VITAL SIGNS, Temperature, Pulse, Respiration, Blood pressure (B/P)

Describe Vital Signs
Define terms related to Vital sign
Describe the physiological concept of temperature, respiration and blood pressure
Describe the principles and mechanisms for normal thermoregulation in the body
Describe factors that can influence each vital sign.
Identify the location of commonly assessed pulse sites.
Recognize normal vital sign values among various age groups
Describe various methods and sites used to measure T.P & B.P
Recognize the signs of alert while taking TPR and B.P.

1. VITAL SIGNS
BY
Muhammad Baqar
MSPH, BScN, RN

2. VITAL SIGNS
Are measurements of the body's most basic functions.
Vital sign are the indicator of the body’s physiologic status and
response to physical environment and psychological
stressor.
1.Temperature,
2.Pulse,
3.Respiration,
4.Blood pressure (B/P)
5.Pain
6.Oxygen saturation
7.Consciousness
8.Emotional status

3. WHEN TO ASSESS VITAL SIGNS
On a client’s admission
According to the physician’s order or the institution’s policy
or standard of practice
During home health visit
Before & after a surgical or invasive diagnostic procedure
Before & after the administration of medicines or therapy
that affect cardiovascular, respiratory & temperature control
functions
When the client’s general physical condition changes
Before, after & during nursing interventions influencing vital
signs
When client reports symptoms of physical distress

4. WHEN TO ASSESS VITAL SIGNS
In the hospital: once every 4 to 8 hours
In the home health setting: at each visit
In the clinic: at each visit
In skilled nursing facilities, also known as convalescent
hospitals: weekly to monthly

5. PURPOSES
To determine the baseline reading of vital signs.
To monitor patient's physical condition
To determine whether infection or inflammatory process
are present.
To aid in assessment and diagnosis of cardiovascular
abnormalities.
To monitor and assess the diaphragm and chest
muscles and air patency.
To determine changes in response to specific therapies
(e.g. Antipyretic medication, immunosuppressive
therapy, invasive procedure).

6. TEMPERATURE
Temperature:Is a measure of the hotness or
coldness of the environment .
Body Temperature: Is the degree of heat
maintained by the body.

7. THERMOREGULATION
Is the process of maintaining a stable
temperature.
To keep the body temperature constant
Balance between heat produced and heat lost by
the body
Heat regulating centre –hypothalamus,
Heat production caused by increasing cell
metabolism
Heat losses(cool off process):
(Radiation, Convection, Evaporation, Conduction)

8. PRINCIPLES OF THERMOREGULATION
Homeostasis: The body tries to maintain a stable internal
environment.
Set Point: The hypothalamus in the brain acts as the body's
thermostat, regulating the set point around which body
temperature is maintained (typically around 37°C or 98.6°F).
Feedback Mechanisms: The body uses negative
feedback loops to adjust temperature. If the body deviates from
the set point, mechanisms are activated to bring it back to
normal.

9. MECHANISMS OF THERMOREGULATION

10. KINDS OF BODY TEMPERATURE

11. CORE TEMPERATURE
Deep body tissue temperature that remains
relatively constant, (abdominal cavity, pelvic
cavity)
It remains relatively constant (37Cº or 98.6 Fº).
True core temperature readings can only be
measured by invasive means,
Such as placing a temperature probe into the
esophagus, pulmonary artery or urinary
bladder.

12. CORE MEASUREMENT SITES
Tympanic
Rectal&
by invasive monitoring devices:
Esophagus
Pulmonary artery
Bladder.

13. SURFACE TEMPERATURE
Surface temperature–skin subcutaneous and
body fat tissue; which changes in response to
the environment
Oral(sublingual)
Axillary
Skin surface

14. SITES FOR MEASURING BODY
TEMPERATURE
Sites
Normal range Adult 97 –99
degrees
Oral, 98.6
Rectal,
99.6
Axillary,
97.6
Tympanic (ear)membrane;
and Skin/Temporal artery
(forehead) and external auditory
canal
98.6

15. NORMAL VITAL SIGN RANGES ACROSS THE
LIFESPAN

16. TEMPERATURE: LIFESPAN
CONSIDERATIONS
Infants
Unstable
Newborns must be kept warm to
prevent hypothermia
Children Tympanic or temporal artery sites
preferred
Elders
Tends to be lower than that of
middle-aged adults

