After completing the chapter, you will be able to accomplish the following:

1. Assess body temperature via the oral, tympanic, temporal, axillary, and rectal routes.
2. Regulate an infant's temperature using an overhead radiant warmer.
3. Regulate temperature using a hypothermia blanket.
4. Assess peripheral pulses by palpation.
5. Assess an apical pulse by auscultation.
6. Assess peripheral pulses using Doppler ultrasound.
7. Assess respiration.
8. Assess blood pressure using an automated, electronic oscillometric device.
9. Assess blood pressure by auscultation.
10. Assess systolic blood pressure using Doppler ultrasound.

• Assessment
• Clinical Decision Making/Clinical Judgment
• Oxygenation
• Perfusion
• Safety
• Thermoregulation

• apnea
• diaphragm
• diastolic pressure
• dyspnea
• expiration
• febrile
• hyperthermia
• hypothermia
• inspiration
• Korotkoff sounds
• orthopnea
• pulse
• pulse deficit
• pulse pressure
• respirations
• systolic pressure
• tachypnea
• temperature
• vital signs

Vital signs are indicators of physiologic functioning and include a person's temperature, pulse, respiration, and blood pressure, abbreviated as T, P, R, and BP. The health status of a person is reflected in these indicators of body function. Identification of a change in data related to assessment of vital signs is a crucial part of determining and recognizing deterioration in the status of a patient (Dalton et al., 2018). Pain assessment is often included along with measurement of vital signs and is discussed in Chapter 10. Pulse oximetry, the noninvasive measurement of arterial oxyhemoglobin saturation, is also often included with the measurement of vital signs and is discussed in Chapter 14.

Vital signs are assessed and compared with accepted normal values and the patient's usual patterns in a wide variety of instances. Consideration is given to potential variations in vital signs related to specific health conditions, illnesses and complications, medications, environmental factors, and therapies. Monitoring and analysis of the significance vital signs are important nursing responsibilities and are crucial to identifying changes in patient status (Dalton et al., 2018). Monitoring and evaluation of trends in intermittently measured vital signs is an important part of early identification of risk for a serious adverse event, contributing to timely intervention and improved patient outcomes (Brekke et al., 2019; Churpek et al., 2016).

Examples of appropriate times to measure vital signs include, but are not limited to, screenings at health fairs and clinics, in the home, upon admission to a health care setting, when medications are given that may affect one of the vital signs, before and after invasive diagnostic and surgical procedures, and in emergency situations. Nurses take vital signs as often as the condition of a patient requires such assessment, prioritizing and adapting assessment of vital signs to address the patient's unique situation. The nurse should consider the patient's medical diagnosis, comorbidities, types of treatments and medications received, the patient's level of acuity and risk for complications, trends in the patient's vital signs, prescribed interventions, and facility policies to help guide the frequency of assessment for an individual patient (Burchill et al., 2015; Jarvis & Eckhardt, 2020).

Although vital sign measurement may be delegated to other health care personnel when the condition of the patient is stable, it is the nurse's responsibility to ensure the accuracy of the data, interpret vital sign findings, and communicate abnormal findings. Principles of delegation should be followed (see Appendix A). If a patient has abnormal or unusual physical signs or symptoms (e.g., chest pain or dizziness) or has unexpected changes in vital signs, the nurse should validate the findings and further assess the patient. Techniques for measuring each of the vital signs are presented in this chapter. Fundamentals Review 2-1 outlines age-related variations in normal vital signs. Fundamentals Review 2-2 provides guidelines for obtaining vital signs for infants and children.

1. First, assess the problem, talking with Tyrone and his mother, using age-appropriate communication with Tyrone. Because potentially he is thought to have an ear infection, he may be having pain in one or both ears. Assess his status and ability to cooperate and consider another route for temperature measurement. Temporal artery or axillary measurement may be indicated, based on your assessment and facility policy.
2. In addition to the respiratory rate, note the depth and rhythm of the respirations. Auscultate lung sounds. Measure the patient's oxygen saturation level with pulse oximetry. Ask the patient about recent activity and the presence of factors that may have caused an acute asthma attack, and for factors that could affect respirations, such as exercise, medications, smoking, chronic illness or conditions, neurologic injury, pain, and anxiety. Note baseline or previous respiratory measurements. Assess patient for any signs of respiratory distress, which include retractions, nasal flaring, grunting, and orthopnea (breathing more easily in an upright position).
3. Home monitoring of blood pressure for patients with hypertension is strongly recommended. Advise Mr. Glatz that automated blood pressure devices in public areas are generally inaccurate and inconsistent. Use a cuff size appropriate for limb circumference. Inform him that cuff sizes range from a pediatric cuff to a large thigh cuff and that a poorly fitting cuff can result in an inaccurate measurement. Discuss digital blood pressure monitoring equipment. Use of an automated validated digital monitoring device is suggested as best practice for HBPM (Whelton et al., 2018). Although more costly than manual cuffs, most provide an easy-to-read recording of systolic and diastolic measurements.