Vitals Assessment: Pulse, Respiration, and Blood Pressure

• Vital signs (VS) are the most frequently measured objective data for monitoring vital body functions.
• VS are a primary indicator of changes in a patient’s condition.
• VS are used to establish a baseline, observe trends, and gauge response to therapy.

Obtaining VS and Clinical Impression

• Five classical vital signs include temperature, pulse rate (PR), respiration rate (RR), blood pressure, and pulse oximetry (SpO2).
• Pulse oximetry measures oxygen saturation (SpO2) and heart rate.
• Initial assessments should also include height, weight, level of consciousness (LOC), responsiveness, and general clinical impression.
• Non-invasive monitoring is increasingly becoming part of standard VS measurements.

Frequency of VS Measurements

• The frequency of VS measurements depends on the patient's condition.
• Baseline measurements should be taken on admission, at the beginning of a shift, prior to treatment or a procedure, and when the patient’s condition changes.
• Routine VS are most commonly recorded every 4-6 hours.
• In respiratory care, VS are taken before and after treatments.
• Following surgery, VS are typically recorded every 15 minutes for 2 hours, then every 30 minutes for 2 hours.

Trends in Vital Signs (VS)

• A trend consists of a series of VS measurements over time.
• A trend is dynamic and clinically more important than a single, isolated measurement.
• Any abnormal measurement should be compared with previous measurements before starting or changing therapy.
• A 24-hour graph allows for visual interpretation of trends.
• VS should be interpreted in relation to the patient’s age, disease, and environment.

Comparing Vital Signs

• Key to VS assessment is to look for constant changes, considering facial expressions, body movements, color, and breathing effort.
• Listen for sounds, rhythm, feelings, and fears.
• Touch for moisture, temperature, pulse quality, and muscle and skin tone.
• Reassess and analyze data by comparing it to previous information to check if it is logical.
• Trend information should be analyzed over a period of time.
• Differential diagnosis (DD) involves comparing multiple signs and symptoms to determine a patient’s diagnosis.

Clinical Impression

• General appearance provides information about the level of distress and severity of illness, personality, hygiene, culture, and reaction to illness.
• If a patient is in distress, the priority is to rapidly evaluate the problem and intervene.
• If the patient is not in distress, perform a head-to-toe inspection.
• Information may include apparent age, posture, motor activity, nutritional status, and mental acuity.

Visual Signs of Distress

• Cardiopulmonary distress presents as irregular, fast, or shallow breathing, choking, wheezing, cyanosis, and chest pain.
• Anxiety may manifest as restlessness, fidgeting, and choppy sentences.
• Pain may present as moaning, shallow breathing, and inability to take a deep breath to cough.
• Bleeding and LOC require immediate intervention.

Level of Consciousness

• Adequate cerebral oxygenation is needed to be awake, alert, and oriented.
• Orientation is evaluated in terms of time, place, and person with person being the most useful.
• With inadequate cerebral blood flow, a person may become restless, confused, disoriented, or comatose.
• Lethargic patients are sleepy, easily aroused, and respond appropriately.
• Obtunded patients are difficult to arouse but respond appropriately.
• Stuporous patients do not wake up completely, respond to pain, and have slow respirations.
• Comatose patients are unconscious and have a loss of reflexes.
• The Glasgow Coma Scale is the gold standard tool for assessing level of consciousness.

Glasgow Coma Scale (GCS)

• Used to assess a patient's level of consciousness based on Eye Opening (E), Verbal Response (V), and Motor Response (M).
• The total score ranges from 3 to 15; lower scores indicate more severe impairment.

Eye Opening (E)

• 4: Spontaneous
• 3: To verbal stimuli
• 2: To pain
• 1: No response

Verbal Response (V)

• 5: Oriented
• 4: Confused
• 3: Inappropriate words
• 2: Incomprehensible sounds
• 1: No response

Motor Response (M)

• 6: Obeys commands
• 5: Localizes pain
• 4: Withdraws from pain
• 3: Abnormal flexion (decorticate)
• 2: Abnormal extension (decerebrate)
• 1: No response

GCS Interpretation

• 13–15: Mild brain injury
• 9–12: Moderate brain injury
• 3–8: Severe brain injury (coma)

Height and Weight

• Routinely measured as part of the physical exam.
• 1 inch = 2.54 cm
• Weight should be recorded in kg (1 kg = 2.2 lb).
• Follow-up is done every 1-2 days for hospitalized patient.
• If dehydration or fluid overload occurs, intake and output are monitored until the patient’s fluid balance is stable.

Body Temperature

• Normal body temperature is 98.6ºF (37℃), with a range of 97º-99.5ºF (36.5-37.5℃).
• Afebrile refers to being without fever.
• Normal elevations in body temperature can occur during exercise, ovulation, and the first trimester of pregnancy.
• Body temperature is balanced between heat loss and heat production, with the hypothalamus as the regulator and the respiratory system removing heat.

