senses body heat in form of infrared energy given off by
a heat source
 Temperature Scales
1. Celsius (centigrade)
2. Fahrenheit.
➢To convert from F to C= (Fahrenheit temperature -
32) X 5/9
Fahrenheit reading is 100 C = (100-32) X 5/9
=68 X 5/9 = 37.7
➢To convert from C to F = (Celsius temperature x
9/5)+32
Celsius reading is 40.0 F = (40 X 9/5) +32 =72+32 =104
 2. Pulse
▪Pulse is a wave of blood created by contraction of the
left ventricle of heart
▪Pulse rate same as rate of ventricular contractions of the
heart.
▪Pulse is pressure of blood pushing against wall of artery
as heart beats and rests
▪Pulse easier to locate in arteries close to skin that can be
pressed against bone
 Pulse
1. Peripheral pulse:
Is the pulse located in periphery of body, for
example, in foot, hand, or neck.
2. Apical pulse
Is a central pulse; it is located at apex of heart.
Apex of heart is located on left of sternum and
under the 4th, 5th, or 6th intercostals space.
Pulse
Factors affecting Pulse Rate
• Age. As age increases, pulse rate decreases.
• Gender. average male's pulse rate is slightly lower than
female's.
• Exercise. increase pulse rate
• Fever. increase pulse rate
• Medication. Some medications decrease pulse rate, and
others increase it
• Hemorrhage. increases pulse rate, but become weak.
• Stress. increases pulse rate
• Position Changes. increases pulse rate
 Sites For Taking Pulse
• Radial: base of thumb most common site
• Temporal: side of forehead
• Carotid : side of neck
• Brachial : inner aspect of elbow
• Femoral: inner aspect of upper thigh
• Popliteal - behind knee
• Dorsalis pedis – top of foot
• Apical pulse – over apex of heart, taken with stethoscope, left side
of chest
 Assessing Pulse
• A pulse assessed by palpation (feeling) and auscultation (hearing).
• The middle three fingertips are used for palpating all pulse sites except the apex of
heart.
• Auscultation method is used to assess apical pulse, by stethoscope
• A pulse is normally palpated by apply moderate pressure with the three middle
fingers of the hand.
• The pads on the most distal aspects of the fingers are the most sensitive areas for
detecting a pulse.
• Thumb is not used in palpating a pulse because the nurse might feel her/his own
thumb pulse.
• Before the nurse assesses pulse, put client in a comfortable position
Peripheral Pulse Assessment :
Usually radial pulse, is assessed by palpation in all
individuals except:
1. Newborns and children up to 2 or 3years .
2. Very obese or elderly clients
3. Individuals with a heart disease (apical pulse)
4. Individuals in whom circulation to a specific
body part must be assessed, e.g. following leg
surgery, pedal is assessed.
 Characteristics of Pulse
1) Rate:
The normal range of pulse is between 60-100
beat/minute.
Tachycardia is excessively fast heart rate (over 100
beats/ minute in an adult).
Bradycardia is heart rate is less than 60/minute in an
adult.
If a client has tachycardia or bradycardia, the apical
pulse should be assessed.
 Characteristics of Pulse
2) Pulse rhythm:
• Is pattern of the beats and intervals between beats.
• Time should be equal between beats.
• A pulse with irregular rhythm is referred to as dysrhythmia or
arrhythmia.
• When a dysrhythmia is detected, apical pulse should be
assessed.
 Characteristics of Pulse
3) Pulse volume( amplitude‫)السعة‬: force of blood with each beat.
• It can range from absent to bounding ‫محدود‬.
• A normal pulse can be felt with moderate pressure of fingers
and can be obliterated with greater pressure.
• Bounding pulse: a strong throbbing blood volume that is
obliterated only with difficulty
• Weak, feeble, or thread pulse obliterated with pressure from the
fingers ‫الخيط‬.
• Pulse volume is the same each beat.
 Respirations
Respiration: process of taking in oxygen and expelling
carbon dioxide from lungs and respiratory tract .
It includes external and internal respiration.
External respiration is interchange of oxygen (O2)
and carbon dioxide (CO2) between alveoli of lungs
and pulmonary blood.
Internal respiration it is interchange of the same gases
between the circulating blood and the cells of the body
tissues.
