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 Vital Signs

• Monitor functions of the body

• Should be a thoughtful, scientific
assessment

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 Introduction

• The traditional vital signs are body

temperature, pulse, respirations, and blood
pressure.
• Many agencies have designated pain as a
fifth vital sign, to be assessed at the same
time as each of the other four.
• saturation is also commonly measured at the
same time as the traditional vital signs and
could be considered the sixth vital sign.
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 When to Assess Vital Signs?
• On admission
• Change in client’s health status
• Client reports symptoms such as chest pain,
feeling hot, or faint
• Before and after surgery/invasive procedure
• Before and after medication administration that
could affect respiratory or CV system
• Before and after nursing intervention that could
affect vital signs

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 1. Temperature

Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc.
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• Body temperature reflects the balance between the heat produced and the
heat lost from the body, and is measured in heat units called degrees.

• There are two kinds of body temperature:

1. core temperature: the temperature of the deep tissues of the body, such as
the abdominal cavity and pelvic cavity. It remains relatively constant. The
normal core body temperature is a range of temperatures (36-37.5)

2. surface temperature: the temperature of the skin, the subcutaneous tissue,

and fat. It, by contrast, rises and falls in response to the environment.

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factors affect the body’s heat
production
1. Basal metabolic rate. The basal metabolic rate (BMR) is the rate of energy utilization in
the body required to maintain essential activities such as breathing. Metabolic rates
decrease with age. In general, the younger the client, the higher the BMR.

2. Muscle activity. Muscle activity, including shivering, increases the metabolic rate.

3. Thyroxine output. Increased thyroxine output increases the rate of cellular metabolism
throughout the body.

4. Epinephrine and norepinephrine and sympathetic nervous system stimulation

(such as with stress). Epinephrine and norepinephrine immediately increase the rate of
cellular metabolism in many body tissues.

5. Fever. Fever increases the cellular metabolic rate and thus increases the body’s
temperature further.

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 Heat loss and Production
Heat is lost from the body through radiation, conduction, convection, and
evaporation.

1. Radiation is the transfer of heat from the surface of one object to the surface of
another without contact between the two objects, mostly in the form of infrared rays.

2. Conduction is the transfer of heat from one molecule to a molecule of lower

temperature. Conductive transfer cannot take place without contact between the
molecules and normally accounts for minimal heat loss except, for example, when a
body is immersed in cold water. The amount of heat transferred depends on the
temperature difference and the amount and duration of the contact.

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3. Convection is the dispersion of heat by air currents. The body usually has a
small amount of warm air adjacent to it. This warm air rises and is replaced by
cooler air, so people always lose a small amount of heat through convection.

4. Evaporation is continuous vaporization of moisture from the respiratory tract

and from the mucosa of the mouth and from the skin.

This continuous and unnoticed water loss is called insensible water loss, and
the accompanying heat loss is called insensible heat loss.

Insensible heat loss accounts for about 10% of basal heat loss. When the body
temperature increases, vaporization accounts for greater heat loss.

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 Factors Affecting Body
Temperature
Age: Infants are greatly influenced by the temperature of the environment and must be
protected from extreme changes. Older adults are also particularly sensitive to extremes
in the environmental temperature due to decreased thermoregulatory controls.

Diurnal variations (circadian rhythms): Body temperatures normally change throughout

the day, varying as much as 1.0°C (1.8°F) between the early morning and the late
afternoon.

Exercise:

Hormones: In women, progesterone secretion at the time of ovulation raises body

temperature by about 0.3°C to 0.6°C (0.5°F to 1.0°F) above basal temperature.

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 Stress: Stimulation of the sympathetic
nervous system can increase metabolic
activity and heat production.

Nurses should anticipate that a highly

stressed or anxious client could have an
elevated body temperature for that reason.

Environment

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 Alterations in Body Temperature

Normal range
•96.8°F to 99.5°F (36°c-37.5 °c)
Pyrexia: A body temperature The client who has a fever is
above the usual range (also referred to as febrile; the one
called hyperthermia, fever) who does not is afebrile

The three physiologic

mechanisms of hypothermia are
Hypothermia: is a core body (a) excessive heat loss, (b)
temperature below the lower inadequate heat production to
limit of normal. counteract heat loss, and (c)
impaired hypothalamic
thermoregulation.

