BY

ASIF ALI MAGSI

LECTURER
SMBBMU LRK

VITAL
SIGNS
OUTLINE
 Introduction
 Body Temperature

 Pulse

 Respiration

 Blood Pressure
Vital signs are temperature, pulse, respiration,
blood pressure and pain. A change in vital signs
may indicate a change in health.

Frequency of vital signs: vital signs are assessed at

least every 4 hours in hospitalized patients with
elevated temperatures, with low or high blood
pressures, with changes in pulse rate or rhythm or
with respiratory difficulty as well as in patients
who are taking medications that effect
cardiovascular or respiratory function or who had
a surgery.
Times to assess vital signs:
 On admission to a health care agency to obtain
baseline data
 When a client has a change in health status or
report symptoms such as chest pain or feelings hot
or faint.
 Before and after surgery or an invasive procedure
 Before and/or after the administration of a
medication that could affect the respiratory or
cardiovascular systems such as before giving
digitalis preparation
 Before and after any nursing interventions that
could affect the vital signs such as ambulating a
client who has been on bed rest.
 BODY TEMPERATURE

Body temperature reflects the balance between the heat

produced and the heat lost from the body, and is
measured in heat units called degrees. There are two
kinds of body temperature:
Core temperature is the temperature of the deep
tissues of the body such as abdominal cavity and
pelvic cavity; it remains relatively constant. The
surface temperature is the temperature of the skin,
the subcutaneous tissue, and fat. It rises and falls in
response to the environment. When the amount of
heat produced by the body equals the amount of heat
loss, the person is in heat balance.
A number of factors affect the body's heat production:
 Basal metabolic rate "BMR" is the rate of energy
utilization in the body required to maintain essential
activities such as breathing.
 Muscle activity; including shivering, increases the
metabolic rate.
 Thyroxine output; increased thyroxine output increases
the rate of cellular metabolism throughout the body.
 Epinephrine, norepinephrene, and sympathetic
stimulation/stress response. These hormones
immediately increases the rate of cellular metabolism in
many body tissues
 Fever; fever increases the cellular metabolism rate and
thus increases the body's temperature further.
MECHANISM OF HEAT LOSS:

Radiation; the transfer of heat from the surface of one object to

the surface of another without contact between the two objects,
mostly in the form infrared rays.
Conduction; is the transfer of heat from one molecule to a
molecule of lower temperature such as the body transfers heat
to an ice pack causing the ice to melt.
Vaporization; the conversion of a liquid to vapor
such as body fluid in the form of perspiration and
insensible loss is vaporized from the skin.
Convection is the dispersion of heat by air
currents. The body usually has a small amount of
warm air adjacent to it. This warm air rises and is
replaced by cooler air.
:
FACTORS AFFECTING BODY
TEMPERATURE
 Circadian Rhythms; predictable fluctuations in measurement of
body temperature and blood pressure such as body temperature
is usually lower in the morning than in the evening.
 Age; the body temperature of infants and children changes
more rapidly in response to both heat and cold.
 Hormones; women tend to have more fluctuations in body
temperature than men as a result of hormones changes
 Stress; the body respond to both emotional and physical stress
as a threat increasing the production of epinephrine and nor
epinephrine as a result the metabolic rate increases raising the
body temperature
 Environmental temperature; we are responding to a change in

environment either by wearing or less clothes.

 Exercise, hard work or strenuous exercise can increase body

temperature.
ALTERATIONS IN BODY
TEMPERATURE
There are two primary alterations in body
temperature: pyrexia and hypothermia.

Pyrexia
A body temperature above the usual range is called
pyrexia, hyperthermia, or fever.
Hyperpyrexia; is a very high fever usually above 41
°C and survival is rare when the temperature
Reaches 44 °C and death due to damaging effects
on the respiratory center.
The client who has a fever is referred to as febrile;
the one who does not is afebrile.
The signs and symptoms of fever: loss of appetite, headache, hot,
dry skin, flushed face, thirst and general malaise. Young
children or other people with high fevers may experience
periods of delirium or seizures.
NURSING INTERVENTIONS FOR
CLIENT'S WITH FEVER:
 Monitor vital signs
 Assess skin color and temperature
 Monitor WBC, HCT, and other laboratory reports for
indications of infection or dehydration
 Remove excess blanket when the client feels warm,
but provide extra warmth when the client feels chilled.
 Measure intake and output
 Provide adequate nutrition and fluid
 Reduce physical activity to limit heat production.
 Administer antipyretic
 Provide oral hygiene to keep the mucous membrane moist.

