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Nursing

Vital Signs

Introduction

Vital sign monitoring is the intermittent assessment of temperature, pulse, respiration and blood pressure. Vital signs are often considered to be the baseline indicators of a patient’s health status. Vital signs should be taken manually, not copied from the monitor display. Exceptions to this are the oxygen saturation reading and automatic blood pressure (BP) readings from the monitor. The automatic BP reading must be validated with a manual BP at the beginning of a shift and/or when a different electronic BP device is being used or when pressure readings prompt concern. Interpret pressure readings with caution when an electronic BP device is used for an active infant; a doppler may be a better choice. Automated blood pressure readings should be performed at the time of documentation; any readings that prompt concern should be repeated manually. Vital signs are never stagnant, and are affected by a variety of internal and external factors, including many disease conditions, anxiety, pain, exercise, and even circadian and diurnal rhythms.

Heart rate

  • Should be taken for one full minute
  • Infants and young children should have their heart rate taken at the apex of the heart using a stethoscope
  • Patients who are older with no cardiac condition may have a radial pulse taken

Respiration

  • Should be taken for one full minute
  • Auscultation with a stethoscope will increase the ability to hear shallow breaths on some patients (e.g. small infants)
  • Respiratory rhythm and depth are also clinically important, and can be determined with manual assessment and observation of the patient's respiratory pattern

Blood Pressure

Can be measured using a manual sphygmomanometer and stethoscope, by the palpation of pulse technique, with a doppler or by using an electronic BP device.

Vital signs ranges

Age

Heart Rate
(beats/min)

Respiratory Rate
(respirations/min)

Blood Pressure

0-1 month

93-182

26-65

45-80/33-52

1-3 months

120-178

28-55

65-85/35-55

3-6 months

107-197

22-52

70-90/35-65

6-12 months

108-178

22-52

80-100/40-65

1-2 years

90-152

20-50

80-100/40-70

2-3 years

90-152

20-40

80-110/40-80

3-5 years

74-138

20-30

80-115/40-80

5-7 years

65-138

20-26

80-115/40-80

8-10 years

62-130

14-26

85-125/45-85

11-13 years

62-130

14-22

95-135/45-85

14-18 years

62-120

12-22

100-145/50-90

 

Oral, Rectal & Axillary Temperatures

Assessment of appropriate route of temperature measurement:

Oral

  • patients assessed as being developmentally and cognitively appropriate, and who are not receiving oxygen via mask or hood
  • note that there are contraindications for the oral temp. route including oral surgery and/or an inflammatory condition of the mouth, respiratory difficulties, use of oral invasive devices (e.g. oral airway, oral endotracheal tube, etc)

Rectal

  • patients who are unconscious or present difficulty with oral temperature measurement related to cognitive function
  • note that there are a number of contraindications for the rectal temp. route including rectal surgery, rectal abnormalities, bradicardia related to vagal stimulation, blood disorders and anti-coagulation therapy which can result in bleeding, oncology and immunocompromized patients, patients receiving thrombolytic agents and patients in whom taking a rectal temperature could result in trauma or injury. 

Axillary

  • patients for whom oral and rectal temperatures are contraindicated
  • in the NICU patient temperatures are monitored by the axillary route

Temperature Ranges

Method

Range (°C)

Fever* (°C)

Oral

36.5 - 37.5

38.0

Rectal

37.0 - 37.8

38.0

Axillary

36.1 - 37.1

37.3

*Note:

  • There is no single definition of fever
  • Fever should be interpreted and managed in the context of the patient’s age, illness and clinical picture
  • Premature and small term infants may not be able to generate an elevated temperature in response to infection

 

Prior to commencing your placement you are required to read the SickKids Vital Sign Monitoring Policy. Please note that this document can only be viewed on the hospital's Intranet

Reference: SickKids Policies and Procedures: Vital Sign Monitoring