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 Clinical Manifestations Fever

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 Box 29-2
Nursing
Interventions
for Clients with
Fever

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Nursing Interventions Monitor vital signs
for Fever

Assess skin color and

temperature

Monitor laboratory results

for signs of dehydration or
infection

Remove excess blankets

when the client feels warm

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 Provide adequate nutrition and fluid
Nursing Interventions
for Fever (cont'd)
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

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 Clinical Manifestations Hypothermia

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 Provide warm Provide dry
Nursing Interventions environment clothing
for Hypothermia

Apply warm Keep limbs close

blankets to body

Supply warm oral

Cover the client’s
or intravenous
scalp
fluids

Apply warming
pads

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 Sites for Measuring
Body Temperature
• Oral: If a client has been taking cold or hot food or fluids or smoking,
the nurse should wait 30 minutes before taking the temperature orally

• Rectal: considered to be very accurate

• Axillary: the preferred site for measuring temperature in newborns
because it is accessible and safe. Axillary temperatures are lower than rectal
temperatures.

• Tympanic membrane : or nearby tissue in the ear canal, is

a frequent site for estimating core body temperature. However, proper
technique must be used. If the probe fits too loosely in the ear canal, the
reading can be lower than the true value. If too tight, the probe can be
uncomfortable

• Skin/Temporal artery : Forehead.

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 Types of Thermometers

• Electronic
• Chemical disposable
• Temperature-sensitive tape
• Infrared (tympanic)
• Temporal artery

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 Temperature Scales

• Can be measured in Centigrade or

Fahrenheit.
• To convert from F to C:

• To convert from C to F:

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 Delegation

• Body temperature
– Routine measurement may be delegated to
UAP
– UAP reports abnormal temperatures
– Nurse interprets abnormal temperature and
determines response

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 Documentation

• Record in client’s record

• Use a graphic sheet
• “R” for rectal
• “AX” for axillary or “X”

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 Temperature: Lifespan Considerations

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 Temperature: Lifespan Considerations

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 2. Pulse

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 Factors Affecting Pulse

Sex: After puberty, the

Age: As age increases, the Exercise: The pulse rate
average male’s pulse rate
average pulse rate normally increases with
is slightly lower than the
gradually decreases. activity (exc. Athletes)
female’s

Fever: increased PR
because of a) the lowered
BP caused by peripheral Hypovolemia/dehydration:
vasodilation associated Medications to compensate the cardiac
with elevated body output.
temperature, (b) increased
metabolic rate.

Stress Position* Pathology

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Figure 29-13 Nine sites for assessing pulse.

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 Rate
Characteristics of the
Pulse

Rhythm

Volume

Arterial wall elasticity

Bilateral equality

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 Pulse Rate and Rhythm

Rate Rhythm
Tachycardia Pattern of beats and intervals between
Bradycardia beats
Dysrhythmia
Arrhythmia

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 normal pulse can be felt
Characteristics of the with moderate pressure of
the fingers and can be
Pulse obliterated with greater
Volume: (Pulse Strength or pressure.
amplitude)
Ranges from absent to bounding

A forceful or full blood

volume that is obliterated
only with difficulty is called
a full or bounding pulse.

A pulse that is readily

obliterated with pressure
from the fingers is referred
to as weak, feeble, or
thready.

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Characteristics of the
Pulse (cont’d)
Arterial wall elasticity: reflects its
expansibility or its deformities. A
healthy, normal artery feels
straight, smooth, soft, and pliable.
Older adults often have inelastic
arteries that feel twisted (tortuous)
and irregular on palpation.

