Chapter 8
Vital Signs
1
T--temperature
P--pulse
Vital Signs
R--respiration
Bp--blood pressure
2
vital signs

reflect the body’s physiological status

present condition

provide information to evaluate homeostatic
balance in status

be a quick and efficient way

to monitor a patient’s condition

to identify problems

to evaluate the patient’s response to intervention
3
vital signs


Vital signs and other physiological
measurements are the basis for clinical
problem solving.
An alteration in vital signs may signal the
need for medical or nursing intervention.
--Vital signs should be taken at regular intervals.
--As nurses we should
know the relevant knowledge about vital signs
be able to measure vital signs accurately
interpret their significance
make decisions about interventions
4
SectionⅠ
Guidelines for Taking Vital Signs
1. select equipment :

be functional and appropriate

based on the patient’s condition and characteristics
2. know the patient’s normal range of vital signs
---serve as a baseline for comparison with findings
taken later
3. know the patient’s medical history, therapies,
and prescribed medications


Some illnesses or treatments cause predictable vital
sign changes.
Most medications affect at least one of the vital signs.
5
SectionⅠ
Guidelines for Taking Vital Signs
4. control or minimize environmental factors
may affect vital signs
5. use an organized, systematic approach
when taking vital signs
---each procedure requires following a step-by-step
approach to ensure accuracy
6. the frequency of vital signs assessment
--based on the physician and the patient’s condition
6
SectionⅠ
Guidelines for Taking Vital Signs
7. use vital sign assessment to determine
indications for medication administration
----cardiac drugs
8. analyze the results of vital sign
measurement--not interpret them in isolation
9. verify and communicate significant changes
in vital signs
7
SectionⅡ Body Temperature

Physiology of Body Temperature

Factors Affecting Body Temperature

Alterations in Body Temperature

Nursing Process and
Thermoregulation
8
Physiology of Body Temperature

Definition of body temperature

Heat production and heat loss

Regulation of body temperature

Average temperature and normal
range of adult
9
Definition of body temperature
Body temperature is the heat of the
body.-- reflects the balance between
the amount of heat produced by body processes
the amount of heat lost to the external
environment
10
Definition of body temperature

core temperature : temperature of deep
tissues (cranium, thorax, abdominal and
pelvic cavity ), relatively constant

Surface temperature :the temperature of the
skin, the subcutaneous and the fat tissue ,
fluctuates from 36℃ to 38℃
11
Heat Production

Heat is produced in the body through
metabolism.

The main heat production organs of the
body are liver and skeletal muscles.

Heat production occurs during rest, voluntary
movements, involuntary shivering, and nonshivering
thermogenesis(brown adipose).
12
Heat Loss
Heat is lost through physical mode. The main
heat loss part of the body is skin. (70%)
(R29%,elimination1%)

Radiation

Conduction

Convection

Evaporation
13
Radiation


Radiation is the transfer of heat between
two objects without direct contact by
electromagnetic waves.
Heat radiates from the skin to any
surrounding cooler object.

increase T difference between two objects

Increase radiating surface area

Increase the extent of vasodilation
heat loss
14
Conduction


Conduction is the transfer of heat from one
object to another with direct contact.
When the warm skin touches a cooler
object(solid; gas; liquid), heat is lost.

Heat loss velocity depends on

Heat conducting capability

T difference between the two objects

Contacting area
15
Convection

Convection is the transfer of heat away by
air or liquid movement.

Heat is first transferred to air or liquid
molecules directly in contact with the skin.
Air or liquid currents carry away the
warmed air or liquid.

Heat loss velocity depends on

current velocity

T difference between the object and air or liquid
16
Evaporation

Evaporation is the transfer of heat energy
when a liquid is changed to a gas.

