This PDF for vital signs chapter of anatomy and physiology book for bsc nursing students

1. Presented by: Ms. Nidhi Prajapati
Nursing Tutor
President Nursing College

2. Vital signs
• Vital signs are one of the most important aspects of assessing
the patient. They act as indicators of the body's ability to
maintain homeostasis.
• Vital signs are also known as
cardinal signs

3. Parameters
• it includes the measurement of:
Temperature
Respiration
Pulse
Blood pressure

4. • Vital signs are a quick and efficient way of monitoring a
patient's condition or identifying problems and evaluating the
patient's response to intervention. Assessment of vital signs
allows the nurse to identify nursing diagnosis, implement
planned interventions and evaluate outcomes.
• Measuring and recording patient's vital signs accurately is
important as this gives an indication of the patient's
physiological state.

5. Guidelines for Measuring Vital Signs
• 1. The nurses should know the normal range of vital signs so
that she can detect a change in patient's condition over time.
• 2. The nurses should have complete knowledge regarding the
patient's history, diagnosis and prescribed medication.
• 3. Equipment and instruments used for assessing vital signs
should be in functional state, accurate and according to the
size and age of the patient.

6. • 4. Minimize or control the environmental factors that may
affect vital signs, for e.g. monitoring pulse rate immediately
after exercise may yield a value that is not a true indicator of
patient's condition.
• 5.Systematic approach should be used while taking vital signs
to ensure accuracy.6. The nurse should verify and
communicate significant changes in vital signs. She should
immediately inform the physician if vital signs are altered.

7. Body temperature

8. Body temperature
• Temperature is the "hotness" or "coldness" of a substance.
Body temperature reflects the balance between the heat
production and heat lost from the body and is measured in
heat units called degrees.

9. Purposes of Taking Temperature
• To determine the cause of the patient's condition: To
assess the health condition of the patient, vital signs recorded.
In some diseases like pneumonia and heat stroke, the body
become warmer than normal whereas in generalized
hypothermia and shock, the body become cooler than normal.

10. • To determine the effectiveness of treatment: If the patient's
condition has caused his body to become warmer or cooler
than normal, then his temperature should return to normal as
he becomes stable. Change or lack of change in the patient's
temperature may indicate if the treatment being used is
effective or not.

11. Physiology of Temperature
• There are two kinds of body temperature:
• 1. Core temperature: It is the temperature of the interior
body tissue below the skin and subcutaneous tissue. The sites
of measurement of core temperature are rectum, tympanic
membrane, esophagus, pulmonary artery, and urinary bladder.

12. • 2. Surface temperature: It refers to the body temperature at
the surface that is of the skin and subcutaneous tissue. This
temperature is generally cooler than core temperature. The
sites of measuring the surface temperature are oral, axilla or
skin.

13. • Body temperature = Heat produced - Heat lost
Oral 37° C(98.6°F)
Rectal 37.5°C(99.5°F)
Tympanic 37.5°C(99.5°F)
Axillary 36.5°C(97.7°F)

14. Regulation of Body Temperature
• The process of regulating the balance between heat produced
and heat loss is known as thermoregulation. It is regulated by
physiological and behavioral mechanisms.
Heat production
Heat loss

15. Heat Production
• Heat is produced by deep tissue organs (brain, liver and
hypothalamus) transmit impulses to reduce the body heat by
triggering perspiring, dilating blood vessels and inhibition
heat production.
• Heat is produced during the following process:

16. Basal metabolic rate (BMR)
Voluntary movement
Shivering
Non shivering heat production

17. Heat Loss
• Heat loss and heat production occur simultaneously. The
skin's structure and exposure to the environment result
inconstant, normal heat loss through radiation, conduction,
convection and evaporation. Heat is lost from the body
through four processes:

18. Conduction
Convection
Radiation
Evaporation

19. Factors Affecting the Body Temperature
• Body temperature changes as there is alteration in heat
production and heat loss. The various factors affecting body
temperature are:
• 1. Age: A newborn baby has some difficulty in adjusting his
body temperature. His temperature may be slightly high one
time and slightly low the next. The newborn's body
temperature is maintained within 35.5-37.5°C (95.9-99.5°F).
By the time, the baby is one year old, the parts of his body
that control his body temperature are fully developed and his
normal body temperature has been established.

20. • 2. Physical activity: Physical activity affects body
temperature. During exercises or hard work, muscles break
down the stored energy supplies in the body (mainly glucose
and fat) into usable energy that causes heat production. So,
physical activity of any form increases heat production and
ultimately increases the body temperature.

