VITAL SIGNS I - ncreased thyroxin production -

V - ital to a person’s physiologic status S - Screenings at health facilities and increased cellular metabolism is d/t inc
for it serves as indicators of body clinics thyroxine output from the thyroid gland,
function. this effect is called CHEMICAL
B - efore and after certain nursing THERMOGENESIS
I - ncludes Temperature, Pulse, interventions that could affect V/S (ex. C - hemical thermogenesis
Ambulating a client who has been on bed E - pinephrine, norepi, SNS stimulation –
Respiration and Blood Pressure and
rest, b/c he may have activity increases the rate of cellular metabolism
recently Pain as the fifth vital sign. intolerance PNS SNS
T - hey are checked to monitor the Decrease
I - n emergency situations or when client Increased
functions of the body, functions that has change in health status or reports Eye d Pupil Eye
Pupil Size
might not be observed. symptoms such as chest pain or feeling Size
hot or faint
A – lso known as Cardinal Signs Decrease Increased
PURPOSE OF ASSESSING VITAL d lacrimal lacrimal
L - isted and evaluated with reference secretion secretion
SIGNS
to the client’s present and prior health
Decrease
status, are compared to the client’s T - o obtain baseline measurement of Increased
Oral d Salivary Oral
usual (if known) and accepted normal the patient’s vital signs salivary flow
flow
standards. T - o assess patient’s response to
treatment or medication Decrease
T - o monitor patient’s condition after Hear Hea Increased
VITAL SIGNS ARE COMMONLY d Heart
invasive procedures t rt heart rate
ASSESSED rate

B- efore and after diagnostic and surgical BODY TEMPERATURE Vasodilati Vasoconstricti
procedures (there might be internal H - eat of the body measured in degrees on on
bleeding) D - ifference between production of heat
and loss of heat from the body Broncho
Lung Lun Bronchodilatio
constricti
U-pon admission to a healthcare setting s gs n
on
to obtain baseline data PROCESS OF HEAT PRODUCTION
OCCURS THROUGH: Inreased Decreased
W- When certain medications are given Gastric
(meds that F - ood Metabolism and Activity – basal GIT GIT Gastic Motility
Motility
could affect respi or cardio system ex. metabolic rate (BMR) or the rate of and and secretion
Digitalis). energy utilization in the body secretion
F - ever = inc metabolic rate
I - In the home M - uscle activity = inc metabolic rate

Keith Nester A. Lavin

 Decreased H – eat, sends out signals intended to E - nvironment – extremes in
pancreatic reduce temperature by decreasing heat environmental temp
secretion production and increase heat loss S - ex – d/t hormones; women > men
Increased hormone fluctuations; progesterone
(sweating and peripheral vasodilation)
pancreati Increased during ovulation rises body temperature
c adrenal E - xercise – can inc temp to as high as
secretion C – old, signals are sent out to increase
secretion 38.3C to 40C (101-104F) rectally
heat production and decrease heat loss
(epinephrine A - ge – infant is greatly influenced by
and cortisol) (vasoconstriction, shivering, and release the temperature of environment and
of ephinephrine). must be protected from extreme
Decreased changes; people 75 y.o & up are at risk
Increased
intestinal TYPES of TEMPERATURE for hypothermia (T < 36C or 96.8F) for a
intestinal
motility motility variety of reasons such as inadequeate
Core Temperature diet, loss of subcutaneous tissue, lack of
T - emperature of the deep tissues of the activity & decreased thermo-regulatory
body such as abdominal cavity & pelvic efficiency
REGULATION OF BODY cavity; relatively constant T - ime of day – also “diurnal variations”
TEMPERATURE M - easured thru tympanic and rectal or “circadian rhythms”; @ 1C between
routes early am and late pm; highest @ 8pm
S - kin has more receptors for cold than and midnight; lowest @ sleep between 4-
warmth Surface Temperature 6 am
T - emperature of the skin, subcutaneous
M - ost sensory receptors are in the skin tissue & fats; rises and falls in response
to the environment PROCESS OF HEAT LOSS OCCURS
When the skin becomes chilled over the M - easured thru oral and axillary routes THROUGH
entire body, our body
R - adiation: surface to surface by waves
S - hivers to increase heat production FACTORS AFFECTING BODY therefore no contact (ex. Nude person
TEMPERATURE standing in room @ normal temperature)
S - weating is inhibited to decrease heat C - onduction : contact between 2
loss – nurses should be aware so that they surfaces; heat transfer to a surface of
can recognize normal temperature lower temperature (ex. immersion in cold
V - asoconstriction decreases heat loss variations & understand the significance water)
of the body temperature measurements C - onvection – mov’t by air currents
that deviate from normal E - vaporation – water to steam;
Hypothalamic integrator, the center continuous & unnoticed evaporation of
that controls temperature is located in S - ome other factors such as food, drugs moisture from the respiratory tract &
the preoptic area of the hypothalamus. E - motions/stress – stimulation of SNS from mucosa of mouth & from skin
E - limination – urination, defecation
Keith Nester A. Lavin
 for 10 minutes; for clients with oral
TYMPAN -Within two seconds
problem( oral inflammation, wired
4 COMMON SITES FOR ASSESSING IC -Up/back for adult
jaws, oral surgery) -35.9 – 37.0C
BODY TEMPERATURE Down/back for pedia
(96.6-98.6F)

