VITAL SIGNS Hypothermia is a core body temperature below the

lower limit of normal. The three physiological

Vital signs are indicators of the body’s ability to mechanisms of hypothermia are (a) excessive heat
maintain homeostasis. Temperature (T), pulse (P), loss, (b) inadequate heat production to counteract
respiration (R), and blood pressure (BP) measurements heat loss, and (c) impaired hypothalamic
are considered vital signs because they measure some thermoregulation.
of the body’s vital functions and provide necessary
information about the patient’s physical well-being. - INTERMITTENT FEVER
Body temperature that alternates between febrile
Vital signs are measures of various physiological and afebrile states
statuses, in order to assess the most basic body - REMITTENT FEVER
functions. When these values are not zero, they Elevated body temperature that remains high
indicate that a person is alive. throughout the day, fluctuating more than 2
All of these vital signs can be observed, measured, and degrees Fahrenheit
monitored. - RELAPSING FEVER
Febrile periods that last for a couple of days, go
This will enable the assessment of the level at which away, and then return
an individual functioning. Normal ranges of - CONSTANT (CONTINUOUS) FEVER
measurements of vital signs change with age and - Elevated body temperatures throughout the day
medical condition. with minimal temperature fluctuation (usually
not more than 1 degree Fahrenheit) over a 24-
Vital signs are useful in detecting or monitoring hour period
medical problems.
PULSE
Vital signs can be measured in a medical setting, at
home, at the site of a medical emergency, or Pulse is a wave of blood created by contraction of the
elsewhere. left ventricle of the heart. The heart is a pulsating
pump and the blood enters the arteries with each
WHEN TO ASSESS VITAL SIGNS heartbeat, causing pulse waves.
1. Upon admission to any healthcare agency. Pulse assessment is the measurement of pressure
2. Based on agency institutional policy and procedures. pulsation created when the heart contracts and ejects
blood into the aorta
3. Anytime there is a change in the patient's condition
CHARACTERISTICS OF PULSE
4. Before and after surgical and invasive procedure
1. Quality.
5. Before and after activity that may increase risk
2. Rate.
6. Before and after administering medications that
affect cardiovascular or respiratory function 3. Rhythm.

TEMPERATURE 4. Volume (strength or amplitude).

PHYSIOLOGICAL BASIS OF BODY

TEMPERATURE PULSE QUALITY refers to the ‘‘feel’’ of the pulse,
Body temperature is the balance between the heat its rhythm and forcefulness
production due to chemical activities by the body and PULSE RATE is an indirect measurement of cardiac
heat lost from the body through radiation, conduction, output obtained by counting the number of apical or
convection, and vaporization (Evaporation) peripheral pulse waves over a pulse point.
The hypothalamus, a gland located in the brain, acts - A normal pulse rate for adults is between 60 and
as a thermoregulator. It is able to adjust body 100 beats per minute.
temperature that results in either increasing or - Bradycardia is a heart rate less than 60 beats per
decreasing heat production throughout the day minute in an adult.
A body temperature above the usual range is called - Tachycardia is a heart rate in excess of 100 beats
pyrexia, hyperthermia, or (in lay terms) fever per minute in an adult.

