The document discusses assessing vital signs including body temperature, pulse rate, respiratory rate, and blood pressure. It provides details on: - The purposes and importance of vital sign assessment - Factors that can affect each vital sign reading - Proper technique for measuring each vital sign, including sites of measurement and positioning - Normal ranges and clinical significance of abnormal readings

1. Vital Signs
Prepared by : Manny Jun P. Padua RN,MAN
Vital Signs
• Monitor functions of the body
• Should be a thoughtful, scientific assessment
• These are composed of body temperature, pulse, respirations and blood pressure. In
some agencies internationally, they assigned a fifth vital sign, which is pain
assessment.
When to Assess Vital Signs
• On admission
• Change in client’s health status
• Client reports symptoms such as chest pain, feeling hot, or faint
• Pre and post surgery/invasive procedure
• Pre and post medication administration that could affect CV system
• Pre and post nursing intervention that could affect vital signs
Body Temperature
• Is the balance between the heat produced and the heat lost from the body and it is measured
in degrees.
2 kinds of body temperature
 Core temperature
• The temperature of the deep tissues of the body.
• This remains relatively constant.
E.g. abdominal cavity and pelvic cavity
 Surface temperature
• Temperature of the skin, the subcutaneous tissue and fat.
• In contrasts, it rises and falls in response to the environment.
Mechanisms of heat production
1. Heat is produced through metabolism of food
 Rate of energy utilization in the body required to maintain essentials activities such as
breathing.
 Metabolic rates decrease with age.
2. Heat is produced through body secretions
E.g. epinephrine, norepinephrine
3. Muscle activity increases metabolic rate.
E.g. shivering
4. Produced physically from the environment.
Mechanisms of heat loss
 Radiation
Transfer of heat between objects that are not in contact
 Conduction
Heat exchange between atoms/molecules of objects in contact
 Convection
Air next to the body is heated, moves away and replaced by cool air
 Evaporation
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2. Moisture and heat loss from the skin, response passages and mucous membranes of
the mouth
Types of fever
 Intermittent - malaria
 Remittent - influenza
 Relapsing -
 Constant – typhoid fever
 Fever spike – bacterial blood infections
Clinical Manifestations of Fever
ONSET OR CHILL PHASE
 Increased heart rate
 Increased respiratory rate and depth
 Shivering
 Pallid, cold skin
 Complaints of feeling cold
 Cyanotic nail beds
 Gooseflesh
 Cessation of sweating
COURSE OR PLATEAU PHASE
 Absence of chills
 Skin that feels warm
 Photosensitivity
 Glassy-eyed appearance
 Increased pulse and respiratory rates
 Increased thirst
 Mild to severe dehydration
 Drowsiness, restlessness delirium or convulsions
 Herpetic lesions of the mouth
 Loss of appetite
 Malaise, weakness and aching muscles
DEFERVESCENCE OR FLUSH PHASE
 Skin that appears flushed and feels warm
 Sweating
 Decreased shivering
 Possible dehydration
Clinical signs of hypothermia
 Decreased body temperature, pulse and respiratory rate
 Severe shivering (initially)
 Feelings of cold and chills
 Pale, cool, waxy skin
 Frostbite (nose, fingers and toes)
 Hypotension
 Decreased urinary output
 Lack of muscle coordination
 Disorientation
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3.  Drowsiness progressing to coma
Sites for Measuring Body Temperature
Oral Rectal Axillary
Tympanic membrane Skin/Temporal artery
Factors Affecting Body Temperature
Age Diurnal variations (circadian rhythms)
Exercise Hormones
Stress Environment
Types of Thermometers
Electronic Chemical disposable
Infrared (tympanic) Scanning infrared (temporal artery)
Temperature-sensitive tape Glass mercury
Pulse Rate
 Refers to the wave of blood or impulse created by the contraction of the left ventricle during the
cardiac cycle.
Factors Affecting Pulse
 Age
 Gender
 Exercise
 Fever
 Medications
 Hypovolemia
 Stress
 Position changes
 Pathology
Figure 29-12 Nine sites for assessing pulse.
Characteristics of the Pulse
 Rate
 Rhythm
 Volume
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4.  Arterial wall elasticity
 Bilateral equality
Pulse Rate
• Beats per minute
• Tachycardia
• Bradycardia
Pulse Rhythm
• Equality of beats and intervals between beats
• Dysrhythmias
• Arrhythmia
Characteristics of the Pulse
 Volume
Strength or amplitude
Absent to bounding
 Arterial wall elasticity
Expansibility or deformity
 Presence or absence of bilateral equality
