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Monday, December 7, 2020

Vital signs: temperature, pulse, respirations, blood pressure (BP) assessment (Nursesnote)

 Vital Signs 

Description: Vital signs include temperature, pulse, respirations, blood pressure (BP) assessment 

Guidelines for measuring vital signs

  • Initial measurement of vital signs provides baseline data on client health status and is used to help identify changes in the client's health status. 
  • Some vital signs measurement (temperature, pulse, respirations, BP) may be delegated to assistive personal, but the nurse is responsible for interpreting the findings. 
  • The nurse collaborates with the primary health care provider in determining the frequency of vital sign assessment and also makes independent decision regarding their frequency on the basis of the client's status. 
When vital signs measured 

  • On initial contact with a client (e.g. when a client is admitted to a health care facility ).
  • During physical assessment of a client. 
  • Before and after invasive diagnostic procedure or surgical procedure. 
  • During the administration of medication that affects the cardiac, respiratory, or temperature-controlling functions (e.g. a client who has a fever); may be required before, during, and after administration of the medication.
  • Before, during, and after a blood transfusion 
  • Whenever a client's condition changes or the client verbalize unusual feelings such as nonspecific symptoms of physical distress.
  • Whenever an intervention (e.g.ambulation ) may affect a client condition.


  • Normal body temperature ranges from 36.4° to 37.5° Celsius (C) ( 97.5° to 99.5° Fahrenheit (F)); the average in a healthy young adult is 37° C (98.6°F).
  • Common measurement sites are the mouth, rectum ( unless contraindicated ), axilla, ear, and across the forehead (temporal artery site ); various types of electronic measuring device are commonly used to measure temperature. 
  • Rectal temperature are usually 1° F (0.5°C) higher and tympanic and axillary temperature about 1° F( 0.5) lower than the normal oral temperature. 
Nursing considerations 
  • Time of day
    • Temperature is generally in the low-normal range at the time of awakening as a result of muscle inactivity. 
    • Afternoon body temperature may be high-normal as a result of the metabolic process, activity, and environmental temperature. 
  • Environmental temperature: Body temperature is lower in cold weather and higher in warm weather. 
  • Age: Temperature may fluctuate during the first year of life because the infants heat-regulating mechanism is not fully developed. 
  • Physical exercise: Use of the large muscles creates heat, causing an increase in body temperature. 
  • Menstrual Cycle: Temperature decrease slightly just before ovulation but may increase to 1° F above normal during ovulation. 
  • Pregnancy: Body temperature may consistently stay at high-normal because of an increase in the woman's metabolic rate.
  • Illness: Infective agents and the inflammatory response may cause an increase in temperature. 
  • The inability to obtain a temperature should not be ignored, because it could represent a condition in very young and older clients.
Methods of measurement 
  • Oral
    • If the client has recently consumed hot or cold foods or liquids or has smoked or chewed gum, the nurse must wait 15 to 30 minutes before taking the temperature orally. 
    • The thermometer is placed under the tongue in one of the posterior sublingual pockets; ask the client to keep the tongue down and the lips closed and to not bite down on the thermometer. 
  • Rectal 
    • Place the client in the Sim's position 
    • The temperature is taken rectally when an accurate temperature cannot be obtained orally or via other methods including by an electronic method, or when the client has nasal congestion, has undergone nasal or oral surgery or had the jaws wired, has a nasogastric tube in place, is unable to keep the mouth closed, or is at risk for seizures.
    • The thermometer is lubricated and inserted into the rectum, towards the umbilicus, about 1.5 inches (3.8 cm) ( no more than 0.5 inches (1.25 cm) in an infant. 
  • Axillary 
    • This method is taking the temperature is used when the oral or other methods of temperature measurement are contraindicated. 
    • Axillary measurement is not as accurate as the oral, rectal, tympanic, or temporal artery method but is used when other methods of measurement are not possible.
    • The thermometer is placed in the client's dry axilla, and the client is asked to hold the arm tightly against the chest, resting the arm on the chest; follow the instructions accompanying the measurement device for the amount of time the thermometer should remain in the axilla area.
  • Tympanic 
    • The auditory canal is checked for the presence of redness, swelling, discharge, or a foreign body before the probe is inserted; the probe should not be inserted if the client has an inflammatory condition of the auditory canal or if there is discharge from the ear.
    • The reading may be affected by an ear infection of excessive wax blocking the ear canal.
  • Temporal artery 
    • Ensure that the client's forehead is dry 
    • The thermometer probe is placed flush against the skin and slid across the forehead or placed in the area of the temporal artery and held in place.
    • If the client is diaphoretic, the temporal artery thermometer probe may be placed on the neck, just behind the earlobe. 


