VITAL SIGNS
Learning objectives
After completing this chapter, you will be able to:
 Explain the physiologic processes responsible for homeostatic
regulation for temp, RR, BP and HR
 Compare factors that increase or decrease the vital signs
 Identify sites for assessing BP, Temp and HR
 Accurately assess vital signs
 Know the normal ranges for vital signs
 Provide information to patients about taking their vital signs at
home
 Assess the heart sounds
 Assess the peripheral pulses
Vital signs
Vital signs are a person’s temperature, pulse, respiration, and blood
pressure (abbreviated as T, P, R, BP). Pain is often included as the fifth
vital sign.
Temperature
Pulse
Respiration
Blood pressure
PAIN : 5th vital sign
When to assess Vital Signs
• Upon admission to any healthcare agency
• Based on agency institutional policy and procedures
• Any time there is a change in the patient’s condition
• Before and after surgical or invasive diagnostic procedures
• Before and after activity that may increase risk
• Before administering medications that affect cardiovascular or
respiratory functioning
Maintenance of Body Temperature
• Thermoregulatory center in the hypothalamus regulates temperature
• Center receives messages from cold and warm thermal receptors on
the body surface
• Center initiates responses to produce or conserve body heat or
increase heat loss
Range of Human Body Temperature
Measured Orally
HIGH GRADE FEVER>>>
(fever of unknown origin,
neurogenic)
FEVER >>>
(infection or tissue injury)
AFEBRILE>>>
(person drowning
>>>
in cold water, buried in snow)
Heat Production





Primary source is metabolism
Hormones, muscle movements, and exercise increase metabolism
Epinephrine and norepinephrine are released and alter metabolism
Thyroid hormones produced by thyroid gland
Shivering controlled by the hypothalamus
Sources of Heat Loss
• Skin (primary source)
• Evaporation of sweat
• Warming and humidifying inspired air
• Eliminating urine and feces
Transfer of Body Heat to
External Environment
• Radiation
• Convection
• Evaporation
• Conduction
Factors affecting body temperature
• Circadian rhythms (variations during the 24hrs)
• Age and gender
• Environmental temperatures (hypothermia, hyperthermia)
Physical Effect of Fever





Loss of appetite
Headaches
Hot, dry flushed face
Thirst
General malaise
 In children: high grade fevers: SEIZURES, dehydration, decreased
urine output and increased HR
Nursing interventions (fever treatment)
• Monitor temp
• Monitor skin status
• Monitor BP, HR, and RR
• Monitor for decreasing level of consciousness
• Monitor for seizures
• Monitor lab tests (WBC)
• Monitor intake-output, electrolyte imbalance, acid-base status
• Administer antipyretics as prescribed
• Encourage bathing and increased fluid intake
Equipment assessing body temperature
• Electronic and digital thermometer
• Tympanic membrane thermometer
• Glass thermometer
• Disposable single-use thermometer
• Temporal artery thermometer
• Automated monitoring devices
Sites & Normal temp for healthy Adults
• Oral – 37.0ºC
• Rectal – 37.5ºC
• Axillary – 36.5ºC
• Tympanic – 37.5ºC
• Forehead – 34.4ºC
Question
What is the term for the heat that is lost when a person goes out in the
cold without a hat?
A. Convection
B. Radiation
C. Evaporation
D. Conduction
Respirations
• Pulmonary ventilation—movement of air in and out of lungs
• Inhalation: breathing in
• Exhalation: breathing out
• Normal respiration is called eupnea
• Under normal conditions, healthy adults breathe about 12 to20 times
each minute
Factors Affecting Respirations
• Exercise
• Age & gender
• Respiratory and cardiovascular disease
• Alterations in fluid, electrolyte, and acid balances
• Medications
• Trauma
• Infection
• Pain
• Anxiety
Assessing respirations
• Inspection
• Listening with stethoscope
• Monitoring arterial blood gas results
• Using a pulse oximeter
• Pattern: tachypnea, bradypnea, apnea, dyspnea, orthopnea
Pulse physiology
• Regulated by the autonomic nervous system through cardiac
sinoatrial node (SA node)
• Parasympathetic stimulation—decreases heart rate
• Sympathetic stimulation—increases heart rate
• Pulse rate = number of contractions felt over a peripheral artery or
heard over the apex of the heart in 1 minute
Pulse physiology (cont’d)
• stroke volume (SV): quantity of blood forced out of the left ventricle with each
contraction
• cardiac output(CO): the amount of blood pumped/minute (av: 3.5 L/min to 8.0
L/min
•
•
•
•
This volume is determined by using the following formula: CO= SV X HR
CO (adult) with SV of 70 mL & HR of 70 beats/min= 4.9 L/min.
