Chapter 26:
Vital Sign Assessment
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Body Temperature
• Humans maintain a consistent internal
body temperature.
• Core temperature: Temperature inside
the body; normal body temperature
ranges between 36.5º and 37.5ºC
(97.6º and 99.6ºF)
• Regulation of core body temperature
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Body Temperature
• Heat production
– Metabolism
– Heat is lost through four processes:
•Radiation; Conduction
•Convection; Evaporation
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Body Temperature
• Factors affecting body temperature
– Age; Environment
– Time of day
– Exercise
– Stress
– Hormones
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Body Temperature
• Factors affecting body temperature
measurement
– Smoking
– Oxygen administered by mask or
cannula
– Intake of hot or cold liquids
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Body Temperature
• Assessing body temperature
– Sites
•Oral; Rectal; Ear
•Temporal artery (forehead)
•Axillary
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Body Temperature
• Equipment
– Electronic thermometers
– Tympanic membrane thermometer
– Temporal artery thermometer
– Disposable paper thermometers
– Temperature-sensitive strips
– Glass mercury thermometer
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Body Temperature
• Scales: Temperature can be measured
on the Celsius or Fahrenheit scale
• Methods: Nurses use critical thinking to
interpret temperature measurements,
document the results, and report
abnormal values
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Question
What is the term used for normal
respiratory rhythm and depth in a client?
a. Eupnea
b. Apnea
c. Bradypnea
d. Tachypnea
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Answer
a. Eupnea
Rationale: Eupnea is the term used for
normal respiratory rhythm and depth in
a client. Apnea is the absence of
respirations in a client. Tachypnea is an
abnormally fast respiratory rate and
bradypnea is an abnormally slow
respiratory rate in an adult client.
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Pulse
• Characteristics
– Rate or frequency; Rhythm; Quality
• Factors affecting pulse rate
– Age
– Autonomic nervous system
– Medications
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Pulse
• Assessing the pulse
– Sites
•Temporal; Carotid
•Apical; Brachial
•Radial; Popliteal
•Pedal; Posterior tibial
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Pulse
• Equipment
– Stethoscope
– Doppler
• Methods
– Palpation
– Auscultation
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Pulse
• Assessing pulse characteristics
– Dysrhythmic: Any pulse out of the
range of normal rate or rhythm
– Rate: Normal adult pulse rate; 60 to
100 pulsations per minute
•Tachycardia; Bradycardia
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Pulse
• Assessing pulse characteristics (cont’d)
– Rhythm
– Quality
– Pulse deficits
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Question
Tell whether the following statement is
True or False.
Cardiac medications like digoxin increase
pulse rate in clients.
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Answer
False.
Cardiac medications like digoxin
decrease pulse rate, whereas atropine
inhibits parasympathetic input, causing
increased pulse rate in clients.
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Respirations
• External respiration
• Tidal volume: Amount of air moving in
and out with each breath
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Respirations
• Factors affecting respirations
– Age
– Medications
– Stress
– Exercise
– Altitude
– Gender
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Respirations
• Assessing respirations
– Rate
– Rhythm and depth
– Quality: Usually automatic, quiet,
and effortless
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Respirations
• Dyspnea
• Methods: Perform the respiratory
assessment without clients being aware
of the assessment
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Blood Pressure
• Physiologic factors determining blood
pressure
– Systolic blood pressure
– Diastolic blood pressure
– Pulse pressure
– Blood flow
– Resistance
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Blood Pressure
• Factors affecting blood pressure
– Age
– Autonomic nervous system
– Circulating volume
– Medications
– Normal fluctuations
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Blood Pressure
• Assessing blood pressure
– Sites
•Upper extremity
•Lower extremity
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Blood Pressure
• Equipment
– Sphygmomanometer
– Stethoscope
– Doppler
– Electronic devices
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Blood Pressure
• Methods
– Proper cuff size
– Proper positioning
– Correlation with the respiratory
cycle
– Proper inflation and deflation
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Blood Pressure
• Methods (Cont’d)
– Auscultation: Korotkoff sounds can
be heard with a stethoscope placed
over the artery
– Palpation: When Korotkoff sounds
are inaudible, blood pressure may
be estimated by palpation
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Blood Pressure
• Abnormalities
– Hypertension
– Prehypertension
– Hypotension
– Orthostatic hypotension
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Question
What is the term used for a high-pitched
musical sound in clients during a
respiratory assessment?
a. Crowing
b. Wheezing
c. Stridor
d. Sigh
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Answer
b. Wheezing
Rationale: The term used for a highpitched musical sound in clients is
wheezing. Stridor is a harsh inspiratory
sound that may also be compared to
crowing. Sighs are breaths of deep
inspiration and prolonged expiration.
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Documenting Vital Signs
• Vital signs
– Documented in a graph format, with
time as the horizontal axis and the
measured value as the vertical axis
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Lifespan Considerations
• Newborn and infant
• Toddler and preschooler
• School-age child and adolescent
• Adult and older adult
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