21. • 3. Hormone level: Hormonal variations during the menstrual
cycle affect body temperature. A woman's body temperature
drops slightly before ovulation, raises about 1°F above
normal during ovulation and then returns to normal level.
Body temperature also changes during menopause.
• 4. Circadian rhythm: Time of day affects body temperature.
A person's body temperature is usually lower in the morning
between 1.00-4.00 am. During the day, temperature rises
steadily. This change is mainly due to warmer weather and
more physical activity occurring later in the day.

22. • 5. Emotions: Emotions affects body temperature. A person
that is excited (joyful, scared or angry) will have an increase
in body temperature. The excitement causes the body to
increase the rate at which it changes stored food (glucose and
fat) into usable energy. As the energy output increases, so the
amount of heat produced by the body is also increased.

23. • 6. Environment: Weather affects body temperature. When a
person's body is exposed to hot weather, his body temperature
rises. When a person's body is ex-posed to cold weather, his
body temperature drops.
• 7. Method of measurement: The axillary temperature would
be slightly lower than the oral temperature while the rectal
temperature would be slightly higher than the oral
temperature.

24. ASSESSMENT OF BODY TEMPERATURE
• Body temperature may be assessed with a variety of devices
like glass thermometers, electronic thermometers
• Types of Thermometers
1. Glass Thermometer:

25. • The mercury in glass thermometer is the most familiar. It is a
glass tube sealed at one end with a mercury-filled bulb at the
other. Exposure of the bulb to heat causes the mercury to
expand and rise in the enclosed tube. The length of the
thermometer is generally marked with centigrade
calibrations. The range is about 35°C to 42°C.
• Three types of glass thermometers are the oral, the axillary
and the rectal.

27. • Electronic/Digital Thermometer: The electronic
thermometer consists of a rechargeable battery powered
display unit, a thin wire cord and a temperature processing
probe covered by a disposable plastic sheath.

29. Common Sites for Measuring Body Temperature
Oral
Axillary
Rectal
Tympanic membrane

30. ALTERATIONS IN BODY TEMPERATURE
• Body tempeature may be within the normal range for one's
age or it may be increased or decreased from the normal
range.
• Fever: A body temperature above the usual range is called
fever. A person with an increased body temperature is said to
be febrile. It results from a response to bacterial or viral
injections

31. Types of Abnormal Temperatures
• 1. Hypopyrexia or subnormal temperature: The
temperature falls below 97°F or 37°C.
• 2. Low pyrexia: Temperature ranges between 99-101°F.
• 3. Moderate pyrexia: Temperature ranges between 101-
103°F.
• 4. High pyrexia: Temperature ranges between 103-105°F.

32. • 5. Hyper pyrexia: Temperature goes above 105°F.
• 6. Constant fever: Body temperature remains almost same
with slight variation of 1 to 2 degrees.
• 7. Remittent fever: There is variation of more than 2 degrees
in the morning and evening temperature but temperature
never falls to normal.
• 8. Intermittent fever: There is a great variation in the
temperature. Temperature rises very high and may fall at
regular intervals. This type of fever is seen in malaria cases.

34. • 9. A relapsing fever is one in which there are brief febrile
periods followed by one or two days of normal temperature
• 10. During a constant fever, the body temperature fluctuates
minimally but always remains above normal. This can occur
with typhoid fever.
• 11. Inverse fever: In this, the highest range of temperature is
recorded in the morning hours and lowest in the evening
hours which are contrary to that found in the normal course of
fever.

35. • 12. Rigor: It is a sudden severe attack of shivering in which
the body temperature rises rapidly to the state of hyper-
pyrexia as seen in malaria.
• 13. Crisis: Crisis is a sudden return to normal temperature
from a very high temperature within a few hours or days.
• a. True crisis: The temperature falls suddenly within few
hours and touches normal, accompanied by marked
improvement in the patient's condition.

36. • b. False crisis: A sudden fall in temperature not accompanied
by an improvement in the general condition.
• 15. Lysis: The temperature falls in a zig-zag manner for two
or three days or a week before reaching normal, during which
time the other symptoms also gradually disappear.

37. Nursing Management of Fever
• 1. Promote heat loss and lower the temperature. Limit
physical activity to decrease heat production, reduce external
covering on client's body to promote heat loss through
radiation and conduction.
• 2. If fever continues, physical therapies can be used to lower
the temperature, such as applying ice packs to axilla and
groin areas. Frequently assess the temperature and record the
readings.

