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Chapter 29 - Vital Signs
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Purpose: to monitor functions of the body
– Reflect changes in bodily functions that might not otherwise be observed
• T. P. R. B/P pain level (0 – 10) Zero – no pain; 10 – the worst pain
– Pulse oxymetry may be taken with vital signs, check the institution’s policy
• VS should be performed with thoughtful scientific assessment while evaluating the patient’s
present and prior health status.
– Not automatic as if performing on auto-pilot, but with critical thinking and evaluation
of the client’s condition, comparing previous vital signs and what is normal for the client
When to Assess Vital Signs:
• On admission
• Change in client’s health status
• Client reports symptoms of chest pain, feeling hot, or fainting
• Pre and post surgery/or invasive procedure
• Pre and post medication administration that could affect CV system, or respiratory system.
(Example: before administering Digitalis)
• Pre and post nursing intervention that could affect vital signs (ambulation, physical therapy,
bathing clients who were on bedrest)
There are Two Kinds Body Temperature
1. Core temperature – deep body tissue temperature that remains relatively constant, (abdominal
cavity, pelvic cavity)
2. Surface temperature – skin subcutaneous and body fat tissue; which changes in response to the
environment
 Metabolism produces heat
 Heat balance: is when the amount of heat produced = the amount of heat lost
TEMPERATURE - Body Temperature as fever:
• Febrile –is the term used for having fever
Intermitten f. – alternates at reg. intervals
Remittent f. – fever occurs with wide fluctuations as seen in colds & flues
Relapsing f. – fevers occurring in short periods of 1 or 2 days
constant f. – usually remains constant with minimal fluctuations; ( as seen in typhoid)
fever spike – a rapid rise in fever level followed by normal temp.; seen in bacterial
blood infections
• Pyrexia - is fever above the usual range
• Hyperpyrexia – very high fever; hyperthermia
Sites for Measuring Body Temperature - Kozier pg. 544
• Oral, Rectal, Axillary, Tympanic (ear)membrane; and Skin/Temporal artery
Types of Thermometers - Kozier pg. 540-541
• Electronic
• Chemical disposable
• Pacifier thermometer (for children < 2 yrs.)
• Temperature-sensitive tape – does not indicate core temp.
• Infrared (tympanic); Scanning infrared (temporal artery)
• Glass mercury – obsolete in healthcare facilities. Should not be used.
• Scanning infrared temporal artery thermometer
• Axillary thermometer placement: Place thermometer in center of axilla. Make sure axilla is dry.
In finfants: hold infant’s arm against the chest. Keep in mind the axillary temp. may not be as
accurate
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Tympanic thermometer placement: Pull the pinna of the ear back and up for placement of a
tympanic thermometer in a child over 3 years of age, back and down for children under age 3.