4. Tympanic membrane – accessible,

1. Oral – most frequently used, least
disruptive, most convenient, done for
3 minutes ; wait 30 mins if client ate
or drank cold or hot food/fluids -
36.4-37.6 C (97.6-99.6F)
CONTRAINDICATIONS:
I - nfants and very young children
P - atients with oral surgery
U - nconscious or irrational patients
S - eizure-prone patients
M - outh breathers and pts. with
oxygen
less invasive; has abundant arterial
blood supply; Within two seconds
Up/back for adult , Down/back for
pedia -37.0-38.1C (98.6-100.6F)
CONTRAINDICATIONS:
P - resence of ear ache
S - ignificant ear drainage
S - carred tympanic membrane
Unexpected Situations in assessing
TEMPERATURE
T - emperature higher/lower than
expected based on how skin feels
(re-assess with new thermometer)
F - eeling lightheaded or passes out
during rectal temp assessment
(remove thermometer immediately,
assess BP & HR, notify doctor, don’t take
another rectal temp)

Pyrexia Elevated BT
2. Rectal – most accurate route, but
invasive and uncomfortable to SPECIAL Hyperpyr
ROUTE BT above 41˚C
patient; done for 2-3 mins – 37.0- CONSIDERATIONS exia
38.1C (98.6-100.6F)
CONTRAINDICATIONS: BT alternates regularly
-Done for 3 minutes
Intermitte between periods o fever,
ORAL -Upon intake of
R - ectal abnormalities – ex. nt fever normal or subnormal
hot/cold fluids, wait 30
Significant hemorroids temperature
minutes
D - iarrhea
-Done for 2-3 minutes
C - ertain heart conditions – ex. CHF; Fluctuations of several
-Presence of fecal
may result to vagal stimulation = Remittent degrees above normal,
RECTAL matter could result to
bradycardia fever but not reaching normal
a false reading
I - mmunosuppressed - may inc risk
-Lubricate tip prior to between fluctuations
of infection
inserting
Clotting disorder Constant Consistently elevated and
AXILLAR
Y -Done for 10 minutes fever fluctuates very little
3. Axillary – safer than the oral method,
non-invasive, least accurate; Done
Keith Nester A. Lavin
 Returns to normal for at
Relapsing
least a day then the fever
fever
occurs
Resolutio
n of Elevated BT returns to
Pyrexia normal suddenly
by crisis
TYPES OF THERMOMETER
1. Tympanic Thermometer/infrared
thermometer – senses body heat in form
of infra red energy given off by the heat
source which is the ear canal (tympanic
membrane) 2. Electronic or Digital
Thermometer – can read temp in 2-60
sec depending on manufacturer
3. Glass Thermometer – traditional;
“mercury-in-glass thermometers”
4. Temperature – sensitive Tape – does
not indicate core temp; w/ liquid crystals
that change color; placed at forehead or
abdomen
5. Chemical Thermometer – uses crystal
dots/bars or sensitive tape applied @
forehead
TEMPERATURE SCALES
C= (Farenheit temperature-32) x 5/9
Keith Nester A. Lavin
F= (Celsius temperature x9/5) +32 Term Meaning
Pulsus
Equal rhythm
regularis
PULSE
T - hrobbing sensation palpated over a Arrhythm
Irregular rhythm
peripheral artery ia
A - ssessed by palpation (feeling) or
auscultation (hearing) Prematur Beat that occurs between
M - iddle three fingertips are used for e beat normal beats
palpating all pulse sites except the apex
of the heart; a stethoscope is used for Heart Time interval between each
assessing apical pulses & FHT rhythm heartbeat
A - wave of blood being pumped into the
arterial circulation by the contraction of
the left ventricle
