VITAL SIGNS

BY: SYAHFITRI ADINDA RISKI

NPM:16.11.146
PSIK 2.1
What are Vital Signs?

Temperature
Pulse
Respirations
Blood Pressure
When to measure vital signs?

 On admission to health care facility

 In a hospital on regular hosp schedule or as MD
ordered (q8hours, q4 hours, etc)
 Before and after procedures (surgery, invasive
diagnostic procedures)
 Before, during, and after blood transfusions
 When patient’s general condition changes (nursing
judgment)
1.Body Temperature

 Difference between heat produced by body

processes and the heat lost to the external
environment
 Range 96.8 – 100.4 F (36 – 38 degree C)
 Average for healthy young adults 98.6F or 37degrees
C
 No single temp is normal for all people
HEAT IS PRODUCED BY: HEAT IS LOST BY:

Increased muscle Vasodilation

activity Convection
Metabolism Radiation
Vasoconstriction Conduction
External sources Evaporization
 TEMP or FEVER?

TEMPERATURE—the
measurement of heat in
the body
FEVER—the
measurement of heat in
the body that is above
normal for the individual
TYPES OF THERMOMETERS
Normal Range Throughout
Life Cycle
Adults- 96.8- Newborn
100.4 degree F range – 95.9-
Adult Avg 98.6 99.5F
F Oral Infants and
Adult Avg 99.5 children –
F Rectal same as adults
Adult Avg 97.7 Elderly – Avg
F Ax 96.8F
Frequently used terms:

 Pyrexia or fever
 Febrile
 Hyperthermia
 Hypothermia
 Afebrile
 FEVER—A DEFENSE
MECHANISM
Indicator of disease in body
Pathogens release toxins
Toxins affect hypothalamus
Temperature is increased
Rest decreases metabolism and
heat production by the body
Factors Affecting Body Temp

 Age ( newborn- temp  Stress

control mechanism
immature, elderly-  Environment
sensitive to temp
changes)
 Exercise
 Hormonal level
 Circadian rhythm
(temp normally
changes 0.9 to 1.8
degree F /24hr Lowest
1-4AM Max-6PM )
ORAL TEMPERATURE

Accessible
Dependable
Accurate
Convenient
RECTAL TEMPERATURE

Most reliable
MUST hold
thermometer
in place
AXILLARY TEMPERATURE

Safe
Non-invasive
Least
accurate
TYMPANIC TEMPERATURE

Non-invasive
Safe
Accurate
Disadvantages
 Excessive cerumen
 Improper technique
AXILLARY TEMPERATURE
IMPORTANT POINTS
 AXILLA MUST HAVE
ADEQUATE TISSUE &
BE FREE OF
PERSPIRATION
 Not good method for
persons with elevated
temp
 Used when cannot get
oral or tympanic
 Leave in place 10
minutes
ORAL TEMPERATURES

Wait 15-30 minutes

after eating,
drinking, chewing
gum or smoking
If mouth breather-do
not take orally
Leave in place 2 – 4
minutes with glass
thermometer
TYMPANIC TEMPERATURES

 Oral & tympanic readings

will be same/ similar
 Must direct probe toward
TM (eardrum)
 Follow instructions
 Keep plugged in and on
charger when not in use
 Usually preferred method
 Adults –pull pinna of ear
up & back
 Children under 3y/o-pull
pinna of ear down & back
RECTAL TEMPERATURES
 MOST accurate
 MUST hold thermometer
in place
 Very high temp
 Unconscious
 Do not take rectal temp on
clients with heart
conditions
 Leave in place 2-3 min
with glass thermometer
 Lubricate thermometer
 DO Not take hand from
thermometer while rectal
in progress
NURSING DIAGNOSIS

Hyperthermia> 100.4F
Hypothermia <96.8F
Risk for altered body temperature

Ineffective Thermoregulation
Pulse

 Pulse- is the palpable bounding of the blood noted at

various points on the body. It is an indicator of
circulatory status.
TERMS RELATED TO PULSE

Pulse—Rate, Rhythm, Quality

Pulse Deficit
Auscultate
Palpate
Tachycardia, Bradycardia
Pulse Sites

 Temporal  Radial
 Carotid  Ulnar
 Apical  Femoral
 Brachial  Popliteal
 Dorsalsis Pedis
(Pedal)  Posterior Tibial
 Radial and
Apical are most
common pulse
sites used!
PULSE RANGES
AGE RANGE

ELDERLY (65+) 60-100

AVERAGE ADULT 60-100 (50 or below if

extremely athletic)
NEWBORN 120-160
0-24 HOURS
INFANT 100-120
1 MONTH – 1 YEAR
CHILDREN (varies with age)
TECHNIQUE
 Feel over BONY area
 DO NOT use thumb
 Use 2-3 fingers
 DO NOT squeeze
 Count 30 seconds if regular
x2
 Note Rate, Rhythm, Quality
 If irregular, count for 1 full
minute or take apical pulse
for 1 minute.
 APICAL-RADIAL PULSE
Requires 2 nurses
1 nurse counts apical
heart rate
1 nurse counts radial
pulse
BOTH count during
the same 60 seconds
1 nurse acts as
timekeeper for both
nurses
PULSE DEFICIT

 Count apical-radial pulse

 The difference is the PULSE DEFICIT
 Apical pulse will always be the same or higher than the
radial pulse if both are counted correctly
 If the radial pulse is higher, one or both nurses counted
incorrectly
Factors Affecting Pulse Rates

 Exercise
 Temperature
 Emotions
 Drugs
 Hemorrhage
 Postural Changes
 Pulmonary Conditions
Variations of Pulse Rates

 Tachycardia – Abnormally elevated pulse rate.

