Chapter 26 Measuring Vital Signs Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Chapter 26Chapter 26

Measuring Vital SignsMeasuring Vital Signs

Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Vital SignsVital Signs

Vital signs reflect the function of three body Vital signs reflect the function of three body processes essential for life.processes essential for life. Regulation of body temperatureRegulation of body temperature BreathingBreathing Heart functionHeart function

The four vital signs of body function are:The four vital signs of body function are: TemperatureTemperature PulsePulse RespirationsRespirations Blood pressureBlood pressure

Some agencies consider “pain” to be a vital sign.Some agencies consider “pain” to be a vital sign.

Slide 2Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Measuring and ReportingMeasuring and ReportingVital SignsVital Signs

A person’s vital signs vary within certain limits.A person’s vital signs vary within certain limits. Vital signs:Vital signs:

Are measured to detect changes in normal body Are measured to detect changes in normal body functionfunction

Tell about treatment responseTell about treatment response Often signal life-threatening eventsOften signal life-threatening events Are part of the assessment step in the nursing Are part of the assessment step in the nursing

processprocess


Measuring and ReportingMeasuring and ReportingVital Signs (cont’d)Vital Signs (cont’d)

Vital signs are measured:Vital signs are measured: During physical examsDuring physical exams When the person is admitted to a health care agencyWhen the person is admitted to a health care agency As often as the person’s condition requiresAs often as the person’s condition requires Before and after surgery, complex procedures, and Before and after surgery, complex procedures, and

diagnostic testsdiagnostic tests After some care measures, such as ambulation (walking)After some care measures, such as ambulation (walking) After a fall or other injuryAfter a fall or other injury When drugs affect the respiratory or circulatory systemWhen drugs affect the respiratory or circulatory system When the person complains of pain, dizziness, light-When the person complains of pain, dizziness, light-

headedness, feeling faint, shortness of breath, a rapid headedness, feeling faint, shortness of breath, a rapid heart rate, or not feeling wellheart rate, or not feeling well

As stated on the care planAs stated on the care planSlide 4Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Vital signs show even minor changes in the Vital signs show even minor changes in the person’s condition.person’s condition. Accuracy is essential when you measure, record, Accuracy is essential when you measure, record,

and report vital signs.and report vital signs. Take vital signs with the person at rest—Take vital signs with the person at rest—

lying or sitting, unless otherwise ordered.lying or sitting, unless otherwise ordered. Report the following at once:Report the following at once:

Any vital sign that is changed from a prior Any vital sign that is changed from a prior measurementmeasurement

Vital signs above the normal rangeVital signs above the normal range Vital signs below the normal rangeVital signs below the normal range


Measuring and ReportingMeasuring and ReportingVital Signs (cont’d)Vital Signs (cont’d)

Body TemperatureBody Temperature

Body temperature is a balance between amount Body temperature is a balance between amount of heat produced and amount lost by the body.of heat produced and amount lost by the body.

Thermometers measure temperature.Thermometers measure temperature. Fahrenheit (F) and centigrade (C) scales are used.Fahrenheit (F) and centigrade (C) scales are used.

Temperature sites include:Temperature sites include: Mouth, rectum, axilla (underarm), tympanic Mouth, rectum, axilla (underarm), tympanic

membrane (ear), and temporal artery (forehead)membrane (ear), and temporal artery (forehead) Each site has a normal range.Each site has a normal range.

Always report temperatures that are above or Always report temperatures that are above or below the normal range.below the normal range. Fever means an elevated body temperature.Fever means an elevated body temperature.


Types of thermometers used:Types of thermometers used: Glass thermometersGlass thermometers Standard electronic thermometersStandard electronic thermometers

• Tympanic membrane thermometersTympanic membrane thermometers• Temporal artery thermometersTemporal artery thermometers

Digital thermometersDigital thermometers Disposable oral thermometersDisposable oral thermometers Temperature-sensitive tapeTemperature-sensitive tape Pacifier thermometersPacifier thermometers

Taking TemperaturesTaking Temperatures The nurse and care plan tell you when to take the The nurse and care plan tell you when to take the

person’s temperature, what site to use, and what person’s temperature, what site to use, and what thermometer to use.thermometer to use.


