VITAL SIGNS

 Temperature (T)

 Pulse (P)

 Respiration (R)

 Blood pressure (BP)

 Pain (often called the fifth vital sign)

 Oxygen Saturation

 Upon admission to a healthcare setting

 When certain medications are given

 Before and after diagnostic and surgical

procedures

 Before and after certain nursing

interventions

 In emergency situations

 Definition: the heat of the body measured

in degrees

› The difference between production of heat and

loss of heat

› Normal temperature: 97.0ºF (36.0ºC) to 99.5ºF

(37.5ºC)

 Process: heat is generated by metabolic

processes in the core tissues of the body,

transferred to the skin surface by the

circulating blood, and dissipated to the

environment

 Core temperatures

› Tympanic and rectal

› Esophagus and pulmonary (invasive

monitoring devices)

 Surface body temperatures

› Oral (sublingual)

› Axillary

 Oral: impaired cognitive functioning,

inability to close lips around

thermometer, diseases of the oral cavity,

and oral or nasal surgery

 Rectal: newborns, small children,

patients who have had rectal surgery, or

have diarrhea or disease of the rectum,

and certain heart conditions

 Tympanic: earache, ear drainage, and

scarred tympanic membrane

 Pulse rate

› Measured in beats per minute

 Pulse quality (amplitude)

› The quality of the pulse in terms of its fullness

 Pulse rhythm

› Pattern of the pulsations and the pauses

between them

 Normally regular

 Palpating the peripheral arteries

 Auscultating the apical pulse with a

stethoscope

 Using a portable Doppler ultrasound

 Temporal

 Carotid

 Brachial

 Radial

 Femoral

 Popliteal

 Posterior tibial

 Dorsalis pedis

 Indications

› Patient is receiving medications that alter heart

rate and rhythm

› A peripheral pulse is difficult to assess accurately

because it is irregular, feeble, or extremely rapid

 Method

› Count the apical rate 1 full minute by listening

with a stethoscope over the apex of the heart

› Most reliable method for infants and small

children; can be palpated with fingertips

 Rate

› Adults: 12 to 20 times per minute

› Infants and children breathe more rapidly

 Depth

› Varies from shallow to deep

 Rhythm

› Regular: each inhalation/exhalation and the

pauses between occur at regular intervals

 Method

› Inspection (observing and listening)

› Listening with the stethoscope

› Counting the number of breaths per minute

 Considerations

› If respirations are very shallow and difficult to

detect visually, observe sternal notch

› Patients should be unaware of the

respiratory assessment to prevent altered

breathing patterns

 Exercise

 Medications

 Smoking

 Chronic illness or conditions

 Neurologic injury

 Pain

 Anxiety

 Retractions

 Nasal flaring

 Grunting

 Orthopnea (breathing more easily in an

upright position)

 Tachypnea (rapid respirations)

 Ineffective Breathing Pattern

 Impaired Gas Exchange

 Risk for Activity Intolerance

 Ineffective Airway Clearance

 Excess Fluid Volume

 Ineffective Tissue Perfusion

 Definition

› The force of the blood against arterial walls

 Systolic pressure

› The highest point of pressure on arterial walls

when the ventricles contract

 Diastolic pressure

› The lowest pressure present on arterial walls

during diastole (Taylor, 2007).

 Blood pressure is measured in millimeters

of mercury (mm Hg)

 Blood pressure is recorded as a fraction

› The numerator is the systolic pressure

› The denominator is the diastolic pressure

 Pulse pressure

› The difference between the systolic and

diastolic pressure

 Using a stethoscope and

sphygmomanometer

 Using a Doppler ultrasound

 Estimating by palpation

 Assessing with electronic or automated

devices

 Use a cuff that is the correct size for the

patient

 Ensure correct limb placement

 Use recommended deflation rate

 Correctly interpret the sounds heard

 Age

 Exercise

 Position

 Weight

 Fluid balance

 Smoking

 Medications

 Purpose

› Measure the arterial oxyhemoglobin

saturation of arterial blood

 Method

› A sensor or probe, uses a beam of red and

infrared light which travels through tissue and

blood vessels

› The oximeter calculates the amount of light

absorbed by arterial blood

› Oxygen saturation is determined by the

amount of each light absorbed

 Monitoring patients receiving oxygen

therapy

 Titrating oxygen therapy

 Monitoring those at risk for hypoxia

 Monitoring postoperative patients