Factors Affecting Body Temperature
• Age, Exercise, Environment, Hormones, Stress
• Diurnal variations (circadian rhythms)
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
Physiologic changes of Fever KNOW
• Increase HR, Pulse, Palid, cold skin, shivering, c/o being cold; “goosepumps”
• Cyanotic nail beds, Cessation of sweating
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
Symptoms Hypothermia
• Decrease body temp., pulse and respirations
• Severe shivering, Pale, feeling cold & chills, waxy skin
• Frostbite (nose, fingers, toes)
• Hypotention (low B/P)
• Decreased urinary output
• Lack of muscle coordination
• Disorientation; drowsiness progressing to coma
Nursing Care for Hypothermia
• 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
PULSE
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A pulse is a blood wave created by a heart contraction of the left ventricle
Compliance – is the ability of arteries to contract and expand
Loss of arteries distensibility will require greater pressure to pump blood into the arteries
Cardiac output – amount of blood pumped by the heart with each ventricular contraction
Factors Affecting Pulse - Kozier pg. pg 546
• Age, Gender, Exercise; Fever, Stress; Medications
• Hypovolemia, Position changes, Pathology
Pulse Sites - KNOW Kozier pg 546
 Temperol
 Carotid – never press both carotids simultaneously
 Apical
 Brachial
 Radial – readily assessable, most commonly used
 Femoral, Popliteal
 Posterial tibial, Dorsalis pedis
Where to locate Apical pulse for a child under 4 yrs, a child 4-6 yrs, and an adult. - Kozier pg 547
Measuring Apical Pulse - Kozier pg 552
Two nurse method of checking the Apical-Radial Pulse
• Locate apical and radial sites
– Decide on starting time
– Nurse counting radial says “start”
– Both count for 60 seconds
– Nurse counting radial says “stop”
– Radial can never be greater than apical
Pulse: Lifespan Considerations
Infants
Newborns may have heart murmurs that are not pathological
Children
The apex of the heart is normally located in the fourth intercostal space in
young children; fifth intercostal space in children 7 years old and older
Elderly
Often have decreased peripheral circulation
When Assessing Pulse,, observe the following:
 Characteristics of the Pulse
• Rate; Rhythm - pattern
• Volume – amplitude or strength; bounding or absent
• Arterial wall elasticity – straight, soft, pliable vs. tortuous; expansibility or deformity
• Bilateral equality
 Pulse Rate and Rhythm
– Rate in Beats per minute
• Tachycardia >100;
Bradycardia < 60
 Rhythm
a. Normal - Equal intervals between beats
b. Dysrhythmias
c. Arrhythmia
Pulse Oximetry - a noninvasive procedure
 Estimates arterial blood oxygen saturation (SpO2)
 Normal SpO2 85-100%; < 70% life threatening
 Detects hypoxemia before clinical signs and symptoms
 Sensor, photodetector, pulse oximeter unit
Pulse Oximetry - Kozier pg. 568
Factors affecting accuracy of Pulse Oximeters:
 Hemoglobin level; Circulation; Activity; Carbon monoxide poisoning
 Assess for poor circulation, thickened nails, use of vaso-constrictive medications
 How to: See Skill 29-7, pg569-570
 If child, instruct that sensor does not hurt, that it is not an invasive procedure
RESPIRATIONS
Inhalation - Diaphragm contracts (flattens), Ribs move upward and outward; the Sternum moves
outward and enlarging the size of the thorax
Exhalation – the diaphragm relaxes and the Ribs move downward and inward, the Sternum moves
inward and the thorax decreases in size
 Respiratory Control Mechanisms – the respiratory center is located in the Medulla oblongata;
and Pons
 Chemoreceptors are located in the Medulla and the Carotid and aortic bodies
 Both respond to O2, CO2, H+ in arterial blood
Factors Affecting Respirations: Exercise, Stress, Environmental temperature, and Medications
Respirations: Lifespan Considerations
Infants
Some newborns display “periodic breathing”
Children
Diaphragmatic breathers
Elders
Anatomic and physiologic changes cause respiratory system to be less efficient
Characteristics of Respirations to Assess
• Rate. Depth, Rhythm – regular, irregular, Quality – effort, sound
• Effectiveness - Uptakes & transports O2 ; Transports & and elimination of CO2
Rate & Depth
• Rate is measured by Breaths per minute. See Kozier pg. 546 for respirations rates by age
• Eupnea - normal
• Bradypnea - < Abnormally slow respirations
• Tachypnea - >abnormally rapid respirations
• Apnea – absence of breathing
see Box 29-5, pg 558
– Depth: is it , normal, Deep, or shallow
BLOOD PRESSURE
BLOOD PRESSURE (Continue)
Factors Affecting Blood Pressure
• Age, Gender, Exercise; Stress, Race, Medications, Diurnal variations, Obesity, Disease process
Blood Pressure: Lifespan Considerations
Infants
Arm and thigh pressures are equivalent under 1 year of age
Children
Thigh pressure is 10 mm Hg higher than arm
Elders
Client’s medication may affect how pressure is taken
Systolic and Diastolic Blood Pressure
– Systolic = Contraction of the ventricles
– Diastolic = Ventricles are at rest
– Lower pressure present at all times
– Pulse Pressure = is the difference between systolic and diastolic pressures
• BP is measured in mmHg and recorded/or documented as a fraction, (120/80)
Measuring Blood Pressure
• Direct (Invasive Monitoring)
– Indirect – by Auscultatory; Palpatory
– Sites used: Upper arm (brachial artery) and the Thigh (popliteal artery)
 To determine appropriate bladder size of BP cuff, the width should be 40% of the arm
circumference, or 20% wider than the diameter of the midpoint of the limb.
