Ati pediatric vital signs

Ati pediatric vital signs DEFAULT

Pediatric Vital Signs Normal Ranges

Pediatric Vital Signs Normal Ranges Summary Table: 

  • Values were derived from numerous sources (listed below) and reflect the most up-to-date guidelines. Normal ranges may include measurements that deviate from these values. Note that the patient's normal range and clinical condition should always be considered.

(Flynn, Kaelber et al. 2017, National High Blood Pressure Education Program Working Group on High Blood Pressure in and Adolescents 2004, Xi, Zong et al. 2016, Morgan & Mikhail's Clinical Anesthesiology,  Chapter 42. Pediatric Anesthesia)

*Age Group (weight in kg)

Age

(years)

Height

(cm)

Blood pressure

(mmHg) (50th-90th percentile)

Respiratory Rate

Heart Rate

Boys

Girls

Awake

Sleeping

Systolic

Diastolic

Systolic

Diastolic

Infant

1-12 months

72 -104

37-56

72-104

37-56

30-60

100-170

75-160

Toddler

(10-14 Kg)

1

77-87

86-101

41-54

85-102

42-58

24-40

80-150

60-90

2

86-98

89-104

44-58

89-106

48-62

Preschooler

(14-18Kg)

3

92-105

90-105

47-61

90-107

50-65

20-34

70-130

4

98-113

92-107

50-64

92-108

53-67

5

104-120

94-110

53-67

93-110

55-70

School-age

(20-42 Kg)

6

111-127

90-109

59-73

91-108

59-73

15-30

65-120

7

116-134

91-111

60-74

92-110

60-74

8

120-140

93-113

60-75

94-112

60-75

9

125-145

94-115

61-75

95-114

61-76

10

130-151

96-117

62-76

97-116

62-77

11

135-157

98-119

62-77

99-118

63-78

12

141-164

100-121

63-78

100-120

64-78

Adolescent

(50 Kg)

>13

147-172

102-124

64-80

102-121

64-79

12-20

55-90

50-90

* For Newborn infants, BP values vary considerably during the first few weeks of life and the definition of HTN in preterm and term neonates also varies. Data have been compiled on neonatal BP values and the summary table is available. Please note that no alternative data have been developed recently. For further information, please see the following articles:

Dionne, J. M., et al. (2012). "Hypertension in infancy: diagnosis, management, and outcome." Pediatr Nephrol 27(1): 17-32.

Dionne, J. M., et al. (2017). "Hypertension Canada's 2017 Guidelines for the Diagnosis, Assessment, Prevention, and Treatment of Pediatric Hypertension." Can J Cardiol 33(5): 577-585.

"Report of the Second Task Force on Blood Pressure Control in Children--1987. Task Force on Blood Pressure Control in Children. National Heart, Lung, and Blood Institute, Bethesda, Maryland." Pediatrics 79(1): 1-25.

When to start screening for high BP and how often?

(National High Blood Pressure Education Program Working Group on High Blood Pressure in and Adolescents 2004)

  • Guidelines suggest that the blood pressure of children should be assessed starting at 3 years of age. (Grade C, moderate recommendation)
  • Children less than 3 years of age should have their BP checked under special conditions including a history of prematurity, congenital heart disease malignancy and other systemic illnesses (Grade C, moderate recommendation)

Hypertension (HTN) or High Blood Pressure

(Chen and Wang 2008, Chiolero, Cachat et al. 2007, McNiece, Poffenbarger et al. 2007, National High Blood Pressure Education Program Working Group on High Blood Pressure in and Adolescents 2004, Weaver 2019)

