JOCELYN C.
TEBRERO, MAN, RN, RM
OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING
LEARNING OBJECTIVES
1. Define what is Vital Signs
2. Describe the procedures used to assess the vital signs
3. To identify the purpose, clinical assessment and
importance of Vital signs taking
4. Identify factors that can influence each vital signs
5. Identify equipment routinely used to assess the vital
signs
6. Different terminologies and procedure in taking
vital signs
7. Properly demonstrate the step by step procedure in
taking vital signs
VITAL SIGNS
This is a common, non invasive physical assessment
procedure done to clients; specifically pulse rate,
temperature, respiratory rate and blood pressure that
indicate the state of a patient’s essential body functions.
This is a clinical measurements that provides data that
reflect the status of several body system including
cardiovascular, peripheral vascular, neurologic and
respiratory systems.
PURPOSES
1. To obtain baseline data
2. To detect or monitor change
in the client’s health status
3. To monitor clients at risk for
alteration in health.
EQUIPMENT
STETHOSCOPE
SPHYGMOMANOMETER
THERMOMETER
WATCH WITH SECOND HAND
PEN
VITAL SIGNS SHEET
COTTON
ALCOHOL
WHEN DO WE TAKE VITAL SIGNS?
Upon admission
Changes in the status of the patient
Nursing or medical order
Before, after and during invasive procedure
Before and after administration of drugs
Before and after any nursing intervention
TEMPERATUR
E between the heat
Balance
produced by the body and the
heat lost from the body.
The degree or intensity of
internal heat of a person’s
body.
TWO KINDS OF
TEMPERATURE
Surface Temperature
Skin, subcutaneous tissue and fat cells
Fluctuates in response to environment.
Core Temperature
Temperature of deep tissue of the body.
Remains relatively constant.
36.5 and 37.70C
HYPOTHALAMUS
FACTORS THAT INFLUENCE BODY
TEMPERATURE
Age
Diurnal Variations (lower when asleep & higher when
active) 8pm-12mn/ 4-6am
Exercise
Hormones (progesterone)
Stress (epinephrine, norepinephrine)
Illness (infection)
Environment
Ovulation
TYPES OF THERMOMETER
1. Glass thermometers
2. STRIP THERMOMETER
TYPES OF THERMOMETER
3. Digital thermometer.
ALTERATIONS IN BODY
TEMPERATURE
Hypothermia
Body loses heat faster than it can produce heat
34 – 35 ⁰C
Pyrexia/Hyperthermia/febrile
Body temperature above the usual range 38 – 41
⁰C
Hyperpyrexia
An extremely high fever 41⁰C or 105.8 ⁰F.
FOUR COMMON TYPES OF FEVER
Intermittent Fever
alternates at regular interval where
temperature is elevated for several hours
or periods of fever and followed by an
interval of normal temperature.
(Malaria) or other infectious disease
Remittent Fever
A wide range of temperature fluctuations,
occurs over the 24-hour period all of
which are above normal (pyrexia)
throughout the day.
Viral upper respiratory tract or may be
caused by drugs.
Relapsing/Recurrent Fever
Short periods of high fever
(40°C) with periods of 1 or 2
days of normal temperature.
Bacterial infections
Constant/Continuous Fever
Fluctuates minimally but always
remains above normal.
Temperature does not touch the
baseline and remains above
normal throughout the day.
SITE FOR TEMPERATURE
MEASUREMENT
SITE ADVANTAGE DISADVANTAGE
1. Oral Accessible & • Thermometers
(36.5-37.5⁰C) convenient break if bitten
• Inaccurate if the
client ingested hot or
cold food, fluid or
smoked
• Could injured the
mouth following oral
surgery
SITE ADVANTAGE DISADVANTAGE
2. Rectal Reliable
(37-38.1⁰C) Measurement
• Inconvenient and more
unpleasant for clients
• Difficult for client who
cannot turn to the side
• Could injure the rectum
following rectal surgery
• Presence of stool may
interfere with
thermometer placement.
SITE ADVANTAGE DISADVANTAGE
3. Axillary Safe and NonInvasive • The thermometer
(35.8-37⁰C) must be left in place
a long time to obtain
an accurate
measurement
SITE ADVANTAGE DISADVANTAGE
4. Tympanic Readily accessible • Can be uncomfortable
and involves risk of
Reflects the core
(36.8-37.9) temperature
injuring the
measurement if the
Very fast probe is inserted too
far.
• Repeated
measurements may
vary, right and left
measurements may
differ.
