VITAL SIGNS - are measures of various physiological statistics,

often taken by health professionals, in order to assess the most basic body functions. The act of taking vital signs normally entails recording body temperature, pulse rate (or heart rate), blood pressure, and respiratory rate, but may also include other measurements. Vital signs often vary by age, sex, weight, exercise tolerance, and condition.

Normal vital sign ranges for the average healthy adult while resting are:

Blood pressure: 90/60 mm/Hg to 120/80 mm/Hg

Breathing: 12 - 18 breaths per minute

Pulse: 60 - 100 beats per minute

Temperature: 97.8 - 99.1 degrees Fahrenheit / average 98.6 degrees Fahrenheit (36 – 38o C)

BODY TEMPERATURE – the level of heat produced and sustained by the

body process. Variations and changes in body temperature are major indicators of disease and other abnormalities.

FACTORS AFFECTING BODY TEMPERATURE•Age•Exercise•Hormone Level•Circadian Rhythm•Stress•Environment•Temperature Alterationsa.Feverb.Hyperthermiac.Heat exhaustiond.Hypothermiae.Frostbite

ASSESSING A TEMPERATURE Goal: To measure body for comparison with accepted normal values. Assessing Oral Temperature

1.Turn on thermometer according to package directions.2.Place the tip of the thermometer under one side of tongue toward the back. Close mouth and breathe through nose.3.Remove the thermometer after you hear the signal (usually a series of beeps) and read the temperature on the screen.

Assessing Axillary Temperature

1.Turn on thermometer according to package directions.2.Place the thermometer in a dry armpit.3.Close the armpit by holding the elbow against the chest.4.Remove the thermometer after you hear the signal (usually a series of beeps) and read the temperature on the screen.

Assessing Temperature with a Glass Thermometer

1.If stored in a chemical solution, wipe thermometer dry with a soft tissue, using a firm twisting motion. Wipe from bulb toward fingers.2.Grasp thermometer firmly with the thumb and forefinger. Using strong wrist movements, shake it until the mercury line reaches at least 36oC.3.Read thermometer by holding it horizontally at eye level and rotating it between the fingers until the mercury line is clearly visualized.4.Place the thermometer’s mercury bulb under one side of tongue toward the back and tell patient to close lips around thermometer (oral) or in the center of the axilla with arm against the chest wall (axillary).

5. Leave thermometer in place for 3 minutes (oral) and 10 minutes (axillary).

6. Remove thermometer. Using a firm twisting motion, wipe it once from fingers down to mercury bulb.

7. Dispose of tissues in a receptacle for contaminated items.

8. Read thermometer to nearest tenth.9. Wash thermometer in lukewarm soapy water. Rinse

it in cool water. Dry and replace thermometer in its container.

PULSE – is the palpable bounding of blood flow noted at

various points on the body. Blood flows through the body in a continuous circuit. The pulse is an indicator of circulatory status. Any artery can be assessed for pulse rate, but the radial and carotid artery are commonly used because they are easily palpated. When a client’s condition suddenly worsens, the carotid site is recommended for quickly finding a pulse. The heart will continue delivering blood to the brain as long as possible.

When cardiac output declines significantly, peripheral pulses weaken and are difficult to palpate. The radial and apical locations are the most common sites for pulse rate assessment. If radial pulse at the wrist is abnormal or intermittent, or if it is inaccessible, the apical pulse is assessed. The brachial or apical pulse is the best site for assessing an infant’s or young child’s pulse because other peripheral pulses are deep and difficult to palpate accurately.

Acceptable Ranges of Heart RateAge Heart Rate (Beats per Minute)

Infant 120-160Toddler 90-140

Preschooler 80-110School-ager 75-100Adolescent 60-90

Adult 60-100

Factors Influencing Pulse RatesFactors Increases Pulse Rate Decreases Pulse Rate

Exercise Short-term exercise. A conditioned athlete who participates in long-term exercise will have a lower heart rate at rest.