38. • 3.Observe intake/output of patient. Contact physician
promptly incase of abnormal conditions.
• 4. Provide nutrients to meet increased energy need. Pro-vide
measures to stimulate appetite and offer well balanced diet.
• 5. Provide fluids at least 3000 ml per day for client with
normal cardiac and renal function to replace fluid loss
through insensible water loss and sweating.

39. Rigor
• Rigor is a sudden feeling of cold with shivering accompained
by a rise in temperature, sweating, especially at the onset of
fever. It is characterized by three stages.
• 1. First stage (Cold stage): In this the patient feels chill,
shivering and temperature rises.
• 2. Second stage (Hot stage): In this stage patient feels hot
and thirsty.

40. • 3. Third stage (Sweating stage): Temperature falls down
due to profuse sweating.

41. Nursing Care in Rigor
• Cold Stage :The patient experiences cold and may shiver.
Skin becomes pale and cool. The face is pinched, pulse is
feeble and rapid. Interventions:
• 1. Monitor vital signs.
• 2.Restrict activity.
• 3. Monitor skin color and temperature.
• 4. Apply extra blankets..

42. • 5. Provide hot drinks to the patient.
• 6. Supply O2 if client has pre-existing cardiac or respiratory
problem
• Hot Stage :It occurs when fever reaches the new higher set
point. The skin is hot and dry.
• 1. Remove excess clothing.
• 2.Cover with light warm clothing to avoid chilling.
• 3. Monitor temperature.
• 4. Encourage cold fluids

43. • 5. Start tepid sponging (Don't use cold water).
• 6. Adjust cooling measures on the basis of temperature
• 7. Apply lubricant to dry lips and nasal mucosa

44. • Sweating Stage:
• decreased shivering and possible fluid volume deficit.
• Interventions:
• 1.Change the clothes that are wet with sweat.
• 2. Put on clean dry clothes and cover the patient with light
cotton blanket.
• 3. Monitor intake and output.4. Monitor electrolyte levels.

45. • Heat Stroke: Heat stroke occurs when the core body
temperature rises above 40°C and is a severe and life
threatening condition provoked by failure of heat regulatory
mechanisms.
• Hypothermia: Hypothermia is a state in which the core body
temperature is lower than 35°C and 95°F.

46. PULSE

47. Definition
• Pulse is an alternate expansion rise) and recoil (fall) of an
artery is a wave of blood is forced through it during the
contraction of left ventricle of the heart.

48. • Peripheral pulse- is a pulse located away from the heart,
e.g, in the foot, wrist or neck.
• Apical pulse- is a central pulse located at the apex of the
heart.
• The Pulse Rate is expressed in beats/ minute (BPM)

49. Pulse Sites
❖ Temporal: where the temporal artery passes over the
temporal bone of the head. The site is superior (above) and
lateral to (away from the midline of) the Eye

50. ❖Carotid: At the side of neck below where the carotid artery
runs between the trachea and sternocleidomastoid muscles

51. ❖ Apical: at the apex of the heart: routinely used for infant
and children <3 y/
• In adults Left mid-clavicular line under the 4th 5th,
6thintercostal space

52. ❖ Brachial: at the inner aspect of the biceps muscle of the arm
or the ante cubital space.
❖Radial: on the thumb side of the inner aspect of the wrist -
readily available and routinely used

53. ❖ Femoral: along the inguinal ligament. Used for infants and
children
❖ Popliteal: behind the knee. By flexing the knee slightly

54. ❖ Posterior tibial: on the medial surface of the ankle
❖Pedal (Dorsalis Pedis): palpated by feeling the dorsum
(upper surface)foot.

56. Factors affecting Pulse Rate
• 1) Age: As age increases, the pulse rate gradually decreases.
The average pulse rate of an infant ranges from 100 to 160
BPM The normal range of the pulse in an adult is 60 to 100
BPM.
• 2) Gender: after puberty the average male's Pulse Rate is
slightly lower than the female's.
• 3) Exercise: Pulse Rate increases with exercise.

57. • 5) Heat: application of heat can increase the heart rate.
• 6) Hypovolemia: Loss of blood from vascular system
increases heart rate.
• 7) Stress: increases the sympathetic nervous stimulation
• 8) Medications: some medications decrease the pulse rate
and others, increase it. For example, cardiac medicine
(digoxin) decreases the heart rate, whereas epinephrine
increases it.