  • What is the definition of HTN?
    • High blood pressure is defined as average systolic BP and/or diastolic BP >/= 95th percentile for age, gender and height on more than 3 occasions.
    • Pre-hypertension is defined as SBP and/or DBP between 90th and 95th percentile.
    • For adolescents, BP readings >/= 120/80 are considered to be pre-hypertensive. 
  • How prevalent is HTN in Children?
    • The prevalence of clinical HTN in children and adolescent is ~3.5%
    • The prevalence of persistent HTN is ~2.2% to 3.5%
      • Higher rates are present among overweight and obese children and adolescents.
  • Does HTN in children track into HTN in adulthood?
    • Data on BP tracking suggest that higher BP in childhood correlates with higher BP in adulthood

A Summary of Pediatric BP Categories, Stages and Follow-Up

  • The table was recreated from the articles listed below. Given that there were slight variations in BP values, we elected to include both percentiles and BP ranges.

(National High Blood Pressure Education Program Working Group on High Blood Pressure in and Adolescents 2004, Chen and Wang 2008, Banker, Bell et al. 2016, Flynn, Kaelber et al. 2017, Weaver 2017, Weaver 2019)

Age <13 years

Age>13 years

Follow-up

Elevated or persistent or pre-HTN

 90th to 95th percentile

or 120/80 mm Hg to <95th percentile

(whichever is lower)

120-129/<80 mm Hg

Recheck in 6 months

Consider school or home BP monitoring

Stage 1 HTN

>95th to 99th percentile + 5 mmHg  

or 130-139/89 mm Hg

(whichever is lower)

130-139/89 mm Hg

Evaluate in 1 week to 1 month

Stage 2 HTN

> 99th percentile + 5 mm Hg

or >/=140/90 mm Hg

(whichever is lower)

>/=140/90 mm Hg

Evaluate in 1 week or sooner if symptomatic

White-coat HTN

> 95th percentile in a medical setting.

Normal outside the medical setting

Consider ABPM as well as home or school BP monitoring

Masked HTN

< 95th percentile in a medical setting.

> 95th percentile outside a medical setting

Consider ABPM in high-risk patients.

Obtaining Accurate Blood Pressure Measurements:

(Scott, Rocchini et al. 1988, Pickering, Hall, et al. 2005)

  • Different methods to measure Blood pressure: The mercury sphygmomanometer is the gold standard device for in-office blood pressure measurement
    • The Auscultatory method 
      •  The most widely used noninvasive method for measuring blood pressure.
      • The preferred method for BP measurement in children
      • Korotkoff technique
        • Discovered by Dr. Nikolai Korotkov over 100 years ago.
        • It involves blocking the brachial artery by inflating a cuff to above systolic blood pressure and gradually deflate to re-establish blood flow.
        • The sounds detected by the stethoscope are known as Korotkoff sounds and are generally classified as phases I -V.
          • Phase I appears as a tapping sound and corresponds to systolic blood pressure
          • Phase V (disappearance of sound) corresponds to diastolic blood pressure (Pickering, Hall et al. 2005).
    • The oscillometric method:
      • The SBP and DBP are estimated indirectly by measuring the mean arterial pressure.
      • Not commonly used as ambulatory blood pressure monitors.
      • Advantages:
        •  No transducer is needed and therefore, the placement of the cuff is not critical
        • Convenient and minimize observer error
      • Current guidelines suggest that if blood pressure reading exceeds the 90th percentile, it should be confirmed by the auscultatory method.
  • Location of measurement:
    • The upper arm is the standard location for blood pressure measurement. Wrist monitors can be used in obese patients because wrist diameter is not significantly affected by obesity
  • Subject preparation: For most accurate blood pressure measurements, the American Heart Association recommends the following:
    • Sitting quietly for at least 5 minutes.
    • The child should be seated comfortably in a chair with back supported and legs uncrossed.  
      • An unsupported back may result in an increase in diastolic blood pressure
      • Crossing the legs may increase systolic blood pressure.
    • Remove all clothing that covers the location of cuff placement
    • child’s arm should be supported at heart level
      • the right arm is preferred due to the possibility of coarctation of the aorta, which may result in a falsely low reading (Scott, Rocchini et al. 1988)
  • Cuff size:
    • The ideal cuff size is one with a bladder length of 80% and a width that is at least 40% of arm circumference
    • Using a cuff that is too narrow will result in inappropriately high blood pressure. whereas a cuff that is too wide will result in an inappropriately low blood pressure reading.
    • Below are recommended BP cuff sizes for children and adolescents for a range of arm circumference.
      • The table recreated from numerous sources listed below. Slight variations were noted.
      • (Mattoo 2002, National High Blood Pressure Education Program Working Group on High Blood Pressure in and Adolescents 2004, Pickering, Hall et al. 2005, Prineas, Ostchega et al. 2007, Palatini and Frick 2012, Ostchega, Hughes, et al. 2014, Weaver 2017, Ostchega, Hughes, et al. 2018)

