VITAL SIGNS

by: marie m.
santos r.n.man c
Pretest
Question 1
The client’s temperature at 8:00 AM using
an oral electronic thermometer is 36.1°C
(97.2°F). If the respiration, pulse, and blood
pressure are within normal range, what
would the nurse do next?

3. Wait 15 minutes and retake it.

4. Check what the client’s temperature was
the last time.
5. Retake it using a different thermometer.
6. Chart the temperature; it is normal.
Question 2
Which of the following clients meets the
criteria for selection of the apical site for
assessment of the pulse rather than a radial
pulse?

3. A client is in shock
4. The pulse changes with body position
changes
5. A client with an arrhythmia
6. It is less than 24 hours since a client's
surgical operation
Question 3
It would be appropriate to delegate the taking of vital
signs of which of the following clients to a UAP?

3. A patient being prepared for elective facial surgery

with a history of stable hypertension.
4. A patient receiving a blood transfusion with a history of
transfusion reactions.
5. A client recently started on a new antiarrhythmic
agent.
6. A patient who is admitted frequently with asthma
attacks.
Question 4
A nursing diagnosis of Ineffective
Peripheral Tissue Perfusion would be
validated by which one of the
following:

3. Bounding radial pulse

4. Irregular apical pulse
5. Carotid pulse stronger on the left side
than the right
6. Absent posterior tibial and pedal
pulses
Question 5
The nurse reports that the client has
dyspnea when ambulating. The nurse
is most likely to have assessed which
of the following?

1. Shallow respirations
2. Wheezing
3. Shortness of breath
4. Coughing up blood
Rationales 1
 Depending on that finding, you might want to retake it
in a few minutes (no need to wait 15 minutes).
 Correct. Although the temperature is slightly lower
than expected for the morning, it would be best to
determine the client’s previous temperature range
next. This may be a normal range for this client.
 There is no need to take temperature again with
another thermometer to see if the initial thermometer
was functioning properly.
 Chart after determining that the temperature has been
measured properly.
Rationales 2
 For clients in shock, use the carotid or
femoral pulse.
 The radial pulse is adequate for determining
change in orthostatic heart rate.
 Correct. The apical rate would confirm the
rate and determine the actual cardiac
rhythm for a client with an abnormal
rhythm; a radial pulse would only reveal the
heart rate and suggest an arrhythmia.
 The radial pulse is appropriate for routine
postoperative vital sign checks for clients
with regular pulses.
Rationales 3
 Correct. Vital signs measurement may be delegated
to UAP if the client is in stable condition, the findings
are expected to be predictable, and the technique
requires no modification. Only the preoperative client
meets these requirements.
 This client is unstable and vital signs measurement
cannot be delegated.
 In addition to the client being unstable, UAP are not
delegated to take apical pulse measurements for the
client with an irregular pulse as would be the case with
the client newly started on antiarrhythmic medication.
 This client is unstable and vital signs measurement
cannot be delegated.
Rationales 4
 Abounding radial pulse is more indicative
that perfusion exists.
 Apical pulses are central and not peripheral.
 Carotid pulses are central and not
peripheral.
 Correct. The posterior tibial and pedal
pulses in the foot are considered peripheral
and at least one of them should be palpable
in normal individuals.
Rationales 5
 Shallow respirations are seen in tachypnea (rapid
breathing).
 Wheezing is a high-pitched breathing sound that may
or may not occur with dyspnea.
 Correct. Dyspnea, difficult or labored breathing, is
commonly related to inadequate oxygenation.
Therefore, the client is likely to experience shortness of
breath, that is, a sense that none of the breaths
provide enough oxygen and an immediate second
breath is needed.
 The medical term for coughing up blood is hemoptysis
and is unrelated to dyspnea.
Vital Signs
• Temperature, Pulse, Respiration, Blood
Pressure and Pain
• Monitor functions of the body
• Should be a thoughtful, scientific
assessment
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
TEMPERATURE
Body Temperature

 Represents
the balance between heat
produced by:
Metabolism
Muscular activity
Other factors and heat lost through the:
Skin
Lungs
Body wastes
Maintenance of Body
Temperature
 Thermoregulatory
center in the
hypothalamus regulates temperature
 Center
receives messages from cold and
warm thermal receptors in the body
 Centerinitiates responses to produce or
conserve body heat or increase heat loss
Heat Production
 Primary source is metabolism
 Hormones, muscle movements, and
exercise increase metabolism
 Epinephrineand norepinephrine are
released and alter metabolism
 Energyproduction decreases and heat
production increases
Sources of Heat Loss
 Skin (primary source)
 Evaporation of sweat
 Warming and humidifying inspired air
 Eliminating urine and feces
Transfer of Body Heat to
External Environment
• Radiation
• Convection
• Evaporation
• Conduction
Radiation
 Thediffusion or dissemination of heat
by electromagnetic waves.
› Ex. The body gives off waves of heat from
uncovered surfaces.
Convection
 Thedissemination of heat by motion
between areas of unequal density.
› Ex. An oscillating fan blows currents of cool
air across the surface of warm body.
Evaporation
 The conversion of liquid to a vapor.
› Ex. Body fluid in the form of perspiration
and insensible loss is vaporized from the
skin.
Conduction
 Thetransfer of heat to another object
during direct contact.
› Ex. The body transfers heat to an ice pack,
causing the ice to melt.
Factors Affecting
Body Temperature
• Age
• Diurnal variations
(circadian rhythms)
• Exercise
• Hormones
• Stress
• Environment
 Equipment