17. FACTORS AFFECTING BODY TEMPERATURE
Hormones
Age
Gender
Environment
Time of Day(Diurnal variation)
Exercise
Stress

18. ALTERATIONS IN BODY TEMPERATURE
Pyrexia: Abody temperature above the normal ranges 38 c –
41 c (100.4 –105.8 F)
Hyper pyrexia: A very high fever, such as 41 C > 42 c leads to
death.
Fever:Temperature above the usual range
A client who has fever is referred as febrile;
The one who has not is a febrile.
Hypothermia: body temperature between 34 c –35 c,
< 34 c is death

19. COMMON TYPES OF FEVERS
Intermittent fever
Remittent fever
Inverse fever
Constant fever

20. COMMON TYPES OF FEVERS
•Intermittent fever is
characterized by episodes
of fever that come and go,
with periods of normal
temperature in between..
•e.g. Malaria
Intermittent
fever
•a wide range of
temperature fluctuation
(more than 2 c) occurs
over the 24 hr period, all of
which are above normal
•colds & flues
Remittent
fever

21. COMMON TYPES OF FEVERS
•Temperature rises in morning
and falls in evening
•e.g.: Sepsis, tuberculosis,
Inverse
fever
•The body temperature usually
remains constant with
minimal fluctuations; ( as
seen in typhoid) but always
remains above normal
•e.g. typhoid fever, Meningitis,
Constant
fever

22. CLINICAL SIGNS OF FEVER
A: Onset (cold or chill stage/ Rigor stage )
1. Increased heart rate and respiratory
rate and depth.
2. Shivering due to increased skeletal
muscle tension and contraction.
3. Cold skin due to vasoconstriction.
4. Cyanotic nail due to vasoconstriction.
5. Complain of feeling cold.
6. Gooseflesh appearance of the skin
7. Rise in body temperature

23. CLINICAL SIGNS OF FEVER
B: Course stage (Hot stage)
1. Skin feels warm.
2. Increased pulse and respiratory rate.
3. Increased thirst.
4. Mild to severe dehydration.
5. Drowsiness, restlessness, or disorientation
and convulsions due to Irritation of the nerve
cells
6. Loss of appetite with prolonged fever.
7. Malaise, weakness, and aching muscles
due to protein breakdown.

24. CLINICAL SIGNS OF FEVER
C: Abatement stage(Perspiration Stage)
1. Flushed and warm skin.
2. Sweating.
3. Decreased shivering.
4. Possible dehydration.

25. NURSING CARE FOR FEVER
Monitor vital signs; Assess skin color and temperature
Monitor laboratory results for signs of dehydration or
infection
Remove excess blankets when the client feels warm
Measure intake and output, and Provide adequate
nutrition and fluid; Provide oral hygiene
Reduce physical activity
Administer antipyretic as ordered
Provide a tepid sponge bath NOT ice or cold water
Provide dry clothing and bed linens

26. TREATMENT OF INCREASING BODY
TEMPERATURE
Antipyretics.
Cold sponge bath.
Cold compresses

27. SYMPTOMS OF HYPOTHERMIA
Decrease body temp., pulse and
respirations
Severe shivering, Pale, feeling cold &
chills, waxy skin
Frostbite (nose, fingers, toes)
Hypotension (low B/P)
Decreased urinary output
Lack of muscle coordination
Disorientation; drowsiness
progressing to coma

28. NURSING CARE FOR HYPOTHERMIA AND
RIGOR STAGE
Provide warm environment, Provide dry clothing
and apply warm blankets
Keep limbs close to body, Cover the client’s
scalp
Supply warm oral or intravenous fluids
Apply warming pads

29. THERMOMETER
Is an instrument used to measure body
temperature

30. TYPE OF THERMOMETER
Oral thermometer: Has long slender
tips
Rectal thermometer: Short,
rounded tips
Axillary: Long and slender tip
Tympanic membrane thermometer
Glass mercury thermometer.
Electronic thermometers
Temporal artery thermometer.
Disposable paper (chemical)
thermometers.

31. TEMPERATURE PROCEDURE
Wear gloves
Shake mercury down below 96
If smoked or had something to drink, wait 10
min
Insert thermometer, wait….
Oral –under tongue, 5 minutes
Axillary –in armpit, 10 minutes
Rectal –in rectum, 3 minutes

32. CONTRAINDICATIONS FOR ORAL
TEMPERATURE
Confused, disoriented
Restless
Unconscious
Coughing, unable to breathe through nose
Seizures
Oral/nasal oxygen
NG

33. AXILLARY
Is the preferred site for measuring temperature
newborn
Contraindication of Axillary temperature
Thin patient
Local inflammation
Unconsciousness, shocked patients
Constricted peripheral blood vessels.

