• Include temperature, respiratory rate, pulse, and blood pressure

  • Pain is sometimes considered the 5th vital sign and should be assessed with other vitals

  • Cardinal Signs are pulse, BP, and respirations

• Data that is trended throughout patient experiences in multiple clinical practice settings

• Follow stated facility guidelines for monitoring

• Use nursing judgment to warrant additional assessment

• Baseline takes precedent

• Every 4 to 8 hours for stable patients

• Every 15 to 60 minutes for postprocedure or postoperative patients

• Every 5 minutes or continuously for critical or unstable patients

• Anytime a patient is admitted to a facility

• During an inpatient stay and for ongoing care

• During a physical assessment

• For any changes in the patient's condition

• Pre-, intra-, and postoperative

• Before and after invasive procedures

• Prior to and after administration of medications that impact cardiac, respiratory, or thermal regulation systems

• Prior to and after certain interventions, such as suctioning

• Before transfer to another unit or discharge

• Infection

• Renal, respiratory, and cardiovascular disease

• Physical environment

• Emotional state of the patient

• Medications

• Food and fluid intake

• Activity level and tolerance.

• BP is NOT normally checked in children less than 3 years of age.

• Whenever possible, avoid rectal route and take a tympanic, inguinal, or axillary temperature.

  • Infant: reverse order of vital signs to respirations, pulse and temperature

  • Preschooler: consider normal fear of body mutilation may increase with any invasive procedure

  • School-age: Promote cooperation by explanation and participation in handling equipment

  • Adolescent: Same consideration as with adults

Age Oral Temp Pulse Respirations SpO2 Systolic Diastolic (BPM) (BPM) (%) (mmHg) (mmHg)

0-3m 35.5°--37.5° C 110--160 35--55 >95 65--85 45--55 (96°--99.5° F)

3-6m 35.5°--37.5° C 110--160 30--45 70--90 50--65 (96°--99.5° F)

6-12m 35.5°--37.5° C 90--160 22--38 80--100 55--65 (96°--99.5° F)

1 yr 35.5°--37.5° C 80--150 22--30 90--105 55--70 (96°--99.5° F)

6 yr 35.5°--37.5° C 60--110 16--22 100--120 60--75 (95.9°--99.5°
F)

15 yr 36.4°--37.6° C 60--100 12--20 110--135 65--85 (97.6°--99.6°
F)

Adult 36.4°--37.6° C 60--100 12--20 90--<120 60--<80 (97.6°--99.6°
F)

• Cellular metabolism needs mean of 37° C at rest

• Steady temp through NEGATIVE feedback mechanism

• Regulated in hypothalamus of brain.

• Balances heat production with heat loss

• changes in body's temperature regulatory mechanism leave aging person less likely to have fever but at greater risk for hypothermia

• Temperature is less reliable index of an older person's true health state; sweat gland activity is also diminished.

• Carotid → Neck

• Brachial → Arm

• Radial → Wrist

• Femoral → Upper Leg

• Popliteal → Behind knee

• Posterior Tibial → Lower Leg

• Dorsalis Pedis → Foot

• Apical → Heart (from middle of the collarbone and down five rib spaces)

  • Always assess full minute; most accurate

★ Healthy Adult = 50/60 - 95/100 BPM

★ Tachycardia = Above 95/100 BPM

★ Bradycardia= Below 50/60 BPM

• Pulse: palpable flow felt in the periphery as a result of pressure wave generation from stroke volume

• Amplitude = strength of the ventricular contractions, amount of circulating blood volume, and blood vessel tone.

  • weak, strong, or bounding when the pulse is palpated.

  • 0-3+ scale

• Pulse contour/configuration =amount and force of blood ejected from the heart into the aorta.

  • Contour with smooth upstroke and downstroke

• Expected Findings→ regular rhythm, strong amplitude, contour with smooth upstroke and downstroke

• Variable and depends on physiologic and emotional factors.

• Age: As age increases from infancy to adulthood, the pulse rate decreases.

• Gender: After puberty, the average male pulse is lower than that of the average female.

• Fever: Pulse increases with fever because of the increased metabolic rate and peripheral vasodilation that occurs.

• Medications: Various medications may either increase or decrease the pulse rate.

• Hypovolemia: Loss of blood normally increases the pulse rate from sympathetic nervous system stimulation.

• Hypoxia and hypoxemia: When oxygen levels decrease, cardiac output increases to attempt to compensate, resulting in an increased pulse rate.

