This document provides information on assessing various vital signs, including temperature, pulse, respiration, and blood pressure. It discusses normal ranges for adults, factors that can affect readings, techniques for taking measurements, and purposes of assessment. Key topics covered include how the body regulates temperature, sites for taking pulse and assessing circulation, types of breathing and factors influencing respiration rate and depth, and the meaning of systolic and diastolic blood pressure measurements.

1. Vital signs

2. Vital Signs
Body
Temperature
Pulse Respiration Blood
Pressure

3. Times to assess
vital signs
On admission
Upon change in health status
Before and after surgery or an
invasive proceduer
Before and/or after the
administration of a medication that
could affect the respiratory or
cardiovascular systems
Before and after any nursing
interventions that affect the vital
signs

4. Body Temperature
It reflect the balance between the heat produced and heat lost from
the body
Is measured in heat unit called degrees
There are two kinds of temperature:
◦ Core temperature: is the temperatures of the deep tissues of the body
(abdominal &pelvic cavity). It remains relatively constant.
◦ Surface temperature: is the temperatures of skin (the subcutaneous tissue
and fat). It raises and falls in response to the environment.

5. Factors affect heat production
Basal metabolic rate (BMR):
◦ Is the rate of energy required to maintain essential
activities such as breathing.
◦ Metabolic rates decrease with age
◦ The younger the persons, the higher the BMR
Muscle activity:
◦ Shivering, increase metabolic rate

6. Thyroxin output:
◦ If increased, the rate of cellular metabolism throughout the
body also increase
Epinephrine, norepinephrine and sympathetic
stimulation/stress response:
◦ increase the rate of cellular metabolism in many body
tissues
Fever:
◦ increases the cellular metabolic rate and thus increases the
body’s temperature further

7. Ways of heat loss
Heat is lost from the body through:
Radiation: transfer of heat from the surface of one object to another
without contact
Conduction: transfer of heat from one molecule to another of lower
temperature
Convection: the diffusion of heat by air current
Evaporation: is continuous vaporization of moisture from skin, mouth
breathing (insensible water loss)
The accompanying heat loss is called insensible heat loss (accounts for
about 10% of basal heat loss).

8. Regulation of body temperature
There are three main systems responsible for regulating the body temperature:
Sensors in the periphery and in the core
◦ Most Sensors are in the skin
◦ It has more receptors for cold than warmth (skin sensors detect cold more efficiently
than warmth)
◦ When skin become chilled over the entire body, 3 physiological processes to increase
the body temp. take place:
◦ Shivering increases heat production
◦ Sweating is inhibited to decrease heat loss
◦ Vasoconstriction decrease heat loss
The hypothalamic integrator
An effector system that adjust the production and loss of heat

10. Factors affecting body temperature
Age
Diurnal variations (circadian rhythms)
◦ Highest (4:00PM and 6:00PM) lowest (4AM and 6AM)
Exercise
Hormones: progesterone raise tep 0.3 C to 0.6 C above
basal level
Stress: Epinephrine & norepinephrine
Environmental

11. Normal range of body temperature for adults
◦36 C – 37.5 C Normal
◦Oral
◦36.0 C in the morning
◦38.5 C - 40 C with hard exercise
◦38 C - 38.5 C Stress
◦Rectal
◦Less than 36 C in the morning
◦37.5 C -38.5 C with hard work or emotional
stress

12. Alteration in body temperature
There are two primary alterations in body temperature:
◦ Pyrexia (hyperthermia)
◦ Hypothermia
Pyrexia: fever 37.6 C - 41C
Hyperpyrexia: a very high fever such as 41 C (lead to
death)
Client who has fever is referred to as febrile, the one who
does not is afebrile

13. Four common types of fevers:
◦ Intermittent fever: temperature alternate at regular intervals between periods of
fever and periods of normal or subnormal temp. (e.g. malaria).
◦ Remittent fever: a wide range of temperature fluctuations which are above normal
(more than 2C) occurs over a 24-hrs period, all of which are above normal (e.g. cold
or influenza).
◦ Relapsing fever: short febrile periods of a few days are interspersed with periods of 1
or 2 days of normal temp.
◦ Constant fever: the body temp. fluctuates minimally but always remains above
normal (e.g. typhoid fever).
◦ Fever spike: the temperature rises to fever level rapidly following a normal temp. &
then returns to normal within a few hours (e.g. bacterial bld infection).
In some conditions, an elevated temp. is not true fever:
◦ Heat exhaustion (due to excessive heat & dehydration)
◦ Heat stroke (exercising in hot weather)

