PT 103 (INTRODUCTION TO PATIENT CARE) - VITAL SIGNS

VITAL SIGNS

There are FOUR VITAL/CARDINAL SIGNS which are standard in medical setting:
1. Temperature
2. Pulse Rate
3. Respiratory Rate
4. Blood pressure

TAKING THE VITAL SIGNS

 It is the manner by which the patient’s temperature, pulse, respiration and blood pressure are taken and recorded.

PURPOSES:
1. To afford an opportunity to observe the general condition of the patient.
2. To serve as a guide in meeting the needs of the patient.
3. To aid the physician and the physical therapist in planning the patient’s therapy program.

GENERAL CONSIDERATIONS:
1. Before vital signs are taken, be sure that the patient has rested and is placed on a comfortable position.
2. The frequency of taking the vital signs depends upon the condition of the patient and the policy of the department.
3. Inform the physician promptly for any significant change in the vital signs.
4. Explain the procedure to the patient so that he/she will feel at ease.

I. BODY TEMPERATURE (To)

 It is the balance between the heat production and heat loss.
 Unit of Measurement: CELSIUS or FAHRENHEIT

 KINDS OF BODY TEMPERATURE:

1. CORE TEMPERATURE - It is the temperature of the deep tissue of the body.
According to O’Sullivan:
 Normal Adult Body Temperature: 36-37.5 o C (96.8-99.5 o F)
 Newborn: 37-37.7 o C (98.6-99.8 o F)
 Older Adult: 35.9-36.3 o C (96.5-97.5 o F)
2. SURFACE TEMPERATURE- Rise and falls in response to the environment.

 LOSS OF BODY HEAT:

1. Radiation  transfer of heat by electromagnetic waves from one object to another
 Eg. Surrounding room object
2. Conduction  Transfer of heat from one object to another through liquid, solid and gas
 Eg. Heat is lost in a cool swimming pool
3. Convection  Transfer of heat by movement of air or liquid
 Eg. Use of fan or a cool breeze
4. Evaporation  Conversion of a liquid to a vapor
 Eg. Profuse sweating

Site of Measurements
1. Oral Temperature
 Oral – (N)= 36.8 ºC/ 98.2 F
 Use of Oral Thermometer – used in measuring temperature through the mouth
 Long, slender tips
 Method is convenient

Generally used for all clients, EXCEPT:

1. Under age of 6 years old because they may bite and break the thermometer
2. Irrational or unconscious individuals
3. Clients who have wired jaw, wound and oral surgery
4. Clients who cannot breathe through their nose and uses the mouth for breathing

PREPARED BY: MIKE JAYROME M. RAGIL, PTRP LORMA COLLEGES-CPRT

 PT 103 (INTRODUCTION TO PATIENT CARE) - VITAL SIGNS

2. Axillary temperature
 Axillary – (N) = 36.2/36ºC
 Long slender tips
 Safe, easy, accessible method
 Less distressing than rectal method
 Less accurate
 Preferred site for temperature measurements for children

3. Rectal Temperature
 Rectal – (N) = 37.2ºC
 It gives the most accurate temperature of internal body because it reflects the 7 degree of the body inside
the large blood vessels of the rectum
 Short rounded thermometer sometimes coded with blue color at the other tip end
 Less influence by the external force

Disadvantages:
1. Placement at the same site each time is difficult
2. Does not respond to changes in Arterial blood temperature as quickly as oral temperature
3. The presence of stool may interfere with thermometer placement
a. Soft- embedded in stool rather than against the wall of the rectum
b. Impacted – depth or insertion is insufficient
4. Newborn and infants may result to tragic ulceration and rectal injuries.

NOTE:
Thermoregulatory Center: Hypothalamus
 Pyrexia  elevation of normal body temperature
 AKA: Fever, Febrile
 Hyperthermia  extremely increased in temperature (>41.1C/ 106F)
 Normothermia  absence of fever; Normal Temperature

TYPES OF FEVER
1. Intermittent  Body temperature alternates at regular intervals between periods of fever and periods of normal
temperatures
2. Remittent  Elevated body temperature that fluctuates more than 3.6 ºF (2ºC) within a 24 hour period but
remains above normal
3. Relapsing  Periods of fever are interspersed with normal temperatures each last at least one day,
 also called as RECURRENT FEVER
4. Constant  Body temperature may fluctuate slightly but is constantly elevated above normal.

