Chapter 16
VITAL SIGNS
Pam Diggens
Introduction
This chapter is concerned with taking
patients’ vital signs as well as factors that
may affect them.
Part 1 – Taking Patients’ Vital Signs
Part 2 – Temperature
Part 3 – Pulse Rate
Part 4 - Respirations
PART 1: Taking Patient’s Vital Signs
Taking Patients’ Vital Signs
Q. There are various reasons for taking patients’
temperature, pulse and respirations (TPR) – can
you identify any?
Remember, it is important to ensure you have
gained patients’ consent prior to taking their vital
signs (Nursing and Midwifery Council (NMC),
2004).
Reasons for Taking Patients’ Vital
Signs
• On admission, to provide a baseline which can
be compared with subsequent measurements,
thereby providing objective data and trends.
• To monitor effects of any treatment or
medication.
• To give an indication of patients’ “general”
condition, and help to identify changes or
deterioration. Patients’ conditions may change
rapidly or slowly over time.
(Perry and Potter, 2002
Remember, a baseline measurement may not
always be the person’s “normal”
measurement.
Remember, a baseline measurement may not
always be the person’s “normal” measurement.
A series of measurements is more useful than
a one off measurement, as it enables a trend
to be recorded. A trend is useful to help identify
and monitor potential problems. Wherever
possible, compare different vital sign trends as
these can also provide additional information.
Look at the following patients’ charts, which
show their vital sign measurements over a
period of time and trends of data.
Evidence-Based Practice
“Monitoring vital signs is often viewed as one
of the more mundane aspects of nursing
care, and is frequently devolved to healthcare
assistances and nursing students. However,
their immense value in patient care should
not be overlooked”
(Davidson & Barber, 2004, pp42)
Trends
Normal Adult Range for Vital
Signs
Q. Do you know the normal ranges for
temperature, pulse and respirations in
adults?
It is important to familiarise yourself with
these if your client base are adults, as this
will assist you to identify abnormal
measurements as well as recognise when
you need to report them to senior/qualified
staff.
Patients’ vital signs may fluctuate. It is
important to acknowledge that these normal
ranges should act as a “guide” and that any
factors that may affect individuals’
temperature, pulse and respiration rates
need to be taken into account. It is also
essential to taken into account that the
“normal” range may vary in certain patients
due to a chronic condition.
PART 2:
Temperature
Factors that Affect Temperature
Q. Before looking at the next slide, can you
identify any factors that might affect our
body temperature?
There are several factors that can affect daily
fluctuation of body temperature, which are:
circadian rhythm, age, exercise, food/drink
intake, hormones, drugs/medication, stress,
ovulation, stress and environmental extremes
in temperature.
1. CIRCADIAN RHYTHM
Generally, in health, a person’s temperature
fluctuates throughout the day. This is known as
the circadian rhythm. A person’s temperature
often rises during the evening and is lower during
the early hours of the morning.
2. AGE
As people age they become more sensitive to
extremely hot or cold environments, which can
affect body temperature. (Perry and Potter, 2002).
3. HORMONES
Hormones can affect our body temperature.
During ovulation, for example, women’s
temperatures can be raised. (Perry and Potter,
2002).
4. EXERCISE
Exercise increases heat production, which results
in an increased body temperature.
5. MEDICATION
Medication such as paracetamol can reduce body
temperature.
6. STRESS
Stress can have an impact on our nervous,
immune and endocrine systems and hence body
temperature. (Perry and Potter, 2002).
7. FOOD AND DRINK
Hot and cold food and drink may affect our
temperature.
8. CLIMATES
Environmental climates where individuals are
exposed to extreme temperature conditions may
result in them developing heat stroke or
hypothermia. Infants/children and elderly people
may be more susceptible to changes of climate.
(Perry and Potter, 2002).
Q. In your learning groups, consider how
the following two patients’ temperatures
might be affected.
1) An elderly patient who has been sitting
near an open window on a cold winters
day.
2) A young adult patient admitted with a
chest infection.
Q. Consider what type of thermometer and
site you would use to obtain a temperature
measurement in each of these three
situations.
