Introduction
 Assessing vital signs or cardinal sign is a routine medical
procedure. And somehow determines the internal functions
of the body
 Vital signs composes of the following:
 Body temperature
 Pulse
 Respiration and
 Blood pressure
 pain
Vital Signs
(continued)
Abbreviations:
 Temperature – T
 Pulse – P
 Respirations – R
 Blood Pressure – BP
 Vital signs - TPR and
3
BP
Vital Signs
(continued)
Purpose
Measured to
detect any
changes in normal
body function
Used to
determine
response to
treatment
4
Assessing a Client’s Health Status
Body Temperature
 Body
temperature
◦ It is a balance between the internal and external
environment of the body, or
◦ It is the balance between the heat produced by the
body and the heat lost from the body.
◦ It is measured in heat units, called degrees
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
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
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)
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
Factors Affecting Body Temperature






Food intake, age, gender
Climate, exercise
Circadian rhythm
Emotions
Illness
Medications
Assessment Sites
Accurate assessment site:
◦ Brain, heart, lower third of the esophagus,
and urinary bladder
 Practical and convenient assessment sites:
◦ Ear, mouth, rectum, and axilla
◦ Ear provides the temperature closest to the
core temperature

Digital thermometer is commonly
used in infants and children, insert it
at the axillary region
closed the arm and wait for timer to
bustle
Remember when taking BT in infants and children make
sure that the patient is not in distress mood because any
change in the activity will directly affect the BT reading.
The Oral Cavity
Parts: Oral Vestibule and Oral Cavity
Proper
Floor of the mouth
Insert the tip at the sublingual fossa
Positioned the thermometer
Let stay for 1 to 2 minutes, tell the
patient to close the mouth
Clinical Thermometers
 Instruments used to measure body temperature





Electronic
Infrared
Chemical
Digital
Glass
Types of Clinical Thermometers
(Refer to Table 12-3 in the textbook.)
Electronic Thermometers
Infrared Tympanic Thermometer
Chemical Thermometer
Digital Thermometer
Glass thermometer (Glass)
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
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
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)
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
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
Phases of Fever

Prodromal phase

Onset or invasion phase

Stationary phase

Resolution or defervescence phase
Phases of Fever and
Physiologic Changes
Question

Is the following statement true or false?
Fever is a condition where the body
temperature exceeds 105.8˚F.
Answer
False.
Fever is a condition where the body
temperature exceeds 99.3˚F.
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)
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
Pulse Rate
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

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

Variations in Pulse Rate
Age
Average
Range
Newborn to 1
month
130
80-180
1 year
120
80-140
2 years
110
80- 130
6 years
100
75- 120
10 years
70
50-90
Adult
80
60- 100
Pulse rate/
Minute
Kozier Barbara, et.al. Fundamentals of Nursing , 5th ed. (US Addison-Wesley Publishing
Company, Inc. 1995) p. 438
Peripheral Pulse Sites
5. The pulse is normally palpated by
applying are moderate pressure with
the three fingers of the hand.
6. The pads of the most distal aspect
of the fingers are the most sensitive
areas of detecting the pulse.
Pulse site
Reasons for Use
Radial
Readily accessible & routinely used
Temporal
Used when radial pulse is not accessible
Carotid
Used for infants, in cases of cardiac arrest and to determine the
circulation to the brain
Apical
Routinely used in infants and children up to 3 years of age, Used to
determine the discrepancies with radial pulse, and Used in
conjunction with some medication
Brachial
Used to measure blood pressure, used for cardiac arrest for infants
Femoral
Used in cases of cardiac arrest, for infants and children, determine
circulation in the leg
Popliteal
Used to determine the circulation in the lower leg and leg blood
pressure
Posterior tibial
Used to determine the circulation in the foot
Pedal
Used to determine circulation in the foot
Respiration
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
Abnormal Breathing Characteristics
• Hyperventilation
• Hypoventilation
• Dyspnea
• Orthopnea
• Apnea
• Stertorous breathing
• Stridor
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
Variations in Respiratory
rate
Age
Average
Range
Newborn
35
30-80
1 year
30
20-40
2 years
25
20-30
8 years
20
15-25
16 years
18
15-20
Adult
16
12-20
Respiratory rate/
Minute
Kozier Barbara, et.al. Fundamentals of Nursing , 5th ed. (US Addison-Wesley Publishing Company,
Inc. 1995) p. 448
BLOOD PRESSURE
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
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
Factors Affecting Blood Pressure

Age

Circadian rhythm

Gender

Exercise and activity

Emotions and pain
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
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

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
Equipments for Measuring
Blood Pressure

Sphygmomanometer

Aneroid manometer

Electronic oscillometric manometer

Inflatable cuff

Stethoscope
Aneroid and Electronic
Oscillometric Manometer
Alternate Techniques for
Assessing Blood Pressure
Palpation
 Using a Doppler stethoscope
 Automatic blood pressure monitoring
 Measuring thigh blood pressure

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

Abnormal Blood Pressure Measurements
(cont’d)

Hypertension or high blood pressure is
associated with:
◦ Anxiety
◦ Obesity
◦ Vascular diseases
◦ Stroke, heart failure
◦ Kidney diseases
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
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

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

Gerontologic Considerations (cont’d)

Susceptible to hypothermia and heat-related
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
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
Aneroid manometer with stethoscope
Part of the sphygmomanometer
Mercury manometer and cuff
Aneroid manometer and cuff
Variations in BP by Age
Age
Mean BP (mm Hg)
Newborn
73/55
1 year
90/55
6 years
95/57
10 years
102/62
14 years
120/80
Adult
120/80
Elderly (over 70 years)
Diastolic pressure may increase
Kozier Barbara, et.al. Fundamentals of Nursing , 5th ed. (US Addison-Wesley Publishing
Company, Inc. 1995) p. 452
The End
My best wishes educator : Ekhlas abu hasna