 Provide a tepid sponge bath to increase heat loss through

conduction.
 Provide dry clothing and bed linens.
Hypothermia; is a core body temperature below the lower limit
of normal. The three physiologic mechanisms of hypothermia
are:
 Excessive heat loss

 Inadequate heat production to counteract heat loss

 Impaired hypothalamic thermoregulation

The clinical signs of hypothermia:
Decreased body temperature, pulse, and

respiration
Severe shivering

Feelings of cold and chills

Pale, cool skin

Hypotension

Decreased urinary output

Lack of muscle coordination

Disorientation

Drowsiness progressing to coma

Frostbite(nose, fingers, toes)

Nursing Interventions for Client's with Hypothermia
Provide a warm environment
Provide dry clothing

Apply warm blanket

Keep limbs close to body

Cover the client's scalp with a cap

Supply warm oral or intravenous fluids

Apply warming pads

Assessing Body Temperature

The four most common sites for measuring body

temperature are oral, rectal, axillary, and the
tympanic membrane and the skin.

Orally: It reflects changing body temperature more

quickly than the rectal method. Oral thermometers
may have long, short, or rounded tips
Contra indication of oral temperature:
 Breathing is difficult or rapid

 Can't close mouth for any reason

 Breathing through mouth

 Mouth is inflamed

 Confused or comatose

 Infant or young children

 Oral surgery/ broken jaw

 Unconscious/agitated people
Rectally; are considered to be very accurate.

Contra indication of rectal temperature

 Diarrhea

 Rectal surgery

 Clotting disorders

 Hemorrhoids "pile"
Axillary; is the preferred site for measuring temperature
newborn because it is accessible and offers no possibility rectal
perforation.
Contraindication of axillary temperature
 Thin patient

 Local inflammation

 Unconsciousness, shocked patients

 Constricted peripheral blood vessels.

Tympanic membrane; nearby tissue in the ear
canal because the membrane has an abundant
arterial blood supply.
Temporal artery thermometer are most useful
for infants and children where a more invasive
measurement is not necessary.
FOUR SITES FOR BODY TEMPERATURE
MEASUREMENT

Temperature scales
The body temperature is measure in degreed on two scales:
Celsius (centigrade) and Fahrenheit.
C= (Fahrenheit temperature – 32) * 5/9
F = (Celsius temperature * 9/5) +32
PULSE

Pulse; is a wave of blood created by contraction of the left

ventricle of the heart.
Cardiac output; is the volume of blood pumped into the arteries
by the heart and equals the result of the stroke volume times
the heart rate.
A peripheral pulse; is a pulse located away from the heart such
as in the foot, wrist neck.
Apical pulse; is a central pulse; that is, located at the apex of the
heart.
FACTORS AFFECTING PULSE:
 Age; as age increases, the pulse rate gradually
decreases.
 Gender, male’s pulse rate is slightly lower than the
female’s.
 Exercise; the pulse rate normally increase with
activity
 Fever; the pulse rate increases in response to the
lowered blood pressure that results from peripheral
vasodilatation associated with elevated temperature
and because of the increased metabolic rate.
 Medications; some medications decrease the pulse
rate, and others increase it such as digitalis decrease
the heart rate.
 Hypovolemia; loss of blood from the vascular system normally
increase pulse rate. Stress; in response to stress, sympathetic
nervous system stimulation increases the overall activity of the
heart.
 Position change; when the person is sitting or standing, blood

usually pools in dependent vessels of the venous system.

 Pathology; certain diseases such as some heart conditions or

those with impair oxygenation can alter the resting pulse rate.
PULSE SITES

 Temporal; passes over the temporal bone of the head.

The site is superior and lateral to the eye.
 Carotid; at the side of the neck between the trachea
and the sternocleiodomastoid muscle.
 Apical; at the apex of the hearty. About 8cm to the left
of the sternum and at the fourth and sixth intercostals
space.
 Brachial; at the inner aspect of the biceps muscle of
the arm
PULSE SITES
 Radial; on the thumb side of the inner aspect of the
wrist
 Femoral; alongside the inguinal ligaments
 Popliteal; behind the knee
 Posterior tibial; on the medial surface of the ankle
 Pedal “dorsalis pedis”; over the bones of the feet
Assessing the Pulse
A pulse is normally palpated by applying moderate pressure
with the three middle fingers of the hand. A pulse is commonly
assessed by palpation “feeling’ or auscultation “hearing”.
Apical pulse; if the peripheral pulse is difficult to assess
accurately because it is irregular. The apical pulse located at 5-
6 intercostals rib.
A Doppler ultrasound stethoscope (DUS) is used for pulses
that are difficult to assess.