Compare corresponding artery
Apical-Radial Pulse
 Locate apical and radial sites
 Two nurse/caregiver method:
Decide on starting time
 Nurse counting radial says “start”
 Both count for 60 seconds
 Nurse counting radial says “stop”
 Radial can never be greater than apical
Respiratory Rate
 The act of breathing, intake of oxygen and output of carbon dioxide
Inhalation
• Diaphragm contracts (flattens)
• Ribs move upward and outward
• Sternum moves outward
• Enlarging the size of the thorax
Exhalation
• Diaphragm relaxes
• Ribs move downward and inward
• Sternum moves inward
• Decreasing the size of the thorax
Respiratory Control Mechanisms
 Respiratory centers
Medulla oblongata
Pons
 Chemoreceptors
Medulla
Carotid and aortic bodies
 Both respond to O2, CO2, H+ in arterial blood
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5. Components of Respiratory Assessment
 Rate
 Depth
 Rhythm
 Quality
 Effectiveness
Respiratory Rate and Depth
 Rate
Breaths per minute
Eupnea
Bradypnea
Tachypnea
 Depth
Normal
Deep
Shallow
Components of Respiratory Assessment
 Rhythm
Regular
Irregular
 Quality
Effort
Sounds
 Effectiveness
Uptake and transport of O2
Transport and elimination of CO2
Blood Pressure
 Force exerted by the blood against a vessel wall
Systolic and Diastolic Blood Pressure
 Systolic
Contraction of the ventricles
 Diastolic
Ventricles are at rest
Lower pressure present at all times
 Pulse Pressure = difference between systolic and diastolic pressures
 Measured in mm Hg
 Recorded as a fraction, e.g. 120/80
 Systolic = 120 and Diastolic = 80
Korotkoff’s Sounds
 Phase 1
First faint, clear tapping or thumping sounds
Systolic pressure
 Phase 2
Muffled, whooshing, or swishing sound
 Phase 3
Blood flows freely
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6. Crisper and more intense sound
Thumping quality but softer than in phase 1
 Phase 4
Muffled and have a soft, blowing sound
Diastolic pressure
 Phase 5
Pressure level when the last sound is heard
Period of silence
Measuring Blood Pressure
 Direct (Invasive Monitoring)
 Indirect
Auscultatory
Palpatory
 Sites
Upper arm (brachial artery)
Thigh (popliteal artery)
Figure 29-17 A, A blood pressure cuff and bulb; B, the bladder inside the cuff.
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7. Name:_______________________________________ Date: ___________________________
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8. 8
Assessing Body Temperature Performed Mastered Comments
Preparation Yes No
1. Assess:
Clinical signs of fever.
Clinical signs of hypothermia.
Site most appropriate for measurement.
Factors that might alter core body temperature.
2. Assemble equipment:
Thermometer
Thermometer sheath or cover
Water-soluble lubricant for a rectal temperature
Disposable gloves
Towel for axillary temperature
Tissues/wipes
Procedure Rationale
1. Introduce yourself and verify the client’s identity.
Explain to the client what you are going to do, why it
is necessary, and how the client can cooperate.
Establishing rapport and explaining the
procedure lessens the apprehension and
anxiety of the client during the procedure,
which will give you a more accurate vital
sign result. Less anxiety and apprehension
will facilitate cooperation of the client.
2. Perform hand hygiene and observe other
appropriate infection control procedures.
This will deter the spread of
microorganisms.
3. Provide for client privacy. Privacy is essential, most especially for
patient who is about to have temperature
taking rectally.
4. Place the client in the appropriate position.
5. Place the thermometer.
Apply a protective sheath or probe cover, if
appropriate.
Lubricate a rectal thermometer.
6. Wait the appropriate amount of time.
Electronic and tympanic thermometers will indicate
that the reading is complete via a light or tone.
Check package instructions for length of time to wait
prior to reading chemical dot or tape thermometers.
7. Remove the thermometer and discard the cover, or
wipe with a tissue, if necessary.
Wipe in a rotating manner. The
thermometer is wiped from the area of least
contamination to that of greatest
contamination
8. Read the temperature.
If the temperature is obviously too high, too low, or
inconsistent with the client’s condition, recheck it
with a thermometer known to be functioning
properly.
9. Wash the thermometer, if necessary, and return it to
the storage location.
Organic materials, such as mucus, must be
removed before the thermometer can be
stored. Organic materials can harbor
microorganisms.
10. Document the temperature in the client record.

