NRG 203
WEEK 1
VITAL SIGNS
• Body temperature, pulse, respirations, and Blood Pressure
• Monitor functions of the body
-Vital signs are a quick and efficient way of monitoring a patient's condition or identifying
problems and evaluating his or her response to intervention.
-Vital signs and other physiological measurements are the basis for clinical decision
making and problem solving.
-Measurement of vital signs provides data to determine a patient's usual state of health (baseline
data
When to Assess Vital Signs
• On admission
• Change in client’s health status
• Client reports symptoms such as chest pain, feeling hot, or faint
• Pre and post surgery/invasive procedure
• Pre and post medication administration that could affect CV system
• Pre and post nursing intervention that could affect vital signs
Body Temperature
• Reflects the balance between the heat produced and the heat lost
from the body
• Measured by heat units called degrees
Factors Affecting Body Temperature
● Age
• Exercise
• Hormones
• Stress
• Environment
Alterations in Body Temperature
• Pyrexia, Hyperthermia, Fever - body temperature above the
usual range
• Febrile - a client who has a fever
• Afebrile - a client who does not have fever
• Hypothermia - core body temperature below the lower limit
of normal
Pulse
• Is a wave of blood created by contraction of the left ventricle of
the heart
• Represents the amount of blood that enters the arteries with each
ventricular contraction
• Peripheral pulse- a pulse located away from the heart Ex. Foot or
wrist
• Apical pulse- is the central pulse that is located at the apex of the
heart
Factors Affecting Pulse
• Age
• Gender
• Exercise
• Fever
• Medications
• Hypovolemia
• Stress
• Position changes
• Pathology
Factors Affecting Respirations
• Exercise
• Stress
• Environmental temperature
• Medications
Factors Affecting Blood Pressure
• Age
• Exercise
• Stress
• Race
• Gender
• Medications
• Obesity
• Disease process
Temperature: Lifespan Considerations
Unstable Newborns must be kept warm to prevent hypothermia
Tympanic or temporal artery sites preferred
Tends to be lower than that of middle-aged adults
Pulse: Lifespan Considerations
Newborns may have heart murmurs that are not pathological
The apex of the heart is normally located in the fourth
intercostal space in young children; fifth intercostal space
in children 7 years old and older
Often have decreased peripheral circulation
Respirations: Lifespan Considerations
Some newborns display “periodic breathing”
Diaphragmatic breathers
Anatomic and physiologic changes cause
respiratory system to be less efficient
Blood Pressure: Lifespan Considerations
Arm and thigh pressures are equivalent under 1 year of age
Thigh pressure is 10 mm Hg higher than arm
Client’s medication may affect how pressure is taken
Sites for Measuring Body Temperature
• Oral
• Rectal
• Axillary
• Tympanic membrane
• Skin/Temporal artery
Types of Thermometers
• Electronic
• Chemical disposable
• Infrared (tympanic)
• Scanning infrared (temporal artery)
• Temperature-sensitive tape
• Glass mercury
Nursing Care for Fever
• Monitor vital signs
• Assess skin color and temperature
• Monitor laboratory results for signs of dehydration or infection
• Remove excess blankets when the client feels warm
•Provide adequate nutrition and fluid
• Measure intake and output
• Reduce physical activity
• Administer antipyretic as ordered
• Provide oral hygiene
• Provide a tepid sponge bath
• Provide dry clothing and bed linens
Nursing Care for Hypothermia
• Provide warm environment
• Provide dry clothing
• Apply warm blankets
• Keep limbs close to body
• Cover the client’s scalp
• Supply warm oral or intravenous fluids
• Apply warming pads
Pulse Sites
Readily accessible
When radial pulse is not accessible
During cardiac arrest/shock in adults
Determine circulation to the brain
Infants and children up to 3 years of age
Discrepancies with radial pulse
Monitor some medications