 Respiration
•Inhalation (Inspiration) is intake of air
into lungs.
•Exhalation (Expiration) is breathing out
or the movements of gases from the lungs
to atmosphere.
•Ventilation is movement of air in and out
of the lungs.
 Types of Breathing
Costal (thoracic) breathing.
• It involves external intercostals muscles and other
accessory muscles, such as the sternocleidomastoid
muscles.
• It can be observed by movement of chest upward and
outward.
Diaphragmatic (abdominal).
• It occurs as a result of contraction and relaxation of the
diaphragm.
• It is observed by the movement of the abdomen.
Respiration is Regulated by:
a) Respiratory centers in medulla oblingata and
the pons of the brain and
b) Chemoreceptors located centrally in the
medulla and periphery in the carotid and
aortic bodies.
These centers and receptors respond to
changes in concentrations of oxygen, carbon
dioxide and hydrogen in the arterial blood.
Factors Affecting Respiratory Rate
•Exercise: increases respiratory rate.
•Stress: increases respiratory rate.
•Environment: increased temperature
increases respiratory rate
•Increased altitude: It lowers oxygen
concentration, it increases respiratory rate.
•Certain medications e.g narcotic,
analgesic. decreases respiratory rate.
 Breathing Patterns
1)Rate.
It is normally described in breaths/ minute.
•Eupnea: normal respiration rate and depth
•Bradypnea abnormally slow respirations
•Tachypnea or polypnea :abnormally fast
respirations
•Apnea is absence or cessation of breathing.
 Breathing Patterns
2) Depth.
• It established by watching the movement of the chest.
• It generally described as normal, deep, or shallow.
➢Deep resp: a large volume of air is inhaled or exhaled, inflating
most of the lungs.
➢Shallow resp involve exchange of a small volume of air and
often the minimal use of lung tissue.
• Tidal Volume: during a normal inspiration and expiration, an
adult takes in about 500 ml of air
 Breathing Patterns
3) Volume
Hyperventilation:
Refers to an increase in amount of air in lungs,
characterized by prolonged, rapid and deep
breathing; may be associated with anxiety.
Hypoventilation
Refers to a reduction in amount of air in lungs;
characterized by shallow respirations.
 Breathing Patterns
Rhythm or Pattern.
•It refers to time between one breath to
next one.
•It is regularity of expirations and
inspirations.
•Respiratory rhythm can be described as
regular or irregular.
 Breathing Patterns
Respiratory Quality or Character (Ease or effort)
• It refers to abnormal breathing
• Usually, breathing does not require noticeable effort
The abnormalities are:
Dyspnea:
• Refers to difficult and labored breathing, and the individual has
persistent, unsatisfied need for air and feels distressed.
Orthopnea
• Refers to ability to breath only in upright sitting or standing
positions.
 Sound of Breathing.
Normal breathing is silent
Abnormal breath sounds that are audible without amplification
are:
1-Stridor is a shrill, harsh sound heard during inspiration with
laryngeal obstruction.
2-Stertor is snoring respiration, usually due to partial obstruction of
the upper airway.
3-Wheeze is continuous, high pitched musical squeak or whistling
sound occurring on expiration and sometimes on inspiration when air
moves through a narrowed or partially obstructed airway.
4-Bubbling is gurgling sounds heard as air passes through moist
secretions in the respiratory tract.
 Sound of Breathing.
Abnormal breath sounds that are audible by stethoscope
are:
• Crackles (rales) are dry or wet crackling sounds stimulated by
rolling a lock of hair near the ear. Generally hard on inspiration
as air moves through accumulated moist secretions.
• Gurgles (rhonchi) is coarse, dry, wheezy, or whistling sound
more audible during expiration as the air moves through
tenacious mucus or narrowed bronchi.
• Pleural friction rub is coarse, leathery, or grating sound
produced by the rubbing together of inflamed pleura.
 Secretions and Coughing
Hemoptysis:
•Is the presence of blood in sputum.
Reproductive cough
•Is cough accompanied by expectorated
secretions.
Non- productive cough
•Is a dry, harsh cough with secretions.
 Blood Pressure (B.P)
Arterial blood pressure
▪ Blood pressure is the force of blood pushing against
walls of arteries
▪ Blood pressure measured in millimeters of mercury
(mm H g) and recorded as a fraction.
