Tammy Spencer, DNP, RN, CNE, ACNS-BC, CCNS
University of Colorado
College of Nursing
Vital Signs
 What are vital signs (VS)?
 When do we take vital signs?
 Baseline vital signs very important! Why?
• Baseline BP: 130/70
• BP now: 100/50
• Is this significant? (Note: serial
measurement)
Physiology of Temperature
 Core Temperature
 Definition: Temperature of central circulation & organs.
Ultimate goal of temperature measurement.
 Three central sites for core measurement: head, chest,
abdomen.
 The hypothalamus is the body’s temperature regulation
center; body’s “thermostat”.

Allows core temperature to vary by only one degree F
throughout the day.
The hypothalamus activates heat loss and
heat production mechanisms in order to
maintain a normal core temperature.
Physiology of Temperature
Heat Loss
Ant. Hypothalamus
* Sweating
* Capillary dilation
98.6 F
Heat Production
Post.Hypothalamus
*Shivering
*Vasoconstriction
*Metabolism
 Normal Oral Temperature :
Oral: 96.4 – 99.1 F (35.8 – 37.3 C)
Gold Standard Oral = 98.6 F (37 C)
(textbook: 97.7 F (36.4 C))
Rectal is 0.7-1.0 F (0.4 – 0.5 C) higher than oral
Convenient Equivalents:
104.0 F = 40.0 C, 98.6 F = 37.0 C, 95.0 F = 35.0 C
Factors Affecting Temperature:
•Age
–Infants/toddlers N = 96-99 F; same as adults
after age 3
–Elderly N = 97.2 F (36.2 C)
•Biologic Diurnal Rhythm
–4pm - 8pm peak temperature
–4am - 6am lowest temperature
•Exercise
•Hormones
•Stress
•Environment
Temperature Variations:Fever (Pyrexia)
“Febrile”
 High temperature (hyperthermia) as a response to
bacteria or virus, or tissue breakdown; thermoregulatory
mechanisms are still intact.
EX:
* Bacterial or viral infection
* Myocardial infarction
* Trauma
Three Stages of Fever
 Cold stage: Increase in core temp. via heat
production mechanisms such as
vasoconstriction, shivering.
 Hot stage: Fever plateau - body radiates heat
 Defervesence: Fever abatement - heat loss
mechanisms such as vasodilation, sweating
(diaphoresis)
Miscellaneous terms to describe fever:
 intermittent, relapsing
 “FUO”
Clinical Application
 What do we see clinically when a patient gets a
‘fever’?
 Why are we seeing these responses?
 Because our thermostat gets reset!
 See page 42, 43, 45 of the Kiekkas article
Increased Temperature: When to Intervene…
•Can fever be therapeutic up to a certain point?
•Can fever have adverse effects?
•Typically will look more aggressively for cause of temp when
temp is above 38.5 C (101.3 F) (textbook = 37.8 (100.04 F))
•Exceptions (these individuals do not develop same fever
response as healthy individuals):
Elderly (mean 36.2 C; 97.2 F)
Immunocompromised patient
Pts. with chronic illness
•Nursing interventions for fever:
–Treat the cause (remove source of infection or treat the
source of infection).
– Acetaminophen
–Tepid sponge bath
–Cooling blanket
–Monitor fluid loss
–Monitor treatment therapeutics (lab values)
Temperature Variations: Hyperthermia without
infection or tissue damage
• Dysfunction of the thermoregulatory mechanisms
• Body unable to lose heat
• Causes:
• Hot weather is the single largest contributor.
• Other factors include dehydration
•Treatment: Prevention is key
• Cool patient
Temperature Variations:Hypothermia
 Exposure to cold chief cause of hypothermia.
 Hypothermia may also be therapeutically induced to
decrease oxygen demands.
 Nursing interventions for hypothermia:
 gradual warming, treat underlying cause
Tools to Measure Temperature
 Electronic Thermometer: IVAC, ACCU-PRO
 Tympanic Thermometer : measures temp.of
blood flowing near tympanic membrane which
shares blood with hypothalamus
 Invasive devices: rectal probe, indwelling
catheter in artery, bladder, esophageal
 Temporal Artery Thermometer
Sites for Measuring Temperature:
Oral, Rectal, Axillary, Tympanic, Temporal Artery
Oral, Rectal, Axillary, Tympanic,
Temporal Artery
Oral Site
 Advantages
 Unobtrusive, accessible, convenient
 Contraindications
 Unconscious or confused patient
 Infants/young children under age of 5
 Disease or surgery of mouth
 Mouth breather, tachypnea
Oral Site
 Factors That Influence Oral Temp.
 Placement of probe: must be in posterior
sublingual pocket
 Hot or iced liquids, eating or smoking: wait at least
15 minutes
 Points to Remember
 Placement important
 Close mouth completely
Rectal Site
 Advantages
 Not influenced by eating, drinking, smoking or
ability of patient to hold probe
 Can be used for comatose, confused patient or
patient in shock, after oral surgery.
 Used when no other routes available
 Disadvantages
 Invasive
 Placement must be observed
 Difficult to place; rectal perforation possible
Rectal Site
 Contraindications
 Rectal surgery
 Rectal organisms
 Severe hemorrhoids
 Diarrhea
 Factors that influence rectal temp
 Probe placement, stool in rectum
Rectal Site
 Points to remember
 Never force
 Use water soluble lubricant
 Gloves
 Insertion:
Adults: 1 inches
 Infants/kids under 6 years old: approx. ½ inch
 Rectal temp is (1) degree F higher than oral temp
(.5 degree higher C)
 Normal rectal temp= 99.6 F, 37.5 C