BP Cuff

Arm Circumference (cm)

Newborn

10

Infant

11 – 15

Child

16 – 22

Small Adult

23 – 26

Adult

27 – 34

Large Adult

35 – 44

Thigh

45 – 52

Childhood Obesity and its Effects on Blood Pressure

  • It is noteworthy that the increasing prevalence of obesity in the United States has not only affected adults but also children. As a result, population-based studies of pediatric weight will vary according to the period to time sampled - and will also affect (as per Keefe 2019) - the prevalence of sleep apnea with its related impact on hypertension.
  • The prevalence of childhood obesity has significantly increased since 1980 with approximately 30% of children who are overweight/obese (Ogden, Carroll et al. 2015).
    • Children with high BMI are more likely to develop hypertension later in life compared to children with lower BMI (Parker, Sinaiko et al. 2016)
  • With the unfortunate rising rates of childhood obesity, obtaining an accurate measurement has proven to be challenging due to an abnormally large arm circumference:
    • Arm circumference can be large enough which requires the use of adult size BP cuff
    • NHANES data from 2007-2010 showed that boys and girls as young as 9 years of age required a standard adult-sized cuff. Additionally, of obese participants, one third required a large adult BP cuff (Palatini and Frick 2012)
      • Disproportionately short arm compared to the cuff required for a given arm circumference
    • Conically shaped arms resulting in an average difference of 8.7 cm between the proximal and distal upper arm circumference (Palatini and Frick 2012)
  • Pathophysiology: (Stefan, Vozarova et al. 2002, Rasouli and Kern 2008, do Carmo, da Silva et al. 2011, Kalil and Haynes 2012, Brambilla, Antolini et al. 2013, Vecchiola, Lagos et al. 2016, Brady 2017)
    • Increased adiposity leads to dysfunctional activation of the sympathetic nervous system:
      • Increased adipose tissue results in an increased production of adipokines (pro- and anti-inflammatory hormones and cytokines) to maintain homeostasis
        • Recent research has been focused on the role of adiponectin (AD) due to its anti-inflammatory and anti-atherogenic effects as well as its role in increasing insulin sensitivity
      • Over time, the disproportionate increase in pro-inflammatory adipokines (IL-6, leptin, etc.) leads to a chronic inflammatory state
        • For example, Leptin’s activation of SNS is mediated via leptin receptors present on POMC neurons in the brain
    • The activation of SNS leads to increased norepinephrine production resulting in elevated BP via the following mechanisms
      •  Increased activity of RAAS and release of renin.
      • Direct vasoconstricting effects
    • Chronic inflammation and increased oxidative stress lead to endothelial damage and vascular dysfunction which manifests clinically as hypertension.

References: 

Banker, A., C. Bell, M. Gupta-Malhotra and J. Samuels (2016). "Blood pressure percentile charts to identify high or low blood pressure in children." BMC Pediatr 16: 98.

Brady, T. M. (2017). "Obesity-Related Hypertension in Children." Front Pediatr 5: 197.

