This document discusses vital signs including body temperature, pulse, respiration, blood pressure, and oxygen saturation. It provides details on physiology, factors that influence each vital sign, abnormal findings, nursing considerations, and guidelines for accurate measurement. Measurement of vital signs is an important part of health assessment and monitoring.

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Chapter 32
Vital Signs
NRS 102

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General Survey
 Physical appearance
 Age
 Sex
 Level of consciousness
 Skin color
 Facial features

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General Survey
 Body structure
 Stature
 Nutrition
 Symmetry
 Posture
 Position
 Body build, contour
 Mobility
 Gait
 Range of motion

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General Survey
 Behavior
 Facial expression
 Mood and affect
 Speech
 Dress
 Personal hygiene

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Guidelines for Measuring
Vital Signs
 Establish a baseline for future
assessments.
 Be able to understand and interpret
values.
 Appropriately delegate measurement.
 Communicate findings.
 Ensure equipment is in working order.
 Accurately document findings.

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Body Temperature
Physiology
 Body temperature:
 Heat produced
 Heat lost
 Temperature range:
 98.6° F to 100.4° F or 36° C to 38° C
 Temperature sites:
 Oral, rectal, axillary, tympanic membrane,
temporal artery, esophageal, pulmonary artery

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Body Temperature Regulation
Neural and vascular
control
Heat production
Heat loss Skin temperature
regulation
Behavioral control Thermoregulation

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Factors Affecting Body
Temperature
Age Exercise
Hormonal level Circadian rhythm
Environment Temperature alterations

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Abnormal Body Temp
Hypothermia
 Heat loss during prolonged exposure to cold
 Classified by core temp (mild-severe)
 May be intentional (surgery)
 Early signs- uncontrolled shivering, loss of
memory, poor judgment
 Later signs- Cyanosis, decreased VS, cardiac
dysrhythmias, loss of consciousness
 Frostbite- body exposure to subnormal temps

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Abnormal Body Temp
Hyperthermia
 Elevated body temp related to body’s inability
to promote heat loss or reduce heat
production
 Heatstroke- prolonged exposure to sun or
high environmental temp. Heat depresses
hypothalamus function
 Heat Exhaustion- profuse diaphoresis result
in fluid & electrolyte loss

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Nursing Process
and Temperature
 Assessment
 Diagnosis
 Planning
 Implementation
 Evaluation

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Pulse, Physiology, and Regulation
 The indicator of circulatory status
 Electrical impulses originate from the
sinoatrial (SA) node.
 Cardiac output, heart rate, stroke volume
 Mechanical, neural, and chemical factors
regulate ventricular contraction and stroke
volume.

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Assessment of Pulse
 Sites
 Use of stethoscope
 Character of pulse
 Nursing process and pulse determination

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Knowledge check!
Which patient would be most likely to present
with a pulse rate that is lower than normal?
A. A 70-year-old telephone salesman
presenting with dehydration.
B. A 20-year-old runner who had surgery 4
days ago for a fractured leg.
C. A 67-year-old who presented with an
exacerbation of his COPD

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Respiration
 Ventilation
 Diffusion
 Perfusion
 Physiological control
 Mechanics of breathing

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Assessment of Ventilation
 Easy to assess
 Respiratory rate
 Ventilatory depth
 Ventilatory rhythm
 Diffusion and perfusion
 Arterial oxygen saturation

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Assessing Respirations
 Assessing rate- observe full inspiration &
expiration
 Assess for full minute
 Normal adult 12 –20 breaths/minute
 Varies with age, rate declines throughout life
 Apnea Monitor

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Normal & Abnormal Respirations
 Eupnea- normal respirations
 Bradypnea- abnormally slow < 12
 Tachypnea- abnormally fast >20
 Hyperpnea- labored, after exercise
 Hyperventilation/Hypoventilation
 Cheyne-Stokes

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Nursing Process and Respiratory
Vital Signs
 Measurements include:
 Respiratory rate, pattern, depth, SpO2,
ventilation, diffusion, perfusion
 Nursing diagnosis
 Interventions
 Planning
 Evaluation

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Arterial Blood Pressure
and Physiology
 Force exerted on walls of an artery
 Systolic and diastolic
 Cardiac output
 Peripheral resistance
 Blood volume
 Viscosity
 Elasticity

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Factors Influencing Blood Pressure
 Age
 Stress
 Ethnicity
 Gender
 Daily Variation
 Medications
 Activity, weight
 Smoking

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Hypertension and Hypotension
 Hypertension
 More common than
hypotension
 Thickening of walls
 Loss of elasticity
 Family history
 Risk factors
 Hypotension
 90 mm Hg
 Dilation of arteries
 Loss of blood volume
 Decrease of blood flow
to vital organs
 Orthostatic/postural

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Factors controlling Blood
Pressure

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Measurement of Blood Pressure

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Slide 9-29
 Blood pressure
 Systolic pressure
 Diastolic pressure
 Pulse pressure
 Mean arterial pressure
Vital Signs

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Measurement of Blood Pressure
 Equipment
 Auscultation
 Children
 Ultrasonic stethoscope
 Palpation
 Lower extremity
 Electronic blood pressure

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Nursing Process and Blood
Pressure Determination
 Assessment of blood pressure and pulse
evaluates the general state of
cardiovascular health.
 Hypertension, hypotension, orthostatic
hypotension, or narrow/wide pulse
pressures define nursing diagnoses.

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Knowledge check!
Significant elevation in blood pressure
measurements from one day to the next
could be attributed to:
A. A decrease in cuff size
B. An increase in cuff size
C. New onset of pain or anxiety
D. A and C

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Measurement of Arterial Oxygen
Saturation
 Pulse oximeter
 Allows indirect measurement of oxygen
saturation
 SpO2 is a reliable estimate of SaO2
 Measurement is affected if extremity is cold,
edematous or if nail polish is present
(interference with light transmission)

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Slide 9-35

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Health Promotion and Vital Signs
 Monitor vital signs.
 Include age-related factors.
 Include environmental and activity factors.