Vital Signs

NUR 152-Nursing Theory and

Science I

Vital Signs
A

means of assessing physiological

functions
Measured

to detect changes in normal

body function
Vary within
Differences
Affected

certain acceptable limits

by many factors
2

Why we Take Vital

Signs
Provide

an understanding of how the

bodys big three organ systems are
functioning:
Heart
Lungs
Brain

Monitoring Vital Signs

Performed

on a regular basis

Frequency determined by:

Physician order and/or nursing judgment
Patients condition
Facility standards

Facility Standards for

Monitoring
Hospital:

Every 4-8 hours

Home

health setting: Each visit

Clinic:

Each visit

Skilled

nursing facilities (SNF): Weekly to

monthly

When to Assess Vital

Signs
Admission

to any healthcare agency

Institutional
Per

policy and procedures

orders of healthcare provider

Any

time there is a change in the patients

condition
Before

and after surgical or invasive

diagnostic procedures
Before

risk

and after activity that may increase

Medications
examples

Vital Signs
Temperature
Pulse
Respirations
Blood

pressure

Pain-the

5th vital sign??????????

Temperature

Body Temperature
Degree

of heat maintained by the body

Thermoregulatory

center is located in the

hypothalamus
Center receives messages from cold and warm
thermal receptors in the body and responds
Center initiates responses to produce or conserve
body heat or increase heat loss

Body Temperature
(cont.)
Stays

fairly stable

thermometer is used to measure body

temperature in the mouth, rectum, axilla, ear,
temporal artery
Measurement
F=Fahrenheit
C=Celsius

10

Measuring Body
Temperature
Oral
Ear

(mouth) most common

(tympanic) quick

Rectal

most accurate ( Core)

Urinary

catheter- most accurate (Core)

Axillary

or groin least accurate (should

not use)
Temporal

11
artery- quick, non-invasive,
very

Temperature
Conversion
Fahrenheit =
(9 divided 5 x temp in C) + 32

Celsius=
(Temp in F 32) x 5 divided by 9

12

Equivalent
Centigrade/Fahrenheit
Scale
Centigrade

Fahrenheit

Centigrade

Fahrenheit

34.0

93.2

38.5

101.3

35.0

95.0

39.0

102.2

36.0

96.8

40.0

104.0

36.5

97.6

41.0

105.8

37.0

98.6

42.0

107.6

37.5

99.5

43.0

109.4

38.0

100.4

44.0

111.2

13

Average Normal Body

Temperatures
Oral

Rectal

Axillary

Tympanic Forehead

37.0 37.5 C 36.5 C 37.5 C 34.4 C

C
98.6 F 99.6 F 97.6 F 99.6 F 94.0 F

14

Variables Affecting Body

Temperature
Circadian

rhythms

Hormones
Age
Exercise
Stress
Food/beverage

consumption
15

Temperature
Variations
Hyperthermia

(Fever)

Increase in body temp above normal

Extreme form=heat stroke

Hypothermia
Decrease in body temp below normal

16

Oral Temperature
Average=37.0 C or 98.6 F
Range=3638 C or 96.8100.4 F
Advantages
Convenient
Easily accessible
Minimally invasive
Disadvantages
Safety
Physical abilities
Accuracy
17

Contraindications to Oral Temp

Infant

or child under 6 years

Unconscious,

confused or disoriented person

Someone

who had surgery or injury to the

face, neck, nose or mouth
Receiving
Paralysis
Seizure

oxygen (>6L/min)

on one side of body

disorder

18

Taking an Oral
Temperature

19

Rectal Temperature
Taken

when oral or other routes cannot be

used
Average=37.5 C or 99.5 F
Range=36.738.5 C or 98.0101.6 F
Advantages
Most accurate
Disadvantages
Safety
Invasive
Uncomfortable

20

Contraindications to Rectal
Temp
Diarrhea
Rectal

disorder or injury

Hemorrhoids
Heart
Rectal

disease
surgery

Patient

who is confused or agitated

21

Taking a Rectal
Temperature

22

Axillary Temperature
Less
Used

reliable
when other sites cannot be used

Average=36.5 C or 97.6 F
Range=35.437.4 C or 95.899.4 F
Advantages
Safe
Noninvasive
Disadvantages
Questionable accuracy
Length of time to obtain measurement

