Vital Signs

Krystle D. Montebon, RN
 Objectives
• To assess vitals signs to ill and well clients
• Identify different types and methods of
taking vitals signs
• Differentiate normal from abnormal vital
signs
• Identify factors to consider in taking vital
signs of an individual
• Apply the correct method/s in taking vital
signs
 Introduction

Vital signs reflect changes in function that

otherwise might not be observed.
Monitoring a client’s vital signs should not
be an automatic or routine procedure; it
should be a thoughtful, scientific
assessment. Vital signs should be
evaluated with reference to clients’ present
and prior health status, their usual vital sign
results (if known), and accepted standards.
 Cardinal Signs

Objective Data
1. Temperature
2. Pulse
3. Respiration
4. Blood pressure
Also included:
Pain and Oxygen saturation
 When to take vital signs?
• Upon admission to any healthcare agency
• Based on agency policy and procedures
• Any time there is a change in the patient’s
condition
• Before and after surgical or invasice
diagnostic procedure
• Before and after activity that may increase
risk
• Before administering medications that affect
cardiovascular or respiratory frunctioning
 Body Temperature
• Defined as the balance between the heat
produced by the body and the heat lost from
the body

Types:
1. Core temperature - temperature of the
deep tissues of the body (oral and rectal)

2. Surface temperature - temperature of the

skin, subcutaneous tissue and fat (axillary
temperature)
 Body Temperature
Maintenance of body temperature:

1. Thermoregulatory center in the

hypothalamus regulates temperature
2. Center receives messages from cold
and warm thermal receptors in the body
3. Center initiates responses to produce or
conserve body heat or increase heat
loss
 Body Temperature
Factors that affect the body’s heat production

1. Basal Metabolic Rate (BMR) - the rate of

energy utilization in the body required to
maintain essential activities such as
breathing and walking; decreases with age
2. Muscle activity (exercise)
3. Thyroxine production
4. Epinephrine, norepinephrine and sypathetic
stimulation
5. Increased temperature of body cells (fever)
 Body Temperature
Factors that affecting temperature

1. Age (infant, elderly people)

2. Gender (female hormones)
3. Diurinal variations (circadian rhythms) - with
lowest levels at 4am to 6am and highest at
8pm to 12 midnight
4. Exercise and activity - increases BMR
5. Stress or SNS stimulation
6. Head injury or tumors
 Body Temperature
Normal range: 36.5°C- 37.5°C

Body temperature above the normal range

- Pyrexia
- Hyperthermia
- Febrile
- Hyperpyrexia - body temperature above 41°C

Body temperature below the normal range

- Hypothermia
 Body Temperature
Types of fever

1. Intermittent fever
- temperature fluctuates between periods of
fever and periods of normal/subnormal
temperature.
2. Remittent fever
- temperature fluctuates within a wide range
over a 24-hour period but remains above
normal range
 Body Temperature
Types of fever

3. Relapsing fever
- temperature is elevated for few days,
alternated with 1 or 2 days of normal
temperature
4. Constant fever
- consistently high temperature
Body Temperature
 Body Temperature
Temperature Conversion
 Pulse Rate
• Defined as the wave of blood created by
contraction of the left ventricle of the heart
moving blood into the arteries
• It is regulated by the autonomic nervous
system
• Factors affecting pulse:
1. Age 6. Hemorrhage
2. Gender 7. Stress
3. Exercise 8. Position changes
4. Fever
5. Medications
 Pulse Rate
Pulse sites:
• Temporal
• Carotid
• Apical
• Brachial
• Radial
• Femoral
• Popliteal
• Dorsalis pedis
• Posterior tibial (Pedal)
 Pulse Rate
Assessment of the pulse
A. Rate - Tachycardia (above normal rate) or
bradycardia (below normal rate)
B. Rhythm - Pattern or interval of beats should
be regular, with equal time elapsed in
between beats;
C. Arterial wall elasticity - feels straight, smooth,
soft and pliable
D. Presense or absence of bilateral equality
E. Volume (Amplitude) - strength or quality of
pulsation
 Pulse Rate
A normal pulse should remain constant with
moderate pressure

Scaling of pulse volume:

0 - Pulse is absent
1 - Pulse is difficult to feel; thready or weak
2 - Normal pulse
3 - Bounding pulse and difficult to obliterate
 Respiration
• Respiration is the act of breathing. Respiratory
rate is the numner of breaths per minute

