VITAL SIGNS

VITAL SIGNS or CARDINAL SIGNS-) reflects in body function that otherwise might not be observed) are * body
temperature * pulse * respiration * blood pressure * pain

“Signs (objective or covert data) are the things you can see about the patient's condition, while Symptoms (subjective or
overt data) are what the patient tells you about his condition”

WHEN TO ASSESS VITAL SIGNS

• Upon admission to any healthcare agency (obtained baseline data)

• Based on a agency institution policy and procedure
• Any time there is a change in the patient’s condition (chest pain, feeling of hot)
• Before and after surgical invasive diagnostic procedure
• Before and after the administration of medication(some meds may affect the respiratory or cardiovascular system
example *digitalis preparation- generics and brand name Cedilanid, Crystodigin, DIGITALI,S DIGITOXIN,
DIGOXIN, Lanoxicaps, Lanoxin ,Novodigoxin : USES: Strengthens weak heart-muscle contractions to prevent congestive
heart failure. Corrects irregular heartbeat: Why? Don't take if: You are allergic to any digitalis preparation. Your
heartbeat is slower than 50 beats per minute. )

SPECIAL CONSIDERATION

• Wash hands before & after a procedure (to maintain asepsis-The state of being free of pathogenic microorganisms.
While Sepsis refers to a bacterial infection in the bloodstream or body tissues)
• Gather equipment needed including watch with a second hand (to maximize time and effort)
• Greet client & introduce oneself (to promote client’s sense of well being)
• Inform client what you will do(to elicit cooperation and allay anxiety )
• Check for proper lighting and diminish noise when necessary (to obtain accurate baseline data)
• Assist to a comfortable resting position(for a child, have the parent remain close by and position the child
comfortably in the parent’s arm) (to ensure comfort)
• Record/ document appropriately and transfer

Factors Affecting Body Factors Affecting the Pulse

Temperature
• Age
• Gender
• Age • Exercise
• Diurnal Variation • Fever
• Exercise • Medication
• Hormones • Hypovolemia
• Stress • Stress
• Environment • Position Changes
• Pathology

Factors Affecting Respiration

Factors Affecting Blood
Increased Pressure
• Exercise - + metabolism
• Age
• Stress – fight or flight • Exercise
• Environmental Temp. • Stress
• Oxygen concentration • Race
• Altitude • Gender
• Medication
Decrease
• Obesity
• Environmental Temp
• Diurnal Variation
• Certain meds (Narcotics) • Disease Process
• Intracranial pressure
 BODY TEMPERATURE

Temperature – Reflects the balance between heat produced and heat loss from the body measure in heat
units called degree Celsius

TWO KINDS OF BODY TEERATURE

Core Temperature - Is the temperature of the deep tissues of the body such as the abdominal cavity and pelvic cavity
“relatively constant”
Surface temperature – Is the temperature of the skin, the subcutaneous and fats. “Rises and falls in response to environment.

Heat balance – when the amount of heat produced by the body equals to the amount of heat loss

PROCESS INVOLVED IN HEAT LOSS

TYPES OF FEVER (PYREXIA)
• RADIATION
Transfer of heat loss from the surface of one • INTERMITTENT
object to the surface of another without contact Temperature fluctuates between
between two object, mostly in the form of periods of fever and periods of
infrared. normal/subnormal temperature
Example
Radiation accounts for 60% of the heat lost • REMITTENT
by a nude person standing in a room at normal Temperature fluctuates within a wide
temperature. range over the 24 hour period but remain
• CONVECTION above normal range
Dissipation of heat by air current
• EVAPORATION • RELAPSING
Continuous vaporization of moisture from the Temperature is elevated for few days,
Inskin, oral, mucous respiratory tract, insensible alternated with 1 to 2 days normal temperature
heat loss
• CONDUCTION • CONSTANT
Transfer of heat from one surface to another Body temperature is consistently high
which require difference two surfaces
Example
When a body is immersed in cold water.
The amount of heat transferred depends on the
temperature difference and the amount of
duration contact

INTERVENTIONS FOR CLIENT WITH TEMPERATURE CONVERSION

FEVER
• Monitor V/S • TO CHANGE FORM F TO C
• Assess skin color and temp. * Subtract 32 degrees form the Fahrenheit
• Monitor Lab. Result reading
• Remove excess blankets when the client * Multiply by 9/9 or divide by 9/5(1.8)
feels warm, but provide extra warmth * C = (F - 32) X 5/9 (1.8)
when the client feels chilled • TO CHANGE FROM C TO F
• Provide adequate nutrition and fluids *Multiply the Celsius reading by 9/5 or
(2500- 3000 ml per day) to meet the 1.8
increased metabolic and prevent *Add 32
dehydration * F = (9/5 X C)+ 32 or (C X 1.8) + 32
• Measure intake and output
• Reduce physical activity to limit heat CLEANING THERMOMETER
production, especially during the flush
stage • Wipe the thermometer in a rotating
• Administer antipyretics as order by doctor manner
Before Use
• Provide oral hygiene to keep mucous
From the bulb to the stem
membranes moist
After Use
• Provide tepid sponge bath to increase heat From the stem to the bulb
loss trough conduction
• Provide dry clothing and bed linens “Cleanest to the dirtiest”
 VARIATIONS IN NORMAL VITAL SIGN BY AGE
Based on Barbara Kozier book 7th Edition

