Chapter 12
Vital Signs
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Vital Signs
• Body temperature
• Pulse
• Respiratory rate
• Blood pressure
• Pain
– Fifth vital sign
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Question
• Is the following statement true or false?
Pain is considered as the fifth vital sign.
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Answer
True.
Pain is considered the fifth vital sign. The
other vital signs include body temperature,
pulse, respiratory rate, and blood pressure.
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Assessing a Client’s Health Status
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Body Temperature
• Shell temperature: the warmth at the skin
surface
• Core temperature: the warmth in deeper
sites within the body like the brain and heart
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Factors Affecting Body Temperature
• Food intake, age, gender
• Climate, exercise and activity
• Circadian rhythm
• Emotions
• Illness or injury
• Medications
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Temperature Measurement
• Fahrenheit scale: uses 32˚F as the
temperature at which water freezes and
212˚F as the point at which it boils
• Centigrade scale: uses 0˚C as the
temperature at which water freezes and
100˚C as the point at which it boils
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Normal Body Temperature
• In normal, healthy adults, shell
temperature generally ranges from 96.6˚F
to 99.3˚F or 35.8˚C to 37.4˚C
• Chances of survival diminish if body
temperatures exceed 110˚F (43.3˚C) or fall
below 84˚F (28.8˚C)
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Normal Body Temperature (cont’d)
• Based on temperature, animals are either:
– Poikilothermic: temperature fluctuates
depending on environmental temperature
– Homeothermic: structural and physiologic
adaptations keep body temperature
within a narrow stable range
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Assessment Sites
• Accurate assessment site: Brain, heart,
lower third of the esophagus, and urinary
bladder
• Practical and convenient assessment sites:
– Ear, temporal artery (on forehead or
behind ear lobe), mouth, rectum, and
axilla
– Ear, temporal artery provide the
temperature closest to the core
temperature
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Clinical Thermometers
• Instruments used to measure body
temperature
– Electronic
– Infrared
– Chemical
– Digital
– Glass
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Types of Clinical Thermometers
(Refer to Table 12-3 in the textbook.)
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Electronic Thermometers
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Infrared Tympanic Thermometer
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Chemical Thermometer
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Automated Monitoring Devices
• Equipment that allows for the simultaneous
collection of multiple data
• Measure the temperature, blood pressure,
pulse, heart rhythm, and pulse oximetry
• Portable to save time and money
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Continuous Monitoring Devices
• Used primarily in critical care areas
• Measure body temperature using internal
thermistor probes within the esophagus of
anesthetized clients, inside the bladder, or
attached to a pulmonary artery catheter
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Elevated Body Temperature
• Fever is a condition in which the body
temperature exceeds 99.3˚F (37.4˚C)
• Pyrexia is a condition in which the
temperature is warmer than the normal
set point
• Hyperthermia is a condition in which core
temperature is excessively high and the
temperature exceeds 105.8˚F (40.6˚C)
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Symptoms of Fever
• Pinkish, red (flushed) skin that is warm
to the touch
• Restlessness in some; excessive
sleepiness in others
• Irritability; poor appetite
• Glassy eyes and sensitivity to light
• Increased perspiration
• Headache
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Symptoms of Fever (cont’d)
• Above-normal pulse and respiratory rates
• Disorientation and confusion (when the
temperature is high)
• Convulsions in infants and children (when
the temperature is high)
• Fever blisters about the nose or lips in
clients who harbor the herpes simplex virus
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Phases of Fever
• Prodromal phase
• Onset or invasion phase
• Stationary phase
• Resolution or defervescence phase
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Phases of Fever and
Physiologic Changes
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Question
• Is the following statement true or false?
Fever is a condition where the body
temperature exceeds 105.8˚F.
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Answer
False.
Fever is a condition where the body
temperature exceeds 99.3˚F.