Temperature Fever and heat. Hypothermia.Emotions Acute pain and anxiety

sympathetic stimulation, affecting heart rate.

Unrelieved severe pain increases parasympathetic stimulation, affecting heart rate; relaxation.

Drugs Positive chronotropic drugs such as epinephrine.

Negative chronotropic drugs such as digitalis; beta and calcium blockers

Hemorrhage Loss of blood increases sympathetic stimulation

Postural changes Standing or sitting. Lying down.Pulmonary conditions Diseases causing poor

oxygenation such as asthma, chronic obstructive pulmonary disease (COPD).

ASSESSING A PULSE Goal: To measure heart rate for comparison with accepted normal values while causing no trauma to the patient. 1.Identify patient.2.Explain procedure to patient.3.Gather equipment.4.Perform hand hygiene as appropriate.5.Select appropriate site.6.Follow steps as outlined below for appropriate pulse assessment.7.Perform hand hygiene.8.Record pulse rate and report abnormal findings.

Palpating the Radial Pulse

1.Patient may either be supine with arm alongside body, wrist extended, and palms lateral or facing down or sitting with forearm at a 90-degree angle to body resting on a support with wrist extended and palm downward or facing laterally.2.Place your first, second, and third fingers along patient’s radial artery and press gently against the radius. Rest your thumb on back of patient’s wrist.3.Apply only enough pressure to distinctly feel the artery.4.Using a watch with a second hand, count the number of pulsations felt for 30 seconds. Multiply this number by 2 to have rate for 1 minute. If pulse’s rate, rhythm, or amplitude are abnormal in any way, palpate for 1 minute longer.

Auscultating the Apical Pulse

1.Use alcohol swab to clean stethoscope ear pieces and diaphragm.2.Assist patient to sit in chair or sit up in bed and then expose chest area.3.Hold stethoscope diaphragm against the palm of your hand for a few seconds.4.Palpate the fifth intercostals space and move to left midclavicular line. Place diaphragm over apex of the heart.5.Listen for heart sounds, identified as a “lub-dub” sound.6.Using watch with a second hand, count heartbeat for 1 minute.

RESPIRATION – the mechanism the body uses to exchange gases

between the atmosphere and the blood and the blood and the cells. It is the easiest of all vital signs, but they are often the most haphazardly measured. It should not be estimated. Accurate measurement requires observation and palpation of chest wall movement. Not letting a client know that respirations are being assessed is a skillful way of assessing the respiration. An aware client may consciously alter the rate and depth of breathing. Measurement can be best done immediately after measuring pulse rate, with the hand still on the client’s wrist as it rests over the chest or abdomen.

Acceptable Range of Respiratory Rate for AgeAge Rate (Breaths per Minute)

Newborn 30-60Infant 30-50

Toddler 25-32Child 20-30

Adolescent 16-19adult 12-20

FACTORS INFLUENCING CHARACTER OF RESPIRATIONS

•Exercise – increases rate and depth to meet the body’s need for additional oxygen and to rid the body of carbon dioxide.•Acute pain – alters rate and rhythm of respiration; breathing becomes shallow. Client may inhibit or splint chest wall movement when pain is in area of chest or abdomen.•Anxiety – increases rate and depth as a result of sympathetic stimulation.•Smoking – changes the lung’s airways, resulting in increased rate of respirations at rest when not smoking.•Body position – a straight, erect posture promotes full chest expansion. A stooped or slumped position impairs ventilator movement. Lying flat prevents full chest expansion.•Medications – narcotic analgesics, general anesthetics, and sedative hypnotics depress rate and depth. Amphetamines and cocaine may increase rate and depth. Bronchodilators slow rate by causing airway dilation.•Neurological injury – injury to the brain stem impairs the respiratory center and inhibits respiratory rate and rhythm.•Hemoglobin function – decreased hemoglobin levels (anemia) reduce oxygen-carrying capacity of the blood, which increases respiratory rate.

