Vital Signs

 “vital” from Latin word “vita, ”which means “life”

 Temperature, pulse, respiration, blood pressure

(B/P) & oxygen saturation are the most frequent
measurements taken by the Nurse.

 Because of the importance of these measurements

they are referred to as Vital Signs. They are
important indicators of the body’s response to
physical, environmental, and psychological
stressors.
 Vital Signs
 VS may reveal sudden changes in a client’s condition in
addition to changes that occur progressively over time.
A baseline set of VS are important to identify changes in
the patient’s condition.

 VS are part of a routine physical assessment and are not

assessed in isolation. Other factors such as physical signs
& symptoms are also considered.

 Important Consideration:
 A client’s normal range of vital signs may differ from the standard
range.
 When to take vital signs
1. On a client’s admission
2. According to the physician’s order or the institution’s policy or
standard of practice
3. When assessing the client during home health visit
4. Before & after a surgical or invasive diagnostic procedure
5. Before & after the administration of meds or therapy that affect
cardiovascular, respiratory & temperature control functions.
6. When the client’s general physical condition changes
LOC, pain
7. Before, after & during nursing interventions influencing vital
signs
8. When client reports symptoms of physical distress
Normal Pulse Rate

Normal Pulse Rate (in Average Pulse Rate (in

Age Group beats per minute) beats per minute)

Newborn 100 - 170 140

Infants (1 year or less) 80 - 170 120

Toddlers (1 - 3 years) 80 - 130 110

Pre-schooler (3 - 6 years) 75 - 120 100

School aged children (7 -

12 years) 70 - 110 90

Adolescent (12 - 17 years) 60 - 90 75

Adults (Above 18 years) 60 - 110 80

Normal Respiratory Rate
Normal Respiratory Average Respiratory
Rate (in breaths per Rate (in breaths per
Age Group minute) minute)

Newborn 30 - 50 40

Infants (1 year or less) 20 - 40 30

Toddlers (1 - 3 years) 20 - 30 25
Pre-schooler (3 - 6
years) 16 - 22 19
School aged children (7
- 12 years) 14 - 20 17
Adolescent (12 - 17
years) 12-20 16
Adults (Above 18
years) 12-20 18
Normal Blood Pressure

Age Group Systolic Diastolic Average

Newborn 65 - 95 30 - 60 80 - 60

Infants (1 year or less) 65 - 115 42 - 80 90 - 61

Toddlers (1 - 3 years) 76 - 122 46 - 84 99 - 65

Pre-schooler (3 - 6 years) 85 - 115 48 - 64 100 - 56

School aged children (6 - 12 years) 93 - 125 46 - 68 109 - 58

Adolescent (12 - 17 years) 99 - 137 51 - 71 118 - 61

Adults (Above 18 years) 100 - 140 60 - 90 120 - 80

 Body Temperature
 Core temperature – temperature of the body tissues, is controlled
by the hypothalamus (control center in the brain) – maintained
within a narrow range.

 Skin temperature rises & falls in response to environmental

conditions & depends on bld flow to skin & amt. of heat lost to
external environment

 The body’s tissues & cells function best between the range from
36 deg C to 38 deg C

 Temperature is lowest in the morning, highest during the evening.

 Thermometers – 3 types
 Glass mercury – mercury expands or contracts in response
to heat. (just recently non mercury)

 Electronic – heat sensitive probe, (reads in seconds) there is

a probe for oral/axillary use (red) & a probe for rectal use
(blue). There are disposable plastic cover for each use.
Relies on battery power – return to charging unit after use.

