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Techniques of Vital SignsTechniques of Vital Signs
John Gazewood, MD, MSPHJohn Gazewood, MD, MSPH
Department of Family MedicineDepartment of Family Medicine
ObjectivesObjectives
Define “normal” in several ways.Define “normal” in several ways.
Describe correct technique of measuring Describe correct technique of measuring vital signs. vital signs.
Describe correct technique for evaluating Describe correct technique for evaluating pulses.pulses.
Know that different populations may have Know that different populations may have different normal values.different normal values.
What Does “Normal” Mean?What Does “Normal” Mean?
AverageAverage•• Population (sample) meanPopulation (sample) mean
“Healthy” “Healthy” -- appropriate physiologic appropriate physiologic functionfunction
These two definitions can be incompatibleThese two definitions can be incompatible
What Does “Normal” Mean?What Does “Normal” Mean?
Average Blood Pressure, by AgeAverage Blood Pressure, by AgeAverage Blood Pressure, by Age
60708090
100110120130140150160170
36 41 46 51 56 61 66 71 76
SPBDBP
AgeAge
Bloo
d Pr
essu
re,
mm
Hg
Bloo
d Pr
essu
re,
mm
Hg
Kannel, Bull NY Acad Kannel, Bull NY Acad Med, 54(6), 1978Med, 54(6), 1978
Risk of CV Disease Increases With SBPRisk of CV Disease Increases Risk of CV Disease Increases With SBPWith SBP
0102030405060708090
74-119 120-139 140-159 160-179 >180Systolic Blood Pressure, mm Hg
Age
adus
ted
annu
al ra
te p
er
1000
Age: 65-94Age: 35-64
Framingham study
TemperatureTemperature
OralOral
RectalRectal•• Often used in infants, continuous monitoring for Often used in infants, continuous monitoring for
severe hypothermia/hyperthermiasevere hypothermia/hyperthermia
AxillaryAxillary•• Poor correlation with rectal temperaturePoor correlation with rectal temperature
•• Don’t use if accurate temperature importantDon’t use if accurate temperature important–– neonates may be exceptionneonates may be exception
BMJ 320(29), April 2000BMJ 320(29), April 2000
Tympanic TemperatureTympanic Temperature
Measures core Measures core temperature temperature
Caution pointCaution point•• Point at TMPoint at TM
•• No waxNo wax
Temperature Temperature -- Normal ValuesNormal Values
Oral Oral -- 373700C C (98.6(98.60 0 F)F), Fever > 38 °C , Fever > 38 °C (100.4°F)(100.4°F)((wunderlichwunderlich))
Oral Oral -- 36.836.800C C (98.2(98.20 0 F)F), Fever > 37.3 °C , Fever > 37.3 °C (99.9(99.900F)F) (JAMA, 269:1578(JAMA, 269:1578--80)80)
Rectal 0.4Rectal 0.400C to 0.5C to 0.500C C (0.7(0.700F to 0.8F to 0.800F)F) higher higher than oralthan oral
Tympanic 0.8Tympanic 0.800C C (1.4(1.400F)F) higher than oralhigher than oral
Respiratory RateRespiratory Rate
Respiratory cycles per minuteRespiratory cycles per minute
Observe rise and fall of chestObserve rise and fall of chest
Depth, effort of breathing, rhythmDepth, effort of breathing, rhythm•• Accessory muscle use, retractions, nasal Accessory muscle use, retractions, nasal
flaringflaring
For infantsFor infants•• observe abdomen observe abdomen
•• count for 60 seconds, or two thirty second count for 60 seconds, or two thirty second intervalsintervals
PulsePulse
Number of cardiac cycles per minuteNumber of cardiac cycles per minute
Pulse affected by:Pulse affected by:•• Volume of blood ejected (stroke volume)Volume of blood ejected (stroke volume)
•• Distensibility of aorta and large arteriesDistensibility of aorta and large arteries
•• Viscosity of bloodViscosity of blood
•• Rate of cardiac emptyingRate of cardiac emptying
•• Peripheral arteriolar resistancePeripheral arteriolar resistance
Palpation of PulsesPalpation of Pulses
Pads of second and third fingersPads of second and third fingers•• Gentle pressureGentle pressure
Assess:Assess:•• Rate (15 or 30 seconds, multiply by 4 or 2Rate (15 or 30 seconds, multiply by 4 or 2
•• Rhythm (regular, irregular, irregularly Rhythm (regular, irregular, irregularly irregular)irregular)
•• AmplitudeAmplitude
•• Contour (upstroke, peak, descending)Contour (upstroke, peak, descending)
Radial Pulse
Brachial Pulse
Carotid PulseCarotid Pulse
Femoral PulseFemoral Pulse
Popliteal Pulse
Dorsalis Pedis (DP) PulseDorsalis Pedis (DP) Pulse
Posterior Tibialis (PT) PulsePosterior Tibialis (PT) Pulse
Describing PulsesDescribing Pulses
Rate and rhythmRate and rhythm
AmplitudeAmplitude•• 0 0 -- absentabsent
•• 1+ 1+ -- decreaseddecreased
•• 2+ 2+ -- normalnormal
•• 3+ 3+ -- increasedincreased
•• 4+ 4+ -- boundingbounding
ContourContour
Abnormal PulsesAbnormal Pulses
Measurement of Blood PressureMeasurement of Blood Pressure
Choose correct size cuffChoose correct size cuff
Place cuff on limb (usually arm)Place cuff on limb (usually arm)
Measure palpable systolic blood pressureMeasure palpable systolic blood pressure
Measure blood pressureMeasure blood pressure
Record the blood pressureRecord the blood pressure
Choose an Appropriately Sized Choose an Appropriately Sized Blood Pressure CuffBlood Pressure Cuff
Bladder width ˜ 40% of limb circumference, Bladder width ˜ 40% of limb circumference, length ˜ 80% of limb circumference. length ˜ 80% of limb circumference.