34. RECTAL TEMPERATURE
Rectally; are considered to be very accurate
When doing rectal temps, remember
Lubricant before inserting thermometer
Insert 1 –1 ½ inches
Hold thermometer in place
NEVER leave resident

35. CONTRAINDICATIONS FOR RECTAL
TEMPERATURE
Diarrhea
Fecal impaction
Rectal bleeding
Hemorrhoids
Surgical rectal closure

36. TEMPORAL ARTERY THERMOMETER
Are most useful for infants and children where
a more invasive measurement is not necessary.

37. 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

38. PULSE
A pulse is a blood wave created by a heart
contraction of the left ventricle
Force against the arterial walls that cause them
to expand with each heartbeat
Count for one minute
Norm adult pulse is 60 –100 beats/min
< 60 beats/min = bradycardia
> 100 beats/min = tachycardia

39. PULSE
Compliance –Is the ability of arteries to
contract and expand
Stroke volume -Is the quantity of blood forced
out by each contraction of the left ventricle
It averages 70 mL
Cardiac output–Amount of blood pumped by
the heart with each ventricular contraction
Cardiac output = Stroke volume ×pulse (heart)
rate=70ml ×80 BPM =5600 ml =5.6 L/min
Is 5,600 mL(or 5.6 liters) per minute

40. PHYSIOLOGY OF PULSE
Blood flows through the body in a continues circuit.
Electrical impulses originating from the SA node travel
through heart muscle to stimulate cardiac contraction.
Approximately 60 to 70 ml (stroke volume) of blood
enters the aorta with each ventricular contraction.
With each stroke volume ejection, the wall distends,
creating a pulse wave that travels rapidly toward the
distal ends of the arteries.
When a pulse wave reaches a peripheral artery, it can
be felt by palpating the artery lightly against underlying
bone or muscles.

41. REGULATION OF PULSE:
Autonomiccontrol of the sinoatrialnode (SA)
the pacemaker
Parasympatheticstimulation of the SA node via
the vagusnerve decreases HR.
Sympathetic stimulation of the SA node
increases HR thus the cardiac output and force
of contraction

42. FACTORS AFFECTING PULSE
Age
Gender
Exercise
Fever
Stress
Medications
Hypovolemia
Position changes
Pathology
Autonomic Nervous System

44. TYPES OF PULSE
1.Peripheral pulse: Is a pulse located away from
the heart, for example, in the foot or wrist.
Assessed via fingers
2.The apical pulse: In contrast, is a central
pulse; that is, it is located at the apex of the
heart. It is also referred to as the point of
maximal impulse (PMI). Assessed or taken via
stethoscope

45. PULSE SITES
1.Radial –Base of thumb
2.Temporal –Side of forehead
3.Carotid –Side of neck
4.Brachial –Inner aspect of elbow
5.Femoral –Inner aspect of upper thigh
6.Popliteal -Behind knee
7.Dorsalis Pedis–top of foot
8.Posterior Tibial
9.Apical pulse –Over apex of heart, taken with
stethoscope, left side of chest

49. PULSE ASSESSMENT
A pulse is commonly assessed by palpation
(feeling) or auscultation using stethoscope.
A pulse is normally palpated by applying
moderate pressure with the three middle
fingers of the hand.
The pads on distal aspects of the finger are the
most sensitive areas for detecting a pulse with
gentle pressure. A stethoscope is used for
assessing apical pulse

50. NURSING CONSIDERATIONS WHEN
ASSESSING PULSE
The nurse should also be aware of the following:
Medication
physically active. If so, wait 10 to 15 minutes.
Any baseline data about the normal heart rate
for the client.
Whether the client should assume a particular
position (e.g., sitting).

51. NURSING CONSIDERATIONS WHEN ASSESSING
PULSE
When assessing the pulse, the nurse collects
the following data:
The rate, rhythm, volume, arterial wall elasticity,
and presence or absence of bilateral equality

52. NURSING CONSIDERATIONS WHEN
ASSESSING PULSE
A Doppler ultrasound stethoscope (DUS) is used
for pulses that are difficult to assess

53. CHARACTERISTICS OF PULSE
Quality.
Rate.
Rhythm.
Volume (strength or amplitude).

54. CHARACTERISTICS OF PULSE
Pulse quality Refers to the ‘‘feel’’ of the pulse,
its rhythm and forcefulness.
Pulse rate is an indirect measurement of
cardiac output obtained by counting the
number of apical or peripheral pulse waves
over a pulse point.
A normal pulse rate for adults is between 60
and 100 beats per minute (80/min).