Tympanic Site
 Advantages
 Noninvasive, used with wide age group
 Minimal chance of cross-contamination
 Used more in clinic settings
 Disadvantages
 Placement can vary, influencing temp
 Contraindications
 Drainage from ear, ear surgery
 Large amount of cerumen (cerumen-impacted ear)
 Pain from perforation or infection; fluid with infection
 Infants and children under the age of 3
 Factors influencing temp: Placement
Tympanic Site
 Points to remember
 Pull ear up & back for kids over 3 years & adults;




down & back for infants – 3 year olds
Place the speculum tip snugly in ear canal (do not
occlude the canal); for adult point speculum toward
the patient’s nose.
Make sure pt. has been indoors for at least 10
minutes
For side-lying patient, take the temperature in the
ear that is exposed (the ‘up’ side). Remove
earplugs, hearing aids and wait 20 minutes.
If you need to take a second temperature, use
opposite ear or wait 2- 3 minutes and repeat in the
same ear.
Temporal Artery Site
• Advantages
• Can be used on infants and adults.
• Previously thought to be as accurate as core temp; new
studies are conflicting as to accuracy.
How to use:
• Measure midline straight across the forehead (think of a
sweatband), from the center to the hairline (or start at the
hairline) ending with a touch on the neck behind the
earlobe.
• Do not slide down the side of the face. If you have to
remove your patient’s glasses, you went incorrectly down
the side of the face.
Temporal Artery Site
• Disadvantages/Contraindications/Factors
influencing temp
• Diaphoretic patient
• If pt. is diaphoretic, the area on the neck behind the
earlobe can be used as an alternative site (this is one
of the last places to get wet when a pt. is diaphoretic).
This area can also be used on the pt. with head
trauma (surgical or accidental).
• If the neck is inaccessible, and if dry, the femoral
artery, lateral thoracic artery areas (see next slide) can
be used. The axillary area can also be used.
Temporal Artery Site
Alternative sites for temperature measurement using the
temporal artery thermometer
Femoral Artery Area:
Scan across the femoral artery in the crease of the
groin, keeping button depressed until scan is complete.
Lateral Thoracic Artery Area:
Scan in a zigzag pattern about 4 inches wide from an
imaginary line in between the axilla and the nipple, scanning
down to the waist and back up to the level of the nipple,
keeping the button depressed until scan is complete.
Axillary:
Place the probe in middle of axilla.
Temporal Artery Site
• If all sites are wet, the pt. temp will be rapidly dropping;
return in 15 minutes when the pt. should be dry and take a
standard temporal artery temperature.
• Wiping the sweat will not work as the sweat glands
secrete too quickly and the area will still show the effect of
evaporative cooling.
Temporal Artery Site
•Points to remember:
• Anything covering the area to be measured would
insulate and prevent the heat from dissipating, resulting in
falsely high readings. Brush the hair aside if covering the
TA, or the area behind the ear.
• Measure only the exposed or ‘up’ side on a patient in a
lateral position. The downside will be insulated, resulting
in a falsely high reading.
• If the pt. has been lying on their side or the area is
covered, wait about 30 seconds before taking a temp.
Temporal Artery Site
•Points to remember:
• Sequential measurements cool the skin, resulting in variable
temps. Wait 30 seconds for the skin to recover or use the
opposite side if exposed.