Body Temperature (cont’d)Body Temperature (cont’d)

Electronic thermometers are commonly used.Electronic thermometers are commonly used. Some have batteries.Some have batteries. Others are kept in battery chargers when not in use.Others are kept in battery chargers when not in use. Standard electronic thermometersStandard electronic thermometers

• Measures temperature in a few secondsMeasures temperature in a few seconds• They have oral (blue) and rectal (red) probes.They have oral (blue) and rectal (red) probes.

Tympanic membrane thermometersTympanic membrane thermometers• Measures temperature in 1 to 3 secondsMeasures temperature in 1 to 3 seconds• Risk of spreading infection is reduced.Risk of spreading infection is reduced.

Temporal artery thermometersTemporal artery thermometers• Measures temperature in 3 to 4 secondsMeasures temperature in 3 to 4 seconds• Measures the temperature of the blood in the temporal Measures the temperature of the blood in the temporal

artery, which is the same temperature of the blood coming artery, which is the same temperature of the blood coming from the heartfrom the heart



Glass thermometers are color coded.Glass thermometers are color coded. Blue—oral and axillaryBlue—oral and axillary Red—rectalRed—rectal

Glass thermometers are reusable. However, Glass thermometers are reusable. However, the following are problems:the following are problems: They take a long time to register.They take a long time to register. They break easily.They break easily. The person may bite down and break an oral The person may bite down and break an oral

thermometer.thermometer.



PulsePulse

A pulse is felt every time the heart beats.A pulse is felt every time the heart beats. The pulse is the beat of the heart felt at an artery The pulse is the beat of the heart felt at an artery

as a wave of blood passes through the artery.as a wave of blood passes through the artery. Pulse sites:Pulse sites:

Temporal, carotid, brachial, radial, femoral, popliteal, Temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis (pedal) pulses are posterior tibial, and dorsalis pedis (pedal) pulses are on each side of the body.on each side of the body.

Radial pulse is used most often.Radial pulse is used most often. Carotid pulse is taken during CPR and other Carotid pulse is taken during CPR and other

emergencies. emergencies. The apical pulse is felt over the heart.The apical pulse is felt over the heart.

• This pulse is taken with a stethoscope.This pulse is taken with a stethoscope.


A stethoscope is an instrument used to listen to A stethoscope is an instrument used to listen to the sounds produced by the heart, lungs, and the sounds produced by the heart, lungs, and other body organs.other body organs. It is used to take apical pulses and blood pressures.It is used to take apical pulses and blood pressures. The device makes sounds louder for easy hearing.The device makes sounds louder for easy hearing.

To use a stethoscope:To use a stethoscope: Wipe the earpieces and diaphragm with antiseptic Wipe the earpieces and diaphragm with antiseptic

wipes before and after use.wipes before and after use. Place the earpiece tips in your ears.Place the earpiece tips in your ears. Tap the diaphragm gently.Tap the diaphragm gently. Place the diaphragm over the pulse site.Place the diaphragm over the pulse site. Prevent noise.Prevent noise.


Pulse (cont’d)Pulse (cont’d)

The pulse rate is the number of heart beats The pulse rate is the number of heart beats or pulses felt in 1 minute.or pulses felt in 1 minute. The rate varies for each age-group.The rate varies for each age-group.

The adult pulse rate is between 60 and 100 The adult pulse rate is between 60 and 100 beats per minute. Report abnormal pulses to beats per minute. Report abnormal pulses to the nurse at once.the nurse at once. Tachycardia is a heart rate of more than 100 Tachycardia is a heart rate of more than 100

beats per minute.beats per minute. Bradycardia is a heart rate of less than 60 beats Bradycardia is a heart rate of less than 60 beats

per minute.per minute.