9. Name:_______________________________________ Date: ___________________________
Name:_______________________________________ Date: ___________________________
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Assessing Pulse Rate Performed Mastered Comme
nts
Preparation Yes No
1. Assess:
Clinical signs of cardiovascular alterations.
Factors that might alter pulse rate.
Site most appropriate for assessment.
2. Assemble equipment:
Watch with a second hand or indicator
If using Doppler ultrasound stethoscope (DUS), assemble
the transducer probe, the stethoscope headset,
transmission gel, and tissues/wipes.
1 Introduce yourself and verify the client’s identity. Explain
to the client what you are going to do, why it is necessary,
and how the client can cooperate.
2 Perform hand hygiene and observe other appropriate
infection control procedures.
3 Provide for client privacy.
4 Select the pulse point.
5 Assist the client to a comfortable resting position.
6 Palpate and count the pulse. Place
two or three middle fingertips lightly
and squarely over the pulse point
• Count for 60 seconds. Record the pulse in beats
per minute on your worksheet.. An irregular pulse
also requires taking the apical pulse.
7 Assess the pulse rhythm and volume.
8 Document the pulse rate, rhythm,
and volume, and your actions in
the client record.

10. 10
Assessing Resperatory Rate Performed Mastered Comme
nts
Preparation Yes No
1. Assess:
Skin and mucous membrane color
Position assumed for breathing
Signs of cerebral anoxia
Chest movements
Activity tolerance
Chest pain
Dyspnea
Medications affecting RR
2. Assemble equipment:
Watch with a second hand or indicator
1 Identify yourself and verify the client’s identity. Explain to
the client what you are going to do, why it is necessary,
and how the client can cooperate.
2 Perform hand hygiene and observe other appropriate
infection control procedures.
3 Provide for client privacy.
4 Observe or palpate and count the
respiratory rate.
If you anticipate the client’s awareness of respiratory
assessment, place a hand against the client’s chest to feel
the chest movements with breathing, or place the client’s
arm across the chest and observe the chest movements
while supposedly taking the radial pulse.
Count the respiratory rate for 30 seconds if the
respirations are regular. Count for 60 seconds if they are
irregular. An inhalation and an exhalation count as one
respiration.
5 Observe the depth, rhythm, and
character of respirations.
Observe the respirations for depth by watching the
movement of the chest.
Observe the respirations for regular or irregular rhythm.
Observe the character of respirations—the sound they
produce and the effort they require.
6 Document the respiratory rate, depth, rhythm, and
character on the appropriate record.

11. Name:_______________________________________ Date: ___________________________
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12. 12
Assessing Blood Pressure Performed Mastered Comme
nts
Preparation Yes No
1. Assess:
Signs and symptoms of hypertension.
Signs and symptoms of hypotension.
Factors affecting blood pressure.
Client for allergy to latex cuff.
2. Assemble equipment:
Stethoscope or DUS
Blood pressure cuff of the appropriate size
Sphygmomanometer
1 Identify yourself and verify the client’s identity. Explain to
the client what you are going to do, why it is necessary,
and how the client can cooperate.
2 Perform hand hygiene and observe other appropriate
infection control procedures.
3 Provide for client privacy.
4 Position the client appropriately.
5 The adult client should be sitting unless otherwise
specified. Both feet should be flat on the floor.
6 The elbow should be slightly flexed, with the palm of the
hand facing up and the forearm supported at heart level.
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8
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10
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Expose the upper arm.
Wrap the deflated cuff evenly around the upper arm.
Locate the brachial artery.
Apply the center of the bladder directly over the artery.
For an adult, place the lower border of the cuff
approximately 2.5 cm (1 inch) above the antecubital
space.
6 If this is the client’s initial examination,
perform a preliminary palpatory
determination of systolic pressure.
Palpate the brachial artery with the fingertips.
7 Close the valve on the bulb.
8 Pump up the cuff until you no longer feel the brachial
pulse. Note the pressure on the sphygmomanometer at
which pulse is no longer felt.
9 Release the pressure completely in the cuff, and wait 1–2
minutes before taking further measurements.
10 Position the stethoscope appropriately.
- Cleanse the earpieces with antiseptic wipe.
11 Insert the ear attachments of the stethoscope in your ears

13. Prepared by: Manny Jun P. Padua RN,MAN
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