Brambilla, P., L. Antolini, M. E. Street, M. Giussani, S. Galbiati, M. G. Valsecchi, A. Stella, G. V. Zuccotti, S. Bernasconi and S. Genovesi (2013). "Adiponectin and hypertension in normal-weight and obese children." Am J Hypertens 26(2): 257-264.

Chen, X. and Y. Wang (2008). "Tracking of blood pressure from childhood to adulthood: a systematic review and meta-regression analysis." Circulation 117(25): 3171-3180.

Chiolero, A., F. Cachat, M. Burnier, F. Paccaud and P. Bovet (2007). "Prevalence of hypertension in schoolchildren based on repeated measurements and association with overweight." Journal of hypertension 25(11): 2209-2217.

Coulthard, M. G. (2020). "Single blood pressure chart for children up to 13 years to improve the recognition of hypertension based on existing normative data." Arch Dis Child.

do Carmo, J. M., A. A. da Silva, Z. Cai, S. Lin, J. H. Dubinion and J. E. Hall (2011). "Control of blood pressure, appetite, and glucose by leptin in mice lacking leptin receptors in proopiomelanocortin neurons." Hypertension 57(5): 918-926.

Flynn, J. T., D. C. Kaelber, C. M. Baker-Smith, D. Blowey, A. E. Carroll, S. R. Daniels, S. D. de Ferranti, J. M. Dionne, B. Falkner, S. K. Flinn, S. S. Gidding, C. Goodwin, M. G. Leu, M. E. Powers, C. Rea, J. Samuels, M. Simasek, V. V. Thaker, E. M. Urbina, S. Subcommittee On and C. Management Of High Blood Pressure In (2017). "Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents." Pediatrics 140(3).

Kalil, G. Z. and W. G. Haynes (2012). "Sympathetic nervous system in obesity-related hypertension: mechanisms and clinical implications." Hypertens Res 35(1): 4-16.

Mattoo, T. K. (2002). "Arm cuff in the measurement of blood pressure." Am J Hypertens 15(2 Pt 2): 67S-68S.

McNiece, K. L., T. S. Poffenbarger, J. L. Turner, K. D. Franco, J. M. Sorof and R. J. Portman (2007). "Prevalence of hypertension and pre-hypertension among adolescents." The Journal of pediatrics 150(6): 640-644. e641.

National High Blood Pressure Education Program Working Group on High Blood Pressure in, C. and Adolescents (2004). "The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents." Pediatrics 114(2 Suppl 4th Report): 555-576.

Ogden, C. L., M. D. Carroll, C. D. Fryar and K. M. Flegal (2015). "Prevalence of Obesity Among Adults and Youth: United States, 2011-2014." NCHS Data Brief(219): 1-8.

Ostchega, Y., J. P. Hughes, T. Nwankwo and G. Zhang (2018). "Mean mid-arm circumference and blood pressure cuff sizes for US children, adolescents and adults: National Health and Nutrition Examination Survey, 2011-2016." Blood Press Monit 23(6): 305-311.

Ostchega, Y., J. P. Hughes, R. J. Prineas, G. Zhang, T. Nwankwo and M. M. Chiappa (2014). "Mid-arm circumference and recommended blood pressure cuffs for children and adolescents aged between 3 and 19 years: data from the National Health and Nutrition Examination Survey, 1999-2010." Blood Press Monit 19(1): 26-31.

Palatini, P. and G. N. Frick (2012). "Cuff and bladder: overlooked components of BP measurement devices in the modern era?" Am J Hypertens 25(2): 136-138.

Parker, E. D., A. R. Sinaiko, E. O. Kharbanda, K. L. Margolis, M. F. Daley, N. K. Trower, N. E. Sherwood, L. C. Greenspan, J. C. Lo, D. J. Magid and P. J. O'Connor (2016). "Change in Weight Status and Development of Hypertension." Pediatrics 137(3): e20151662.

Pickering, T. G., J. E. Hall, L. J. Appel, B. E. Falkner, J. Graves, M. N. Hill, D. W. Jones, T. Kurtz, S. G. Sheps and E. J. Roccella (2005). "Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research." Circulation 111(5): 697-716.