55. CHARACTERISTICS OF PULSE
Pulse rhythm is the regularity of the heartbeat.
It describes how evenly the heart is beating or
Time between each beat or pattern of
pulsations and the pauses between them
Described as normal, weak or bounding
Regular (the beats are evenly spaced).
Irregular (the beats are not evenly spaced).
•Dysrhythmia(arrhythmia)is an irregular rhythm
caused by an early, late, or missedheartbeat.

56. CHARACTERISTICS OF PULSE
Volume: Pulse volume is a measurement of the
strength or amplitude of force exerted by the ejected
blood against the arterial wall with each contraction.
Normal-It is described as (full, easily palpable).
Weak(thready and usually rapid), or
Strong(bounding).

57. PULSE VOLUME SCALE
A pulse volume can be measured on a scale of
0 to 4 (indicated by ×/4):
0Absent, not discernible
+1Thready or weak, difficult to feel
+2Normal, detected readily, obliterated by
strong pressure
+3Increased
+4Bounding

58. RESPIRATION
Exchange of oxygen & carbon dioxide in lungs
1 respiration = 1 inhalation + 1 exhalation
Ventilation;The movement of gases between in
and out of the lungs (inspiration and expiration
Diffusion; The movement of oxygen and carbon
dioxide between the alveoli and the red blood
cells.
Perfusion; The distribution of red blood cells to
and from the capillaries.

59. RESPIRATION
Ventilation;The movement of gases between in
and out of the lungs (inspiration and expiration
Diffusion; The movement of oxygen and carbon
dioxide between the alveoli and the red blood
cells.
Perfusion; The distribution of red blood cells to
and from the capillaries.

60. PHYSIOLOGICAL CONTROL
Regulated by the medulla Oblangata
Normal adult rate is 16 –20 breaths/min
Normal breathing is quiet, effortless, & regular
in rhythm
Ventilation is regulated by CO2, O2, and
hydrogen ion concentration (PH) in the arterial
blood.

61. PHYSIOLOGICAL CONTROL
The most important factor in the control of
ventilation is the level of CO2 in the arterial
blood.
An elevation in the Co2 level causes the
respiratory control system in the brain to
increase the rate and depth of breathing. The
increased ventilatory effort removes excess
CO2 by increasing exhalation.

62. MECHANICS AND REGULATION OF
BREATHING
Pulmonary ventilation depends on changes in
the capacity of the chest cavity.
Inspiration or Inhalation
Expiration Or Exhalation

63. INSPIRATION OR INHALATION
Impulses sent from the respiratory center along
the phrenicnerve,
The thoracic muscles and the diaphragm
contract.
1 to 1.5 seconds for inspiration.

65. EXPIRATION OR EXHALATION
Passive and normally takes 2 to 3 seconds
Diaphragm and thoracic muscles relax,
The chest cavity decreases in size, the lungs
recoil, forcing air.
The pressure reaches atmospheric pressure

68. THE PROCESS OF RESPIRATION
Consists of two aspects:
Mechanical and
Chemical.

69. MECHANICAL
The mechanical aspects of respiration involve
The active movement of air into
Out of the respiratory system
This is known as pulmonary ventilation
(Breathing)

70. CHEMICAL.
The chemical aspects of respiration include:
External respiration—The exchange of oxygen
and carbon dioxide between the alveoli and the
pulmonary blood supply
Gas transport—The transport of these gases
throughout the body
Internal respiration—The exchange of these
gases between the capillaries and body tissue
cells

71. TYPES OF BREATHING
Costal (thoracic) Observed by the movement of
the chest up ward and downward. Commonly
used for adults
Diaphragmatic (abdominal) Involves the
contraction and relaxation of the diaphragm,
observed by the movement of abdomen.
Commonly used for children.

72. FACTORS AFFECTING RESPIRATION
Pain
Anxiety
Exercise
Medications
Trauma
Infection
Respiratory and cardiovascular disease.
Alteration in fluids, electrolytes, acid-base
balances

73. ASSESSMENT OF RESPIRATION
Rate
Rhythm
Depth –shallow, norm, deep
Effort involved to take breaths
Discomfort it causes
Position
Sounds that accompany it
Color of skin, mucous membranes, nail,
check for cyanosis

74. ALTERED BREATHING PATTERNS
RATE
Tachypnea: Rapid respiration marked by quick,
shallow breaths
Bradypnea:Abnormally slow breathing
Apnea: Pause of breathing

75. ALTERED BREATHING PATTERNS
VOLUME
Hyperventilation:An increase in the amount of air
in the lungs, characterized by increased rate
and depth of breaths
• Hypoventilation: A reduction in the amount of
air in the lungs, characterized by shallow
respirations
• Kussmaul’srespiration: Abnormally deep, very
rapid sighing respirations as in diabetic
ketoacidosis