• Low readings can be caused by a dirty lens; biweekly
cleaning of the lens is a good idea.
•Note: Adhesive allergy is not a contraindication to using a
temporal artery thermometer.
What’s the most accurate?
 Peripheral thermometers have poor sensitivity for detecting low-
grade fever, which is a potentially important sign of infection in
patients who may not manifest a typical infectious prodrome (for
example, elderly patients or those with immune system impairments,
connective tissue disease, or tumors).
 Given the excellent level of agreement between nonvascular central
thermometers and the pulmonary artery catheter—the gold
standard— clinicians should consider using central thermometers
when accurate measurement of a patient's temperature will influence
diagnosis and management. Rectal thermometers could be used
for most of these patients, and bladder thermometers could be
used for those requiring a bladder catheter.
 When a central thermometer is best avoided (for example, in patients
with neutropenia) or impractical, electronic oral thermometers (for
use in adults) or tympanic membrane thermometers(for use in
adults and children) that are calibrated before use seem to be
the best alternative
Pulse
 Physiology: Peripheral pulse is the pressure wave
transmitted from the left ventricle to aorta to peripheral
vessels.
 Pulse is an indirect assessment of the cardiovascular
system and the cardiac output.
Pulse Physiology
C.O. = S.V. X HR
Volume of blood
pumped by the
heart each minute.
N = 4 - 6 L/min
Volume of blood
pumped with each
heartbeat
Beats per
minute
N = 60 - 80 cc/beat
HR and S.V. stay in balance to maintain C.O. - each affects the
other . For example:
• SV decreases --- HR increases
• HR increases --- SV decreases
Assessment Sites: Peripheral Pulse
 Temporal
 Carotid
 Brachial
 Femoral
 Radial and Ulnar
 Popliteal
 Posterior Tibial (PT)
 Dorsalis Pedis (DP)
“Pedal Pulses”
Sites for Pulse Assessment:
Head to Toe
• Don’t forget
temporal pulse!
• Special
consideration with
carotid pulse
+
= ‘Pedal Pulses’
Apical Impulse pg 469 - 470
 Refers to the apex of the heart; contraction of the left
ventricle
 Located at the 4th – 5th intercostal space (ICS), at or medial
to the left midclavicular line ( 5 ICS, (L) MCL)
 May be able to see with inspection; typically auscultated
(each “lub - dub” = 1 beat)
 In ~40% of population, can be palpated as a short ‘tap’ felt
only during early systole; approximately 1 cm in diameter
 Typically counted for one full minute; may count for 30
seconds and multiply by 2 if regular.
 Used for some cardiac medications or if peripheral pulse
irregular or rapid
Apical Pulse: p 479
Note: Typically not considered a “peripheral pulse”.
How do you find the 5th
ICS?
Pulse: Factors to Assess
Rate : number of pulsations/minute
 N = 50 -95 bpm (normal resting heart rate for 95%
of healthy individuals). May still see 60 – 100 bpm
(adult) but no evidence supports this range.
 Bradycardia – generally, less than 60 bpm
(American Heart Association). May be normal
variation for some
 Tachycardia – greater than 100 bpm (American
Heart Association)
Rhythm: pattern of pulsations or pauses
 described as irregular or regular (N = regular)
 dysrhythmia/arrhythmia = any deviation from
normal rhythm of heart.
Pulse: Factors to Assess
 Amplitude/force: subjective estimate of the
strength of left ventricular contraction (S.V.)


Described as bounding, diminished, absent
May use scale 0-3
 absent = 0
 weak, ‘thready’ = 1+
 N = 2+
 full, bounding = 3+
 Symmetry: Are pulses equal on both sides?