The body continuously loses heat by
evaporation. --R;skin 300-400ml/d

By regulating sweating, the body promotes
additional evaporative heat loss. --febricide

Evaporation is the main heat loss mode when
environment temperature is higher than
body temperature.
17
Regulation of Body Temperature

Neural and Vascular Control

Behavioral Control
18
Neural and Vascular Control

T regulation center :the hypothalamus ,
controls body temperature the same way a
thermostat works in the home (reflex arc)

the anterior hypothalamus controls heat
loss Via sweating, vasodilation, inhibition of heat
production

the posterior hypothalamus controls heat
production via muscle shivering , heat
conservation by vasoconstriction of surface blood
vessels
19
Normal Blood Temperature
(37℃ )
(to or toward)
Factors which
increase metabolic rate or
Environmental temperature
Increased blood temperature
above level at which “thermostat”
in hypothalamus is set (37℃ )
Decreased blood
temperature
Stimulated thermal receptors
Of heat-dissipating center
in hypothalamus, initiating
impulses that lead to
Increased heat
Loss by evaporation
Increased sweat
secretion
Increased heat
Loss by radiation
Dilation of skin
blood vessels
Heat loss mechanisms to maintain normal body temperature
20
Behavioral Control

environmental temperature fall:
add clothing
move to a warmer place
raise the thermostat setting
increase muscular activity by running
sit with arms and legs tightly wrapped together
21
Behavioral Control

The ability of a person to control body
temperature depends on


the degree of temperature extreme
the person’s ability to sense feeling
comfortable or uncomfortable--infants, older
adults

thought processes or emotions--depression

the person’s ability to remove or add clothes
—infants, children
22
Average Temperature
and Normal Range of Adult
site
average temperature
normal range
oral
37℃
36.3-37.2℃
rectal
37.5℃
36.5-37.7℃
axillary
36.5℃
36.0-37.0℃
23
Factors Affecting Body Temperature

Measurement site

Circadian rhythms :
drops between 2 and 6 AM
peaks between 1 and 6PM

Age: With age,T tends to fall .
infancy: temperature regulation is labile
aging: control mechanisms deteriorate
24
Factors Affecting Body Temperature

Hormonal influences :
progesterone: raise the body temperature

Exercise :increase body temperature

Medications:
anaesthetic: depress T regulation center
promote vasodilation
T
febrifuge: T
25
Factors Affecting Body Temperature

Stress: Stimulate sympathetic nervous system
-- epinephrine and norepinephrine production ,
-- metabolic activity

heat production --T
Environment: the extent of exposure,
air temperature and humidity
the presence of convection currents

Ingestion of hot/cold liquids

Smoking: increase body temperature
26
Alterations in Body Temperature

Fever or Hyperthermia

Hypothermia
27
Fever or Hyperthermia

A body temperature above the usual range
is called fever.

A true fever results from an alteration in
the hypothalamic set point.

Pyrogens such as bacteria and virus cause
a rise in body temperature.

Fever is an important defense mechanism.
28
Fever process and manifestation

Fever-chill phase: heat production>heat loss;
experience tiredness, paleness, dryness, chills,
shivers, and feels cold (2 patterns)

plateau phase : heat production=heat loss;
warm , dry, R , P , headache, faint, inappetence

fever break phase: heat production<heat loss;
skin -- warm, flushed, diaphoresis (2 patterns)
29
Hyperthermia (clinical)

An elevated body temperature related to the
body’s inability to promote heat loss or
reduce heat production is hyperthermia.

Any disease or trauma to the hypothalamus
can impair heat loss mechanisms.
30
Classification of Fever (Oral)
℃
℉
Mild
37.5℃-37.9℃
99.5℉-100.2℉
Moderate
38.0℃-38.9℃
100.4℉-102.0℉
Severe
39.0℃-39.9℃
102.2℉-105.6℉
Profound
>41℃
>105.8℉
31
Patterns of Fever

is the modality of a temperature curve.

differ depending on the causative pyrogen.

The increase or decrease in the amount of
pyrogens results in fever spikes and declines
at different times of the day.

