Vital Signs

Examination
Dr. Ratna Saraswati, SpPD

Reference
Bates
Guide to physical examination and history taking
8th edition
Lynn S. Bickley, MD & Peter G. Szilagyi, MD, MPH
Lippincott William & Wilkins, Philadelphia, 2003

VITAL SIGNS
Blood pressure
Heart rate
Respiratory rate
Temperature

Equipment
Needed

A Stethoscope
A Blood Pressure Cuff
(Sphygmomanometer)
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.

VITAL SIGNS

Blood pressure
Heart rate
Respiratory rate
Temperature

Blood pressure cuff (sphygmomanometer):

anaeroid or mercury type

Selecting the correct blood pressure

cuff
Width of the inflatable bladder of the cuff
should be about 40% of upper arm
circumference (about 12-14 cm in the average
adult)
Length of inflatable bladder should be about
80% of upper arm circumference (almost long
enough to encircle the arm)
If anaeroid, recalibrate periodically before use
Cuff that are too short or too narrow may give falsely high
reading. If too long or too wide BP may falsely low.
Using a regular-size cuff may lead to a false diagnosis of
hypertension

Getting ready to measure blood

pressure
Ideally, ask the patient to avoid smoking or
drinking alcohol, caffeinated beverages for 30
minutes before the blood pressure is taken and to
rest for at least 5 minutes.
Check to make sure the examining room is quite
and comfortably warm.
Make sure the arm selected is free of clothing.
There should be no arteriovenous fistula for
dialysis, scarring from prior brachial artery
cutdowns, or signs of lymphedema (seen after
axillary node dissection of radiation therapy)
Palpate the brachial artery to confirm that it has a
viable pulse

 Position the arm so that the brachial artery, at the

antecubital crease, is at heart level (roughly level at
the 4th interspace at its junction with the sternum.
If the patient is seated, rest the arm on a table a
little above the patients waist; if standing, try to
support the patients arm at the midchest level.

If the brachial artery is much below heart level, blood

pressure appears falsely high.
The patients own effort to support the arm may raise the
blood pressure.
A loose cuff or bladder that baloons outside the cuff leads
to falsely high reading.

Measure the blood pressure

Center the inflatable bladder over the brachial

artery. The lower border of the cuff should be about
2.5 cm above the antecubital crease. Position the
patients arm so that it is slightly flexed at the elbow.

To determine how high to raise the cuff pressure,

first estimate the systolic pressure by palpation. As
you feel the radial artery with the fingers of one
hand, rapidly inflate the cuff until the radial pulse
disappears. Read this pressure on the manometer
and add 30 mmHg to it. This will avoid occasional
error caused by ausculatory gap (a silent interval
that may present between systolic and diastolic
pressure)

Deflate the cuff promptly and completely, wait 15

30 seconds

Place the stethoscope lightly over the brachial artery,

taking care to make an air seal with its full rim.

Inflate the cuff rapidly again to the level just

determined and then deflate it slowly at a rate 2-3
mmHg per second.

Note the level at which you hear the sounds of at

least two consecutive beats. This is the systolic
pressure

Continue to lower the pressure until the sounds

muffle and disappear. To confirm the disappearance
of sounds, listen as the pressure falls another 10 20
mmHg. The disapperance point, which is usually only
a few mm Hg below the muffling point, is the best
estimate of true diastolic pressure in adult.

Record the blood pressure as systolic over diastolic

("120/80" for example).

Definition of normal and abnormal

levels
Blood Pressure Classification in Adults ( 18 y/o)
Category

Systolic

Diastolic

Hypertension
Stage 3 (severe)
Stage 2 (moderate)
Stage 1 (mild)
Isolated systolic hypertension

180
160 179
140 159
140

110
100 109
90 99
< 90

High normal

130 139

85 89

Normal

< 130

< 85

Optimal

< 120

< 80

Source: 2003 European Society of Hypertension-European Society of

cardiology guideline for the management of arterial hypertension.
When the systolic and diastolic level indicate different categories,
use the higher category.

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. Anxiety is a frequent cause of
high BP, especially during initial visit (white coat
hypertension).
Always recheck "unexpected" blood pressures yourself.

Bell or Diaphragm? - Even though the Korotkoff

sounds are low frequency and should be heard
better with the bell, it is often difficult to apply the
bell properly in the antecubital fold. For this
reason, it is common practice to use the
diaphragm when taking blood pressure.

Maximum Cuff Pressure - When the baseline blood

pressure is already known or hypertension is not
suspected, it is acceptable in adults to inflate the
cuff to 200 mmHg and go directly to auscultating
the blood pressure. Be aware that there could be
an auscultory gap (a silent interval between the
true systolic and diastolic pressures).