CONVERSION:
 C = (F-32) 5/9
 F = (C * 9/5) +32
o Eg. Convert 26° Celsius (A nice warm day!) to Fahrenheit
F = (C * 9/5) +32
= (26° × 9/5) +32
= (234/5) +32
= 46.8 + 32
= 78.8° F
II. PULSE RATE (PR)
 It is the wave of blood within an artery. The wave is created by contraction of the left ventricle of the heart
 Unit of measurement: beats per minute (bpm)
 Recording: full 60 seconds

NORMAL VALUES:
 For adult pulse rate  Newborn: 120-160 bpm
o In resting period: 60-100 bpm  Infants: 100-120 bpm
o During sleep: 40 bpm  Children: 80-100 bpm
o During strenuous exercise: 200-220 bpm

PREPARED BY: MIKE JAYROME M. RAGIL, PTRP LORMA COLLEGES-CPRT

 PT 103 (INTRODUCTION TO PATIENT CARE) - VITAL SIGNS
CAUSES OF INCREASED PR
1. After exercise 3. Stress
2. Medication effect 4. Infection

PULSE SITES
 Temporal Pulse - located on the temple directly in front of the ear (temporal artery)
 Carotid Pulse - located in the neck (carotid artery).
 Radial Pulse - located on the thumb side of the wrist (radial artery)
 Ulnar Pulse - located on the little finger side of the wrist (ulnar artery)
 Brachial Pulse - located between the biceps and triceps, on the medial side of the elbow cavity; frequently used in
place of carotid pulse in infants (brachial artery)
 Femoral Pulse - located in the thigh (femoral artery)
 Popliteal Pulse - located behind the knee in the popliteal fossa, found by holding the bent knee. The patient bends
the knee at approximately 120°, and the physician holds it in both hands to find the popliteal artery in the pit behind
the knee.
 Tibialis Posterior Pulse- located in the back of the ankle behind the medial malleolus (posterior tibial artery).
 Dorsalis Pedis Pulse- located on top of the foot (dorsalis pedis artery)

PULSE ABNORMALITITES: (According to O’ Sullivan)

1. Pulsus Tardus or Rarus
 A pulse beat slow to rise and fall
 Possible Cause: Aortic valve stenosis
2. Pulsus Alternans
 Regular pulse rhythm with alternation of weak and strong beats
 Possible cause: Left ventricular failure
3. Pulsus Bigeminus
 Irregular pulse rhythm in which premature beats alternate with sinus beats
 Possible Cause: Premature Ventricular beats caused by heart failure, hypoxia or other conditions
4. Pulsus Bisferiens
 A strong upstroke, downstroke, and second upstroke during systole
 Possible cause: Aortic insufficiency, Aortic regurgitation and Aortic stenosis
5. Pulsus Paradoxus
 Pulse with markedly decreased amplitude during inspiration
 Possible cause: Constrictive Pericarditis, Pericardial tamponade and severe lung disease
6. Water Hammer Pulse
 AKA: Corrigan’s Pulse
 Bouncing and forceful pulse
 Possible cause: Aortic regurgitation

III. RESPIRATORY RATE (RR)

 It is the number of breaths a living being, such as a human, takes per minute
 Unit of measurement: cycles per minutes
 Recording: full 60 seconds

NORMAL VALUES
 (N) adult: 12- 20 cpm  Infants: 25-50 cpm
 Children: 15-30 cpm  Neonates: 40-60 cpm

Abnormal Breathing Pattern

Breathing pattern Rate Depth Rhythm
Eupnea Normal Normal Regular
Bradypnea Slow Normal/ Shallow Regular
Tachypnea Fast Shallow Regular
Hyperpnea Normal Increase Regular
Hyperventilation Fast Increase Regular
Apnea (-) (-) (-)
Cheyne-stokes (B/L lesion of diencephalon) Slow ↓/↑ and periods of apnea Irregular-regularly
Biot’s (lesion in CNS) Slow Shallow with periods of apnea Irregular/irregularly

PREPARED BY: MIKE JAYROME M. RAGIL, PTRP LORMA COLLEGES-CPRT

 PT 103 (INTRODUCTION TO PATIENT CARE) - VITAL SIGNS

According to O’ Sullivan
1. Eupnea  Normal respiration, with equal rate and depth, 12-20 breath/min
2. Bradypnea  Slow respirations, <10 bpm
3. Tachypnea  Fast respirations, <24 bpm, usually shallow
4. Kussmaul’s Respirations  Respirations that are regular but abnormally deep and increased in rate
5. Biot’s respiration  Irregular respirations of variable depth (usually shallow), alternating with periods of apnea
(absence of breathing)
6. Cheyne-Stokes  Gradual increase in depth of respirations followed by gradual decrease and then a period of
apnea
7. Apnea  Absence of breathing

