ASSESSING VITAL SIGNSVital Signs or Cardinal Signs are:

Body temperature Pulse Respiration Blood pressure

Vital signs are fundamental in establishing baseline values of the client’s cardiorespiratory integrity. Baseline values establish the norm against which subsequent measurements can be compared. Variations from normal findings may indicate potential problems with the client’s health status.

We should confirm “normal” measurements with clients because the perception of what is normal may vary among clients.

Vital signs are taken whenever the client is admitted to a health care facility or service, for example, home health care, clinic, or other ambulatory setting, and on a routine basis in the hospital.

The frequency of vital sign measurements for the hospitalized client is determined by the client’s health status, physician orders, and the established standards of care for the particular clinical setting or service. Whenever a change is suspected in the client’s status, we should measure the vital signs, regardless of the setting.

I. Body Temperature The balance between the heat produced by the body and the heat loss from the body. Body heat is primarily produced by metabolism. The heat regulating center is found in the hypothalamus.

Types of Body Temperature Core temperature Surface body temperature

Factors affecting the body’s heat production1. Basal metabolic rate – the younger the person, the higher the BMR. The older the person, the

lower the BMR.2. Muscle Activity – increases cellular metabolic rate.3. Thyroxine Output – increases cellular metabolic rate.4. Epinephrine, Nor-epinephrine and sympathetic stimulation – increases the rate of cellular

metabolism.5. Increased temperature of body cells (fever) – increases the rate of cellular metabolism. “Fever

further causes fever.”

Processes involved in heat loss are as follows:1. Radiation – the transfer of heat from the surface of one object to the surface of another

without contact between two objects.2. Conduction – the transfer of heat from one surface to another. It requires two temperature

differences from one another.3. Convection – the dissipation of heat by air currents.4. Evaporation – the continuous vaporization of moisture from the skin, oral mucous, respiratory

tract.

Alteration in body Temperature Pyrexia – Body temperature above normal range( hyperthermia) Hyperpyrexia – Very high fever, 41ºC(105.8 F) and above Hypothermia – Subnormal temperature.

Factors affecting temperature are as follows:1. Age – the infant’s body temperature is greatly affected by the temperature of the environment.

Elderly people are at risk of hypothermia due to decreased thermoregulatory controls, decreased subcutaneous fat, inadequate diet, and sedentary activity.

2. Diurnal variations – highest temperature is usually reached between 8:00 PM to 12 MN3. Exercise4. Hormones – progesterone, thyroxine, norepinephrine and epinephrine increases body

temperature, estrogen decreases body temperature.5. Stress – SNS stimulation increases production of epinephrine and norepinephrine, thereby

increasing the BMR and heat production.NORMAL ADULT TEMPERATURE RANGES

ROUTE ºC ºFOral 36.5 –37.5 ºC 97.6 – 99.6 ºFAxillary 35.8 – 37.0 ºC 96.6 – 98.6 ºFRectal 37.0 – 38.1 ºC 98.6 – 100.6 ºFTympanic 36.8 – 37.9ºC 98.2 – 100.2 ºF

TYPES OF FEVER1. Intermittent fever – temperature fluctuates between periods of fever and periods of

normal/subnormal temperature.2. Remittent fever – temperature fluctuates within a wide range over the 24 hour period but

remains above normal range.3. Relapsing fever – the temperature is elevated for few days, alternated with 1 or 2 days of

normal temperature.4. Constant fever – body temperature is consistently high.

CLINICAL SIGNS OF FEVER1. Onset (cold or chill stage) of fever

Increased heat rate Increased respiratory rate and depth Shivering Pale, cold skin Cyanotic nail bed Complaints of feeling cold “goose flesh” appearance of the skin Cessation of sweating Rise in body temperature

2. Course of fever Absence of chills Skin that feels warm Feeling of neither hot nor cold Increased pulse and respiratory rates Increased thirst Mild to severe dehydration Drowsiness, restlessness, delirium and convulsions Herpetic lesions of the mouth (fever blisters) Loss of appetite to eat Malaise, weakness and aching muscles

3. Defervescence (fever abatement) Skin that appears flushed and feels warm Sweating Decreased shivering Possible dehydration

CG INTERVENTIONS Monitor VS Assess skin color and temperature Remove excess blankets when the client feels warm; provide extra warmth when the client feels

chilled Provide adequate foods and fluids Promote rest. To reduce body heat production Provide good oral hygiene. To prevent herpetic lesions of the mouth Provide cool, circulating air using a fan to dissipate heat by convection Provide dry clothing and bed linens Provide TSB (water is 80-98OF) Administer antipyretic as ordered.

Methods of Temperature-Taking1. Oral – most accessible and convenient method.Contraindications

Young children and infants Patients who are unconscious or disoriented Who must breath through the mouth Seizure prone Patient with N/V Patients with oral lesions/surgeries

2. Rectal- most accurate measurement of temperatureContraindications

Patient with diarrhea Recent rectal or prostatic surgery or injury because it may injure inflamed tissue Recent myocardial infarction Patient post head injury

3. Axillary – safest and non-invasive4. Tympanic thermometer5. Chemical-dot/ chemical Strip thermometer

II. Pulse – It is the wave of blood created by contractions of the left ventricles of the heart.FACTORS AFFECTING THE PULSE RATE

1. Age 2. Sex/gender3. Exercise4. Fever5. Medications6. Hemorrhage7. Stress8. Position changes

PULSE SITES1. Temporal – over the temporal bone of the head; superior and lateral to the eye.2. Carotid – at the lateral aspect of the neck; below the ear lobe.3. Apical – at the left mid-clavicular line, 5th ICS. Use stethoscope.4. Brachial – inner aspect of the upper arm or medially at the antecubital space5. Radial – on the thumb side of the inner aspect of the wrist.6. Femoral – along the side of the inguinal ligament.7. Posterior tibial – at the medial aspect of the ankle, behind the medial malleolus.8. Popliteal – at the back of the knee.9. Pedal (dorsalis pedis) – at the dorsum of the foot.