Body Temperature/Fever

• Hyperthermia is being febrile with a temperature above normal.
• Hyperthermia can occur as a result of diseases, infection, or normal activity, like exercise.
• If temperature is above 102ºF, it is most likely from infection.
• An increase in body temperature leads to an increase in metabolic rate, O2 consumption, and CO2 production.
• For every 1℃ elevation, there is a 10% increase.

Heart Rate

• Evaluate for rate, rhythm, and strength or character synchronicity.
• Palpate for vessel wall thickness, radio-femoral delay, and peripheral pulse.
• Normal adult heart rate is 60-100 bpm.
• HR ≥ 120 bpm indicates tachycardia.
• Common causes of tachycardia include anxiety, fear, exercise, fever, hypotension, anemia, hypoxemia, hyperthyroidism, and medications like adrenaline.
• HR < 60 bpm indicates bradycardia.
• Causes of bradycardia include diseased heart or IHD, being an athlete, hypothermia, hypothyroidism, and drugs like atropine.
• The most common non-emergency site for pulse measurement is the radial artery.
• Pulse rate should be assessed for 1 minute.
• If hypotension is present, assess centrally.
• If the radial pulse is not felt, check the carotid arteries.
• The brachial artery is the best site in emergency conditions for infants.

Heart Rate/Pulse Rate Measurement

• 0: absent
• 1+: weak, thready
• 2+: slightly reduced
• 3+: normal
• 4+: bounding large

Normal Heart Rate by Age (Simplified)

• Newborn (0–1 month): 100–180 bpm
• Infant (1–12 months): 100–160 bpm
• Toddler (1–3 years): 90–150 bpm
• Child (3–10 years): 70–140 bpm
• Adolescent & Adult (10+ years): 60–100 bpm

O2 Saturation/SpO2 & Pulse Oximetry

• Pulse oximetry measures O2 saturation % and pulse rate (PR).
• Checking O2 saturation is good for reducing O2 flow/L at the bedside, checking HR during short-term therapy, and continuous monitoring.

Respiratory Rate (RR)

• Varies with age.
• Normal adult value is 12-20 breaths/min (cycle/min).
• Tachypnea: RR above the normal. Causes are similar in etiology to tachycardia.
• Bradypnea: RR below the normal. Causes include head injury, hypothermia, narcotic overdose, and other drug overdoses.
• Apnea is the cessation of breathing.
• Eupnea is a normal rate and depth of breathing.
• Hypopnea is a decrease in the depth of breathing.
• Hyperpnea is an increase in depth which may or may not be associated with an increase in rate.
• Intermittent-irregular breathing with periods of apnea.
• Measured by direct visualization of abdominal and thoracic movement.
• Diaphragm moves downward, while the chest moves upward.
• Watching the abdomen will determine the diaphragmatic movement.
• Must be counted while the patient is not aware.
• Counting should be for one minute, as there will be variation in the rate and the rhythm.

Blood Pressure

• The force applied to the wall of the arteries as blood moves through post ventricular contraction.
• Systolic pressure measures peak force during ventricular contraction.
• Diastolic pressure measures force during the relaxed phase.
• Pulse pressure is the difference between systolic and diastolic, the normal is 35-40 mmHg.
• Normal BP varies with age – Adults; 120/80 (90/60-140/90) mmHg.

Blood Pressure/Measurement

• A sphygmomanometer is used with a cuff applied around the arm and pressurized to exceed systolic BP until blood flow to the artery stops.
• As pressure is released, pulsation can be felt by palpation.
• Partial obstruction of the arterial blood flow + turbulence produces the Korotkoff sounds, which are audible with a stethoscope.

Blood Pressure/Measurement

• Phase-1: First appearance of a palpable pulse – systole.
• Phase-11: Sounds are softer and longer.
• Phase-111: Sounds become louder.
• Phase-1V: Sounds become softer.
• Phase V: Sounds disappear – diastole.

Blood Pressure/Errors in Measurement

• High BP readings occur if: the cuff is too narrow, the cuff is applied too tight or too loose, or there is excessive pressure to the cuff or incomplete deflation.
• A low BP reading occurs if the cuff is too wide.
• Static electricity, ventilation, and room sounds may cause erroneous readings.
• Systolic BP decreases slightly during inspiration.
• If it drops more than 10 mmHg, it indicates pulsus paradoxus.
• Pulsus paradoxus is present in severe bronchial asthma and cardiac tamponade (fluid around the heart, causing it to be compressed).
• Due to negative intrathoracic pressure, blood return increases to the right side of the heart and decreases arterial flow to the left side of the heart.
• Hypotension can be caused by a weak left ventricle, blood loss, vasodilation, certain medications such as diuretics, administration of sedatives, paralyzing agents, and some anesthetics.

Assess your knowledge of vital signs including pulse assessment techniques for infants, pulse qualities, and respiration rates. Also covers accurate pulse oximetry description, respiratory rate terminology, blood pressure measurement, and pulsus paradoxus.