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Hypothermia
• Core body temperature less than 95˚F
(35˚C)
• Mildly hypothermic: 95˚F to 93.2˚F (35˚C
to 34˚C)
• Moderately hypothermic: 93˚F to 86˚F
(33.8˚C to 30˚C)
• Severely hypothermic: below 86˚F (30˚C)
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Symptoms of Hypothermia
• Shivering until body temperature is
extremely low
• Pale, cool, and puffy skin
• Impaired muscle coordination
• Listlessness and irregular heart rhythm
• Slow pulse and respiratory rates
• Incoherent thinking and diminished pain
sensation
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Pulse
• Produced by the movement of blood during
the heart’s contraction
• In most adults, the heart contracts 60 to
100 times per minute at rest
– Pulse rhythm
– Pulse volume
– Pulse rate
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Pulse Assessment Techniques
• Primary pulse assessment site: radial artery
located at inner (thumb) side of the wrist
• Alternate assessment techniques
– Counting the apical heart rate
– Obtaining an apical–radial rate
– Using a Doppler ultrasound device over a
peripheral artery
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Peripheral Pulse Sites
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Respiration
• Exchange of oxygen and carbon dioxide
• Respiratory rate is the number of
ventilations per minute
• Cheyne-Stokes respiration: a breathing
pattern in which the depth of respirations
gradually increases, followed by a gradual
decrease, and then a period when breathing
stops briefly before resuming again
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Respiratory Rate
• Rapid respiratory rate
– Tachypnea accompanies elevated
temperature or diseases affecting cardiac
and respiratory systems
• Slow respiratory rate
– Bradypnea can result from medications;
observed in clients with neurologic
disorders or hypothermia
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Abnormal Breathing Characteristics
• Hyperventilation
• Hypoventilation
• Dyspnea
• Orthopnea
• Apnea
• Stertorous breathing
• Stridor
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Blood Pressure
• Force that the blood exerts within the
arteries
• Lower-than-normal volumes of circulating
blood cause a decrease in blood pressure
• Excess volumes cause an increase in
blood pressure
• Regular aerobic exercise increases tone of
heart muscle and increases efficiency
• Cardiac output
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Blood Pressure (cont’d)
• Cardiac output is approximately 5 to 6 L
in adults at rest
• Blood pressure measurements provide
physiologic data about:
– Ability of arteries to stretch
– Volume of circulating blood
– Amount of resistance heart must
overcome when it pumps blood
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Factors Affecting Blood Pressure
• Age
• Circadian rhythm
• Gender
• Exercise and activity
• Emotions and pain
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Factors Affecting Blood Pressure
(cont’d)
• Lower blood pressure
– Lower when lying down than when sitting
or standing
• Higher blood pressure
– When urinary bladder is full, when the
legs are crossed, when the person is cold
– When drugs that stimulate the heart are
taken
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Pressure Measurements
• Systolic pressure
• Diastolic pressure
• Blood pressure is expressed in millimeters
of mercury (mm Hg) as a fraction; systolic
pressure/diastolic pressure
• Pulse pressure: difference between systolic
and diastolic blood pressure measurements
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Assessment Sites
• Usually assessed over the brachial artery
• Lower arm and radial artery
• Measured over the popliteal artery behind
the knee in case:
– Client’s arms are missing
– Both of a client’s breasts have been
removed
– Client has had vascular surgery
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Equipments for Measuring
Blood Pressure
• Sphygmomanometer
• Aneroid manometer
• Electronic oscillometric manometer
• Inflatable cuff
• Stethoscope
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Aneroid and Electronic
Oscillometric Manometer
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Measuring Blood Pressure
• Phase I: first faint but clear tapping sound
that follows a period of silence as pressure
is released from the cuff
• Phase II: change from tapping sounds to
swishing sounds
• Phase III: change to loud and distinct
sounds—crisp knocking sounds
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Measuring Blood Pressure (cont’d)
• Phase IV: sounds muffled and has a
blowing quality—first diastolic pressure
measurement
• Phase V: point at which the last sound is
heard—second diastolic pressure
measurement
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Characteristics of Korotkoff Sounds
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Question
• Is the following statement true or false?
First diastolic pressure measurement is
taken at phase III of Korotkoff sounds.
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Answer
False.
First diastolic pressure measurement is taken
at phase IV of Korotkoff sounds.
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Alternate Techniques for
Assessing Blood Pressure
• Palpation
• Using a Doppler stethoscope
• Automatic blood pressure monitoring
• Measuring thigh blood pressure
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Abnormal Blood Pressure
Measurements
• Blood pressures above or below normal
ranges indicate significant health problems
• Hypertension: high blood pressure
• Hypotension: low blood pressure
• Postural or orthostatic hypotension: sudden
but temporary drop in blood pressure when
rising from a reclining position
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Abnormal Blood Pressure
Measurements (cont’d)
• Hypertension or high blood pressure is
associated with:
– Anxiety
– Obesity
– Vascular diseases
– Stroke, heart failure
– Kidney diseases
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Documenting Vital Signs
• Once vital sign measurements are obtained:
– Document the data in medical record for
analysis of patterns and trends
– Enter the data, along with any other
subjective or objective information in
narrative nursing notes
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Nursing Implications
• Vital sign assessment is the basis for
identifying problems
• Nurses identify from the nursing diagnoses:
– Hyperthermia, hypothermia, ineffective
thermoregulation, decreased cardiac
output, risk for injury, or ineffective
breathing pattern
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Gerontologic Considerations
• Lower “normal” or baseline temperature
• Changes in thermoregulation system
• Delayed or diminished febrile response to
illnesses
• Change in cognitive function, restlessness,
or anxiety may be initial sign of illness
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Gerontologic Considerations (cont’d)
• Susceptible to hypothermia and heatrelated conditions; elevated blood pressure
readings in clinical settings
• Blood pressure assessment in bilateral
arms; document subsequent trends
• Older adults are more susceptible to
arrhythmias and postural and postprandial
hypotension
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Gerontologic Considerations (cont’d)
• If older client is hypotensive, plan for
limited activities during the hour following
eating or for frequent smaller food
consumption throughout the day
• More profound responses to cardiovascular
medications than younger adults
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