Vital Signs

• examination of vital signs includes the following:

1. pulse
2. blood pressure
3. respiration rate
4. body temperature

Vital Signs: Pulse

• pulse information can be obtained from many locations on the body

radial pulse • radial pulse can be felt on the distal lateral aspect of the arm at the wrist
• use the pads of your first three fingers on the flexor surface of the wrist
laterally along the radious bone
• partial flexion of the patient’s wrist can help in feeling the pulse
Rhythm • define if pulse is regular or irregular
Regular pulse: count heart beats for 15 sec. then multiply by 4 (beats per
min)
Irregular : count heart beats for 1 min: using radial artery or while
auscultating the heart

Rate • normal heart rate is 60 to 100 beats/min

• > than 100 indicates tachycardia
• < than 60 indicates bradycardia

Causes of Pulse Changes:

• weak (thready) pulses: anemia, bleeding, low BP
• strong (bounding) pulses: hypertension, exercise
• abnormal pulses re cardiac events:

Pulsus Paradoxus 
pulse that changes on inspiration and expiration → the amplitude increases with
expiration and decreases with inspiration. This occur in conditions that block venous
return to the right side of the heart or block left ventricular filling: cardiac tamponade,
constrictive pericarditis, pulmonary embolism and asthmatic attacks.

Water-Hammer (Corrigan’s) pulse 

aortic valve regurgitation (grater than normal force then collapses suddenly  wide
pulse pressure.
Location of Pulse:
• there are many different pulses which can be felt on the body and include the
following:

radial pulse • radial pulse can be felt on the distal lateral aspect of the arm at the wrist
• with the finger tips on the flexor surface of the wrist laterally
• partial flexion of the patient’s wrist can help in feeling the pulse
brachial pulse • flex the patient’s elbow slightly and with the thumb of the opposite hand
palpate the brachial artery just medial to the biceps tendon at the
antecubital crease
• the brachial artery can also be felt proximal in the groove between the
biceps and triceps muscles
carotid pulse • inspect the neck for pulsations
• carotid pulsations are located just medial to the sternomastoid muscles
• place your index or middle fingers on the right carotid artery in the lower
3rd of the neck
• never press both left and right carotid arteries at the same time
femoral pulse • can be felt as the femoral artery emerges from the inguinal canal on the
anterior aspect of the leg
• press deeply below the inguinal ligament midway between the anterior
superior iliac spine and the symphysis pubis
popliteal pulse • located in the popliteal fossa at the back of the knee
• the patient’s knee should be flexed with the leg relaxed
• grasp the knee with both hands so the fingertips meet in the midline of the
knee and press into the popliteal fossa
dorsalis pedis pulse • can be felt as the anterior tibial artery becomes the dorsal pedis artery on
the dorsal aspect of the foot
• feel the dorsal surface of the foot lateral to the extensor hallucis longus
posterior tibial pulse • can be felt as the medial malleolar artery wraps around the medial
malleolus
• palpate behind and below the medial malleolus of the ankle

• with each contraction, the left ventricle ejects a volume of blood into the aorta, which
proceeds into the arterial tree
• a pressure wave moves rapidly through the arterial system where it can be felt in the
arterial pulse which is called a pressure wave (= arterial pulse)
• peripheral pulses have a palpable delay between themselves and ventricular
contraction since the pressure wave moves much more quickly than the blood itself
• due to this delay peripheral pulses unsuitable for timing cardiac events
• in critical situations, palpate the pulse at the carotid artery because it directly reflects
the left ventricular and aortic pulsations

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Vital Signs: Blood Pressure

Measuring Blood Pressure from the arm:

