french essay on vital signs

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The global elements of vital signs' assessment: a guide for clinical practice

Malcolm Elliott

Senior Lecturer, Monash Nursing and Midwifery, Monash University, Melbourne, Australia

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The assessment of vital signs is critical for safe, high-quality care. Vital signs' data provide valuable insight into the patient's condition, including how they are responding to medical treatment and, importantly, whether the patient is deteriorating. Although abnormal vital signs have been associated with poor clinical outcomes, research has consistently found that vital signs' assessment is often neglected in clinical practice. Factors contributing to this include nurses' knowledge, clinical judgement, culture, tradition and workloads. To emphasise the importance of vital signs' assessment, global elements of vital signs' assessment are proposed. The elements reflect key principles underpinning vital signs' assessment and are informed by evidence-based literature.

Vital signs' assessment is a key component of safe, high-quality care and a fundamental nursing priority. Trends in vital sign data provide early warning of impending sepsis and respiratory failure, and can independently predict mortality ( Churpek et al, 2014 ; Nielsen et al, 2015 ). Furthermore, vital signs' data is important for medical emergency teams and early warning scores to function effectively, but only if there is adherence to vital sign monitoring protocols ( Hands et al, 2013 ).

Despite their clinical importance, research has consistently found that vital signs' assessment is often inaccurate, incomplete or falsified ( Ludikhuize et al, 2012 ; Philip et al, 2013 ; Cooper et al, 2014 ). The reasons for this are not clear, but nurses' knowledge, skills and clinical judgement, culture, tradition and ritual, along with laziness and workload have been identified as contributing factors ( Hogan, 2006 ; Yeung et al, 2012 ; Philip et al, 2013 ; Burchill et al, 2015 ; Cardona-Morrell et al, 2016 ). It has therefore been recommended that nurses need ongoing education to improve their attitudes towards vital sign monitoring ( Mok et al, 2015 ).

To help emphasise the importance of vital signs' assessment, Global Elements of Vital Signs' Assessment are proposed. The Elements reflect key principles underpinning vital signs' assessment and are grounded in national and international guidelines and the current literature. The Elements aim to address the enduring neglect of vital signs' assessment and are a guideline for clinical practice. The Table of Elements ( Figure 1 ) can be printed for students and clinicians to use as a visual prompt. The Elements can also be used for audit, benchmarking and teaching.

Respiratory rate

Changes in respiratory function are increasingly recognised as the most sensitive indicator of clinical deterioration ( Cahill et al, 2011 ). Respiratory rate is an early and extremely good indicator of conditions such as hypoxia, hypercapnia and acidosis ( Rolfe, 2019 ). Respiratory rate is also often the first vital sign to be affected if there is a change in the patient's cardiac or neurological state ( Liddle, 2013 ). The global elements of respiratory rate assessment are ( Figure 1 : dark blue cells):

• Sensitive marker (Sm): Respiratory rate is the most S ensitive m arker of acute illness ( Cahill et al, 2011 ). A respiratory rate of 21–24 breaths per minute is an early clinical sign of deterioration ( Wheatley, 2018 ). A decrease in respiratory rate is also indicative of deterioration ( Rolfe, 2019 )
• First sign (Fs): Respiratory rate is often the F irst s ign affected if there is an acute change in the patient's condition ( Kelly, 2018 ). Alteration in the respiratory rate can occur up to 24 hours before other signs of clinical deterioration ( Malgaard et al, 2016 )
• Powerful predictor (Pp): Respiratory rate is a P owerful p redictor of disease severity and of a poor outcome ( Kellett, 2017 ; Bunkenborg et al, 2019 ).
• Illness marker (Im): A high or increasing respiratory rate is an I llness m arker and a warning that the patient may deteriorate suddenly ( Resuscitation Council UK (RCUK), 2021 )
• Minor changes (Mc): M inor c hanges in respiratory rate (3–5 breaths/minute) can be an early sign of deterioration ( Dougherty et al, 2015 ; Kelly, 2018 )
• Never falsify (Nf) : Respiratory rate should N ever be f alsified or not assessed simply because ‘the patient looks fine’ or the oxygen saturations are normal
• Assess independently (Ai): Respiratory rate should be A ssessed i ndependently of oxygen saturation (SpO 2 ), as respiratory rate measurements correlate poorly with SpO 2 measurements ( Kellett and Sebat, 2017 )
• Count manually (Cm): The respiratory rate must be C ounted m anually rather than guessed or estimated ( ACT Government Health, 2011 )
• One minute (Om): The ideal length of time to measure respiratory rate is O ne m inute, without the patient's awareness that they are being assessed ( Hill et al, 2018 )
• Other characteristics (Oc): When assessing the respiratory rate, O ther c haracteristics such as respiratory depth, use of accessory muscles, pattern and signs of distress should also be assessed ( Rolfe, 2019 ).

Oxygen saturation

A pulse oximeter measures peripheral arterial oxygen saturation (SpO 2 ), reflecting the percentage of haemoglobin that is bound with oxygen ( Williams, 2018 ). SpO 2 readings should be interpreted within clinical context—and appropriate clinical judgement rather than complete reliance on oximetry readings should provide the basis for effective patient management ( Pretto et al, 2014 ). The global elements of oxygen saturation assessment are ( Figure 1 : light blue cells):

• Clinical context (Cc): Interpret SpO 2 readings within C linical c ontext ( Pretto et al, 2014 )
• Not ventilation (Nv): SpO 2 does N ot reflect the adequacy of v entilation ( Pretto et al, 2014 )
• Pulsatile flow (Pf): A pulse oximeter requires adequate P ulsatile blood f low to be accurate. Without a pulse signal, any SpO 2 readings are meaningless ( World Health Organization (WHO), 2011 )
• Probe site (Ps): The P robe s ite may affect the reliability of SpO2 readings ( Fernandez et al, 2007 ). Depending on the patient's clinical condition, some probe sites are more reliable than others ( Chan et al, 2013 )
• Random checks (Rc): Although R andom SpO 2 c hecks have clinical benefit, they cannot be used to accurately estimate PaO 2 , particularly because the response time of oximeter probes varies ( Pretto et al, 2014 ; Jubran, 2015 )
• Allow time (At): A llow t ime for the oximeter to detect the pulse and calculate the oxygen saturation ( WHO, 2011 ). The response time of oximeter probes varies ( Jubran, 2015 )
• Impaired delivery (Id): SpO 2 does not necessarily reflect tissue oxygen delivery ( Pretto et al, 2014 ). SpO 2 readings may actually be normal, despite I mpaired O 2 d elivery. Oxygen delivery to the tissues cannot be solely determined by using a pulse oximeter because an oximeter does not evaluate the haemoglobin concentration or cardiac output ( Casey, 2011 )
• Waveform (Wf): If the W ave f orm displayed on the oximeter is attenuated or inconsistent, the SpO 2 reading is unreliable ( Chan et al, 2013 )
• Unreliable readings (Ur): Many factors may cause U nreliable or misleading SpO 2 r eadings such as poor perfusion, venous pulsations, excessive movement, fingernail polish, and severe anaemia ( Chan et al, 2013 )
• No surrogate (Ns): SpO 2 is N ot a s urrogate marker or replacement for respiratory rate assessment ( Rolfe, 2019 ). It is possible, for example, for the SpO 2 to be normal but for the respiratory rate to be increased due to hypercapnia ( Parkes, 2011 )
• Not attach (Na): Do N ot a ttach the probe to an area that is oedematous, has compromised skin integrity, to fingers or toes that are hypothermic, or where the patient has peripheral vascular disease ( ACT Government Health, 2011 )
• Re-evaluate (Ev): After manually palpating the patient's pulse, compare it with the pulse rate calculated by the pulse oximeter. If a difference exists, re- Ev aluate the probe placement ( ACT Government Health, 2011 )
• Remain normal (Rn): During early stages of deterioration, the SpO 2 may R emain in the n ormal range due to an increase in respiratory rate to compensate for inadequate O 2 delivery ( Kellett and Sebat, 2017 ; Dix, 2018 ).

Although heart rate is calculated by a pulse oximeter, manual pulse assessment provides an opportunity to touch the patient and thus assess numerous characteristics related to cardiac output. These include heart rate, rhythm, amplitude or strength, equality and regularity ( Elliott and Coventry, 2012 ). The global elements of pulse assessment are ( Figure 1 : orange cells):

• Alteration (Al): Al teration in the pulse rate along with respiratory rate is often the first sign of deterioration ( Tollefson and Hillman, 2019 )
• Assess manually (Am): Pulse rate should be A ssessed m anually; reliance on automated machines should be avoided where possible ( ACT Government Health, 2011 )
• Thirty sixty (Ts): If the pulse is regular, count for T hirty seconds and multiply by two; if the pulse is irregular, count for s ixty seconds ( ACT Government Health, 2011 )
• Ignore monitor (Im): I gnore any m onitor's heart rate reading until you have assessed the pulse manually; doing so will help validate your findings. Manual palpation also allows for assessment of pulse amplitude and volume—information that monitors are not designed to evaluate ( Dougherty et al, 2015 )
• Characteristics (Ch): When palpating the pulse, assess all Ch aracteristics such as rate, rhythm, quality and regularity ( RCUK, 2021 )
• Normal range (Nr): Know the N ormal r ange for an adult patient and ideally the patient's normal range ( Liddle, 2013 ). Using established normal ranges can help quantify abnormal findings ( Chester and Rudolph, 2011 ).

Blood pressure

Blood pressure is one of the most inaccurately measured vital signs, despite being an indicator of oxygen delivery ( Pickering et al, 2005 ). Automated blood pressure monitors, for example, might be used to save time, but their use increases the risk of measurement error ( Elliott and Coventry, 2012 ). Even if blood pressure is measured manually, there is still the risk of an inaccurate reading due to human error ( Coogan et al, 2015 ). The global elements of blood pressure assessment are ( Figure 1 : red cells):

• Use cautiously (Uc): U se automated blood pressure monitors c autiously. Manual auscultatory blood pressure assessment is the gold standard ( Liu et al, 2015 ; Shahbabu et al, 2016 ). If there is doubt about a blood pressure reading obtained from an automated monitor, it should be verified by auscultatory assessment ( Dougherty et al, 2015 )
• Carefully verify (Cv): Automated blood pressure machines provide less reliable readings than those taken manually ( Mirdamadi and Etebari, 2017 ). Once systolic blood pressure falls below 100 mmHg, detection by automated monitors is unreliable. All low blood pressure readings should be C arefully v erified ( Kellett and Sebat, 2017 )
• Second reading (Sr): If the automated blood pressure reading is outside the patient's usual range, a manual S econd r eading should be obtained ( ACT Government Health, 2011 )
• Normal (No): Even in shock the blood pressure may be No rmal because compensatory mechanisms increase peripheral resistance in response to reduced cardiac output ( RCUK, 2021 )
• Late sign (Ls): A change in a blood pressure reading is a L ate s ign of clinical deterioration as compensatory mechanisms fail ( Tollefson and Hillman, 2019 )
• Never assume (Na): An abnormal blood pressure should N ot be a ssumed to be the patient's normal; it should be assessed in relation to previous readings, the patient's clinical condition and other assessments ( Dougherty et al, 2015 )
• Contraindications (Ci): Assess the patient for C ontra i ndications to cuff placement, eg arteriovenous (AV) fistula, lymphoedema, intravenous (IV) therapy ( ACT Government Health, 2011 ). If these are present, the other limb should be used.