Pickering, T. G., J. E. Hall, L. J. Appel, B. E. Falkner, J. W. Graves, M. N. Hill, D. H. Jones, T. Kurtz, S. G. Sheps, E. J. Roccella, P. Council on High Blood Pressure Research and A. H. A. Public Education Subcommittee (2005). "Recommendations for blood pressure measurement in humans: an AHA scientific statement from the Council on High Blood Pressure Research Professional and Public Education Subcommittee." J Clin Hypertens (Greenwich) 7(2): 102-109.

Prineas, R. J., Y. Ostchega, M. Carroll, C. Dillon and M. McDowell (2007). "US demographic trends in mid-arm circumference and recommended blood pressure cuffs for children and adolescents: data from the National Health and Nutrition Examination Survey 1988-2004." Blood Press Monit 12(2): 75-80.

Rasouli, N. and P. A. Kern (2008). "Adipocytokines and the metabolic complications of obesity." J Clin Endocrinol Metab 93(11 Suppl 1): S64-73.

Scott, W. A., A. P. Rocchini, E. L. Bove, D. M. Behrendt, R. H. Beekman, M. Dick, 2nd, G. Serwer, R. Snider and A. Rosenthal (1988). "Repair of interrupted aortic arch in infancy." J Thorac Cardiovasc Surg 96(4): 564-568.

Stefan, N., B. Vozarova, T. Funahashi, Y. Matsuzawa, C. Weyer, R. S. Lindsay, J. F. Youngren, P. J. Havel, R. E. Pratley, C. Bogardus and P. A. Tataranni (2002). "Plasma adiponectin concentration is associated with skeletal muscle insulin receptor tyrosine phosphorylation, and low plasma concentration precedes a decrease in whole-body insulin sensitivity in humans." Diabetes 51(6): 1884-1888.

Vecchiola, A., C. F. Lagos, C. A. Carvajal, R. Baudrand and C. E. Fardella (2016). "Aldosterone Production and Signaling Dysregulation in Obesity." Curr Hypertens Rep 18(3): 20.

Weaver, D. J., Jr. (2017). "Hypertension in Children and Adolescents." Pediatr Rev 38(8): 369-382.

Weaver, D. J., Jr. (2019). "Pediatric Hypertension: Review of Updated Guidelines." Pediatr Rev 40(7): 354-358.

Xi, B., X. Zong, R. Kelishadi, Y. M. Hong, A. Khadilkar, L. M. Steffen, T. Nawarycz, M. Krzywinska-Wiewiorowska, H. Aounallah-Skhiri, P. Bovet, A. Chiolero, H. Pan, M. Litwin, B. K. Poh, R. Y. Sung, H. K. So, P. Schwandt, G. M. Haas, H. K. Neuhauser, L. Marinov, S. V. Galcheva, M. E. Motlagh, H. S. Kim, V. Khadilkar, A. Krzyzaniak, H. B. Romdhane, R. Heshmat, S. Chiplonkar, B. Stawinska-Witoszynska, J. El Ati, M. Qorbani, N. Kajale, P. Traissac, L. Ostrowska-Nawarycz, G. Ardalan, L. Parthasarathy, M. Zhao, T. Zhang and C. International Child Blood Pressure References Establishment (2016). "Establishing International Blood Pressure References Among Nonoverweight Children and Adolescents Aged 6 to 17 Years." Circulation 133(4): 398-408.

Sours: https://medicine.uiowa.edu/iowaprotocols/pediatric-vital-signs-normal-ranges

____ are measurements of the body's most basic functions and include temperature, pulse, respiration, and blood pressure.

Many facilities also consider pain level and ______ vital signs.

____ reflects the balance between heat the body produces and heat lost tot he environment.

_____ is the measurement of the heart rate and rhythm. It corresponds to the bounding of blood flowing through various points in the circulatory system.

