VITAL SIGNS

PREPARED BY:

J.A. TRIMOCHA,R.N .
 Vital Signs
 The vital signs are BODY TEMPERATURE, PULSE, RESPIRATIONS, AND BLOOD
PRESSURE.
 PAIN ASSESSMENT – recently considered as fifth vital signs
 Vital SIGNS reflect changes in function that otherwise might not be observed.
 Monitoring a client’s vital signs should not be automatic or routine procedure; it should be a
thoughtful, scientific assessement


TIMES TO ASSESS VITAL SIGNS:



 On admission to health care agency to obtain baseline data

 When a client has change in health status or reports symptoms such as chest
pain or feeling hot or faint.
 Before and/ or after the administration of a medication that could affect the
respiratory or cardiovascular systems, for example, before giving digitalis
preparation
 Before and after any nursing intervention that could affect the vital signs (e.g.
ambulating a client who has been on bed rest)

Body Temperature
Reflects the balance between the heat
production and the heat lost from the body,
and is measured in heat units called degrees.
There are two kinds of body temperature:
CORE and SURFACE TEMPERATURE.
Core temperature is the temperature of deep
tissues of the body, such as abdominal
cavity and pelvic cavity. It remains constant.
Surface temperature is the temperature of the
skin, the subcutaneous tissue, and fat. It, by
contrast, rises and falls in response to the
environment.
FACTORS affecting HEAT
PRODUCTION
1.Basal Metabolic Rate(BMR) – is the rate of
energy utilization in the body required to
maintain essential activities such as
breathing.
2.Muscle activity – including shivering = increase
metabolic rate
3.Thyroxine output – increases thyroxine output
increases the rate of cellular metabolism
throughout the body.
Chemical thermogenesis – the stimulation of
heat production in the body through
increased cellular metabolsism

4. Epinephrine, norepinephrine, and sympathetic
stimulation stress response - these hormones
immediately increase rate of cellular
metabolism in many body tissue.
5. Fever – increases cellular metabolic rate and

this increasing body temperature further.

How HEAT is lost?
Radiation – is the transfer of heat from the
surface of one object to the surface of
another without a contact between two
objects (infrared rays)
Conduction – is the transfer of heat from one
molecule to a molecule of lower temperature.
(body is immersed in cold water)
Convection – is the dispersion of heat by air
currents.
Vaporization – is continuous evaporation of
moisture from the respiratory tract and from
mucosa of the mouth and from the skin.
Insensible water loss and insensible heat loss
Factors affecting Body
Temperature
Age
Diurnal variations (circadian rhythms)
1600 – 1800 hours – highest body temp.
0400 – 0600 hours – lowest body temp.
Exercise
Hormones
Stress
Environment

Alterations in Body Temp.
Two primary alterations : PYREXIA and
HYPOTHERMIA


PYREXIA – a body temp. that is above normal

 Hyperthermia and fever
 Hyperpyrexia – a very high fever such as 41 C (1o5.8
F)
 Febrile and afebrile
Four common types of fever :
 Intermittent – the body temp. alternates between
periods of fever and periods of normal
 Remittent – a wide range of temperature
fluctuations(more than 2C) occurs over 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
temp.
Hypothermia – is a core body temperature
below the lower limit of normal.
3 physiologic mechanisms of hypothermia
1.Excessive heat loss
2.Inadequate heat production to counteract heat
loss
3.Impaired hypothalamic thermoregulation

Assessing body
temperature
Site Advantages Disadvantages
oral Accessible and Thermometers can break if
convenient bitten
Inaccurate if client ingested hot
or cold food or fluids
Could injure the mouth
following oral surgery
Rectal Reliable measurement Inconvenient and more
unpleasant to client
Presence of stool may interfere
with thermometer placement
Axillary Safe and noninvasive The thermometer must be left in
place for a long time to obtain
accurate measurement
Tympanic Readily accessible, Can be uncomfortable and
membrane
Temporal reflects
Safe andthe core involveselectronic
Require risk if of injuring the
equipment
artery temperature.
noninvasive.
Very fast Very membrane
that may beifexpensive
the probe or
is
fast inserted too far
unavilable
Types of thermometers
Glass thermometers
Electronic thermometers
Chemical disposable thermometers
Temperature – sensitive tape
Infrared thermometers
Temporal artery thermometers