58. • 9) Position changes: In a sitting or standing position, blood
usually pools independent vessels of the venous system.
Pooling results in decrease in the venous blood return to heart
and subsequent decrease in BP and increase in heart rate.
• 10) Pathology: certain diseases like heart conditions can alter
the pulse rate. E.g. conduction abnormalities

59. Assessing the Pulse
• 1. A pulse is commonly assessed by palpation or auscultation.
• 2.3 middle fingers are used for palpating all pulse site, except
for apical pulse.
• 3. Stethoscope is used in assessing apical pulse and fetal heart
tones.
• 4. The pulse is normally palpated by applying moderate
pressure with the three fingers of the hand.

60. • 5. The pads of the most distal aspect of the fingers are the
most sensitive areas of detecting the pulse.
• 6. When assessing the pulse, there is a need to take note of
the following:
• Rate
• Rhythm
• Volume
• Arterial wall elasticity
• Presence or absence of bilateral equality.

61. Characteristics of Pulse
• 1) Rate- It is number of pulse beats in a minute.
• pulse Fate over 100 beats per minute is referred to as
tachycardia.
• A pulse rate 60 beats/minute or less is referred to as
bradycardia.
• If a client has tachycardia or bradycardia, the apical pulse
should be assessed Variations in Pulse Rate:

63. • 2) Rhythm- The pulse rhythm is the pattern of beats and the
interval between the beats.
• It also refers as the regularity of beats.
• Normally the heart beats are spaced at equal intervals and
they are said to be regular.
• When the interval varies between the beats it is said to be
irregular.
• A pulse with an irregular rhythm is referred to as a
Dysrhythmia or arrhythmia.

64. • Intermittent pulse: It is one in which the beats are missed at
regular intervals. In an intermittent pulse, there is difference
between apical pulse and peripheral pulse known as Pulse
Deficit. (note: For normal pulse, pulse deficit is zero)

65. • 3) Volume/Strength- The pulse strength, volume or the
amplitude refers to the force of blood with each beat.
• Volume depends on the amount of blood in the arteries
• It can range from absent to bounding
• If the volume of the blood is decreased (e.g. by hemorrhage),
the pulse will be weak/feeble/ thready/ diminished or barely
palpable. This pulse will be readily obliterated with pressure
from the fingers.

66. • A normal pulse can be felt with moderate pressure of the
fingers and can be obliterated with greater pressure.
• A forceful or full blood volume that is obliterated only with
difficulty is called a full or bounding pulse. It signifies an
increased stroke volume as seen in anxiety, exercise etc.

67. • Pulsus alternans: The rhythm is regular but the volume has an
alternative strong and weak character. This may be noticed in
the left ventricular failure.
• 4) Elasticity of arterial wall: It reflects the expansibility of
the arterial wall.
• A healthy, normal artery feel straight, smooth, soft and
pliable
• While, elderly people often have inelastic arteries that feels
twisted or tortuous and irregular upon palpation.

68. • 5) Equality: Assess all symmetrical pulses for equality in
rate, rhythm and volume.

69. RESPIRATION

70. Respiration
• It is the act of breathing; it includes the intake of oxygen and
the output of carbon dioxide.
• Types:
• 1. External respiration- the interchange of O₂ and CO₂
between the alveoli and the pulmonary blood.
• 2. Internal respiration- takes place throughout the body; it is
the interchange of gases between the circulating blood and
the cells of the body tissues.

71. • Terminologies:
• Inhalation or inspiration- the act of intake of air into the lungs
• Exhalation or expiration- the act of breathing out of gases
from the lungs to the environment
• Ventilation- movement of air in and out the lungs
• Hyperventilation- refers to very deep and rapid ventilation
• Hypoventilation- refers to very shallow respiration
Ventilation

72. Factors affecting Respiration
• 1) Age: Normal growth from infancy to adult hood results in
a larger lung capacity. As lung capacity increases, lower
respiratory rates are sufficient for exchange of gases.
• 2) Medications: Respiratory depressants such as Narcotics,
sedatives etc. decrease respiratory rate. Stimulants drugs such
as caffeine, stimulates the respiratory center and the reflex
centers, thus respiration is increased.
• 3) Stress or strong emotions increases the rate & depth of
respirations.

73. • 4) Exercise: Exertion increases metabolic rate and stimulates
respiration. Thus exercise increases the rate & depth of
respirations.
• 5) Altitude: The rate & depth of respirations at higher
elevations (altitude) increases to improve the supply of
oxygen available to the body tissues
• 6) Temperature changes: Exposure to cold increases the
oxygen need. In order to keep the body warm, it shivers. The
individual takes deep breaths. If the temperature of the body
is raised due to fever, the metabolic rate is increased and thus
increasing respiratory rate.