 Infrared Tympanic (Ear) – sensor probe shaped like an

otoscope in external opening of ear canal. Ear canal must
be sealed & probe sensor aimed at tympanic membrane –
ret’n to charging unit after use.
Sites
Sites
Oral
Posterior sublingual pocket –
under tongue (close to carotid
artery)
Axillary
Bulb in center of axilla
Lower arm position across
chest
Rectal
Side lying with upper leg
flexed, insert lubricated bulb
(1-11/2 inch adult) (1/2 inch
infant)
Ear
Close to hypothalmus –
sensitive to core temp. changes
Adult - Pull pinna up & back
Child – pull pinna down &
back
Things to consider Duration of Placement
No hot or cold drinks or Leave in place 3 min
smoking 20 min prior to temp.
Must be awake & alert.
Not for small children (bite
down)
Non invasive – good for Leave in place 5-10 min.
children. Less accurate (no Measures 0.5 C lower than oral
major bld vessels nearby) temp.
When unsafe or inaccurate by Leave in place 2-3 min.
mouth (unconscious, Measures 0.5 C higher than
disoriented or irrational) oral
Side lying position – leg flexed
Rapid measurement 2-3 seconds
Easy accessibility
Cerumen impaction distorts
reading
Otitis media can distort
reading
 Converting
°C to °F
°F to °C
 Formula for: °C to °F
°C = °F – 32/1.8
 Formula for: °F to °C

°F = °C *1.8+32
Abnormal temperatures

Fever, febrile, hyperthermia all indicate someone who has an elevated

temperature (greater than 100 degrees Fahrenheit).

High fever would include anything over 103 degrees Fahrenheit.

Moderate fever would include anything 100 - 103 degrees Fahrenheit.

Hypothermia is subnormal temperature. This can be equally

problematic for a person. Anything under 96 degrees Fahrenheit would
indicate hypothermia.
Types of Fever

Continuous Uniformly high temperatures, e.g. in typhus, pneumococcal

pneumonia, brucellosis.
Remittent Differences between morning and evening temperatures of more
than 33.8 °F without remission of fever in the morning, e.g. in tuberculosis,
sinusitis, bronchial pneumonia, viral infections, rheumatic fever.
Intermittent Daily fluctuations of more than 33.8 °F and a minimal
temperature at or below the normal value, e.g. in septic processes, abscesses,
acute pyelonephritis, malaria tropica.
Recurrent Regular, periodic episodes of fever interrupted by one to several
days without fever, e.g. in malaria, recurrent fever, cholangitis.

Undulating With a long rise, or fall to normal temperatures, respectively,

over a period of days, and periods without fever, e.g. in Hodgkin's disease,
brucellosis.

Fever with chills Rapid rise in fever to high levels associated with severe
muscular contractions, e.g. in septicemia, bacterial endocarditis, pneumonia,
and also allergic reactions and transfusion incidents.
 Assessing Radial Pulse
 Left ventricle contracts causing a wave of bld to surge through arteries
– called a pulse. Felt by palpating artery lightly against underlying
bone or muscle.
 Carotid, brachial, radial, femoral, popliteal, posterior tibial,

dorsalis pedis
 Assess: rate, rhythm, strength – can assess by using palpation &
auscultation.

 Pulse deficit – the difference between the radial pulse and the apical
pulse – indicates a decrease in peripheral perfusion from some heart
conditions ie. Atrial fibrillation.
 Procedure for Assessing Pulses
 Peripheral – place 2nd, 3rd & 4th fingers lightly on skin where an artery
passes over an underlying bone. Do not use your thumb (feel
pulsations of your own radial artery). Count 30 seconds X 2, if
irregular – count radial for 1 min. and then apically for full minute.

 Apical – beat of the heart at it’s apex or PMI (point of maximum

impulse) – 5th intercostal space, midclavicular line, just below lt. nipple
– listen for a full minute “Lub-Dub”
 Lub – close of atrioventricular (AV) values – tricuspid &

mitral valves
 Dub – close of semilunar valves – aortic & pulmonic valves
 Assess: rate, rhythm, strength & tension
 Rate – N – 60-100, average 80 bpm
 Tachycardia – greater than 100 bpm

 Bradycardia – less than 60 bpm

 Rhythm – the pattern of the beats (regular or irregular)

 Strength or size – or amplitude, the volume of bld pushed against the wall of an artery
during the ventricular contraction
 weak or thready (lacks fullness)

 Full, bounding (volume higher than normal)

