Vital Signs: Temperature, Pulse, Respiration, Blood Pressure, and Oxygen Saturation

Core temperature

37 °C = 98.6 °F (readings may vary due to the method used to measure)

Significant fever

38 °C = 100.4 °F

Cold patient

36 °C

Oral temperature measurement

Check for lesions (wear gloves), wait 15 min if the patient has eaten or smoked in the last 30 min, use a disposable probe cover and insert sublingually.

Rectal temperature measurement

Wear gloves, use a probe cover and lubricate, and insert about 1 in. Most accurate measure of core temperature - reads up to 1°F higher than oral temp.

Tympanic membrane temperature measurement

Use special probe cover, insert into ear canal aiming at tympanic membrane.

Temporal artery temperature measurement

Slide across the forehead and behind ear.

Infrared scanner

Hold 1-2 in from forehead.

Pulse

With every heartbeat, blood leaves the left ventricle and produces pressure.

Normal pulse rate

50-95 bpm.

Bradycardia

A resting heart rate in adults of <50 bpm (accompanied by dizziness).

Tachycardia

A heart rate in adults of >100 bpm.

Pulse strength scale

1+ - weak pulse, 2+ - average, 3+ - strong pulse.

Radial pulse measurement

Use 2-3 finger tips to press the artery against the wrist at the base of the thumb, count beats for 1 min, note the rate, rhythm, and strength.

Carotid pulse measurement

Locate the rings of the trachea with your fingertips, then slide your fingers laterally into the groove between the trachea and the sternomastoid muscle, count beats for 1 min, note the rate, rhythm, and strength.

Apical pulse measurement

If you feel an irregular heartbeat, auscultate the apical pulse with your stethoscope for one full minute just below the left breast.

Respiration

Air moving in and out of lungs (10-20 per min).

Counting breaths

Watch for rise and fall of chest, count for one full minute.

Blood Pressure

Measuring the force of blood pushing through the body.

Normal BP range for adults

90/60 to 120/80.

Systolic Pressure

Pressure against walls of artery during systole (contraction).

Diastolic Pressure

Pressure against walls of artery during diastole (relaxation).

Cuff Positioning for BP

Select proper cuff size, place smoothly against bare skin.

Patient Positioning for BP

Patient can be sitting up or lying down, feet flat, arm should be supported at heart level.

Checking BP - Palpable Systolic

Position patient and cuff correctly, palpate the radial pulse then inflate the cuff with slow pumps, slowly release air from the cuff, noting the radial pulse.

Auscultating BP

Place the diaphragm or bell at the antecubital space over the brachial pulse point, slowly inflate cuff 20-30 higher than the palpable systolic, slowly release the air, first beat you hear is the systolic measurement, the last beat you hear is the diastolic measurement.

Developmental Differences in Vital Signs

Techniques may vary depending on the age/ability of your patient.

Infants and Children - Temperature

Can tolerate tympanic or temporal reading best. 5+ years can tolerate oral readings.

Infants and Children - Pulse

Auscultate the apical heart rate for 1 full minute for infants and toddlers. The radial pulse can be used from about age 3 and up.

Infants and Children - Respirations

Easiest to count breaths while sleeping (30-40 per min).

Infants and Children - Blood Pressure

Use an appropriately sized cuff and stethoscope.

Aging Adults - Temperature

Older adults less likely to run a fever, and more likely to be hypothermic.

Aging Adults - Pulse

Normal rate is 50-95, but rhythm may be irregular.

Aging Adults - Respirations

Aging causes decrease in lung function, so you may find that respirations are shallower and more rapid.

Aging Adults - Blood Pressure

The aorta and arteries harden with age, so blood pressure readings tend to increase over time.

Oxygen Saturation

(normal = 95+), place on fingertip with light beam centered over fingernail.

Electronic vital signs monitor

Can measure temp, pulse, BP, and O2 saturation.

Doppler

Hand-held device that uses sound waves to detect blood pumping.