The duration and degree of fever depends on
the pyrogen’s strength and the ability of the
individual to responds.
----serve a diagnostic purpose.
32
Patterns of Fever

Constant Fever

Remittent Fever

Intermittent fever

Irregular Fever
33
Constant Fever

sustains between 39~40℃

demonstrates little
fluctuation of less than 1℃
within 24 hours.
( pneumonia , typhoid)
34
Remittent Fever

has great fluctuation
above the normal with
more than 1℃ in 24 hours
and cannot return to
normal temperature level.
(septicemia , rheumatic
fever)
35
Intermittent fever

fluctuates greatly in 24 hours,
may suddenly rise above the
normal then suddenly fall to or
below the normal

alternates regularly between a
period of fever and a period of
normal temperature levels
(malaria, tuberculosis)
36
Irregular Fever

irregularity alternates
between a period of fever
and a period of normal
temperature values.
( influenza , cancer)
37
Hypothermia



A body temperature below the lower limit
of normal 35℃ is called hypothermia．
Heat loss during prolonged exposure to cold
overwhelms the body’s ability to produce
heat，causing hypothermia．
Hypothermia may be intentionally induced
during surgical procedures to reduce
metabolic demand and the body’s need for
oxygen．
38
Classification of Hypothermia
℃
℉
Mild
33.1℃-36℃
91.5℉-96.8℉
Moderate
30.0℃-33℃
86.1℉-91.4℉
Severe
27℃-30℃
80.6℉-86.0℉
Profound
<27℃
<80.6℉
39
Manifestation of Hypothermia

34.4-35℃: uncontrolled shivering，loss of
memory，depression, poor judgment

falls below 34.4℃
heart and respiratory rates
blood pressure fall

skin ---- cyanotic
progress--- cardiac dysrhythmias，
loss of consciousness，
unresponsive to painful stimuli
40
Nursing Process
and Thermoregulation

Assessment

Nursing Diagnosis

Planning

Implementation

Intervention
41
Assessment

Sites: mouth，rectum, axillary
tympanic membrane

Thermometers
Glass Thermometer
Electronic Thermometer
Disposable Thermometer
42
Glass Thermometer
VCD
43
Electronic Thermometer
44
Disposable Thermometer
45
Nursing Diagnosis
Nursing diagnosis
Hyperthermia
Diagnostic foundation
Increase body temperature above usual range
Flushed skin, skin warm to touch
Increased pulse and respiratory rate
Herpetic lesions of the mouth
Hypothermia
Decreased body temperature
Pale, cool skin
Decreased pulse and respiratory rate
Feelings of cold and chill
Ineffective
Older adults or infants, weak inability to adapt
thermoregulation
to environmental temperature
46
Planning

require an individualized care plan -maintaining normothermia and reducing risk
factors．

education is important

Objects:
restoring normothermia
minimizing complications
promoting comfort

care plan should support goals
47
Examples for goals and outcomes

Goal
Restore and maintain normothermia.

Outcome
Temperature
maintained
within
normal
range during environment changes.
48
Examples for goals and outcomes

Goal

Outcomes
Minimize complications of altered body
temperature.
patient’s blood pressure, pulse, and respirations
are within normal limits
patient’s skin integrity maintained
patient’s nutritional intake meets body needs
patient’s mucous membranes are moist
patient is able to participate in ADL activities
patient’s skin is warm and pink
patient reports sense of rest and comfort
49
Examples for goals and outcomes

Goal
Reduce risk of altered body temperature.

Outcomes
patient identifies risk factors for altered
body temperature
patient practices measures to prevent
body
temperature alteration
50
Implementation

Nursing measures for patient with
a fever

Nursing Interventions for patient
With Hypothermia
51
Nursing measures
for patient with a fever

Assessment
• Obtain body temperature during each phase of febrile
episode．
•Assess for contributing factors such as dehydration，
infection，or environmental temperature．
•Identify physiological response to temperature.
Obtain a11 vital signs．
Observe skin color．
Assess skin temperature．
Observe for shivering and diaphoresis．
Assess patient comfort and well-being．
•Determine phase of fever--chill，plateau，fever break．
52
Nursing measures
for patient with a fever
Intervention

1.Promote heat loss and lower the
temperature.
Limit physical activity--heat production
reduce external covering--heat loss
physical therapies:ice packs ; bathing with alcoholwater solutions
medication
Take temperature after lowering the temperature
physically for 30 minutes, record the readings.
53

2.Intensify observation of the patient’s
conditions.
•take temperature
1 time/4h--severe fever,
4 time/day T<38.5℃
1-2 times/day for three days after body temperature
returns normal.
• Observe patient’s face color, pulse, respiration,
diaphoresis and other signs when taking patient’s
temperature.
• Assess for contributing factors such as dehydration，
infection，or environmental temperature．
• Observe therapeutic effect.
• Observe the intake of liquids and the output of urine.
• Contact physicians
conditions.
promptly
when
find
abnormal
54