IV. BLOOD PRESSURE (BP)

 It refers to the force exerted by circulating blood on the walls of blood vessels
 Unit of measurement: mmHg
 With the use of sphygmomanometer , mercury manometer and stethoscope
 It is recorded in fraction: Systolic BP
Diastolic BP
o Systolic pressure is defined as the peak pressure in the arteries, which occurs near the beginning of the
cardiac cycle
o Diastolic pressure is the lowest pressure (at the resting phase of the cardiac cycle).
 In some conditions, it is important to indicate what the position the BP was obtained and occasionally even the side
of the limb
 The difference between the two sides of the limb : range to 5-10 mmHg
 In palpation: 10 mmHg difference between palpatory and with the use of stethoscope

PULSE PRESSURE
 It is the difference between the systolic and the diastolic pressure
 FORMULA: PP= SBP- DPB

MEAN ARTERIAL PRESSURE (MAP)

 It is a term used in medicine to describe a notional average blood pressure in an individual.
 It is defined as the average arterial pressure during a single cardiac cycle.
 FORMULA: MAP = DP + 1/3 (SP-DP)

 For example, if systolic pressure is 120 mmHg and diastolic pressure is 80 mmHg
MAP = 80 mmhg +1/3 (120 mmHg – 80 mmHg)
= 80 mmHg +1/3 (40mmHg)
MAP = 93 mmHg

BP CLASSIFICATION (Ages 18 and Older Adults):

BP Classification Systolic BP Diastolic BP
Normal <120 <80
Pre-Hypertension 120-139 80-89
Hypertension Stage 1 140-159 90-99
Hypertension Stage 2 ≥160 ≥100

Pediatric:
 Newborn: systolic is less than 60 mmHg  Preschool: 85/60 mmHg
 Infancy: 80/ 55 mmHg  School child: 90/60 mmHg

Falsely elevated BP: Falsely reduced BP:

1. After exercise 1. Recent Eating
2. Patients in pain 2. Dehydration or Volume Depletion
3. Recent smoking
4. Sleeplessness
5. Chilling – General cooling – increase of BP
- General heating – decrease of BP
6. Distended bladder

PREPARED BY: MIKE JAYROME M. RAGIL, PTRP LORMA COLLEGES-CPRT

 PT 103 (INTRODUCTION TO PATIENT CARE) - VITAL SIGNS

VITAL SIGNS PROCEDURES

I. Temperature
Special Considerations
1. Take the body temperature by mouth unless otherwise ordered or contraindicated
2. Stay with the client while the thermometer is in place
3. Use only oral thermometer for taking oral temperature and rectal thermometer for rectal temperature
4. When the patient has diarrhea, do not take temperature by rectum
5. When using the axillary method, see to it that the axilla is dry and the bulb of the thermometer is within the
hollow of the axilla.

A. Oral
1. Equipment – oral thermometer, cotton balls, watch with hand
2. Procedure:
a) Remove the thermometer from the solution and rinse it with water
b) Dry it with cotton ball from the bulb towards the fingers with the firm twisting motion
c) Hold the thermometer firmly at the stem with a strong wrist motion, shake it until the mercury is down to 35
deg Celsius or 95 deg Fahrenheit
d) Ask the client to open the mouth and gently place thermometer under the tongue in the posterior sublingual
pocket lateral to the center of the lower jaw
e) Ask the client to hold thermometer with lips close
f) Leave the thermometer in place for 2-3 min.
g) Carefully remove thermometer and read immediately at eye level.
h) Inform the client of the temperature reading
i) Wash the thermometer with soap and water
j) Dry with cotton balls

B. Rectal
1. Equipment – rectal thermometer, cotton balls, watch with second hand, lubricant, gloves, tissue paper
2. Procedure:
a) Draw curtain or screen around bed or close the door
b) Place small amount of lubricant on a piece of cotton balls
c) Lubricate thermometer about 1 inch for the mercury bulb
d) Rinse, dry, shake and check thermometer as suggested in obtaining oral thermometer
e) Place client in lateral Sims position with upper leg flexed and then insert 1- 1 ½ inches (adult) ½ - 1 inch
(infants)
f) Hold thermometer in place for 2 min or according to the agency policy
g) Carefully remove thermometer and wipe off secretions with tissue
h) Read thermometer at eye level
i) Inform client of the thermometer reading
j) Wipe the anal area to remove lubricant or feces
k) Wash thermometer with soap and water
l) Dry with cotton balls, shake thermometer place it to the soaking bottle solutions

C. Axillary
1. Equipment – axillary thermometer
2. Procedure:
a) Rinse, dry, shake and read the thermometer as indicated in the procedure for oral method
b) Pat the axilla dry.
c) Place the thermometer into the center of axilla and place arm across the client’s chest
d) Leave the thermometer in place for 5-10 minutes
e) Same procedures in oral temperature taking from g-j

PREPARED BY: MIKE JAYROME M. RAGIL, PTRP LORMA COLLEGES-CPRT

 PT 103 (INTRODUCTION TO PATIENT CARE) - VITAL SIGNS

II. Obtaining Pulse Rate (Radial Artery)

Special Consideration
1. Remember that one pulse move or one complete rise and fall of the arterial wall is considered as one beat or
count
2. Be sure that both patient and health workers are in a comfortable position
3. When taking pulse, note the rate, rhythm and quality
4. Do not take pulse when the patient is restless, or when the child is crying
5. If peripheral pulse is difficult to obtain, take the apical or cardiac rate
6. Use the middle two or three fingertips to palpate the pulse. Do not use the thumb.

