Rationale: Vital signs were broken up into 4 standard categories. The categories were heart rate (how many beats the heart makes in one minute), respiratory rate (how many breaths the patient takes in one minute), blood pressure (the maximum contraction and resting pressure of the heart during beats), and temperature (an indication of how hot or cold the patient’s internal environment is). A 5th vital sign, pain, has recently been added in the medical field. When a patient is assessed by the healthcare worker, the vital signs are a critical communication to the physician as to what the status of the patient is. The vital signs, in connection with the patient history, give the healthcare staff a starting point in developing a plan of care for the patient.
Rationale: Taking an accurate temperature reading relays important information about the patient’s current metabolic state. It is important to know that an individual’s body temperature steadily increases throughout the day, being coolest in the morning and warmest in the evening. The normal oral temperature range is from 96.8-99.8 degrees Fahrenheit. An average temperature is different for each individual. In the case of infants, it is important to note that temperatures taken rectally tend to run .5-1 degree higher than orally, and temporal (across the forehead) run around .5-1 degree cooler than orally. The axillary method is an alternative to the rectal method. This involves placing the thermometer under the patient’s armpit to receive a reading. This is preferred in older patients because it is far less invasive. Tympanic (ear canal) thermometers are also in use in medical facilities.
Rationale: To record the respirations per minute, just count the number of inhalations the patient makes in one minute. It is advisable to be cautious about how obvious you are when counting the breaths. A patient may be inclined to change the rate of the breathing if they know they are being monitored. A simple way to disguise this is by continuing to hold a patient’s wrist after you have recorded the heart rate, and just shift your attention to the breathing instead. A typical range for an adult’s breathing will be 12-20 respirations per minute. A newborn may breathe around 60 times per minute. A toddler may make 20-26 respirations per minute. If a patient makes more respirations than their range, it is called tachypnea. If a patient breaths less respirations than their range, it is called bradypnea.
Rationale: During the assessment of a patient, there is an opportunity to measure their awareness to the immediate environment. To properly categorize this, the four levels of consciousness were developed. This is a quick way to communicate if a patient seems to be stable, or if they require immediate medical attention. The first LOC is alert and conscious. This will be a majority of the patients. They are aware of their surroundings and can answer questions without distraction. The second LOC is drowsy but responsive. This communicates that the patient may be extremely lethargic, but will eventually answer questions if given some time. The third LOC is unconscious but responsive to painful stimulation. The patient is incapable of answering any questions, but the body will react to pain. The fourth LOC is comatose. The patient is completely incapacitated and does not respond to questioning or stimulus of any kind.
Rationale: The fever, or pyrexia, is a common enough occurrence that patients may seem complacent about having one. However, this is a process that can throw a patient’s homeostasis into chaos. There are couple different stages of pyrexia, and because everyone has a different “normal” temperature, these stages can fluctuate to some degree. The fever begins in the range of 99.5-100.5 degrees Fahrenheit. The patient can expect chills in spite of the rising internal temperature, lethargy, and sleepiness. The extreme end of pyrexia is hyperpyrexia. This range is from 104-106.9 degrees Fahrenheit. This denotes a severe medical emergency. At these temperatures the body can expect neurological deterioration if the patient does not receive immediate intervention. Such a high temperature can result from sepsis and hemorrhages.
Rationale: Blood pressure (BP) is comprised of two separate readings. They are called systolic (first number) and diastolic (second number). Systolic readings are a measurement of the left ventricle pushing blood into the arterial network. The diastolic reading is an indication of the ability for that arterial network to accept the blood being pumped into it. The normal blood pressure reading for an adult is 120/80 mmHg (mmHg stands for millimeters of Mercury). The systolic number can measure between 95-120 mmHg and still be considered normal. Diastolic pressure can be considered normal within the range of 60-80 mmHg. If the blood pressure is in a range of 120-139/80-89 mmHg, it is considered pre-hypertension. Stage 1 hypertension begins when the range of 140-159/90-99 mmHg is met. Stage 2 hypertension is the most severe, and it is set at 160/100 mmHg and higher. Blood pressures are measured using the stethoscope (listening tool) and the sphygmomanometer (blood pressure cuff).
Rationale: When the heart pumps, the left ventricle is responsible for pushing blood back out into the arterial system. This pressure pushes a wave of blood with each contraction. This wave is the pulse. It is measured in beats per minute (BPM). Different ages of individuals have drastically different heart rates. Newborn babies tend to have a resting heart rate of 125 BPM. A teenager’s heart will beat around 75-80 times when at rest. An adult, female or male, will have an average resting heart rate of 60-100 BPM. If a patient has a heart rate that exceeds this range, it is known as tachycardia. If a patient has a heart rate that falls below their range, it is called bradycardia. The most common site to take a patient’s heart rate is at the wrist or radial artery. However, there are several alternatives. These are the temporal (side of the forehead), carotid (neck), apical (the heart), femoral (in the hip), and pedal (the foot) sites.
Just above the antecubital space
Rationale: The sphygmomanometer is a tool used to gauge a patient’s blood pressure. The sphygmomanometer is also referred to as a blood pressure cuff, and is connected to a bulb pump with a valve. The cuff should be placed securely just above the antecubital space. The gauge on the cuff should be placed where it can be easily seen. Once the cuff is secured, palpate the antecubital space to find the pulse of the brachial artery. Place the stethoscope’s diaphragm over the brachial artery. Once the stethoscope is in position, close the valve on the bulb pump, and inflate the sphygmomanometer to 180 mmHg. Then, open the valve, slowly releasing the pressure. At this point, listen through the stethoscope. When the first beat is heard, record that pressure as the systolic reading. The point when the intensity of the beat grows, then suddenly becomes much softer, is the diastolic reading.
Peripheral Oxygen Saturation
Rationale: The pulse oximeter, or pulse ox, is a device placed on a patient’s finger to measure peripheral oxygen saturation (SpO2). Oxygen saturation, or Sats, is the measurement of the percentage of hemoglobin saturated with oxygen at any one time. This saturation begins in the pulmonary arteries of the heart. The pulmonary arteries are the only arteries that carry deoxygenated blood. These pulmonary arteries lead to the alveoli of the lungs, where carbon dioxide is removed from the blood and expelled. The oxygen is then attached to the hemoglobin. The newly oxygenated blood is carried back to the heart via the pulmonary veins (the only veins in the body that carry oxygenated blood), and is distributed throughout the body. There are several different types of oxygen saturation; Arterial oxygen saturation (measures oxygen delivery, SaO2), tissue oxygen saturation (measure oxygen in various tissues, StO2), and venous oxygen saturation (measures oxygen consumption, SvO2).
Rationale: There are elements to taking a blood pressure and heart rate that go beyond simple counting. Once you become familiar with the pulse sounds and sensations, you will be able to feel an inconsistency. If a patient’s heart rate is beating particularly fast, over 100 BPM, this is known as tachycardia. But a patient’s heart can be racing, and at the same time the pulse can be weak. It is this combination that is known as having a thready pulse. This weak and rapid pulse may be a strong indication that the patient’s heart is not pumping enough blood into the system. This is a quality to the blood pressure that needs to be brought to the attention of the physician. Make sure that you document this in your physical assessments as well.