• Very Expensive
SITE ADVANTAGE DISADVANTAGE
5. Temporal Safe, Non-invasive Requires electronic
equipment that may be
Very Fast expensive or unavailable
variation in technique
needed if the client has
perspiration on the
forehead.
SIGNS AND SYMPTOMS OF FEVER
1. Sweating
2. Chills, shivering or shaking
3. Hot or flushed skin
4. Headache
5. Body ache
6. Fatigue/weakness
7. Loss of appetite
8. Increased heart rate
9. Dehydration
MANAGEMENT FOR FEVER
1. Take your temperature and assess symptoms
2. Stay in bed and rest
3. Keep hydrated or increase fluid intake
4. Stay cool or manage stress
5. Tepid sponge bath/ use of cold compress
6. Take over the counter medication or take
medication as prescribed
PULSE
Wave of blood created by
contraction of the Left Ventricle
of the heart.
Regulated by ANS (Autonomic
Nervous System)
PULSE
Assess: rate, rhythm, strength – can
assess by using palpation &
auscultation.
Pulse deficit – the difference between
the radial pulse and the apical pulse –
indicates a decrease in peripheral
perfusion from some heart conditions
FACTORS AFFECTING PULSE RATE
Age
Gender
Exercise and Fever
Medications
Hemorrhage
Stress
Position changes
TYPES OF PULSE
Central- or Apical pulse
-It is located on the apex of the heart that is
monitored using a stethoscope.
Peripheral- Pulses that can be felt on the
periphery of the body by palpating an
artery over a bony prominence.
L SE
P U T S
O I N
P
PERIPHERAL PULSE POINTS
TEMPORAL BRACHIAL
CAROTID RADIAL
PERIPHERAL PULSE POINTS
FEMORAL DORSALIS PEDIS
POPLITEAL POSTERIOR
APICAL PULSE
Is measured by listening over the apex of the heart on the left side
of the chest, using a stethoscope
The apex is usually found at the 5th intercostal space just inside the
midclavicular line
PULSE RATE
PULSE
AGE RANGE
AVERAGE
NEWBORN 130 120 – 160
1 YEAR 120 80 – 140
5 – 8 YEARS 100 75 – 120
10 YEARS 70 50 – 90
TEENS 75 50 – 90
ADULT 80 60 – 100
OLDER ADULT 70 60 - 100
RHYTHM
Patterns of beats and interval
between the beats.
Dysrhythmia or arrhythmia
may be a random, irregular beats
or predictable pattern of irregular
beats.
Apical pulse, ECG
PULSE VOLUME
SCALE DESCRIPTION OF PULSE
0 ABSENT
THREADY OR WEAK, DIFFICULT TO
1+
FEEL
NORMAL, DETECTED READILY,
2+ OBLITERATED, WITH MODERATE
PRESSURE
3+ FULL, BOUNDING
BOUNDING AND DIFFICULT TO
4+
OBLITERATE
ARTERIAL WALL
ELASTICITY
An artery is straight, smooth, soft, and
pliable/ elastic.
An elastic artery contains collagen and
elastin filaments which gives it the ability
to stretch in response to each pulse.
It reflects expansibility and deformities
PRESENCE / ABSENCE OF
BILATERAL EQUALITY
Absence of bilateral equality will
also affect blood pressure
Each time the heart beats, pressure is
created that pressure may indicates
cardiovascular disorder
TERMINOLOGIES
1. Bradycardia – rate of less than 60
beats/min.
2. Tachycardia – rate of more than 100
beats/min.
3. Bounding / full – strong pulse
4. Thready / weak – diminished
strength
RESPIRATION The act of
breathing or
ventilation.
Normally
regular, even,
& quiet
POINTS TO REMEMBER
INSPIRATION/ INHALATION
intake of air into the lungs.
EXPIRATION/ EXHALATION
breathing out of gases into the atmosphere.
SYMMETRY – sides of the chest normally rise &
fall together
ASYMMETRICAL – rise & fall are not together
POINTS TO REMEMBER
Assess by observing rate, rhythm & depth
I&E is automatic & controlled by the medulla
oblongata (respiratory center of brain)
Normal breathing is active & passive
Women breathe thoracically, while men & young
children breathe diaphramatically ***usually
Asses after taking pulse, while still holding hand,
so patient is unaware you are counting
respirations
TYPES OF BREATHING
Costal (thoracic)
Involves the movement of the
chest
Diaphragmatic (abdominal)
involves movement of the
abdomen.
RATE
Describes as breaths per minute/CPM.