74. Characteristics of Respiration
• 1) RATE: It is number of full respirations in a minute. Rate is
normally described inbreaths per minute.
• Eupnea- Breathing is normal in rate and depth.
• Bradypnea- Abnormally slow breathing (less than 12
breaths/min)
• Apnea- cessation of breathing/ absence of breathing

77. • 2) Respiratory depth: is established by watching the
movement of the chest.
• It is generally described as normal, deep or shallow.
• Deep respirations are those in which a large volume of air is
inhaled and exhaled.
• Shallow respiration involve the exchange of small volume of
air

78. • 3) Respiratory rhythm It refers to regularity of expiration
and inspiration• It can be described as Regular or Irregular.
• Cheyne-Stokes breathing: Respiratory rate and depth are
irregular, characterized by alternating periods of apnea and
hyperventilation. Respiratory cycle begins with slow, shallow
breaths that gradually increase to abnormal rate and depth.
The pattern reverses; breathing slows and becomes shallow,
concluding as apnea before respiration resumes.

80. • Kussmaul's: Kussmaul's breathing pattern is acompensatory
mechanism that is often seen in diabetic patients. This
breathing pattern is very deep and rapid as the body attempts
to lower the acid levels that are created in diabetic
ketoacidosis. It is also associated with crush syndrome (renal
failure following the crushing of a large muscle mass).

81. • 4) Quality: Breathing can be of normal or abnormal quality.
• 1. Normal: Normal breathing does not require conscious
effort. It is automatic, regular and even. It produces no noise,
discomfort or pain.
• 2. Abnormal: It includes:
• a. Pain: Injuries to the chest and certain diseases can cause
pain while breathing.

82. • b. Labored breathing: Labored breathing occurs when the
person is trying to get as much air into his lungs as possible.
It is also called "air hunger" and "dyspnea." Labored
breathing is normal during vigorous work or athletic activity.
• c. Orthopnea is the term used if the patient can breathe only
when in an upright position.
• d. Apnea is the absence of respirations.

83. Assessing Respiration
• Before assessing a client's respiration, a nurse should be
aware of the following:
• 1. The client's normal breathing pattern is when he/she is
relaxed.
• 2. Any behavior (anxiety)/ activities (exercise) of the patient
as well as medication or therapies which may affect the
respiration

84. • 3. influence of client’s health problems( heart diseases) 4. the
rate, depth, rhythm and quality should be assessed

85. BLOOD PRESSURE

86. Blood pressure
Arterial Blood Pressure is a measure of the pressure exerted by
the blood as it flows through the arteries.
Two blood pressure measurements:
1. Systolic pressure- is the maximum pressure of the blood as a
result of contraction of the ventricles.
2. Diastolic Pressure-is the lowest pressure when the ventricles
are at rest.

87. • The difference between the systolic and diastolic pressure is
called as Pulse Pressure.
• (120-80=40)It is expressed in terms of millimeters of mercury
(mm of Hg) and recorded as a fraction.
• The systolic pressure is written over the diastolic pressure.
• The average blood pressure of a healthy adult is 120/80
mmHg.

88. Characteristics of Blood pressure

89. Factors affecting Arterial Blood Pressure
• AGE: Newborns have a mean systolic pressure of about 75
mm Hg. The pressure rises with age, reaching a peak at the
onset of puberty, and then tends to decline. In older people,
elasticity of the arteries is decreased; the arteries are rigid and
less yielding to the pressure of the blood. Thus producing an
elevated blood pressure.

90. • STRESS: Stimulation of sympathetic nervous system
increases cardiac output and vasoconstriction of arterioles,
thus increasing the blood pressure.
• OBESITY: both childhood and adult obesity predispose to
high blood Pressure.
• GENDER: After puberty, females usually have lower blood
pressures than males of the same age; this difference is due to
hormonal variations. After menopause, women generally
have higher blood pressures than before.

91. • MEDICATIONS: Many medicines increase or decrease
blood pressure.
• DIURNALVARIATIONS: pressure is usually lowest early
in the morning, when the metabolic rate is lowest, then rises
throughout the day and peaks in the late afternoon or early
evening.
• DISEASE PROCESS: any condition affecting the cardiac
output, blood volume, and/or compliance of the arteries has a
direct effect on the blood pressure.

92. • SMOKING: Smoking results in vasoconstriction, a
narrowing of blood vessels. BP rises when a person smokes
and returns to baseline about 15minutes after stopping
smoking.
•