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2. This is a Course on Physiology & Vital Signs. The first part will be a study module for
the nursing assistant to read and digest. The second part will be an examination at the
end of this study material.
NO RN or LVN Credit Available. This class is specifically intended for the Certified Nurse
Aide (CNA), the Certified Home Health Aide (CHHA), or the Restorative Nurse Aide
(RNA) in compliance with certification board continuing education requirements.
”Role of the Certified Nursing Assistant in Patient Emergencies: Vital Signs”

3.  To present the normal values of temperature, pulse rate,
respiratory rate, and blood pressure.
 To demonstrate how to measure the vital signs.
 To emphasize the purpose of obtaining the vital signs.
 To enumerate the factors that affect the vital signs.
Objectives

4. Basic Emergency Care
Goals:
 Quick and competent emergency
care is the key to rapid stability,
prevention of complication and
early recovery
 Stabilize critically ill
 Prevent deterioration of a client’s
condition
 Promote optimal function
 Do no harm

5. Triage
Rations patient treatment efficiently when resources
are insufficient for all to be treated immediately
To sort and prioritize
Triage systems identify who will receive medical
attention first.

6. Triage Category
Expectant: The casualty is expected not to reach higher medical support alive
without compromising the treatment of higher priority patients. Care should not be
abandoned, spare any remaining time and resources after Immediate and Delayed
patients have been treated.
Immediate: The casualty requires immediate medical attention and will not survive if
not seen soon. Any compromise to the casualty's respiration, hemorrhage control, or
shock control could be fatal.
Delayed: The casualty requires medical attention within 6 hours. Injuries are
potentially life-threatening, but can wait until the Immediate casualties are stabilized
and evacuated.
Minimal: "Walking wounded," the casualty requires medical attention when all
higher priority patients have been evacuated, and may not require stabilization or
monitoring.
Source: US Army Guide

7. Tag Triage System
Red - Emergent
Yellow - Urgent
Green – Non-urgent
Black - Dead or expected
to die

8. Measuring Vital Signs
 Vital signs taking are one of the most frequent data
collection interventions performed by a nurse.
 These include the measurement of temperature, pulse rate,
respiration rate and blood pressure.
 These measurements indicate the physiologic functioning of
the circulatory, respiratory, neural and endocrine systems.
 The data obtained will serve as baseline values used by the
nurse to determine the client’s level of care.

9. Normal Rates
Thermoregulation: the body’s physiologic function of heat
regulation to maintain a constant internal body
temperature.
The main reason for checking body temperature is to
solicit any signs of systemic (overall) infection or
inflammation in the presence of a fever (temp > 38.5°C or
sustained temp > 38°C), or elevated significantly above
the individual's normal temperature.
Body temperature can be measured by different sites with
varying results.

10. Thermoregulation
Oral and rectal temperature measurements are
higher than axillary because the measuring
device is in contact with the mucous
membrane.
Rectal measurements are higher than oral
because of the seal created by the anal
sphincter, which decreases contact with
environmental air.
The axilla is commonly used as site for infants
and children with disabilities because it is the
safest, even though the least accurate method.

11. Oral Temperature

12. Nursing Diagnosis: Body Temperature Alterations
Risk for imbalanced body temperature
Failure to maintain body temperature
within normal range
Hyperthermia
Body temperature elevated beyond
normal range
Hypothermia.
Body temperature below normal range
Ineffective thermoregulation
Temperature fluctuation between
hyperthermia and hypothermia.

13. TABLE 1.
Normal Body Temperature According to Age
Age Route Celsius Fahrenheit
Newborn Axillary 35.5- 39.5˚C 96.0- 99.5˚F
1 year Oral 37.7˚C 99.7˚F
3 years Oral 37.2˚C 99.0˚F
5 years Oral 37˚C 98.6˚F
Adult Oral
Axillary
Rectal
37˚C
36.4˚C
37.6
98.6˚F
97.6˚F
99.6˚F
70 + years Oral 36˚C 96.8˚F
Source: Fundamentals of Nursing Standards and Practice 3rd Edition

14. Temperature Summary
Measuring the body temperature is a
reliable and easy way to determine
someone’s basic state of health.
Measuring the body temperature is a
reliable and easy way to determine if
someone is ill.
Body temperature represents the balance
between heat production and heat loss.
Body heat can be lost by conduction,
convection, evaporation, or radiation.