• Stress: Sympathetic nervous system stimulation from stress (e.g., fear, anxiety, and the perception of pain) increases the heart rate.

• Pathology: Heart conditions or illnesses that impair oxygenation can alter the pulse rate as cardiac output attempts to compensate for low oxygen levels. Head injuries can cause a drop in pulse to compensate for increased intracranial pressure.

• Electrolyte imbalance: Changes in potassium and calcium affect pulse rate and rhythm.

• Fear

• Caffeine

• Palpate or auscultate an apical rate with infants and toddlers.

• In children older than 2, use radial sites.

• Count pulse for a full minute to consider normal irregularities, such as sinus arrhythmia.

• Heart rate normally fluctuates more with infants and children than adults from exercise, emotion, and illness.

• normal range of heart rate is 50 to 95 bpm, but rhythm may be slightly irregular

• Radial arteries may feel stiff, rigid, and tortuous in older people, although this does not necessarily imply vascular disease in the heart or brain.

• Increasingly rigid arterial walls need faster upstroke of blood, so pulse is easier to palpate.

• Normal = relaxed, regular, automatic, and silent.

• Diaphragm moves downward, pulling air into lung = respiration

• Air pushed out of lungs = expiration

• To assess respirations, count them while your hand is still in position for taking the pulse.

  • That way, the patient is not aware that respirations are being counted and will not alter the breathing pattern.

• Normally, respirations are relaxed, regular, automatic, and silent.

• The normal rate varies with the patient's age, and the ratio of the pulse rate to respiratory rate commonly is 4 to 1.

• No dyspnea, or difficulty breathing

• Regular rhythm, or pattern of breathing

• Rate between 12 and 20 breaths per minute

• Pronounced thoracic movement when sitting up; pronounced abdominal movement when lying supine

• Ratio of respirations to heartbeats should be about 1:4

• Bradypnea = less than 12 breaths per minute

• Tachypena = more than 20 breaths per minute

• Watch the infant's abdomen for movement, because infant's respirations are normally more diaphragmatic than thoracic.

• Sleeping respiratory rate is the most accurate in infants.

• Count for a full minute due to pattern variation.

• Higher respiratory rates due to weakened respiratory muscles.

• Blood pressure is the force of the blood pushing against the blood vessel walls.

• BP is the force of blood pushing against the vessel wall

• Strength of push changes with events in cardiac cycle.

  • Systolic pressure

    • the maximum pressure felt on the artery during left ventricular contraction (or systole).

    • Systolic = left ventricular contraction = top number

  • Diastolic pressure

    • the elastic recoil (or resting) pressure the blood exerts constantly between contractions.

    • Diastolic = rest between each contraction = bottom number

  • Pulse Pressure

    • difference between systolic and diastolic

    • Reflects stroke volume

  • Mean Arterial Pressure

    • pressure forcing blood into tissues, averaged over cardiac cycle

• Average BP varies normally with many factors:

  • Age: gradual rise through childhood and into adult years

    • BP rises with age related to stiffening of the Aorta and Arterial Walls

  • Sex: after puberty, females show a lower BP than males; after menopause, females higher than males

  • Race: Differences exist relative to combination of genetics and environment.

  • Social Determinants: Effects of environment & social factors lead to increased risk of HTN

  • Diurnal rhythm: Daily peak and trough levels r/t timing cycles

    • 3-4am

  • Weight: Obesity increases blood pressure as compared to normal weight recorded measurements of the same age.

  • Exercise: Will cause a transitory increase in blood pressure

  • Emotions: Will increase in response to sympathetic nervous system response

  • Stress: Will increase in response to increased stress and tension

  • Position: Systolic decreases when changing from sitting to standing, diastolic slight change also

1. Cardiac output: increase in CO leads to increase in BP whereas decrease in CO leads to decrease in BP

2. Peripheral vascular resistance: increased resistance(vasoconstriction) leads to increase in BP whereas decrease in resistance(vasodilation) leads to decrease in BP

   • Incr. resistance = vasoCONSTRICTION = high BP

   • Decr. resistance = vasoDILATION = low BP

3. Volume of circulating blood: fluid retention leads to increased BP whereas hemorrhages leads to decreased BP

4. Viscosity: increase associated with increase in BP

5. Elasticity of vessel walls: increasing rigidity associated with increase in BP

• Hypotension (Less than 90 mmHg Systolic or less than 60 mmHg Diastolic)

  • can be caused by dehydration, heart failure, neurologic, cardiac or endocrine disorders

• Orthostatic Hypotension occurs when systolic decreases by 20+ mmHg or diastolic decreases by 10+ mmHg with position change

• At least 3 separate BP measurements to confirm hypertension

• Ensure you have the correct size

  • 40% as wide and 80% as long as patients arm circumference

  • Too Narrow = Falsely High

  • Too Large= Falsely Low

• Usually use Brachial Artery on Right Arm

• Limb should be supported and maintained at heart level.

