Body temperature readings may reflect the core body temperature, the temperature of the internal organs, or the temperature of the body’s surfaces, which change temperature due to environmental exposure [9] . The normal body temperature of a person varies depending on gender, recent activity, food, fluid consumption, time of day, and, in women, the stage of the menstrual cycle. Normal body temperature can range from 97.8 degrees Fahrenheit (F), equivalent to 36.5 degrees Celsius (C) to 99 degrees F (37.2 degrees ˚C) for a healthy adult. A person’s body temperature can be taken in any of the following ways, orally, rectally, axillary, by ear, or by skin using a thermometer.

The pulse rate is a measurement of the heart rate or the number of times the heart beats per minute. As the heart pushes blood through the arteries, the arteries expand and contract with the flow of the blood. Taking a pulse not only measures the heart rate but also can indicate the heart rhythm and strength of the pulse. The normal range for pulse of healthy adults is 60 to 100 beats per minute. The pulse rate may fluctuate and increase with exercise, illness, injury, and emotions.

The respiration rate is the number of breaths a person takes per minute. The respiration rate is usually measured when a person is at rest. Counting the number of breaths for one minute by counting how many times the chest rises and falls is the respiration rate. Respiration rates may increase with fever, panic, stress, illness, and other health conditions. Normal respiration rates for an adult person at rest range from 12 to 16 breaths per minute [9] .

Blood pressure is the force of the blood pushing against the artery walls during contraction and relaxation of the heart. Pumping blood into the arteries each time the heart beats results in the highest blood pressure as the heart contracts. When the heart relaxes, the blood pressure falls. Two numbers are recorded when measuring blood pressure. The higher number, or systolic pressure, is the pressure inside the artery when the heart contracts and pumps blood through the body. The lower number, or diastolic pressure, is the resting pressure inside the artery when the heart relaxes, filling with blood. Both the systolic and diastolic pressures are recorded as “mm Hg” (millimeters of mercury). This recording represents how high the mercury column in an old-fashioned manual blood pressure device (called a mercury manometer or sphygmomanometer) is raised by the pressure of the blood [9] .

Pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage [10] . Pain assessment is critical to pain management and interventions. The absence of pain is a coveted state of personhood. Several aspects define pain and its effects: pain severity, chronicity, and pain experience. Pain severity contains pain-related interference with activities or disability, and the intensity of pain [11] . It is a universal experience that clients manifest when in certain pathological conditions. It is an integral part of the assessment to determine the appropriate management of clients. Two aspects of pain severity may form a bidimensional or a unidimensional scale depending on the specific instruments tested. High intercorrelations between pain-intensity measures and pain-related disability support the concept of using them as a unitary construct of pain severity [12] . Moreover, disability is a major indicator of the severity of a pain condition and several tools have been developed to assess pain-related disability [13] .

The conceptualization of resilience is complex because resilience has been a subject of study and inquiry by a myriad of theoreticians, and conceptualizers. and until recently a finding of immune resilience despite inflammatory stress promoting longevity and favorable health outcomes including resistance to infection [14] - [16] . Resilience encompasses the capacity to resist, adapt, recover, or bounce back from a challenge [17] . Resilience is the human regenerative capacity to resist, adapt, recover, or grow from a challenge [18] . It maintains health and function in the face of loss, trauma, disease, or bending without breaking. In resilience, the system’s response to a challenge will fluctuate and show various degrees of responses depending on the severity and length of time of exposure to the challenge with innate psychobiological factors. If successful, it will transform failure into growth and challenges into opportunities; but resiliency is fungible and expendable. Studies show that the human attribute of resilience comes with positive adaptation as a marker [19] - [22] .

The concept of resilience is found in theories of motivation, self-advocacy, and self-efficacy [23] . Resilience is considered an attribute that supports health outcomes for those who have been exposed to trauma, environmental hazards, or experiences of abuse [24] [25] . Resilience throughout the life course enhances the ability to recover from adversity, thrive with a sustained purpose, and grow in a world of change, trauma, and chronic illness [26] . Resilience allows individuals to adapt to the wear and tear of living while coping with problems and crises in ways that leave them feeling stronger and wiser than they would have been if they had not encountered those problems and improved healthspan [7] . Furthermore, resilience is seen as both an intervention process and an outcome, while others consider resilience a trait or inborn capability or as a more fluid attribute that comes into play as one equilibrates thinking, feeling, and behaving.

