CHAPTER

10
V I TA L S I G N S
 O B J E C T I V E D ATA : V I TA L
SIGNS
• Include temperature, respiratory rate, pulse, and blood
pressure
• Data that is trended throughout patient experiences in
multiple clinical practice settings
• Follow stated facility guidelines for monitoring

• Use nursing judgment to warrant additional assessment

V I TA L S I G N S :
T E M P E RAT U R E ( 1 O F 3 )
• Mechanism of regulation
– Cellular metabolism requires a stable core, or “deep body,”
temperature of a mean of 37° C at rest
– Body maintains steady temperature through feedback
mechanism regulated in hypothalamus of brain.
– Balances heat production with heat loss
– Various routes of temperature measurement reflect body’s
core temperature.
V I TA L S I G N S :
T E M P E RAT U R E ( 2 O F 3 )
• Normal temperature is influenced by the following:

– Diurnal cycle of 1° F to 1.5° F, with trough occurring in early

morning hours and peak occurring in late afternoon to early
evening
– Menstruation cycle in women: progesterone secretion, occurring
with ovulation at midcycle, causes a 0.5° F to 1.0° F rise in
temperature that continues until menses
– Exercise: moderate to hard exercise increases body temperature
– Age: wider normal variations occur in infant and young child due
to less effective heat control mechanisms; in older adults,
temperature usually lower than in other age groups, with a mean
of 36.2° C (97.2° F) via oral route
V I TA L S I G N S :
T E M P E RAT U R E ( 3 O F 3 )
• Normal temperature readings
• Oral temperature accurate and convenient
• Oral sublingual site has rich blood supply from carotid arteries
that quickly responds to changes in inner core temperature
• Normal oral temperature in a resting person is
37° C (98.6° F), with a range of 35.8° C to 37.3° C (96.4° F to
99.1° F)
• Rectal measures 0.4° C to 0.5° C (0.7° F to 1° F) higher

*Fever > 100.0°-100.4°F

 THE PROCEDURE: ORAL
T E M P E RAT U R E
• Shake

– a mercury-free glass thermometer down to 35.5° C (96° F) and

place it at base of tongue in either of posterior sublingual pockets;
not in front of tongue.
• Instruct

– person to keep his or her lips closed.

• Leave

– in place 3 to 4 minutes if person is afebrile, and up to 8 minutes if

febrile; take other vital signs during this time.
• Wait

– 15 minutes if person has just taken hot or iced liquids and 2

minutes if he or she has just smoked.
01/22/2026 7
T H E P R O C E D U R E : R E C TA L
T E M P E RAT U R E

• Take

– rectal temperature only when other routes are not practical

due to clinical presentation but it the most accurate

• Wear gloves and insert lubricated

– rectal probe cover on an electronic thermometer only 2 to 3

cm (1 in) into adult rectum, directed toward umbilicus.
• For a glass thermometer, leave in place for 2½ minutes.

• Disadvantages to rectal route are patient discomfort and time-

consuming and disruptive nature of activity
T H E P R O C E D U R E : T E M P E RAT U R E
TYMPANIC MEMBRANE

• Tympanic membrane thermometer (TMT) senses infrared

emissions of tympanic membrane (eardrum).
– Tympanic membrane shares same vascular supply that
perfuses hypothalamus (internal carotid artery).
– Probe tip has shape of otoscope.
– Gently place covered probe tip in person’s ear canal;
temperature can be read in 2 to 3 seconds.
– Pinna positioning up and back for adult or straight down for
a child under 3  straighten ear canal
01/22/2026 10
THE PROCEDURE: TEMPORAL
A RT E RY T H E R M O M E T E R
• Temporal artery thermometer (TAT)

• Uses infrared emissions from temporal artery

• Sliding probe across forehead

• Takes multiple readings and produces average result

• Reading takes approximately 6 seconds.

• Report temperature in both Fahrenheit and Celsius

01/22/2026 12
 V I TA L S I G N S : P U L S E
• Pulse: palpable flow felt in the periphery as a result of pressure wave
generation from stroke volume
– Provides indicator of rate and rhythm of heartbeat as well as local
data on condition of artery

• Palpation technique

– Using pads of the first three fingers, palpate radial pulse at flexor
aspect of wrist laterally along radius bone until strongest pulsation is
felt.
– If rhythm is regular, count number of beats in 30 seconds and
multiply by 2.
– The 30-second interval is most accurate and efficient when heart
rates are normal or rapid and when rhythms are regular.
– For irregular pulse, count for full minute.
– Assess pulse for rate, rhythm, force, and elasticity.
01/22/2026 14
 H E A RT RAT E
• In resting adult, current research indicates normal heart rate range is 50 to 95 beats
per minute (bpm).
– Rate normally varies with age.
• More rapid in infancy and childhood and moderate during adult and older years
– Rate also varies with gender; after puberty, females have slightly faster rate than males.

