ASSESSING VITAL SIGNS
Esteve Adrian Z. Estiva PhD, RN
Learning Objectives:
• Describe factors that affect the vital signs;
• Identify the normal ranges for each vital sign;
• Compare oral, rectal, and axillary methods of measuring body
temperatures;
• Identify nine pulse sites commonly used to assess the pulse;
• Identify the characteristics that should be included in a
respiratory assessment;
• Differentiate systolic from diastolic blood pressure; and
• Demonstrate accurate vital signs taking techniques.
VITAL SIGNS
• aka Cardinal signs
• TEMPERATURE
• PULSE
• RESPIRATIONS
• BLOOD PRESSURE
VITAL SIGNS MUST BE MEASURED, REPORTED, AND RECORDED ACCURATELY
IF YOU ARE NOT SURE OF A MEASUREMENT, RECHECK IT
FACTORS THAT AFFECT
VITAL SIGNS
• ILLNESS
• EMOTIONS – ANGER, FEAR, ANXIETY, PAIN
• EXERCISE AND ACTIVITY
• AGE
• SEX
• ENVIRONMENT - WEATHER
• FOOD AND FLUID INTAKE
• MEDICATIONS
• TIME OF DAY – ↓ IN THE MORNING, ↑ IN THE AFTERNOON/EVENING
• NOISE and STRESS
A CHANGE IN ONE VITAL SIGN WILL CAUSE A CHANGE IN THE OTHERS
REPORT THE VITAL SIGNS
TO THE NURSE IF:
• ANY VITAL SIGN IS CHANGED FROM A PREVIOUS
MEASUREMENT
• VITAL SIGNS ARE ABOVE THE NORMAL RANGE
• VITAL SIGNS ARE BELOW THE NORMAL RANGE
MANY AGENCIES HAVE TEMP BOARDS OR TPR BOOKS
REPORTING
AND RECORD VITAL SIGN MEASUREMENTS AS SOON AS
POSSIBLE
RECORDING CARRY A SMALL NOTEBOOK IN YOUR POCKET SO
YOU CAN RECORD THEM AS YOU TAKE THEM
VITAL SIGNS ABBREVIATIONS
TEMPERATURE – T
PULSE – P
RESPIRATIONS – R
BLOOD PRESSURE - BP
RESPOND TO PATIENT OR
VISITOR QUESTIONS ABOUT
VITAL SIGNS ACCORDING TO
FACILITY POLICY
REFER THEIR QUESTIONS TO
THE NURSE
BODY TEMPERATURE
THE AMOUNT OF HEAT IN THE BODY
IT IS A BALANCE BETWEEN THE AMOUNT OF HEAT
PRODUCED AND THE AMOUNT OF HEAT LOST
HEAT IS PRODUCED BY :
THE CONTRACTION OF MUSCLES DURING EXERCISE
THE BREAKDOWN OF FOOD DURING DIGESTION
THE ENVIRONMENTAL TEMPERATURE
HEAT IS LOST THROUGH :
URINE FECES
RESPIRATIONS PERSPIRATION
TEMPERATURE
MEASUREMENT SITES
BODY TEMPERATURE IS MEASURED IN ONE OF
FOUR AREAS OF THE BODY
THE MOUTH – ORAL
THE RECTUM – RECTAL
THE AXILLA (UNDERARM) – AXILLARY
THE EAR – TYMPANIC
WE NOW ALSO HAVE THE TEMPORAL SITE -
FOREHEAD
VARIATIONS IN BODY
TEMPERATURES BY AGE
AGE Route Ave Temp
Newborn Axillary 36.1- 37.7 C 97.0-100 F
1 year Oral 37.7 C 99.7 F
3 years Oral 37.2 C 99.0 F
5 years Oral 37.0 C 98.6 F
Adult Oral 37.0 C 98.6 F
Axillary 36.4 C 97.6 F
Rectal 37.6 C 99.6 F
Forehead 34.4 C 94.0 F
Tympanic 37.7 C 99.9 F
Elderly Oral 36.0 C 96.8 F
NORMAL BODY TEMPERATURE
• SITE NORMAL RANGE
• ORAL 98.6 ° F 97.6 ° TO 99.6 ° F
• RECTAL 99.6 ° F 98.6 ° TO 100.6 ° F
• AXILLARY 97.6 ° F 96.6 ° TO 98.6 ° F
• TYMPANIC 98.6 ° F 98.6 ° F
• TEMPORAL 98.6° F 98.6° F
TEMPERATURE SCALES
Celsius/
Centigrade
• C= (F-32) x 5/9
Fahrenheit • F= (C x 9/5) + 32
ELECTRONIC
THERMOMETER
• BATTERY OPERATED
• HAVE AN ORAL PROBE AND A RECTAL
PROBE
• DISPOSABLE PROBE COVER IS PLACED
ON THE PROBE
• THE TEMPERATURE REGISTERS IN
ABOUT 30 SECONDS
DIGITAL
THERMOMETER
• USE A DISPOSABLE SHEATH
DISPOSABLE ORAL
THERMOMETER
TYMPANIC THERMOMETER
• MEASURES THE TEMPERATURE IN THE TYMPANIC MEMBRANE
(EARDRUM)
• FAST AND ACCURATE - 1 TO 3 SECONDS
INFANTS – PULL THE EAR STRAIGHT BACK
ADULTS AND CHILDREN OVER ONE YEAR –
PULL THE EAR UP AND BACK
GUIDELINES FOR TAKING AN
ORAL TEMPERATURE
• DO NOT TAKE AN ORAL TEMPERATURE ON:
• AN INFANT OR YOUNG CHILD ( UNDER AGE 6)
• AN UNCONSCIOUS PATIENT
• A PATIENT THAT HAS HAD ORAL SURGERY OR AN INJURY TO THE FACE, NECK, NOSE, OR
MOUTH
• A PERSON RECEIVING OXYGEN
• A PATIENT WITH A NASOGASTRIC TUBE IN PLACE
• A PATIENT WHO IS CONFUSED OR RESTLESS
• A PATIENT WHO IS PARALYZED ON ONE SIDE OF THE BODY
• HAS A HISTORY OF SEIZURES
• A PATIENT WHO BREATHES THROUGH THE MOUTH
GUIDELINES FOR TAKING A
RECTAL TEMPERATURE
• DO NOT TAKE A RECTAL TEMPERATURE ON:
• A PERSON WHO HAS HAD RECTAL SURGERY OR RECTAL INJURY
• IF THE PERSON HAS DIARRHEA
• IF THE PERSON IS CONFUSED OR AGITATED
• IF THE PERSON HAS HEART DISEASE ( STIMULATES THE VAGUS
NERVE WHICH SLOWS THE HEART RATE )
ALTERATIONS IN BODY
TEMPERATURE
PYREXIA/ FEVER/ Body temperature above the usual range
HYPERTHERMIA
HYPERPYREXIA Very high fever (41 C or 105.8 F)
FEBRILE A client who has fever
AFEBRILE A client without fever
HYPOTHERMIA Core body temperature below the lower limit
of normal
PULSE
• THE BEAT OF THE HEART FELT AT AN ARTERY AS A WAVE
OF BLOOD PASSES THROUGH THE ARTERY
•
• THE PULSE SHOULD BE THE SAME IN ALL PULSE SITES
ON THE BODY
• THE PULSE RATE IS AFFECTED BY MANY FACTORS –
AGE, FEVER, EXERCISE, FEAR. ANGER, ANXIETY,
EXCITEMENT, HEAT, POSITION, AND PAIN.
• MEDICATIONS CAN BE TAKEN THAT EITHER INCREASE
OR DECREASE A PERSON’S PULSE RATE.