Volume/amplitude – also pulse strength;
ASSESSMENT PARAMETERS / amount of blood pumped with each
CHARACTERISTICS OF PULSE heartbeat
Normal pulse – can be felt w/ moderate
Rate – number of beats per minute pressure of the fingers & can be
AGE obliterated w/ greater pressure
PULSE RANGE Full or bounding pulse – forceful or full
GROUP
blood volume that is obliterated only
Newborn 80-180 bpm with difficulty
Weak, feeble, thready – pulse that is
readily obliterated w/ pressure from the
Adults 60-100 bpm fingers
Elderly 60-100 bpm
Cardiac Output – 5-6 Liters of blood is
forced out of the left ventricle per minute
Pulse Deficit – difference between the
ASSESSMENT FINDINGS:
apical and radial counts taken
TACHYCARDIA, BRADYCARDIA
simultaneously
Rhythm – pattern or regularity of beats
LOCATION OF PERIPHERAL PULSES
and interval between each beat
temporal – superior and lateral to the Used to determine 5. Prolonged heat application – inc
eye circulation to the brain metabolic rate, inc PR
carotid - @ side of cheek 6. Body positions- when sitting or
brachial – inner aspect of the bicep R - outinely used for
muscle of the arm or medially in the infants 7 children up to 3 Regular Effortless, quiet
antecubital space yrs.
radial - @ the thumb side of the inner Apical U - sed to determine
aspect of the wrist discrepancies with radial
femoral - @ inguinal ligament pulse Irregular Abnormal
politeal – behind the knee U - sed in conjunction with
posterior tibial – medial surface of the some medications
ankle Used to measure blood standing, blood usually pools in
dorsalis pedis/ pedal – over the bones of pressure dependent vessels of venous system
Brachial Used during cardiac arrest  transient dec in venous return to
the foot
for infants the heart  inc HR to compensate
7. Pain – d/t SNS stimulation
Used in cases of cardiac 8. Decreased BP – inc HR as
arrest compensatory mechanism
Femoral Used for infants and 9. Increased temperature – inc
children metabolic rate
Used to determine 10.Any conditions resulting to poor
circulation to the leg oxygenation of blood ex. CHF – inc HR
Used to determine to compensate
Popliteal
circulation to the lower leg
RESPIRATION-ACT OF BREATHING
REASONS FOR USING SPECIFIC Posterior Pulmonary ventilation –(breathing)
PULSE SITE Used to determine movement of air in and out of the lungs
tibial ,
circulation to the foot Inspiration –(inhalation) act or breathing
Pedal
Pulse in
Reasons for Use
Site Expiration –(exhalation) act of breathing
out
Radial Readily accessible Factors Affecting Pulse Rate External respiration – exchange of O2
and CO2 between alveoli and blood
Used when radial pulse is Internal respiration – exchange of O2 and
Temporal 1. Age – inc age, dec PR
not accessible 2. Sex/gender – after puberty male’s CO2 between blood and tissue cells
pulse is slightly lower than femlae’s
Carotid Used in cases of cardiac
3. Exercise – inc exercise, inc PR
arrests ASSESSMENT PARAMETERS /
4. Emotions/stress – SNS stimulation
(fear, anxiety, perception of pain) CHARACTERISTICS OF RESPIRATION
Keith Nester A. Lavin
Rate – number of breaths per minute ASSESSMENT FINDINGS REGARDING AGE RESPIRATORY
RESPIRATION GROUP RANGE
Rhythm – regularity of respiration,
inhalation and exhalation are evenly Eupnea Normal, effortless Newborn 30 – 60 bpm
spaced; – regular, irregular breathing