Temperature

Core body temperature is a valuable vital sign in the seriously ill patient ( Smith et al, 2005 ). Nurses should use their judgement about whether the recorded temperature is within an acceptable range for the patient's condition and if more frequent temperature measurement is needed ( Grainger, 2013 ). The global elements of temperature assessment are ( Figure 1 : green cells):

• Temperature differs (Td): Normal body T emperature d iffers between anatomical sites ( Elliott and Coventry, 2012 ). Awareness of this is important when interpreting readings
• Favourable conditions (Fc) : Check for F avourable c onditions of the site to perform accurate temperature monitoring, eg for the oral site, no recent consumption of hot or cold beverages ( ACT Government Health, 2011 )
• Repeat (Re): If the temperature reading is abnormally high or low, Re peat the reading with another thermometer ( ACT Government Health, 2011 )
• Individual variability (Iv): As body temperature varies with age, gender and site of measurement, it should be assessed in relation to I ndividual v ariability, ie a baseline value ( Sund-Levander and Grodzinsky, 2013 )
• Three temperatures (Tt): Clinically, there are T hree t emperatures: core body temperature, how the patient says they feel, and how the patient feels to touch. These are not always the same and awareness of these might make interpretation of conflicting assessment findings easier ( Elliott and Coventry, 2012 )
• Accuracy (Ac): Numerous factors affect the Ac curacy of temperature measurements such as the device and technique ( Jevon, 2020 )
• Hypothermia (Ho): Research has found only modest increases in mortality associated with temperatures above 38°C; a low temperature though was found to be much more ominous ( Bleyer et al, 2011 ; Kellett and Kim, 2012 ; Kellett, 2017 ). The clinical importance of a low temperature ( H yp o thermia) should not be ignored.

Consciousness and cognition

Many factors, both primary and secondary, can affect a patient's level of consciousness or cognition. Accurate assessment of consciousness is therefore paramount for the early diagnosis and management of deterioration, as changes in conscious level are associated with poor outcomes ( Rylance et al, 2009 ; Vink et al, 2018 ). The global elements of consciousness and cognition assessment are ( Figure 1 : lilac cells):

• Routinely assess (Ra) : Because many factors may affect consciousness or cognition, these should be R outinely a ssessed in all patients ( National Institute for Health and Care Excellence (NICE), 2007 ). The established vital signs (eg temperature, pulse, blood pressure, respiratory rate) fail to provide insight into a patient's cognitive function and mental status ( Chester and Rudolph, 2011 )
• Validated scale (Vs) : Use a V alidated s cale or tool to quantify the assessment, eg the Glasgow Coma Scale, Alert Verbal Pain Unresponsive ( RCUK, 2021 ). Terms such as semiconscious or stuporous should be avoided because they are subjective ( Dougherty et al, 2015 )
• Predictor (Pr): A decrease in the Glasgow Coma Scale score Pr edicts an adverse event. A drop of two or more predicts a major adverse event ( Massey et al, 2015 )
• Subtle changes (Sc): c hanges to consciousness or cognition are often S ubtle. Mild alteration of mental status is therefore often not noticed, even though this might reflect early deterioration ( Kellett, 2017 )
• Perform frequently (Pf): In patients with an acute or rapidly changing status, assessment of consciousness should be P erformed more f requently, ie every 15–60 minutes ( Tollefson and Hillman, 2019 )
• Delayed signs (Ds): Vital sign changes are a D elayed s ign of neurological deterioration ( Tollefson and Hillman, 2019 ).

Critical elements (CE)

Underpinning all vital signs' assessments are the following critical elements ( Figure 1 : yellow cells):

• Compare (Co): Never trust the monitor. Co mpare manual assessments of the patient with the anticipated result and the monitor
• Anticipate (An) : An ticipate the vital sign measurement before you assess it. Doing so will help validate the data obtained
• Patient's baseline (Pb) : Know the P atient's b aseline where possible, because changes from an individual reference point may indicate important warning signs and thus require additional evaluation ( Chester and Rudolph, 2011 ; Liddle, 2013 )
• Previous readings (Pr) : Ignore the P revious vital signs r eadings (until you have assessed the signs yourself)
• Don't copy (Dc) : D o not c opy the last vital sign readings. Although a patient's vital signs might remain stable, each assessment must be an objective measurement of physiological function, ie measured not surmised ( Chester and Rudolph, 2011 )
• No blanks (Nb) : Leave N o b lanks on the chart. Assess and document all vital signs ( McGhee et al, 2016 ). The ability of a chart to identify deterioration depends on the reliability and completeness of the observations ( Clinical Excellence Commission, 2021 )
• Increase frequency (If) : I ncrease f requency of vital sign assessments if abnormal vital signs are observed ( NICE, 2007 ). If the patient is acutely ill, for example, vital signs may need to be assessed every 15 minutes ( Alexis, 2010 )
• Eight hourly (Eh): In the absence of a documented monitoring plan, patients should have a completed set of vital signs assessed at least 3 times per day at E ight- h ourly intervals ( Clinical Excellence Commission, 2021 ). Eight-hourly measurement results in earlier detection of physiological abnormalities and clinical deterioration ( Ludikhuize et al, 2014 ; Kellett and Sebat, 2017 )
• Trends (Tr): Vital signs are constantly changing, so they are better expressed and interpreted by their Tr ends rather than just their precise value at any point in time ( Kellett, 2017 ). Vital sign trends significantly improve the accuracy of detecting clinical deterioration compared to the current vital sign values alone ( Churpek et al, 2016 )
• Clinical judgement (Cj): C linical j udgement, rather than complete reliance on vital signs' readings, should be the basis for effective patient management ( Pretto et al, 2014 )
• Calling criteria (Cc): Know the C alling c riteria for emergency medical assistance ( DeVita et al, 2010 ).
• No delegation (Nd): Vital signs' assessment should N ot be d elegated to less qualified or experienced nursing staff. The recognition of and response to acute physiological deterioration requires appropriately qualified, skilled and experienced staff ( Australian Commission on Safety and Quality in Health Care (ACSQHC,) 2017 ). Recognising patients whose condition is acutely deteriorating is essential for safe and high-quality care ( ACSQHC, 2017 )
• Full set (Fs): A F ull s et of vital signs should be assessed prior to and on transfer of care from one ward to another, from emergency departments, high dependency or intensive care units to general wards, and from one facility to another ( ACT Government Health, 2018 ). When vital signs' assessment is incomplete, physiological instability is often missed ( Clifton et al, 2015 )
• Document interpret (Di): Accurate D ocumentation and i nterpretation of accurately measured vital signs helps improve patient outcomes ( Rolfe, 2019 )
• Analyse collectively (Ac): Vital signs should not be assessed in isolation but A nalysed c ollectively in conjunction with other signs and the patient's ongoing health condition ( Tollefson and Hillman, 2019 ).

Vital signs serve as a universal communication tool for patient status and severity of illness and are a critical component of early warning scores and medical emergency teams ( Chester and Rudolph, 2011 ). When acting on abnormal vital signs, any clinical intervention needs to be implemented in a timely manner to prevent, where possible, any further deterioration in the patient's condition ( Grainger, 2013 ). For this to happen, nurses must understand the clinical importance of vital signs' monitoring, but research suggests that this is not always the case ( Cardona-Morrell et al, 2016 ; Burchill et al, 2015 ).

The proposed Global Elements guide can be used as a benchmarking tool when auditing vital sign assessment patterns or when performing a root cause analysis to determine specific areas of neglect of vital signs' assessment. For example, one coroner's case involved a 46-year-old woman who was admitted to a ward following an endoscopic procedure to correct complications of previous surgeries ( Patient Safety Surveillance Unit, 2014 ). During the second postoperative night, her heart rate, blood pressure and respiratory rate were elevated and oxygen saturation low. No concern was expressed about these signs. She remained unwell with persistently elevated heart rate, temperature and respiratory rate, and hypoxia requiring supplemental oxygen. Routine observations continued 4-to 6-hourly. Although these vital signs constantly met the emergency medical call criteria, no call was made and the frequency of observations was not increased. The patient continued to deteriorate requiring further surgery and later died from surgical complications ( Patient Safety Surveillance Unit, 2014 ).

Using the Global Elements as a guide, numerous deficits can be seen in this patient's vital sign assessments. The clinical importance of the patient's elevated respiratory rate is reflected in the respiratory rate Elements sensitive marker (Sm), First sign (Fs), powerful predictor (Pp), illness marker (Im) and minor changes (Mc). These Elements highlight the critical nature of the patient's initial respiratory rate elevation and emphasise that action should have been taken at that point. An increased frequency of respiratory rate assessment should have been evident on her vital signs' chart. Similarly, the low oxygen saturation in the clinical context (Cc) of an elevated respiratory rate and heart rate should have triggered urgent clinical action. The alteration (Al) in heart rate also reflected the initial deterioration in her condition and a deviation from normal range (Nr). An increased frequency of pulse rate assessment should also have been evident on the vital signs' chart (If) in response to the heart rate elevation.

Finally, the abnormal vital signs should have triggered staff to increase the frequency (If) of vital sign assessments, and familiarity with the emergency calling criteria (Cc) should also have promoted action. The staff continued to assess vital signs 4-to 6-hourly, suggesting they did not understand the importance of vital signs' assessments nor recognise the patient's deterioration. The application of the Global Elements highlights the care deficits in this case.

The current limited research on vital signs' assessment means that clinicians have little guidance for establishing a policy for evidence-based practice ( McGhee et al, 2016 ). It is hoped that the global elements proposed here are one small advance towards enhancing nurses' understanding of the critical importance of vital signs' assessments.

• Vital signs' assessment is a key component of safe, high-quality care
• Abnormal vital signs are associated with poor clinical outcomes
• Research shows that vital signs' assessment is often neglected in clinical practice
• To help emphasise the importance of vital signs' assessment, Global Elements of vital signs' assessment are proposed
• The proposed framework of Global Elements reflects the key principles underpinning vital signs' assessment

CPD reflective questions

• What is the purpose of assessing patients' vital signs?
• Why is vital signs' assessment often neglected by nurses?
• How can vital signs' data be used to influence clinical management?

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Vital Signs

Your vital signs show how well your body is functioning. They are usually measured at doctor's offices, often as part of a health checkup , or during an emergency room visit. They include:

• Blood pressure, which measures the force of your blood pushing against the walls of your arteries. Blood pressure that is too high or too low can cause problems. Your blood pressure has two numbers. The first number is the pressure when your heart beats and is pumping the blood. The second is from when your heart is at rest, between beats. A normal blood pressure reading for adults is lower than 120/80 and higher than 90/60.
• Heart rate, or pulse, which measures how fast your heart is beating. A problem with your heart rate may be an arrhythmia . Your normal heart rate depends on factors such as your age, how much you exercise, whether you are sitting or standing, which medicines you take, and your weight.
• Respiratory rate, which measures your breathing. Mild breathing changes can be from causes such as a stuffy nose or hard exercise. But slow or fast breathing can also be a sign of a serious breathing problem .
• Temperature, which measures how hot your body is. A body temperature that is higher than normal (over 98.6 °F, or 37 °C) is called a fever .
• Aging changes in vital signs (Medical Encyclopedia) Also in Spanish
• All about Heart Rate (Pulse) (American Heart Association)
• Blood Pressure: Does It Have a Daily Pattern? (Mayo Foundation for Medical Education and Research) Also in Spanish
• Blood Pressure: Is It Affected by Cold Weather? (Mayo Foundation for Medical Education and Research) Also in Spanish
• Body temperature norms (Medical Encyclopedia) Also in Spanish

• Pulse (Medical Encyclopedia) Also in Spanish
• Temperature measurement (Medical Encyclopedia) Also in Spanish
• Thermometers: Understand the Options (Mayo Foundation for Medical Education and Research) Also in Spanish
• Wrist Blood Pressure Monitors: Are They Accurate? (Mayo Foundation for Medical Education and Research) Also in Spanish

Clinical Trials

Journal articles references and abstracts from medline/pubmed (national library of medicine).

• Article: DEMA: A Deep Learning-Enabled Model for Non-Invasive Human Vital Signs Monitoring...
• Article: Ballistocardial Signal-Based Personal Identification Using Deep Learning for the Non-Invasive and...
• Article: Predictive health monitoring: Leveraging artificial intelligence for early detection of infectious...
• Vital Signs -- see more articles

The information on this site should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

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Vital Signs (Body Temperature, Pulse Rate, Respiration Rate, Blood Pressure)

What are vital signs.

