Fundamentals of Nursing:

Human Health and Function

Chapter 17:
Vital Signs

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Body Temperature
• Humans maintain a consistent internal body
temperature
• Core temperature: Temperature inside
the body; normal body temperature
when measured orally ranges between
36.5º and 37.5ºC (97.6º and 99.6ºF)

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Body Temperature (Cont’d)
• Regulation of body temperature
– Heat production
•Metabolism
– Heat loss
•Heat is lost through four processes:
Radiation; conduction; convection;
evaporation

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Body Temperature (Cont’d)
• Factors affecting body temperature
– Age
– Environment
– Time of day
– Exercise
– Stress
– Hormones
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Body Temperature (Cont’d)
• Factors affecting oral body temperature
measurement
– Smoking; chewing gum
– Oxygen administered by mask or cannula

– Intake of hot or cold liquid drinks

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Body Temperature (Cont’d)
• Assessing body temperature
– Sites
•Oral
•Rectal
•Ear
•Forehead (temporal artery)
•Axillary
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Body Temperature (Cont’d)
• Assessing body temperature (cont’d)
– Equipment
•Electronic thermometers
•Tympanic membrane thermometers
•Temporal artery thermometers
•Disposable paper (chemical)
thermometers
•Glass mercury thermometers
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Body Temperature (Cont’d)
• Assessing body temperature (cont’d)
– Scales: Temperature can be measured on
the Celsius or Fahrenheit scale
– Methods: Nurses use critical thinking to
interpret temperature measurements,
document the results, and report
abnormal values

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Pulse
• Characteristics
– Rate or frequency; rhythm; quality
• Factors affecting pulse rate
– Age
– Autonomic nervous system
– Medications
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Pulse (Cont’d)
• Assessing the pulse
– Sites
•Temporal; carotid
•Apical; brachial
•Radial; femoral; popliteal
•Pedal; posterior tibial
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Pulse (Cont’d)
• Equipment
– Stethoscope
– Doppler ultrasound device
• Methods
– Palpation
– Auscultation
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Pulse (Cont’d)
• Assessing pulse characteristics
– Dysrhythmic: Any pulse out of the
range of normal rate or rhythm
– Rate: Normal adult pulse rate is
60 to 100 pulsations per minute
•Tachycardia; bradycardia

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Pulse (Cont’d)
• Assessing pulse characteristics (cont’d)
– Rhythm
– Quality
– Pulse deficits

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question
Tell whether the following statement is
true or false:
Cardiac medications such as digoxin
increase pulse rate in patients.

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer
False.
Rationale: Cardiac medications such as
digoxin decrease pulse rate, whereas
atropine inhibits parasympathetic input,
causing increased pulse rate in patients.

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Respirations
• External respiration; internal
respiration
• Tidal volume: Amount of air moving in
and out with each breath

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Respirations (Cont’d)
• Factors affecting respirations
– Age
– Medications
– Stress
– Exercise
– Altitude
– Gender
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Respirations (Cont’d)
• Assessing respirations
– Rate
– Rhythm and depth
– Quality: Usually automatic, quiet,
and effortless

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Respirations (Cont’d)
• Assessing respirations (cont’d)
– Quality
• Dyspnea
– Methods: Perform the respiratory
assessment without patients being
aware of the assessment

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question
What is the term used for normal
respiratory rhythm and depth in a
patient?
a. Eupnea
b. Apnea
c. Bradypnea
d. Tachypnea
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
a. Eupnea
Rationale: Eupnea is the term used for
normal respiratory rhythm and depth
in a patient. Apnea is the absence of
respirations in a patient. Tachypnea is
an abnormally fast respiratory rate, and
bradypnea is an abnormally slow
respiratory rate in an adult patient.

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Blood Pressure
• Physiologic factors determining blood
pressure
– Systolic blood pressure
– Diastolic blood pressure
– Pulse pressure
– Blood flow
– Resistance

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Blood Pressure (Cont’d)
• Factors affecting blood pressure
– Age
– Autonomic nervous system
– Circulating volume
– Medications
– Normal fluctuations

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Blood Pressure (Cont’d)
• Assessing blood pressure
– Sites
•Upper extremity
•Lower extremity

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Blood Pressure (Cont’d)
• Assessing blood pressure (cont’d)
– Equipment
•Sphygmomanometer
•Stethoscope
•Doppler ultrasound
•Automated devices

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Blood Pressure (Cont’d)
• Assessing blood pressure (cont’d)
– Methods
•Proper cuff size
•Proper positioning
•Correlation with the respiratory cycle
•Proper inflation and deflation

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Blood Pressure (Cont’d)
• Assessing blood pressure (cont’d)
– Methods (cont’d)
•Auscultation: Korotkoff sounds can be
heard with a stethoscope placed over
the artery
•Palpation: When Korotkoff sounds are
inaudible, blood pressure may be
estimated by palpation
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Blood Pressure (Cont’d)
• Assessing blood pressure (cont’d)
– Abnormalities
•Hypertension; prehypertension
•Hypotension
•Orthostatic hypotension

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question
What is the term used for a high-pitched
musical sound in patients during a
respiratory assessment?
a. Crowing
b. Wheezing
c. Stridor
d. Sigh
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
b. Wheezing
Rationale: The term used for a high-
pitched musical sound in patients is
wheezing. Stridor is a harsh inspiratory
sound, which may also be compared to
crowing. Sighs are breaths of deep
inspiration and prolonged expiration.

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Documenting Vital Signs
• Data entered into an EMR may be
viewed in a graph format that allows
vital sign trends to be seen easily
• Trends may reflect normal variations
or a change in response to disease or
therapy

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Lifespan Considerations

• Newborn and infant

• Toddler and preschooler
• School-age child and adolescent
• Adult and older adult

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins