Vital Signs: Temperature, Pulse, Respiration & Blood Pressure

Learning Objectives

• Comprehensive mastery goals derived from lecture slides/pages:
  • Describe the four vital signs assessed in dentistry: temperature, pulse, respirations, blood pressure.
  • Explain WHY recording vitals is integral to dental/ dental-hygiene care (screening for systemic disease, determining treatment modifications, preventing emergencies).
  • Identify temperature ranges that define:
  • Hyperthermic >104^\circ\text{F}
  • Pyrexic (fever) >99.5^\circ\text{F}
  • Hypothermic <96^\circ\text{F}
  • Normal 97–99^\circ\text{F}
  • Demonstrate and accurately document temperature, pulse, respiration (RR), blood-pressure (BP) readings.
  • Discuss “rate” for both pulse (beats · min^{-1}) & respirations (breaths · min^{-1}).
  • Know adult ranges for normal, tachy-, and brady- forms of pulse/respiration.
  • List & describe three interpretation characteristics for both pulse (rate, rhythm, force) and respirations (depth, rhythm, quality/sound).
  • Define systolic vs. diastolic BP; define normal pulse pressure, hypertension, postural (orthostatic) hypotension.
  • Execute full BP procedure, recognize readings warranting faculty/dentist consultation or patient dismissal.

Overview of Vital Signs

• Vital signs act as baseline physiologic indicators; deviations flag physiologic stress, systemic disease, drug reactions.
• Four measures: Temperature → Pulse → Respirations → Blood Pressure (TPR-BP), always obtained with patient seated upright after explanation & consent.
• If ANY reading is outside normal limits, advise medical follow-up & document.

Patient Preparation & Communication

• Position: Upright, arm supported at heart level, legs uncrossed.
• Explain: “Your vital signs help us plan safe dental care and screen for hidden problems.”
• Obtain informed consent; reassure that procedure is non-invasive.
• If abnormal: Document conversation in SOAP format (e.g., “Informed pt of elevated BP and associated risks; advised MD follow-up.”)

Body Temperature

Normal Ranges by Age

• Adults: Average 98.6^\circ\text{F} (range 97–99^\circ\text{F}).
• Older adults (>70 y): Slightly lower average 96.8^\circ\text{F} (36^\circ\text{C}).
• Children (selected milestones):
  • 1 y: 99.1^\circ\text{F}\,(37.3^\circ\text{C})
  • 4 y: 99.4^\circ\text{F}\,(37.5^\circ\text{C})
  • 5 y: 98.6^\circ\text{F}\,(37^\circ\text{C})
  • 12 y: 98^\circ\text{F}\,(36.7^\circ\text{C})

Factors Affecting Temperature

• Time of day: Lowest early AM/ sleep; highest late afternoon/evening.
• Temporary ↑: Exercise, hot drinks, smoking, external heat.
• Pathologic ↑: Infection, dehydration, hyperthyroidism, MI, trauma.
• Decrease: Starvation, hemorrhage, shock.

Temperature Variations & Clinical Actions

• Pyrexia (Fever): >99.5^\circ\text{F} → evaluate; may postpone elective care.
• Hyperthermia: >104^\circ\text{F} → medical emergency; consider hospital referral.
• Hypothermia: <96^\circ\text{F} → monitor; warm patient; potential medical consult.
• Clinic dismissal threshold (per slide): 100.4^\circ\text{F}.

Thermometer Types

• Digital, tympanic, temporal artery scanners, glass/mercury (obsolete). Choose appropriate, follow manufacturer infection-control.

Review Prompt

• “Pt temp 100.5^\circ\text{F} = Fever; 104^\circ\text{F} = Hyperthermia → stop dental care, arrange medical eval; >104^\circ\text{F} counts as emergency.”

Pulse (Heart Rate)

Physiology & Definition

• Pulse = intermittent arterial expansion with each left-ventricular contraction.
• Common site: Radial artery (thumb-side wrist).