Vital signs are measurements of the body's most basic functions. The four main vital signs routinely monitored by medical professionals and health care providers include the following:

Body temperature

Respiration rate (rate of breathing)

Blood pressure (Blood pressure is not considered a vital sign, but is often measured along with the vital signs.)

Vital signs are useful in detecting or monitoring medical problems. Vital signs can be measured in a medical setting, at home, at the site of a medical emergency, or elsewhere.

What is body temperature?

The normal body temperature of a person varies depending on gender, recent activity, food and fluid consumption, time of day, and, in women, the stage of the menstrual cycle. Normal body temperature can range from 97.8 degrees F (or Fahrenheit, equivalent to 36.5 degrees C, or Celsius) to 99 degrees F (37.2 degrees C) for a healthy adult. A person's body temperature can be taken in any of the following ways:

Orally. Temperature can be taken by mouth using either the classic glass thermometer, or the more modern digital thermometers that use an electronic probe to measure body temperature.

Rectally. Temperatures taken rectally (using a glass or digital thermometer) tend to be 0.5 to 0.7 degrees F higher than when taken by mouth.

Axillary. Temperatures can be taken under the arm using a glass or digital thermometer. Temperatures taken by this route tend to be 0.3 to 0.4 degrees F lower than those temperatures taken by mouth.

By ear. A special thermometer can quickly measure the temperature of the ear drum, which reflects the body's core temperature (the temperature of the internal organs).

By skin. A special thermometer can quickly measure the temperature of the skin on the forehead.

Body temperature may be abnormal due to fever (high temperature) or hypothermia (low temperature). A fever is indicated when body temperature rises about one degree or more over the normal temperature of 98.6 degrees Fahrenheit, according to the American Academy of Family Physicians. Hypothermia is defined as a drop in body temperature below 95 degrees Fahrenheit.

About glass thermometers containing mercury

According to the Environmental Protection Agency, mercury is a toxic substance that poses a threat to the health of humans, as well as to the environment. Because of the risk of breaking, glass thermometers containing mercury should be removed from use and disposed of properly in accordance with local, state, and federal laws. Contact your local health department, waste disposal authority, or fire department for information on how to properly dispose of mercury thermometers.

What is the pulse rate?

The pulse rate is a measurement of the heart rate, or the number of times the heart beats per minute. As the heart pushes blood through the arteries, the arteries expand and contract with the flow of the blood. Taking a pulse not only measures the heart rate, but also can indicate the following:

Heart rhythm

Strength of the pulse

The normal pulse for healthy adults ranges from 60 to 100 beats per minute. The pulse rate may fluctuate and increase with exercise, illness, injury, and emotions. Females ages 12 and older, in general, tend to have faster heart rates than do males. Athletes, such as runners, who do a lot of cardiovascular conditioning, may have heart rates near 40 beats per minute and experience no problems.

How to check your pulse

As the heart forces blood through the arteries, you feel the beats by firmly pressing on the arteries, which are located close to the surface of the skin at certain points of the body. The pulse can be found on the side of the neck, on the inside of the elbow, or at the wrist. For most people, it is easiest to take the pulse at the wrist. If you use the lower neck, be sure not to press too hard, and never press on the pulses on both sides of the lower neck at the same time to prevent blocking blood flow to the brain. When taking your pulse:

Using the first and second fingertips, press firmly but gently on the arteries until you feel a pulse.

Begin counting the pulse when the clock's second hand is on the 12.

Count your pulse for 60 seconds (or for 15 seconds and then multiply by four to calculate beats per minute).

When counting, do not watch the clock continuously, but concentrate on the beats of the pulse.

If unsure about your results, ask another person to count for you.

If your doctor has ordered you to check your own pulse and you are having difficulty finding it, consult your doctor or nurse for additional instruction.

What is the respiration rate?

The respiration rate is the number of breaths a person takes per minute. The rate is usually measured when a person is at rest and simply involves counting the number of breaths for one minute by counting how many times the chest rises. Respiration rates may increase with fever, illness, and other medical conditions. When checking respiration, it is important to also note whether a person has any difficulty breathing.

Normal respiration rates for an adult person at rest range from 12 to 16 breaths per minute.

What is blood pressure?

Blood pressure is the force of the blood pushing against the artery walls during contraction and relaxation of the heart. Each time the heart beats, it pumps blood into the arteries, resulting in the highest blood pressure as the heart contracts. When the heart relaxes, the blood pressure falls.

Two numbers are recorded when measuring blood pressure. The higher number, or systolic pressure, refers to the pressure inside the artery when the heart contracts and pumps blood through the body. The lower number, or diastolic pressure, refers to the pressure inside the artery when the heart is at rest and is filling with blood. Both the systolic and diastolic pressures are recorded as "mm Hg" (millimeters of mercury). This recording represents how high the mercury column in an old-fashioned manual blood pressure device (called a mercury manometer or sphygmomanometer) is raised by the pressure of the blood. Today, your doctor's office is more likely to use a simple dial for this measurement.

High blood pressure , or hypertension, directly increases the risk of heart attack, heart failure, and stroke. With high blood pressure, the arteries may have an increased resistance against the flow of blood, causing the heart to pump harder to circulate the blood.

Blood pressure is categorized as normal, elevated, or stage 1 or stage 2 high blood pressure:

Normal blood pressure is systolic of less than 120 and diastolic of less than 80 (120/80)

Elevated blood pressure is systolic of 120 to 129 and diastolic less than 80

Stage 1 high blood pressure is systolic is 130 to 139 or diastolic between 80 to 89

Stage 2 high blood pressure is when systolic is 140 or higher or the diastolic is 90 or higher

These numbers should be used as a guide only. A single blood pressure measurement that is higher than normal is not necessarily an indication of a problem. Your doctor will want to see multiple blood pressure measurements over several days or weeks before making a diagnosis of high blood pressure and starting treatment. Ask your provider when to contact him or her if your blood pressure readings are not within the normal range.

Why should I monitor my blood pressure at home?

For people with hypertension, home monitoring allows your doctor to monitor how much your blood pressure changes during the day, and from day to day. This may also help your doctor determine how effectively your blood pressure medication is working.

What special equipment is needed to measure blood pressure?

Either an aneroid monitor, which has a dial gauge and is read by looking at a pointer, or a digital monitor, in which the blood pressure reading flashes on a small screen, can be used to measure blood pressure.

About the aneroid monitor

The aneroid monitor is less expensive than the digital monitor. The cuff is inflated by hand by squeezing a rubber bulb. Some units even have a special feature to make it easier to put the cuff on with one hand. However, the unit can be easily damaged and become less accurate. Because the person using it must listen for heartbeats with the stethoscope, it may not be appropriate for the hearing-impaired.

About the digital monitor

The digital monitor is automatic, with the measurements appearing on a small screen. Because the recordings are easy to read, this is the most popular blood pressure measuring device. It is also easier to use than the aneroid unit, and since there is no need to listen to heartbeats through the stethoscope, this is a good device for hearing-impaired patients. One disadvantage is that body movement or an irregular heart rate can change the accuracy. These units are also more expensive than the aneroid monitors.

About finger and wrist blood pressure monitors

Tests have shown that finger and/or wrist blood pressure devices are not as accurate in measuring blood pressure as other types of monitors. In addition, they are more expensive than other monitors.

Before you measure your blood pressure:

The American Heart Association recommends the following guidelines for home blood pressure monitoring:

Don't smoke or drink coffee for 30 minutes before taking your blood pressure.

Go to the bathroom before the test.

Relax for 5 minutes before taking the measurement.

Sit with your back supported (don't sit on a couch or soft chair). Keep your feet on the floor uncrossed. Place your arm on a solid flat surface (like a table) with the upper part of the arm at heart level. Place the middle of the cuff directly above the bend of the elbow. Check the monitor's instruction manual for an illustration.

Take multiple readings. When you measure, take 2 to 3 readings one minute apart and record all the results.

Take your blood pressure at the same time every day, or as your healthcare provider recommends.

Record the date, time, and blood pressure reading.

Take the record with you to your next medical appointment. If your blood pressure monitor has a built-in memory, simply take the monitor with you to your next appointment.

Call your provider if you have several high readings. Don't be frightened by a single high blood pressure reading, but if you get several high readings, check in with your healthcare provider.

When blood pressure reaches a systolic (top number) of 180 or higher OR diastolic (bottom number) of 110 or higher, seek emergency medical treatment.

Ask your doctor or another healthcare professional to teach you how to use your blood pressure monitor correctly. Have the monitor routinely checked for accuracy by taking it with you to your doctor's office. It is also important to make sure the tubing is not twisted when you store it and keep it away from heat to prevent cracks and leaks.

Proper use of your blood pressure monitor will help you and your doctor in monitoring your blood pressure.

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Vital Signs

Vital signs include the measurement of: temperature, respiratory rate, pulse, blood pressure and, where appropriate, blood oxygen saturation. These numbers provide critical information (hence the name "vital") about a patient's state of health. In particular, they:

• Can identify the existence of an acute medical problem.
• Are a means of rapidly quantifying the magnitude of an illness and how well the body is coping with the resultant physiologic stress. The more deranged the vitals, the sicker the patient.
• Are a marker of chronic disease states (e.g. hypertension is defined as chronically elevated blood pressure).

Most patients will have had their vital signs measured by an RN or health care assistant before you have a chance to see them. However, these values are of such great importance that you should get in the habit of repeating them yourself, particularly if you are going to use these values as the basis for management decisions. This not only allows you to practice obtaining vital signs but provides an opportunity to verify their accuracy. As noted below, there is significant potential for measurement error, so repeat determinations can provide critical information.

Getting Started: The examination room should be quiet, warm and well lit. After you have finished interviewing the patient, provide them with a gown (a.k.a. "Johnny") and leave the room (or draw a separating curtain) while they change. Instruct them to remove all of their clothing (except for briefs) and put on the gown so that the opening is in the rear. Occasionally, patient's will end up using them as ponchos, capes or in other creative ways. While this may make for a more attractive ensemble it will also, unfortunately, interfere with your ability to perform an examination! Prior to measuring vital signs, the patient should have had the opportunity to sit for approximately five minutes so that the values are not affected by the exertion required to walk to the exam room. All measurements are made while the patient is seated.

Observation: Before diving in, take a minute or so to look at the patient in their entirety, making your observations, if possible, from an out-of-the way perch. Does the patient seem anxious, in pain, upset? What about their dress and hygiene? Remember, the exam begins as soon as you lay eyes on the patient.

Temperature: This is generally obtained using an oral thermometer that provides a digital reading when the sensor is placed under the patient's tongue. As most exam rooms do not have thermometers, it is not necessary to repeat this measurement unless, of course, the recorded value seems discordant with the patient's clinical condition (e.g. they feel hot but reportedly have no fever or vice versa). Depending on the bias of a particular institution, temperature is measured in either Celcius or Farenheit, with a fever defined as greater than 38-38.5 C or 101-101.5 F. Rectal temperatures, which most closely reflect internal or core values, are approximately 1 degree F higher than those obtained orally.

Respiratory Rate: Respirations are recorded as breaths per minute. They should be counted for at least 30 seconds as the total number of breaths in a 15 second period is rather small and any miscounting can result in rather large errors when multiplied by 4. Try to do this as surreptitiously as possible so that the patient does not consciously alter their rate of breathing. This can be done by observing the rise and fall of the patient's hospital gown while you appear to be taking their pulse. Normal is between 12 and 20. In general, this measurement offers no relevant information for the routine examination. However, particularly in the setting of cardio-pulmonary illness, it can be a very reliable marker of disease activity.

Pulse: This can be measured at any place where there is a large artery (e.g. carotid, femoral, or simply by listening over the heart), though for the sake of convenience it is generally done by palpating the radial impulse. You may find it helpful to feel both radial arteries simultaneously, doubling the sensory input and helping to insure the accuracy of your measurements. Place the tips of your index and middle fingers just proximal to the patients wrist on the thumb side, orienting them so that they are both over the length of the vessel.

The pictures below demonstrate the location of the radial artery (surface anatomy on the left, gross anatomy on the right).