Rhythm and force of the pulseRhythm and force of the pulse Pulse rhythm should be regular (felt in a pattern with Pulse rhythm should be regular (felt in a pattern with

the same interval between beats).the same interval between beats).• An irregular pulse occurs when the beats are not evenly An irregular pulse occurs when the beats are not evenly

spaced or beats are skipped.spaced or beats are skipped. Force relates to pulse strength.Force relates to pulse strength.

• A forceful pulse is described as strong, full, or bounding.A forceful pulse is described as strong, full, or bounding.• Hard-to-feel pulses are described as weak, thready, or Hard-to-feel pulses are described as weak, thready, or

feeble.feeble. Electronic blood pressure equipment can also count Electronic blood pressure equipment can also count

pulses.pulses.• Some show if the pulse is regular or irregular.Some show if the pulse is regular or irregular.• You need to feel the pulse to determine its force.You need to feel the pulse to determine its force.



You will take radial, apical, and apical-radial You will take radial, apical, and apical-radial pulses.pulses. You must accurately:You must accurately:

• Count. Count.

• Report and record.Report and record.

The radial pulse is used for routine vital signs.The radial pulse is used for routine vital signs.• Count the pulse for 30 seconds and then multiply the Count the pulse for 30 seconds and then multiply the

number by 2.number by 2.

• If the pulse is irregular, count it for 1 minute.If the pulse is irregular, count it for 1 minute.



The apical pulse is on the left side of the The apical pulse is on the left side of the chest slightly below the nipple.chest slightly below the nipple. It is taken with a stethoscope.It is taken with a stethoscope. Count the apical pulse for 1 minute.Count the apical pulse for 1 minute. Count each lub-dub as one beat.Count each lub-dub as one beat. Apical pulses are taken on persons who:Apical pulses are taken on persons who:

• Have heart disease.Have heart disease.

• Have irregular heart rhythms.Have irregular heart rhythms.

• Are taking drugs that affect the heart.Are taking drugs that affect the heart.



Taking an apical-radial pulseTaking an apical-radial pulse The apical and radial pulse rates should be the The apical and radial pulse rates should be the

same.same. To see if the apical and radial pulses are equal, two To see if the apical and radial pulses are equal, two

staff members are needed.staff members are needed.• One takes the radial pulse.One takes the radial pulse.• The other takes the apical pulse.The other takes the apical pulse.• Doing this at the same time is called the Doing this at the same time is called the apical-radial apical-radial

pulse.pulse. The pulse deficit is the difference between the The pulse deficit is the difference between the

apical and radial pulse rates.apical and radial pulse rates.• To obtain the pulse deficit, subtract the radial rate from the To obtain the pulse deficit, subtract the radial rate from the

apical rate.apical rate.



Checking pedal pulsesChecking pedal pulses Pedal (dorsalis pedis) pulse is used to check Pedal (dorsalis pedis) pulse is used to check

circulation in the foot.circulation in the foot. Doppler ultrasound stethoscope (DUS) is used Doppler ultrasound stethoscope (DUS) is used

when the pedal pulse cannot be felt.when the pedal pulse cannot be felt.• Your role may include using a DUS. Make sure you:Your role may include using a DUS. Make sure you:

Have received the necessary training.Have received the necessary training. Follow the nurse’s directions.Follow the nurse’s directions. Follow the manufacturer’s instructions.Follow the manufacturer’s instructions.



Respiration means breathing air into (inhalation) Respiration means breathing air into (inhalation) and out of (exhalation) the lungs.and out of (exhalation) the lungs. Oxygen enters the lungs during inhalation.Oxygen enters the lungs during inhalation. Carbon dioxide leaves the lungs during exhalation.Carbon dioxide leaves the lungs during exhalation.

Each respiration involves one inhalation and one Each respiration involves one inhalation and one exhalation.exhalation. The chest rises during inhalation.The chest rises during inhalation. The chest falls during exhalation.The chest falls during exhalation.