▪ Systolic pressure ‫انقباضي‬is written over the diastolic
pressure‫االنبساطي‬
▪ Average blood pressure of a healthy adult is 120/80
 Systolic Pressure
Is the pressure of the blood as a result of contraction
of the ventricles, pressure of the height of the blood
wave.
Diastolic Pressure
Is the pressure when ventricles are at rest. It is the
pressure present at all times within the arteries.
Pulse Pressure
Is the difference between diastolic and systolic
pressure.
 Factors affecting Blood Pressure (B.P)
There are many factors affecting may decrease or increase Bp.
❖Age. Blood pressure rises with age,.
❖Exercise. Physical activity increases the blood pressure.
❖Stress: increasing blood pressure
❖Race. African males over 35 years have higher BP
❖Obesity. BP is higher in obese people
❖Gender females have lower blood pressure. After menopause, women generally
have higher blood pressure
❖Medications: may decrease or increase Bp
❖Daytime Variation. Bp is lower in the morning, then rises throughout the day
and peaks in the late afternoon or early evening.
❖Disease Process.
 Assessing Blood Pressure
• BP measured with BP cuff, a sphyg-mo-manometer, and a
stethoscope.
• BP cuff consists of a rubber bag that can be inflated with air. It
is called the bladder.
• It covered with cloth and has two tubes attached to it. One
tube connects to a rubber bulb that inflates the bladder and the
other tube is attached on a sphygmomanometer.
• Bp usually assessed using brachial artery in the client's arm
• Assessing the blood pressure on a client's thigh is indicated if
the blood pressure can't be measured on either arm
 Assessing Blood Pressure
Bp is not measured on a client's arm or thigh if :
1) Shoulder, arm, or hand (or the hip, knee, or ankle) is
injured or diseased,
2) there is a cast or bandage on any part of the limb,
3) client has had breast or axilla (or hip) surgery
4) client has an intravenous infusion or a blood transfusion
running,
5) client has an arteriovenous fistula for renal dialysis.
 Types of Sphygmomanometer

•Mercury sphygmomanometer is a
calibrated cylinder filled with mercury
•Aneroid sphygmomanometer is a
calibrated dial with a needle that points to
the calibrations
•Electronic sphygmomanometers,
 Methods assessing Blood pressure
1- Direct (invasive monitoring)
measurement involves insertion of a
catheter into the brachial, radial, or
femoral artery. this pressure reading is
highly accurate.
2- Indirect methods of measuring blood
pressure using sphygmomanometer
 Measuring Blood Pressure
•Normal blood pressure range
•Systolic: 90-140 millimeters of mercury
•Diastolic: 60-90 millimeters of mercury

118
76
 The conditions are reflected by changes in
blood pressure are:
I- Hypertension
oBp above >140/90.
oIt is asymptomatic and is a contributing factor to
myocardial infarctions.
Types of Hypertension
Primary.
• It is elevated Bp of unknown cause.
Secondary.
• It is elevated of Bp of known cause, such as renal
disease, pregnancy.
 OXYGEN SATURATION
Pulse oximetry:
➢Noninvasive device that measure an 02 saturation
(sao2), the amount of oxygenated hemoglobin in arterial
blood.
➢It is connected to a sensor attached to the client's finger,
toe, nose, earlobe, or forehead.
➢It can detect hypoxemia before clinical signs and
symptoms.
 Pain
• Is the most common reason; people seek help from a physician
Pain threshold :
• Is amount of pain stimulation a person requires in order to feel pain.
Pain reaction includes:
• Autonomic nervous system and behavioral responses to pain.
Pain tolerance:
• Is maximum amount and duration of pain that an individual is willing
to endure.
What we need:
• For the time being we need to identify how to measure pain?
• Given the highly subjective and individually unique nature of pain, a
comprehensive assessment of the pain experience (physiologic,
psychologic, behavioral, emotional, spiritual, and sociocultural)
provides the necessary foundation for optimal pain control.
• It is important to base clinical decision making on client assessment
versus relying only on a severity rating score.
Pain score
• The extent and frequency of the pain assessment varies according to
the situation and the organizational policy. For clients experiencing
severe acute pain, the nurse may focus only on location, quality, and
severity, and provide interventions to control the pain before
conducting a more detailed evaluation.