AGE AVERAGE RANGE
Newborn to 1 month 130 80-180
1 year 120 80-140
2 years 110 80-130
6 years 100 75-120
Adult 80 60-100
VARIATIONS IN PULSE RATE BY AGE
RADIAL PULSE
• MOST COMMON SITE USED FOR TAKING A
PULSE
• CAN BE TAKEN WITHOUT DISTURBING OR
EXPOSING THE PERSON
• PLACE THE FIRST TWO OR THREE FINGERS OF
ONE HAND AGAINST THE RADIAL ARTERY
• THE RADIAL ARTERY IS ON THE THUMB SIDE
OF THE WRIST
• DO NOT USE YOUR THUMB TO TAKE A
PERSON’S PULSE
• USE GENTLE PRESSURE
USING A STETHOSCOPE
• ALWAYS CLEAN THE EARPIECES OF THE
STETHOSCOPE WITH ALCOHOL BEFORE AND
AFTER USE
• WARM THE DIAPHRAGM IN YOUR HAND BEFORE
PLACING IT ON THE PERSON
• HOLD THE DIAPHRAGM IN PLACE OVER THE
ARTERY
• DO NOT LET THE TUBING STRIKE AGAINST
ANYTHING WHILE THE STETHOSCOPE IS BEING
USED
APICAL - RADIAL
PULSE
• THE APICAL AND RADIAL PULSE RATES SHOULD
BE EQUAL
• SOMETIMES THE HEART BEAT IS NOT STRONG
ENOUGH TO CREATE A PULSE IN THE RADIAL
ARTERY
• THIS WOULD CAUSE THE RADIAL PULSE TO BE
LESS THAN THE APICAL PULSE
• ONE PERSON COUNTS THE APICAL WHILE THE
OTHER PERSON COUNTS THE RADIAL
• THE DIFFERENCE IN PULSES IS CALLED THE
PULSE DEFICIT
REMINDERS
• NORMAL ADULT PULSE RATE IS – 60 TO 100
BEATS PER MIN.
• TACHYCARDIA – HEART RATE OVER 100
• BRADYCARDIA – HEART RATE BELOW 60
REPORT ABNORMAL HEART RATES TO THE NURSE
IMMEDIATELY
RESPIRATIONS
The act of breathing
Includes the intake of oxygen and the output
of carbon dioxide
COUNTING RESPIRATIONS
• ONE RESPIRATION CONSISTS OF ONE INSPIRATION
AND ONE EXPIRATION
• THE CHEST RISES DURING INSPIRATION (BREATHING
IN) AND FALLS DURING EXPIRATION (BREATHING
OUT)
• COUNT EACH TIME THE CHEST RISES
• DO NOT LET THE PERSON KNOW YOU ARE
COUNTING THEIR RESPIRATIONS
• COUNT AFTER TAKING THE PULSE – KEEP YOUR
FINGERS ON THE PULSE SITE
• NORMAL RESPIRATORY RATE FOR ADULT IS 12 – 20
BREATHS PER MIN.
ABNORMAL RESPIRATIONS
• TACHYPNEA – RESPIRATORY RATE OVER 20
• BRADYPNEA – RESPIRATORY RATE BELOW 12
• DYSPNEA – SHORTNESS OF BREATH – DIFFICULTY IN
BREATHING
• APNEA – NO BREATHING
• HYPERVENTILATION – FAST AND DEEP RESPIRATIONS
• HYPOVENTILATION – SLOW AND SHALLOW RESPIRATIONS
BLOOD PRESSURE
• THE MEASUREMENT OF THE AMOUNT OF FORCE THE BLOOD EXERTS AGAINST
THE ARTERY WALLS
SYSTOLIC PRESSURE – PRESSURE EXERTED WHEN THE HEART MUSCLE IS
CONTRACTING
DIASTOLIC PRESSURE – PRESSURE EXERTED WHEN THE HEART MUSCLE IS
RELAXING BETWEEN BEATS
• BLOOD PRESSURE IS RECORDED AS A FRACTION WITH THE SYSTOLIC
PRESSURE ON TOP AND THE DIASTOLIC PRESSURE ON THE BOTTOM
SYSTOLIC /DIASTOLIC
120/80 mmHg
PULSE PRESSURE - THE DIFFERENCE BETWEEN THE DIASTOLIC AND SYSTOLIC
PRESSURE
FACTORS THAT AFFECT
BLOOD PRESSURE
AGE – BLOOD PRESSURE INCREASES AS A PERSON GROWS OLDER.
