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Assessing Vital Signs
Introduction

Assessing vital signs or cardinal sign is a routine
medical procedure. And somehow determines
the internal functions of the body

Vital signs composes of the following:
◦ Body temperature
◦ Pulse
◦ Respiration and
◦ Blood pressure
◦ Pain
What is Body
Temperature?
 Body temperature
◦ It is the balance between the heat
produced by the body and the heat
lost from the body.
◦ It is measured in heat units, called
degrees
Types of Body temperature
CORE Temperature- (temperature of the deep
tissues of the body)
 It remains relatively constant (37 °C/ 98 °F)

SURFACE temperature- (temperature of the
skin, the subcutaneous tissues and fat)
 It varies from 20 °C (68 °F) to 40 °C (104 °F)

Sites commonly used in taking BT
Oral- most common
 Axilla –mostly used in infants and children
 Rectal- second choice
 Tympanic membrane- most favorable site

Factors that affect heat production





BMR- (Basal Metabolic Rate)
Muscle ActivityThyroxine outputSympathetic stimulationFever-
Processes of Heat loss
1. Radiation (without contact between
the two objects)
 2. Conduction (transfer of heat from
one molecule to another)
 3. Convection (dispersion of heat by air
currents)
 4. Evaporation (continuous evaporation
of moisture).

Factors affecting Body temperature





1. Age
2. Diurnal variations (circadian rhythms)
3. Exercise
4. Hormones
5. Stress-
Alteration in Body temperature

Pyrexia, hyperpyrexia or feverincrease body temperature
 Types of fever
 Intermittent-alternate body temperature
(time)
 Remittent- wide range of temperature
fluctuation
 Relapsing- short febrile periods few days
then normal
 Constant- continuous

Hypothermia- decrease in core
temperature below the low limit of
normal
Types of Thermometer





1. Mercury in glass
2. Electronic thermometer
3. Chemical thermometer
4. Temperature sensitive strip
5. Infrared thermometer
Chemical thermometer
Oral thermometer (Glass)
Digital Thermometer
Infrared thermometer
o LUBRICATE THE THERMOMETER BEFORE INSERTING INTO THE RECTUM
o PLACE THE PERSON IN A SIDE-LYING POSITION
o INSERT THE THERMOMETER 1 INCH INTO THE RECTUM
o HOLD THE THERMOMETER IN PLACE FOR 2 MINUTES
o REMOVE THE DISPOSABLE COVER AND READ THE THERMOMETER
METHODS of Temperature Taking:
Tympanic: readily accessible, reflects the core
temperature, very fast
Nursing Considerations:
 Can be very uncomfortable and involve risks of injuring
the membrane if the probe is inserted too far
 Repeated measurements may vary (right and left ears may
differ)
 Presence of cerumen can affect the reading
 Normal value:
98.2 o – 100.2 oF (36.8 o – 37.9 oC)
Temperature conversion

°C = (Fahrenheit – 32 ) x 5/9
◦ Convert 100 °F

°F = (Celsius x 9/5) + 32
◦ Convert 40 °C
◦ Normal/ Average temperature is between 36-37.9 °C
or 96.8 – 100.3 °F
Pulse Rate
Pulse

Is a wave of blood created by contraction of left
ventricle of the heart

Stroke volume output ( amount of blood
that enters the arteries with each ventricular
contraction)

Compliance (ability of the arteries to
contract and expand)

Peripheral pulse- is a pulse located in the
periphery of the body.

