Putting the Vital in Vital
Signs
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STEVE MERCADO, MD
STAFF PHYSICIAN
UTMB/CORRECTIONAL MANAGED CARE
Overview
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 INTRODUCTION
 TEMPERATURE
 BLOOD PRESSURE
 HEART & RESPIRATORY RATE (discuss together)
 PULSE OXIMETER (discuss briefly)
 MEDICAL/LEGAL ISSUES
 “OFF THE RECORD” (ACLS, HIV, Hep C)
Who is this?
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Introduction
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1. Definition of Vital= (adjective) critical; urgently needed;
absolutely necessary in order for something to succeed or
exist.
2. “Tee Shot”
-no ETOH, tobacco, caffeine, or vigorous exercise within
30 minutes of taking vitals.
3. Technology
-more accurate?
Temperature
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5 Methods Obtain Temperature
 Oral
 Rectal
 Axillary
 Ear
 Forehead
Normal range 97.8-99.0 degrees:
 -dependent on gender/stage of menstrual cycle
 -recent activity
 -food/fluid consumption
 -time of day
Temperature-Methods
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1. Oral
-normal 98.6
-mercury thermometers have been replaced by digital technology
(mercury can vaporize; toxic inhalation)
2. Rectal
-normal 99.6 (0.5-0.7 higher than oral)
-closest to “true” core body temperature
-infants/toddlers; not “convenient” for school age kids
3. Axillary
-normal 97.6 (0.3-0.4 lower than oral)
-least accurate???
Temperature-Methods
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4. Ear
-normal 99.6 (same as rectal
-infrared light measures heat/body temp of tympanic membrane
-variables can affect accuracy (ear infection, cerumen, curved ear
canals)
-least accurate??? Probably accurate enough for most clinical
settings but don’t rely on for major medical decisions (lumbar
puncture, hospital admission).
5. Skin/forehead (temporal artery thermometers)
-normal 99.0 (slightly higher than oral; slightly less than rectal.
Check with manufacturer)
-introduced in 2000; infrared scanner measures temperature of
arterial artery in forehead (?)
-highly heat sensitive (hot/sweaty, nearby lights, office/room
temperature) -$$$
-Forehead strips; get rid of! Highly inaccurate.
Temperature - Studies
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Study: “Accuracy and Precision of non-invasive
temperature measurements in adults ICU patients”.
American Journal of Critical Care, Sept. 2011.
-60 ICU patients
-compared 4 non-invasive methods (oral, ear, axillary,
temporal artery thermometers)
-outpatient clinical implications (no rectal
thermometers)
-comparing temperature of non-invasive methods to
pulmonary artery catheter temperature ( true core temp)
-oral and temporal artery thermometer readings closest
to pulmonary artery core temperature.
-axillary better than ear!!!
Blood Pressure
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American Heart Association:
-take BP twice (sitting) on each arm and take average of
each arm. Use arm with higher reading.
-slight difference between arms is normal but >15 point
difference is significant.
Normal BP (Nelson’s Textbook of Pediatrics, 17th edition):
Age 3-6 yrs= 95-110/60-75
Age 6-12 yrs= 100-120/60-75
Age 12-18 yrs= 110-135/65-85
Blood Pressure-Sources of Error
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1. Equipment
-straightforward; if its broke, fix it or get new one
2. Patient
-talking
-pain
-anxiety/emotions
-time of day (peak BP in mid afternoon)
-office temperature (cold room; peripheral
vasoconstriction; LOW BP)
Blood Pressure-Sources of Error
(continued)
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3. YOU!
-cuff size (“too small too high; too big too
low”)
-sitting/back supported/feet flat on floor (not
trivial; supported by studies)
-arm supported at heart level (“too high too
low; too low too high”)
-bell vs diaphragm? Bell best (low frequency s
ounds)
Blood Pressure - Technology
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Wrist Machines
-very accurate when used correctly
-cuff size not really an issue
-again, must be at heart level
-easier to get erroneous readings because of increased
sensitivity to movement (“hand talkers”)
-Mount Sinai Hospital study…..”more accurate than
arm cuff”
-great for home monitoring
HEART & RESPIRATORY RATE
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Nelsons Textbook of Pediatrics, 17th edition
HR
RR
Age 3-6:
65-110
20-25
Age 6-12:
60-95
14-22
Age >12:
55-85
12-18
HEART & RESPIRATORY RATE
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Rosens Emergency Medicine Text, 5th edition
HR
RR
Age 2-5:
80-140
22-34
Age 6-12: 70-120
18-30
Age >12: 60-100
12-16
HEART & RESPIRATORY RATE
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Emergency Care, 11th edition
HR
RR
Age 3-5:
80-120
20-30
Age 6-10:
70-110
15-30
Age 11-14:
60-105
12-20
HEART & RESPIRATORY RATE
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Advanced Pediatric Life Support
HR
RR
Age 2-5:
95-140 25-30
Age 5-12:
80-120 20-25
Age >12
60-100
15-20
HEART & RESPIRATORY RATE
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Saunders Comprehensive Review for the NCLEX- RN
exam, 3rd edition
HR
RR
Preschooler
70-110
16-22
School age
60-100
16-20
Adolescent
55-90
12-20
HEART & RESPIRATORY RATE
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Pediatric Basic & Advanced Life Support (AHA)
HR
Age 2-10:
60-140 (awake), 60-90 (sleeping)
Age >10:
60-100 (awake), 50-90 (sleeping)
Preschooler
School age
Adolescent
RR
22-34
18-30
12-16
What’s My Point?!
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-Study: “Normal ranges of HR and RR in Children
from birth to 18 yrs of age; a systematic review of
observational studies”. The Lancet, vol. 377, issue
9770, March 2011
*meta-analysis and statistics applied to numerous
studies around the world that mentioned heart or
respiratory rate ranges in children
*conclusion- “comparison of our percentile charts
with existing published reference ranges for HR &
RR show striking disagreement”.
What’s My Point?!
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- Study: “Age related reference changes for HR & RR in
children age 4-16”. Archives of Disease in Childhood, vol. 90,
issue 11, 2005. South Africa
*conclusion- “this study has shown that the range of published
“normal” values for HR & RR varies widely depending on the
source referred to, and has shown the lack of evidence behind
these values”.
-Expert panels agree on what is “normal”; not backed by
evidence
-Problems? Rewriting/standardizing texts. “Fringe” values for
vital signs.
-Discuss with your provider.
PULSE OXIMETRY
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-Pulse ox <95% on room air is significant (patient is
hypoxic); needs provider intervention.
-O2/Hgb dissociation curve
-“The 90’s”
MEDICAL/LEGAL ISSUES
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-Nursing accountability and documentation (school
nurses)
”don’t let the sun set on abnormal vital signs”
-Nurse/Provider communication (office nurses)
*inform providers of abnormal vital signs
*providers get busy/careless
“OFF THE RECORD”
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-March 2010 AHA ACLS guidelines
-March 2012 Infectious Disease recommendations
(HIV, Hep C)