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Chapter 46
Vital Signs
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Vital Signs
• *Vital signs (or cardinal symptoms)
– Temperature, pulse, respiration, and blood pressure
– Indicators of functions of the body that are
necessary, and within normal limits, to maintain life
– Pulse oximetry is often included.
– Pain is considered to be the fifth vital sign.
– Documentation is essential to collecting information
regarding the client’s status and well-being.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Recording Vital Signs
• Graphic record
– Documents large amounts of information
– Vital signs must be recorded accurately and promptly
to provide continuous and current documentation.
– Helps providers diagnose and respond to the client’s
changing condition
• Paper record
• Electronic graphic record
• Frequent vital signs sheet
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Regulation of Body Temperature
• Body temperature
– Measure of core temperature on the Celsius
(centigrade—C) or the Fahrenheit (F) scale.
• Hypothalamus controls body temperature by controlling
blood temperature.
• Normal body temperature
• Elevated body temperature: Fever or pyrexia
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Range of Temperatures**
• Oral
– 35.5-37.5C or 95.9-99.5F
• Rectal
– 36.6-38C or 97.9-100.4F
• Axillary
– 34.7-37.3C or 94.5-99.1F
• Tympanic
• Temporal
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Fever
• Intermittent fever
• Alternates between a fever and a normal or subnormal
reading
• remittent fever
• Temp that rises several degrees above normal and
return to normal or near normal
• constant fever
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Fever
• crisis
• Sudden drop form fever to normal
• lysis
• Elevated temp that gradually returns to normal
• relapsing fever
• Fever that returns to normal for at least a day and
then occurs again
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Regulation of Body Temperature (cont’d)
• Lowered body temperature or hypothermia
– A temperature significantly below normal
• Clinical hypothermia
– Used to perform some surgical procedures
• Accidental hypothermia
– Life threatening and requires immediate treatment
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Equipment for Measuring Temperature
• Electronic or automatic thermometer
– Probes are encased in a new cover for each client.
– Discarded according to agency protocol
• Disposable single-use thermometer
– Made of paper, often used in isolation units*
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Measuring Body Temperature
• Several locations are used to measure body temperature.
– Oral (O)—mouth
– Rectal (R)—anus
– Axillary (Ax)—armpit
– Tympanic, aural, or otic
• (TM—tympanic membrane)—ear canal
– Temporal artery (TA)—forehead
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Measuring Body Temperature (cont’d)
• Oral Temperature: Measures the temperature within the
lingual arteries under the tongue (sublingual)
• More accurate than axillary and less accurate than rectal
measurement
• Not used for
– Infants and children, clients with active seizure
disorder, clients who had oral surgery
• Wait 15 minutes before measuring temperature.
– If client has had a hot or cold drink or has been
smoking
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Measuring Body Temperature (cont’d)
• Rectal temperature
– Highly accurate
– Contraindicated after rectal surgery (and often after
vaginal surgery) and in conditions such as diarrhea,
colitis, or cancer of the rectum
• Axillary temperature
– Least accurate measurement
– Used to take temperature of newborns
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Measuring Body Temperature (cont’d)
• Tympanic temperature
– Tympanic thermometer is placed snugly into the
client’s outer ear canal.
– Ideal site for measuring the body’s core temperature
• Temporal artery temperature
– Quickest, noninvasive*
– Temporal artery temperature scanner
– Calculates core body temperature or peak body
temperature
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Glass Thermometer
• Glass mercury-containing thermometers are illegal in the
United States.
• Patient education
– Properly dispose of any mercury-containing items.
• Extended-care facility
– May use thermometers containing alcohol
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The Pulse
• Pulse
– Every heartbeat produces a wave of blood that
causes pulsations through the arteries.
– Temporal pulse
– Mandibular pulse
– Carotid artery pulse
– Femoral pulse
– Radial pulse
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Regulation of Pulse
• Pulse Rate: The normal adult pulse rate is 60 to 80 beats
per minute (bpm). Women have a slightly higher average
rate than men* Newborns range from 120-140bpm*,
toddlers range 80-140*
– Tachycardia
– Bradycardia
• Pulse volume
• Pulse rhythm
– Apical-radial pulse
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Methods and Equipment
• Palpation
– To assess the radial, temporal, mandibular, carotid,
and femoral pulses
• Auscultation and counting the apical pulse will usually
give the most accurate assessment of pulse rate. For this
assessment, use a stethoscope.
• An ultrasonic vascular Doppler device is sometimes used
to detect peripheral pulses.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Measuring the Pulse
• Radial pulse
• Apical pulse (AP)
– More accurate than radial, always used for children
younger than 2 years of age**
• Apical-radial pulse (A-R)
– It is impossible for the apical pulse to be lower than the
radial.
– If radial is less than apical pulse, a pulse deficit occurs!
• Pedal pulse
• Popliteal pulse
• Carotid pulse
– DO NOT reach across the persons neck to obtain!!
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Respiratory rates at various ages**
• Newborn
– 30-80
• Early childhood
– 20-40
• Late childhood
– 15-25
• Adults
– 12-18
– 16-20
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Regulation of Respiration
• Respiratory control
– Apnea
• Rate and depth
– Eupnea, tachypnea, bradypnea
– Kussmaul’s respirations
• Labored breathing, deep and gasping*
• Respiration sounds
– Snoring
– Stertorous breathing
– Obstruction near the glottis causes a hissing, crowing
sound** Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Difficult Breathing
• Dyspnea: Difficult or painful breathing
• Orthopnea: Can breathe only when in an upright position
• Asthma: Spasms and edema of the bronchi cause
breathing difficultly.
• Characteristic signs of breathing difficulty
– Heaving of the chest and abdomen, a distressed
expression, and cyanosis in the skin
• Cheyne-Stokes respirations
– Regular pattern with alternating deep and shallow
breaths with apnea*
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Regulation of Blood Pressure
• Blood pressure is determined by cardiac output and
peripheral resistance.
• Cardiac output:
– Combination of heart rate and stroke volume
– Measured over 1 minute
• Systolic blood pressure (SBP)
• Diastolic blood pressure (DBP)
• AHA says normal BP is 115/75*
• Pulse pressure
– Difference of systolic pressure minus diastolic
pressure
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Blood Pressure: Methods and Equipment
• Measure in both arms
– Difference of 5-10 points may exists, but if more
than 10 points exist, this indicates and arterial
occlusion in the arm with the lower pressure*
• Sphygmomanometer
• Aneroid manometer
• Electronic blood pressure apparatus
• Palpation
• Doppler ultrasound*
– Used when sounds are difficult to hear or indistinct
– Amplifies sound
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Measuring Blood Pressure
• Korotkoff’s sounds
– Sounds heard in the stethoscope when taking BP*
• Physical exertion or emotional stress will affect BP.
• Orthostatic blood pressure measurement
– Older clients
– Those who are taking certain medications
• Orthostatic or postural hypotension
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Pulse Oximetry
• Pulse oximetry
– Component of baseline vital signs
– Noninvasive procedure
– Uses a photoelectric impulse to measure the amount
of light transmitted or reflected by deoxygenated
versus oxygenated hemoglobin
• Pulse oximeter or transducer
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