15. Temperature Summary
 Body temperature represents the
balance between heat production and
heat loss.
 Body heat can be lost by conduction,
convection, evaporation, or radiation.
 Body temperature can be measured in
various ways: the rectal or otic are the
most accurate and are higher than the
axillary, forehead, or oral methods.

16.  The normal oral temperature is 98.2°F ±
1.2° or 36.8°C ± 0.7°. The normal rectal
temperature is 99.6°F ± 0.7° or 37.5°C ±
0.7°.
 Fever is defined as an oral temperature
100°F or higher or a rectal temperature
101°F or higher. In the Celsius scale, a
fever would be an oral temperature 37.7°
or higher or a rectal temperature 38.3° or
higher.
 The specific numbers for normal body
temperature and fever are not absolute.
 If a patient has a fever, report this
immediately to an RN or your supervisor.
Temperature Summary

17.  The pounding of blood flow in an artery that is
palpable at various points on the body
 Its rate is usually measured either at the wrist or
the ankle and is recorded as beats per minute.
 Your pulse is lower when you are at rest and
increases when you exercise (because more
oxygen-rich blood is needed by the body when
you exercise).
 It can be measured by applying gentle pressure
over a pulse point in one full minute (60
seconds).
 Pulse points are located all through out the body.
Pulse

18. TABLE 2
Normal Resting Pulse According
Age Normal Range Average
Rate/ minute
Newborn 100-170 140
1 year 80- 170 120
3 years 80-130 110
6 years 75- 120 100
10 years 70- 110 90
14 years 60-110 90
Adult 60-100 80
Source: Fundamentals of Nursing Standards and Practice 3rd Edition

19. TABLE 3
Normal Resting Respirations According to Age
Age Normal Range Avg Rate/Min
Newborn 30-50 40
1 year 20-40 30
3 years 20-30 25
6 years 16-22 19
14 years 14-20 17
Adult 12-20 18
Source: Fundamentals of Nursing Standards and Practice 3rd Edition

20.  Measurement of pressure pulsations
exerted against the blood vessel walls
during systole and diastole.
 Normal arteries expand during systole
and contract during diastole.
 It is measured in millimetres of
mercury (mmHg).
Blood Pressure

21. 1. Systolic Blood Pressure
is the measurement of the maximal
pressure exerted against arterial walls
during systole (during contraction and
tightening of myocardial fibres to eject
blood from the ventricles), primarily a
reflection of cardiac output.
2. Diastolic Blood Pressure
is a measurement of pressure remaining
in the arterial system during diastole
(period of relaxation that reflects the
pressure remaining in the blood vessels
after the heart has pumped), primarily a
reflection of peripheral vascular
resistance.
Two distinct blood pressure phases

22. TABLE 4
Normal Blood Pressures According to Age
Age Blood Pressure (mmHg)
Newborn Up to 70/45
5 years Up to 115/75
6 to 12 years Up to 125/80
13 to 15 years Up to 126/78
16 to 18 years Up to 132/82
Over 18 < 120/80
These Blood pressure measurements are general guidelines and may not be accurate if a child is particularly tall or short for his or her age.
Source: Fundamentals of Nursing Standards and Practice 3rd Edition

23.  The purpose of non-invasive blood
pressure measurement is to detect
any changes from normal values,
which may indicate disease.
 Measurement is also performed to
monitor the effectiveness of
medication and other methods used
to control elevated blood pressure.
Purpose of Taking a Blood Pressure

24. Factors Influencing Blood Pressure
Age.
• Blood pressure varies throughout life
from childhood to adolescence.
• An adult’s blood pressure continues to
increase with age.
According to the JNC 7 (2003), men over the
age 45 and women over age 55 are at higher
risk for developing high blood pressure
(hypertension).

