Assessment of Vital Signs

• Temperature
• Pulse
• Respirations
• Blood Pressure
• The fifth vital sign
– Pain
– Oxygen Saturation
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.
Evaporation
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
Oral

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Rectally; are considered to be very accurate.

Contra indication of rectal temperature

• Diarrhea
• Rectal surgery
• Clotting disorders
• Hemorrhoids "pile"
Rectal thermometer

Vital signs (Temperature) 11/10/2011 ٢٧

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.
Axillary temperature

Vital signs (Temperature) 11/10/2011 ٢٩

Tympanic membrane; nearby tissue in the ear
canal because the membrane has an abundant
arterial blood supply.
Tympanic

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Temporal artery thermometer are most useful
for infants and children where a more invasive
measurement is not necessary.
 Advantages and disadvantages of 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
– 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.
 Respirations

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 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

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.
 PAIN SCALE
• 5TH OR 6TH VITAL SIGN.
• MONITOR ON A REGULAR BASIS.
• ASSESS PATINET’S SELF-REPORT OF PAIN
LEVEL. USING SCALE OF 0-10.
• OBSERVE FOR NON-VERBAL CUES.
• DOCUMENT.
Pain is defined by the International Association
for the Study of Pain (IASP) as "an
unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described in
terms of such damage”
• Pain—Definition is based upon our own
experiences with pain.

• Pain is subjective and influenced by our

background and emotional status.
• Originally pain is an important signalling/
warning system: it helps to notice and to
avoid harmful stimuli.
• Pain caused by diagnosed illnesses or by
medical intervention is of no use, but causes
suffering and gives start to harmful
pathophysiologic processes → it
must be prevented or eliminated !!!
Pain scale:1 to 10.

• 1 to 3—mild pain.
• 4 to 6---moderate pain
• 7 to 10—severe pain
• Pain vs. pain and inflammation.
 Judgement of pain intensity

0 max
For children:
Visual Analog Scale

VAS
NAS 0 1 2 3 4 5 6 7 8 9 10

Verbal Rating Scale:

Numeric analog scale
extreme
very strong
strong
mild
no pain at all
The most important questions :

• Where? - the localization of pain -segmental?

• When? – How long do you experience the pain?
What does provoke the start of the
pain? How often?
Changes in the character of the pain?
Fluctuation? Sesonal appearance?
• How? - quality, characteristics of the pain
»Lancinating, stiching, lightning,
continuous, spastic, etc.
• How strong? - scales, scores
• Accompanying symptoms
• What gives help/attenuation of pain?
• Important points of medical help
• Let the patient speak!!!– TIME!!
• Physical evaluation
• General state, habitus, antropometric measures,
• Psychosomatic character, neurologic disorders/deficits?
• Painful spots, areas - continuous pain, or?
Raction to touching (allodynia?)
• Temperature differences? Others? (edema, muscle strength,
sensory function, colour ? etc.)
• Instreumental diagnostic evaluation
• Laboratory, X ray, CT, MRI - recognition of pathology
requireing surgery or other medical intervention
• Therapeutic plan: - long term care necessary!
– Causal therapy – if possible
– Systemic analgetics – + adjuvant therapy (!)
– Regional anesthesia techniques
– Mechanic/physical therapeutic methods– physicoth,
AKU,
TENS..
– Invasive methods?