Vital Signs
► Temperature
► Heart
Rate/ Pulse
► Respiratory Rate
► Blood Pressure
► Pain Level
► Oxygen Saturation
Vital Signs
► Never
look at just the numbers
► Look at the whole patient
Temperature
► Temperature-
What's Normal?
► Body temperature for an adult is said to be normal
at 98.6 degrees F (37 degrees C). However, it is
quite normal for body temperature to vary by one
or two degrees (97.5 to 99.5 degrees F or 36-38
degrees C). Some people run sub normal and
some run a degree higher. Body temperature will
also vary with the time of day. It can be lower in
the morning and slightly higher in the late
afternoon or evening.
Influencing Factors
►
►
►
►
►
Temperature can be influenced by factors such as
smoking, exercise or a lot of activity prior to checking the
temperature. Drinking cold or hot liquids can also affect an
oral temperature. Of course the accuracy of the
thermometer can also affect the results.
Time of day, hormones
Core temperature less affected than surface body
temperature unless exposed to environmental extremes.
Body conserves heat by constricting peripheral vessels
Produces heat through metabolism.
Signs and Symptoms of Elevated
Body Temperature
Thirst
► Anorexia
► Flushed, warm skin
► Irritability
► Glassy eyes/photophobia
► Headache
► Elevated pulse and respiratory rates
► Restlessness or excessive sleepiness
► Increased perspiration
► Disorientation progressing to febrile seizures in infants and
children
►
Types of Thermometers
► There
are several types of thermometers. These
include glass or digital thermometers. An oral
thermometer is used by placing it under the
tongue for an oral temperature; or into the armpit
for an axillary temperature.
► A rectal thermometer is primarily used for infants
and small children. The tip of the rectal
thermometer is placed (carefully) into the rectum.
► An ear thermometer takes a tympanic
temperature.
► Temporal thermometers measure temperature by
being run across the forehead, down the temple
and then behind the ear.
How Will the Site Affect the
Temperature?
► An
axillary temperature will typically read one-half
to one degree lower than an oral temperature and
a rectal temperature will typically read a degree
higher than an oral temperature. The tympanic
temperature is usually the same as an oral
temperature, and considered to be more accurate
as there are fewer influencing factors.
When to use Which Thermometer
► No
oral temps: comatose, disoriented,
infants, oral surgery
► Avoid rectal temps after rectal surgery
► Rectal temps are normally 1 degree higher
than oral
► Avoid tympanic temperatures in presence of
ear infections, surgery
► Axillary temps are least accurate. Used
mostly in the small infant.
Fever vs Hypothermia
► Fever,
hyperthermia, pyrexia
► Temp > 99
► Temp > 105 causes damage to body cells
► Hypothermia Temp < 97
► Temp < 93.2 can cause death
Nursing Interventions for the Patient
with Altered Body Temperature
► Make
sure reading is accurate
► Reduce coverings or provide warmth
► Monitor
► Keep bed linens and clothing dry
► Encourage fluids as appropriate
► Assess for cause of temperature alteration
► Oral Hygiene
► Eliminate drafts
What is the Pulse?
►
A pulse is when the left ventricle of the heart contracts.
When this happens, blood is suddenly pushed from the
ventricle to the main artery (aorta). This sudden forcing of
blood from the heart into the arteries causes two things to
happen.
 a. Artery Expansion. The sudden rush of blood increases the
volume of blood in the arteries. In order to accept this increased
volume, the arteries expand (stretch). As the arteries quickly
contract (go back to normal size), blood is forced from the arteries,
through the capillaries, and into the veins.
 b. Pulse. In addition to the expansion of the arteries, a "wave"
travels through the arteries. This wave is the pulse. All arteries
have a pulse, but the pulse is easier to feel (palpate) when the
artery is near the surface of the body
WHAT IS PULSE RATE?
► The
pulse rate is the number of times that
you can feel a pulse wave passing a point in
one minute. Since a pulse wave occurs
whenever the heart beats, the pulse rate
equals the heartbeat rate. However, "taking
a patient's pulse" means more than just
determining his pulse rate. It also includes
noting certain other factors about the pulse.
Things to note
► When
taking a patient's pulse, you should note the
patient's pulse rate, the strength of the pulse, and
the regularity of the pulse.
► a. Pulse Rate.
 (1) The normal adult has a pulse rate of about 72 beats
each minute. Infants have higher average pulse rates.
The normal pulse rate ranges based upon age are given
below.
 Adults: 60 to 100 beats per minute.
 Children: 70 to 120 beats per minute.
 Toddlers: 90 to 150 beats per minute.
 Newborns: 120 to 160 beats per minute.
►
(2) Pulse rates that are outside the normal range are
classified as tachycardia or bradycardia.
 (a) Tachycardia. If the patient's pulse rate is over 100 beats per
minute, the patient is said to have tachycardia. Tachycardia means
"swift heart." Constant tachycardia could be a sign of certain
diseases and heart problems. Often, however, tachycardia is only
temporary. Temporary tachycardia can be caused by exercise, pain,
strong emotion, excessive heat, fever, bleeding, or shock.
 (b) Bradycardia. If the patient's pulse rate is below 50 beats per
minute, the patient is said to have bradycardia. Bradycardia means
"slow heart." Bradycardia can be sign of certain diseases and heart
problems. Certain medicines, such as Digitalis, can result in
bradycardia.