Comp
are
Presence or absence of corres
bilateral equality pondi
ng
pulse

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 Delegation

• Pulse
– Radial or brachial pulse may be delegated to
UAP
– Nurse interprets abnormal rates or rhythms
and determines response
– UAP are generally not responsible for
assessing apical or one person apical-radial
pulses

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 Document in client’s record

Documentation

Use a graphic sheet

Document the pulse rate, rhythm,

and volume

Variation in pulse rate

Abnormal skin color and

temperature

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Measuring Apical
Pulse
Indicated for those whose peripheral pulse
is irregular or unavailable

Primarily used prior to administering

medications that affect heart rate

Also used for newborns, infants, and

children up to 2-3 years old

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 Document in client’s record
Documentation

Pulse rate and rhythm

Variation in pulse rate

Abnormal skin color and

temperature

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 Apical-Radial Pulse

• Locate apical and radial sites

• Pulse deficit: Any discrepancy between the two pulse rates.
• Two nurse method:
– Decide on starting time
– Nurse counting radial says “start”
– Both count for 60 seconds
– Nurse counting radial says “stop”

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 Documentation

• Document in client’s record

• Document apical and radial (AR) pulse
rates, rhythms, volume, and any pulse
deficit
• Variation in pulse rate
• Pallor, cyanosis, or dyspnea

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 Pulse: Lifespan
Considerations

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 3. Respiration

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 Mechanics and Regulation
• Inhalation • Exhalation
– Diaphragm – Diaphragm relaxes
contracts (flattens) – Ribs move downward
and inward
– Ribs move upward
– Sternum moves
and outward
inward
– Sternum moves – Decreasing the size of
outward the thorax
– Enlarging the size
of the thorax

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Respiratory Control Mechanisms
Three Main mechanisms
that control respiratory Respiratory centers
process:
• Medulla oblongata
• Pons

Chemoreceptors

• Medulla
• Carotid and aortic bodies

Both respond to O2, CO2,

H+ in arterial blood

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 Factors Affecting
Respirations
Relaxed

Exercise

Anxiety

After exercise
• Client’s tolerance to activity

Aware of client’s normal breathing

Client’s health problems

Medications

Relationship of client’s respirations to cardiovascular function

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 Components of Respiratory
Assessment
• Rate
– Breaths per minute
– Eupnea: Normal status
– Bradypnea: less than normal rate
– Tachypnea: more than normal rate
– Apnea: Absent breathing rate

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 Components of Respiratory
Assessment (cont'd)
• Depth • Rhythm
– Normal – Regular
– Deep – Irregular

– Shallow • Quality
– Effort
– Sounds
– Labored
• Effectiveness
– Uptake and transport of O2
– Release of CO2 from the blood into expired
air
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Copyright ©2012 by Pearson Education, Inc.
All rights reserved.
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc.
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 Delegation

• Respirations
– Counting and observing respirations may be
delegated to UAP
– Nurse interprets abnormal respirations and
determines response

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 Documentation

• Document in client’s record

• Document the respiratory rate, depth,
rhythm, and character

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 Respirations:
Lifespan Considerations

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 4. Blood Pressure

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 Contraction of
Systolic and Diastolic Systolic the ventricles
Blood Pressure

Ventricles are at rest

Diastolic Lower pressure
present at all times

Pulse Pressure =
difference between systolic
and diastolic pressures

Measured in mm Hg

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 Systolic and Diastolic Blood
Pressure (cont'd)
• Recorded as a fraction, e.g. 120/80
• Systolic = 120 and Diastolic = 80

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 Hypertenion: A blood pressure that is persistently above normal

Hypotension: a blood pressure that is below normal, that is, a systolic

reading consistently between 85 and 110 mmHg in an adult whose normal
pressure is higher than this.

Orthostatic hypotension (or postural hypotension) is a blood pressure that

decreases when the client changes from a supine to a sitting or standing
position. It is usually the result of peripheral vasodilation in which blood
leaves the central body organs, especially the brain, and moves to the
periphery, often causing the client to feel faint.

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 Assessing for orthostatic
hypotension
Place the client in a supine position for at least 5 minutes.

Record the client’s pulse and blood pressure. Assist the client to slowly sit or stand. Support
the client in case of faintness.

Immediately recheck the pulse and blood pressure in the same sites as previously.

Measure the pulse and blood pressure again after 3 minutes. Some research indicates that
BP and pulse should be measured at 30, 60, 120, and 180 seconds after standing, although
the 1- and 3-minute measurements are the most valuable (Jones & Kuritzky, 2018).