Frequently, you can see transmitted pulsations on careful visual inspection of this region, which may help in locating this artery. Upper extremity peripheral vascular disease is relatively uncommon, so the radial artery should be readily palpable in most patients. Push lightly at first, adding pressure if there is a lot of subcutaneous fat or you are unable to detect a pulse. If you push too hard, you might occlude the vessel and mistake your own pulse for that of the patient. During palpation, note the following:

• Quantity: Measure the rate of the pulse (recorded in beats per minute). Count for 30 seconds and multiply by 2 (or 15 seconds x 4). If the rate is particularly slow or fast, it is probably best to measure for a full 60 seconds in order to minimize the impact of any error in recording over shorter periods of time. Normal is between 60 and 100.
• Regularity: Is the time between beats constant? In the normal setting, the heart rate should appear metronomic. Irregular rhythms, however, are quite common. If the pattern is entirely chaotic with no discernable pattern, it is referred to as irregularly irregular and likely represents atrial fibrillation. Extra beats can also be added into the normal pattern, in which case the rhythm is described as regularly irregular. This may occur, for example, when impulses originating from the ventricle are interposed at regular junctures on the normal rhythm. If the pulse is irregular, it's a good idea to verify the rate by listening over the heart (see cardiac exam section). This is because certain rhythm disturbances do not allow adequate ventricular filling with each beat. The resultant systole may generate a rather small stroke volume whose impulse is not palpable in the periphery.
• Volume: Does the pulse volume (i.e. the subjective sense of fullness) feel normal? This reflects changes in stroke volume. In the setting of hypovolemia, for example, the pulse volume is relatively low (aka weak or thready). There may even be beat to beat variation in the volume, occurring occasionally with systolic heart failure.

Rhythm Simulator

Blood Pressure: Blood pressure (BP) is typically measured using an anaeroid manometer, with readings reported in millimeters of mercury (mm Hg). While most BP readings in hospitals and clinics are initially taken with digital machines, it's still relevant to learn how to use manual cuffs, as clinicians will need to check the validity of digital readings on occasion (e.g. when BP unexpectedly high or low). The size of the BP cuff will affect the accuracy of these readings. The inflatable bladder, which can be felt through the vinyl covering of the cuff, should reach roughly 80% around the circumference of the arm while its width should cover roughly 40%. If it is too small, the readings will be artificially elevated. The opposite occurs if the cuff is too large. Clinics should have at least 2 cuff sizes available, normal and large. Try to use the one that is most appropriate, recognizing that there will rarely be a perfect fit.

In order to measure the BP, proceed as follows:

The pictures below demonstrate the antecubital fossa anatomy (surface anatomy on the left, gross anatomy on the right).

• Wrap the cuff around the patient's upper arm so that the line marked "artery" is roughly over the brachial artery, located towards the medial aspect of the antecubital fossa (i.e. the crook on the inside of their elbow). The placement does not have to be exact nor do you actually need to identify this artery by palpation.
• Turn the valve on the pumping bulb clockwise (may be counter clockwise in some cuffs) until it no longer moves. This is the position which allows air to enter and remain in the bladder.
• Hold the bell in place with your left hand. Use your right hand to pump the bulb until you have generated 150 mmHg on the manometer. This is a bit above the top end of normal for systolic blood pressure (SBP). Then listen. If you immediately hear sound, you have underestimated the SBP. Pump up an additional 20 mmHg and repeat. Now slowly deflate the blood pressure cuff (i.e. a few mm Hg per second) by turning the valve in a counter-clockwise direction while listening over the brachial artery and watching the pressure gauge. The first sound that you hear reflects the flow of blood through the no longer completely occluded brachial artery. The value on the manometer at this moment is the SBP. Note that although the needle may oscillate prior to this time, it is the sound of blood flow that indicates the SBP.

• Repeat the measurement on the patient's other arm, reversing the position of your hands. The two readings should be within 10-15 mm Hg of each other. Differences greater than this imply that there is differential blood flow to each arm, which most frequently occurs in the setting of subclavian artery atherosclerosis.
• Occasionally you will be unsure as to the point where systole or diastole occurred and wish to repeat the measurement. Ideally, you should allow the cuff to completely deflate, permit any venous congestion in the arm to resolve (which otherwise may lead to inaccurate measurements), and then repeat a minute or so later. Furthermore, while no one has ever lost a limb secondary to BP cuff induced ischemia, repeated measurement can be uncomfortable for the patient, another good reason for giving the arm a break.
• Avoid moving your hands or the head of the stethescope while you are taking readings as this may produce noise that can obscure the Sounds of Koratkoff.
• You can verify the SBP by palpation. To do this, position the patient's right arm as described above. Place the index and middle fingers of your right hand over the radial artery. Inflate the cuff until you can no longer feel the pulse, or simply to a value 10 points above the SBP as determined by auscultation. Slowly deflate the cuff until you can again detect a radial pulse and note the reading on the manometer. This is the SBP and should be the same as the value determined with the use of your stethescope.

Implications, interpretation and other clinical pearls related to hypertension:

Hypertension is a common disease, affecting > 40% of the adult US population. With the steady increase in obesity rates, it’s anticipated that this % will continue to increase.

Normal values and definitions for hypertension are as follows:

• Normal < 120/80 mm Hg
• Elevated: SBP 120-129 and DBP < 80 mm Hg
• Stage I hypertension: SBP 130-39 or DBP 80-89 mm Hg
• Stage II hypertension: SBP >= 140 or DBP >= 90 mm Hg

The diagnosis of hypertension is typically based on 2 readings, done at 2 different settings. A one-time measurement > 160/100 should prompt consideration for treatment. Home readings (with a validated device) can also be used for the diagnosis and management of hypertension. Careful attention must be paid to the use of appropriate techniques (described above), as measurement error(s) can lead to inaccurate values and diagnoses.

Hypertension (HTN) causes and accelerates the progression of: Coronary artery disease, heart failure with reduced ejection fraction (HFrEF), heart failure with preserved ejection fraction (HFpEF), left ventricular hypertrophy, aortic aneurysm development, peripheral arterial disease, stroke, chronic kidney disease, and retinopathy. The risk of HTN induced damage correlates with both the height of BP and the chronicity of elevation (i.e. longer and higher is worse).

The treatment of HTN prior to the development of Target Organ Damage (a.k.a. TOD) is referred to as "primary prevention," while treatment to prevent and/or slow progression once disease has already been established is called "secondary prevention." Evaluation of patients with HTN requires careful history taking, physical exam, labs, and other studies to search for co-morbid problems (e.g. diabetes, sleep apnea, etc.) and/or occult TOD. Most patients with HTN are asymptomatic, at least until they develop target organ damage, which can take years to manifest.

A few additional clinically oriented thoughts:

• The development of hypertension is directly affected by weight, inactivity, alcohol consumption, and salt intake. As such, life style interventions directed to address each of these issues are important. Making use of resources and persons with expertise in these areas can increase the effectiveness of interventions. This can include enlisting the help of nutritionists, exercise programs, comprehensive weight loss systems, alcohol/addiction specialists, etc. And it’s important for clinicians to continually assess every patient’s interest (e.g. via motivational interviewing techniques) and level of engagement at each interaction with the health care system. Lifestyle interventions alone are reasonable for patients with stage I hypertension and Estimated by ACC Atherosclerotic Risk Calculator or other similar tool). And even if meds are ultimately used, lifestyle changes can have a synergistic effect.
• Hypertension swims in the same vascular risk factor waters as diabetes, hyperlipidemia, and smoking. As such, these other areas must also be addressed, including appropriate use of aspirin.
• The trigger value at which anti-hypertensive treatments should be initiated varies with a patient’s risk for atherosclerosis. In those with established disease (e.g. known coronary artery disease, Diabetes), or 10y risk ( Estimated by ACC Atherosclerotic Risk Calculator or other similar tool) > 10%, pharmacologic treatment is started if BP > 130/80. For those without known disease and risk 140/90. It’s also worth noting that BP targets and thresholds to initiate treatment have changed over the years and will likely continue to do so.
• For those receiving treatment, BP target is < 130/80, regardless of ASCVD risk.
• Most drugs within the same class (e.g. any of the 8 or so ACE-Inhibitors) are equally efficacious.
• Effective treatment requires continual reassessment of medication adherence - a major reason for lack of response to Rx. It helps to know the common side effects for each medication, as they can affect adherence (e.g. ACE-I →cough; thiazides → mild increase in urination; all anti-hypertensive meds→ hypotension).
• The majority of patients with HTN (> 60%) will require at least 2 meds for treatment.
• Initial medication choices can be thiazide diuretics, Ace- Inhibitors/Angiotensin Receptor Blockers, or calcium channel blockers.
• For those with starting BP values > 160/100, it's best to start with 2 meds simultaneously. Instances where 3 or more medications are required is relatively common, often related to obesity and other comorbid conditions (e.g. CKD). Non-adherence should also be considered.
• Certain conditions favor particular meds, including: Diabetes → ACE-I or ARBs; Coronary artery disease → Beta blockers; HFrEF→ Ace-I/ARBs, selective Beta blockers, loop diuretics.
• Where you start isn't where you end, so expect to reassess BP and related issues repeatedly over time. This includes review of adherence to medication and other treatment plans, weight gain, use of medications with adverse affect on BP (e.g. NSAIDs, ADHD meds), and the appearance of new symptoms (e.g. SOB, CP) that might suggest hypertension related TOD.
• Medications (e.g. NSAIDs, decongestants, stimulants, many others) or excess alcohol intake.
• Chronic kidney disease: As evidenced by decreased GFR on labs and symptoms such as SOB, fatigue; PE: Hypertension, edema if volume overload.
• Obstructive sleep apnea: Poorly rested in the morning, awakening in middle of night gasping for air, snoring, noted by partner to stop breathing, chronic day time sleepiness; PE: Elevated BMI, difficulty visualizing the posterior pharynx, large neck diameter (> 17 inches men, > 16 inches women).
• Hyperaldosteronism: Unexplained hypokalemia and/or hypokalemia that is disproportionate to inciting medications; PE: Hypertension.
• Hypothyroidism: Weight gain, constipation, fatigue, weakness, dry skin, cold intolerance; PE: Hypertension pretibial edema, lateral thinning of eyebrows, decreased relaxation phase of reflexes, sometimes thyromegaly.
• Hyperthyroidism: Weight loss, diarrhea, fatigue, weakness, irritability, heat intolerance, palpitations; PE: elevated heart rate (atrial fibrillation), hypertension, tremor, proptosis, hyper-reflexia, warm/moist skin.
• Renal artery stenosis: Chronic kidney disease; PE: Hypertension, sometimes abdominal bruit, decreased peripheral pulses/other evidence atherosclerosis.
• Pheochromocytoma: Paroxysms of hypertension, awareness of heart pounding, headache, fatigue; PE: Hypertension, sweating, elevated heart rate during a “spell”
• Excess cortisol production (Cushings): Central weight gain, weakness, fatigue, bruising; PE: Hypertension, obesity, posterior cervical fat pad (“buffalo hump”), abdominal striae, round face (‘moon facies’), echymoses.
• Growth hormone excess (Acromegaly): Growth of hands and feet as an adult, fatigue, weakness, joint pain, headache, altered vision; PE: Hypertension, large jaw, gaps between teeth, prominent brow, large hands and feet, large tongue, bi-temporal visual field cuts.
• Coarctation of the aorta: Typically noted in young (< 30 y.o.) patients; PE: Hypertension, BP difference between arms and legs, diminished peripheral pulses (i.e. femoral compared with radial), bruit (back, chest, or abdomen).
• Acute interventions to immediately lower BP are usually reserved for those instances when there is clear evidence of acute symptoms related to acute TOD, referred to as a hypertensive emergency. Those situations include acute heart failure, coronary ischemia, hypertensive encephalopathy, and acute kidney injury.
• Low end of normal BP is ~ 90/100/70, though the minimal blood pressure required to maintain perfusion varies with the individual patient. Therefore, interpretation of low values must take into account the clinical situation. Those with poorly functioning hearts, for example, can adjust to a chronically low SBP (e.g. 80-90) and live without symptoms of hypo-perfusion. However others, used to higher baseline values, might become quite ill if their SBPs were suddenly decreased to these same levels.