Body temperature may be abnormal due to fever (high temperature) or hypothermia (low temperature). A fever is present when body temperature rises about one degree or more over the normal temperature of 98.6 degrees Fahrenheit. Hypothermia is a drop in body temperature below 95 degrees. [1] It is important to compare body temperature readings to baseline values for an individual [9] . An abnormal temperature may indicate a pathology, such as infection. Monitoring the body temperature dynamically throughout treatment is important. Prolonged exposure to cold makes internal organs hypothermic needing to balance body temperature [9] .

The pulse rate normally varies throughout the day based on activity and rest. A prolonged increase or decrease in rate could indicate exercise, illness, injury, or emotions [1] [9] . Those who do a lot of cardiovascular conditioning, for example, may have rates below 60 and experience no problems [1] . In addition to rate, the pulse is assessed for regularity, strength, and symmetry. An abnormal rhythm could indicate a chronic condition, such as atrial fibrillation, or an acute adverse response to drugs.

Respiration rate is the number of breaths a person takes per minute. The rate is usually measured when a person is at rest and simply involves counting the number of breaths for one minute by counting how many times the chest rises. Normal respiration rates for an adult person at rest range from 12 to 16 breaths per minute [1] . Respiration allows the lungs to access oxygen and eliminate carbon dioxide [9] . Respiration rates may increase with fever, illness, and other medical conditions. While counting, one also assesses if the person exhibits any difficulty breathing as evidenced by posture, nasal flaring, pursed lips, or use of accessory muscles.

Blood pressure is the force of the blood pushing against the artery walls during contraction and relaxation of the heart. High blood pressure, or hypertension, directly increases the risk of heart attack, heart failure, and stroke. With high blood pressure, the arteries may have an increased resistance against the flow of blood, causing the heart to pump harder to circulate the blood. Severe hypertension requires additional assessment as causes may vary from age, pregnancy, or drug use, and treatment would be very different for each. Causes of severe hypotension range from heart failure, sepsis, or hemorrhage. Dynamic monitoring of blood pressure is vital to evaluate the effectiveness of any treatment plan.

It is recognized that psychological, psychosocial, and contextual [27] factors may influence pain perception. These factors have a powerful effect on the experience of pain itself. With this background, pain acceptance, pain tolerance, and pain-related anxiety as factors influencing coping strategies are discussed. Finally, a recommendation for a minimum as well as for a more comprehensive pain assessment is suggested by Pozza, Azevedo & Lopes [11] .

At the core of resilience are stress responses that are sufficient as well as efficient for recovery following stress [19] . Exposure to severe trauma, continuous stress, or illness diminishes one’s resilience. Resilience activates healthy emotional regulation, reappraisal, and help-seeking behaviors [7] breaking the cycle of depletion. Studies have shown resilience and social support go hand and glove because positive emotions arise from belongingness and self-esteem. and help-seeking behaviors, ingredients of social properties of resilience, thus replenishing resilience, and social support and magnifying the practical effect of the intervention.

The potential impact of a resilience intervention in terms of an empirical basis is significant: Adequate resilience to master challenges; coping with stressors through positive emotions and help-seeking behaviors; acceptance of situations beyond one’s control; capacity for cognitive reappraisal; and healthy emotional regulation. Resilience, therefore, is both an intervention and an outcome, though some consider resilience a trait or inborn capability, and others a more fluid attribute that comes into play as one equilibrates thinking, feeling, and behaving [28] .

Hoare [18] suggested that the human attribute of resilience comes with positive adaptation as a marker. The construct of resilience is found in theories of motivation, self-advocacy, and self-efficacy [19] . Resilience is considered an attribute that supports health outcomes for those who have been exposed to trauma, abuse, or environmental. Resilience throughout the life course enhances the ability to recover from adversity, thrive with a sustained purpose, and grow in a world of change, trauma, and chronic illness. Resilience allows individuals to adapt to the wear and tear of living while coping with problems and crises in ways that leave them feeling stronger and wiser than they would have been if they had not encountered those problems and improved healthspan.

Operationalization of temperature involves the assessment and management of a physiologic or pathologic process that affects thermoregulation. Tracking processes such as ovulation which causes a temperature rise is useful for those desiring pregnancy. Restoration of normal body temperature may be an indication of the resolution of a disease process. Slight elevations in temperature, though, are a normal immune response and do not necessarily demand pharmacological intervention. Moreover, the use of pharmacological agents to reduce fevers brings risks in masking the true nature of a disease process.