Assess by feeling pulses simultaneously (except
carotid)
Factors Influencing Pulse
 Age: Pulse decreases with age.
 Infants 100-180 (awake) bpm
 Adults 50-95 bpm (normal resting heart rate for
95% of healthy people based on literature).
 Gender: After puberty, male slower than female
 Exercise : Increases pulse; physically fit individuals
have a lower heart rate at rest
 Medications: May increase or decrease
 Fluid loss
 Disease/Illness: depends on disease or illness
Pulse: Points to remember
 Use pads of first three fingers
 Recorded as bpm.
 If regular, count for 30 seconds (not 15 seconds); multiply
by (2) for bpm.
 If getting baseline assessment, count for (1) minute
 If irregular, auscultate the apical or radial pulse for one
minute noting any pattern in irregularity.
Alternative methods to assess pulse: Invasive, Doppler
Doppler
Respiration
 Physiology: Breathing is largely an automatic act,
controlled in the brain stem and mediated by the muscles
of respiration. Regulation of ventilation/ breathing is
based primarily on acid-base physiology and
acidosis/alkalosis.
Respirations: Factors to assess
Rate, rhythm,depth
 Rate: Recorded as number of breaths / minute
 Normal adult respiratory rate = 10-20 breaths/minute
(eupnea)
 Variations:

Tachypnea

Bradypnea

Apnea
Respirations: Factors to assess
 Rhythm: Regular vs. irregular
 Depth: Shallow (small volume) vs. deep (large
volume)
Miscellaneous Terms: Respiration
 Dyspnea: Subjective feeling of shortness of breath
(SOB)
 Orthopnea: Dyspnea that increases when client lies
down. May be recorded as number of pillows used.
 Cheyne-Stokes: A cycle of breathing alternating
increased resp. rate and depth with periods of
apnea.
 Kussmaul: Rapid, deep respirations
Factors that Influence Respiration
 Disease/Illness
 Medications
 Exercise
 Anxiety
 Altitude
 Age: newborn 30-40 bpm
 Smoking
Respiration: Points to remember
 Count inspiration and expiration as (1) breath.
 Count for 30 seconds (not 15) if regular

