Vital Signs
OBJECTIVES
State the basic components of vital signs.
List factors that can cause variations in vital signs.
Define terminology related to vital signs.
Identify the normal ranges of vital signs.
Describe the protocol for reporting and recording vital
signs.
State the procedure for measuring height and weight in
an adult.
Vital Signs
Temperature (T)
Pulse (P)
Respiration (R)
Blood pressure (BP)
Pain (often called the fifth vital sign)
Factors which Causes
Changes in Vital Signs
1. Temperature
2. Physical Exertion
3. Effect of Illness
Factors effecting
pulse/respirations/blood pressure
Body build
Blood pressure
Drugs
Exercise
Foods
Temperature
Disease processes
Pain
Age
Occasions for Measuring V/S
Screenings at health fairs and clinics
Upon admission to a healthcare setting
When certain medications are given
Before and after diagnostic and surgical
procedures
Before and after certain nursing interventions
In emergency situations
Hospital routine
Changes in general condition
Nonspecific symptoms of physical distress and stress.
Body Temperature
Definition: the heat of the body measured in
degrees
The difference between production of heat and
loss of heat
Normal temperature: 97.0ºF (36.0ºC) to 99.5ºF
(37.5ºC)
Process: heat is generated by metabolic
processes in the core tissues of the body,
transferred to the skin surface by the circulating
blood, and dissipated to the environment
Factors which Cause Variations in
Body Temperature
1.
Age
2. Exercise
3. Hormonal Influences
4. Diurnal Variations
5. Stress
6. Environment
7. Ingestion of hot/cold liquids
Sites for Measurement of
Temperatures
Core temperatures
Tympanic and rectal
Esophagus and pulmonary (invasive
monitoring devices)
Surface body temperatures
Oral (sublingual)
Axillary
Temporal
Inserting Tympanic Thermometer
into Patient’s Ear
Contraindications to Temperature
Measurement sites
Oral: impaired cognitive functioning,
inability to close lips around thermometer,
diseases of the oral cavity, and oral or nasal
surgery
Rectal: newborns, small children, patients
who have had rectal surgery, or have
diarrhea or disease of the rectum, and
certain heart conditions
Tympanic: earache, ear drainage, and
scarred tympanic membrane
Overhead Radiant
Warmers
Used for infants exposed to stressors or
chilling
Used for infants with underlying conditions
that interfere with thermoregulation
Minimizes the oxygen and calories that the
infant would expend to maintain body
temperature
Minimizing the effects of body temperature
changes on metabolic activity
Cooling
Blanket/Hypothermia Pad
Conducts a cooled solution, usually
distilled water, through coils in a plastic
blanket or pad
Helps to lower or maintain body
temperature
Characteristics of the Pulse
Pulse rate
Measured in beats per minute
Pulse quality (amplitude)
The quality of the pulse in terms of its
fullness
Pulse rhythm
Pattern of the pulsations and the pauses
between them
Normally regular
Methods of Assessing the
Pulse
Palpating the peripheral arteries
Auscultating the apical pulse with a
stethoscope
Using a portable Doppler ultrasound
Common Pulse Sites
Temporal
Carotid
Brachial
Radial
Femoral
Popliteal
Posterior tibial
Dorsalis pedis
Palpating the Radial Pulse
Assessing an Apical Pulse
Indications
Patient is receiving medications that alter heart
rate and rhythm
A peripheral pulse is difficult to assess
accurately because it is irregular, feeble, or
extremely rapid
Method
Count the apical rate 1 full minute by listening
with a stethoscope over the apex of the heart
Most reliable method for infants and small
children; can be palpated with fingertips
Assessing Respirations
(Normal Findings)
Rate
Adults: 12 to 20 times per minute
Infants and children breathe more rapidly
Depth
Varies from shallow to deep
Rhythm
Regular: each inhalation/exhalation and the
pauses between occur at regular intervals
Assessing Respiratory
Rate, Depth, and Rhythm
Method
Inspection (observing and listening)
Listening with the stethoscope
Counting the number of breaths per minute
Considerations
If respirations are very shallow and difficult
to detect visually, observe sternal notch
Patients should be unaware of the respiratory
assessment to prevent altered breathing
patterns
Factors Affecting Respirations
Exercise
Medications
Smoking
Chronic illness or conditions
Neurologic injury
Pain
Anxiety
Respiratory patterns
Dyspnea
Tachypnea
Shallow
Cheyne-stokes
Hyperventilation
Kussmaul's respirations
Signs of Respiratory Distress
Retractions
Nasal flaring
Grunting
Orthopnea (breathing more easily in an
upright position)
Tachypnea (rapid respirations)
Sample Nursing Diagnoses
Related to Respiratory Status
Ineffective Breathing Pattern
Impaired Gas Exchange
Risk for Activity Intolerance
Ineffective Airway Clearance
Excess Fluid Volume
Ineffective Tissue Perfusion
Blood Pressure
Definition
The force of the blood against arterial
walls
Systolic pressure
The highest point of pressure on arterial
walls when the ventricles contract
Diastolic pressure
The lowest pressure present on arterial
walls during diastole (Taylor, 2007).
Measuring Blood Pressure
Blood pressure is measured in
millimeters of mercury (mm Hg)
Blood pressure is recorded as a fraction
The numerator is the systolic pressure
The denominator is the diastolic pressure
Pulse pressure
The difference between the systolic and
diastolic pressure
Blood Pressure Assessment
(Methods)
Using a stethoscope and
sphygmomanometer
Using a Doppler ultrasound
Estimating by palpation
Assessing with electronic or automated
devices
Measuring Blood
Pressure
Ensuring an Accurate Blood Pressure
Reading
Use a cuff that is the correct size for the
patient
Ensure correct limb placement
Use recommended deflation rate
Correctly interpret the sounds heard
Factors Affecting Blood Pressure
Reading
Age
Exercise
Position
Weight
Fluid balance
Smoking
Medications
Pain
Acute pain is of short duration, usually the result of
an injury, surgery or illness. This type of pain includes
acute injuries, post-operative pain and post-trauma
pain.
Chronic pain is an ongoing condition, such as back
and neck pain, headaches
Pain
Nociceptive pain is caused by stimulation of peripheral
nerve fibers that respond only to stimuli approaching or
exceeding harmful intensity (nociceptors)
The most common categories being "thermal" (heat or cold),
"mechanical" (crushing, tearing, etc.) and "chemical" (iodine
in a cut, chili powder in the eyes).
Neuropathic pain is caused by damage or disease affecting
any part of the nervous system involved in bodily feelings .
Peripheral neuropathic pain is often described as
“burning,” “tingling,” “electrical,” “stabbing,” or “pins
and needles.”
Pain
Phantom pain is pain from a part of the body that has
been lost or from which the brain no longer receives
signals. It is a type of neuropathic pain.
Numerical Pain Scale – 0-10 scale
Oxygen Saturation
Oxygen saturation is an indicator of the percentage of
hemoglobin saturated with oxygen at the time of the
measurement.
P U R P O S E: Pulse oximetry is a noninvasive monitoring
technique used to estimate the measurement of arterial
oxygen saturation (SaO2) of hemoglobin.
Normal oxygen saturation values are 97% to 99% in the
healthy individual. An oxygen saturation value of 95% is
clinically accepted in a patient with a normal hemoglobin
level.