A very high fever, such as 41°C (105.8°F), is called PULSE RHYTHM is the regularity of the heartbeat.
hyperpyrexia (Figure 29–4 •). The client who has a It describes how evenly the heart is beating:
fever is referred to as febrile; the one who does not is - Regular (the beats are evenly spaced).
afebrile - Irregular (the beats are not evenly spaced).
 - Dysrhythmia (arrhythmia) is an irregular rhythm Respiration, or the act of breathing, is the process of
caused by an early, late, or missed heartbeat. inhaling oxygen into the body and exhaling carbon
dioxide. One respiration also called the respiratory
PULSE VOLUME is a measurement of the strength cycle, consists of one expiration (exhalation) and one
or amplitude of force exerted by the ejected blood inspiration (inhalation).
against the arterial wall with each contraction.
CHARACTERISTICS OF RESPIRATION
- It is described as normal (full, easily palpable).
- Weak (thready and usually rapid), or Respiration rates should not be measured if the patient
- Strong (bounding) has recently experienced exertion, such as climbing
stairs or exercising, unless so ordered by the physician.
Radial
When counting a patient’s respiration rate, watch or
- Readily accessible feel the rise and fall of the chest. Each rise and fall
constitute one complete respiration
Temporal
The patient’s respiration rate should be measured
- Used when radial pulse is not accessible without the patient knowing
Carotid RESPIRATORY RATE
- Used in cases of cardiac arrest Respiratory rate is the number of respirations per
- Used to determine circulation to brain minute.
Apical An adult respiratory rate below 12 (bradypnea) or
above 20 (tachypnea)
- Routinely used for infants & children up to 3
yrs. of age Apnea means the absence of breathing for a period
- Used to determine discrepancies w/radial lasting longer than 19 seconds, and Eupnea refers to
pulse normal breathing
- Used in conjunction w/ some medications
RESPIRATORY DEPTH
Brachial
The depth of respiration is the volume of air that is
- Used to measure blood pressure inhaled and exhaled. It is described as either “shallow”
- Used during cardiac arrest for infants or “deep.”
Femoral Hyperventilation refers to deep and rapid respirations,
- Used in cases of cardiac arrest and hypoventilation refers to shallow and slow
- Used for infants & children respirations
- Used to determine circulation to a leg
Popliteal When a patient is unable to take in enough oxygen
- Used to determine circulation to the lower leg during inhalation, the body becomes deprived of the
Posterior Tibial amount of oxygen needed for proper functioning. If
- Used to determine circulation to the foot oxygen deprivation continues, the skin around the
Pedal mouth and nail beds of the hands and feet may appear
- Normal Value:60-80 beats per minute (adult) bluish in color because of the increase of carbon
- Used to determine circulation to the foot 60- dioxide (CO2). The resulting condition is called
100 beats per minute (child cyanosis.
Compliance
- ability of the arteries to contract and expand BREATH SOUNDS
Cardiac Output 1. STRIDOR
- volume of the blood pumped into the arteries - A shrill, harsh sound, heard more clearly
by the heart during inspiration but that can occur during
- Stroke Volume (SV) X Heart rate (HR) expiration. This sound may occur when there
is airway blockage, such as in children with
Peripheral Pulse croup and patients with laryngeal obstruction.
- a pulse located away from the heart 2. STERTOR (stertorous breathing)
Apical Pulse - Noisy sounds during inspiration, sounds
- a central pulse located at the apex of the heart similar to those heard in snoring.
Stroke volume 3. CRACKLES (also called rales)
- Amount of blood ejected from the left - Crackling sounds resembling crushing tissue
ventricle with each contraction paper, caused by fluid accumulation in the
airways. Crackles can be further defined as
RESPIRATION coarse or fine. Crackles can be heard with
 pulmonary edema, asthma, early congestive
heart failure, and some types of pneumonia.
4. RHONCHI
- Rattling, whistling, low-pitched sounds made
in the throat. Rhonchi can be heard in patients
with pneumonia, chronic bronchitis, cystic
fibrosis, or COPD (chronic obstructive
pulmonary disease).
5. WHEEZES
- Sounds similar to rhonchi but more
highpitched, made when airways become
obstructed or severely narrowed, as in asthma
or COPD.
6. CHEYNE-STOKES BREATHING
- Irregular breathing that may be slow and
shallow at first, then faster and deeper, and
that may stop for a few seconds before
beginning. The pattern again. This type of
breathing may be seen in certain patients with
traumatic brain injury, strokes, and brain
tumor
BLOOD PRESSURE
Blood pressure (BP) is one of the most important vital
signs because it aids in diagnosis and treatment,
especially for cardiovascular health. Blood pressure
readings are almost always taken at every medical
visit, even if it is the only vital sign obtained.
BLOOD PRESSURE READING
Blood pressure is the amount of force exerted on the
arterial walls while the heart is pumping blood—
specifically, when the ventricles contract
Systolic blood pressure is the highest pressure that
occurs as the left ventricle of the heart is contracting.
Diastolic blood pressure is the lowest pressure level
that occurs when the heart is relaxed and the ventricle
is at rest and refilling blood.
PULSE PRESSURE
Pulse pressure is the difference between the systolic
and diastolic readings and is calculated by subtracting
the diastolic reading from the systolic reading. If the
blood pressure is 120/80, the pulse pressure is 40. In
general, a pulse pressure that is greater than 40 mmHg
is considered widened, and one that is less than 30
mmHg is considered to be narrowed.
A widened pulse pressure may be an indicator for
cardiovascular disease and anemia. A narrowed pulse
pressure may be an indicator for congestive heart
failure (CHF), stroke, or shock