Orthostatic (a.k.a. postural) measurements of pulse and blood pressure are often part of the assessment for hypovolemia and/or dizziness. This requires first measuring HR and BP when the patient is supine and then repeating them after the patient has stood for a few minutes.

Normally, SBP doesn’t vary by more than ~20 points and DBP by more than ~10 points when a patient moves from lying to standing. In the setting of significant volume depletion, a greater drop may be seen. This may also be associated with symptoms of cerebral hypo-perfusion (e.g. light headedness). In the setting of acute GI bleeding, for example, a drop in blood pressure and/or rise in heart rate when moving from lying to standing is a marker of significant blood loss and has important prognostic implications. It is also possible to have volume loss without attendant postural changes (i.e. the absence of changes doesn’t rule out hypovolemia).

Orthostatic measurements may also be used to determine if postural dizziness or syncope/presyncope are the result of a fall in blood pressure. For example, patients who suffer from diabetes may have autonomic nervous system dysfunction and impaired ability to appropriately vasoconstrict when changing positions. If their dizziness/lightheadedness is the result of orthostatic changes, then their BP will drop when they move from a lying to standing position and their symptoms will be reproduced. The 20-point value is a rough guideline. In general, the greater the change in BP, the more likely it is to cause symptoms and be of clinical significance.

The following are links to useful additional information about BP measurement and hypertension.

• AHA/ACC 2017 Guideline for High Blood Pressure in Adults
• New England Journal of Medicine - BP Measurement
• Moser M, et al. Resistant or difficult to control hypertension. NEJM 2006; 355: 385-92.

Oxygen Saturation: Over the past decade, this non-invasive measurement of gas exchange and red blood cell oxygen carrying capacity has become available in all hospitals and many clinics. While imperfect, it can provide important information about cardio-pulmonary dysfunction and is considered by many to be a fifth vital sign. In particular, for those suffering from either acute or chronic cardio-pulmonary disorders, it can help quantify the degree of impairment.

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95 Conclusion

As you become more proficient in measuring vital signs and interpreting the findings, you should remember a few key points.

There are many methods to take vitals signs. The correct technique is essential to obtaining an accurate measurement.

Vital sign measurements have very little meaning on their own. Healthcare providers engage in critical thinking and correlate these measurements with subjective and other objective data. Thinking critically about these measurements will best inform clinical decision-making. Healthcare providers look holistically at the person and their health and wellness state to determine whether vital sign measurements are within normal limits for this individual person.

It is also essential to acknowledge that clients may have additional information that can provide insight into their body, which may influence the technique and location for measuring vital signs and the significance of the findings. Sharing findings with clients is also a good opportunity for health promotion teaching.

Points to Consider 

It is important to document vital signs in a timely manner. The healthcare provider reports any abnormal and unexpected findings to the most responsible provider. For example, students should share the findings with their preceptor or clinical instructor in a timely manner.

Figure 7.1:  Cells  (Illustration credit: Hilary Tang)

Artist Statement – Cells

The human body is a messy phenomenon. From the organ to the cell, the brain to the neurotransmitter, like clockwork, everything is constantly happening. Down to our very core, the tiniest components are working in conjunction, harmoniously, to let us eat, breathe, and move. Without our constant consciousness, we are living. What an organized chaos our bodies are.

Vital Sign Measurement Across the Lifespan - 1st Canadian edition Copyright © 2018 by Ryerson University is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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Vital Signs: Overview and Practice Questions

by John Landry, BS, RRT | Updated: May 9, 2024

Vital signs are measurements of the body’s most basic functions. They include temperature, pulse, respiratory rate, blood pressure, and oxygen saturation.

Medical professionals use vital signs to get a general sense of a patient’s overall condition. They help detect and monitor medical problems and can be a warning sign of a serious illness.

In this article, we’ll take a closer look at each of the different types of vital signs and what they can tell us about our health.

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Primary Vital Signs

There are five primary vital signs that are recognized in the healthcare setting:

• Respiratory rate
• Blood pressure

Body Temperature

• Oxygen saturation

The primary vital signs can be measured objectively. That is, their values can be obtained without the need for interpretation by the patient.

For example, heart rate can be measured by feeling the pulse or by using an electrocardiogram (ECG) . Respiratory rate can be measured by counting the number of breaths per minute.

Blood pressure can be measured using a sphygmomanometer or an automated blood pressure machine. Body temperature can be measured using a thermometer. And oxygen saturation can be measured using a pulse oximeter.

Heart rate , or pulse, is the number of times your heart beats per minute. A normal heart rate is 60–100 beats/min.

Heart rate can increase due to physical activity, anxiety, stress, fever, or certain medications. It can decrease due to hypothermia, hypotension, and shock.

An abnormal heart rate can be a sign of a number of medical conditions, such as arrhythmias, heart failure, and myocardial infarctions .

Respiratory Rate

Respiratory rate is the number of breaths you take per minute. A normal respiratory rate is 12–20 breaths/min.

Respiratory rate can increase due to exercise, anxiety, infections, and some medical conditions (e.g., COPD, asthma). It can decrease due to head injuries and some medications (e.g., opioids).

An abnormal respiratory rate can be a sign of a number of medical conditions, such as pneumonia, heart failure , and other cardiopulmonary conditions.

Blood Pressure

Blood pressure is a measurement of the force of blood pushing against the walls of your arteries. Two readings are recorded:

• Systolic blood pressure (the top number) is the pressure when your heart beats and pumps blood out to the rest of your body.
• Diastolic blood pressure (the bottom number) is the pressure when your heart rests between beats.

The normal range for blood pressure is 120/80 mmHg.

Blood pressure can increase due to exercise, anxiety, and some medical conditions (e.g., heart failure, aortic stenosis). It can decrease due to head injuries, hypovolemia, and some medications (e.g., beta blockers).

Body temperature is a measurement of the body’s heat production and loss. The normal range for body temperature is 36–37.5°C (96.5–99.5°F).

Body temperature can increase due to exercise, fever, and some medical conditions (e.g., hyperthyroidism). It can decrease due to hypothermia, head injuries, and some medications (e.g., antipyretics).

An abnormal body temperature can be a sign of a number of medical conditions, such as infections, heat stroke, and cold exposure.

Oxygen Saturation

Oxygen saturation is a measurement of the concentration of oxygen that is bound to hemoglobin in arterial blood. The normal range for oxygen saturation is 93–100%.

Oxygen saturation can decrease due to hypoventilation, lung disease, and some medical conditions (e.g., anemia). It can increase as a result of receiving supplemental oxygen .

Hypoxemia is an abnormally low concentration of oxygen in the blood and can be a sign of several medical conditions, such as pneumonia, heart failure, and COPD .

Normal Vital Signs: Adults

Normal vital signs: infant, secondary vital signs.

In addition to the vital signs described above, there are a number of other measurements that can be considered vital signs in certain situations.

These secondary vital signs include:

• Level of consciousness
• Blood glucose
• Pupillary assessment

Pain is a subjective measurement of discomfort that can vary depending on the individual patient.

It is often measured using a pain scale, which is a numerical rating system of 0–10 that allows patients to communicate the level of their pain to their healthcare providers.

Level of Consciousness

The level of consciousness is a measurement of a person’s responsiveness to their environment.

It can be measured using the Glasgow Coma Scale, which is a score of 3–15 that is based on a person’s ability to open their eyes, follow commands, and speak.

Blood Glucose

Blood glucose is a measurement of the concentration of sugar (glucose) in the blood. It is typically measured using a fingerstick blood test or a continuous glucose monitor.

The normal range for blood glucose is 70–139 mg/dL.

Hyperglycemia is a condition in which the blood sugar levels are abnormally high and can be a sign of diabetes .

Hypoglycemia is a condition in which the blood sugar levels are abnormally low, which is associated with taking too much insulin, digestive problems, or an inadequate diet (e.g., skipping a meal).

The assessment of a patient’s skin color can provide clues about their underlying health status. Abnormal skin colors may include:

Redness and flushing can be signs of infection or inflammation. Pallor can be a sign of anemia or blood loss. Cyanosis is a bluish tint to the skin that can be a sign of low oxygen levels in the blood.

Jaundice is a yellowing of the skin that can be a sign of liver disease or obstruction of the bile duct. Mottling is a marbled appearance of the skin that can be a sign of poor circulation.

Pupillary Assessment

The assessment of a patient’s pupils can provide clues about their level of consciousness and underlying health status. Abnormal pupil reactions may include:

• Reactivity to light

Both pupils should be equal in size and shape, and they should react equally to light. If one pupil is larger than the other (anisocoria), it can be a sign of a serious condition, such as a brain tumor.

If the pupils do not react to light, it can be a sign of serious conditions, such as a stroke or cranial nerve damage.

Delirium is a state of confusion that can be caused by a number of medical conditions, such as infections, electrolyte imbalances, and drug toxicity.

It is often measured using the Confusion Assessment Method (CAM), which is a bedside test that assesses a patient’s level of consciousness , orientation, and ability to follow commands.

Vital Signs Practice Questions:

1. What are the most common Vital Signs? Pulse Rate, Respiratory Rate, Blood Pressure, Body Temperature, and Oxygen Saturation.

2. What is the normal pulse rate? 60–100 beats/minute.

3. Where can you find the pulse? The radial, brachial, femoral, and carotid arteries.

4. What is the normal respiratory rate? 12–20 breaths/minute.

5. What is the normal Blood Pressure? 110–120/70–80.

6. What is the normal body temperature? Oral: 97.7–99.5 F (36.5–37.5 C); Axillary: 96.7–98.5 F (35.9–36.9 C); Rectal or ear: 98.7–100.5 F (37.1–38.1 C).

7. What is the normal Oxygen Saturation? 95–99% or greater than 93%.

8. What is the normal Heart Rate? 60–100.

9. A low oxygen saturation is a good indicator of what? Hypoxemia.

10. What are complications with pulse oximeters? Low perfusion, incorrectly fitted probe, the vascular bed is not pulsating dark fingernails, or the light is unable to pass through.

11. What is the accuracy range on a pulse oximeter? + or – 4%

12. What is the heart rate for someone who is bradycardic? Less than 60 beats per minute.

13. What is the respiratory rate for someone who is tachypneic? Greater than 20 breaths per minute.

14. What is the blood pressure for someone with hypotension? Less than 90/60.

15. What is the breathing rate of someone who is apneustic? Long gasping inspirations with insufficient expiration.

16. What are the primary causes of eupnea? The normal physiology of being a human being.

17. Identify the following breathing pattern: Fast and deep breaths with periods of apnea and no set rhythm. Biot’s breathing.

18. Which breathing pattern is normal in newborns and elderly, but abnormal for healthy adults? Cheyne-Stokes.

19. What tool is required for listening when performing a manual blood pressure measurement? Stethoscope

20. Which part of a stethoscope allows a practitioner to hear sound during a manual blood pressure measurement? The chest piece, which is made up of the diaphragm and bell

21. What is normally the heart rate for a newborn? 90–180 beats per minute.

22. What describes a patient’s heart rate that is greater than 100 beats/min? Tachycardia

Daily TMC Practice Questions

23. What is DKA? It stands for Diabetic Ketoacidosis. A shortage of insulin which causes the body to burn fatty acids and produce acidic ketone bodies.

24. The pulse rate and rhythm can be measured by what? It can be measured by auscultation or palpation of any artery.

25. What arteries can be used for the pulse to be checked? Radial Artery, Brachial Artery, Femoral Artery, Carotid Artery, and Pedal.