The nurse should aware of the following:

 Any medications that could affect the heart
rate.
 Whether the client has been physically
active.
 Whether the client should assume a
particular position.
When assessing the pulse the nurse collect the following data:

1. Rate, an excessively fast heart rate over 100 BPM in an adult is

called Tachycardia. A heart rate in an adult of less than 60BPM
is called Bradycardia.
2. Rhythm is the pattern of the beats and the intervals between the
beats. A pulse with an irregular rhythm is referred to as a
dysrhythmia or arrhythmia.
3. Volume is called pulse strength or amplitude, refers to the force
of blood with each beat. It can range from absent to bounding.
4. Elasticity of the arterial wall reflects its expansibility or its
deformities. A healthy, normal artery feels straight, smooth, soft,
and pliable. Elders often have inelastic arteries that feel twisted
and irregular upon palpation.
Apical-Radial Pulse Assessment
It may need to be assessed for clients with certain
cardiovascular disorders. Normally the apical
pulse and radial are identical.
Pulse deficit; the discrepancy between the radial
pulse and apical pulse.
Mechanics and regulation of breathing
During inhalation, the diaphragm contracts the ribs move upward
and outward, and the sternum moves outward, thus enlarging
the thorax and permitting the lungs to expand.
During exhalation. The diaphragm relaxes, the ribs move
downward and inward, and the sternum moves inward, thus
decreasing the size of the thorax as the lungs are compressed.
 RESPIRATION
Respiration is controlled by (a) respiratory centers in the medulla
oblongata and the pons of the brain and (b) by chemo receptors
located centrally in the medulla and peripherally in the carotid
and aortic bodies.
External respiration; the interchange of oxygen and carbon
dioxide between the alveoli of the lungs and the pulmonary
blood. Internal respiration; the interchange of these same
gases between the circulating blood and the cells of the body
tissues.
Assessing Respiration
 Nurses should be aware of the following before having
respiration rate:
 The client’s normal breathing pattern
 The influence of the client’s health problems on respirations
 Any medications or therapies that might affect respirations
 The relationship of the client’s respiration to cardiovascular
function
The respiratory rate is normally described in breaths per minute,
normal in depth and rate called eupnea. Bradypnea;
abnormally slow respirations. Tachypnea; abnormally fast
respirations. Apnea; the absence of breathing.
Factors affecting Respirations
Factors increase the rate:
Exercise

Increase metabolism

Stress

Increased environmental temperature

Lowered oxygen concentration

 Factors decrease respiration rate:
 Decreased environmental temperature
 Certain medications such as narcotics

 Increased intra cranial pressure

Respiration depth; is generally described as normal, deep, or
shallow. Deep respirations; large volume of air is inhaled and
exhaled, inflated most of the lungs.
Shallow breathing involve the exchange of a small volume of air
and often the minimal use of a lung tissue
Hyperventilation; refers to very deep, rapid respiration.
Hypoventilation; refers to very shallow respirations
Respiratory rhythm refers to the regularity of the expirations
and the inspirations .An respiratory rhythm can be described as
regular or irregular.
- Cheyne-stokes breathing, from very deep to very shallow
breathing and temporary apnea.
 Kussmaul …….. Increased rate and depth of
respiration above 20bpm
Respiratory quality, usually breathing does not require
noticeable effort. Dyspnea, difficult and labored breathing.
Orthopnea, ability to breath only in upright sitting or standing
positions.
Breath sounds
- Stridor, harsh sound heard during inspiration with laryngeal
obstruction
- Stertor, snoring respiration usually due to a partial obstruction
of the upper airway.
- Wheeze, continuous, high pitched musical sound occurring on
expiration when air moves through narrowed or partially
obstructed air way.
Secretions and coughing
- Hemoptysis, the presence of blood in the sputum
- Productive cough, a cough accompanied by expectorated
secretions
- Nonproductive cough, a dry, harsh cough without secretions
BLOOD PRESSURE