• In adult, a heart rate less than 50 bpm is bradycardia.

• More is called tachycardia
• This occurs normally in well-trained athletes whose heart muscle develops
along with skeletal muscles.
– Stronger, more efficient heart muscle pushes out a larger stroke volume with each beat,
thus requiring fewer beats per minute to maintain a stable cardiac output.
– A more rapid heart rate, over 95 bpm, is tachycardia.

• Occurs normally with anxiety or with increased exercise to match body’s

demand for increased metabolism
 H E A RT R H Y T H M

• Rhythm of pulse normally has a regular, even tempo.

– Sinus arrhythmia: one irregularity commonly found in

children and young adults
• Heart rate varies with respiratory cycle, speeding up at peak of
inspiration and slowing to normal with expiration.
• Inspiration momentarily causes a decreased stroke volume from
left side of heart.
• To compensate, heart rate increases.

– If any other irregularities are felt, auscultate heart sounds for

a more complete assessment.
H E A RT F O RC E : S T R E N GT H
OF PULSE
• Force of pulse is strength of heart’s stroke volume.

– Weak, thready pulse reflects a decreased stroke volume (e.g.,

as occurs with hemorrhagic shock).
– Full, bounding pulse denotes increased stroke volume, as
with anxiety, exercise, and some abnormal conditions.
– Pulse force recorded using three-point scale
• 3+ Full, bounding

• 2+ Normal

• 1+ Weak, thready

• 0 Absent
V I TA L S I G N S :
R E S P I RAT I O N S
• Normally person’s breathing is relaxed, regular, automatic, and
silent.
– Because most people are unaware of their breathing, do not mention
that you will be counting respirations, because sudden awareness
may alter normal pattern.
– Instead, maintain your position of counting radial pulse and
unobtrusively count respirations.
– Count for 30 seconds or a full minute if you suspect an abnormality.
– Average rate healthy adult 20 breaths/min, range 16 to 25
breaths/min
– Normally both pulse and respiratory rates rise as a response to
exercise or anxiety.
V I TA L S I G N S : B L O O D
PRESSURE
• Blood pressure (BP) is force of blood pushing against side of its
container, vessel wall.
– Strength of push changes with event in cardiac cycle.
– Systolic pressure: maximum pressure felt on artery during
left ventricular contraction, or systole
– Diastolic pressure: elastic recoil, or resting, pressure that
blood exerts constantly between each contraction
– Pulse pressure: difference between systolic and diastolic
• Reflects stroke volume

– Mean arterial pressure (MAP): pressure forcing blood into

tissues, averaged over cardiac cycle
V I TA L S I G N S : B LO O D
PRESSURE
FA C T O R S ( 1 O F 2 )

• Average BP varies normally with many factors:

– Age: gradual rise through childhood and into adult years
– Sex: after puberty, females show a lower BP than males; after
menopause, females higher than males
– Race: Differences exist relative to combination of genetics
and environment.
– Social Determinants: Effects of environment & social factors
lead to increased risk of HTN
– Diurnal rhythm: Daily peak and trough levels r/t timing cycles
V I TA L S I G N S : B LO O D
PRESSURE
FA C T O R S ( 2 O F 2 )
• Average BP varies normally with many factors:

– Weight: Obesity increases blood pressure as compared to

normal weight recorded measurements of same age.
– Exercise: Will cause a transitory increase in blood pressure
– Emotions: Will increase in response to sympathetic nervous
system response
– Stress: Will increase in response to increased stress and
tension
BLOOD PRESSURE

01/22/2026 22
BLOOD PRESSURE
FA C T O R S
• Level of BP determined by five factors