1. make sure to use the right cuff (ex. for obese patients, children etc).
2. the patient should be seated and relaxed and their left or right arm should be
located at the level of the heart and relaxed
3. place the inflatable cuff over the brachial artery (2.5cm above the antecubital
fossa/crease) Not too tight or loose
4. place your right hand on the patients radial pulse and inflate the cuff
5. note the level of mmHg that the pulse disappears, deflate the cuff promptly and
remember the point
6. repeat the process using your stethoscope and add 30mmHg to the level of
mmHg where the radial pulse disappeared the first time
7. place the stethoscope medially on the brachial artery pressing firmly
deflate the cuff, (deflate the cuff slowly at a rate of about 2-3 mmHg/sec).
Listen for the first appearing sound (systolic blood pressure) and note the level of
mmHg.
8. note when the last sound disappears (the diastolic blood pressure)
9. if you miss the sounds you may repeat the procedure but no more than 2 or 3
times because it could change the blood pressure reading
10. when you see a patient for the first time BP should be taken in both arms to
compare

• May be a difference in systolic BP up to 10 mmHg.

• If > than 10 –15 mmHg may suggest arterial compression or obstruction on the
side with lower pressure, dissection of the aorta

Define Auscultatory Gap.

Blood Pressure Classification (CURRENT)

Category Systolic (in mmHg) Diastolic (in mmHg)
Normal <120 <80
Prehypertensionl 120-139 80-89
Hypertension
Stage 1 140- 159 90-99
Stage 2 ≥ 160 ≥ 100
th
The 7 Report. The Joint National Committee on Prevention, Detection Evaluation and
treatment of High Blood Pressure.

• Target organs: eyes, heart, brain, and kidneys.

Measuring Blood Pressure From the Leg:

• blood pressure may be taken on the leg if there is a problem with the arm
1. to do this, have the patient in the prone position with their leg slightly flexed
2. place the cuff over the lower 1/3 of the thigh and place the diagram of the

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 stethoscope over the popliteal artery
3. repeat the steps 4 – 10 for measuring blood pressure in the arm
• the blood pressure on the leg should be a bit higher due to gravity
• in a comparison of the femoral and radial pulses, if the femoral pulse is
delayed it could indicate obstructive disease such as atherosclerosis, tumor, etc.

Pulse Pressure: reflects stroke volume

(N stroke volume– 70ml –amount of blood heart pumps with every beat)

• pulse pressure: the difference between systolic and diastolic blood pressures. For
example, if systolic pressure is 120 mmHg and diastolic pressure is 80 mmHg.
Pulse pressure = 40 mmHg

25% - 50% • normal

of systolic pressure
> 50%
of systolic pressure
< 25%
of systolic pressure
• suggestive of aortic insufficiency = aortic valve regurgitation
• ex. 150/50 or 170/60
• suggests pericardial effusion or constrictive pericarditis

Physiologic Processes Controlling Blood Pressure:

cardiac output
peripheral vascular resistance
• depends on the amount of blood ejected from the heart during
one minute
• depends on heart rate and strength of cardiac muscle
• pathologies where pumping action is impaired will therefore
result in low blood pressure
• ex. congestive heart failure (CHF), myocardial infarction,
cardiomyopathy
• seen in cases of hypertension

vasodilatation • results from different drugs, or shock

volume • may be decreased in hemorrhaging, increased in IV fluid

overload
viscosity • increases in smokers as well as in platelet aggregation

rigidity/hardening • arteriosclerosis occurs when the arterial wall is thickened

• in elderly this may be seen as isolated hypertension

Common Errors in Blood Pressure Measurement:

• taking the blood pressure when the patient is anxious; some sort of stimulant
(coffee, nicotine etc).
• wrong arm position (above the level of the heart) can give falsely low BP
reading. Arm position below the heart can conversely give falsely high BP
readings.

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• inflating cuff too tight can cause pain and falsely low BP
• deflating cuff too slow can give falsely high diastolic result.

falsely high levels • anxiety, increased activity, nicotine

• when arm is below heart level
• Pt’s own effort to support the arm, loose cuff
falsely low levels • when arm is above the heart level, cuff is too tight or deflated
too slowly