If irregular, getting baseline assessment, or
respirations less than 12 per minute or more than 20
per minute, count for (1) full minute
 Try to count when client is not watching you.
Blood Pressure
 Recorded as
systolic
diastolic
 Systolic = force or pressure in walls of arteries
when (L) ventricle contracts (reflects systole)
 Diastolic = force or pressure on walls of
arteries when heart is filling (reflects diastole)
Blood Pressure
 Several body systems assist with regulating blood
pressure including the cardiovascular system, the
kidneys, the endocrine system and the nervous
system.
 …So why is taking an accurate BP so important?
Physiology of BP
 The interaction of C.O. and peripheral
vascular resistance (PVR) is an important
concept to understand in the regulation of BP.
PVR is the semi-contracted state of arteries
that maintain a relatively constant resistance
to blood flow.
BP = CO X PVR
By manipulating the CO & PVR, we can
change the BP
How can we manipulate the C.O. and PVR?
 Volume: the greater the volume, the greater the
pressure
 Elasticity: as elasticity decreases, pressure increases
 Dilation, constriction (PVR): dilation
BP, constriction
BP.
 Pumping action of heart: decreased pumping ability,
decreased pressure &
CO
 Viscosity of blood: “thickness” of blood; thicker the
blood, the pressure increases.
By manipulating these variables, the BP is
changed.
Clinical application?
BP Categories in Adults*
*Whelton, P.K & Carey, R.M. (2018). 2017
ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guidelines for the
Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults. Journal
of the American College of Cardiology, 71(19).
Other terms related to BP:
 Pulse Pressure: Systolic pressure minus
diastolic pressure.
 N = 30-40 mm Hg
 Higher in older adults due to increased systolic
pressure
 Hypotension: Abnormally low BP (less than
95/60 mmHg)
 No real numerical value for hypotension as long as
organs are perfused
Recommendations from the 2017 American College
of Cardiology/American Heart Association Task
Force on Clinical Practice Guidelines*
Most older patients will become hypertensive.
People who are normotensive at age 45 have an ~ 80 - 90%
lifetime risk for developing hypertension.
Prehypertension begets hypertension: think prevention.
For people 40 to 70 years old, the risk of cardiovascular
disease doubles with each increment of 20/10 mmHg above
115/75.
All hypertensive pts should know lifestyle modifications: lose
weight, eat fruits, vegetables, low-fat dairy products, reduce
Na intake (1 tsp./day), exercise, alcohol in moderation.
*Whelton, P.K & Carey, R.M. (2018). 2017
ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guidelines for the Prevention,
Detection, Evaluation and Management of High Blood Pressure in Adults. Journal of the
American College of Cardiology, 71(19).
Assessment sites for BP (Primary sites to be used)
 Arm/brachial artery: most common site
 Contraindications: burns, trauma to arm, dialysis
access (graft or fistula), IV (BP cuff may be placed
distally to the IV), breast surgery
 Forearm/ Radial artery: Apply cuff midway
between elbow and wrist. False high readings may
occur unless cuff at heart level.
 Contraindications: arm/hand injury
Assessment sites for BP
 Thigh/ Popliteal Artery:Apply cuff over lower third of
thigh, auscultate over popliteal artery
 Contraindications: hip surgery, injury.
 Normally 20-30 mm Hg higher systolic than arm BP
 Calf/dorsalis pedis, posterior tibial: apply cuff 2.5 cm
above malleoli
 Contraindications: injury or trauma to ankle, foot, calf,
deep vein thrombosis
Other methods: palpate (see ausculatory gap – step #4,
slide 76), electronic, direct, doppler
Factors Influencing BP
Age
 Decrease compliance of arteries with age; elderly
BP increased with increase pulse pressure
Ethnicity
• The incidence of HTN is twice as high in African
Americans as in non-Hispanic whites for reasons
not fully understood
Gender
 After puberty, F have lower BP than M
Factors Influencing BP
Diurnal (biologic) Rhythm
 BP lower in AM, peaks in late PM
Practitioner Influences
 “White Coat HTN”
Use of caffeine/tobacco
Disease/Illness, Medications
Emotions
Stress
Exercise
Weight
Taking a Blood Pressure
Technique: pg. 146-148
 Measure BP in both arms while sitting (feet flat) and back
supported. On initial exam; should not vary between arms more
than 10 mmHg, however in 20-40% of healthy patients there
may be a difference of 10 – 20 mm Hg. If consistent difference,
use arm with higher pressure.
 May also measure BP in lying and sitting position on initial
exam. Supine BP typically higher than sitting BP by 8mmHg
 Rest at least 5 minutes prior to taking; 1-2 minutes between
measurements. Wait 30 minutes if client has smoked or
ingested caffeine. Be quiet! BP increases with talking (or using
cell phone!).
 Avoid constrictive clothing

Increases BP by increasing occlusion
Taking a Blood Pressure
Step #1: Apply cuff/bladder to BARE arm
 Arm should be supported and at level of heart
 If arm lower than level of heart - increase BP
 If arm higher than level of heart - lower BP
 If pt. support arm - increase BP
 Width of bladder should cover 40% of the circumference of the
upper arm
 Length of bladder should reach 80% of the arm circumference.
 Center the bladder 2 – 3 cm (~1inch)above antecubital fossa
Taking a Blood Pressure
Step #1 (Cont.): Errors in cuff (pg.
149)
 Width too narrow - falsely high BP
 Width too wide - falsely low BP
 Cuff too loose - falsely high BP
 Leak in cuff or tubing - unable to
maintain pressure in cuff
 Why is this important????
Taking a Blood Pressure
 Steps 2 – 6 refer to taking a manual blood pressure
 Step #2: Position the manometer vertically at eye level no more than 1 yard
away.
 Step #3: Place stethoscope over brachial artery - light pressure (locate the
brachial artery by palpation first).

