Everything You’ll Ever Need to Know About Vital Signs!

Complete Guide to Vital Signs!

This is part 3 of a 5 part series covering health assessment. Part 1 is a step-by-step guide of a health history. Part 2 is an overview of a physical assessment. Part 4 is the step-by-step guide of a head-to-toe assessment. Part 4 covers a mental assessment.

What are Vital Signs?

Check out this FREE, complete guide to vital signs!

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In this complete guide you will learn the following:

  1. What are vital signs?
  2. What are baseline vital signs?
  3. Body temperature
    1. How to assess
    2. Normal limits
  4. Pulse/heart rate
    1. Technique
    2. Normal limits
    3. Sites to palpate
    4. Sites to auscultate
    5. Intensity of pulse
  5. Respiration
    1. Breathing patterns
    2. Breathing sounds
    3. Technique
  6. Blood pressure
    1. Technique
    2. Systolic vs. diastolic
    3. Hypertension vs. hypotension
    4. Pulse pressure
  7. Oxygen saturation
    1. Technique
    2. Normal limits
  8. Bonus: Pain
    1. How to measure it
    2. Behaviors indicating pain
    3. 2 mnemonics to aid in remembering how to assess pain

Free Cheat Sheets For Everyone!

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Nursing Necessities Cheat SheetAce Nursing School – Complete Guide to Vital Signs!

  • Vital signs
    • Clinical measurements that specify the state of a patient’s essential body functions.
    • Baseline vitals – used to determine a patient’s typical state of health.
      • Variation from baseline typically signify a change in physiological function
    • List of vital signs*:
      1. Body temperature
      2. Heart rate (pulse)
      3. Respiratory rate (and breathing sounds)
      4. Blood pressure
*For a free cheat sheet that includes vital sign normal values for each age group sign up for the Ace Nursing School Newsletter!