76. ALTERED BREATHING PATTERNS
RHYTHM
Cheyne-Stokes respiration: Rhythmic expanding
and disappearing of respirations, from very
deep to very shallow breathing and temporary
apnea; associated with increased intracranial
pressure or brain damage and can indicate
impending death

77. ALTERED BREATHING PATTERNS
RHYTHM
Ease or Effort
Dyspnea: The subjective sensation of difficult
or uncomfortable reathing or breathlessness
(shortness of breath)
Orthopnea: Ability to breathe only in upright
sitting or standing positions
Nasal flaring: Widening of nostrils during
inspiration, which may indicate respiratory
distress

78. CHARACTERISTICS OF NORMAL
BREATHING
Eupnea: Refers to easy respirations with a normal
rate of breaths per minute that is age specific.
Slow and regular, Breathing in and out through
the nose only.
Invisible-No effort should be visible, the
diaphragm should be moving gently.
Quiet with: No panting. No wheezing. No
sighing. No deep inhalations or exhalations

80. PROCESS OF TAKING TPR
Take temperature first
Pulse second
Respirations last
When taking respiration, keep fingers on pulse
so that client does not know you are counting
respiration
Document all together

81. BLOOD PRESSURE
Pressure exerted against walls of blood vessels
Systolic –highest reading
Pressure when heart contracting
Diastolic –lower reading
Pressure when heart is at rest

82. Hear thumping sounds as blood flows through
arteries
Sounds correspond to numbers representing
mm Hg on sphygmomanometer
First sound heard is systolic
Last sound heard is diastolic
BLOOD PRESSURE

83. Normal adult reading
120/80
Normal systolic = 100 –140
Normal diastolic = 60 –90
Abnormal readings
Hypertension –BP > 140/90
Hypotension –BP < 90/60
BLOOD PRESSURE

84. PHYSIOLOGY OF ARTERIAL BLOOD PRESSURE
Blood pressure reflects the interrelationships of
cardiac output,
Peripheral vascular resistance, blood volume,
blood viscosity, and artery elasticity.

85. PULSE PRESSURE
Pulse pressure is the numeric difference
between the systolic and diastolic blood
pressure .
For example, if the resting blood pressure is
120/80 millimeters of mercury (mm Hg), the
pulse pressure is 40.
A pulse pressure within 40 is the normal and
healthy pulse pressure.

86. A pulse pressure greater than 40 mm Hg is
abnormal. A high pulse pressure may be a
strong predictor of heart problems (valve
regurgitation), especially for older adults.
A pulse pressure lower than 40 may mean a
patient have poor heart function.
PULSE PRESSURE

88. FACTORS INCREASING BLOOD PRESSURE:
Strong emotion
Exercise
Sitting or standing
Excitement
Pain
Decrease of vessel size
Digestion
Improperly placed or sized cuff

89. FACTORS DECREASING BLOOD PRESSURE
Rest/sleep
Lying down
Depression
Shock
Hemorrhage
Improperly sized cuff

90. ASSESSMENT
Blood pressure may be assessed:
Directly or
•ArterialBloodPressure(ABP)
Indirectly.
•Photo plethysmography (PPG)
•The auscultatory method

91. ASSESSMENT SITES
1.Upper arm(Using brachial artery (commonest)
2.Forearm (Radial artery)
3.Thigh(Popliteal artery)
4.Leg (Posterior tibialor dorsal pedis)

92. EQUIPMENT FOR ASSESSING BLOOD
PRESSURE
Sphygmomanometer
Cuff
Stethoscope
Electronic or digital
devices.
Alcohol cotton swap.

93. PROCEDURE FOR TAKING BLOOD
PRESSURE
Guidelines
Measure BP at brachial artery
Do not use injured arm, arm with
IV.
Resident should be at rest
Position arm level with heart
Apply cuff to exposed arm NOT
over clothing
Use appropriate size cuff
Position sphygmomanometer at
eye level

94. FALSE HIGH & FALSE LOW
Cuff too narrow gives false high
Cuff below heart level will give false high
Cuff too large or improperly placed can give
false low

96. CHARTING VITAL SIGN
Report normal & abnormal to licensed nurse
Record on flow sheets, graphic records, & NA
notes according to facility
Record in TPR order
Chart rectal temps with “R”
Chart Axillary temps with “Ax”
Pulse readings other than radial are noted
If BP in a place other than arm, note location
Write BP on chart as a part

97. CONCLUSION
Vital sign are an important indicator of
patients’ Health Status.
Your ability to take vital Sign and reported
accurately is very important.
Doctor make treatment decisions based on
patient vital Sign.