Vital Sign

Tony Suharsono

Learning Objective
Describe the physiological mechanism governing
temperature, pulse, respiration, and blood
pressure
Identify the normal age related variation for vital
sign variation
Select the appropriate equipment used to take
vital sign
Identify the sites for measuring vital sign
Assess temperature, pulse, respiration and blood
pressure

Background
Assesing and monitoring a client condition is
the main reason nursing care is required
Vital sign meaning the measurement of client
Temperature (T)
Pulse (P)
Respiration (R)
Blood Pressure (BP)

Indicate circulatory, respiratory, neural and

endocrine sistem

The Vital Sign

Vital sign are fundamental to assessment to
establish base line values of the client
cardiorespiratory integrity
Variation from normal finding may indicate
potential problems
Vital sign are taken whenever the client admited
to health care facilities or service
The frequency of vital sign measurement is
determined by the client health status, the
phisician order, and standart of care in particular
setting

Thermoregulation
The body regulation function of het regulation
to maintain a constant internal body
temperature
Measure in unit callled degrees
The core internal temperature of 98,6F atau
37C does not vary more than 1,4F (0,77C)

Thermoregulation
Heat is produced in the body cell through food
metabolism that result energy
When heat rises, the hipotalamus transmit
impulse to reduce body heat by triggering
perspiring, vasodilatation and inhibit heat
production
When heat decrease, opposite phisiologic
respond occurs, vasoconstriction, muscle
shivering, and pieloerection

Respiration
Act of breathing
Defined by physiological functioning as :
External respiration
Internal respiration
Inspiration
Expiration
Vital capacity

Respiration
Provide oxygen to the tissue and remove
carbondioxide through :
Ventilation
Circulation
Diffusion
Transport
Regulation

Hemodinamic Regulation
Physiological function of blood circulation to
maintain an appropriate environtment in
tissue fluids
Stroke volume : 60-70 ml
Cardiac output
Pulse pressure

Pulse
The bounding of blood flow in an artery that is
palpable at various point on the body
Pulse site : temporal, carotid, apical, brachial,
radial, femoral, popliteal, posterior tibial and
doesalis pedis

Pulse point

Blood Pressure
Measurement of pressure pulsation exerted
against the blood vessel wall during sistole
and diastole
It is measured in term of milimeter of mercury
(mmHg)
Sistolic blood pressure
Diastolic blood pressure

Regulator of Blood Pressure

Blood volume
Cardiac output
Peripheral vascular resistance
Viscocity

Factors Influencing Vital Sign

Age
Gender
Heredity
Race
Lifestyle
Environtment
Medication
Pain
Other factor

Factors Influencing Vital Sign

Equipment Used for Vital Sign

Measurement

Equipment Used for Vital Sign

Measurement

Measuring Body Temperature

Body temperature is measured during the
routine physical examination by using one of
the instruments
Frequent monitoring is required for clients
who have or are at risk for infection;
Accuracy of temperature measurement is
essential because it guides nursing and
medical decision making and interventions

Measuring Body Temperature

A centigradecalibrated scale ranges from 34
to 42C, and a Fahrenheit calibrated scale
ranges from 94 to 108F.
Traditional sites for measuring the bodys
internal (core) temperature are
oral (OT),
rectal (RT),
axillary (AT), and
Thympani

Measuring Body Temperature

Oral and rectal temperature measurements are
higher than axillary because the measuring
device is in contact with the mucous membrane.
Rectal measurements are higher than oral
because of the seal created by the anal sphincter,
which decreases contact with environmental air.
If there is danger that the client will bite and
break the thermometer.

Measuring Body Temperature

The axilla is commonly used as a site for
infants and children with disabilities because
it is the safest, even though least accurate,
method
Axillary or rectal sites are used for clients who
are uncooperative, comatose, or who have a
nasogastric or feeding tube in place.

Measuring Body Temperature

Alteration in Thermoregulation

Measuring Pulse
There are multiple pulse points. The most
accessible peripheral pulses are the radial and
carotid sites.
Because the body shunts blood to the brain
whenever a cardiac emergency such as
hemorrhage occurs, thecarotid site should
always be used to assess the pulse in these
situations.

Measuring Pulse
The common sites for each type of assessment
are:
Complete physical assessmentapical and all
bilateral peripheral pulses
Initial assessmentapical and bilateral
peripheral radial and dorsalis pedis pulses
Routine vital sign assessmentapical and radial
pulses in adults and apical and temporal pulses in
infants and children

Measuring Pulse

Respiratory Measurement
Normal breathing is slightly observable,
effortless, quiet, automatic, and regular.
It can be assessed by observing chest wall
expansion and bilateral symmetrical
movement of the thorax.

Respiratory Measurement
Eupnea refers to easy respirations with a normal rate of
breaths per minute that are age-specific.
Bradypnea is a respiratory rate of 10 or fewer breaths per
minute.
Hypoventilation is characterized by shallow respirations.
Tachypnea is a respiratory rate greater than 24 breaths per
minute.
Hyperventilation is characterized by deep, rapid
respirations.
Dyspnea refers to difficulty in breathing as observed by
labored or forced respirations through the use of accessory
muscles in the chest and neck to breathe.

Measuring Blood Pressure

The most common site for indirect blood
pressure measurement is the clients arm over
the brachial artery
When the clients condition prevents
auscultation of the brachial artery, the nurse
should assess the blood pressure in the
forearm or leg sites

Measuring Blood Pressure

Measuring Blood Pressure

Hypotension refers to a systolic blood pressure
less than 90 mm Hg or 20 to 30 mm Hg below the
clients normal systolic pressure.
Orthostatic hypotension (postural hypotension)
refers to a sudden drop of 25 mm Hg in systolic
pressure and 10 mm Hg in diastolic pressure
when the client moves from a lying to a sitting or
a sitting to a standing position
Hypertension refers to a persistent systolic
pressure greater than 140 mm Hg and a diastolic
pressure greater than 90 mm Hg