May use bell or diaphgram to obtain an accurate reading
 Step #4: Inflate cuff 20 - 30 mmHg above client’s normal or estimated systolic BP

If baseline unknown, palpate prior to auscultating BP to get estimate of
systolic pressure
Taking a Blood Pressure
 Step #5: Deflate cuff at a rate of 2 - 3 mm Hg/ second
Too fast - miss Korotkoff sounds
 Too slow - congestion increases BP
 Step #6: Listen for Korotkoff sounds
 Partial obstruction of arterial flow creates turbulence which
produces sounds known as Korotkoff sounds.
 These sounds can be heard over arteries with the
stethoscope and are used to record blood pressure.
 Listen for first sound and last sound; continue to listen for 10
– 20 mm Hg after the last sound you hear.

Taking a Blood Pressure: Korotkoff Sounds
Phase I First sound heard. Pressure of cuff equals
the systolic pressure inside the vessel.
Phase II Swishing sound as vessel distends with blood
Phase III Sound becomes crisper
Phase IV Muffling of sound. Pressure begins to equal diastolic.
True diastolic pressure for kids.
Phase V The last audible sound (marking the disappearance
of sound). True adult diastolic. Used to determine
diastolic pressure in all age groups.
 Record systolic and diastolic BP at the closest even number
heard; do not round up or down
https://www.practicalclinicalskills.com/blood-pressure-coursecontents?courseid=102
Details - Step #4:





Put cuff on (do not inflate); palpate brachial artery.
Inflate cuff, note point on manometer where pulse disappears.
This approximates the systolic pressure.
Deflate cuff, wait 30 seconds, and proceed to take BP in normal
fashion; inflate cuff 30 mmHg above the point where artery is
occluded.
This is also the technique used for patients with unknown
baseline BP.
Also known as the ‘Two-Step Method’ in the Clinical Essentials Modules
(uses palpated pulse when deflating the cuff as systolic)
Why is measuring a BP accurately important???
Do healthcare providers typically follow
recommendations in clinical practice?
What might be the patient outcome if BP is not
accurately assessed?
Variations in BP: Orthostatic Hypotension
Defined as a decrease in systolic BP greater than 20
mm Hg and an increase in pulse of 10 -20 bpm when
moving from lying to standing position.
 Causes: hypovolemia (volume depletion), prolonged
bedrest, medications (antihypertensives)
 Assessment technique: Measure BP in lying and
standing position.
 Place pt in supine position for 2-5 minutes; check BP and
record
 Assist patient to sitting position.
 If pt is not dizzy while sitting, immediately assist to standing.
Measure BP within (1) minute of standing.
Evidence Based Practice:
Orthostatic hypotension
Juraschek, S.P., Daya, N., Rawlings, A.M., et al. (2017). Comparison of early versus late
orthostatic hypotension assessment times in middle-age adults. JAMA Intern Med., 177,
1316-1323.
What’s wrong with
this picture?
From: Handler(2008). The
importance of accurate blood
pressure measurement. The
Permanente Journal, 13 (3), 5154.
Vital Signs: The Big Picture
 Baseline vitals important
 Trending vitals is important
 Use the correct equipment
 YOUR technique counts!
 Numbers are great….don’t forget about
the patient!
 Great website to listen to Korotkoff sounds, lung
sounds, with Case Studies:
https://www.practicalclinicalskills.com/blood-pressure-coursecontents?courseid=102
Clinical Application:
Critical Thinking
 Mr. A has just been dropped off to the ED by
his friend with gunshot wounds to his chest
and abdomen. He has massive bleeding from
the wounds.
 What would you expect his vital signs to be
upon admission to the ED assuming no
treatment has been given? Why?
 You have administered 10 liters of normal
saline to Mr. A. What would be the expected
change to his pulse and BP? Why?
Clinical Application:
Critical Thinking
 Ms. L., an 85-year-old female, has a long
standing history of osteoporosis with severe
kyphosis. She presents to your clinic with
complaints of a cough and weakness for three
days, and states she has not felt like eating or
drinking for about three days as well.
 When taking Ms. L’s oral temperature, you
note it to be 99.4 F. Is this cause for concern?
 What would you expect her other vital signs to
be? Why?
Clinical Application:
Critical Thinking
 Ms. O., a 78-year-old female, has been on
bedrest for 2 days following hip replacement
surgery. She has been on a clear liquid diet
and tolerating it well. You are now getting her
up for the first time since her surgery.
 What nursing intervention re: assessment of
her BP would you want to perform? Why?