14. Clinical signs of fever
The clinical signs of fever vary with the onset, course, and abatement stages of
the fever.
Onset (cold or chill phase):
Increased HR
Increase RR & depth
Shivering
Pallid, cold skin
Complaints of feeling cold
Cyanotic nail bed
“Gooseflesh” appearance of the skin
Cessation of sweating

15. Course (plateau phase):
Absence of chills
Skin that feels warm
Photosensitivity
Glassy-eyed appearance
Increase pulse & RR
Increased thirst
Mild or severe dehydration
Drowsiness, restlessness, delirium or convulsions
Herpetic lesions of the mouth
Loss of appetite (if the fever prolonged)
Malaise, weakness, and aching muscles

16. Defervescence (fever abatement/flush phase):
Skin that appears flushed and feels warm
Sweating
Decreases shivering
Possible dehydration

17. Nursing interventions for client with
fever
Monitor VS
Assess skin colour and temperature
Monitor WBCs count
Remove excess blankets or provide extra warmth as needed
Provide adequate nutrition and fluid (e.g., 2.500-3000 ml/day )
Measure I&O
Reduce physical activity
Administer antipyretics
Provide oral hygiene/sponge bath and dry clothes and Lenin

18. Hypothermia:
Is a core BT below the lower limit of normal.
There are three physiological mechanisms of hypothermia:
◦ Excessive heat loss
◦ Inadequate heat production to counteract heat loss
◦ Impaired hypothalamic thermoregulation

19. Clinical signs of hypothermia
Decreased body temp., pulse & respirations
Severe shivering (initially)
Feeling cold & chills
Pale, cool, waxy skin
Frostbite (discoloured, blistered nose, fingers, toes)
Hypotension
Decreased UOP
Lack of MS coordination
Disorientation
Drowsiness

20. Nursing interventions for client
with hypothermia
Provide a warm environment
Provide dry clothing
Apply warm blankets
Keep limbs close to body
Cover the clients’ scalp with a cap
Supply warm water or IV F
Apply warm pads

21. Assessing Body temperature
The most common sites for measuring BT are:
◦ Oral
◦ Rectal
◦ Axillary
◦ Tympanic membrane
◦ Temporal artery
Each of these sites has advantages and disadvantages

22. Oral
◦ Advantages: accessible and convenient
◦ Disadvantages: thermometers can break if bitten.
◦ inaccurate if client has just ingested hot or cold food or fluid or smoked.
◦ could injure the mouth following oral surgery
Rectal
◦ Advantages: reliable measurement
◦ Disadvantages: inconvenient and more unpleasant for clients difficult for client who cannot
turn to the side.
◦ could injure the rectum
◦ presence of stool may interfere with thermometer placement
Axillary
◦ Advantages: safe and non-invasive
◦ Disadvantages: the thermometer may need to be let in place a long time to obtain an accurate
measurement.

23. Tympanic membrane
Advantages: readily accessible reflects the core temperature very fast.
Disadvantages: can be uncomfortable and involves risk of injuring the membrane
if the probe is inserted too far.
repeated measurements may vary right and left measurements can differ
presence of cerumen can affect the reading
Temporal artery
Advantages: safe and non-invasive very fast.
Disadvantages: requires electronic equipment that may be expensive or
unavailable variation in technique needed if the client has perspiration on the
forehead

24. Types of thermometers:
◦ Electronic thermometers
◦ Infrared (tympanic) thermometer
◦ Temporal artery thermometer
◦ Temperature-sensitive skin tape
◦ Temperature scales

25. Pulse
Pulse: is a wave of a blood created by contraction of the left
ventricles of the heart .
Compliance of arteries: is their ability to contract and expand
Cardiac out put: is the volume of blood pumped into arteries
by the heart & equals the result of the stroke volume times the
heart rate (SV x HR)
Peripheral pulse: is a pulse located away from the heart (e.g.
foot or wrist)
Apical pulse: is a central pulse; that is, it is located at the apex
of the heart (PMI).