 Imperceptible (cannot be felt or heard)

0----------------- 1+ -----------------2+--------------- 3+ ----------------4+

Absent Weak NORMAL Full Bounding
 Normal Heart Rate
Age Heart Rate (Beats/min)

Infants 120-160

Toddlers 90-140

Preschoolers 80-110

School age 75-100

Adolescent 60-90

Adult 60-100
If it is impossible to palpate a peripheral pulse, you may have to count the apical
heart rate.
You will need a stethoscope for this procedure and a watch with a second hand.
1. Explain the procedure to patient and place him in a comfortable position
2. Wash hands
3. Place the stethoscope on the patient's chest, slightly below the left nipple in
line with the middle of the clavicle (around the interspace below the 5th rib)

As the heart beats, it makes a rhythmical sound described as LUB - DUB.

LUB is a soft sound made when the tricuspid and mitral valves close. DUB is a shorter,
sharper sound made when the pulmonary and aortic valves close.

You should listen for the following:

 Respirations
 Assess by observing rate, rhythm & depth
 Inspiration – inhalation (breathing in)
 Expiration – exhalation (breathing out)
 I&E is automatic & controlled by the medulla oblongata
(respiratory center of brain)
 Normal breathing is active & passive
 Women breathe thoracically, while men & young children
breathe diaphragmatically ***usually

 Asses after taking pulse, while still holding hand, so pt is

unaware you are counting respirations
 Assessing Respiration
Rate # of breathing cycles/minute (inhale/exhale-1cycle)
N – 12-20 breaths/min – adult - Eupnea – normal rate & depth breathing
Abnormal increase – tachypnea
Abnormal decrease – bradypnea
Absence of breathing – apnea

Depth Amt. of air inhaled/exhaled

normal (deep & even movements of chest)
shallow (rise & fall of chest is minimal)
SOB shortness of breath (shallow & rapid)
Rhythm Regularity of inhalation/exhalation
Normal (very little variation in length of pauses b/w I&E

Character Digressions from normal effortless breathing

Dyspnea – difficult or labored breathing
Cheyne-Stokes – alternating periods of apnea and hyperventilation, gradual
increase & decrease in rate & depth of resp. with period of apnea at the end
of each cycle.
Types of Abnormal Breathing Patterns:

Cheyne-Stokes breathing describes a waxing and waning ventilation, sometimes

with periods of apnoea, that occur in cycles. It is due to a delay in the medullary
chemoreceptor response to blood gas changes.

Kussmaul breathing is deep sighing respiration due to stimulation of the

respiratory centre by acidosis.
Kussmaul breathing is a sign of a metabolic acidosis, common causes being:
diabetic ketoacidosis
renal failure

Biot or ataxic breathing is breathing that is irregular in timing and depth. It is

indicative of meningitis or medullary lesions.

Sleep apnoea is a condition that occurs during sleep where the patient is woken -
not necessarily to full awareness - by airway obstruction.
It is prominent during REM sleep (when muscle tone is at its lowest).
Patients with this condition may wake from 3 to 400 times a night.
 Blood Pressure
 Force exerted by the bld against vessel walls. Pressure of bld within the
arteries of the body – lt. ventricle contracts – bld is forced out into the aorta to
the lg arteries, smaller arteries & capillaries
 Systolic- force exerted against the arterial wall as lt. ventricle

contracts & pumps bld into the aorta – max. pressure exerted on
vessel wall.
 Diastolic – arterial pressure during ventricular relaxation, when the

heart is filling, minimum pressure in arteries.