25. Factors Influencing Blood Pressure
Gender.
• Males in general have higher blood
pressure than females of the same age.
• In some women, blood pressure can
increase if they use birth control pills,
become pregnant, or take hormone
therapy during menopause

26. Used to auscultate the blood pressure
(hear the sounds created by blood flowing through the artery).
The accuracy of blood pressure reading requires the correct width of the blood pressure
cuff as determined by the circumference of the client’s extremity.
Use of the Stethoscope

27. The client cuff must encircle the width
and length of the site. According to the
American Heart Association (1987),
the bladder width should be
approximately 40% of the
circumference or 20% wider than
diameter of the midpoint of the
extremity.
To measure the width of the bladder,
the nurse should place the cuff
lengthwise on the client’s extremity
and extend the width to cover 40% of
the extremity’s circumference.
Use of the Stethoscope

28. TABLE 5. Guidelines for Sphygmomanometer Selection
Source: Fundamentals of Nursing Standards and
Practice 3rd Edition
Midpoint*
arm
circumference
Bladder Cuff Width Bladder Length
5-7.5cm (newborn) 3cm 5cm
7.5-13 cm (infant) 5cm 8cm
13-20 cm (child) 8cm 13cm
24-32cm (average) 13cm 24cm
32- 42cm (large
adult)
17cm 32cm

29. Procedure for obtaining a blood pressure using a
stethoscope and sphygmomanometer.

30.  Wash hands/hand hygiene
 Determine which extremity is
most appropriate for reading.
Do not take a pressure reading
on an injured or a painful
extremity or one in which an
intravenous line is running.
 Select cuff size appropriate for
the client. An obese client may
need a larger- size cuff to
obtain an accurate reading.

31.  Have client’s arm resting on a
support so the midpoint of the
upper arm is at the level of the
heart. Extend the elbow with
palm turned upward.
 Fully deflate the bladder cuff and
check if the pump valve moves
freely. Place the manometer so
the centre of the mercury column
or aneroid dial is at eye level and
easily visible to the observer.

32.  Palpate the brachial artery to
determine the placement of the
stethoscope.
 Inflate the cuff rapidly to 70mmHg
and increase by 10mm-increments
while palpating the radial pulse.
Note the level of pressure at which
the pulse disappears and
subsequently reappears during
deflation.

33.  Insert the earpieces of the
stethoscope into the ear canal with
a forward tilt to fit snugly.
 Relocate the brachial artery with
non- dominant hand, and place the
bell of the stethoscope over the
brachial artery pulsation.

34.  The stethoscope chest piece should
not touch the blood pressure cuff.
 With dominant hand, turn the valve
clockwise to close. Compress the
pump to inflate the cuff rapidly and
steadily until manometer registers
20 to 30 mmHg above the level
previously determined by the
palpation.

35. Partially unscrew (open) the valve counter- clockwise to
deflate the bladder at 2mm/ sec while listening for the
appearance of the five phases of Korotkofff’s sounds. Note the
manometer reading for these sounds
I. A faint, clear, tapping sound that increase in
intensity can be heard
II. Swishing sound
III. Intense sound
IV. Abrupt, distinctive, muffled sound
V. Sound disappears

36.  After the last Korotkoff’’s sound is heard, deflate the cuff
slowly for at least another 10 mmHg to ensure that no other
sounds are audible; then deflate rapidly and completely.
 Allow the client to rest for at least 30 seconds and remove
cuff. Take two or more additional readings and average
them.

37. Guidelines /precautions/contraindications
to taking a blood pressure.
 Certain patient condition contraindicates
blood pressure taking on the involve side:
 Venous access devices, such as an
intravenous infusion or arteriovenous
fistula for renal dialysis
 Surgery involving the breast, axilla,
shoulder, arm or hand
 Injury or disease of the shoulder, arm,
hand such as trauma, burns, or application
of a cast or bandage.