• 2 Types:
a. Costal (thoracic) breathing - involves the
external inter costal muscles and other
accessory muscles

b. Diaphragmatic (abdominal) breathing -

involves the contraction and relaxation of
the diaphragm, and it is observed by the
movement of the abdomen
 Respiration
• Respiratory centers:
1. Medula oblongata - primary center
2. Pons
a. Pneumotaxic center - rhythm
b. Apneustic center - deep and
prolonged
3. Carotid and aortic bodies - response to
low oxygen concentration in the bood
- The primary chemical stimulation for
breathing is high carbon dioxide in the
blood
 Respiration
Major factors affecting respiratory rate
1. Exercise and activity
2. Stress
3. Environmental temperature
4. Body temperature
5. Increased altitude
6. Medication
7. Disease process
 Respiration
Assessing respiration:
- client should be relaxed and unaware of the
assessment or while the nurse is watching the
movement of the client’s chest wall

a. Rate: Normal range si 16-20 breaths per

minute
b. Depth: Observe the movement of the chest,
is it normal, deep or shallow?
c. Rhythm: Regularity of exhalations and
inhalations
 Respiration

d. Quality or character: respiratory effort and

sound of breathing with each cycle; should
have no sound and effortless
- Variations:
i. Dyspnea
ii. Orthopnea
iii. Tachypnea
iv. Bradypnea
v. Hyperventilation
vi. Hypoventilation
 Respiration
Different rates and depths of respiration
Eupnea Normal breathing at 16-20 breaths per minute

Bradypnea Slower than normal rate, with normal depth and regular rhythm

Tachypnea Rapid, shallow breathing at >24 breaths per minute

Hypoventilation Shallow, irregular breathing

Apnea Period of cessation of breathing. Time and duration varies.

Regular cycle where the rate and depth of breathing increases,
Cheyne Strokes
then decreases accompanied by apnea

Biot’s respiration Periods of normal breathing followed by a varying period of apnea

Respiration
 Respiration
Type Physiology Auscultation Sound Possible Conditions
Crackles Air passing through More commonly heard Fine, high pitched or Pneumoniam heart
fluid in small during inspiration coarse low pitched failure, atelectasis,
airways or sudden poppung sounds that emphysema
opening of deflated, are short and
weakened airways discontinuous
Rhonchi Large airway Heard commonly Low pitched, COPD,
obstructed by fluid during expiration continuous snoring bronchospasm,
sound pneumonia
Wheezes Air passing through Can be heard High pitched whistling Airway obstruction,
narrowed airways throughout inspirationa sound bronchospasm as in
and expiration asthma, COPD
Pleural Rubbing of May occur throughout Scratching, grating, Inflamed pleura,
friction rub inflammed pleura respiratory cycle, heard rubbing, creaking pulmonary infarction.
best at base of lung at
end of expiration
 Blood Pressure
Defined as the pressure exerted by the blood as it
pulsates through the arteries

• Systolic pressure - contraction of ventricles

• Diastolic pressure - relaxation of ventricles

• Pulse pressure - the difference between the

systolic and diastolic pressures; normally at
30-40 mmHg
 Blood Pressure
Factors affecting blood pressure:

− Age, gender, race - Emotional state

− Circadian rhythm - Body position
− Food intake - Drugs/medications
− Exercise - Disease process
− Weigth/Obesity - Stress
Variations: Blood Pressure
Hypertension - an abnormally high blood pressure,
over 140 mmHg systolic and 90 mmHg diastolic for
at least 2 consecutive readings

Hypotension - a systolic reading consistently

between 85 and 110 mmHg

Orthostatic hypotension - postural hypotension; a

blood pressure that decreases when the clietn
changes from supine to a sitting or standing
position
 Blood Pressure
Determinants of blood pressure:
Blood volume
Peripheral resistance
Cardiac output
Elasticity or compliance
Blood viscosity

Korotkoff sound - Sound heard during BP taking

 Blood Pressure
Assessing the Blood Pressure
Ensure that the client is rested
Allow 30 minutes to pass if the client had smoked or ingested caffeine before
taking the BP
Use appropriate size of BP cuff
Position: sitting or supine
Position the arm at the level of the heart, with the palm of the hand facing up
Apply the cuff snugly, 1 inch above the antecubital space
Inflate and deflate the BP cuff slowly

Wait 1-2 minutes before making further determinations

Blood Pressure
End