Temperature scales
Fahrenheit – celsius
C = (Fahrenheit temp. – 32 ) X 5/9


Celsius – fahrenheit
F = (Celsius temp. X 9/5) + 32
PULSE
Is a wave of blood created by contraction o the
left ventricle of the heart
Peripheral pulse – is a pulse located away from
the heart
Apical pulse – is a central pulse, that is, it is
located at the apex of the heart. It is also
referred to as the point of maximal impulse
(PMI)
Factors affecting the
Pulse
Age
Gender
Exercise
Fever
Medications
Hypovolemia
Stress
Position changes
Pathology



Pulse sites
Temporal – site is superior(above) and lateral to
(away from the midline of) the eye
Carotid- between trachea and sternocleidomastoid
muscle
Apical – 5th intercostal space(area between the
ribs), left midclavicular area
Brachial- inner aspect of the biceps muscle of the
arm
Radial- on the thumb side of the inner aspect of
the wrist
Femoral- alongside the inguinal ligament
Popliteal- behind the knee
Posterior tibial- medial surface of the ankle
Variations in Pulse by age
Age pulse average
Newborn 130 (80 – 180)
1 year 120 (80 – 140)
5-8 years 100(75 – 120)
10 years 70 (50 – 90)
Teen 75 (50-90)
Adult 80 (60 – 100)
Older adult 70 (60 – 100)


Bradycardia
Tachycardia

RESPIRATIONS
Is an act of breathing
Inhalation or inspiration – refers to the intake
of air in the lungs
Exhalation or expiration – refers to the
breathing out or the movement of gases
from the lungs to the atmosphere.
Ventilation – is also used to refer to the
movement of air in and out of the lungs.
Factors affecting
respirations
Increase the respiratory rate
Exercise
Stress (fight or flight)
Increased environmental temperature
Lowered oxygen concentration
Decrease the respiratory rate
Decreased environmental temperature
Certain medication (narcotics)



Altered breathing
patterns
Rate
Tachypnea – quick shallow breaths
Bradypnea – abnormally slow breathing
Apnea- cessation of breathing
Volume
Hyperventilation – overexpansion of the lungs
characterized by rapid and deep breaths
Hypoventilation – underexpansion of the
lungs; characterized by shallow breaths

Rhythm
Cheyne – stokes breathing – rhythmic waxing
and waning of respirations, from a very deep
to very shallow breathing and temporary
apnea
Ease and effort
Dyspnea – difficult and labored breathing
during which the individual has a persistent
need for air and feels distressed
Orthopnea – ability to breath in upright sitting
or standing position

Audible without Amplification
Stridor – a shrill, harsh sound heard during
inspiration with laryngeal obstruction
Stertor – snoring or sonorous respiration,
usually due to partial obstruction of the
upper airway
Wheeze – continous, high pitched musical
squeak or whistling sound occuring on
expiration and sometimes on inspiration
when air moves through a narrowed or
partially obstructed airway
Bubbling – gurgling sound heard as air passes
through moist secretions in the respiratory
tract



Chest movement
Intercostal retraction – indrawing between the
ribs
Substernal retraction – indrawing beneath the
breatstbone
Suprasternal retraction – indrawing above the
clavicles


Secretions and coughing

Hemoptysis – the presence of blood in the
sputum
Productive cough – a cough accompanied by
expectorated secretions
Non productive cough – a dry, harsh cough
without secretions
BLOOD PRESSURE
ARTERIAL BLOOD PRESSURE – is a measure of the
pressure exerted by the blood as it flows through
the arteries.
 Systolic pressure – is the pressure of the blood as a
result of contraction of the ventricles, that is, the
pressure of the height of the blood wave.
 Diastolic pressure – is the pressure when the
ventricles are at rest. Present at all times within
the arteries. It is the lower pressure
Pulse pressure – the difference between diastolic
and systolic pressures. Normal is about 40mmHg
to 100mmHg.
Determinants of BP
Pumping action of the heart
Peripheral vascular resistance
Blood volume
Blood viscosity
Factors affecting BP
Age
Exercise
Stress
Race
Gender
Medications
Diurnal variations
Disease process
Classification of BP
Category systolicBP diastolicBP
Normal <120 and <80


 Prehypertension 120-139 and 80-89



Hypertension
Stage 1 140-159 or 90-99
Stage 2 >160 or >100