38. 1. Place the client in a supine position for 5
minutes to allow for equilibration of the
blood pressure, and measure the pulse and
blood pressure.
2. Assist the client to a standing position, and
wait 1 minute to obtain a full evaluation of
the orthostasis, and then recheck the pulse
and blood pressure.
3. Reassess the vital signs after 2 minutes to
allow for an evaluation of the client’s
mechanisms to compensate for the presence
of any orthostasis.
Procedure for Taking Orthostatic Blood Pressure

39. The systolic (Phase I) and diastolic (Phase V) pressure should
be immediately recorded, rounded off (upward) to the nearest 2
mmHg.
Identify two consecutive tapping sounds to confirm systolic
reading.
For children under 13 years old, use Phase IV sounds as the
diastolic level. Even though five phases of Korotkoff’s sounds
have been identified, most clients have only two clearly distinct
sounds (phase I and V), identified as the systolic and diastolic
sounds
Recording Systolic and Diastolic Pressure

40. Abnormal findings
Category Systolic Diastolic
Pre-hypertension 120-139 80-89
High Blood
Pressure
Stage I
Hypertension
140-159 90-99
Stage II
Hypertension
>160 >100
Source: Fundamentals of Nursing Standards and Practice 3rd Edition

41.  Pulse assessment reflects the heart’s
pumping action and the adequacy of
peripheral artery blood flow.
 Above or below normal pulse means
that the heart is unable to pump
blood efficiently.
Purpose of Obtaining a Pulse Rate

42. Sex. Women have slightly faster pulse rate than men.
Age. Pulse rate gradually decreases from birth to
adulthood then increases with advancing old age
Body Temperature. There is a 7-10 beat increase in every
degree of temperature elevation.
Digestion. Increased metabolic rate during digestion
slightly increases the pulse rate.
Factors Affecting a Pulse Rate

43. Pain. Increases pulse rate
Emotion. Fear, anger, anxiety and excitement increase pulse
rate
Exercise. The heart must beat faster during exercise to meet
the oxygen demand
Blood pressure. Heart rate and pulse rate have an inverse
relationship. When the blood pressure is low, the pulse rate
as the heart attempts to increase the output of blood from
(cardiac output).
Factors Affecting a Pulse Rate

44. 1. Wash hands/ hand hygiene
2. Inform the client of the site(s) where pulse will be measured.
3. Flex client’s elbow and place lower part of arm across chest.
4. Support client’s wrist by grasping outer aspect with thumb
5. Place index fingers on inner aspect of the client’s wrist over the
radial artery, and apply light but firm pressure until pulse is
palpated.
6. Identify pulse volume
7. Determine the rhythm.
8. Count pulse Rate using the second hand on watch.
– For regular rhythm, count number of beats for 30 seconds
and multiply by 2
– For irregular rhythm, count the beats in one full minute.
Procedure for Taking a Radial Pulse

45. Procedure for taking an apical pulse
1. Wash hands/ hand hygiene
2. Raise the client’s gown to expose the sternum and left side of
chest.
3. Cleanse earpiece and diaphragm of stethoscope with an alcohol
swab
4. Put stethoscope around neck.

46. Procedure for taking an apical pulse
5. Locate apex of the heart:
– With client lying on left side, locate suprasternal notch.
– Palpate second intercostals space to left of sternum
– Place index finger in intercostal space, counting downward until fifth intercostals
space is located.
– Move index finger along fourth intercostals space left of the sternal border and to
the fifth intercostals space, left midclavicular line to palpate the point of maximum
impulse (PMI) Keep non-dominant hand on the PMI