 Electronic digital or infrared

thermometer or tympanic thermometer
or glass thermometer.
 Water-soluble lubricant (for rectal
temp.)
 Gloves (for rectal temp)
 Facial tissue
 Disposable thermometer sheath or
probe

 Sites for Measuring
Body Temperature
• Oral
• Rectal
• Axillary
• Tympanic membrane
• Skin/Temporal artery
Types of Thermometers
Range of Human Body
Temperature Measured Orally
Temperature: Lifespan
Considerations
Infants Unstable
Newborns must be kept
warm to prevent
Children hypothermia
Tympanic or temporal artery
sites preferred

Elders Tends to be lower than that

of middle-aged adults
Normal Temperatures for
Healthy Adults

Oral – 37.0ºC, 98.6ºF

Rectal – 37.5ºC, 99.5ºF

Axillary – 36.5ºC, 97.6ºF

Tympanic – 37.5ºC, 99.5ºF

Forehead – 34.4ºC, 94.0ºF
T˚C = 5/9(T˚F – 32)
Do’s & Don’ts

 Don’t
avoid taking an oral temperature
when the patient is receiving nasal O2
because O2 administration raises oral
temperature by only about 0.3˚F (0.2˚C)
STEP-BY-STEP PROCEDURE
PULSE
 PULSE
•Pulse rate = number of contractions over a peripheral artery in 1 minute
Equipment

 Watch with second hand

 Stethoscope (for auscultating apical
pulse)
 Doppler ultrasound blood flow detector
 Alcohol pad
Sites for Assessing Pulse
 Palpating peripheral arteries
 Auscultating apical pulse with
stethoscope
 Assessing apical-radial pulse
Sites for Assessing Pulse by
Palpation
Front of the ear and
lateral to eyebrow

Beside the larynx

5th intercostal space just inside

Medial antecubital fossa the midclavicular line
(hollow in front of elbow)
Thumb side of the Halfway between the anterior
forearm at wrist superior iliac spine and the
symphysis pubis, below the
inguinal ligament

Behind knee in the

popliteal fossa

Inner side of the ankle slightly Dorsum of the foot with

below the medial malleolus the foot plantar flexed
Factors Affecting
Pulse
• Age
• Gender
• Exercise
• Fever
• Medications
• Hypovolemia
• Stress
• Position changes
• Pathology
Pulse: Lifespan
Considerations
Infants Newborns may have heart
murmurs that are not
pathological
Children 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
Elders Often have decreased
peripheral circulation
Pulse Sites
Radial Readily accessible

Temporal When radial pulse is not accessible

Carotid During cardiac arrest/shock in

adults
Apical Determine circulation
Infants and children to3the
up to brain
years of
age
Discrepancies with radial pulse
Monitor some medications
Pulse Sites
Brachial Blood pressure
Cardiac arrest in infants

Femoral Cardiac arrest/shock

Circulation to a leg;
Popliteal Circulation to lower leg
Posterior Circulation to the foot
tibial
Dorsalis Circulation to the foot
pedis
Characteristics of the Pulse

• Rate
• Rhythm
• Volume
• Arterial wall elasticity
• Bilateral equality
Pulse Rate and Rhythm
• Rate • Rhythm
– Beats per minute – Equality of beats and
– Tachycardia intervals between
– Bradycardia
beats
– Dysrhythmias
– 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
Measuring Apical Pulse
Assessing Peripheral Pulses
Do’s & Don’ts

 Don’tuse your thumb to take the

patient’s pulse.
because you may mistake your thumb’s own
strong pulse.
STEP-BY-STEP PROCEDURE
RESPIRATION
Respiration

 Interchange
of gases between an
organism and the medium in which it
lives.
External respiration or breathing in – is the
exchange of O2 and CO2 between the
atmosphere and the body.
Internal respiration – takes place throughout
the body at the cellular level.
 Respiratory Control
Mechanisms
• Respiratory centers
– Medulla oblongata
– Pons
• Chemoreceptors
– Medulla
– Carotid and
– aortic bodies
• Both respond to O2,
CO2, H+ in arterial blood
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
Blood Circulation

C6H12O6 + O2 → ATP + CO2 + H2O

Factors Affecting
Respirations
• Exercise
• Stress
• Environmental temperature
• Medications
Respirations:
Lifespan Considerations
Infants Some newborns display
“periodic breathing”

Children Diaphragmatic breathers

Elders Anatomic and physiologic

changes cause respiratory
system to be less efficient
Components of Respiratory
Assessment
• Rate
• Depth
• Rhythm
• Quality
• Effectiveness
Respiratory Rate and Depth