3. Provide nutrients to meet increased
energy needs
• Provide measures to stimulate appetite，and offer wellbalanced meals．
• Provide fluids at least 3000ml per day for patient with
normal cardiac and renal functional to compensate
fluids lost through insensible water loss and sweating．
55

4.Promote comfort and prevent
complications.
• Allow rest periods.
• Control temperature of the environment without
inducing shivering．
• Provide oral hygiene and keep oral moist to prevent
oral infection.
• Keep clothing and bed sheet dry to increase comfort
and heat loss through conduction and convection．
56

5.Provide psychological care.
• Meet patient’s reasonable requirements.
• Provide health education about fever.

6.Obtain blood cultures when ordered.

7.Provide supplemental oxygen therapy as
ordered to improve oxygen delivery to body
cells when ordered ．
57
Nursing Interventions
for patient With Hypothermia
• Control environment temperature at 22~24℃.
•Elevate body temperature.
• patients are monitored closely for cardiac
irregularities and electrolyte imbalances.
Observe the vital signs, take temperature
once at least per hour until the temperature
returned normal and stability.
• Eliminate pathogeny.
• Health education.
58
Evaluation

all nursing goals have been met

use other evaluative measures such as
palpation of the skin and assessment of
pulse and respirations

If therapies are effective，body
temperature will return to a normal range，
other vital signs will stabilize and the
patient will report a sense of comfort．
59
Section Ⅲ
Pulse

Physiology and Regulation

Character of The Pulse and
Observation of Abnormal Pulse

Nursing process and Pulse
Determination
60
Physiology and Regulation

The pulse is the rhythmical throbbing of
arteries produced by the regular
contraction of the heart.

The number of pulsing sensations
occurring in 1 minute is the pulse rate．

Healthy adult pulse rate can range
between 60-100 beats per minute in
quiet state.
61
Forming of Pulse

Electrical impulses from the sinoatrial node travel
through heart muscle to stimulate cardiac
contraction．

Approximately 60 to 70 ml (stroke volume) of blood
enters the aorta with each ventricular contraction．

The arterial walls expand to compensate for the
increase in pressure. As the ventricle of the heart is
in diastole, arterial walls return to original status by
its own elasticity and peripheral resistance.
62
Forming of Pulse

The expansion and retraction of the aorta
sends a wave through the walls of the
arterial system that can be felt as a light tap
on palpation. The pulse is the palpable
bounding of the blood flow．
63
Factors Influencing Pulse Rate

Age Normally Pulse Rates at Varies Ages
Age
normal range of pulse rate (beats/min)
Infants
120-160
Toddlers
90-140
Preschoolers
80-110
School ages
75-100
Adolescent
60-90
Adult
60-100
64

Sex : After puberty, the average male pulse rate is
slightly lower than the female. 5 times/min

Exercise

Temperature: Fever ;

Emotions: Acute pain ,anxiety -- pulse rate
Hypothermia
Unrelieved severe pain-- pulse rate


Drugs : atropine
digitalis
Postural changes: Standing or sitting , Lying
down

Hemorrhage:

Pulmonary conditions: poor oxygenation
65
Character of The Pulse and
Observation of Abnormal Pulse

Pulse Rate

Pulse Rhythm

Strength

Equality
66
Abnormal Pulse Rate

Tachycardia
is an abnormally elevated heart
rate，above 100 beats per minute in adults． (fever,
anemia, hemorrhage, hyperthyroidism)

Bradycardia
is a slow rate, below 60 beats per
minute in adults．(atrioventricular block, increased
intracranial pressure, hypothyroidism )
67
Pulse Rhythm

Normally a regular interval of time occurs
between each pulse or heart beat．An
interval interrupted by an early or late beat
or a missed beat indicates an abnormal
rhythm or dysrhythmia．
68
Abnormal Pulse Rhythm

Intermittent Pulse

Pulse Deficit
69
Intermittent Pulse

one pulse missing during regular or
irregular pulse patterns

one pulse absents every one pulse-bigeminy

one pulse absents two normal pulses be
called -- trigeminy

occur in cardiomyopathy, myocardial
infarction, digitalis intoxication, and
transient symptoms caused by excited
emotion or fear
70
Intermittent Pulse

threatens the heart ability to provide
adequate cardiac output

An electrocardiogram (ECG) is necessary to
define the pulse dysrhythmia.