1) An unconscious adult admitted with
hypothermia.
2) A breathless patient with a respiratory
problem.
3) A patient with an ear infection.
PART 3: Pulse Rate
Palpable Pulse Sites
Although the most common site used for
taking patients’ vital signs is the radial
(Massey, 2006), there are other sites at
which a pulse can be palpated.
Q. Can you name any and identify their
location on the body?
Look at the next slide – consider in what
situation you might need to palpate a pulse at
any of these sites.
Dorsalis pedis
Femoral
Posterior Tibia
Factors that Affect Pulse Rate
Q. Before you look at the next slide can
you identify any factors that can affect our
pulse rate?
Factors that Affect Pulse Rate
There are various physical, neural and
chemical factors that affect the heart rate
and, consequently, the pulse rate. (Marieb,
2004)
Some of the physiological factors that can
affect pulse rate include: age, gender,
exercise, and temperature. (Perry and
Potter, 2002; Marieb,2004)
As we get older our heart rate and, hence,
pulse decreases (Marieb, 2004)
Generally, male pulse rates are lower than
female. (Jarvis, 2004)
Exercise causes the sympathetic nervous
system to increase the heart rate, which
subsequently increases the pulse rate.
(Marieb,2004)
Temperature can affect the pulse rate; in cold
conditions heart and pulse rate are decreased.
(Marieb,2004)
Practical Tips
When feeling for the pulse, you need to be aware of
certain characteristics, such as rate, strength and rhythm.
Make sure you count for one full minute (Castledine,
2006), as this will ensure that any irregular rhythms are
detected.
Tachycardia is a term used when the heart rate and
pulse rates are greater than 100 beats per minute (bpm).
Conversely, a rate slower that 60 bpm is referred to as
bradycardia (Marieb,2004).
It can take time to develop skills needed to determine
pulse strength. If you are in any doubt, always get your
mentor or a qualified member of staff to check.
Be aware that some individuals may be extremely fit
and as a result may have resting pulse rates slower
than 60 bpm. In particular, trained athletes can have
resting rates of 40 bpm. (Marieb,2004)
In some situations you may see or have to palpate
pulses simultaneously, bilaterally (both sides). You
must never palpate both carotid pulses at the same
time as this can occlude blood flow to the brain
causing the patient to black out. (Bickley and Szilaygi,
2003).
PART 4: Respiration
Factors that Affect Respirations
Q.Before you look at the next slide can you
identify any factors that can affect our
respiration?
Factors that Affect Respirations
There are a variety of factors that can affect
respirations. These include: exercise, pain,
smoking, certain medications and body
position.
Exercise increases the body’s demand for
oxygen, so the rate and depth of respirations
likewise increases.
Respiration rate and rhythm can be altered
by pain.
Changes in the pulmonary system may
occur due to smoking, causing respiratory
rate to be increased.
Certain medication used in general
anaesthetics may cause the respiratory rate
and depth to be decreased.
Patients who are slumped in their
beds/chairs or lying flat have restricted lung
movement and expansion. (Perry and
Potter, 2002)
Evidence-Based Practice
A change in respiration rate, in
conjunction with changes in heart rate,
can often be an early indicator that there
is a deterioration in the patient’s condition.
(Goldhill et al, 1999)..
Any abnormalities should be reported
immediately, as the patient may be at risk
of deteriorating.(Hogan, 2006)
Q. Look at the next slide which has Susan
Jones’ chart, showing her vital sign
measurements over the past 13 hours.
What do you see?
Consider what action you would take in
this situation.
Answer
Susan Jones’ chart shows the measurements recorded
for her vital signs over the past 13 hours. This collection
of vital signs enables trends to become visible.
Observing her chart, you can see that her pulse rate has
increased to 110 beats per minute (bpm), which is above
the normal range. A rate greater than 100 bpm is known
as tachycardia. Her respiration rate has also increased to
30 breaths per minute (bpm) and is termed tachypnoea.
Unless anyone has already done so, you would need to
report this to a qualified nurse or senior member of staff
as a matter of urgency. Susan’s condition could
potentially deteriorate and she needs to be fully reassessed.