AGE ORAL PULSE(AVERAGE RESPIRATION BLOOD

TEMPERATURE AND RANGES) (AVERAGE AND PRESSURE
RANGES) Millimeters of
UNITS Degree Celsius Beats per minute Beats per minute mercury
Newborn 36.8 (axillary) 130 (80 - 180) 35 (30 – 80) 73/55
1year old 36.8(axillary) 120(80-140) 30 (20 -40) 90/55
5-8years 37 100 (75- 120) 20 (15-25) 95/57
10 years 37 70 (50-90) 19 (15 – 25) 102/62
Teen 37 75 (50 – 90) 18 (15 – 20 ) 120/80
Adult 37 80 ( 60 – 100) 16 (12 – 20) 120/80
Older Adult 37 70(60 – 100) 16 (15 -20) Possible increased
Older than 70 diastolic

Pediatric Vital Sign Normal Ranges

Systolic Weight
Respiratory Heart Weight
Age Group Blood in
Rate Rate in kilos
Pressure pounds
Newborn 30 - 50 120 - 160 50 - 70 2-3 4.5 - 7
Infant (1-12 months) 20 - 30 80 - 140 70 - 100 4 - 10 9 - 22
Toddler (1-3 yrs.) 20 - 30 80 - 130 80 - 110 10 - 14 22 - 31
Preschooler (3-5 yrs.) 20 - 30 80 - 120 80 - 110 14 - 18 31 - 40
School Age (6-12 yrs.) 20 - 30 70 - 110 80 - 120 20 - 42 41 - 92
Adolescent (13+ yrs.) 12 - 20 55 - 105 110 - 120 >50 >110

REMEMBER:

• The patient's normal range should always be taken into consideration.

• Heart rate, BP & respiratory rate are expected to increase during times of fever or stress.
• Respiratory rate on infants should be counted for a full 60 seconds.
• In a clinically decompensating child, the blood pressure will be the last to change. Just because your pediatric
patient's BP is normal, don't assume that your patient is "stable".
• Bradycardia in children is an ominous sign, usually a result of hypoxia. Act quickly, as this child is extremely critical.
 COMMON SITE FOR MEASURING BODY TEMPERATURE
ORAL
This is the most accessible and
convenient. However, because
of the mercury in glass
thermometer, this is
contraindicated for children
under 6 years and clients who
are confused or who have
convulsive disorder
AXILLARY
This is the safest and most
noninvasive. It is the preferred
site for measuring temperature in
newborns because there was no
possibility of rectal perforation.
RECTAL
This is considered the most
accurate. However, it is
inconvenient and more
unpleasant for client. It is
contraindicated for clients who
are undergoing rectal surgery or
have diarrhea or diseases of the
rectum.
TYMPANIC MEMBRANE
This is readily accessible and
reflects the core temperature. The
tympanic has an abundant arterial
blood supply, primarily from
branches of the external carotid
artery. The noninvasive infrared
thermometers are now used for
this purpose.
 PULSE
This is a wave of blood created by contraction of the left ventricle of the heart. The heart is a pulsating pump, and the blood
enters the arteries with each heartbeat, causing pressure pulses or pulse waves. Generally, the pulse wave represents the stroke
volume and the compliance of the arteries

Pulse Sites

1. Temporal, where the temporal artery passes over

the temporal bone of the head. The site is superior
and lateral to the eye.
2. Carotid, at the side of the neck below the lobe of
the ear, where the carotid artery runs between the
trachea and the sternocleidomastoid muscle.
3. Apical, at the apex of the heart.
4. Brachial, at the inner aspect of the biceps muscle of
the arm (especially in infants) or medially in the
antecubital space (elbow crease).
5. Radial, where the radial artery runs along the radial
bone, on the thumb site of the inner aspect of the
wrist.
6. Femoral, where the femoral artery passes alongside
the inguinal ligament.
7. Popliteal, where the popliteal artery passes behind
the knee. This point is difficult to find, but it can be
palpated if the client flexes the knee slightly.
8. Poserior tibial, on the medial surface of the ankle
where the posterior tibial artery passes behind the
medial malleolus.
9. Pedal (dorsalis pedis), where the dorsalis pedis
artery passes over the bones of the foot. This artery
can be palpated by feeling the dorsum of the foot on
the imaginary line drawn from the middle of the
ankle to the space between the big and second toes.
Characteristics of Normal Pulse WARNING!!!