(above 100 beats/ min)
 Bradycardia – Abnormally slow pulse rate (less than 60
beats / min)
Pulse Rhythm

 Regular – A regular interval of time occurs between

each heartbeat or pulse felt.
 Irregular – Interval interrupted by early, late, or missed
beat.
Strength and Quality of Pulse

 Pulse strength may be described as

weak, strong, bounding, or thready.
 PULSE GRADING (0-4 rating scale)
 0 – absent, not palpable
 1+ - diminished, barely palpable
 2+- easily palpable, normal pulse
 3+ - full, increased strength
 4+ - bounding, cannot be obliterated
Respirations

 Mechanism the body uses to exchange gases

between the atmosphere, blood, and the cells.
Involves three processes:
 Ventilation
 Diffusion
 Perfusion
PROCESS OF RESPIRATION

EXTERNAL RESPIRATION
Inhaled air enters lungs, at alveoli O2
crosses over to bloodstream
CO2 and other wastes cross over from
bloodstream to alveoli and are exhaled
INTERNAL RESPIRATION
O2 carried in bloodstream crosses over to
body cells
CO2 and other wastes from body cells
cross over to the bloodstream
 RESPIRATION

 Chest Cavity—airtight vacuum with negative pressure

 INSPIRATION—diaphragm contracts and pulls down, ribs move up,
lungs fill with air
 EXPIRATION—diaphragm relaxes and moves up, ribs move down,
lungs expel air
NORMAL RESPIRATION RANGE

AGE RANGE

ELDERLY (65+) 12-20

AVERAGE ADULT 12-20

NEWBORN 30-60
0-24 HOURS
INFANT 30-50
1 MONTH – 6 Months
CHILDREN (varies with
age)
COUNTING RESPIRATIONS

 Count pulse first, then

count respirations while
holding wrist
 Note rate, rhythm,
quality, and character
 Observe a full
inspiration and
expiration
 Respiratory rates below
12 or greater than 20
require further
assessment.
Counting Respirations cont.

 If respirations regular, count

respirations for 30 seconds and
multiply times 2.
 If irregular, less than 12 or greater
than 20, count for 1 full minute.
 Quality of respirations- assess
movement of chest or abdominal
wall- deep, normal, shallow
 Deep- full expansion of lungs
 Normal- normal
 Shallow- limited expansion of lungs
Factors Influencing
Characteristics of Respirations

Exercise Medications
Acute Pain Neurological
Anxiety injury
Smoking Age
Body position Environmental
Temp
Hemoglobin
Function
Blood Pressure

 Force exerted on the walls of the artery.

Created by the pulsing blood under pressure
of the heart.
 Systolic- Peak and maximum pressure of
ejection of blood from the heart into the
aorta. This is the top number.
 Diastolic- The minimal pressure remaining the
heart when the heart relaxes. This is the
bottom number.
 Recorded as a ratio Ex. 120/80
 Pulse pressure- Difference between the
systolic and diastolic. ( 120/80 – Pulse
pressure 40)
EQUIPMENT FOR BP
“DOPPLER” OR ELECTRONIC BP
READINGS
ALTERNATIVE SITES
MEASURING BP
MEASURING BLOOD PRESSURE

 Cuff must be
appropriate size
 Cuff should be snug,
not loose
 Do not put
stethoscope under
cuff ( place cuff 1-2
inches above elbow)
 Make mental note of
systolic and diastolic
numbers
MEASURING BP CONT’D

 If unsure of reading,
wait 30 seconds
and recheck-if
unsure, have
someone else
check with you
 Loosen cuff even if
to be checked q 15
minutes
 Make sure all air is
out cuff before
applying
MEASURING BP

 False high if cuff too

small, false low if cuff is
too loose
 Auscultatory gap-
temporary
disappearance of
sound between first
sound and next sound.
 Don’t take BP on arm
with IV, sling, surgery,
mastectomy, renal
dialysis shunt, etc.
MEASURING BP CONT’D

 Pt should be sitting
or lying with arm at
the level of the
heart
 Distinguish Korotkoff
sounds (sounds
heard when taking
BP) from artifact
ASSESSMENT OF BP IN BOTH ARMS

Heart disease
1st time BP
5-10 mm Hg
difference-use
reading that is
highest
Difference of
10mm Hg should
be reported
HOW and WHY BP TAKEN BY
PALPATION
 HOW-apply cuff over
brachial artery
 Pump up to 20-30
points above last
systolic reading
 Feel with 2 fingers for
systolic pressure; will
not feel diastolic
pressure
 WHY- unable to hear
weak BPs
FACTORS AFFECTING BP

 Exercise-increases
 Arteriosclerosis (loss
of vessel elasticity)
& Atherosclerosis
(build up of
plaque)-increases
 Transfusions-
increases
 Emotions -increases
FACTORS CONT’D

Drugs
Medications
Diurnal variations
FACTORS CONT’D

 PAIN-increases
 Hemorrhage –
decrease
 Sex/Gender
 RACE-Blacks more
prone increase
 Age
 Heredity-increased
chance if immediate
family history
Alterations In BP control

 Hypotension- When systolic blood pressure falls to 90 or

below.
 Orthostatic (Postural) Hypotension- Occurs when a
normotensive person develops symptoms and low
blood pressure when rising to an upright position.
THANKS YOU 