Record the results. A drop in blood pressure of 20 mmHg systolic or 10 mmHg diastolic or an
increase in pulse of 20 beats/min indicates orthostatic hypotension

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 Factors Affecting
Blood Pressure*

Age Exercise Stress Race

Diurnal
Sex Medications Obesity
variations

Medical
Temperature
conditions

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Table 29-4 Classification of
Blood Pressure

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 Measuring Blood Pressure

Direct (Invasive Monitoring)

Indirect

• Auscultatory
• Palpatory

Sites

• Upper arm (brachial artery)

• Thigh (popliteal artery)

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• Assessing the blood pressure on a client’s thigh is indicated in these
situations:
1. The blood pressure cannot be measured on either arm (e.g., because of
burns or other trauma).
2. The blood pressure in one thigh is to be compared with the blood pressure
in the other thigh.

• Blood pressure is not measured on a particular client’s limb in the

following situations:
1. The shoulder, arm, or hand (or the hip, knee, or ankle) is injured or
diseased.
2. A cast or bulky bandage is on any part of the limb.
3. The client has had surgical removal of breast or axillary (or inguinal) lymph
nodes on that side.
4. The client has an IV infusion or blood transfusion in that limb.
5. The client has an arteriovenous fistula (e.g., for renal dialysis) in that limb.

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 Korotkoff sounds
• When taking a blood pressure using a stethoscope, the nurse identifies
phases in the series of sounds called Korotkoff sounds
• Five phases occur but may not always be audible

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Figure 29-23 Korotkoff’s sounds can be differentiated into five phases. In the illustration the blood pressure is 138/90
or 138/102/90.

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 Korotkoff’s Sounds

Phase 1
• First faint, clear
tapping or thumping
sounds
• Systolic pressure
Phase 2
• Muffled, whooshing,
or swishing sound
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 Korotkoff’s Sounds (cont'd)
Blood flows
freely
Crisper and
more intense
Phase 3 sound
Thumping
quality but
softer than in
phase 1

Muffled and
have a soft,
Phase 4 blowing
sound

Pressure
level when
the last sound
is heard
Phase 5 Period of
silence
Diastolic
pressure

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Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc.
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 Delegation

• Blood pressure
– May be delegated to UAP
– Nurse interprets abnormal readings and
determines response

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 Documentation

• Document in client’s record

• Document and record pertinent data
• RA-right arm
• RL-right leg
• LA-left arm
• LL-left leg

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Blood Pressure:
Lifespan Considerations

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 5. Oxygen Saturation SpO2

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Figure 29-25 Fingertip oximeter sensor (adult).

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Figure 29-26 Fingertip oximeter sensor (cordless).
Courtesy of Nonin Medical, Inc.

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 Pulse Oximetry

Estimates
arterial blood
Noninvasive oxygen
saturation
(SpO2)

Detects
Normal SpO2
hypoxemia
95-100%; <
before clinical
70% life
signs and
threatening
symptoms

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 Pulse Oximetry
• Factors that affect accuracy include:
1. Hemoglobin : If the hemoglobin is fully saturated with oxygen, the
SpO2 will appear normal even if the total hemoglobin level is low.
Thus, the client could be severely anemic and have inadequate
oxygen to supply the tissues but the pulse oximeter would return a
normal value
2. Circulation: The oximeter will not return an accurate reading if the
area under the sensor has impaired circulation. (e.g hypotension)
3. Activity: Shivering or excessive movement.:
4. Carbon Monoxide poisoning: Pulse oximeters cannot
discriminate between hemoglobin saturated with carbon monoxide
and oxygen. this case, other measures of oxygenation are needed.

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 Prepare site

Pulse Oximetry

Align LED and photodetector

Set and turn on alarms

Ensure client safety

Ensure accuracy

Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc.
Audrey Berman • Shirlee Snyder All rights reserved.
 Delegation

• Oxygen saturation
– Application of the pulse oximeter sensor and
recording the SpO2 may be delegated to UAP
– Nurse interprets oxygen saturation value and
determines response

Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc.
Audrey Berman • Shirlee Snyder All rights reserved.
 Documentation

• Document oxygen saturation on the

appropriate record

Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc.
Audrey Berman • Shirlee Snyder All rights reserved.
 Pulse Oximetry:
Lifespan Considerations

Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc.
Audrey Berman • Shirlee Snyder All rights reserved.