Blood pressure is referred to the force of the blood against

arterial walls. Maximum blood pressure is exerted on the walls
of arteries when the left ventricles of the heart pushes blood
through the aortic valve into the aortas during contraction, the
highest pressure thus called systolic pressure.
Diastolic pressure is the pressure when the ventricles are at rest.
Diastolic pressure, then, is the lower pressure present at all
times within the arteries. The differences between the two
called the pulse pressure
DETERMINATION OF BLOOD
PRESSURE
 Pumping action of the heart; when the pumping action of the
heart is weak, less blood is pumped into arteries "lower cardiac
output", and the blood pressure decreases.
 Peripheral vascular resistance; peripheral vascular can increase
blood pressure. The diastolic pressure especially is affected.
Some factors that create resistance in the arterial system are the
capacity of the arterioles, the compliance of the arteries, and
the viscosity of the blood
 Blood volume; when the blood volume decreases as a result of
hemorrhage, the blood pressure decreases because of the
decreased fluid in the arteries.
 Blood viscosity; blood pressure is higher when the blood is

highly viscous "thick" that is, when the proportion of RBC to

the blood plasma is high.
FACTORS AFFECTING BLOOD
PRESSURE

 Age; the pressure rises with age, reaching a peak

at the onset of puberty, and then tend to decline.
 Exercise; physical activity increases the cardiac

output and hence in blood pressure; thus 20-30

minutes of rest following exercise is indicated
before the resting blood pressure can reliably
assessed.
 Stress; stimulation of the nervous system increases cardiac
output and vasoconstriction of the arterioles, however severe
pain can decrease blood pressure greatly by inhibiting the
vasomotor center and provide vasodilatation
 Race (African American males over 35 years have higher BP

than European American males)

 Gender; after puberty, female usually have lower blood

pressure than males at the same age. After menopause the

female has higher blood pressure than males
 Medications
 Obesity; predispose to high blood pressure

 Diurnal variations; pressure is usually lowest early

in the morning when metabolic rate is low.

 Disease process; any condition affecting the

cardiac output, blood volume, blood viscosity, and

compliance of the arteries has a direct effect on
the blood pressure.
HYPERTENSION
Hypertension; an abnormally high blood
pressure, over 140mm Hg systolic and 90 mm Hg
diastolic.
Factors associated with hypertension
 Thickening of the arterial walls, which reduces the

size of the arterial lumen

 Elasticity of the arteries

 Lifestyle as cigarette smoking

 Obesity
 Lack of physical exercise

 High blood cholesterol level

 Continued exposure to stress

Hypotension; blood pressure below normal that is systolic
reading between 85-110mm Hg. It occurs as a result of
peripheral vasodilatation in which blood leaves the central
body organs especially the brain and moves to the periphery

Factors associated with hypotension

 Analgesics

 Bleeding

 Severe burn

 Dehydration.
It is important to monitor hypotensive clients carefully to prevent
falls. When assessing the orthostatic hypotension:
 Place the client in a supine position for 2-3 minutes
 Record the client's pulse and blood pressure
 Assist the client to slowly sit or stand. Support the client in case of
faintness
 After one minute in the upright position, check the pulse and blood
pressure in the same site as previously
 Record the results, a rise in pulse of 40 beats per minute or a drop in
blood pressure of 30mm Hg indicates abnormal vital signs.
Equipments used to assess pulse and blood pressure
 Stethoscope; is used to auscultated and assess body sounds

including the apical pulse and the blood pressure

 Sphygmomanometer; is used to assess blood pressure consist

of cuff, good selection of the cuff in order to obtain accurate

blood pressure.
Blood pressure sites
Assessing the blood pressure on a client’s thigh is indicated in
these situations:
 The blood pressure can not be measured on either arm due to burn
or other trauma
 The blood pressure on one thigh is to be compared with the blood
pressure in the other thigh
Blood pressure is not measured on a particular clients’ limb in
the following situations:
1) Avoid having blood [pressure in injured or an area with cast
2) The client has had removal of axilla lymph node on that site
3) The client has intravenous line in that limb
4) The client has an arteriovenous fistula for dialysis in that limb
Oxygen Saturation
A pulse oximeter; is a non invasive device that measures a
client's arterial blood oxygen saturation by means of a sensor
attached to the client's finger, toe, nose, earlobe, or forehead.
The pulse oximeter can detect hypoxemia before clinical signs
and symptoms such as dusky skin color and dusky nailbed
color.
Factors affecting oxygen saturation reading
 Hemoglobin; if the hemoglobin is fully saturated with oxygen,

the saturation will appear normal even if the total hemoglobin

level is low
 Circulation

 Activity; shivering or excessive movement of the sensor site

may interfere with accurate reading.

 Carbon monoxide poisoning.