Chapter 4 General Inspection and Measurements of Vital Signs

axillary, temporal, and tympanic temperatures

For pediatric patients newborn to 5 years of age use:

Axillary temperature

place the probe in the middle of the axilla

Poorly reflects core temperature (not close to major blood vessels

Temperatures are 1 degree lower than oral temperatures

temporal temperature

uses Infrared technology to measure temporal artery temperature

place the disposable cover on the probe

place in the center of the forehead, press the button, and slide along the hairline and behind the ear then release the button

Non-invasive and shows a high level of accuracy in children and critically ill adults

tympanic temperature

measures tympanic membrane temperature

probe is covered and placed inside the external ear canal with firm but gentle pressure

the probe must come into contact with all sides of the ear canal

tug the helix of the ear downward for infants/children

tug helix of the ear upward for adults

impacted cerumen can interfere with the measurement

research has shown that likely due to errors in technique this method may be unreliable

oral temperature

acceptable for ages 5 to adults (hold probe for children)

In adults- smoking, eating, and drinking can impact for 10 minutes

place in the posterior sublingual pocket

measures the temperature of the carotid artery

pacifier thermometers are gaining popularity for infants

rectal temperature

last resort in children because of fear and potential rectal perforation

position children in a side-lying position with knees flexed

lubricate the probe and insert a maximum of 2.5 cm

96.4 F - 99.1 F with an average of 98.6 F

The expected temperature ranges from:

Diurnal variations of 1 F to 1.5 F

The lowest temperature is found early in the morning and the highest temperature is found in the late afternoon and early evening

0.5 F to 1 F at ovulation until the cycle ceases

during the menstrual cycle, a woman's temperature increases by:

newborns temperature

Less effective heat-control mechanisms

Hyperthermia - viral/bacterial infections, dehydration, exposure to heat

Hypothermia - environmental exposure

older adult temperature

Usually lower due to decreased metabolism and less physical activity (97.2 degree F)

oxygen saturation

measured with a pulse oximeter

estimates the oxygen saturation of hemoglobin in the blood

probe clipped to finger, toe, ear lobe, or nose

90% to 100% is the normal range

hypoxia

less than 90% oxygen saturation

Low oxygen saturation of the body, not enough oxygen in the blood

heart rate

The number of times the heart beats per minute

commonly assessed indirectly by palpating a pulse

radial artery, brachial artery, carotid artery, and auscultating apical pulse

can find heart rate by palpating the:

apical pulse

auscultation of the heart

usually done in infants

can use bell or diaphragm to count the heart sounds

left side of the chest in the 5th intercostal space at the midclavicular line

The apical pulse is located at the:

rhythm

time between each pulsation

rate

number of pulsations per minute

if regular, palpate for 30 seconds and multiply by 2

if irregular, palpate for 1 full minute

infants/children auscultate for 1 full minute

100-160 bpm

infant (1 to 12 months) heart rate:

98-140 bpm

toddler (1 to 3 years) heart rate:

75-118 bpm

school-age child (3 to 12 years) heart rate:

60-100 bpm

adolescent (12-18 years) heart rate:

60-100 bpm

adult heart rate:

increases as much as 10-15 bpm

pregnancy heart rate:

cardia

heart rate

tachycardia

fast heart rate

bradycardia

slow heart rate

respiratory rate

the number of complete ventilator cycles (inspiration/expiration) in one minute

abdominal breathers

men/babies are:

thoracic breathers

women are:

rhythm, depth, and effort

In addition to assessing the respiratory rate, note the:

fever, anxiety, exercise, and increased altitude

elevations of respiratory rate:

30-53 breaths/min

newborn (birth to 28 days) or infant (1 month-12 months) respiratory rate:

22-37 breaths/min

toddlers (1 to 3 years) respiratory rate:

18-25 breaths/min

school-age children (3 to 12 years) respiratory rate:

12-20 breaths/min

adolescent (12 to 18 years) respiratory rate:

12-20 breaths/min

adult respiratory rate:

pnea

respiratory rate or breathing

tachypnea

fast respiratory rate or breathing

bradypnea

slow respiratory rate or breathing

pediatric blood pressure assessment

measurement should occur with every health visit over age 3

may be taken in arm or leg

less than 120 and less than 80

normal blood pressure

120-129 and less than 80

elevated blood pressure

130-139 OR 80-89

stage 1 hypertension

140 or higher OR 90 or higher

stage 2 hypertension

180 or higher OR 120 or higher

hypertensive crisis

blood pressure

measurement of the force of blood against arterial walls

reflects the relationship between cardiac output and peripheral resistance

systolic blood pressure

maximum pressure on arteries when ventricles contract

diastolic blood pressure

minimum blood pressure exerted on vessels as ventricles are relaxed

pulse pressure

difference between systolic and diastolic pressure

usually 30-40 mmHg is expected

Example: 120-80 mmHg = 40 mmHg

direct blood pressure

invasive procedure of inserting catheter into an artery

continuous measurement and arterial waveforms

used in critical care setting

indirect blood pressure

includes manual blood pressure and automated blood pressure

manual blood pressure

auscultation of sounds using sphygmomanometer

automated or oscillometric blood pressure

detection of blood flow vibrations and converts to electrical impulses

blood pressure auscultation method

Blood flows freely until the inflated cuff occludes the artery and silences sound.

As pressure is released listen for Korotkoff sounds (clear rhythmic thumping)

first Korotkoff sound

systolic blood pressure

Fifth Korotkoff sound

when the sound disappears

diastolic blood pressure

age, gender, pregnancy, race, diurnal variations, emotions, pain, personal habits, and weight

physiologic factors that affect blood pressure are:

patient's legs crossed, arm below the level of heart, cuff bladder is too narrow, cuff is too loose, reinflating without complete deflation, and failure to wait 1-2 minutes before repeating measurements

false high blood pressure:

the patient's arm is above the level of the heart, the cuff is too wide, not inflating enough, deflating cuff too quickly (faster than 2 mmHg per second), and pressing diaphragm too firmly on brachial artery

false low blood pressure:

midway between the olecranon and acromial process

the arm circumference should be measured:

80 to 100% of arm circumference

cuff bladder length:

40% of arm circumference

cuff bladder width:

orthostatic hypotension

a decrease in systolic blood pressure of at least 20 mmHg or a decrease in diastolic blood pressure of at least 10 mmHg when the patient moves from a lying or sitting position to standing

systolic 72-104 and diastolic 37-56

newborn (birth to 28 days) blood pressure:

systolic 86-106 and diastolic 42-63

toddler (1 to 3 years) blood pressure:

systolic 97-115 and diastolic 57-76

school-age children (3 to 12 years) blood pressure:

systolic 110-131 and diastolic 64-83

adolescent (12-18 years) blood pressure:

systolic less than 120 and diastolic less than 80

adult blood pressure:

height assessment

Taken at every visit until age 18-20years

Infants - recumbent length (head to heel)

Have the patient stand on the scale without shoes

Move the headpiece to the top of head

Record in inches or centimeters

Adult height is achieved between 18-20years

Most older adults have a decrease r/shortening of vertebrae and thinning vertebral disks

weight assessment

taken at every visit until age 18-20 years

Infant: platform scale. Has curved sides to keep the infant from rolling off. Place paper on the scale. Child in a dry diaper.

Older adult: may need handles on the scale or close by

BMI is calculated beginning at age 2

Pregnancy: target weight gain is 25-35pounds for normal prepregnancy weight

Unintentional changes can be a significant finding

Fluid retention- 1 L of fluid increases weight by 2.2 lbs. (1 kg)

Older adults: over 80 yrs may decrease r/tmuscle wasting and a decrease in water

skinfold caliper

a tool used to measure the thickness of subcutaneous tissue

wood lamp

used to detect fungal infections of the skin or corneal abrasions of the eye

ophthalmoscope

the instrument used to inspect the internal structures of the eye

otoscope

the instrument used to inspect external auditory canal and tympanic membrane

audioscope

used to perform basic screening for hearing acuity

The patient is instructed to raise an index finger when the tone is heard, which should correspond to the light seen on the audiometer

tuning fork

auditory screening and assessment of vibratory sensation

nasal speculum

Spreads opening of nares to inspect internal surfaces of nose

doppler

a device that amplifies sounds that are difficult to hear with an acoustic stethoscope

goniometer

an instrument used to measure the flexure or extension of a joint

percussion hammer

an instrument with a rubber head, used for testing reflexes

monofilament

an instrument used to test for sensation on the lower extremities

vaginal speculum

an instrument used to open the vagina to examine it and the cervix

transilluminator

used to differentiate the characteristics of tissue, fluid, and air within a specific body cavity