Eupnea- normal
Tachypnea- fast/rapid respiration
Bradypnea- slow respiration
Apnea- absence of breathing
RATE (CYCLE/BREATHS PER
MINUTE
AGE RANGES
NEWBORN 30 – 80
1 YEAR 20 – 40
5 – 8 YEARS 15 – 25
10 YEARS 15 – 25
TEEN 15 – 20
ADULT 12 – 20
OLDER ADULT 15 – 20
RHYTHM
Cheyne Stoke
Characterized by a gradual increase in breathing then
decrease followed by apnea
very deep, very shallow with apnea
Kussmauls
A rapid, deep, labored breathing associated with
acidosis particularly diabetes.
Biots
Is characterized by regular deep inspirations followed
by regular or irregular periods of apnea.
EFFORT OF RESPIRATION
Orthopnea – refers to a need to sit
up/upright position in order to breath
Dyspnea – describes difficult & labored
breathing
DEPTH OF RESPIRATION
1. Normal
2. Deep
3. Shallow
ABNORMAL PATTERNS
1. Hyperventilation – increased amount of air in
the lungs characterized by prolonged deep
breaths.
It is a condition in which you start to breathe very
fast.
Symptoms:
- Dizziness, shortness of breath, bloating, dry mouth,
weakness, confusion, sleep disturbances, numbness
and tingling or your arms, muscle spasms, chest pain
and palpitations.
2. Hypoventilation – decreased in amount of
air in lungs caused by shallow breaths
(hypopnea) or too slow (bradypnea) or
may be caused by diminished lung
function.
Symptoms:
-Bluish discoloration of the skin caused by
lacked of oxygen, fatigue, drowsiness,
headaches, swelling of ankles, waking up
many times at night or waking up from sleep
unrested.
BLOOD PRESSURE
Reflects the pressure exerted on the walls of the
arteries
It is a measurement of the pressure of the blood
in the arteries when the ventricles are contracted
(systolic) and when the ventricles relaxed
(diastolic).
Systolic Pressure
Pressure of blood as a result of contraction of the ventricles.
Diastolic Pressure
Lower pressure as a result of ventricular relaxation.
POINTS TO REMEMBER
May vary- position of the body and
the arm
BP in a normal persons who is
standing is usually higher due to
gravity
BP in a normal reclining is slightly
lower due to decrease resistance.
TERMINOLOGIES
PULSE PRESSURE
The difference between systolic and
diastolic pressure
STROKE VOLUME
The volume of blood ejected with
each heartbeat.
PARTS
POINTS TO REMEMBER
Cuff – inflatable rubber bladder, tube connects to the manometer, another to
the bulb, important to have correct cuff size (judge by circumference of the
arm not age)
Support arm at heart level, palm turned upward - above heart causes false low
reading
Cuff too wide – false low reading
Cuff too narrow – false high reading
Cuff too loose – false high reading
Listen for Korotkoff sounds – series of sounds created as blood flows through
an artery after it has been occluded with a cuff then cuff pressure is gradually
released.
Do not take B/P in
Arm with cast
Arm with arteriovenous (AV) fistula
Arm on the side of a mastectomy i.e. rt mastectomy,
right arm
FACTORS THAT INFLUENCE BLOOD
PRESSURE
Age Lower during sleep
Exercise Lower with blood loss
Stress Position changes BP
Race
Obesity
Sex
Medication
Caffeine or nicotine intake
Extreme emotions/pain
Diurnal Variation
FACTORS CONTRIBUTING TO IN
TAKING ABNORMAL BLOOD
PRESSURE
Cardiac Output- The more blood the heart pumps, the greater the
pressure in the blood vessels.
Circulating blood volume- An increase in volume,
will increase BP.
Peripheral vascular resistance- An increase in resistance in the
peripheral vascular system such as circulatory disorders, will increase
BP.
Viscosity of blood- If blood become thicker such as polycythemia,
will increase BP.
Elasticity of Vessel walls- An increase stiffness such as
atherosclerosis, will increase BP.
ALTERATION IN BLOOD PRESSURE
HYPERTENSION
Abnormally high blood pressure over
140/90, confirmed by a minimum of 2
consecutive visits.
Primary Hypertension.
Secondary Hypertension
HYPOTENSION
Abnormally low blood pressure below
100 mmHg systolic.
Between 85-100 mmHg systolic.
Orthostatic hypotension
Is a sudden drop in blood pressure
when you stand from seated or lying
down position.
CLASSIFICATION OF BLOOD
PRESSURE SYSTOLI
CATEGORY DIASTOLIC
C
NORMAL < 120 >80
PREHYPERTENSION 120 - 139 80 - 90
HYPERTENSION, STAGE 1 140 - 159 90 - 99
HYPERTENSION
> 160 > 100
STAGE 2
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