GENDER – WOMEN USUALLY HAVE LOWER BLOOD PRESSURE THAN MEN
BLOOD VOLUME – SEVERE BLEEDING LOWERS THE BLOOD PRESSURE
STRESS – HEART RATE AND BLOOD PRESSURE INCREASE AS PART OF THE BODY’S RESPONSE TO STRESS
PAIN – INCREASES BLOOD PRESSURE
EXERCISE – INCREASES HEART RATE AND BLOOD PRESSURE
WEIGHT – BLOOD PRESSURE IS HIGHER IN OVERWEIGHT PERSONS
RACE – BLACK PERSONS GENERALLY HAVE HIGHER BLOOD PRESSURE THAN WHITE PERSONS DO
DIET – A HIGH-SODIUM DIET INCREASES THE FLUID VOLUME IN THE BODY WHICH INCREASES BLOOD PRESSURE
MEDICATIONS – CAN BE TAKEN TO RAISE OR LOWER BLOOD PRESSURE
POSITION – BLOOD PRESSURE IS LOWER WHEN LYING DOWN
TYPES OF BLOOD PRESSURE CUFFS
THE PROPER NAME FOR A BLOOD PRESSURE CUFF IS
SPHYGMOMANOMETER
GUIDELINES FOR MEASURING
BLOOD PRESSURE
• DO NOT TAKE A BLOOD PRESSURE ON AN ARM WITH AN IV, A CAST, OR A DIALYSIS SHUNT.
• DO NOT TAKE A BLOOD PRESSURE ON THE SIDE THAT A PERSON HAS HAD BREAST
SURGERY ON.
• MEASURE BLOOD PRESSURE WITH THE PERSON SITTING OR LYING.
• APPLY THE CUFF TO THE BARE UPPER ARM. DO NOT APPLY THE CUFF OVER CLOTHING.
• USE A LARGE CUFF IF NECESSARY.
• MAKE SURE THE ROOM IS QUIET.
• IF YOU DO NOT HEAR THE BLOOD PRESSURE, WAIT 30 TO 60 SECONDS AND TRY AGAIN. IF
YOU STILL CAN NOT HEAR IT OR ARE UNSURE OF YOUR READINGS, HAVE THE NURSE
CHECK YOUR MEASUREMENTS.
ABNORMAL
BLOOD HYPERTENSION –
PRESSURE MEASUREMENTS ABOVE
THE NORMAL SYSTOLIC OR
DIASTOLIC PRESSURES
HYPOTENSION –
MEASUREMENTS BELOW
THE NORMAL SYSTOLIC OR
DIASTOLIC PRESSURES
PAIN
Pain means to ache, Pain is a warning from Pain is personal.
hurt, or be sore. the body.
Types of Acute pain – felt suddenly from an injury,
disease, trauma, or surgery
pain
Chronic pain – lasts longer than 6 months.
Pain can be constant or occur on and off.
Radiating pain – felt at the site of tissue
damage and in nearby areas.
Phantom pain – felt in a body part that is no
longer there.
ASK FOR:
• Location – Where is the pain?
• Onset and duration – When did the pain start?
• Intensity – Rate the pain on a scale of 1 to 10, with 10 as the most severe
• Description – Can you use words to describe the pain?
• Factors causing pain – What were you doing when the pain started?
• Vital signs – Take the person’s vital signs when they complain of pain.
• Other signs and symptom
• Body responses - ↑ vital signs, nausea, pale skin, sweating, vomiting
• Behaviors – crying, groaning, holding affected body part, irritability, restlessness
Thank you