 Factors affecting B/P

 lower during sleep

 Lower with bld loss

 Position changes B/P

 Anything causing vessels to dilate or constrict - medications

 B/P
 Measured in mmHg – millimeters of mercury
 Normal range
 syst 110-140 dias 60-90

 Hypertensive - >160, >90

 Hypotensive <90

 Non invasive method of B/P measurement

 Sphygmomanometer, stethoscope

 3 types of sphygmomanometers

 Aneroid – glass enclosed circular gauge with needle that registers the
B/P as it descends the calibrations on the dial.
 Mercury – mercury in glass tube - more reliable – read at eye level.
 Electronic – cuff with built in pressure transducer reads systolic &
diastolic B/P
 B/P
 Cuff – inflatable rubber bladder, tube connects to the manometer, another to
the bulb, important to have correct cuff size (judge by circumference of the
arm not age)
 Support arm at heart level, palm turned upward - above heart causes false low
reading
 Cuff too wide – false low reading
 Cuff too narrow – false high reading
 Cuff too loose – false high reading

 Listen for Korotkoff sounds – series of sounds created as bld flows through
an artery after it has been occluded with a cuff then cuff pressure is
gradually released.
 Do not take B/P in
 Arm with cast

 Arm with arteriovenous (AV) fistula

 Arm on the side of a mastectomy i.e. rt mastectomy, rt arm

Blood Pressure
 systolic pressure = the maximum pressure
exerted by the blood against the wall of the
brachial artery when the heart beats

 diastolic pressure = the minimum pressure

between successive heart beats (laminar blood
flow)
 The Korotkoff sounds
 are the sounds heard through the stethoscope as the pressure cuff deflates

 the sounds are first heard when the cuff pressure equals the systolic pressure

 cease to be heard once the cuff has deflated past the diastolic pressure
 Procedure – B/P
Assessment Determine best site & baseline B/P

Nursing Diagnosis Decreased cardiac output

Fluid volume excess
Fluid volume deficit
Planning Expected outcome
Have pt rest 5 min before taking B/Pa
Wash hands
Implementation Palpate brachial pulse
Position cuff 1inch above pulse - Arm at level of
heart, wrap snugly around arm
Manometer at eye level
 Procedure
Inflate cuff while palpating brachial Artery. Note
Implementation reading at which pulse disappears continue to Inflate
cuff 30 mmHg above this point. Deflate cuff slowly
and note when reading when pulse is felt. Deflate cuff
completely and wait 30 sec.
With stethoscope in ears locate the brachial artery –
place diaphragm over site
Close valve of pressure bulb. Inflate cuff 30 mm hg
above palpated systolic pressure
Slowly release valve
Note point on manometer when first clear sound is
heard (1st phase Korotkoff) – systolic pressure
Continue to deflate noting point @ which sound
disappears – 5th phase Korotkoff (4th korotkoff in
children
Deflate & remove cuff
 B/P Lower Extremity
 Best position prone – if not – supine with knee
slightly flexed, locate popliteal artery (back of
knee).

 Large cuff 1 inch above artery, same procedure as

arm. Systolic pressure in legs maybe 10-40 mm hg
higher

 If unable to palpate a pulse – you may use a

doppler stethoscope
 Oxygen Saturation (Pulse Oximetry)
 Non-invasive measurement of oxygen saturation

 Calculates SpO2 (pulse oxygen saturation) reliable estimate of arterial oxygen

saturation
 Probes – finger, ear, nose, toe

 Patient with PVD or Raynauds syndrome – difficult to obtain.

 Normal – 90-100%
 Remove nail polish

 Wait until oximeter readout reaches constant value & pulse display

reaches full strength

 During continuous pulse oximetry monitoring – inspect skin under the

probe routinely for skin integrity – rotate probe.

 Procedure – Vital Signs
Assessment Route of temperature – po, tympanic, axilla, rectal
Determines if client has had anything hot/cold to drink or
smoked (20 min)
Planning Obtain equipment – thermometer, watch, stethoscope, B/P cuff
& graphic sheet
Wash hands
Implementation Explains procedure to client
Temperature tympanic - thermometer
Pulse - Position client’s arm @ side or across chest, palpate
radial artery
Resp – Keeps fingers on wrist – count respirations
Documents TPR on graphic sheet
B/P – correct position, client’s arm supported @ heart level
Document
 Vital Signs (cont.)
Evaluation V/S within normal range

Critical Thinking You are assessing a client’s pulse and the

rate is irregular. How would you proceed?