Vital Signs

1. Blood Pressure

1.1. Normal: Less than 120/80

1.2. Arm stable at heart level

1.3. Cuff Size

1.3.1. Too narrow=false high

1.3.1.1. To large =false low

1.4. Korotkoff Sounds

1.4.1. 1 Systolic/Tapping

1.4.1.1. V Diastole/Silence

2. Respirations

2.1. 10-20

2.1.1. Increased = tachypnea

2.2. Do not let the client see you counting them

2.3. Abnormal findings

2.4. Labored, shallow, deep breathing, using accessory muscles, retractions

3. Temperature

3.1. 35.8 C -37.3 C

3.1.1. 94.4-99.1 F

3.1.1.1. Hyperthermia is considered greater than 100.4 F/ 38 degrees C

3.1.1.2. Hypothermia is considered less than 96.8 F/ 36 degrees C

3.1.2. Oral

3.1.2.1. Base of tongue, in sublingual pocket

3.1.3. Rectal

3.1.3.1. For a core temperature

3.1.3.1.1. Critically ill

3.1.4. Tympanic

3.1.5. Temporal Artery

3.1.5.1. Slide across forehead behind the ear

3.1.6. Axillary

4. Pulse

4.1. Bunny ears

4.1.1. Do not use thumbs

4.2. Rate: 60-100

4.3. Rhythm

4.3.1. Regular, even tempo

4.4. Force

4.4.1. 3+ bounding

4.4.2. 2+ normal

4.4.3. 1+ weak/thready

4.4.4. o absent