*use the middle 2 to 3 fingers to palpate.

ASSESSMENT OF THE PULSE1. Rate – the normal pulse rate area as follows.

AGE Beats per minuteNewborn to 1 month 80 – 180 beats/min1 year 80 – 140 beats/min2 years 80 – 130 beats/min6 years 75 – 120 beats/min10 years 60 – 90 beats/minAdult 60 – 100 beats/min

Tachycardia – pulse rate of above 100 beats/min Bradycardia- pulse rate below 60 beats/min Irregular – uneven time interval between beats

2. Rhythm – the pattern and intervals of beats. Dysrhythmia is irregular rhythm.3. Volume – the strength of the pulse.

Normal pulse – felt with moderate pressure. Full or bounding pulse – can be obliterated only by great pressure. Thread pulse – can easily be obliterated.

4. Arterial wall elasticity – artery feels straight, smooth, soft, and pliable.5. Presence or absence of Bilateral Equality – absence means there is a CV disorder.

III. Respiration the exchange of oxygen and carbon dioxide between the atmosphere and the body the act of breathing

3 PROCESSES OF BREATHING1. Ventilation – the movement of gases in and out of the lungs.

a. Inhalation (Inspiration)b. Exhalation (Expiration)

2. Diffusion – the exchange of gases from an area of higher pressure to an area of lower pressure. It occurs at the alveolar-capillary membrane.

3. Perfusion – the availability and movement of blood for transport of gases, nutrients, and metabolic waste products.

2 TYPES OF BREATHING1. Costal (thoracic)2. Diaphragmatic (abdominal)

Medulla Oblongata – primary respiratory center.

Assessing Respiration1. Rate – Normal is 12-20 breaths/min in adult2. Depth – observe movement of the chest. Maybe normal, deep, or shallow.3. Rhythm – observe for regularity of exhalations and inhalations4. Quality or character – refers to respiratory effort and sound of breathing.

MAJOR FACTORS AFFECTING RESPIRATORY RATE1. Exercise2. Stress3. Environment – increased/decreased temp4. Increased altitude 5. Medications

As you count the respiration, assess and record breath sound as: Stridor - A whistling sound when breathing (usually heard on inspiration); indicates obstruction

of the trachea or larynx Wheezing - breathing with a whistling sound Stertor - act of snoring or producing a snoring sound

Medical Terms: Eupnea – normal respiration that is quiet, rhythmic, and effortless Tachypnea – rapid respiration above 20 breaths/minute in an adult Bradypnea – slow breathing less than 12 breaths/minute in an adult Dyspnea – difficult and labored breathing Apnea – absence of respiration Orthopnea – ability to breath only in upright position Hyperventilation – deep rapid respiration. CO2 is excessively exhaled (respiratory alkalosis) Hypoventilation – slow, shallow respiration. CO2 is excessively retained (respiratory acidosis) External respiration—the exchange of oxygen and carbon dioxide between the alveoli of the

lungs and the pulmonary blood system Internal respiration—the interchange of oxygen and carbon dioxide between the circulating

blood and cells throughout the body Vital capacity—the amount of air exhaled from the lungs after a minimal full inspiration

IV. Blood Pressure- The measure of the pressure exerted by the blood as it pulsates through the arteries.- Systolic pressure – the pressure of blood as a result of contraction of the ventricles- Diastolic pressure – the pressure when the ventricles are at rest- BP = Cardiac Output X Total Peripheral Resistance / BP = CO x TPR

Pulse pressure - the difference between the systolic and diastolic pressures (S-D=PP)Normal is 30-40 mmHg

Hypertension – an abnormally high BP over 140 mmHg systolic and or above 90 mmHg diastolic for at least two consecutive readings

Hypotension – an abnormally low blood pressure, systolic pressure below 100 mmHg, diastolic pressure is below 60 mmHg

DETERMINANTS OF BP1. Blood volume – Hypervolemia raises BP. Hypovolemia lowers BP2. Peripheral resistance – Vasoconstricton raises BP. Vasodilation lowers BP3. Cardiac Output – when the pumping action of blood is weak, BP will decrease4. Elasticity or Compliance of Blood Vessels – in older people, elasticity of blood vessels decreases

thereby increasing BP5. Blood viscosity - HcT

FACTORS AFFECTING BP1. Age2. Exercise3. Stress4. Race5. Obesity6. Sex/gender7. Medications8. Diurnal variations 9. Disease process

SYSTOLIC in mmHg DIASTOLIC in mmHg CATEGORY

<120

and/or

<80 NORMAL BLOOD PRESSURE

120-139 80-89 PREHYPERTENSION

140-159 90-99 STAGE 1 HYPERTENSION

160 or more 100 or more STAGE 2 HYPERTENSION