47. 6. Inform the client that his or her heart will be listened to. Instruct the client to
remain silent.
7. With dominant hand put earpiece of the stethoscope in ears and grasp diaphragm of
the stethoscope in the palm of the hand for 5- 10 seconds.
8. Place diaphragm of stethoscope over the PMI and auscultate for sounds S1 and S2
to hear the lub-dub sound.
9. Note the regularity of rhythm
10. Start to count while looking at second hand of watch. Count lub-dub sound as one
beat:
– For a regular rhythm, count arte for 30 seconds and multiply by 2
– For an irregular rhythm, count rate for a full minute, noting number of
irregular beats.
11. Share findings with the client

48.  It is important to record the
data gathered for reference
and documentation purposes.
 Record the pulse rate obtained
by site the rate, rhythm, and if
applicable, the number of
irregular beats.
Recording Pulse Rate

49. Tachycardia is a heart rate more than 100 beats per minute in an
adult
Bradycardia is a heart rate less than 60 beats per minute in an
adult
Arrhythmia/Dysrhythmia is an irregular rhythm caused by an
early, late, or missed heartbeat.
Abnormal Pulse Rate

50.  The pulse is a measurement of the number of heartbeats in one
minute.
 The pulse can be increased or slowed down by illness, injury,
infection, drugs, the environment, or activity level.
 The normal pulse for an adult should be regular and between 60
and 100 beats per minute.
 A pulse rate that is abnormally slow is called bradycardia.
 A pulse rate that is abnormally fast is called tachycardia.
 The two most accurate places to measure the pulse are the radial
artery and the chest.
 Notify the R.N. or your supervisor if the patient’s heart rate
rate bradycardic, tachycardic or is unusually slow or fast for
fast for that patient.
Pulse Rate Summary

51.  is the act of breathing.
 Physiological process
that enables the
exchange of carbon
dioxide, the primary
product of cellular
respiration, for fresh air
Respiration

52. Purpose of obtaining a
respiratory rate:
• Respiratory assessment is the
measurement of the breathing
pattern
• Assessment of respirations
provides clinical data
regarding the pH of arterial
blood.
Factors influencing
respiratory rate:
• Age
• Environmental and lifestyle
• Disease process
Respiration

53. TABLE 3
Normal Resting Respirations According to Age
Age Normal Range Average Rate/
minute
Newborn 30-50 40
1 year 20-40 30
3 years 20-30 25
6 years 16-22 19
14 years 14-20 17
Adult 12-20 18
Source: Fundamentals of Nursing Standards and Practice 3rd Edition

54. 1. Wash hands/ hand hygiene.
2. Make sure that chest movement is visible. Client may need to
remove heavy clothing.
3. Observe one complete respiratory cycle. If it is easier, place the
client’s hand across the abdomen and your hand over the client’s
wrist.
4. Start counting with first inspiration while looking at the second
hand of your watch
– Infants and children: count a full minute.
– Adults: count for 30 seconds and multiply by 2. If an irregular
rate or rhythm is present, count for one full minute.
Procedure for obtaining respiratory rate:

55. 5. Observe character or respirations:
– Depth of respirations by degree of chest wall movement,
(shallow, normal, or deep)
– Rhythm of cycle (regular or interrupted)
6. Replace client’s gown if needed.
7. Wash hands/ hand hygiene.
Recording respirations:
Note the rate and character of respirations.
Procedure for obtaining respiratory rate:

56. Taking Respiratory Rate

57. Tachypnea
Respiratory rate greater than 24 beats per minute
Bradypnea
Respiratory rate below 10 or less breaths per minute
Apnea
Cessation of breathing
Abnormal Respiratory Rates and Patterns

58. Respirations Summary
• The respiratory rate is a measurement of the number of
breaths in one minute.
• The normal respiratory rate for an adult is 12 to 20
breaths a minute.
• The respiratory rate for newborns, infants, and children
is higher than the respiratory rate of adults.
• The respiratory rate should be regular.
• A respiratory rate that is below the normal limits is
called bradypnea.
• A respiratory rate that is above the normal limits is
called tachypnea.