Korotkoff’s Sounds
• Phase 1: the First faint sound, sounds like clear tapping or a thumping sounds – marks the
Systolic pressure
• Phase 2: A Muffled, whooshing, or swishing sound
• Phase 3: Blood flows freely, has a Crisper and more intense sound with a thumping quality but
softer than in phase 1
• Phase 4: a Muffled sound that has a soft, blowing sound
• Phase 5: the Pressure level when the last sound is heard then a Period of silence, this is the
Diastolic pressure
Delegating the Measurement of Vital Signs
• General considerations prior to delegation
– Nurse assesses to determine stability of client
– Measurement is considered to be routine
– Interpretation rests with the nurse
• Delegating to UAP
– Body temperature - UAP reports abnormal temperatures and the nurse interprets
abnormal and determines appropriate response
– Pulse - Radial or brachial pulse may be delegated to UAP but Nurse interprets abnormal
rates or rhythms and determines appropriate response
– UAP are generally not responsible for assessing apical or one person apical-radial pulses
Documentation of Vital Signs - see example on pg. 543, Kozier
Case Study
A 20-year-old client is brought in to the clinic with complaints of fever, chills and fatigue.
His vital signs upon admission are BP 120/70, P 116, RR 20, and oral Temp 102.1°F. His mother
reports that his temperature rises to fever level rapidly and then returns to normal within a few
hours. The doctor who examines him orders blood work.
1. What are the normal vital signs for a 20-year-old male client?
2. What type of fever is the client most likely experiencing?
3. Why has the doctor ordered blood work?
Case Study
A 20-year-old client is brought in to the clinic with complaints of fever, chills and fatigue.
His vital signs upon admission are BP 120/70, P 116, RR 20, and oral Temp 102.1°F. His mother
reports that his temperature rises to fever level rapidly and then returns to normal within a few
hours. The doctor who examines him orders blood work.
1. What are the normal vital signs for a 20-year-old male client?
2. What type of fever is the client most likely experiencing?
3. Why has the doctor ordered blood work?
AMSWERS
1. BP = 120/80 – w pulse pressure 40
Oral T = 37°C or 98.6°F
P = 60-100
R = 12-20
2. Type of fever = fever spike
3. R/O bacterial infections that are causing the fever
Classroom Assignments
1. Demonstrate the two-nurse method of checking the Apical-Radial Pulse
2. Explain the 5 phases of Korotkoff’s sounds.
3. Identify the nine sites used for assessing pulses and state the reasons for their use
4. Describe factors that affect the vital signs and the accuracy of measurements
a. What are the common errors in assessing BP
pg 564
b. Factors affecting Oxygen Saturation
5. Case Study
A 20-year-old client is brought in to the clinic with complaints of fever, chills and fatigue.
His vital signs upon admission are BP 120/70, P 116, RR 20, and oral Temp 102.1°F. His
mother reports that his temperature rises to fever level rapidly and then returns to
normal within a few hours. The doctor who examines him orders blood work.
1. What are the normal vital signs for a 20-year-old male client?
2. What type of fever is the client most likely experiencing?
3. Why has the doctor ordered blood work?