  • Pulse is a palpable bounding of blood flow in a peripheral artery; it is an indirect indicator of circulatory status.
  • The average adult pulse rate is 60 to 100 beats per minute. 
  • Changes in pulse rate are used to evaluate the client's tolerance of interventions such as ambulation, bathing and exercise.
  • Pedal pulses are checked to determine whether the circulation is blocked in the artery up to that pulse point.
  • When the pedal pulse is difficult to locate, a Doppler ultrasound stethoscope may be needed to amplify the sounds of pulse waves.
Nursing considerations 
  • The heart rate slows with age.
  • Exercise increases the heart rate.
  • Emotions stimulate the sympathetic nervous system, increasing the heart rate.
  • Pain increased the heart rate
  • Increased body temperature causes the heart rate to increases. 
  • Stimulant medications increase the heart rate; depressants and medications affecting the cardiac system slow it.
  • When the BP is low, the heart rate is usually increased. 
  • Haemorrhage increase the heart rate.
Assessing pulse qualities 
  • When the pulse is being counted, note the rate,  rhythm, strength, and equality 
  • Once you have checked these parameters, use the grading scale for pulses to assess the information you have elicited 
Pulse points and locations
  • The temporal artery can be palpated anterior to or in the front of the ear.
  • The carotid artery is located in the grooves between the trachea and the sternocleidomastoid muscle, medial to and alongside the muscle.
  • The apical pulse may be detected at the left midclavicular, fifth intercostal space.
  • The brachial pulse is located above elbow at the antecubital fossa, between the biceps and triceps muscles. 
  • The radial pulse is located in the groove along the radial or thumb side of the client's inner wrist.
  • The ulnar pulse is located on the medial side of the wrist (little finger side of the forearm at the wrist )
  • The femoral pulse is located below the inguinal ligament, midway between the symphysis pubis and the anterosuperior iliac spine.
  • The popliteal pulse is located behind the knees.
  • The posterior tibial pulse is located on the inner side of the ankle, behind and below  the medial malleolus(ankle bone)
  • The dorsalis pedis pulse is located on the top of the foot, in line with the groove between the extensor tendons of the great and first toes.
" The apical pulse is counted for 1 full minute and is assessed in clients with an irregular radial pulse or a heart condition, before the administration of cardiac medications such as digoxin and beta-blockers, and in children younger than 2 years"

Pulse deficit 
  • In this condition, the peripheral pulse rate (radial pulse ) is less than the ventricular contraction rate (apical pulse)
  • A pulse deficit indicates a lack of peripheral perfusion; it can be an indication of cardiac dysrhythmias.
  • One-examiner technique: Auscultate and count the apical pulse first and then immediately count the radial pulse.
  • Two examiner technique: One person counts the apical pulse and the other counts the radial pulse simultaneously. 
  • A pulse deficit indicates that cardiac contractions are ineffective, failing to send pulse waves to the periphery.
  • If a difference in pulse rate is noted, the PHCP is notified.


  • Respiration is a mechanism the body uses to exchange gases between the atmosphere and the blood and between the blood and the cells.
  • Respiratory rates vary with age
  • The normal adult respiratory rate is 12 to 20 breaths per minute. 
Nursing considerations
  • Many of the factors that affect the pulse rate also affect the respiratory rate.
  • An increased level of carbon dioxide or a lower level of oxygen in the blood results in an increase in respiratory rate.
  • Head injury or increased intracranial pressure will depress the respiratory centre in the brain, resulting in shallow respirations or slowed breathing.
  • Medication such as opioid analgesics depress respirations. 
  • Additional factors that can affect the respiratory rate include exercise, pain, anxiety, and body position. 
Assessing respiratory rate
  • Count the client's respirations after measuring the radial pulse. ( continue holding the client's wrist while counting the respirations or position the hand on the client's chest)
  • One respiration includes both inspiration and expiration.
  • The rate, depth, pattern, and sounds are assessed 
"The respiratory rate may be counted 30 seconds and multiplied by 2, except in a client who is known to be very ill or is exhibiting irregular respirations, in which case respirations are counted for 1 full minute"

Blood Pressure 

  • Blood pressure (BP) is the force on the walls of an artery exerted by the pulsating blood under pressure from the heart.
  • The heart's contraction forces blood under high pressure into the aorta; the peak of maximum pressure when ejection occurs is the systolic pressure; the blood remaining in the arteries when the ventricles relax exerts a force known as the diastolic pressure. 
  • The different between the systolic and diastolic pressures is called the pulse pressure. 
  • For an adult (age 18 years and older), a normal BP is a systolic pressure below 120 mm Hg and a diastolic pressure below 80 mm Hg.
  • In postural (orthostatic ) hypotension, a normotensive client exhibits symptoms and low BP on rising to an upright position. 
  • To obtain orthostatic vital sign measurements, check the BP and pulse with the client supine, sitting, and standing; readings are obtained 1 to 3 minutes after the client changes position. 
Nursing consideration 
  • BP tends to increases as the ageing process progresses.
  • Stress result in sympathetic stimulation that increases the BP.
  • Antihypertensive medications and opioid analgesics can decrease BP.
  • BP is typically lowest in the early morning, gradually increases during the day, and peaks in the late afternoon and evening. 
  • After puberty, males tend to have higher BP than females; after menopause, women tend to have higher BP than men of the same age.
  • Additional factors affecting the BP include smoking, activity, and body weight.
Guidelines for measuring BP
  • Determine the best site for assessment 
  • Avoid applying a cuff to an extremely into which intravenous (IV) fluids are infusing, where an arteriovenous shunt or fistula is present, on the side on which breast or axillary surgery has been performed, or an extremely that has been traumatized or is diseased.
  • The leg may be used if the brachial artery is inaccessible; the cuff is wrapped around the thigh and the stethoscope is placed over the popliteal artery. 
  • Ensure that the client has not smoked or exercised in the 30 minutes before measurement, because both activities can yield falsely high readings. 
  • Have the client assume a sitting ( with feet flat on floor ) or lying position and then rest for 5 minutes before the measurement; ask the client not to speak during the measurement. 
  • Ensure that the cuff is fully deflated, then wrap it evenly and snugly around the extremity.
  • Ensure that the stethoscope being used fits the examiner and does not impair hearing. 
  • Documents the first Korotkoff sound at phase 1 ( heard as the blood pulsates through the vessel when air is released from the BP cuff and pressure on the artery is reduced ) as the systolic pressure, and the beginning of the fifth Korotkoff sound at phase 5 as the diastolic pressure. 
  • BP reading obtained electronically with a vital sign monitoring machine should be checked with a manual cuff if there is any concern about the accuracy of the reading. 

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