Vital Signs

Equipment Needed

A Stethoscope
A Blood Pressure Cuff
A Watch Displaying Seconds
A Thermometer

General Considerations

The patient should not have had alcohol, tobacco, caffeine, or performed vigorous exercise within 30 minutes of the exam.
Ideally the patient should be sitting with feet on the floor and their back supported. The examination room should be quiet and the patient comfortable.
History of hypertension, slow or rapid pulse, and current medications should always be obtained.

Temperature

Temperature can be measured is several different ways:

Oral with a glass, paper, or electronic thermometer (normal 98.6F/37C) [p129] [1]
Axillary with a glass or electronic thermometer (normal 97.6F/36.3C)
Rectal or "core" with a glass or electronic thermometer (normal 99.6F/37.7C)
Aural (the ear) with an electronic thermometer (normal 99.6F/37.7C)

Of these, axillary is the least and rectal is the most accurate.

Respiration

Best done immediately after taking the patient's pulse. Do not announce that you are measuring respirations. [p129, p237] [2]
Without letting go of the patients wrist begin to observe the patient's breathing. Is it normal or labored? [p252]
Count breaths for 15 seconds and multiply this number by 4 to yield the breaths per minute.
In adults, normal resting respiratory rate is between 14-20 breaths/minute. Rapid respiration is called tachypnea.

Pulse

Sit or stand facing your patient. [p274]
Grasp the patient's wrist with your free (non-watch bearing) hand (patient's right with your right or patient's left with your left). There is no reason for the patient's arm to be in an awkward position, just imagine you're shaking hands.
Compress the radial artery with your index and middle fingers.
Note whether the pulse is regular or irregular:
Regular - evenly spaced beats, may vary slightly with respiration [p300]
Regularly Irregular - regular pattern overall with "skipped" beats
Irregularly Irregular - chaotic, no real pattern, very difficult to measure rate accurately
Count the pulse for 15 seconds and multiply by 4.
Count for a full minute if the pulse is irregular. [3]
Record the rate and rhythm.

Interpretation

A normal adult heart rate is between 60 and 100 beats per minute (see below for children).
A pulse greater than 100 beats/minute is defined to be tachycardia. Pulse less than 60 beats/minute is defined to be bradycardia. Tachycardia and bradycardia are not necessarily abnormal. Athletes tend to be bradycardic at rest (superior conditioning). Tachycardia is a normal response to stress or exercise.

Blood Pressure

Position the patient's arm so the anticubital fold is level with the heart. Support the patient's arm with your arm or a bedside table. [p277]
Center the bladder of the cuff over the brachial artery approximately 2 cm above the anticubital fold. Proper cuff size is essential to obtain an accurate reading. Be sure the index line falls between the size marks when you apply the cuff. Position the patient's arm so it is slightly flexed at the elbow. [4]
Palpate the radial pulse and inflate the cuff until the pulse disappears. This is a rough estimate of the systolic pressure. [5]
Place the stetescope over the brachial artery. [6]
Inflate the cuff to 30 mmHg above the estimated systolic pressure.
Release the pressure slowly, no greater than 5 mmHg per second.
The level at which you consistantly hear beats is the systolic pressure. [7]
Continue to lower the pressure until the sounds muffle and disappear. This is the diastolic pressure. [8]
Record the blood pressure as systolic over diastolic ("120/70" for example).

Interpretation

Higher blood pressures are normal during exertion or other stress. Systolic blood pressures below 80 may be a sign of serious illness or shock.
Blood pressure should be taken in both arms on the first encounter. If there is more than 10 mmHg difference between the two arms, use the arm with the higher reading for subsequent measurements.
It is frequently helpful to retake the blood pressure near the end of the visit. Earlier pressures may be higher due to the "white coat" effect.
Always recheck "unexpected" blood pressures yourself.


Blood Pressure Classification in Adults

Category

Systolic

Diastolic

Normal

<140 <90 Isolated Systolic Hypertension >140

<90 Mild Hypertension 140-159 90-99 Moderate Hypertension 160-179 100-109 Severe Hypertension 180-209 110-119 Crisis Hypertension >210

>120


In children, pulse and blood pressure vary with the age. The following table should serve as a rough guide:


Average Pulse and Blood Pressure in Normal Children

Age

Birth

6mo

1yr

2yr

6yr

8yr

10yr

Pulse

140

130

115

110

103

100

95

Systolic BP

70

90

90

92

95

100

105




Notes

Page numbers refer to Barbara Bates' A Guide to Physical Examination and History Taking, Sixth Edition , published by Lippincott in 1995.
Unlike pulse, respirations are very much under voluntary control. If you tell the patient you are counting their breaths, they may change their breathing pattern. You cannot tell someone to "breath normally," normal breathing is involuntary.
With an irregular pulse, the beats counted in any 15 second period may not represent the overall rate. The longer you measure, the more these variations are averaged out.
Do not rely on pressures obta