Also note
►
b. Strength. The strength (force) of the pulse is determined by the amount of
blood forced into the artery by the heartbeat. A normal pulse has a normal
strength. You will be able to identify a normal strength pulse with practice.
 (1) Bounding. If the heart is pumping a large amount of blood with each heartbeat,
the pulse will feel very strong. This strong pulse is called "bounding" pulse (as in "by
leaps and bounds"). A bounding pulse can be caused by exercise, anxiety, or alcohol
consumption.
 (2) Weak. If the heart is pumping only a small amount of blood with each heartbeat,
the pulse will be harder to detect. This type of pulse is called weak, feeble, or
thready. If the pulse is weak, you may have trouble finding (palpating) the pulse at
first.
 (3) Strong. A strong pulse is stronger than normal pulse, but is less than bounding.
Shock and hemorrhage (serious bleeding) can cause a strong pulse.
►
c. Rhythm. Rhythm refers to the evenness of the beats. In a regular pulse,
the time between beats is the same (constant) and the beats are of the same
strength.
 (1) Irregular. A pulse is irregular when the rhythm does not have an even pattern.
The time between beats may change, or the strength of the beats may change or
the pulse may vary in both time between beats and strength.
 (2) Intermittent. An intermittent pulse is a special type of irregular pulse. A pulse is
intermittent when the strength does not vary greatly, but a beat is skipped (missed)
either at regular or irregular intervals. If the missing beats in an intermittent pulse
were present, then the pulse rhythm would be normal.
Check for Symmetry
► Peripheral
pulses come in pairs
► Are both radial (pedal, etc) pulses the
same?
► NEVER check both carotid pulses at the
same time
Where to take a Pulse
Heart rate
► Apical
pulse
 Always before giving Digoxin
 Listen for one full minute
► Pulse
deficit
Factors Influencing Heart Rate
Age
► Exercise
► Fever/ heat
► Acute pain/ Anxiety
► Medications
► Hemorrhage/ hypovolemia
► Postural changes
► Metabolism
► Hormones
► Pulmonary conditions
► Respirations
►
Pulse Volume Variations
►0
Absent pulse, none felt
► 1+ Thready, difficult to feel, easily
obliterated with slight pressure
► 2+ Weak pulse, somewhat stronger, easily
obliterated with light pressure
► 3+ Normal pulse, easily felt but obliterated
with moderate pressure
► 4+ Bounding pulse, Full, spring-like even
with moderate pressure
Respirations
► Respiration
 Taking in and utilization of oxygen
 Internal process: gas exchange at the cellular level
 External process: The act of breathing: inhaling and
exhaling
 Rate is controlled by medulla
 Activities that increase metabolism increase respiratory
rate
 Note: rate, depth, rhythm, quality
Respiratory Rate
►
Normal: adult 12- 20
Infant (birth–1 year) 30–60
Toddler (1–3 years) 24–40
Preschooler (3–6 years) 22–34
School-age (6–12 years) 18–30
Adolescent (12–18 years) 12–16
►
►
<12 Bradypnea
>20 Tachypnea
Quality
► Dyspnea:




breathing with difficulty
Labored breathing
Pursed lips
Retractions: supraclavicular, intercostal
Flared nostrils
► Apnea:
Lack of spontaneous respirations
► Shortness of breath: subjective complaint
Respiratory Patterns
Blood Pressure
► Pressure
exerted by blood on vessel walls
► Systolic: represents ventricular contraction
► Diastolic: Ventricular relaxation
► Pulse pressure: Systolic – diastolic
► Normal:






One month
1 year
6 years
10– 13 years
14- 17 years
>18 years
85/54
95/65
105/65
110/65
120/75
120/80
Hypertension
► BP>
140/90 = Hypertension
► Essential: essentially we have no idea what is
causing it
► (AKA Primary HTN)
 Risk factors:
► Aging
► Family
history
► Smoking
► Obesity
► Heavy alcohol consumption
► Elevated blood cholesterol
► Chronic stress
Orthostatic Blood pressure
► Obtain
BP on both arms in supine position
► Leave BP cuff on arm with highest BP
► Have patient sit on edge of bed
► After 1-3 minutes re-take BP
► Leave cuff in place, assist pt to stand
► In 1 minute re-take BP
► Record pressures as lying, sitting, standing
How to take A Blood Pressure
► Patient
should be comfortable
► Choose appropriate cuff
► Place cuff on upper arm
► Pump cuff 30mmHg above where radial
pulse is obliterated
► Deflate cuff slowly
► Record the point at which the first sound is
heard and the last sound disappears
Factors that Influence BP
► Hemorrhage/
fluid depletion
► ICP
► Acute
pain
► ESRD
► General
► Exercise
► smoking
anesthesia
SaO2
► Oxygen
saturations are routinely done with
vital signs
► Oximeter is place on a warm finger with no
nail polish
► Measures the percent saturation of blood
► Normally >95%
Pain
► The
5th vital sign
► Many scales
► 0- 10 scale is most
common
Pain
► Assess
with every routine set of VS
► Before administering pain meds
► After administering pain meds
Height and Weight
► On
admission
► Do not take stated weights
Documentation
► Always
document vital signs
► Make sure time signature is correct
► Report abnormals to RN or MD
► Record what was done as a result of
abnormal findings