Normal Adult Pulse

• Broad normal 60–100\,\text{bpm} (slightly ↑ in women).
• Children: Rate declines with age (e.g., infant 80–160\,\text{bpm}; school-age 75–110\,\text{bpm}).

Abnormal Adult Pulse

• Tachycardia: >100\,\text{bpm}.
• Bradycardia: <50\,\text{bpm}.

Assessment Procedure

1. Explain measurement; ensure arm supported, legs uncrossed.
2. Locate radial pulse with index + middle finger (never thumb).
3. Once pulse felt, count for 1 full minute while watching a clock.
4. Observe & record:
   • Rate (\text{bpm})
   • Rhythm: Regular vs. irregular
   • Strength/Volume: Strong, weak, bounding, thready
5. Chart example: "Pulse: 75\,\text{bpm}, regular, strong."

Mnemonic Example

• Meme slide “Ahem, pulse check” emphasizes clinician mindfulness.

Review Prompt

• Typical adult range? Answer: 60–100\,\text{bpm}.

Respirations (RR)

Function & Definition

• Respiration exchanges O2 for CO2; one inspiration + one expiration = 1 breath.
• Influenced by age, stress, medical status.

Normal Ranges

• Adults: 12–20\,\text{rpm} (slightly ↑ in women).
• Older adults: RR >20 may predict serious events; monitor closely.
• Children: Gradual decline with age; infants 30–60\,\text{rpm}; school-age 18–30\,\text{rpm}.

Abnormal Rates (Adults)

• Bradypnea: <12\,\text{rpm}.
• Tachypnea: >28\,\text{rpm}; >60\,\text{rpm} = dangerous.

Measurement Technique

1. Immediately after pulse, keep fingers on radial artery so pt remains unaware.
2. Count chest rises for 60 s.
3. Maintain patient’s normal posture; avoid verbal cues.

Interpretation Parameters

• Depth: Shallow / Normal / Deep.
• Rhythm: Regular vs. irregular.
• Quality / Sounds: Easy, labored, wheezing, gurgling.
• Document any cyanosis, positional intolerance, or dyspnea.

Review Prompt

• Normal adult RR? 12–20\,\text{rpm}.

Blood Pressure (BP)

Physiology Refresher

• BP = force of circulating blood on arterial walls.
• Generated by left-ventricular systole; propagates through aorta → arteries → arterioles → capillaries.

Components & Normal Values

• Systolic (SBP): Peak during ventricular contraction; target <120\,\text{mmHg}.
• Diastolic (DBP): Trough during relaxation; target <80\,\text{mmHg}.
• Pulse Pressure: \text{SBP} - \text{DBP}; normal \approx 30–40\,\text{mmHg}.

Hypertension (HTN)

• Affects 1⁄3 U.S. population; leading mortality contributor.
• Classification (ACC/AHA guidelines mirrored in slide):
  • Normal: SBP <120 AND DBP <80
  • Elevated: SBP 120–129 AND DBP <80
  • Stage 1 HTN: SBP 130–139 OR DBP 80–89
  • Stage 2 HTN: SBP \ge 140 OR DBP \ge 90
  • Hypertensive Crisis: \ge180/\ge120\,\text{mmHg} → seek emergency care.

Dental-Clinic Protocol (Stage 2 ≥160/95)

1. Take initial BP; record.
2. Wait 5 min → manual retake left arm; record.
3. If still ≥160/95, wait 5 min → third reading; record.
4. Present to faculty & dentist → dismiss patient & refer (treatment postponed; no written medical clearance required).

Hypertensive Crisis Management

• Reading \ge180/120 → stop treatment, inform dentist, consider 911 or hospital referral.

Factors Influencing BP

• ↑: Exercise, meals, stimulants, emotional stress, oral contraceptives.
• ↓: Fasting, rest, depressants, shock, acute blood loss.
• Underlying determinants: Cardiac output (force), peripheral resistance (arterial condition), blood volume.