Procedure:
1. Have the patient rest his arm along-side of his body with the wrist extended and the palm of the hand downward
2. Place the middle three fingers along the radial artery and press it gently against the radius, rest the thumb on
the back of the patient’s wrist.
3. Apply only enough pressure so that you can feel the patient’s pulsating artery distinctly.
4. Using a watch with second hand, count number of pulsations felt on the patient for one full minute.
5. If the pulse rate is abnormal repeat the counting in order to determine accurately its rate, rhythm, quality

III. Respiratory Rate

Special Consideration
1. Note the rate, rhythm, depth and character of respiration
a. Rhythm – observe for regularity of exhalation and inhalation
b. Depth – Observe for the movement of the chest; maybe normal, deep or shallow
2. While counting, observe the patient closely for any sign of abnormality
3. Take care that the patient is not made aware that his respiration is being counted.

Procedures:
1. While the fingertips are still in place after counting the pulse rate, observe the patient’s respiration
2. Note the rise and fall of the patient’s chest with each inspiration. Observation can be made without disturbing
the patient’s clothes
3. Using the watch with second hand count the number of respirations for full minute. If respiration is abnormal,
repeat the count in order to determine accurately the rate and characteristics

IV. Taking the Blood Pressure

EQUIPMENTS
a. Sphygmomanometer
 Cuff – contains an airtight, flat, rubber bladder covered with cloth
 Rubber tubes, manometer, bulb and valve
b. Stethoscope
 Flat disc diaphragm, bell-shaped diaphragm, ear piece, rubber tube

A. Sphygmomanometer B. Stethoscope

PREPARED BY: MIKE JAYROME M. RAGIL, PTRP LORMA COLLEGES-CPRT

 PT 103 (INTRODUCTION TO PATIENT CARE) - VITAL SIGNS

Different Kinds of Sphygmomanometer:

A B C
A: Mechanical sphygmomanometer with aneroid manometer and stethoscope
B: Digital sphygmomanometer
C: Mercury manometer

Special considerations
1. Avoid taking BP on the arm that injured, IV infusion or with cast. If the patient with breast surgery, BP is not taken
on that side
2. Let the patient rest for about 15 min before taking BP
3. The cuff is applied to the bare arm; it is not applied over clothing as clothing can affect the measurement.
4. Do not re-inflate the cuff without completely deflating it, wait for at least 30-60 second
5. When using the mercurial type of BP apparatus, always read at eye level to prevent error.

Procedure:
1. Gather all equipment needed. Be sure that the cuff is an appropriate size for the patient
2. Explain the procedure
3. Place the patient in a relaxed reclining position or sitting position with forearm supported and at heart level with
palm of the hand upward.
4. Wrap cuff snugly and smoothly around upper arm about 1 inch above the antecubital space with the center of the
bladder over the brachial artery
5. Determine palpatory BP before auscultation BP to prevent auscultatory gap
6. Palpate brachial artery and place diaphragm on the medial antecubital fossa where the brachial pulse is felt
7. Place ear piece in the ears.
8. Close valve of manometer pump.
9. To avoid distortion, read pressure with mercury at eye level
10. Gradually deflate cuff by opening valve on pump until the first Korotkoff sound is heard
11. Continue to deflate cuff and release pressure gradually. Do not re-inflate without letting cuff totally deflated.
12. Do not leave the cuff inflated for a prolonged period since this produces discomfort on the patient
13. Remove cuff from patient’s arm. Provide comfort for the patient.
14. Record BP and inform staff nurse or the doctor if reading is below or above normal value.

REFERENCES:
 A Learning guide for Allied health Students towards Community Health Development by Arnold Acaina (Chapter
11)
 Patient Care Skills by Minor
 Introduction to Physical Therapy and Patient Care by Tyrone Reyes, MD and Ofelia Luna-Reyes, MD (Chapter XIII)
 Physical Rehabilitation 6th ed. By Susan O’ Sullivan, Thomas Schmitz and George Fulk

PREPARED BY: MIKE JAYROME M. RAGIL, PTRP LORMA COLLEGES-CPRT