Pulse Sites
Blood pressure Cardiac arrest in infants
Cardiac arrest/shock
Circulation to a leg;
Circulation to a leg;
Circulation to lower leg
Circulation to the foot
Circulation to the foot
Characteristics of the Pulse
• Rate tachycardia- over 100 BPM
bradycardia- less than 60 BPM
• Rhythm dysrhytmia or arrhythmia- irregular pulse
• Volume force of blood with each beat absent to bounding
• Arterial wall elasticity •
Bilateral equality
Pulse Rate and Rhythm
Rate Rhythm
– Beats per minute – Equality of beats and intervals
between beats
– Tachycardia
– Dysrhythmias
– Bradycardia
– Arrhythmia
Characteristics of the Pulse
• Volume – Strength or amplitude – Absent to bounding
• Arterial wall elasticity – Expansibility or deformity
• Presence or absence of bilateral equality – Compare corresponding artery
Inhalation
• Diaphragm contracts (flattens)
• Ribs move upward and outward
• Sternum moves outward
• Enlarging the size of the thorax
Exhalation
● Diaphragm relaxes
• Ribs move downward and inward
• Sternum moves inward
• Decreasing the size of the thorax
Respiratory Control Mechanisms
• Respiratory centers
– Medulla oblongata
– Pons
Components of Respiratory Assessment
• Rate
• Depth
• Rhythm
• Quality
• Effectiveness
Respiratory Rate and Depth
• Depth
• Rate
– Normal
– Breaths per minute
– Deep
– Apnea
– Shallow
– absence of breathing
– Bradypnea abnormally slow respirations
– Tachypnea abnormally fast respirations
Components of Respiratory Assessment
• Rhythm • Effectiveness
– Regular
– Uptake and transport of O2
– Irregular
– Transport and elimination of CO2
• Quality
– Effort
– Sounds
Alteratered Breathing Patterns
• Rate • Volume
– Tachypnea -Hyperventilation
– quick, shallow breaths - overexpansion of the lungs
– Bradypnea- abnormally characterized by rapid and deep
shallow breathing breaths
– Apnea- absence or cessation of -Hypoventilation
breathing
- underexpansion of the lungs
characterized by shallow respirations
Alteratered Breathing Patterns
• Rhythm • Ease or Effort
– Cheyne- Stroke breathing – Dyspnea- difficult and labored
- rhythmic waxing and waning of breathing during which the
respirations, from very deep to very individual has a persistent,
shallow breathing and temporary unsatisfied need for air and feels
apnea distressed
– Orthopnea- ability to breathe
only in upright sitting or standing
positions
Alteratered Breath Sounds
• Stridor
– a shrill, harsh sound heard during inspiration with laryngeal obstruction
• Wheeze
- continuous, high pitched musical squeak or whistling sound occuring on expiration
Systolic and Diastolic Blood Pressure
• Systolic – Contraction of the ventricles
• Diastolic – Ventricles are at rest – Lower pressure present at all times
• Pulse Pressure = difference between systolic and diastolic pressures
• Measured in mm Hg
• Recorded as a fraction, e.g. 120/80
• Systolic = 120 and Diastolic = 80
Korotkoff’s Sounds
• Phase 1 – First faint, clear tapping or thumping sounds
– Systolic pressure
• Phase 2 – Muffled, whooshing, or swishing sound
• Phase 3 – Blood flows freely – Crisper and more
intense sound – Thumping quality but softer than in
phase 1
• Phase 4 – Muffled and have a soft, blowing sound
• Phase 5 – Pressure level when the last sound is heard –
Period of silence – Diastolic pressure
Measuring Blood Pressure
• Direct (Invasive Monitoring)
• Indirect – Auscultatory – Palpatory
• Sites – Upper arm (brachial artery) – Thigh (popliteal artery)
Video taking vital signs
https://www.youtube.com/watch?v=gUWJ-6nL5-8&t=100s
Resources • Audio Glossary • HyperHEART Shows the heart pumping and talks about
diastolic and systolic cycles. Has tutorials for atrial systole and others. Very fun site. •
Best Practice--Vital Signs Reviews research studies related to vital signs. Covers all
aspects of vital signs and even gives implications for practice and recommendations. •
The Medical Center--Vital Signs Provides an overview of vital signs. Nicely done.