  • If below heart level= falsely low

• For patients who receive hemodialysis the nurse should avoid the arm on the side with the arteriovenous fistula ➔ Use the Two Step Method to obtain Blood Pressure

• Orthostatic vital signs are taken when the patient is in various positions: supine, sitting, and standing.

• Blood pressure can be taken in the thigh if the blood pressure measured in the arm is excessively high.

1. With the patient's bare arm supported at heart level, center the cuff about 1 inch above the brachial artery and wrap it evenly.

2. After placing the stethoscope bell over the brachial artery, inflate the cuff 20 to 30 millimeters of mercury above the point where the arterial pulsation is obliterated.

3. Then deflate it slowly and note the points at which you hear Korotkoff sounds I, IV, and V.

   1. Appearance: the first loud tapping sound heard→systolic

   2. Softening: Weakened clapping sound and soft wind like murmur

   3. Sharpening: Blowing wind like murmur disappears

   4. Muffling: Tone is suddenly dull

   5. Disappearance: Loss of all sound → Diastolic

4. Document the patient's blood pressure, include the arm used, patient's position, and cuff size, if different from a standard adult cuff.

• In children aged 3 and older, and in younger children at risk, measure a routine BP at least annually.

• For accurate measurement in children, make some adjustment in choice of equipment and technique.

• Most common error is to use incorrect cuff size.

• Cuff width must cover two thirds of the upper arm, and the cuff bladder must completely encircle it.

• Use a pediatric-sized endpiece on a stethoscope to locate sounds.

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• If possible, allow crying infant to become quiet for 5 to 10 minutes before measuring the BP; crying may elevate the systolic pressure by 30 to 50 mm Hg

• Use disappearance of sound (phase V Korotkoff) for diastolic reading in children.

• For consistency, typically take in the right arm

• Note guidelines for BP standards based on sex, age and height for precise classification

• Children younger than 3 years have such small arm vessels that it is difficult to hear Korotkoff sounds with a stethoscope.

  • Instead, use an electronic BP device that uses oscillometry, such as Dinamap, and gives digital readout for systolic, diastolic, and MAP and pulse.

  • Or use a Doppler ultrasound device to amplify sounds

• aging causes decrease in vital capacity and decreased inspiratory reserve volume

• You may note shallower inspiratory phase and an increased respiratory rate.

• The measurement of oxygen saturation is an additional noninvasive method of general physical assessment.

• A sensor attached to the individual's finger or earlobe has a diode that emits light and measures light absorption of pulsatile flow.

  • Uses a photodetector with two diodes connected to a mini processor that provides a visual output of the oxygen saturation

  • Oxygenated hemoglobin absorbs the light

  • The amount of light is used to calculate the ratio of Oxygenated to Deoxygenated

• A Doppler may be used to locate peripheral pulse sites or for blood pressure measurement when sounds are difficult to hear with a stethoscope alone.

  • In many situations, pulse and BP measurement is enhanced by using an electronic device, Doppler ultrasonic flow meter.

  • Technique works by a principle that sound varies in pitch in relation to distance between sound source and listener: pitch is higher when distance is small, and pitch lowers as distance increases.

  • In this case, the sound source is blood pumping through the artery in a rhythmic manner.

  • Handheld transducer picks up changes in sound frequency as blood flows and ebbs, and it amplifies them.

• Percentage of hemoglobin that is saturated with oxygen

  • Tells the nurse how much oxygen is being carried in the blood as a percentage of the maximum it can carry

• Must be placed on area where the skin is translucent

  • (finger, toe, or pinna of the ear)

• When used on an infant may use foot, big toe, palm of hand and thumb

• aorta and major arteries tend to harden with age

• As the heart pumps against a stiffer aorta, systolic pressure increases, leading to widened pulse pressure.

• In many older people, both systolic and diastolic pressures increase, making it difficult to distinguish normal aging values from abnormal hypertension.