26. Factors affecting the pulse
Age
Gender: male lower than females
Exercise: athletes lower rate RT greater cardiac size and strength
Fever: hypotension (vasodilatation )or increase metabolic rate
Medication
Hypovolemia/dehydreation
Stress
Position
Pathology

27. Pulse
Sites

28. Reasons for using specific pulse site:
◦ Radial: Readily accessible
◦ Temporal: Used when radial pulse is not accessible
◦ Carotid:
◦ Used during cardiac arrest/shock in adults.
◦ Used to determine circulation to the brain.
◦ Avoid:
◦ compression of carotid sinus which is located at the level of the top of thyroid cartilage.
◦ simultaneous palpation of both carotid arteries.
◦ By mechanical stimulation of the receptors in its wall, produces reflexly bradycardia and peripheral
vasodilatation. On the other hand, pressure applied below the carotid sinus, by occluding the carotid artery,
causes hypotension in the sinus, and produces reflexly tachycardia and peripheral vasoconstriction.

29. Apical:
◦ Routinely used for infants and children up to 3 years.
◦ Used to determine discrepancies with radial pulse.
◦ Used in conjunction with some medications.
Brachial: Used to measure blood pressure.
Femoral:
◦ Used in cases of cardiac arrest/shock
◦ Used to determine circulation to leg
Popliteal: Used to determine circulation to lower leg
Posterior tibial: Used to determine circulation to the foot
Dorsalis pedis: Used to determine circulation to the foot

30. Assessing the pulse
Tachycardia: over 100 BPM
Bradycardia: less than 60 BPM
Pulse rhythm: is the pattern of beats and intervals between the beats
Dysrhythmia or arrhythmia: random, irregular beats
Pulse volume (strength or amplitude): force of blood with each beat
Elasticity of the arterial wall: reflects its expansibility or its deformities. A
healthy, normal artery feels straight ,smooth, and soft.

31. Purposes of assessing :
◦ A peripheral pulse
◦ To establish baseline data for subsequent evaluation
◦ To identify wether the pulse rate within normal range
◦ To determine the pulse volume and wether the pulse rhythm is
regular
◦ To determine the quality of corresponding peripheral pulses on
each side of the body
◦ To monitor and assess changes in the client’s health status
◦ To monitor clients at risk for pulse alterations
◦ To evaluate blood perfusion to the extremities

32. ◦ An apical pulse
◦ To obtain heart rate of an adult with an irregular peripheral
pulse
◦ To establish baseline data for subsequent evaluation
◦ To determine wether the cardiac rate is within normal range
and the rhythm is regular
◦ to monitor clients with cardiac, pulmonary, or renal diseases
and those receiving medications to improve heart action.

33. Respirations
Is the act of breathing.
Inhalation or inspiration: refers to the intake of air into the lungs.
Exhalation or expiration: refers to breathing out or the movement of gases from
the lungs to the atmosphere.
Ventilation: is a term used to refer to the movement of air in and out of the
lungs.

34. The thoracic cavity, or chest cavity, always has a slight, negative pressure which
aids in keeping the airways of the lungs open.
During the process of inhalation, the lung volume expands as a result of the
contraction of the diaphragm and intercostal muscles (the muscles that are
connected to the rib cage), thus expanding the thoracic cavity. Due to this
increase in volume, the pressure is decreased, based on the principles of Boyle’s
Law.
This decrease of pressure in the thoracic cavity relative to the environment
makes the cavity pressure less than the atmospheric pressure. This pressure
gradient between the atmosphere and the thoracic cavity allows air to rush into
the lungs; inhalation occurs.

35. The resulting increase in volume is largely attributed to an increase in alveolar
space because the bronchioles and bronchi are stiff structures that do not
change in size.
During this process, the chest wall expands out and away from the lungs. The
lungs are elastic; therefore, when air fills the lungs, the elastic recoil within
the tissues of the lung exerts pressure back toward the interior of the lungs.
These outward and inward forces compete to inflate and deflate the lung with
every breath.