– Cardiac output: increase in CO leads to increase in BP whereas

decrease in CO leads to decrease in BP
– Peripheral vascular resistance: increased resistance
(vasoconstriction) leads to increase in BP whereas decrease in
resistance(vasodilation) leads to decrease in BP
– Volume of circulating blood: fluid retention leads to increased
BP whereas hemorrhages leads to decreased BP
– Viscosity: increase associated with increase in BP
– Elasticity of vessel walls: increasing rigidity associated with
increase in BP
MEASURING BLOOD
PRESSURE
• Blood pressure measured with
stethoscope and aneroid
sphygmomanometer
– Aneroid gauge subject to drift and
must be recalibrated at least once
each year and must rest at zero.
– Cuff is inflatable bladder inside a
cloth cover.
– Width of rubber bladder should
equal 40% of circumference of
person’s arm; length of bladder
should equal 80% of this
circumference.
THE PROCEDURE: ARM
PRESSURE (1 OF 2)

• Person may be sitting or lying, with bare arm supported at

heart level.
– Palpate brachial artery; with cuff deflated, center it about 2.5
cm (1 in) above brachial artery and wrap it evenly.
– Now palpate brachial or radial artery.
– Inflate cuff until artery pulsation obliterated and then 20 to
30 mm Hg beyond.
• This will avoid missing an auscultatory gap, when Korotkoff
sounds disappear during auscultation.
– Deflate cuff quickly and completely; wait 15 to 30 seconds
before reinflating so blood trapped in veins can dissipate.
THE PROCEDURE: ARM
PRESSURE (2 OF 2)

– Place bell of stethoscope over site of brachial artery, making

a light but airtight seal.
– Diaphragm endpiece usually adequate, but bell designed to
pick up low-pitched sounds of blood pressure reading
– Rapidly inflate cuff to maximal inflation level you determined.
– Then deflate the cuff slowly and evenly, about 2 mm Hg per
heartbeat.
– Note points at which you hear first appearance of sound,
muffling of sound, and final disappearance of sound.
01/22/2026 27
01/22/2026 28
KO R O T KO F F S O U N D S

• Phases of sound: I through V

– Note first appearance of sound.
– Hear muffling of sound.
– Hear final disappearance of sounds.

• For all age-groups, fifth Korotkoff phase is now used to

define diastolic pressure.
• However, when a variance greater than 10 to 12 mm Hg
exists between phases IV and V, record both phases
along with systolic reading.
• Clear communication is important because results
significantly affect diagnosis and planning of care.
COMMON ERRORS IN BP
MEASUREMENT
Leads to high readings

• Taking when physiologically active, following activity, or emotionally

labile
• Narrow cuff size and/or applied too loose
• Reinflating during procedure
Leads to low readings

• Decreased inflation
• Too large cuff size

Can lead to high or low readings—examiner/observer

error
• Position of arm or leg
• Improper cuff size
• Deflating cuff too quickly

01/22/2026 30
O RT H O S TAT I C O R ( P O S T U RA L )
V I TA L S I G N S

• Take serial measurements of pulse and blood pressure in

the following situations:
– You suspect volume depletion.
– Person is known to have hypertension or taking
antihypertensive medications.
– Person reports fainting or syncope.
– Position changed from supine to standing, normally slight
decrease (less than 10 mm Hg) in systolic pressure may
occur.
THE PROCEDURE:
O RT H O S TAT I C V I TA L S I G N S
• Have person rest supine for 2 or 3 minutes,
take baseline readings of pulse and BP, and
then repeat with person sitting and then
standing.
• For person who is too weak or dizzy to stand,
assess BP supine and then sitting with legs
dangling.
– Record BP by using even numbers.
– Also record person’s position, arm used, and cuff size,
if different from standard adult cuff.
THE PROCEDURE: THIGH
PRESSURE
• When BP measured at arm is excessively high, compare it with
thigh pressure to check for coarctation of aorta (congenital
form of narrowing).
– Particularly in adolescents and young adults
– Normally thigh pressure higher than that in arm
– If possible, turn person to prone position on abdomen.
– Wrap large cuff around lower third of thigh, centered over
popliteal artery on back of the knee.
– Auscultate popliteal artery for reading.
– Normally systolic value is 10 to 40 mm Hg higher in thigh
than in arm, and diastolic pressure is same.
01/22/2026 34
I N FA N T S A N D C H I L D R E N :
D E V E LO P M E N TA L C O M P E T E N C E

• Vital signs

– BP is not normally checked in children less than 3 years of age.

