Basic Home Nursing

Vital Signs
BDRRMC - Crossing Bayabas
 1 Definition of Vital signs

Contents: 2 Definition of Body Temperature

3 Assessing Body Temperature

4 Definition of Pulse

5 Assessing Pulse

6 Definition of Respiration

7 Assessing Respiration

8 Definition of Blood Pressure

9 Assessing Blood Pressure

Vital Signs
Vital signs also known as cardinal signs include
body temperature, pulse respiration and blood
pressure. These signs are used to determine the
functioning of the body.

Purposes:
Can identify the existence of an acute medical
problem.
Are a means of rapidly quantifying the
magnitude of an illness and how well the body
is coping with the resultant physiologic stress.
Are a marker of chronic disease states
Guidelines on when to assess
the vital sign
When you arrive at the area where the accident occurs.
On admission to a health care agency to obtain baseline data.
When a client has a change in health status or reports symptoms such as
chest pain or feeling faint.
According to a nursing or medical order.
Before and/or after the administration of a medication that could alter the
respiratory or cardiovascular systems.

Before and after surgery or an invasive diagnostic procedure.

Before and after nursing intervention that could affect the vital signs.
 Body
Temperature
Temperature is the balance between the
heat produced by the body and heat loss
from the body measured in head units
called degrees.

Types of body temperature

1. Core Temperature – Temperature of deep tissues of the
body, such as the abdominal cavity or pelvic cavity.
2. Surface Temperature - Temperature of skin,
subcutaneous tissue and fat.
Factors affecting body temperature

AGE Diurnal Exercise. Hormones.

Variation.

Stress. Environment. Pyrexia.

Hypothermia.
 Purpose of assessing body
temperature

To establish baseline To determine changes in

data the body temperature in
To identify if the response to specific
body temperature is therapies or to the
incident.
within the normal
To monitor clients at risk
range. for alterations in body
temperature.
Average temperature by age
Pulse
It is the wave of blood created by
contraction of the heart's left ventricle.
Purposes of
assessing the Pulse
1. To establish baseline data for subsequent evaluation.
2. To identify whether the pulse rate is within normal range.
3. To determine the pulse volume and whether the pulse
rhythm is regular.
4. To determine the equality of corresponding peripheral
pulses on each side of the body.
5. To monitor and assess changes in the client's health status.
6. To monitor clients at risk for pulse alterations (e.g., those
with a history of heart disease or experiencing cardiac
arrhythmias, hemorrhage, acute pain, infusion of large volumes
of fluids, or fever).
7. To evaluate blood perfusion to the extremities.
 Factors Affecting the Pulse

Medications
Fever
AGE Sex Exercise.

Pathology

Hypovolemia Stress Position

/Dehydration
 Definition of terms commonly
associated with pulse
Pulse Sites

Temporal
1. Peripheral pulse - Pulse located away
from the heart (e.g. foot or wrist)
Carotid
2. Tachycardia - An excessively fast hear Apical
rate. Brachial
3. Bradycardia - A heart rate in adult of Radial
less than 60 beats/min.
Femoral
4. Pulse rhythm - Patterns of the beats
and the intervals between the beats.
Popliteal
5. Dysrhythmia/Arrhythmia - A pulse with Posterior Tibial
an irregular rhythm. Dorsalis Pedis
Reasons for Using Specific
Pulse Site
 Respiration
Ø It is the act of breathing.
Ø It is the act of inhaling and exhaling air in
order to exchange oxygen for carbon
dioxide

Purposes:
1. To acquire baseline data against which future
measurements can be compared.
2. To monitor abnormal respirations and respiratory
patterns and identify changes.
3. To monitor respirations before or after the
administration of a general anesthetic or any
medication that influences respirations.
4. To monitor clients at risk for respiratory
alterations.
 Definition of terms commonly
associated with Respiration
Tidal volume. During a normal inspiration and expiration, an adult takes in about 500 mL of air
Hyperventilation. Refers to very deep, rapid respirations
Hypoventilation. Refers to very shallow respirations
Respiratory rhythm. It is the regularity of the expirations and the inspirations.
Respiratory Quality. Refers to those aspects of breathing that are different from normal, effortless breathing.

Factors affecting respiration

1. Exercise
2. Stress
3. Increased environmental temperature, and lowered oxygen
concentration at increased altitudes
4. Decreased environmental temperature
5. Certain medications
6. Increased intracranial pressure (ICP)
7. Body position
 Blood
Pressure
It is a measure of the pressure exerted by the blood as it flows
through the arteries
a. SYSTOLIC PRESSURE – the pressure of the blood as a result
of contraction of the ventricles, that is, the pressure of the
height of the blood wave.
b. DIASTOLIC PRESSURE –the pressure when the ventricles are
at rest.
c. PULSE PRESSURE – difference between the diastolic and the
systolic pressures
Factors Affecting the Blood Pressure

Medications
Race
AGE Sex Exercise.

Medical
Conditios
Obesity Stress Diurnal
Variation.
Definition of terms commonly
associated with blood pressure
1. Hypertension. A BP that is persistently above normal.
2. Hypotension. Is a BP that is below normal, that is, a systolic reading consistently
between 85 and 110 mmHg in an adult whose normal pressure is higher than this.
3. Orthostatic hypotension. Is a BP that decreases when the client sits or stands
 Purposes:
To obtain baseline data
To determine client's hemodynamic status
To identify and monitor changes in BP

Note: Note:
When having difficulty hearing blood
If this is the initial nursing pressure sounds, the following technique is
assessment of a patient, take the recommended;
blood pressure on both arms. It is 1. With cuff in place raise the client's arm,
normal to have a 5-to 10-mm Hg over his or her head for 15 seconds before
rechecking the blood pressure.
difference in the systolic residing
2. Inflate the cuff while the arm is elevated,
between arms. Use the arm with and gently lower the arm while continuing
the higher reading for subsequent to support it.
pressure. 3. Position the stethoscope, and deflate the
cuff at the usual rate while listening for
Korotkoff sounds.
 Purposes:
To obtain baseline data
To determine client's hemodynamic status
To identify and monitor changes in BP

Note: 1. Use cuff size appropriately for limb

circumference. Inform client that cuff
Raising the arm over the head sizes range from a pediatric cuff to a
helps relieve congestion of large thigh cuff and that a poorly
blood in the limb, increases fitting may result in an accurate
pressure differences, and measurement.
makes the sounds louder and 2. Inform patient about availability of
more distinct when blood digital blood pressure monitoring
enters the lower arm. equipment. Though costly, most
provide an easy-to-read recording of
systolic and diastolic measurements.
Any Questions?
Clarifications?