Apical pulse- is a central pulse located at the
apex of the heart.
Sites of Pulse





Temporal
Carotid
Apical
Brachial
Radial
• ulnar
 Femoral
 Popliteal
 Dorsalis Pedis
1. Temporal
Slightly anterior to the external auditory meatus
2. carotid
Lateral to the thyroid cartilage
3 brachial
Medial o the bicepd tendon
4. radial
Just lateral to the flexor carpi radialis tendon
5. ulnar
Just lateral to the flexor carpi ulnaris tendon
6. femoral
Just inferior to the midway point on the inguinal
ligament
Inferior portion of the popliteal fossa
7. Popliteal
8. Posterior
tibial
Between medial maleous and the achillis tendon
9. Dorsalis
pedis
Just lateral to extensor hallicus longus tendon
PULSE site: TEMPORAL
Carotid pulse
Radial and Brachial pulse
PULSE site: APICAL
PULSE site: FEMORAL
Posterior tibial & Dorsalis pedis Pulse
Pulse site
Reasons for Use
Radial
Readily accessible & routinely used
Temporal
Used when radial pulse is not accessible
Carotid
Used for infants, in cases of cardiac arrest and to determine the
circulation to the brain
Apical
Routinely used in infants and children up to 3 years of age, Used to
determine the discrepancies with radial pulse, and Used in
conjunction with some medication
Brachial
Used to measure blood pressure, used for cardiac arrest for infants
Femoral
Used in cases of cardiac arrest, for infants and children, determine
circulation in the leg
Popliteal
Used to determine the circulation in the lower leg and leg blood
pressure
Posterior tibial
Used to determine the circulation in the foot
Pedal
Used to determine circulation in the foot
Assessing the Pulse
1. A pulse is commonly assessed by palpation or
auscultation.
 2. 3 middle fingers are used for palpating all
pulse site, except for apical pulse.
 3. Stethoscope is used in assessing apical pulse
and fetal heart tones.
 4. Doppler ultrasound is used for pulses that is
to difficult to assess.







7. When assessing the pulse, there is a need to
take note of the following
1. rate
2. rhythm
3. volume
4. arterial wall elasticity
5. presence or absence of bilateral equality.
Variations in Pulse Rate
Age
Average
Range
130
80-180
1 year
120
80-140
2 years
110
80- 130
6 years
100
75- 120
10 years
70
50-90
Adult
80
60- 100
Newborn to 1
month
Pulse rate/
Minute
Rate- referred to tachycardia- (over 100
beats/ minute) bradycardia –(60
beats/minute or less)
 Rhythm- is the patterns of beat and the interval
between the beats.
 Dysrhythmia or arrhythmia is an example of
irregular rhythm.


Volume- is the pulse strength or the amplitude,
refers to the force of blood with each beat. E.g.
bounding/full; weak/feeble/thready pulse
Scale
Description of pulse
0
Absent
1
Thready or weak; difficult to feel
2
Normal, detected readily, obliterated
by strong pressure
3
Bounding; difficult to obliterate
Kozier Barbara, et.al. Fundamentals of Nursing , 5th ed. (US Addison-Wesley Publishing
Company, Inc. 1995) p. 440
Factors affecting pulse rate







1. Age
2. Sex- after puberty the man’s pulse rate is
slightly lower than the female
3. Exercise
4. Fever- pulse rate increases when metabolic
rate increases
5. Medications
6. Hemorrhage- loss of blood increase pulse rate
7. Stress
Respiration

Is the act of breathing; it includes the intake of
oxygen and the output of carbon dioxide
Types
1. External respiration- the interchange
of O2 and CO2 between the alveoli and the
pulmonary blood
 2. Internal respiration- takes place
throughout the body; it is the interchange of
gases between the circulating blood and the
cells of the body tissues


Terminologies





Inhalation or inspiration- the act of intake
of air into the lungs
Exhalation or expiration- the act of
breathing out of gases from the lungs to the
environment
Ventilation- movement of air in and out
the lungs
Hyperventilation- refers to very deep and
rapid ventilation
Hypoventilation- refers to very
shallow respiration
Types of breathing
1. Costal or thoracic breathing
 2. Diaphragmatic or abdominal breathing

Costal breathing

It involves the external intercostal muscle and
other intercostal muscle. It can be observed by
the movement of the chest upward and outward
or downward
Diaphragmatic breathing

It involves the contraction and relaxation of the
diaphragm, it is observed by the movement of
the abdomen
Assessing Respiration
1. The client normal breathing pattern is
assessed therefore the client should be at
resting mode.
 2. Identify behavior/ activities of the patient as
well as medication or therapies because these
will affect the respiration taking.
 3. Identify if there are any health problems such
as heart problems and others