23

Taking an Axillary Temperature

24

Tympanic Temperature
Average
Range=same as oral and rectal
Advantages
Convenient
Fast
Safe
Reduced risk of spreading infection
Disadvantages
Questionable accuracy
Technique affects reading
Contraindications

25

Taking a Tympanic Temperature

26

Electronic
Thermometers
Battery

operated

Measure temperature in seconds

Tympanic thermometers within 1 to 3 seconds
Have oral and
Rectal=red
Have

rectal probes

disposable sheaths for the probe (probe

covers)
Single use
27

Electronic
Thermometers
Oral/
rectal

Tympanic

Oral/rectal
Temporal

28

Pulse

29

Pulse
The

beat of the heart felt as a wave of

blood passes through an artery
Number

of contractions over a peripheral

artery in 1 minute

30

Pulse Rate
Normal

range for adults = ?

Average=70-80

bpm

Tachycardia
Pulse rate greater than 100 beats per minute
Bradycardia
Pulse rate less than 60 beats per minute

31

Pulse Rhythm
Regular

vs. Irregular

Should

be regular (same time interval

between beats)
What

is an irregular pulse?

32

Pulse Volume
Force,

strength

Absent

to bounding

Easy

to feel=normal or bounding

Hard

to feel=weak or thread

Use 3 or 4-point
0 = absent
1 = thready
2 = weak
3 = normal
4 = bounding

scale for measuring

33

Pulse Sites
Peripheral
Apical pulseover apex of heart
Most accurate
5th intercostal space, left mid-clavicular line
Taken with a stethoscope
LUB DUB
Count for 1 full minute

34

Peripheral Pulses
Radial
Pedal
Dorsalis pedis
Posterior tibialis
Popliteal
Femoral
Brachial
Carotid
Temporal

35

Peripheral Pulse Sites

36

Taking a Pulse
Find

the pulse by placing the first 2 or 3

fingers of one hand against the artery
Count

for 30 seconds

Multiply
Or

by 2 = HR/minute

count for 1 full minute

Note-if

pulse is irregular, count for full

minute
37

Taking a Radial Pulse

38

Factors Affecting Heart

Rate
Age
Gender
Activity/exercise
Metabolism
Fever
Emotional status
Pain
Stimulants
Medications
Sympathetic

stimulationincreases heart rate

Parasympathetic stimulationdecreases heart rate

39

Apical-Radial Pulse
Should

be equal

Difference

between two is called the pulse

deficit
People

with heart disease may have pulse

deficit

40

Respirations

41

Respirations
Oxygen

(O2) & carbon dioxide (CO2)

exchange
Act

of breathing

Breathing

air into (inhalation) and out of

(exhalation) the lungs
Quiet,

effortless and regular

Equal

chest expansion
42

43

Rate and Depth of

Breathing
Normal

adult rate is 12-20 per minute

Rate

and depth changes in response to

body demands
Controlled

by respiratory centers in the

brain
Increase

in carbon dioxide is the most

powerful respiratory stimulant
44

Assessing Respirations
Count

the respirations when the person is at rest

Assess

immediately after taking pulse (while fingers

still on artery)
Discretion
Make

sure patient is positioned so you can see

chest/abdomen
To

count the respirations watch the chest rise and fall

Count

for 30 seconds and multiply by 2

Irregular,

count for full minute

45

Assessing Respirations

46

Abnormal Findings
Apnea
Tachypnea
Bradypnea
Dyspnea
Orthopnea

47

Respirations
Exercise
Respiratory
Alterations

and cardiovascular disease

in fluid, electrolyte, and acid balances

Medications
Trauma
Infection
Pain
And

48

Oxygen Saturation
Pulse Ox
SpO2
Normal

90%-100%
Report

<90%

49

Blood Pressure

50

Blood Pressure
Force

of the blood against arterial walls

Pressure

rises as ventricle contracts and falls

as heart relaxes
Measured

in mm Hg

Non-invasive

(NIBP) vs. Invasive

Korotkoff sounds
Sounds heard during measurement of blood pressure
51

Korotkoffs Sounds
1st sound:
As

you deflate the BP cuff, a sound that occurs

during systole (systolic BP)

