VITAL SIGNS

Shoul d be be looked at in total are checked to monitor the function of the body. The signs
reflect changes in function that otherwise might not be observed.

TEMPERATURE

. Core temperature is the temperature of the deep tissues of the body, such as the
abdominal cavity and pel-vic cavity.

. The surface temperature is the temperature of the skin, the subcutaneous tissue, and fat.
It, by contrast, rises and falls in response to the environment. 


1. PAT DRY (RUB = FRICTION = HEAT)

2. PLACE AXILLA
3. PLACE ARM ACROSS CHEST

NORMAL
36.5-37.5
PULSE

Peripheral pulse = wrist or foot

Central pulse = Apical Pulse -> PMI point of maximal impulse
Pulse sites:
Temporal – used when radial pulse is not accesible
Carotid – used to determine circulation to the brain
Apical – for infants and children up to 3 years old
Brachial – for blood pressure
Radial – readily accessible
Femoral -
Popliteal
Posterios tibial
Dorsalis pedis

Pulse is palpated by applying moderate pressure with the 3 middle fingers of the hand. The
pads on the most distal aspects of the fingers are the most sensitive areas for detecting a pulse.

Collect the following data:

Rate
Rhythm – pattern of the beats and intervals between beats (arrhythmias)
Volume – pulse strength or amplitude (bounding pulse, weak, feeble or thread)

Arterial wall elasticity – DTRAIGHT SMOOTH SOFT PLIABLE

Presence or absence of bilateral equality – when assessing a peripheral pulse to determine
adequacy of blood flow to a particular area of the body, the nurse should also assess the
corresponding pulse on the other side

*Using the thumb is contraindicated because the nurse’s thumb has a pulse that could be
mistaken for the client’s pulse

60 – 100 BPM

RESPIRATIONS

2 types:
costal (thoracic) = involves the external intercostal muscles and other accessory muscle, such as
sternocleidomastoid muscles, observedby the movement of the chest upward and outward
diaphragmatic = contraction and relaxation of the diaphragm, onbserved by the movement of
the abdomen

normal adult inspiration 1 to 1.5 seconds, expiration 2-3 seconds

respiration is controlled by medulla oblongata and pons

12 – 20

VS OF AT HOME