ASSESSING RESPIRATION Goal: To measure pulmonary ventilation for comparison with accepted normal values while causing no trauma to the patient. 1.While your fingers are still in place after counting the pulse rate, observe patient’s respirations.2.Note rise and fall of patient’s chest.3.Using a watch with a second hand, count number of respirations for a minimum of 30 seconds. Multiply this number by 2 for respiratory rate per minute.4.If respirations are abnormal in any way, count respirations for at least 1 minute.5.Perform hand hygiene.6.Document respiratory rate and report any abnormal findings.

BLOOD PRESSURE – is the force exerted on the walls of an

artery by the pulsing blood under pressure from the heart. Blood flows throughout the circulatory system because of pressure changes. It moves from an area of high pressure to an area of low pressure. The heart’s contraction forces blood under high pressure into the aorta. The peak of maximum pressure when ejection occurs is the systolic blood pressure. When the ventricles relax, the blood remaining in the arteries exerts a minimum or diastolic pressure. Diastolic pressure is the minimal pressure exerted against the arterial walls at all times.

FACTORS INFLUENCING BLOOD PRESSURE

•Age•Stress•Ethnicity•Gender•Diurnal Variation•Medications

ASSESSING A BLOOD PRESSURE Goal: To measure force of blood against arterial walls for comparison with accepted normal values while causing no trauma to the patient. 1.Identify the patient.2.Explain procedure to the patient.3.Gather equipment.4.Perform hand hygiene.5.Delay obtaining the blood pressure of the patient is emotionally upset, is in pain, or has just exercised, unless it is urgent to obtain blood pressure.

6. Select appropriate arm for application of cuff (no intravenous infusion, breast, or axilla surgery on that side; injured or diseased limb).

7. Have patient assume a comfortable lying or sitting position with forearm supported at the level of the heart and with palm upward.

8. Expose area of brachial artery by removing garments or moving sleeve, if it is not too tight, above area where cuff will be placed.

9. Center the bladder of the cuff over brachial artery approximately midway on arm, so lower edge of cuff is about 2.5 to 5 cm (1 to 2 inches) above the thinner aspect of the elbow. Tubing should extend from cuff edge nearer patient’s elbow.

10.Wrap cuff smoothly and snugly around the arm. Fasten it securely or tuck end of cuff well under preceding wrapping. Do not allow any clothing to interfere with proper placement of cuff.

11.Check that the needle on the aneroid gauge is within the zero mark. If using mercury manometer, check to see that the manometer is in a vertical position and that the mercury is within the zero level with the gauge at eye level.

12.Palpate the pulse at the brachial or radial artery by pressing gently with the fingertips.

13.Tighten the screw valve on the air pump.

14.Inflate the cuff while continuing to palpate artery. Note the point on the gauge where the pulse disappears.

15.Deflate the cuff and wait 15 seconds.16.Assume a position that is no more than 3 feet away

from the gauge.17.Place the stethoscope earpieces in the ears. Direct

the ear tips forward into the canal and not against the ear itself.

18.Place the stethoscope bell or diaphragm firmly but with as little pressure as possible over the brachial artery. Do not allow stethoscope to touch clothing or cuff.

19.Pump the pressure 30mmHg above the point at which the systolic pressure was palpated and estimated. Open manometer valve and allow air to escape slowly (allowing gauge to drop 2 to 3 mm per heartbeat).

20.Note the point on the gauge at which the first faint, but clear, sound appears and slowly increases in intensity. Note this number as the systolic pressure.

21.Read pressure to the closest even number.22.Do not reinflate cuff once air is being released to

recheck the systolic pressure reading.23.Note the pressure at which the sound first becomes

muffled. Also observe point at which sound completely disappears. These may occur separately or at the same point.

24.Allow remaining air to escape quickly. Repeat any suspicious reading but wait 30 to 60 seconds between readings to allow normal circulation to return to limb. Be sure to deflate cuff completely between attempts to check blood pressure.

25.Remove cuff. Clean and store equipment.26.Perform hand hygiene.27.Record the findings and report any abnormal

findings to appropriate person.

HEIGHT AND WEIGHT MEASUREMENT