26. Which artery is most commonly used to check for a pulse? Radial Artery

27. How is pulse calculated? The pulse is counted for 15 seconds and multiplied by 4 to get beats/minute.

28. How is respiratory rate measured? By inspection of the movement of the chest for 1 minute.

29. What is the normal blood pressure for adults? 110–120/70–80

30. What is used to measure blood pressure? Sphygmomanometer.

31. What are the ways that the body temperature can be measured? Orally, rectally, and axillary.

32. What is the normal body temperature? 37 degrees Celsius ( 97 degrees F).

33. What is fever? A higher than normal body temperature (hyperthermia).

34. What is the normal pulse rate for an adult? 60–100 beats/minute.

35. What does pulse oximetry estimate? It noninvasively estimates the hemoglobin oxygen saturation of arterial blood.

36. What factors affect the accuracy of pulse oximetry reading? Movement, bright light, extreme cold, extreme darkness, and high methemoglobin.

37. What would you call a respiratory rate less than 12? Bradypnea.

38. What would you call a respiratory rate greater than 20? Tachypnea.

39. What would you call a heart rate less than 60? Bradycardia.

40. What would you call a heart rate greater than 100? Tachycardia.

41. What is hypotension? A blood pressure less than 90/60.

42. What is hypertension? A blood pressure greater than 140/90.

43. What is the normal newborn pulse? 90–170/minute.

44. What is the normal 1-year-old pulse? 80–160/minute.

45. What is the normal preschool-age kid pulse? 80–120/minute.

46. What is the normal 10-year-old pulse? 70–110/minute.

47. What is the normal adult pulse? 60–100/minute.

48. What is the systolic blood pressure? The top number which measures the pressure in the artery when the heart beats.

49. What is the diastolic blood pressure? The bottom number that measures the pressure in the arteries when the heart muscle is resting.

50. How is the strength (amplitude) of a pulse measured on a scale? 4–bounding, 3–full, 2–normal, 1–diminished, and 0–absent.

51. What is bradycardia? A slower than normal heart rate of less than 60 beats per minute.

52. What is tachycardia? A faster than normal heart rate greater than 100 beats per minute.

53. What is hypotension? Low blood pressure, which can cause dizziness or fainting (Less than 90/60).

54. What is hypertension? High blood pressure, which can cause heart disease (Greater than 140/90).

55. What is eupnea? A normal respiratory rate (12-20 breaths per minute), normal rhythm. Causes: normal physiology.

56. What is apnea? The absence of breathing. Causes: respiratory or cardiac arrest and an increased intracranial pressure.

57. What are the types of pulse oximetry probes? Finger probe, foot probe, toe probe, forehead probe, and ear probe.

58. Can cool or heated aerosols affect a body temperature reading? Yes, yes they absolutely can.

59. Which vital signs provide information about gas exchange ? Oxygen saturation, heart rate, and respiratory rate

60. What test is helpful in addition to vital signs to assess a patient’s acid-base status ? An arterial blood gas (ABG)

Final Thoughts

Vital signs are an important part of a routine medical assessment and can provide clues about a patient’s underlying health status. The most common vital signs include:

• Body temperature

Each of these vital signs can be measured using a variety of methods, and the normal ranges may vary depending on the age and health of the patient.

We have similar guides on breath sounds and abnormal breathing patterns that I think you’ll find helpful. Thanks for reading!

Written by:

John Landry is a registered respiratory therapist from Memphis, TN, and has a bachelor's degree in kinesiology. He enjoys using evidence-based research to help others breathe easier and live a healthier life.

• Egan’s Fundamentals of Respiratory Care. 12th ed., Mosby, 2020.
• Wilkins’ Clinical Assessment in Respiratory Care. 8th ed., Mosby, 2017.
• Neonatal and Pediatric Respiratory Care. 5th ed., Saunders, 2018.
• Sapra, Amit, et al. “Vital Sign Assessment.” National Library of Medicine, Treasure Island (FL): StatPearls Publishing, Jan. 2022, www.ncbi.nlm.nih.gov/books/NBK553213 .
• —. “Vital Sign Assessment.” National Library of Medicine, Treasure Island (FL): StatPearls Publishing, Jan. 2022, www.ncbi.nlm.nih.gov/books/NBK553213 .
• Kebe, Mamady, et al. “Human Vital Signs Detection Methods and Potential Using Radars: A Review.” National Library of Medicine, Sensors (Basel), Mar. 2020, www.ncbi.nlm.nih.gov/pmc/articles/PMC7085680 .

Recommended Reading

Thoracic imaging: overview and practice questions, abnormal respiratory patterns: overview and practice questions, how to perform a patient assessment (explained), breath sounds: overview and practice questions, assessment of oxygenation and ventilation (practice questions).

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Reflection essay on vital signs using Driscoll's model

This assignment is a reflection that I undertook during my first clinical practice, using Driscoll’s (2000) reflective model, a recognised framework to demonstrate my ability to reflect critical thought in theory to practical skills. Reflection is defined as process of explaining and expressing from one’s own experiences and helps to enables us to develop and improve our skills and knowledge towards becoming professional practitioners (Jasper, 2003).

Temperature, blood pressure, pulse rate and respiration are the vital signs that indicate the condition of someone’s ability to maintain blood flow, regulate body temperature, rate of breathing and heart-beat (National Institute for Health and Care Excellence (NICE, 2007). A small change in one vital sign can lead to detention in another vital sign. This assessment was analysed and interpreted in order to record and measure the vital signs accurately which significantly allowed practitioners to take appropriate action to meet the needs of the patient (The Nursing and Midwifery Council (NMC), 2010).

The first stage of Driscoll’s reflective mode (Johns 1994) describes what happened.  The main purpose of this simulation is to increase student confidence and also to prepare student for real clinical setting.We were paired up where one took the blood pressure and the othertook the temperature, the respiration and the pulse rate. According to the (NMC, 2010) communication is the key element therefore I introduced myself, informed patient about the procedure and asked for patient consent to ensure that decisions are made on behalf of the service user (NMC 2010) about taking the vital signs. Hand washing is the most crucial part for the prevention of cross contamination (NICE 2005) so my colleague and Iwashed our hands using the six steps techniques (NPSA, 2009) lasting 30 seconds before and after contacting with the patient. Prior to going over patient’s health and safety, I made sure the equipment available in the ward was clean and functioning well. I found out that the battery on the tympanic thermometer was not functioning; I informed my colleague and I made sure the battery was replaced before using it. After the assessment, I forgot to interpret the recording in the NEWS chart and according to NMC (2010) good record keeping is an important component to the provision of safe and effective care. Then we pulled the curtain for privacy to ensure that Miss X received care in a dignified way that does not confound her whereothers are unable to hearher condition and to make sure she is comfortable (NMC, 2008).

This is a preview of the whole essay

Before the assessment, I was excited because I was going to use my theory skills in real clinical practice. But I was nervous and anxious as I entered in the ward because this was my first time taking the vital signs on the real patient therefore I forgot to make sure the patient in the bed was Miss X and when asked by the patient about the procedure I could not explain it to her clearly(RCN, 2007). Having experienced in this simulation I now I realised  that I  have to learn more to become aware of different practices concerning the correct procedure of taking the vital signs in future assessment. The learning gained from this assessment will impact my future practice in various areas which include communication and team work. Critical things like forgetting to document the finding result lack of information for my colleagues to carry the further procedure. Highlighting the difficulties in communication during the assessment, I failed to know what miss X was trying to say.  At the same time, looking at the positive aspect I was success in following the 6 step of hand washing correctly. At the end I noticed that my colleague was happy about simulation because she was confident about the procedure of taking the TPR. Also she had the experienced in working in the care home with various types of patients.

Ultimately, I failed to demonstrate the good understanding about measuring and recording the vital signs. I have slightly improved my understanding of vital signs by practising in clinical seminar with my colleagues. However, I have not sufficiently developed my skills in communication and it means that I need to work on my communication skills. For example, communicating with my lecturer and colleagues.  This skill will be useful to me as a learner because I am not yet confident about explaining the situation if being asked by someone and nursing is all about good communication and practice to illustrate the different condition of the patient and their family members. As a next step, I need to concentrate more on my practical skills such as practising on taking blood pressure with the correct procedures, communication skills and my confidence level in order to achieve success in my further clinical assessment.

In conclusion, looking at the some key factors now I realise how important communication is in order to understand the client needs, feelings and reactions. The concept of reflection is helpful in order to know my strength and weakness and also give me the concept to justify specialist practice in the light of further evidence-based care, accountability and practice. Also I have learnt that reflection can be used as a tool in order to turn an unpleasant experience into a positive one.

References:

Bulman, C. and Schutz, S, (2008).  Reflective practice in nursing . 4th ed. Cornwall: Blackwell publishing Ltd. Driscoll, J., (2007).  Practising clinical supervision . 2nd ed. Philadelphia: Elsevier limited.

Elliott, M and Coventry, A. (2012). Critical care: the eight vital signs of patient monitoring .  British Journal of Nursing . 21 (10), pp.621-624

NHS (June, 2003).  National Institute for Clinical Excellence . [ONLINE] Available at: http://www.nice.org.uk/nicemedia/pdf/CG2fullguidelineinfectioncontrol.pdf. [Last Accessed 17/04/2013].

NMC (2009).  Standards for pre-registration midwifery education . [ONLINE] Available at: http://www.nmc-uk.org/Documents/NMC-Publications/nmcStandardsforPre_RegistrationMidwiferyEducation.pdf. [Last Accessed 17/04/2013].

Royal College Of Nursing (December 2007). Standards for assessing, measuring and monitoring vital signs in infants, children and young people . [ONLINE] Available at: http://www.rcn.org.uk/__data/assets/pdf_file/0004/114484/003196.pdf. [Last Accessed 17/04/2013].

Sutcliffe H, (2011). Understanding the NMC code of conduct: a student perspective .  Nursing Standard . 25 (52), pp.35-39

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Reading Signs

If you’re planning a trip to France one of the most important and basic things to learn is how to read signs. This is a brief list of the most important signs you’ll need to know.

• À Louer For Rent
• À Vendre For Sale
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• Ascenseur Elevator/Lift
• Attendez Ici Wait Here
• Attention Au Chien! Beware Of Dog!
• Attention! Caution!
• Bienvenue! Welcome!
• Caisse Cashier
• Chaud! Hot!
• Chemin Privé Private Way
• Chiens Interdits No Dogs
• Complet No vacancies/Full
• Dames Women
• Défence De Fumer No Smoking
• Entrée Entrance
• Entrée Interdit No Entrance
• Fermé Closed
• Fermer La Porte Close The Door
• Fumeurs Smoking Area
• Hommes Mens
• Ne Pas Déranger Do Not Distrurb
• Ne Pas Toucher Do Not Touch
• Occupé In Use/Occupied
• Ouvert Opened
• Peinture Fraîche Fresh Paint
• Photo Interdit No Pictures
• Renseignements Information
• Reservé Reserved
• Salle D’Attente Waiting Room
• Sortie Exit
• Sortie De Secours Emergency Exit

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Exploring the clinical relevance of vital signs statistical calculations from a new-generation clinical information system

Juan ignacio muñoz-bonet.

1 Paediatric Intensive Care Unit, Hospital Clínico Universitario, Av. Blasco Ibáñez 17, 46010 Valencia, Spain

2 Department of Paediatrics, Obstetrics, and Gynaecology, University of Valencia, Valencia, Spain

Vicente Posadas-Blázquez

Laura gonzález-galindo, julia sánchez-zahonero, josé luis vázquez-martínez.

3 Paediatric Intensive Care Unit, Hospital Universitario Ramón y Cajal, Madrid, Spain

Andrés Castillo

4 Paediatric Technological Innovation Department, Foundation for Biomedical Research of Hospital Niño Jesús, Madrid, Spain

Juan Brines

Associated data.