If you find an ausculatory

gap, record your findings
completely
e.g. 200/98 with an
ausculatory gap from
170 - 150
Unrecognized ausculatory gap may lead to serious
underestimation of systolic pressure (e.g. 150/98 in this
example) or overestimation of diastolic pressure.

Systolic Pressure - In situations where ausculation

is not possible, you can determine systolic blood
pressure by palpation alone. Deflate the cuff until
you feel the radial or brachial pulse return. The
pressure by auscultation would be approximately
10 mmHg higher. Record the pressure indicating
it was taken by palpation (60/palp).
Diastolic Pressure - If there is more than 10
mmHg difference between the muffling and the
disappearance of the sounds, record all three
numbers (120/80/45).
Arrhytmia: irregular rhythms produce variations
in pressure and therefore unrealiable
measurement. Ignore the effects of an occasional
premature contraction.

Sources of error
Sphygmomanometer

Poor maintenance

Incorrect cuff application

Incorrect bladder size

Tube/pump leakage
Patient

Obesity

Arrhythmias

Arm position
The

observer
Poor technique
Observer bias
Terminal digit preference e.g. 120/70 or 125/75, instead
of real pressure e.g. 122/72
Note that the is graduate in 2s , there is no 5
Distance from scale should be <1m

VITAL SIGN
Blood pressure

Heart rate
Respiratory rate
Temperature

Heart rate and rhythm

The radial pulse is commonly used to assess the heart rate.
With the pads of you index and middle fingers, compress the
radial artery until a maximal pulsation is detected.

If the rhythm is regular and the rate

seem normal, count the rate for 15
seconds and multiply by 4. If the rate
is unusually fast or slow, however
count it for 60 seconds.
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.

When the rhythm is irregular, the rate should be

evaluated by cardiac auscultation, because beats that
occur earlier than others may not be detected
peripherally and the heart rate can thus be seriously
underestimated.

Rhtyhm
To begin your assessment of rhythm, feel the radial
pulse. If there are any irregularities, check the rhythm
again by listening with your stethoscope at the cardiac
apex - is the rhythm regular or irregular?
Regular - evenly spaced beats, may vary slightly with
respiration
Regularly Irregular - regular pattern overall with
"skipped" beats
Irregularly Irregular - chaotic, no real pattern, very
difficult to measure rate accurately

Interpretation
A normal adult heart rate is between 60 and 100
beats per minute.
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

 In adult, 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.

The pulse pressure is about 30-40 mmhg. The pulse

contour is smooth and rounded (the notch on the
descending slope is not palpable

Abnormalities of the arterial pulse

waves

and pressure

Abnormalities of the arterial pulse

waves

and pressure

Irregular rhythm

Irregular rhythm

Irregular rhythm

Irregular rhythm

VITAL SIGN
Blood pressure
Heart rate

Respiratory rate
Temperature

Respiration

Best done immediately after taking the patient's

pulse. Do not announce that you are measuring
respirations.
Without letting go of the patients wrist begin to
observe the patient's breathing. Is it normal or
labored?
Count breaths for 15 seconds and multiply this
number by 4 to yield the breaths per minute.
Normal
The respiratory rate is about
14 -20/min in nomral adults
and up to 44/min in infants

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.

Abnormality rate and rhythm of breathing

Rapid swallow breathing
(tachypnea)

Rapid deep breathing

(hyperpnea, hyperventilation)

Slow breathing (bradypnea)

Obstructive breathing

Cheyne stokes breathing

Ataxic breathing
(Biots breathing)
Sighing respiration

VITAL SIGN
Blood pressure
Heart rate
Respiratory rate

Temperature

Temperature
Temperature can be measured is several different ways:
Oral (sublingual) with a glass, or electronic
thermometer
(the average normal 98.6oF/37oC, in the morning hours it may fall
as low as 35.8oC, and the late afternoon of evening it may rise as
high as 37.3oC)).

Axillary (under the arm) 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 (in the ear) with an electronic thermometer

(normal 99.6F/37.7C)

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

accurate.
Other site: skin (forehead), groin, bladder (via
cathether), central (via cathether)

Interpretation
Normally, the core temperature of the body
(defined as temp of arterial blood
surrounding the major organ), is maintain
within the narrow range: between 36
37.5oC (apyrexial or normal temperature)
Hypothermia (low temperature) = <35oC
Pyrexia (high temperature) = >38oC
Hyperpyrexia (very high temperature) =
>40oC