The healthy adult has 12 to 20 respirations/min. The healthy adult has 12 to 20 respirations/min. Respirations are normally quiet, effortless, and Respirations are normally quiet, effortless, and

regular.regular.Slide 18Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

RespirationsRespirations

Respirations (cont’d)Respirations (cont’d)

Count respirations when the person is at rest.Count respirations when the person is at rest. Position the person so you can see the chest Position the person so you can see the chest

rise and fall. rise and fall. The person should not know that you are The person should not know that you are

counting respirations.counting respirations. Count respirations right after taking a pulse.Count respirations right after taking a pulse.

• Keep your fingers or stethoscope over the pulse site. Keep your fingers or stethoscope over the pulse site.

To count respirations, watch the chest rise and To count respirations, watch the chest rise and fall.fall.


Blood PressureBlood Pressure

Blood pressure (BP) is the amount of force Blood pressure (BP) is the amount of force exerted against the walls of an artery by the exerted against the walls of an artery by the blood.blood.

Blood pressure is controlled by:Blood pressure is controlled by: The force of heart contractionsThe force of heart contractions The amount of blood pumped with each heartbeatThe amount of blood pumped with each heartbeat How easily the blood flows through the blood vesselsHow easily the blood flows through the blood vessels

Systole is the period of heart muscle contraction.Systole is the period of heart muscle contraction. Diastole is the period of heart muscle relaxation.Diastole is the period of heart muscle relaxation.


Blood Pressure (cont’d)Blood Pressure (cont’d)

Systolic pressure—the pressure in the arteries Systolic pressure—the pressure in the arteries when the heart contractswhen the heart contracts

Diastolic pressure—the pressure in the arteries Diastolic pressure—the pressure in the arteries when the heart is at restwhen the heart is at rest

Blood pressure is measured in millimeters (mm) of Blood pressure is measured in millimeters (mm) of mercury (Hg).mercury (Hg). The systolic pressure is recorded over the diastolic The systolic pressure is recorded over the diastolic

pressure.pressure. Blood pressure has normal ranges.Blood pressure has normal ranges.

• Systolic pressure—90 mm Hg or higher but lower than Systolic pressure—90 mm Hg or higher but lower than 120 mm Hg

• Diastolic pressure—60 mm Hg or higher but lower than Diastolic pressure—60 mm Hg or higher but lower than 80 mm Hg


Treatment is indicated for:Treatment is indicated for: Hypertension—When the systolic blood pressure Hypertension—When the systolic blood pressure

is 140 mm Hg or higher (hyper), or the diastolic is 140 mm Hg or higher (hyper), or the diastolic blood pressure is 90 mm Hg or higherblood pressure is 90 mm Hg or higher• Report any systolic measurement at or above 120 mm Report any systolic measurement at or above 120 mm

Hg.Hg.• Report any diastolic pressure at or above 80 mm Hg.Report any diastolic pressure at or above 80 mm Hg.

Hypotension—Systolic blood pressure is below Hypotension—Systolic blood pressure is below (hypo) 90 mm Hg, or the diastolic blood pressure (hypo) 90 mm Hg, or the diastolic blood pressure is below 60 mm Hgis below 60 mm Hg• Report a systolic pressure below 90 mm Hg.Report a systolic pressure below 90 mm Hg.• Report a diastolic pressure below 60 mm Hg.Report a diastolic pressure below 60 mm Hg.



A stethoscope and a sphygmomanometer A stethoscope and a sphygmomanometer are used to measure blood pressure.are used to measure blood pressure. The sphygmomanometer has a cuff and a The sphygmomanometer has a cuff and a

measuring device.measuring device. These types of sphygmomanometers are used These types of sphygmomanometers are used

(follow the manufacturer’s instructions):(follow the manufacturer’s instructions):• Aneroid typeAneroid type• Mercury typeMercury type• Electronic typeElectronic type• Wrist monitorWrist monitor

Blood pressure is normally measured in the Blood pressure is normally measured in the brachial artery.brachial artery.



PainPain

Pain is a warning sign from the body.Pain is a warning sign from the body. Pain can signal tissue damage.Pain can signal tissue damage. Many agencies consider pain to be a vital sign.Many agencies consider pain to be a vital sign.


Chapter 26 Measuring Vital Signs Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

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