Pulse provides information about ______.

_____ is the body's mechanism for exchanging oxygen and carbon dioxide between the atmosphere and the blood and cells of the body, which is accomplished through breathing and recorded as the number of breaths per minute.

_______ reflects the force the blood exerts against the walls of the arteries during contraction (systole) and relation (diastole) of the heart.

Systolic blood pressure (SBP) occurs during _______ systole of the heart, when the ventricles force blood into the aorta and pulmonary artery, and it represents the max amount of pressure exerted on the arteries when ejection occurs.

Diastolic blood pressure (DBP) occurs during ventricular diastole of the heart, when the ____ relax and exert minimal pressure against the arterial walls, and represents the minimum amount of pressure exerted on the arteries.

The neurological and ______ systems work together to regulate body temperature. Disease or trauma of the hypothalamus or spinal cord will alter temperature control.

rectum
tympanic membrane
temporal artery
pulmonary artery
esophagus
urinary bladder

The skin, mouth, and _____ are surface temperature measurement sites.

_____ results from increases in basal metabolic rate, muscle activity, throxine output, testosterone, and sympathetic stimulation, which increase _____.

heat production
heat production

Heat loss through the body occurs through ___- which is the transfer of heat from the body directly to another surface (when the body is immersed in cold water)

Heat loss through the body occurs through ______ is the dispersion of heat by air currents (wind blowing across exposed skin)

Heat loss through the body occurs through ______ which is the dispersion of heat through water vapor (perspiration).

Heat loss through the body occurs through ______ is a transfer of heat from one object to another object without contact between them (heat lost form the body to a cold room(

Heat loss through the body occurs through ______ which is visible perspiration on the skin.

An oral temperature range in both C and F.

36 to 38 C
96.8 to 100.4 F
The average is 37C or 98.6 F

Rectal temperatures are usually ____C or ___F higher than oral and tympanic temperatures.

Axillary temperatures are usually ____C or ____F lower than oral and tympanic temperatures.

Temporal temperatures are close to ____, but they are nearly 0.5C or 1 F higher than oral, and 1C higher than axillary temps.

A client's usual temp serves as a ____ for comparison.

______ have a large surface to mass ration, so they lose heat rapidly to the environment. A _____ temperature should be between 36.5 or 37.5C and ____ to ____ F.

Newborns
newborn
97.7F to 99.5 F

Older adult clients experience a loss of subcutaneous fat that result in lower body temperatures and feeling cold. Their average body temperature is ___c or ___F.

Older adult clients are more likely to develop adverse effects from ______ in environmental temps (heat stroke, hypothermia). It also takes longer for the body temperature to register on a _____ due to changes in temperature regulation.

_____ changes can influence temperature. In general, temperature rises slightly with ovulation and menses. With menopause, intermittent body temperature can increase by up to ___ C or ____ F.

hormonal changes
4C or 7.2 F

Exercise, activity, and _____ can contribute to the development of hyperthermia.

______ can cause elevations in temperature. Fever is the body's response to infectious and inflammatory processes.

___ causes an increase in the body's immune response.

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In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of the changes and abnormailities in vital signs in order to:

  • Assess and respond to changes in client vital signs
  • Apply knowledge needed to perform related nursing procedures and psychomotor skills when assessing vital signs
  • Apply knowledge of client pathophysiology when measuring vital signs
  • Evaluate invasive monitoring data (e.g., pulmonary artery pressure, intracranial pressure)

Assessing and Responding to Changes/Abnormalities in Vital Signs

The vital signs include the assessment of the pulse, body temperature, respirations, blood pressure and oxygen saturation, which is the newest of all the vital signs.