Variations in Respiratory
rate
Age
Newborn
1 year
Average
35
30
Range
30-80
20-40
2 years
25
20-30
8 years
16 years
Adult
20
18
16
15-25
15-20
12-20
Respiratory rate/
Minute
Kozier Barbara, et.al. Fundamentals of Nursing , 5th ed. (US Addison-Wesley Publishing Company,
Inc. 1995) p. 448
Respiratory rate






is normally described in breaths per minute
Types:
Eupnea- Normal Breathing
Bradypnea- Abnormally slow
Tachypnea or polypnea- Abnormally fast
Apnea- cessation of breathing
Respiratory rhythm/ pattern
It refers to regularity of expiration and
inspiration
 Types
 Regular
 Irregular

◦ Dsypnea- difficulty in breathing
◦ Orthopnea- ability to breath in an upright position
BLOOD PRESSURE
Arterial blood Pressure
is a measure of the pressure exerted by the blood
as it flows through the arteries.
Two blood pressure measurements
1.Systolic pressure- is the maximum pressure
developed on the ejection of blood from the left
ventricle into the arteries
2.Diastolic Pressure-is the lowest pressure
and is a measure of the peripheral resistance.
Factors Affecting Blood Pressure:
 Age, gender, race
 Circadian rhythm
 Food intake
 Exercise
 Weight
 Emotional state
 Body position
 Drugs/medications
 Disease process
Aneroid manometer with stethoscope
Part of the sphygmomanometer
In measuring the BP
By means of auscultation- the systolic pressure
is taken at the point when beats becomes
audible. As the mercury continues to fall, the
sound of the beats becomes louder, then
gradually diminishes until a point is reached at
which there is a sudden, marked diminution in
intensity.
 The average BP is about 120/80 at 20 yrs old
and at the age of 60 is 160/90

Taking BP
It is measured with a blood pressure cuff, a
sphygmomanometer and a stethoscope
 The BP cuff has a bladder than can be inflated
with air, it is covered with cloth and has two
tubes attached to it (sometimes it’s three), one
tube is connected to the rubber bulb.
 To introduce air turn the valve clockwise and to
release air turn it counterclockwise, the second
tube to the sphygmomanometer and the third to
stethoscope

Auscultatory method of obtaining BP
Korotkoff’s sound- this is a series of sounds
heard during BP assessment.
 Phases of Korotkoff’s sound
 Phase 1- The first faint clear tapping sound is
heard. This sound gradually becomes strong and
deep
 Phase 2- This is the period during
deflation when the sounds have a swishing
quality.

 Phase
3- The period during which the
sounds are forceful and powerful
 Phase 4- The time when the sounds begins
to decrease in intensity, and has a less
bounding force
 Phase 5- The pressure level wherein the
sound disappear.
Reading Blood Pressure

The first sound heard is the systolic pressure
and the last sound heard is the diastolic pressure
Mercury manometer and cuff
Aneroid manometer and cuff
2 types of sphygmomanometer
Aneroid and mercury manometer
 Aneroid is a calibrated dial with a needle that
points to the calibrations while the other is a
calibrated cylinder filled with mercury.

Other types
Electric sphygmomanometer
 Doppler stethoscope

Variations in BP cuff

If the bladder is too narrow, the obtained BP
reading is erroneously elevated; if it is too wide
the reading will be erroneously low

The width should be 40% of the circumference
or 20% wider than the diameter of the midpoint
of the limb on which it is used

The length of the bladder should be sufficiently
long almost to encircle the limb and to cover at
least 2/3 of its circumference
Variations in BP by Age
Age
Newborn
1 year
6 years
Mean BP (mm Hg)
73/55
90/55
95/57
10 years
102/62
14 years
Adult
Elderly (over 70 years)
120/80
120/80
Diastolic pressure may increase
Kozier Barbara, et.al. Fundamentals of Nursing , 5th ed. (US Addison-Wesley Publishing
Company, Inc. 1995) p. 452
The End
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