Too large cuff underestimates blood Too large cuff underestimates blood pressure.pressure.
Too small cuff overestimates blood Too small cuff overestimates blood pressure.pressure.
Place the Blood Pressure Cuff on Place the Blood Pressure Cuff on the Limbthe Limb
Don’t use arm with arteriovenous fistula or Don’t use arm with arteriovenous fistula or on side of radical mastectomyon side of radical mastectomyNo clothing on upper arm, or very light No clothing on upper arm, or very light sleeve.sleeve.On arm, lower edge of cuff 2 to 3 cm above On arm, lower edge of cuff 2 to 3 cm above antecubital fossaantecubital fossaPlace cuff snugly about the limb. Place cuff snugly about the limb. Center bladder over brachial arteryCenter bladder over brachial artery
Measure the Palpable Systolic Measure the Palpable Systolic Blood PressureBlood Pressure
Support patient’s arm, at heart level.Support patient’s arm, at heart level.
Palpate radial artery, rapidly pump up cuff Palpate radial artery, rapidly pump up cuff until pulse no longer palpable.until pulse no longer palpable.
Pump up cuff another 20 mm hg.Pump up cuff another 20 mm hg.
Release pressure at 2 to 3 mm hg per Release pressure at 2 to 3 mm hg per second, until pulse is felt. second, until pulse is felt.
Rapidly release pressure from cuff.Rapidly release pressure from cuff.•• Wait 30 secondsWait 30 seconds
Measure the Blood PressureMeasure the Blood Pressure
Bell of stethoscope over arteryBell of stethoscope over arteryRapidly pump up cuff to 20 Rapidly pump up cuff to 20 -- 30 mm hg over 30 mm hg over palpable systolic blood pressure.palpable systolic blood pressure.Release pressure in cuff at 2 to 3 mm hg Release pressure in cuff at 2 to 3 mm hg per second, listen forper second, listen for korotkoffkorotkoff sounds.sounds.Record BP as systolic/diastolic (120/80)Record BP as systolic/diastolic (120/80)Repeat in other arm. Take higher reading as Repeat in other arm. Take higher reading as patient’s blood pressure.patient’s blood pressure.
Korotkoff Phases of BPKorotkoff Phases of BP
Important Considerations in BP Important Considerations in BP MeasurementMeasurement
Sphygmomanometer dial/column should Sphygmomanometer dial/column should be at eye level.be at eye level.
Patient seated, back supported and feet on Patient seated, back supported and feet on the floorthe floor
Patient at rest for 5 minutes Patient at rest for 5 minutes
Pt. Refrain from caffeine or nicotine Pt. Refrain from caffeine or nicotine •• JAMA, 273; pp 1211JAMA, 273; pp 1211--1218, 19951218, 1995
Pitfalls in blood pressure Pitfalls in blood pressure measurementmeasurement
ArrhythmiasArrhythmias
Venous congestionVenous congestion
Korotkoff sounds do not disappearKorotkoff sounds do not disappear
Does This Patient Have Does This Patient Have Hypertension?Hypertension?
Diagnosis should be based on average of Diagnosis should be based on average of two or three readingstwo or three readings•• Individual variation in blood pressureIndividual variation in blood pressure
•• Regression to the meanRegression to the mean
•• Especially in patients near diagnostic cut pointEspecially in patients near diagnostic cut point
JNC VI BP ClassificationJNC VI BP Classification
Category Systolic Diastolic Follow-upOptimal <120 and <80 2 yearsNormal <130 and <85 2 yearsHighNormal
130-139 or 85-89 1 year
Stage 1 140-159 or 90-99 2 monthsStage 2 160-179 or 100-109 1 monthStage 3 ≥180 or ≥110 1 wk
Does the patient have Does the patient have hypovolemia?hypovolemia?
Measure pulse and blood pressure in Measure pulse and blood pressure in supine and standing positionsupine and standing position•• Supine Supine -- wait 1 minutewait 1 minute
•• Standing Standing -- wait 2 minuteswait 2 minutes
Pulse increase Pulse increase ≥≥ 30 bpm30 bpm
Unable to stand for VS measurementUnable to stand for VS measurementJAMA, 281 (11); 1022JAMA, 281 (11); 1022--10291029
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