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

New information on the intensive care applications of new generation ‘high-density data clinical information systems’ (HDDCIS) is increasingly being published in the academic literature. HDDCIS avoid data loss from bedside equipment and some provide vital signs statistical calculations to promote quick and easy evaluation of patient information. Our objective was to study whether manual records of continuously monitored vital signs in the Paediatric Intensive Care Unit could be replaced by these statistical calculations. Here we conducted a prospective observational clinical study in paediatric patients with severe diabetic ketoacidosis, using a Medlinecare ® HDDCIS, which collects information from bedside equipment (1 data point per parameter, every 3–5 s) and automatically provides hourly statistical calculations of the central trend and sample dispersion. These calculations were compared with manual hourly nursing records for patient heart and respiratory rates and oxygen saturation. The central tendency calculations showed identical or remarkably similar values and strong correlations with manual nursing records. The sample dispersion calculations differed from the manual references and showed weaker correlations. We concluded that vital signs calculations of central tendency can replace manual records, thereby reducing the bureaucratic burden of staff. The significant sample dispersion calculations variability revealed that automatic random measurements must be supervised by healthcare personnel, making them inefficient.

Introduction

There is a broad consensus that future healthcare will require the intensive use of information technology to acquire, store, process, analyse, and use the information extracted from medical data 1 , 2 . The Anaesthesia and Critical Care specialities are the most technical and data-driven medical environments and so the development of new approaches for the integration and use of the data generated in these fields is almost mandatory 1 – 7 . However, the basic approach to data collection and management has remained largely unchanged over the past 40 years 2 . Indeed, it is now becoming especially difficult to integrate and take advantage of the information provided by patient bedside monitoring and treatment devices 2 . In critical patients, this information is traditionally registered by nursing staff, who collect the most representative values from each period, usually once an hour 8 . This chart is used as the baseline by which patient evolution is then assessed 9 .

Given that these patient monitoring charts are costly to prepare, some centres have replaced this type of record keeping with automatic random data collection by different clinical information systems (CIS) 2 , 8 . These CIS usually collect one data point per parameter every 15, 30, or 60 min 8 , 10 . This means that more than 99% of the information generated at the bedside is lost with no possibility reaping the benefits that its exploitation could mean for patients and the healthcare system 2 , 4 , 11 , 12 . In addition, CIS do not provide any processing or analysis of the information obtained 2 . Thus, although some of these systems provide access to up to 1 piece of data per minute, the volume of data makes its routine manual evaluation by healthcare personnel difficult 13 and most of the information is still lost. Because of all the above, Intensive Care Unit (ICU) teams continue to express frustration with the current patient data representation by CIS 14 .

Therefore, a new approach to the use of information generated at the bedside is required to prevent this data loss and to facilitate its clinical use 4 , 8 , 11 . The main objective of this new approach is to apply big-data principles (volume, velocity, variety, veracity, and data value) to the concept of personalised medicine. In this sense, information has already been published about the application of high-density data CIS (HDDCIS) in intensive care contexts, both in development studies 2 , 3 , 13 , 15 – 17 and as original research 4 , 8 , 12 , 18 – 23 . Although the use of HDDCIS is not yet common in ICUs, in the future they will help revolutionise the monitoring of vital signs as we currently know it. In this context, Matam et al. analysed the technical difficulties and feasibility of adapting HDDCIS to their Paediatric Intensive Care Unit (PICU) and created a machine learning system that predicts cardiac arrest in children 15 , 24 . In turn, Brossier et al. argued for the importance of these systems being able to indefinitely store all the monitoring data for ‘perpetual patients’ as well as their advantages for the development of clinical decision support systems (CDSS) 4 , 25 , 26 .

Furthermore, the development of artificial intelligence (AI) is likely to strongly impact intensive care medicine. Indeed, one of the main lines of ongoing research for many groups working in this field involves the use of AI to give HDDCIS the ability to detect clinically important events. For example, in the field of mechanical ventilation, systems that predict accidental extubation 27 or that protect the lungs by avoiding volutrauma 28 are already available. The detection of events in the operating room during anaesthesia has also been analysed by leveraging the information contained in databases that integrate information from different clinical records such as electrocardiograms, oxygen saturation, heart rate, and bispectral index results 29 , 30 . Thus, the integration of vital signs records has already allowed the creation of machine learning systems capable of detecting, in real time, events such as acute hypotension 31 , responses to vasoactive drugs 32 , or the need for massive transfusion in the operating room 33 . In most cases, the AI technology used to detect events is based on the registration of vital signs data and leverages pre-defined scores. Among these indices, it is worth highlighting the Inadequate Oxygen Delivery Index (IDO2-Index) that warns of the risk of adverse events such as cardiorespiratory arrest, the development of enterocolitis, need for extracorporeal membrane oxygenation (ECMO), or renal replacement therapy in children undergoing cardiac surgery 34 .

In this line, our team has several years of clinical experience with the use of this technology 35 and we have been able to verify the clinical usefulness of the hourly statistical calculations of vital signs provided by the HDDCIS 6 . However, the use of these calculations has not yet been validated. Thus, the objective of this current work was to study whether manual records of continuously monitored vital signs can be replaced by the statistical calculations of central tendency provided by an HDDCIS.

Materials and methods

This prospective observational clinical study was conducted in children with severe diabetic ketoacidosis consecutively admitted to the PICU at the University Clinical Hospital of Valencia (a 6-bed multivalent unit in a tertiary hospital), between 2017 and 2020. The inclusion criteria were (1) blood glucose exceeding 11.1 mmol/L; (2) ketonemia greater than 1 mmol/L; (3) bicarbonate less than 8 mEq/L; and (4) base excess exceeding − 20 mEq/L. We selected these patients for their special clinical characteristics. Upon admission, they presented a serious metabolic alteration that affected their vital signs but without associated respiratory, cardiocirculatory, or other pathologies or confounding factors such as the requirement for mechanical ventilation, administration of inotropic drugs, sedatives, or analgesics, among others 9 , 22 . Thus, with appropriate treatment, their vital signs returned to normal within hours, therefore making them good models to assess clinical evolutionary changes and to compare different study parameters.

This study was conducted in accordance with the amended Declaration of Helsinki and was approved by the Ethics Committee at the Biomedical Research Institute INCLIVA (grant number 2017/022). Informed consent was obtained from the families of the patients. We used the Medlinecare ® HDDCIS (Medical Online Technology S.L., Valencia, Spain) which receives and transmits information from bedside monitoring and treatment equipment at a rate of 1 data point per monitored parameter every 3–5 s, (720–1200 data points per hour), including equipment from multiple manufacturers. This allowed us to continuously monitor the clinical status of our patients in real time. In addition, the HDDCIS stores data and automatically calculates hourly statistical indicators of the sample central trends (mean, mode, and median) and dispersion as the maximum (99th percentile), and minimum (1st percentile) values. These calculations were performed in the first few minutes of each new hour.

The data collected during patient admissions to the PICU are shown in Table ​ Table1. 1 . The nursing staff did not have access to the information provided by the HDDCIS or knowledge of the objective of this current study. We used pulse oximetry technology from Masimo Corp. (Irvine, CA) and collected oxygen saturation (SpO 2 ) and pulse oximetry heart rate (pHR) data using disposable fingertip probes. We also collected electrocardiography heart rate (eHR) and respiratory rate data measured by impedance (iRR) using Infinity Delta XL multiparameter monitors from Dräger Medical (Lübeck, Germany). To uncover whether the clinical evolution of the patients could affect the correlation study of the parameters, the data series were divided into two groups according to the level of bicarbonate present in the blood of the patients: the severe acidosis group versus the improvement group , with the bicarbonate cut-off point being ≥ 10 meq/L.

Data collected during patient admissions to the Paediatric Intensive Care Unit.

PICU Paediatric Intensive Care Unit, n prefix records made manually by nurses.

Statistical analysis

SPSS software (v26.0 IBM Corp., Armonk, NY) was used to carry out the statistical analyses. The relationships between continuous variables were evaluated employing the Pearson or Spearman correlation coefficient, depending on the data distribution (after assessing the latter using the Kolmogorov–Smirnov test). We also used Student t -tests for related samples, Lin’s concordance correlation coefficient (CCC) to assess the data agreement 36 , and Bland–Altman plots for multiple measurements per patient, as calculated with MedCalc software 37 . Analysis of variance (ANOVA) was used to study the relationship between the continuous variables of each group. However, when statistically significant results failed to meet the ANOVA assumptions, we resorted to an alternative robust test (Welch’s test). The significance level threshold was set at an alpha of 0.05 in all cases.

Thirty-two consecutive patients (21 boys and 11 girls) aged 9.1 ± 4.3 years were included in this study cohort. Around 2,761,000 measurements were used to obtain 1027 hourly statistical calculations for pHR, eHR, and SpO 2 , as well as 745 calculations of iRR. Simultaneous hourly nursing records (denoted with the ‘n’ prefix) were also collected for the heart rate (nHR = 1025), respiratory rate (nRR = 716), and oxygen saturation (nSpO 2  = 980). In addition, 212 periodic determinations of glycaemia, ketonemia, lactate, and acid–base balance were also collected. Upon admission, the patients presented the following blood analytical test data: blood glucose = 25.8 ± 7.6 mmol/L, ketonemia = 5.3 ± 1.7 mmol/L, lactate = 2.2 ± 0.9 mmol/L, pH = 7.05 ± 0.1, PCO 2  = 19.6 ± 7.5 mmHg, bicarbonate = 5.6 ± 2.9 mEq/L, and base excess =  − 24.7 ± 4.7 mEq/L.

The hourly calculations of the central tendency for pHR and eHR were identical and their CCC was almost perfect (Fig.  1 ). These calculations showed identical values, very strong correlations, and a substantial CCC with the nHR data (Table ​ (Table2). 2 ). Indeed, both the nHR and the central tendency calculations for pHR and eHR showed the same moderately significant correlations with the evolution of the acid–base balance. For example, for pH, r  = − 0.51 for nHR and r  = − 0.5 for pHR, for PCO 2 , r  = − 0.53 and − 0.55, respectively, for bicarbonate r  = − 0.55 and − 0.55, respectively, and for base excess, r  = − 0.56 and − 0.56, respectively.

Scatter diagram of the automatic hourly calculation of the ‘median heart rate’ obtained by pulse oximetry (pHR-median) and electrocardiography (eHR-median). Note how the line of equality and the trend line (blue) are identical (locally weighted scatterplot smoothing span = 0%; concordance correlation coefficient [CCC] = 0.9983; Pearson p for precision = 0.9984; bias correction factor for accuracy = 1 [95% CI 0.9982–0.9986]; p  < 0.0001). Similar results were obtained for the central tendency calculations for the ‘mean heart rate’ and ‘modal heart rate’ (CCC > 0.99).

Descriptive statistics, correlations, and concordances between the manual nursing records and automatic statistical calculations.

nHR hourly heart rate recorded by nurses, pHR automatic hourly calculation of the heart rate through pulse oximetry, eHR automatic hourly calculation of the heart rate through electrocardiography, nRR hourly respiratory rate recorded by nurses, iRR automatic hourly calculation of the respiratory rate through impedance, nSpO 2 hourly oxygen saturation recorded by nurses, SpO 2 automatic hourly oxygen saturation calculation through pulse oximetry. The Student t -test results indicated that the best correlation with the nursing values was obtained with the median for heart rate and oxygen saturation and with the mode for the respiratory rate.

The central tendency calculations for the iRR and SpO 2 behaved in a similar way, with identical or remarkably similar values and strong correlations with the nursing staff references (except for the mean iRR, which showed a moderate correlation). The maximum and minimum hourly calculations differed from their nursing references and from the central tendency calculations in all the variables by showing weaker correlations. These differences were clinically significant for heart rate (HR) and respiratory rate (RR). The concordance study results are shown in Tables ​ Tables2 2 and ​ and3 3 and in Fig.  2 .

The difference between the manual data recordings by nurses and by the automatic statistical calculations.

nHR heart rate recorded by nurses, nRR respiratory rate recorded by nurses, nSpO 2 oxygen saturation recorded by nurses, pHR hourly calculation of the pulse-based heart rate, iRR hourly calculation of the respiratory rate by impedance, SpO 2 hourly calculation of the oxygen saturation. Data calculated using the Bland–Altman method. The differences between the nHR and electrical heart rate (eHR) are not provided because of their similarity to those of the pHR.