2nd sound:
As

you further deflate the cuff, a soft swishing

sound caused by blood turbulence

52

Korotkoffs Sounds
3rd sound:
Begins

midway through the BP and is a sharp,

rhythmic tapping sound

4th sound:
Similar

fading

to the third sound, but softer and

5th sound:
Silence,

BP)

corresponding with diastole (diastolic

53

Blood Pressure Readings

Typical adult B/P 118/78
Range 90-140/60-90
Pre-hypertension
SBP 120-139
DBP 80-89
Hypertension
B/P >140/90
Hypotension
B/P <90/60
54

Hypotension
Systolic

blood pressure <90 mm Hg; some

clients normally have low BP; ask if client is
light-headed or dizzy
Orthostatic

or postural hypotension is a
sudden drop in BP on moving from a lying to
a sitting or standing position

55

Systolic and Diastolic

Pressure
Systole
Period of heart muscle contraction
Force needed to pump blood out of heart into arterial
circulation
Top (higher) number
1st Korotkoff sound
Diastole
Period of heart muscle relaxation
Pressure in the arteries when the heart is at rest
Bottom (lower) number
Cessation of Korotkoff sounds
BP

recorded as systolic pressure over diastolic

pressure
56

Pulse Pressure
Systolic

pressure minus the diastolic

pressure
Around

40mm Hg in healthy adults

Example:

BP 120/80, pulse pressure = 40

BP 112/68, pulse pressure = ?

57

BP Regulation
Influenced By
Cardiac

function

Peripheral vascular resistance

Blood volume

58

Non-Invasive BP
Monitoring
Equipment
Stethoscope-to amplify sounds
Sphygmomanometer (2 types)
Aneroid
Mercury

59

Sphygmomanometer
Types
ANEROID

MERCURY

60

Electronic BP Monitoring Device

No

stethoscope needed

Dynamap

61

Cuff Size
Must

use proper cuff size

Too

big

Too

small

62

Measuring Blood
Pressure

63

Measuring BP
Place

stethoscope over brachial artery

Inflate

the cuff; the artery is occluded as the

pressure of the cuff exceeds the pressure in
the artery
Deflate

the cuff; blood begins to flow rapidly

through the partially open artery, producing
turbulent flow you will hear through the
stethoscope
64

Procedure for Measuring Blood Pressure

Select

proper cuff size and apply to arm

Position

arm horizontally and support at

mid-sternal level
Position

manometer at eye level

Estimate systolic pressure

Palpate the brachial pulse and inflate cuff until the
pulsation disappears
Deflate

cuff

65

Procedure for Measuring Blood

Pressure (cont.)
Place

stethoscope over brachial artery

Inflate

the cuff to 30 mm Hg above the estimated

systolic pressure
Reduce

cuff pressure at a rate of 2-3 mm Hg per

second
The

point at which the 1st Korotkoff sound is heard

is the systolic blood pressure
Note this measurement to the nearest 2 mm Hg

Continue

to slowly deflate cuff until sound is no

66
longer heard

Procedure for Measuring Blood

Pressure (cont.)
The

point where the Korotkoff sounds

disappear is the diastolic blood pressure
Note this measurement to the nearest 2 mm Hg

Finish

deflating cuff

Remove

cuff

Document

BP
67

Factors Affecting Blood Pressure

Age,

gender, race

Circadian

rhythm

Diet
Exercise
Weight
Blood volume
Hypervolemia
Hypovolemia
68

Factors Affecting Blood Pressure

(cont.)
Emotional
Body

state

position

Drugs/medications
Stress
Pain

Position

Smoking
Alcohol
White

coat syndrome

69

Remember
Nurses

can delegate the activity of taking

vital signs, but the nurse is responsible for
interpretation of vital signs, vital sign trends,
and decisions based on abnormal vital sign
findings

70

Questions?

71