Operationalization of the pulse includes assessing the rate, rhythm, and strength of the palpated pulse at sites throughout the body as appropriate. Comparing pulse rate from various sources of the body such as left to right radial pulses, or lower extremity pulses distal to proximal. Pulse integrity is vital in the assessment of cardiovascular status and peripheral perfusion. Pulse rate is important in monitoring a disease process or preparing for a procedure, such as the Allen test to confirm ulnar perfusion.

Operationalization of the respiratory rate involves observing the rise and fall of the chest for a full minute. Assessment of the respiration rate could be performed discreetly as knowledge that breaths are being counted can affect the rate. Assessment of rate, depth, and effort becomes part of the diagnostic process as well as the evaluation of treatment.

New guidelines consider any blood pressure of 140/90 as elevated and requiring intervention. Blood pressure may fluctuate dynamically in an acute medical situation that is monitored hourly or sooner or it may be monitored at home over time.

The blood pressure reading is only a guide. A single blood pressure measurement that is higher than normal is not necessarily an indication of a problem. It may be necessary to collect multiple blood pressure measurements over several days or weeks before making a diagnosis of high blood pressure and starting treatment.

Pain severity contains pain-related interference with activities (disability) and the intensity of pain. It was found that these two aspects of pain severity may form a bidimensional or a one-dimensional scale (depending on the specific instruments used. High intercorrelations between pain-intensity measures and pain-related disability measures support the concept of using them as a unitary construct of pain severity [11] . The pain experience contains pain intensity and pain effect. Pain intensity describes how much a patient is in pain whereas pain effect describes the ‘degree of emotional arousal or changes in action readiness caused by the sensory experience of pain. As the perception of pain may differ within a period, recent studies have mentioned that it is more valuable to ask patients to rate their ‘usual’ pain on average over a past short period, e.g., 1 week, than to ask for ‘current’ pain at the specific time of fulfilling a questionnaire [29] . It must also be kept in mind that the same method of assessing pain may have different thresholds of clinical significance, depending on the setting, for example, acute or chronic pain [11] [30] [31] .

The Visual Analogue Scale (VAS) consists of a straight line with the endpoints defining extreme limits such as ‘no pain at all’ and ‘pain as bad as it could be [11] .

We suggest measuring resilience subjectively and objectively as a vital contribution to routine health assessments. To measure psychological resilience subjectively, we suggest using a revised version of the Connor-Davidson Resilience Scale. The revised CD-RISC comprises 5 items, and each item on the scale is rated on a 5-point Likert scale from 0 (not true) to 4 (true nearly all the time). The 5 items are: 1) I can adapt when changes occur, 2) I can deal with whatever comes my way, 3) Cope with stress can make me feel stronger, 4) I am not easily discouraged by failure, and 5) Under pressure, I stay focused and think clearly. The total score ranges from 0 to 20, with higher total scores indicating greater resilience. The Connor-Davidson Resilience Scale demonstrated good construct validity and internal consistency (α = 0.85) during the development of the scale [32] . The CD-RISC-10 also had a good Cronbach’s alpha level of 0.85. The revised CD-RISC interview can be completed in 2 - 3 minutes. The scale can easily be incorporated into a practitioner’s assessment protocol. Patients can complete the scale while waiting to see their provider. Obstacles associated with the incorporation of the scale and resilience as a vital sign may follow a course comparable to the incorporation of pain as a vital.

To measure resilience objectively, we suggest using Immune Resilience (IR) levels, the level of resilience to preserve and/or rapidly restore immune resilience functions that promote disease resistance and control inflammation and other inflammatory stress. IR levels according to [33] are assessed with peripheral blood metrics that quantify the balance between CD8 and CD4 T-cell levels and saliva metrics of gene expression signatures tracking longevity-associated immunocompetence and mortality- or entropy-associated inflammation. Using whole blood and flow cytometric analysis (e.g., cell counting, cell sorting, cell function), a well-known method, the CD4-CD8 ratio can be accurately measured. IR deregulation is potentially reversible by decreasing inflammatory stress. IR metrics and mechanisms have utility as vital signs of biomarkers for measuring immune health and improving health outcomes [14] .