Oxygen saturation

  • Body temperature
    • Measurement between heat lost and heat produced by body
    • Measured by a thermometer
      • Orally (under tongue)
        • 6°F, 37.0°C
      • Axillary (under arm)
        • 6°F, 36.5°C
      • Rectal (in rectum)
        • 6°F, 37.6°C
      • Temporal (forehead/temple)
        • 6°F, 37.0°C
      • Maintained by homeostasis
        • Heat is lost through perspiration, respiration, and excretion
        • Heat is gained through digestion and muscle contraction
      • Hyperthermia – elevated body temperature in relation to body’s inability to effectively reduce heat
        • Fever – when the body is above 101°F.
      • Hypothermia – decreased body temperature due to prolonged exposure to cold temperature
        • Classified as any body temperature below 96°F
      • Factors affecting body temperature
        • Dehydration
        • Environment
        • Recently eating/drinking something hot/cold
        • Infection
  • Heart Rate / Pulse
    • The number of times the heart beats in one minute
    • Techniques:
      • May be assessed by palpation or auscultation
      • Use tips of index and middle finger to palpate
      • Count number of pulsations per 30 seconds and multiply by 2
    • Assess:
      • Rate (60-100bpm)
      • Rhythm (steady beat)
      • Intensity (explained below)
    • Common sites to palpate
    • Pedal Intensity
      • 0+ = no palpable pulse
      • 1+ = weak, “thready” pulse
      • 2+ = slightly diminished pulse
      • 3+ = normal palpable pulse
      • 4+ = bounding pulse
    • Common sites to auscultate
      • Mnemonic to remember each one: All People Enjoy The Mall – 2, 2, 3, 4, 5 (intercostal spaces)
      • A – Aortic – 2nd right intercostal space
      • P – Pulmonic – 2nd left intercostal space
      • E – Erb’s Point – 3rd left intercostal space
      • T – Tricuspid – 4th left intercostal space
      • M – Mitral – 5th left intercostal space
    • Factors affecting pulse
      • Drugs, exercise, age, gender, temperature, blood pressure, pathology
  • Respiratory rate / Breathing Sounds
    • The number of breaths taken per minute
    • The process of inhaling oxygen and exhaling carbon dioxide from the lungs
    • One complete breath consists of inhalation and exhalation
    • Assess by observing or feeling the chest for 30 seconds, counting the number of breaths, and multiplying by 2
    • Assess:
      • Rate (12-20 breaths per minute)
      • Pattern (even bilaterally0
      • Depth (normal)
      • Difficulty (unlabored)
      • Breath sounds (clear)
    • Pattern to auscultate
    • Breathing Patterns
      • Abdominal respirations – breathing accomplished by abdominal muscles and diaphragm
      • Apnea – temporary cessation of breathing
      • Cheyne-Stokes – breathing becomes deeper and faster, then decreases to apnea, then repeats
      • Dyspnea – difficult or painful breathing
      • Hyperpnea – extremely deep breathing
      • Hyperventilation – extremely rapid, deep breathing
      • Hypoventilation – extremely slow breathing
      • Kussmaul’s – marked increase in depth and rate (appears hungry for air)
      • Orthopnea – body must be upright to breathe
      • Paradoxical – one lung deflates during inspiration
      • Periodic – pauses in breathing for 10 seconds followed by rapid shallow breaths
    • Breathing Sounds
      • Crackles – brief rattling sound caused by explosive opening of small airways, usually due to inflammation.
      • Rales – small clicking, bubbling, or rattling sounds in lungs heard on inhalation. May be described as moist, dry, fine, or coarse
      • Rhonchi – low-pitched, snoring sound
      • Stridor – extremely high-pitched “wheeze” usually due to blockage of air flow in trachea
      • Wheeze – high-pitched sound produced by a narrowed or obstructed airway best heard on exhalation (asthma)
      • Factors affecting respiration
        • Anxiety, fever, drugs, pathology
  • Blood Pressure
    • The pressure of blood pushing against vessel walls as it travels through the circulatory system
    • Measured with a sphygmomanometer
    • How to measure blood pressure
  1. Place patient’s arm at heart level and rest it on a stable surface
  2. Snuggly wrap the cuff around the upper arm
  3. Find the patient’s brachial pulse and place the diaphragm of your stethoscope over it
  4. Close the air valve and use the rubber bulb to inflate the cuff to approximately 180mmHg
  5. Open the valve slowly, at approximately 3 mmHg per second
  6. Listen closely for a thumping sound, also known as Korotkoff sounds
  7. When you start hearing thumping, remember the number on the dial – this is your systolic number
  8. When you stop hearing the thumping, remember this number on the dial – this is your diastolic number
  • Systolic blood pressure
    • Top number in the fraction
    • Highest level blood pressure reaches when the heart contracts
    • Normal limits are 90-120mmHg
  • Diastolic blood pressure
    • Bottom number in the fraction
    • Lowest level blood pressure reaches as the heart relaxes
    • Normal limits are 60-80mmHg
  • Pulse pressure
    • Difference between systolic and diastolic values (30-40mmHg)
  • Hypertension (high blood pressure)
    • Occurs when blood pressure is greater than 140/90mmHg
  • Hypotension (low blood pressure)
    • Occurs when blood pressure is lower than 100/60mmHg
  • The cuff must be cover at least 2/3 of the patient’s upper arm
  • Factors affecting blood pressure
    • Anxiety, drugs, cardiac output, vascular resistance, arterial elasticity, blood volume, weight, exercise, pathology
  • Oxygen Saturation (SpO2)
    • Measures the percentage of hemoglobin that is loaded with oxygen
    • Normal limits are 95%-100%.
    • Measured through use of a pulse oximeter (noninvasive)
      • Commonly placed on a fingertip or ear lobe
    • Factors affecting oxygen saturation
      • Nail polish, cold extremities, pathology
  • Bonus: Pain
    • Considered by some facilities and organizations as a vital sign
    • Measured on a scale of 0-10, with 0 being no pain and 10 being the worst pain imaginable.
      • The patient is the only person who can truly state a pain level – as a nurse we must record the patient states
    • Measured by pictures in those who cannot speak or understand the numerical scale
    • Behaviors indicating pain
      • Clenched teeth
      • Wrinkled forehead
      • Biting lips
      • Tightly closed eyes
      • Crying
      • Moaning
      • Restlessness
      • Muscle tension
      • Silence
      • Withdrawal
    • OLDCART
      • O – Onset
      • L – Location
      • D – Duration
      • C – Characteristics
      • A – Aggravating factors
      • R – Radiation
      • T – Treatment (what makes it better?)
    • PQRST
      • P – Provoke (what causes it?)
      • Q – Quality (stabbing, dull, etc.)
      • R – Region
      • S – Severity (0-10 scale)
      • T – Timing (when it started)
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