Equipment

• Sphygmomanometer (cuff + manometer): Mercury (gold standard), aneroid (requires calibration), electronic.
• Stethoscope: Clean earpieces before/after use; earpieces angled forward in ears.

Cuff Selection & Placement

• Width ≈ 1/3$–$1/2 arm circumference; bladder length \ge80\% of arm circumference.
• Position: Lower edge 1\," above antecubital fossa; center over brachial artery (medial to biceps tendon).

Measurement Steps (Manual)

1. Palpate brachial artery; apply cuff snugly.
2. Palpate radial pulse; inflate cuff until pulse disappears → note reading = Estimated SBP.
3. Inflate 30 mmHg beyond estimated SBP → Maximum Inflation Level (MIL) ensuring artery occlusion without excessive discomfort.
4. Place stethoscope over brachial artery; release valve 2–3 mmHg · s^{-1}.
5. Korotkoff sounds:
   • Phase I (first clear “tap”) → SBP.
   • Phase V (last distinct sound) → DBP.
6. Deflate cuff fully; record reading with units (e.g., 118/76\,\text{mmHg}, left arm, seated).

Documentation & Patient Education

• Chart vitals; if elevated, verbally inform patient:
  • Example script: “Your BP is a little high today (e.g., 142/88\,\text{mmHg}). High BP increases risk of emergencies like heart attacks and strokes. We’ll re-check each visit, but please follow up with your physician.”
• SOAP entry: “Informed pt of elevated BP & risks; advised MD f/u.”

Follow-Up & Ethical Obligations

• Record vitals on ALL new patients; re-check at least annually.
• Provide lifestyle counseling (diet, exercise, tobacco cessation) at any BP level.
• Screening in dental settings proven effective because many pts unaware of HTN.

Review Prompts

• Device name? Sphygmomanometer.
• Normal adult BP? Approximately

Resting Vital Sign Reference (Table 12-1 Excerpt)

• (Converted key values into concise bullets)
  • Temperature: Infants 99.4–99.7^\circ\text{F} → Adults 97–99^\circ\text{F}.
  • Pulse: Infants 80–160\,\text{bpm} → Adults 60–100\,\text{bpm}.
  • Respirations: Infants 30–60\,\text{rpm} → Adults 12–20\,\text{rpm}.
  • BP: Systolic rises with age; by ≥13 y target 104–<120/60–<80\,\text{mmHg}.

Consolidated Numeric “Cheat Sheet”

• Temp dismissal cutoff (clinic): \ge100.4^\circ\text{F}.
• Adult benchmarks:
  • Pulse 60–100\,\text{bpm} (Tachy >100, Brady <50).
  • RR 12–20\,\text{rpm} (Tachy >28, Brady <12).
  • BP categories per ACC/AHA (see above table).
• Hypertensive crisis: \ge180/120\,\text{mmHg}.
• Maximum Inflation Level: Estimated SBP + 30\,\text{mmHg}.

Practical / Ethical / Real-World Connections

• Early detection of fever prevents spread of infection & cross-contamination in dental office.
• Identifying HTN in dental settings reduces national burden of stroke & CVD; supports inter-professional care.
• Respiration monitoring critical for local anesthetic + nitrous oxide administration; abnormal RR signals sedation or medical emergency.
• Pulse & BP guidance help tailor epinephrine dosage in local anesthetics for cardiac-compromised pts.

Memes & Humor References (Contextual Examples)

• “No thermometer…No fever!” meme underscores false assumptions; always verify clinically.
• Labor vs. male fever meme highlights perceived severity but clinically objective thresholds matter.
• “Picture it, Sicily 1912” Golden Girls meme: reminder not to skip counting respirations out of habit.
• “You claimed you don’t have high BP” meme: stresses medication cross-check with medical history.

End-of-Lecture Reminder

• “EVERYTHING IS IMPORTANT!” — All vitals interrelate; accurate technique & documentation are non-negotiable for patient safety.