Vital Signs
• Blood pressure: A measurement of the force, or pressure, of the
circulating blood on the interior walls of the blood vessels. 120/80
• Pulse: The rhythmic dilation of the arteries that occurs with the
beating of the heart.
• Body temperature: The balance of heat produced by the body and
the heat lost to the environment.
• Respiratory rate: The number of breaths taken per minute.
• Oxygen saturation: The estimated amount of oxygen bound to the
hemoglobin molecule in red blood cells, indicating the amount of
oxygen being transported to body tissues.
• Systolic BP: The maximum amount
of pressure exerted when the
heart contracts and forces blood into the
aorta.
• Diastolic BP: The minimum amount
of pressure exerted when the heart is
relaxed.
Alteration in Blood Pressure:
Hypotension 80/56
is a blood pressure that is
below the expected reference range as
determined by a client’s usual baseline
measurement.
• In the absence of baseline data, a systolic
pressure less than 90 mm Hg or a diastolic
pressure less than 60 mm Hg is typically
considered hypotension for an adult.
• Manifestations of hypotension can include
dizziness, nausea, blurred vision, increased
pulse, and fatigue.• Increase fluids.
• Place in an upright position unless medically contraindicated.
• Evaluate the medications the client is taking.
• Instruct the client about the risk for dizziness and falling.
• Encourage the client to change positions slowly.
• Avoid extremes in temperature.
• Stay well hydrated.
Alteration in Blood Pressure:
Hypertension
Hypertension is a blood pressure above the
expected reference range.
• A client is diagnosed with stage I hypertension when
the systolic pressure is 130 to 139 mm Hg or the
diastolic pressure is 80 to 89 mm Hg.
• When a client’s systolic pressure is greater than 140
mm Hg or the diastolic pressure is greater than 90
mm Hg, they have stage II hypertension.
• A hypertensive crisis occurs when the systolic
pressure is greater than 180 mm Hg and/or the
diastolic pressure is greater than 120 mm Hg.
• Encourage the client to adopt lifestyle interventions such as
exercise, stress reduction techniques, a low-sodium diet,
and weight loss if needed.
• Provide the client with information about antihypertensive medications, if
prescribed by the provider, including expected adverse
effects and when the provider should be notified.
Pulse
• The pulse is the rhythmic dilation of the arteries and pulsation of blood flow
that occurs with each contraction of the heart.
• The expected reference range is 60 to 100 beats per minute.
- Less than 60 would be bradycardi
- More than 100 would be tachycardia
• The pulse rate is variable and influenced by many factors including:
• body position.
• age.
• activity level.
• health conditions.
• body temperature.
Grading Pulses
0 = pulse that is absent/nonpalpable
+1 = pulse that is weak/diminished
+2 = pulse that is normal
+3 = pulse that is increased/strong
+4 = pulse that is bounding
Alteration in Pulse Rate:
Tachycardia
• Pulse greater than 100/minute.
• Possible causes
• Exercise
• Anxiety
• Certain medications
• Caffeine and nicotine
• Abnormality in the electrical system
of the heart
• Some clients experience no symptoms. Some report a “racing” feeling in the chest.
Alteration in Pulse Rate:
Bradycardia
• Pulse less than 60 beats per minute.
• Possible causes
• Expected in physically fit individuals
• Congenital cardiac abnormalities
• Heart failure
• Heart muscle damage
• Hypothyroidism
• There are often no symptoms in physically fit individuals. Other individuals may report dizziness, fatigue, shortness of breath, chest pain, of confusion.
Body Temperature
• The measurement of the balance of heat produced by the body and the heat lost to the
environment.
• Measured in degrees.
• Expected body temperature is between 36° C and 38° C (96.8°F and 100.4° F).
• Average temperature for most clients is 37° C (98.6° F).
Alteration in Body Temperature:
Fever/Hyperthermia
• A fever is an increase in body temperature above the expected reference range of 38°C
(100.4° F).
• Commonly caused by infection.
• Symptoms may include a flushed face, diaphoresis, skin that feels “hot,” tachycardia, and increased respiratory rate.
• Encourage sips of cool fluids.
• Remove excess clothing.
• Administer medications as ordered.
• Antipyretics to reduce or prevent fever
• Antibiotics or antivirals if an infection is present
• Place the client in a cooler environment.
• Give a tepid bath
Respiratory Rate
Respiration consists of inspiration and expiration.
• Inspiration is the intake of air by the lungs in order to oxygenate body tissues and support cellular function.
• Expiration expels carbon dioxide
from the lungs.
Expected reference range is 12 to 20 breaths per minute.
Alteration in Respiration:
Tachypnea
• Respiratory rate above the expected reference range (greater than 20 breaths per minute).
• Possible causes
• Physical activity
• Anxiety
• Pain
• Health conditions (e.g., asthma)
• Common symptoms
• Dizziness
• Tingling in the hands
Alteration in respiration:
Bradypnea • Respiratory rate that is below the
expected reference range (less
than 12 breaths per minute).
• Possible causes
• Health conditions
• Medications: opioids,
sedatives
• Common symptoms
• Dizziness
• Fatigue
• Weakness
• Confusion
• Impaired coordination
Oxygen Saturation
• Oxygenation saturation is the estimated amount of oxygen bound to
the hemoglobin.
• Expressed as a percentage
• Direct reflection of a client’s respiratory status
• Expected reference range is 95% to 100%.
Alterations in Oxygenation
• Decreased oxygen saturation is a level below 95%.
• Possible causes
• Health condition (e.g., pneumonia, chronic lung disease, pulmonary edema, poor cardiac output).
• Common symptoms
• Decrease in mental alertness
• Confusion
-wheezing - bronchoconstriction
-stridor - blockage
-rhonchi - mucus
-rales / crackles - fluids