– Whenever possible, avoid rectal route and take a tympanic,
inguinal, or axillary temperature.
– Infant: reverse order of vital signs to respirations, pulse and
temperature
– Preschooler: consider normal fear of body mutilation may increase
with any invasive procedure
– School-age: Promote cooperation by explanation and participation
in handling equipment
– Adolescent: Same consideration as with adults
I N FA N T S A N D C H I L D R E N :
T E M P E R AT U R E : T Y M PA N I C
A N D T E M P O RA L A RT E RY
• Tympanic measurement (TMT and TAT)

– Useful with toddlers who squirm at restraint needed for rectal

route, and useful with preschoolers not yet able to cooperate
for oral temperature
– Rapid that it is usually over before child realizes it
I N FA N T S A N D C H I L D R E N :
T E M P E RAT U R E : A X I L L A RY
AND ORAL
• Axillary route safer and more accessible than rectal
route; however, its accuracy and reliability have been
questioned
• When axillary route used, place tip well into axilla, and
hold child’s arm close to body.
• Use oral route when child old enough to keep mouth
closed; usually at age 5 or 6, although some 4-year-old
children can cooperate.
• When available, use an electronic thermometer because
it is unbreakable, and it registers quickly.
I N FA N T S A N D
CHILDREN:
T E M P E R AT U R E : R E C TA L
• Use rectal route with infants or with other age groups when other
routes are not feasible, such as with the child who is unable to
cooperate, agitated, unconscious, critically ill, or prone to seizures.

• Infant may be supine or side lying, with examiner’s hand flexing

knees up onto the abdomen.

• Separate buttocks with one hand and insert lubricated electronic

rectal probe no farther than 2.5 cm (1 in); insertion any deeper
risks rectal perforation.

• Normally rectal temperatures measure higher in infants and young

children than in adults, with an average of 37.8° C (100° F) at 18
months.

• Also, temperature normally may be elevated in late afternoon,

after vigorous playing or after eating.
I N FA N T S A N D C H I L D R E N :
P U L S E , H E A RT RAT E , A N D
R E S P I RAT I O N S
• Pulse

– Palpate or auscultate an apical rate with infants and toddlers.

(brachial)
– In children older than 2, use radial site.
– Count pulse for a full minute to consider normal irregularities, such as
sinus arrhythmia.
– Heart rate normally fluctuates more with infants and children than
adults from exercise, emotion, and illness.

• Respirations

– Watch infant’s abdomen for movement, because infant’s respirations

are normally more diaphragmatic than thoracic.
– Sleeping respiratory rate is the most accurate in infants.
– Count for a full minute due to pattern variation.
I N FA N T S A N D C H I L D R E N :
BLOOD PRESSURE (1 OF 3)
• In children aged 3 and older, and in younger children at
risk, measure a routine BP at least annually.
• For accurate measurement in children, make some
adjustment in choice of equipment and technique.
• Most common error is to use incorrect size cuff.

• Cuff width must cover two thirds of upper arm, and cuff
bladder must completely encircle it.
• Use a pediatric-sized endpiece on stethoscope to locate
sounds.
I N FA N T S A N D C H I L D R E N :
BLOOD PRESSURE (2 OF 3)

• If possible, allow crying infant to become quiet

for 5 to 10 minutes before measuring the BP;
crying may elevate the systolic pressure by 30
to 50 mm Hg
• Use disappearance of sound (phase V Korotkoff)
for diastolic reading in children.
• For consistency, typically take in the right arm

• Note guidelines for BP standards based on sex,

age and height for precise classification
I N FA N T S A N D C H I L D R E N :
BLOOD PRESSURE (3 OF 3)
• Children younger than 3 years have such small
arm vessels that it is difficult to hear Korotkoff
sounds with a stethoscope.
– Instead, use an electronic BP device that uses oscillometry,
such as Dinamap, and gives digital readout for systolic,
diastolic, and MAP and pulse.
– Or use a Doppler ultrasound device to amplify sounds
T H E A G I N G A D U LT : V I T A L
SIGNS (1 OF 2)
• Temperature: changes in body’s temperature regulatory
mechanism leave aging person less likely to have fever but at
greater risk for hypothermia
– Temperature is less reliable index of older person’s true
health state; sweat gland activity is also diminished.
• Pulse: normal range of heart rate is 50 to 95 bpm, but rhythm
may be slightly irregular
– Radial artery may feel stiff, rigid, and tortuous in older
person, although does not necessarily imply vascular disease
in heart or brain.
– Increasingly rigid arterial wall needs faster upstroke of blood,
so pulse is easier to palpate.
T H E A G I N G A D U LT : V I T A L
SIGNS (2 OF 2)

• Respirations: aging causes decrease in vital capacity and

decreased inspiratory reserve volume
– You may note shallower inspiratory phase and an increased
respiratory rate.