Tachypn RR > 24 bpm Adults 12-20 bpm

Depth – assessed by watching the ea
movement of the chest– normal, deep or
Whee
shallow Bradypn RR < 10 bpm zing
Ease & effort – dyspnea, orthopnea ea narrowing of airways, causing whistling
Breath sounds – stridor, bubbling, rales
or sighing sounds
Volume –: hyperventilation Apnea Absence of breathing Stridor - high-pitched sounds heard on
(overexpansion of lungs),
inspiration
hypoventilation (underexpansion of Hyperpn Deeper respiration with
Rales - sound caused by air passing thru
lungs) ea normal rate fluid or mucus in the airways usually
heard on inhalation
2 TYPES OF BREATHING Cheyne Resp. becomes faster and
Rhonchi sound caused by air passing
Costal/thoracic breathing – involves stokes deeper then slower with
external intercostal muscles and other thru airways narrowed by fluids, edema,
alternate periods of
accessory muscles; Observed thru muscle spasm usuallyheard during
apnea(20-60sec)
upward and outward movement of the exhalation
chest Biot’s Faster and deeper than
Diaphragmatic (abdominal) breathing –
normal with abrupt
involves contraction & relaxation of the
diaphragm pauses in between each BLOOD PRESSURE
breath F - orce of the blood against the arterial
walls
FACTORS AFFECTING RESPIRATION M - easured in millimeters of mercury
A.F. REGARDING RESPIRATION (mmHg)
Exercise – inc RR
Certain medications – eg. Narcotics Kussmaul’s - Faster and deeper
Age respiration without pauses in between Since blood moves in waves, there are 2
Emotions – inc RR panting BP measures:
Cardiac illness Apneustic - Prolonged grasping followed
Stress – inc RR by extremely short insufficient 1. Systole – the highest pressure;
Inc ICP = dec RR exhalation pressure of the blood as a result of
Dyspnea - difficulty of breathing contraction of ventricles
Orthopnea - DOB unless sitting
Keith Nester A. Lavin
2. Diastole – the lowest pressure;
pressure of the blood when ventricles
are at rest
Pulse pressure – difference between the
systole and diastole
ABNORMAL FINDINGS
Hypertension – above 140/90 mmHg
Hypotension – below 90/60 mmHg
Orthostatic Hypotension – decrease in
Bp when changing position
KOROTKOFF”S SOUND – SCHEMATIC
DIAGRAM
FACTORS THAT CONTROL BLOOD
PRESSURE
Cardiac Output – amount of blood
ejected from the heart per
contraction
Blood Volume – adult has about 5-6 liters
of circulating blood
Elasticity of arterial walls – yields
upon systole and retracts upon
diastole
FACTORS AFFECTING BLOOD
PRESSURE
Age – newborns systolic = 75mmHg; BP
rises w/ age
Keith Nester A. Lavin
Emotions/stress – SNS stimulation = inc
BP
Exercise – inc cardiac output = inc BP
Drugs – dopamine, dobutamine,
epinephrine
Obesity – predispose to hypertension
Disease process – any dse affecting C.O.,
blood volume, blood viscosity and
compliance of the arteries
ASSESSMENT FINDINGS
H - ypertension – dx made when the ave
of 2 or more diastolic readings on 2 visits
subsequent to initial assessment is 90
mmHg or higher or ave of multiple
systolic BP readings is higher than
140mmHg
H - ypotension = systolic pressure is
consistently between 85-110 mmHg
O – rthostatic hypotension = a blood
pressure that falls when the client sits or
stands
To ensure accuracy in taking the BP,
you must:
Let the patient rest for a minimum of 5
minutes for routine assessment
Should not have ingested caffeine or
nicotine 30 minutes before
Delay assessing if patient is:
a. in pain
b. emotionally upset, or
c. have just exercised.
BLOOD PRESSURE SITES
Assessment of BP in a client’s thigh is
usually indicated for:
The BP cannot be measured on either
arm (e.g.. because of burns and trauma)
Blood pressure is not measure on a
client’s arm or thigh in the following
situations:
The shoulder, arm or hand (or the hip,
knee, or ankle) is injured or diseased.
A cast or bulky bandage is on any part of
the limb.
The client has had removal of axilla (or
hip) lymph nodes on that side.
The client has an intravenous infusion in
that limb
That client has an arteriovenous fistula
( for renal dialysis for that limb)
METHODS
Direct invasive monitoring measurement
– insertion of a catheter into the brachial,
radial or femoral artery, represented by
waves on an oscilloscope.
Non-invasive
Auscultatory- uses sphygmomanometer,
a cuff, and a stethoscope
Palpatory – uses palpation
Error Effect
Bladder cuff to Erroneously high
 narrow
Bladder cuff
Erroneously low
too wide
Cuff wrapped
to loosely or Erroneously high
unevenly
Erroneously low
Deflating cuff
systolic and high
to quickly
diastolic readings
Deflating cuff Erroneously high
to slowly diastolic reading
Failure to use
Inconsistent
the arm
measurements
consistently
Arm above
level of the Erroneously low
heart
Assessing
immediately
after a meal or
Erroneously high
while client
smokes or has
pain

Keith Nester A. Lavin