36. Upon exhalation, the lungs recoil to force the air out of the lungs. The intercostal
muscles relax, returning the chest wall to its original position. During exhalation,
the diaphragm also relaxes, moving higher into the thoracic cavity.
This increases the pressure within the thoracic cavity relative to the
environment. Air rushes out of the lungs due to the pressure gradient between
the thoracic cavity and the atmosphere.
This movement of air out of the lungs is classified as a passive event since there
are no muscles contracting to expel the air.

37. Inhalation and exhalation: The lungs, chest wall, and diaphragm are all involved
in respiration, both (a) inhalation and (b) expiration.

40. There are two types of breathing
There are different types, or modes, of breathing that require a slightly
different process to allow inspiration and expiration.
During inhalation, the lungs expand with air and oxygen diffuses across the
lung’s surface, entering the bloodstream.
During exhalation, the lungs expel air and lung volume decreases. The various
types of breathing, specifically in humans, include:

41. 1) Eupnea: a mode of breathing that occurs at rest and does not require the
cognitive thought of the individual. During eupnea, also referred to as quiet
breathing, the diaphragm and external intercostals must contract.
2) Diaphragmatic breathing: a mode of breathing that requires the diaphragm to
contract. As the diaphragm relaxes, air passively leaves the lungs. This type of
breathing is also known as deep breathing.
3) Costal breathing: a mode of breathing that requires contraction of the
intercostal muscles. As the intercostal muscles relax, air passively leaves the lungs.
This type of breathing is also known as shallow breathing.

42. 4) Hyperpnea: a mode of breathing that can occur during exercise or actions
that require the active manipulation of breathing, such as singing.
◦ During hyperpnea, also known as forced breathing, inspiration and expiration both
occur due to muscle contractions.
◦ In addition to the contraction of the diaphragm and intercostal muscles, other
accessory muscles must also contract.
◦ During forced inspiration, muscles of the neck, including the scalenes, contract and
lift the thoracic wall, increasing lung volume.
◦ During forced expiration, accessory muscles of the abdomen, including the
obliques, contract, forcing abdominal organs upward against the diaphragm.
◦ This helps to push the diaphragm further into the thorax, pushing more air out.
◦ In addition, accessory muscles (primarily the internal intercostals) help to compress
the rib cage, which also reduces the volume of the thoracic cavity.

43. Assessing Respirations
The client’s normal breathing pattern
The influence of the clients’ health problems on respirations
Any medications or therapies that might affect respirations
The relationship of the client’s respirations to cardiovascular function.
Normal respiration rates for an adult person at rest range from 12 to 16
breaths per minute.

44. When assessing respirations all the following should be assessed:
Rate
◦ Eupnea: breathing in normal rate
◦ Bradypnea: abnormally slow respirations
◦ Tachpnea: abnormally fast respirations
◦ Apnea: absence of breathing
Depth
◦ Hyperventilation: very deep, rapid respirations
◦ Hypoventilation: very shallow respirations
Rhythm
Quality
◦ Dyspnea: difficult and labored breathing
◦ Orthopnea: ability to breath only in upright sitting or standing positions
Effectiveness

45. Blood pressure
Arterial blood pressure: is a measure of the pressure exerted by the blood as it
flows through the arteries.
Systolic pressure: is the pressure of the blood as a result from contraction of
ventricles
Diastolic pressure: pressure when ventricles are at rest
Pulse pressure: the difference between diastolic and systolic pressure
B.P is measured in millimetres mercury (mmHg)
Typical BP is 120/80 mmHg (pulse pressure of 40)

46. Determinants of blood
pressure
Pumping action of the heart
Peripheral vascular resistance
Blood volume
Blood viscosity

47. Factors affecting blood
pressure
Age
Exercise
Stress
Race
Gender
Medications
Obesity
Diurnal variations
Medical conditions
Temperature

48. Hypertension:
Is a BP that is persistently above normal (above 140/90)
It is usually asymptomatic and is often a contributing factor to
myocardial infarction (heart attacks).
Primary hypertension: an elevated BP of unknown cause
Secondary hypertension : an elevated BP of a known cause
Hypotension:
Is a BP that is below normal
Orthostatic hypotension: is a BP that falls when the client sits or stands.