Bland–Altman plot for multiple measurements per patient of the heart rate measured hourly by nursing staff (nHR) alongside the hourly automatic calculation of the median heart rate (pHR-median) and maximum heart rate (pHR-max). The sample size was N  = 1025.

In the comparison by groups (severe acidosis versus improvement), blood glucose, ketonemia, lactate, and acid–base balance measurements all improved, reaching levels of clinically and statistically significant differences ( p  < 0.001). HR and RR were also significantly improved for all variables from both the clinical and statistical perspective, except for the maximum iRR (Tables ​ (Tables4 4 and ​ and5). 5 ). In contrast, SpO 2 decreased with improving acidosis, although these differences did not reach the level of clinical significance (Table ​ (Table4 4 ).

Descriptive statistics and group comparisons for the heart rate and oxygen saturation.

nHR heart rate recorded by nurses, pHR hourly calculation of the pulse-based heart rate, nSpO 2 oxygen saturation recorded by nurses. There were statistically significant differences between the groups for all the monitored parameters (*) p  < 0.001, (#) p  = 0.001. Note how there was a significant intragroup oscillation in the HR (the maximum and minimum values differed by ≈ 25 bpm). The evolution of the electrical heart rate (eHR) by groups was not provided because it was identical to that of the pHR.

Descriptive statistics, concordances, and comparisons of the respiratory rate by groups.

nRR hourly nursing record of respiratory rate, iRR automatic hourly calculation of respiratory rate measured by impedance. Note (1) the marked intragroup oscillation of the RR (≈ 25 bpm); (2) the asymmetry and kurtosis values were close to the normal distribution in the group of patients with severe acidosis. In contrast, in the improved group, the nRR and, especially, the central tendency calculations presented high asymmetries and kurtosis, showing a leptokurtic curve with a distribution tail stretching to the right for values above the mean (the true measurements of RR were grouped into the leptokurtic values, while the movement artifacts, which were more frequent in the improvement group, were grouped into the tail on the right); (3) the poorest correlation and concordance values were obtained for the iRR-maximum (which included motion artifacts); (4) as expected, the RR decreased as acidosis improved, with the differences between the groups being clinically and statistically significant for all the parameters, except for the iRR-maximum. (*) p  < 0.001, (#) p  = 0.001. Deviation error: (a) 0.18, (b) 0.1, (c) 0.36, (d) 0.21.

The physiological basis and main characteristics of high-density data clinical information systems

Drs. Horvat and Ogoe pointed out that “with the conventional approach, the patient data generated in the ICU are continually reduced to summary information, which has the risk of over-distilling the relevant and complex physiology of these patients”. Thus, these authors and others believe that the use of high-frequency data systems, “may further our understanding of intensive care physiology and eventually support the development of more individualised therapeutic regimens” 5 , 9 . As described in the introduction, this technology is already being applied in hospitals all over the world. More specifically, four basic properties characterise HDDCIS (Fig.  3 ) as follows:

• Sampling frequency. Although this can differ according to the parameters recorded, for vital signs and other fundamental parameters, this frequency must be less than 1 data point every 10 s. However, many current systems capture these values at intervals of minutes, which is insufficient to follow patient evolution in real time or to detect and evaluate clinical events.
• Multidevice capacity. Anaesthesia and critical care environments are complex by nature and are home to countless medical devices for patient monitoring and treatment. Thus, to include any parameter of clinical interest, it must be possible to capture data, at a high sampling frequency, from different pieces of medical equipment. To do this, the problem of device synchronisation must be solved.
• Information processing. This is important both in terms of real-time care functionality, as well as in the evaluation of clinical evolution based on historical data 6 . As Sun et al. stated, “we must develop a data acquisition system that facilitates the access and review of historical data for medical personnel. Furthermore, acquired data should be […] presented to clinical staff in such a manner that supports clinical decision making” 13 . Thus, improving this information processing will directly enhance care provider wellbeing, patient outcomes, and quality of care 14 . Moreover, HDDCIS are of great educational utility and can also help improve quality of care because they can fully detect clinical episodes as they happen, at high resolution, and can also reproduce them for later analysis (see Supplementary Figs. S1 – S3 ).
• Ability to exploit information. These systems will provide medical staff with a powerful research tool which, by combining their clinical observations with supervised and unsupervised machine learning, can be used to develop and test CDSS and other AI functions 4 , 38 . However, the loss of information from the current CIS prevents the development of these functions. Moreover, it should be noted that, after the COVID-19 global pandemic, the development and use of AI has exponentially increased 39 , 40 thanks to its freer availability and ability to integrate large amounts of information about an unknown disease and present it in a simple way to clinicians.

Record of information provided by patient bedside monitoring and treatment devices. (*) CIS clinical information systems, (**) AI artificial intelligence.

Our previous experience and justification of this study

In a previous study in ventilator-dependent patients hospitalised at home, we observed the usefulness of the HDDCIS for telemedical real-time patient assessment. Furthermore, the statistical indicators it provides are of great clinical use because they allow the quick and complete analysis of all the information during the morning telemedical rounds 6 , 35 . However, we were previously unable to validate its use given that specialised healthcare personnel were not available to perform monitoring in domestic settings. In our experience, the application of this technology in the fields of anaesthesiology and intensive care is proving to be extremely useful, especially in the most serious clinical cases, because the resulting monitoring of these patients is more complete and produces fewer artifacts caused by movements, disconnections, or sensor misplacements.

A possible limitation of this study was related to the gold standard used for comparison, given that inaccuracy in the manual recording of vital signs in hospitalised patients has been previously reported 41 , 42 . However, unlike the random automatic vital sign data-point collections carried out by the current CIS or collected during patient visits by nursing staff in conventional hospitalisation wards 41 , the anaesthesiologist in the operating room and nursing staff in ICUs continuously follow-up and assess patients. Thus, this information is of immense value as it is the most representative of the period in question. Therefore, these registries have formed the basis used to assess the evolution of patients over the last 40 years, thereby facilitating clinical communication and working well in countless clinical studies 9 .

Discussion of our results

In this current study the perfect correlation we found between the central tendency indicators of both heart rate measurements supports the use of this technology for the purposes set out in this study (Fig.  1 ). Thus, the values we obtained for manual nursing heart rate measurements (nHR) and the automatic calculations of central tendency (pHR and eHR) were identical and showed very strong correlations and concordances (Tables ​ (Tables2, 2 , ​ ,3, 3 , ​ ,4). 4 ). In addition, the identical correlation of these parameters with the evolution of the acid–base balance—the main pathophysiological alteration present in these patients—indicates that all the clinical value of the nursing records was also captured by the automatic calculations of central tendency. These results indicate that these calculations could replace manual records, thus reducing the bureaucratic burden this task places on staff. Moreover, they allow reliable monitoring measurements to be obtained in settings where staff are not available, as we have already seen in our previous work in home-based settings 6 , 35 .

In a similar vein, the hourly central tendency calculations for iRR and SpO 2 were analogous to those for HR, with good (but in this case, not exceptional) correlations with their nursing references. This meant that when the more demanding CCC test (comprising two metrics, one for precision and the other of accuracy) was done, poor values (< 0.9) were obtained and, for reasons intrinsic to the test, these could not exceed their own measure of precision (the Pearson r coefficient). These results can be explained in a different way for each parameter. For the iRR, it was related to the movement artifacts that affect this measurement, as discussed below. For SpO 2 , it was related to the low variability of this parameter (especially in these patients without oxygenation problems), which determined the low Pearson correlation coefficient values, regardless of the accuracy and overall concordance of these measurements 43 . Thus, the almost perfect values of its accuracy component (bias correction factor) indicate adequate concordance with the nursing reference values (Table ​ (Table2 2 ).

The clinical evolution by group was as expected, with statistically significant data indicating patient progression towards clinical normality (Tables ​ (Tables4 4 and ​ and5). 5 ). Moreover, it was interesting to observe how the decrease in respiratory rate also conditioned a statistically significant decrease in SpO 2 , although this did not translate into clinical significance (Table ​ (Table4). 4 ). The logic of this observation is rooted in patient physiology; however, the accuracy of this evolution, reflected both by the nursing records and the hourly statistical calculations, was of far more relevance. Hence, taken together, these current findings also support the use of HDDCIS calculations.

The evolution of the RR was also interesting (Table ​ (Table5). 5 ). Movements in these patients, which were initially infrequent while they rested but later increased as they started to recover, likely caused artefacts to appear in the iRR measurements. This could explain the fact that the central tendency calculations initially showed strong Pearson correlations with the nursing reference data, which then became moderate correlations in the improvement group. Thus, these inaccuracies were attributable to the measurement method, not to the data processing. Moreover, this processing ensured that the mode and median still maintained a certain level of clinical utility. Nonetheless, given the importance of this variable, as with HR, we can simultaneously monitor RR using capnography and spirometry as well, thereby allowing us to isolate any discrepancies of this type. Thus, for example, increases only in RR measured by impedance are usually related to the patient's movements.

Finally, we can say that at their highest degree of accuracy, the manual records should match the automatic calculations of central tendency. Therefore, in the absence of major measurement artifacts, we consider that these automatic central tendency calculations should be used as the gold standard for assessing patient evolution.

Like the central tendency parameters, the clinical evolutionary assessment of the minimum (1st percentile) and maximum (99th percentile) hourly calculations was simple for the care staff and was based on the patient age and their clinical situation. Interestingly, despite the selection of these percentiles and the haemodynamic and respiratory stability of these patients, there were significant clinical differences in the HR and RR minimum and maximum hourly calculations with their corresponding nursing references (Fig.  2 and Tables ​ Tables2, 2 , ​ ,3, 3 , ​ ,4, 4 , ​ ,5). 5 ). Of note, similar variations were also described for the HR 8 . These findings indicate that automatic random sampling to assess the evolution of these important parameters can differ significantly according to when the sampling is conducted. This could explain, in part, the so-called ‘smoothing effect’. In other words, the trend toward normal or average physiology in the nursing and anaesthesia records 41 , 42 . Hence, in the operating room and ICU, this smoothing phenomenon could indicate just the opposite: the inaccuracy of random samples and their impaired ability to reflect the true clinical situation of patients. This therefore highlights the need to monitor and modify automatic random registrations 4 , 8 , 9 . Thus, given all the above, and in line with these authors, we also believe that random vital sign measurements require supervision, thereby making them inefficient.

Conclusions

The current CIS discard most of the information generated at the bedside and so the benefits that its storage, processing and exploitation could entail are lost. Furthermore, the random automatic data collection they perform must be supervised by healthcare personnel, making them inefficient. However, a new generation of HDDCIS now being used in anaesthesia and critical care medicine could overcome these limitations. These systems avoid data loss and improve data processing and integration to support the development of more personalised therapeutic regimens. Although more research is still needed to validate this potential for individualising therapeutics, our findings indicate that automatic hourly vital signs calculations of central tendency could replace manual anaesthesia and critical care records, thereby freeing up highly qualified staff for other more demanding tasks.

Supplementary Information

Acknowledgements.

We would like to express our gratitude to Dr. Francisco Ruza and Dr. Ignacio Ibarra for critically reviewing this manuscript. We also thank Dr. Maria Ledran for linguistic services.

Author contributions

J.I.M. and J.B. conception of the study. J.I.M, V.P. and L.G. design of the study. J.I.M., V.P., L.G. and J.S. literature review. V.P. and L.G. acquisition of the data. All the authors contributed to the analysis and interpretation of the data. J.I.M., V.P. and L.G. drafted the submitted article. J.S., J.L.V., A.C. and J.B. provided substantial revision of the intellectual content of the article. All the authors approved the final version to be published and have agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Data availability

Competing interests.

J.I.M. declares, as a researcher at the University of Valencia and the INCLIVA Biomedical Research Institute, that he collaborates in the development of telemedicine solutions at the Medical Online Technology S.L. company. None of the other authors have any conflicts of interest to declare.

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The online version contains supplementary material available at 10.1038/s41598-023-40769-3.