↑during physical activity &↓ sleep;
varies with body size and metabolic needs
Question
Tell whether the following statement is true or false.
The normal pulse rate for adolescents and adults ranges from 60 to
100 beats per minute.
A. True
B. False
Characteristics of the Pulse
Increased or decreased pulse rate
• Tachy/brady
Pulse amplitude and quality
• Left ventricular contraction
• (0- 4)
Regular or irregular pulse rhythm
• Arrhythmias/dysrhythmias
Assessing Heart Sounds
(Refer to your physical assessment book: Weber ch. 11)
• Auscultation: determine the heart sounds caused by closure of the heart
valves
• Focus on the overall rate and rhythm of the heart and the normal heart
sounds “lub-dubb”
• Systematic auscultation:
1.
2.
3.
4.
5.
Aortic area, S2: R 2nd intercostal space (ICS)
Pulmonic area, S2: L 2nd ICS
Erb’s point: L 3rd ICS
Tricuspid area, S1: L 5th (or 4th) ICS
Mitral area, S1: 5th L ICS (PMI)
• How is 2nd intercostal located ? Locate it by finding the sternal angle
(which is felt as a ridge in the sternum approximately 5 cms below the
sternal notch).
• How is 5th intercostal located ?= is at the junction of the sternum and
the xyphoid process
Base
Precordium
Apex
S2
S2
L 3rd ICS
Erb’s point
S1
S1
Sites for Assessing Pulse
• Palpating peripheral arteries
• Auscultating apical pulse with stethoscope
• Assessing apical-radial pulse
Sites for Assessing Pulse by Palpation
Physiology of Blood Pressure
Force of the blood against arterial walls
Controlled by a variety of mechanisms to maintain adequate tissue
perfusion
Pressure rises as ventricle contracts (systole) and falls as heart
relaxes (diastole)
• Highest pressure is systolic
• Lowest pressure is diastolic
• Pulse pressure: difference
Factors affecting Blood Pressure
See box 24-6 page 532
• Age, gender, race
• Circadian rhythm
• Food intake
• Exercise
• Weight
• Emotional state
• Body position
• Drugs/medications
Equipment assessing Blood Pressure
• Stethoscope and sphygmomanometer
• Cuff size (wide vs. narrow)
• Arm position
• Doppler ultrasound
• Electronic or automated devices
Question
Which one of the following pulse sites is located on the inside of the
elbow?
A. Temporal
B. Radial
C. Femoral
D. Brachial
Sites for blood Pressure
• Brachial
• C/I: an arm with IV line, mastectomy
• Popliteal
• Expected readings: When the patient’s brachial artery is inaccessible, the
nurse can assess the blood pressure using the popliteal artery in the leg. The
systolic pressure is normally 10 to 40 mm Hg higher at this site, although the
diastolic pressure is the same.
• Teaching tips: T 24-2 page 539
• Guidelines for Nursing care 24-7 (assessing BP in leg) page 538
Assessing Blood Pressure
Listening for Korotkoff sounds with stethoscope
• First sound is systolic pressure
• Last sound (5th): Change or cessation of sounds occurs—diastolic pressure
The brachial artery and popliteal artery are commonly used
Blood pressure is measured in millimeters of mercury(mm Hg) and is
recorded as a fraction. The numerator is the systolic pressure; the
denominator is the diastolic pressure.
Parts of a Sphygmomanometer – 3 Sizes of
Cuffs
Normal Ranges for Vital Signs
for Healthy Adults
• Oral temperature — 37.0ºC
• Pulse rate — 60 to 100 (80 average) b/min
• Respirations — 12 to 20 breaths/minute
• Blood pressure — 120/80 mmHg