We can begin to look at the mechanisms that drive resilience, allowing a person to rebound from previous disease, injury, or adversity. The Trans National Institute Resilience Working Group has developed a three-component resilience framework that outlines the mechanisms of resilience. The framework begins with a challenge in the form of a stressor that affects a system composed of the environment, community, or individuals, resulting in a response. The response is described as resistance that can lead to collapse to growth/recovery ( https://ods.od.nih.gov/Research/resilience.aspx ) [33] .

Considering the various degrees to which recovery occurs among people, there must be variability in the mechanisms that drive this response. We can see this trend through tangible measurements of resilience, both biological and psychological. Ahuja labeled the biological aspect “immune resilience” (IR) [14] , while the psychological aspect has been substantiated by Connor and David [4] .

Biological Measurement of Immune Resilience

The immune system is the body’s inherent defense system and is constantly fighting off stressors with which the body is confronted. Resilience encompasses the ability to fight off stressors; therefore, it makes sense that there would be a chemical mechanism behind resilience. One of the only studies conducted about this was done by [14] , who aimed to define the term “immune resilience” in terms of measurable hematologic and genetic markers. The study (n = 48,500) consisted of multiple observational study phases of various methods: some longitudinal, some prospective. Each phase of the study involved a group of people, sometimes controlled for age, sex, or both, who had been exposed to some medium of antigenic stimulation, including HIV, COVID-19, sepsis, or common viral respiratory infection. Individuals with high immunocompetence and low inflammatory processes had an increased lifespan, and an increase in COVID-19 survival, and sepsis survival. From their observations, the group determined two concrete facets of the immune system that are associated with trends in response to antigenic stimulation: the CD4-CD8 ratio, and gene expression.

The CD4-CD8 Ratio: Immune Health Grades

CD4 and CD8 cells are both T-cell lymphocytes that function within the immune system. CD4 cells are known as helper cells and have a high-level role in directing mechanisms of immune response, which includes regulating CD8 cell function. CD8 cells are known as cytotoxic cells, which are directly responsible for destroying pathogenic cells [34] . A high quantity of CD4 cells indicates greater immune preparedness (and a stronger immune system), whereas a high quantity of CD8 cells indicates an active response to infection or inflammation. A state of optimal health consists of a higher CD4 cell count and a lower CD8 cell count; thus, a normal CD4-CD8 ratio is one (1). For reference, normal CD4 cell counts are between 500 and 1200, while normal CD8 counts are between 150 and 1000 [35] . To distinguish levels of CD4-CD8 balance, Ahuja and colleagues developed the concept of “immune health grades.” [14] An immune health grade (IHG) of 1 represented “optimal immune resilience (IR)” where CD4 cell counts are high and the CD4-CD8 ratio is one (1) or proximate to 1. An IHG of 2 was less optimal, with low CD4 counts but a ratio still greater than one. IHG-3 had high CD4 counts but a ratio of less than one. IHG-4 was deemed the least optimal IR, with low CD4 and a ratio of less than one. These proportions can be visualized in Figure 1 [14] .

The Immune health grade proposed by Ahuja et al. [14] can be used by practitioners to understand the clinical application of IR and the CD4-CD8 ratio. An immune health grade of one (optimal state) is associated with a CD4-CD8 ratio of one or near one and suggests no need to immediately intervene. With the erosion of immunocompetence and an increase in inflammatory processes, the immune health grade changes from one to two, three, or four. A change in the health grade can prompt the practitioner to intervene because the optimate state no longer exists.

Gene Expression: Transcriptomic Profiles

The group was also able to identify genetic sequences that were associated with specific health outcomes after antigenic stimulation. Some gene signatures resulted in traits that allowed for patient survival (survival-associated signature/SAS-1), while others led to patient entropy (mortality-associated signature/MAS-1). It could be assumed that a greater number of survival-associated

traits would correlate with greater immunocompetence (IC) and IC-related genes. Conversely, it could be assumed that a greater number of entropy-associated traits would correlate with greater inflammation (IF) and IF-related genes. The ideal profile, and an indicator of optimal IR using these metrics, would be SAS-1^high-MAS-1^low because it represents high immunocompetence and low inflammation and was predicted to result in the greatest longevity ( Figure 2 ). Longevity has been refined based on a continuum of survival and entropy; when referred to in this biological context, entropy means degradation of the body trending toward death [36] [37] .