1. Rate The three fingertips are used for palpating all

This is the number of pulse beats per minute
(60-100beats/min in the adult). An excessively fast heart
rate (100 beats/min) is referred to as tachycardia. A
heart rate in the adult of 60 beats/minute or less is called
bradycardia.
2. Pulse rhythm
This is the pattern of the beats and the intervals
between the beats. Equal time elapses between beats of a
normal pulse. A pulse with an irregular rhythm is
referred to as a dysrhythmia or arrhythmia. It may
consist of random, irregular beats or a predictable
pattern of irregular beats.
pulse sites except the apex of the heart. A Stethoscope
is used for assessing apical pluses and fetal heart
tones. A Doppler ultrasound
• A pulse is normally palpated by applying
moderate pressure with the three middle
fingers of the hand.
• The pads on the most distal aspects of
the finger are the most sensitive areas for
detecting a pulse.
• With excessive pressure one can
obliterate a pulse
• Too little pressure one may not be able
to detect it.

• Any medication that could affect the heart

3. Pulse volume
This is also called the pulse strength or amplitude. It
refers to the force of blood with each beat. It can range
from absent to bounding. A normal pulse can be felt
with moderate pressure of the fingers and can be
obliterated with greater pressure. A forceful or full blood
volume that is obliterated only with difficulty is called a
full or bounding pulse. A pulse that is readily obliterated
with pressure from the fingers is referred to as weak,
feeble, or thready. A pulse volume is usually measured
on a scale 0 to 3.
rate
• Wheatear the client has been physically
active. If so wait for 10 to 15 minutes until
the client has rested and the pulse gas slowed
to its usual rate
• Any baseline data about the normal heart rate
for the client for example. a physically fit
athlete may have a heart rate below 60 BPM
• Wheatear the client should assume a
particular position example. Sitting. In some
clients, the rate changes with the position
because of changes in blood flow volume and
autonomic nervous system activity
 RESPIRATION

Resting respirations should be assessed when the client is at rest because exercise affects respirations, and increase their rate
and depth as well. Respiration may also need to be assessed after exercise to identify the client’s tolerance to activity.

ALTERED BREATHING PATTERN AND SOUND

Breathing Patterns Breaths sounds

RATE Audible without amplification

.
• Tachypnea – quick, shallow breaths
• Bradypnea – abnormally slow breathing
• Apnea – cessation of breathing
VOLUME
• Hyperventilation – overexpansion of the lungs
characterized by rapid and deep breaths
• Hypoventilation – under expansion of the
lungs, characterized by shallow respirations
• Stridor – a shrill, harsh sound heard during
inspiration with laryngeal obstruction
• Stertor – snoring or sonorous respiration, usually
due to a partial obstruction of the upper airway
• Wheeze – continuous, high pitched musical squeak
or whistling sound occurring on expiration and
sometimes on inspiration when air moves through a
narrowed or partially obstructed airway
• Bubbling- gurgling sounds heard as air passes
through moist secretion in the respiratory tract

RHYTHM Chest movements

• Cheyne –stroke breathing – rhythmic waxing
and waning of respirations, form very deep to
very shallow breathing and temporary apnea
EASE OR EFFECT
• Intercostal retraction – Indrawing between ribs
• Substernal retraction – indrawing beneath the
breastbone
• Suprasternal retraction – indrawing above the
clavicle

• Dyspnea – difficult and labored breathing Secretion and Coughing

during which the individual has a persistent,
unsatisfied need for air and feels distressed
• Orthopnea – ability to breathe only in upright
sitting or standing positions
• Hemoptysis – the presence of blood in the sputum
• Productive cough – a cough accompanied by
expectorate secretions
• Nonproductive cough – a dry, harsh cough without
 BLOOD PRESSURE

This is the force exerted by the blood against a vessel wall. Arterial blood pressure is a measure of the pressure exerted by the
blood as it flows through the arties. There are two blood pressure measures:

1. Systolic pressure. This is the pressure of the blood because of contraction of the ventricles, which is the height of the
blood wave.
2. Diastolic pressure. This is the pressure when the ventricles are at rest. It is the lower pressure present at all times
within the arteries.

Pulse pressure is the difference between the diastolic and systolic pressures.

Blood pressure is measured in millimeters of mercury (mm Hg) and recorded as a fraction. The systolic pressure is
written over the diastolic pressure. The average blood pressure of a healthy adult is 120/80 mm Hg. A number of conditions are
reflected by changes in blood pressure. The most common is hypertension, an abnormally high blood pressure. Hypotension is
an abnormally low blood pressure below 100min Hg systolic.

Common Errors in Blood Pressure Assessment

Error Effect
Bladder cuff too narrow Erroneously high
Bladder cuff too wide Erroneously high
Arm unsupported Erroneously high
Insufficient rest before the
Erroneously high
assessment
repeating assessment too quickly Erroneously high
Cuff wrapped too loosely or
Erroneously high
unevenly
Erroneously low systolic and high
Deflating cuff too quickly
diastolic interpretation
Deflating cuff too slowly Erroneously high diastolic reading
Failure to use the same arm
Inconsistent measurements
consistently
Arm above level of the heart Erroneously low
Assessing immediately after a meal
Erroneously high
or while client smokes
Failure to identify auscultatory gap Erroneously low systolic pressure and
pressure erroneously low diastolic

Auscultatory gap is the temporary disappearance of sounds normally haerd over the brachial artery when the cuff pressure is
high and the reappearance of the sounds at a lower level.