vital signs

vital signs

temperature

pulse

respiratory rate

blood pressure

orthostatic

pulse oximetry

height and weight

normal temperature

core body temperature average = 37º C (98.6ºF)

• oral average = 36.5ºC (97.7ºF)

• rectal average = 37º (98.6ºF)

  • more accurate

abnormal temperature

hyperthermia - 37.8ºC (100.4ºF); febrile

hypothermia - <36ºC (96.8ºF)

variations in temperature due to:

diurnal cycle

• 1º-1.5ºF, trough in early morning hours and peak in late afternoon/early evening

menstruation cycle

• progesterone secretion causes 0.5º-1ºF increase until menses

exercise

• moderate to hard exercise increases body temperature

age

• wider variations in infant and young child

  • lower temperature in older adults → 36.2ºC via oral

pulse

palpation of artery

count radial pulse for 30 seconds

apical pulse - most accurate location to assess heart rate

• infants and children → 4th intercostal space, left midclavicular line

• adults → 5th intercostal space, left midclavicular line

• count for full 60 seconds

normal pulse

60-100 bpm

• higher in children

• 50-95 bpm in aging adult

  • easier to palpate and may feel more stiff

abnormal pulse

bradycardia <60 bpm

tachycardia >100 bpm

force of pulse

3+ - full, bounding

2+ - normal

1+ - weak, thready

0 - absent

normal respiratory rate

10-20 breaths per minute

4:1 ratio HR:RR

effort or working of breathing (WOB)

higher rate in children

aging causes decrease in vital capacity and IRV

• shallower inspiratory phase and increase rate

abnormal respiratory rate

tachypnea >24 breaths per minute

bradypnea <10 breaths per minute

blood pressure

systolic - maximum pressure during LV contraction (systole)

diastolic - pressure during resting or filling (diastole)

Korotkoff sounds used to assess BP

pulse pressure = difference between systolic and diastolic

mean arterial pressure (MAP) = (SBP+2(DBP))/3

• ≥60 mmHg needed to maintain organ perfusion

normal blood pressure

average = 120/80 mmHg

abnormal blood pressure

hypotension <90/60 mmHg

hypertension

• elevated sys = 120-129 dia <80

• stage 1 HTN sys = 130-139 dia = 80-89

• stage 2 HTN sys≥140 dia≥90

five factors of blood pressure

1) cardiac output

• increased CO = increased BP

2) peripheral vascular resistance

• vasoconstriction = increased BP

3) volume of circulating blood

• fluid retention = increased BP

• hemorrhage = decreased BP

4) viscosity

• increased BP

5) elasticity of vessel walls

• rigidity = increased BP

variations in blood pressure due to:

age

• rise through childhood and into adult years

sex

• after puberty, females lower than males

• after menopause, females higher than males

race

social determinants

• effect of social and environmental factors lead to increased risk of HTN

diurnal rhythm

weight

• obesity increased blood pressure

exercise

emotions

• BP increases in response to SNS

stress

• BP increases

common errors in blood pressure reading

high reading

• taken when active

• narrow cuff size

• applied too loose

• reinflating during procedure

• crossed legs

low reading

• decreased inflation

• too large cuff size

• deflating cuff too quick

• arm raised too high

orthostatic vital signs

used when suspect volume depletion, concerns related to blood pressure, medications, dizziness, or syncope

orthostatic testing

1) rest supine for at least 3 minutes → take baseline BP and pulse

2) sit patient up → take BP and pulse

3) stand patient up → take BP and pulse

4) wait 3 minutes with patient still standing → retake BP and pulse

orthostatic hypotension

drop in SBP ≥ 20 or DBP ≥ 10

pulse oximetry

pulse oximeter used to noninvasively measure arterial oxygen saturation (SpO₂)

• sensor emits light to detect oxygen molecules saturating hemoglobin

normal pulse oximetry

>95% on room air

challenges to pulse oximetry

poor circulation, cold extremities, dark nail polish

height

measure with wall-mounted device or scale stadiometer

person stands shoeless, head level

record in centimeters and inches

weight

use standardized or electronic scale

no shoes or heavy clothing

record in kilograms and pounds

keep conditions consistent: time of day, clothing, etc

compare to previous weight

BMI

kg/m²

tells about nutrition or obesity

does not account for body fat distribution