• Rate • Depth
– Breaths per minute – Normal
– Eupnea – Deep
– Bradypnea – Shallow
– Tachypnea
Components of Respiratory
Assessment
• Rhythm • Effectiveness
– Regular – Uptake and transport
– Irregular of O2
• Quality – Transport and
elimination of CO2
– Effort
– Sounds
Assessing Respirations
Inspection
Listeningwith stethoscope
Monitoring arterial blood gas results
Using a pulse oximeter
STEP-BY-STEP PROCEDURE

To be discussed by Prof. Myrna Pares

BLOOD PRESSURE
Physiology of Blood Pressure

Force of the blood against arterial walls

Controlled by a variety of mechanisms
to maintain adequate tissue perfusion
Pressure rises as ventricle contracts and
falls as heart relaxes
› Highest pressure is systolic
› Lowest pressure is diastolic
Factors Affecting
Blood Pressure
• Age
• Exercise
• Stress
• Race
• Gender
• Medications
• Obesity
• Diurnal variations
• Disease process
Blood Pressure:
Lifespan Considerations
Infants Arm and thigh pressures are
equivalent under 1 year of
age
Children Thigh pressure is 10 mm Hg
higher than arm

Elders Client’s medication may

affect how pressure is taken
Systolic and Diastolic Blood
Pressure
• Systolic • Measured in mm Hg
– Contraction of the • Recorded as a
ventricles fraction, e.g. 120/80
• Diastolic Cardiac Cycle.mpg

• Systolic = 120 and

– Ventricles are at rest Diastolic = 80
– Lower pressure
present at all times
• Pulse Pressure =
difference between
systolic and diastolic
pressures
Korotkoff’s Sounds
Korotkoff’s Sounds

• Phase 1
– First faint, clear tapping or thumping
sounds
– Systolic pressure
• Phase 2
– Muffled, whooshing, or swishing sound
Korotkoff’s Sounds
• 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)
Equipment for Assessing
Blood Pressure
Stethoscope and sphygmomanometer
Doppler ultrasound
Electronic or automated devices
Assessing Blood Pressure
Listeningfor Korotkoff sounds with
stethoscope
› First sound is systolic pressure
› Change or cessation of sounds occurs—
diastolic pressure
The brachial artery and popliteal artery
are commonly used
 For infant, small child,
or frail adult

Normal adult-size

Measure BP on the
leg or arm of an
obese adult
Parts of Sphygmomanometer
Figure 29-19 Blood pressure monitors register systolic and diastolic blood pressures and often other vital
signs.
Normal Ranges for Vital Signs
for Healthy Adults
Oral temperature — 37.0ºC, 98.6ºF
Pulse rate — 60 to 100 (80 average)
Respirations — 12 to 20 breaths/minute
Blood pressure — 130/85
Delegating to UAP

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

• 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
Delegating to UAP

• Respirations
– Counting and observing respirations may
be delegated to UAP
– Nurse interprets abnormal respirations and
determines response
Delegation to UAP
• Blood pressure
– May be delegated to UAP
– Nurse interprets abnormal readings and
determines response
• Oxygen saturation
– Application of the pulse oximeter sensor
and recording the Sp02 may be delegated
to UAP
– Nurse interprets oxygen saturation value
and determines response
Post Test
1. The proper time frame for waiting to check a temperature for the
patient who has just had a drink of water is
a. 2 minutes.
b. 5 minutes
c. 10 minutes
d. 15 minutes
2. The best thing to do when you get a reading on a digital thermometer
that does not seem quite right is to
a. record that temperature
b. do nothing
c. repeat the temperature measurement
d. report the measurement immediately
1. The best location for taking the apical pulse
is
Over the base of the heart
At the 5th intercostal space just inside the midclavicular
line
Upper left chest near nipple
At the 3rd intercostal space just inside the midclavicular
line.
2. The location for assessing peripheral pulses
are
a. Radial, temporal, carotid, clavicular femoral, popliteal,
pedal, and posterior tibial
b. Radial, temporal, carotid, brachial, femoral, crucial, pedal,
and posterior tibial
c. Radius, temporal, carotid, brachial, femoral, crucial,
pedal, and posterior tibial
d. Radial, temporal, carotid, brachial, femoral, popliteal,
pedal, and posterior tibial
3. A patient who is experiencing eupnea is said
to be
a. Breathing slowly
b. Breathing rapidly
c. Breathing normally
1. A normal respiratory rate for the adult
is
a. 10 to 20 breaths per minute
b. 12 to 20 breaths per minute
c. 14 to 20 breaths per minute
d. 16 to 20 breaths per minute
2. Which of these factors can affect
blood pressure? (Choose all that
apply)
a. Age
b. Height
c. Recent activity
d. Position
3. The point which the heart is beating
and exerting its greatest force is
called
a. Systolic pressure
Answers

1. d TOTAL POINTS = 10
2. c
3. b
4. d
5. c
6. b
7. a, c, d
8. a