• Blood pressure: aorta and major arteries tend to harden with

age
– As heart pumps against a stiffer aorta, systolic pressure
increases, leading to widened pulse pressure.
– In many older people, both systolic and diastolic pressures
increase, making it difficult to distinguish normal aging values
from abnormal hypertension.
M E A S U R E M E N T O F OX Y G E N
S AT U RAT I O N ( 1 O F 2 )
• Pulse oximeter: a noninvasive method to assess SpO2

• Sensor attached to person’s finger or ear lobe has diode

that emits light and detector measures relative amount
of light absorbed by HbO2 and unoxygenated (reduced)
Hb
– Compares ratio of light emitted to light absorbed and
converts this ratio to percentage of oxygen saturation
M E A S U R E M E N T O F OX Y G E N
S AT U RAT I O N ( 2 O F 2 )
• Healthy person with no lung disease and no anemia

normally has an SpO2 of 97% to 99% on room air

– Select appropriate pulse oximeter probe
– Finger probe spring loaded and feels like clothespin attached
to finger but does not hurt
– At lower oxygen saturations, ear lobe probe more accurate
and less affected by peripheral vasoconstriction
 E L E C T R O N I C V I TA L S I G N S
MONITOR(DINA MAP)
• Used frequently in the clinical setting

• Noninvasive, fast and has automated settings

• Will provide BP, MAP, and pulse

• Can also provide temperature and pulse oximetry

• Used for serial measurements  trending data

THE DOPPLER TECHNIQUE

• In many situations, pulse and BP measurement is

enhanced by using an electronic device, Doppler
ultrasonic flow meter.
• Technique works by a principle that sound varies in pitch
in relation to distance between sound source and
listener: pitch is higher when distance is small, and pitch
lowers as distance increases.
• In this case, sound source is blood pumping through
artery in rhythmic manner.
• Handheld transducer picks up changes in sound
frequency as blood flows and ebbs, and it amplifies
them.
THE PROCEDURE:
DOPPLER TECHNIQUES (1 OF 2)

• Listener hears whooshing pulsatile beat.

• Doppler technique is used to locate peripheral pulse sites.

• For BP measurement, Doppler technique augments Korotkoff

sounds.
• Through this technique, you can evaluate sounds that are hard to
hear with a stethoscope, such as those in critically ill individuals
with a low BP, in infants with small arms, and in obese persons in
whom sounds are muffled by layers of fat.
• Also, proper cuff placement is difficult on obese person’s cone-
shaped upper arm.
• In this situation, you can place cuff on more even forearm and
hold Doppler probe over radial artery.
THE PROCEDURE:
DOPPLER TECHNIQUES (2 OF
2)
• For either location, use the following procedure:

– Apply coupling gel to transducer probe.

– Turn Doppler flow meter on.
– Touch probe to skin, holding probe perpendicular to artery.
– A pulsatile whooshing sound indicates location of artery.
– May need to rotate probe but maintain contact with skin.
– Do not push probe too hard or you will wipe out pulse.
– Inflate cuff until sounds disappear; then proceed another 20 to 30
mm Hg beyond that point.
– Slowly deflate cuff, noting point at which first whooshing sounds
appear; this is systolic pressure.
 ABNORMAL FINDINGS
A S S O C I AT E D W I T H V I TA L S I G N S
• Hypotension

– Normotensive adults under 90/60 mm Hg

– Hypertensive adults under the person’s average reading but above 90/60
mm Hg
– Children under expected value based on age
– Seen in acute myocardial infarction (AMI), shock, hemorrhage, vasodilation,
and/or Addison’s disease

• Essential or primary HTN (no known cause, accounts for 95% of HTN cases in
adults)
– BP Pressure Guidelines
• ACC/AHA Task Force

• JNC-8 Guidelines

• Stage 1 and 2 HTN

 C A R D I O VA S C U L A R R I S K
S T R AT I F I C AT I O N

• Major risk factors impacting target organs and

vasculature
– Smoking
– Dyslipidemia
– Diabetes Mellitus  above 60 year of age, gender (men and
postmenopausal women)
– Family history of cardiac disease  women under 65 years of age
and men under 55 years of age
L I F E S T Y L E M O D I F I C AT I O N S
FOR HTN
• Prevention and management

– Weight loss
– Limit alcohol use
– Increase aerobic exercise activity pattern
– Reduce sodium intake
– Maintain adequate sources of dietary potassium, calcium and
magnesium
– Smoking cessation
– Reduce intake of saturated fats and cholesterol