Children often have a sinus dysrhythmia,
which is an irregular heartbeat that speeds
up with inspiration and slows down with
expiration.
71
Pulse Deficit

Refers to pulse rate is less than heart rate

An inefficient contraction of the heart
--fails to transmit a pulse wave to the
peripheral pulse site --creates a pulse
deficit．

To assess a pulse deficit
simultaneously
--one nurse assess radial rates
--a colleague assess apical rates

It can be seen in patients with atria
fibrillation.
72
Strength

reflects the volume of blood ejected against
the arterial wall with each heart contraction
and the condition of the arterial vascular
system leading to the pulse site

normally remains the same with each
heartbeat

may be graded or described as strong，
weak，thready，or bounding
73
Abnormal Strength

Bounding Pulse

Thready Pulse

Alternating pulse

Water Hammer Pulse

Paradoxical Pulse
74
Bounding Pulse

an increased stroke volume, which can be
palpated by fingertips slightly

often be seen with fever, hyperthyroidism,
and aortic valve incompetence.
75
Thready Pulse

weak and diminished, which is barely by
fingertips

often occurs with massive hemorrhage,
shock, and aortic stenosis
76
Alternating pulse

alternates between increased and
diminished patterns along with strong and
weak contraction of the ventricles

common causes are hypertensive heart
disease, myocardial infarction
77
Water Hammer Pulse

The abrupt distension and quick collapse of
the pulse is palpated following the
increased cardiac output with resultant
pulse pressure surges.

It often occurs with hyperthyroidism,
aortic valve incompetence.
78
Paradoxical Pulse

The pulse is obviously weak or not
palpable on inspiration. It results from
the declined strokes by the left ventricle
on inspiration.

Common causes are pericardial effusion
and constrictive pericarditis.
79
Equality

The nurse should assess both radial pulses
to compare the characteristics of each. A
pulse in one extremity may be unequal in
strength or absent in many diseases, such
as thrombosis, aberrant blood vessels, or
aortic dissection.

The carotid pulse should not be measured
simultaneously because excessive pressure
may stop blood supply to the brain.
80
Nursing process and
Pulse Determination

Assessment

Nursing Diagnosis

Nursing Plan

Implementation

Evaluation
81
Assessment
the nurse should collect the following data:

the patient’s general condition, such as
age , sex, status of an illness and treatment;

the pulse rate, rhythm, strength, equality
and factors influencing pulse

arterial wall elasticity
82
Nursing Diagnosis

Tachycardia; bradycardia;
dysrhythmias ; activity intolerance;
anxiety; fear; fluid volume deficit;
gas exchange impaired;
Hyperthermia; and hypothermia
83
Nursing Plan

interventions based on the nursing diagnosis
identified and the related factors;

the expected outcomes generally:

patients can tell the normal range and physiological
changes of the pulse;

patients can cooperate with the treatment and care.
84
Implementation

Instruct the patients to rest to decrease
heart energy consuming.

Oxygen
administration
is
provided,
according to the patient’s condition.

Observe the patients’ condition closely.
85
Implementation

Instruct the patients to take medicine on
time and observe the effect and side effect
of the medicine.

Tell the patients to keep first-aid medicine
along with them.

Provide mental support, let the patients to
keep steady mood.
86
Implementation

Health education:

stop smoking and drinking




take light and digestible diet, keep bowels
smooth;
teach the patients to monitor the pulse prior
to taking medicines that affect the heart rate.
Tell the patients to report any notable
changes of heart rate or rhythm to health
care provider.
Teach the patients and family members the
basic first-aid skills.
87
Evaluation

evaluate the therapeutic effect by assessing
the pulse rate, rhythm, strength, and
equality;

evaluate the patients’ mental status,
cooperation with treatment and nursing;

evaluate the patients’ knowledge about
health．
88