Vital signs are considered vital to the rapid assessment of the client when it is necessary to determine major changes in the client's basic physiological functioning. Baseline vital signs are taken prior to many procedures and treatments including upon admission to an acute care facility, prior to the administration of medications, prior to the administration of a blood transfusion, and prior to surgery and other invasive procedures These baseline vital signs are taken because they are vitally important for comparison to those vital signs that are taken during and after a treatment, a procedure or a significant change in the client. Vital signs are highly responsive to client abnormalities and changes. For example, a significant drop in blood pressure may indicate the presence of hemorrhage and bleeding, a drop in terms of a client's oxygen saturation can indicate the early stages of hypoxia, and a rise in the client's temperature can indicate the presence of infection. The sensitivity of vital signs to even subtle changes in the client's condition is so effective that vital signs are routinely taken for all acute care clients on a regular and ongoing basis.

Physiologically, the vital signs reflect the adequacy or inadequacy of basic bodily functions. For example, the blood pressure reflects the cardiac output and the systemic vascular resistance. Respirations and the respiratory rate are reflective of a number of factors including the functioning of the chemoreceptors or baroreceptors in the brain stem, the aorta and the carotid arteries; and the bodily pulses are the physiological functioning of the parasympathetic nervous system, the autonomic nervous system and the cardiovascular system functioning.

All significant changes in terms of vital signs must be reported and documented. Many facilities use a graphic flow chart for their patients' vital signs.

Applying the Knowledge Needed to Perform Related Nursing Procedures and Psychomotor Skills When Assessing Vital Signs

Temperature

Bodily temperature results from the differences between heat production and heat losses. The normal bodily temperature is 98.6 degrees F, or 36.7 to 37 degrees centigrade, with some small, minor and normal variations among children, and also as impacted by stress, one's circadian rhythm, female hormonal changes and the external environment.

Temperature can be taken at a number of sites including the mouth, rectum, ear, axillae, the temporal area and the forehead depending on the type of thermometer that is used. Oral temperatures are contraindicated among neonates, infants, young children and those adult clients adversely affected with confusion, agitation and a decreased level of consciousness; and rectal temperatures are contraindicated when a client is has a seizure disorder, heart disease or a rectal disorder.

Respirations

Respirations are assessed and monitored using inspection for the rise and fall of the chest or abdomen or by gently placing your hand on the chest or abdomen to monitor and assess the rate, regularity, depth and quality of the client's respirations.

A decreased respiratory rate can indicate and signal a number of disorders such as central nervous system depression secondary to opioids or central nervous system damage, a coma, planned sedation and sedation as a side effect to a medication and alkalosis; increased respiratory rates can occur secondary to a fever, pain, acidosis and anxiety.

The normal respiratory rates along the life span are as follows:

  • Neonate: From 30 to 60 per minute
  • Infant: From 30 to 60 per minute
  • Toddler: From 20 to 40 per minute
  • Pre School Child: From 22 to 30 per minute
  • School Age Child: From 20 to 26 per minute
  • Adolescent: The same as the adult from 16 to 22 per minute
  • Adult: From 16 to 22 per minute

Pulses

Pulses are assessed with both palpation and auscultation. Peripheral pulses are assessed with palpation, often bilaterally. These peripheral pulses include the radial pulse, the femoral pulse, the brachial pulse, the popliteal pulse, the dorsalis pedis pulse of the foot and the posterior tibial pulse near the ankle. During the palpation of the pulse the index finger and/or the middle finger is used to count the number of beats and to assess other characteristics of the pulse such as its regularity, fullness or volume, and other characteristics. At times, a Doppler is used for difficult to palpate and assess peripheral pulses.

The apical pulse is assessed with auscultation and the point of maximum intensity for the adult is on the left side of the chest at the fifth intercostal space. This point differs somewhat along the lifespan until adolescence and during later years secondary to an enlarged heart.

The normal parameters for pulse rates along the life span are:

  • Neonate: From 80 to 180 beats per minute
  • Infant: From 100 to 160 beats per minute
  • Toddler: From 90 to 140 beats per minute
  • Pre School Child: From 80 to 110 beats per minute
  • School Age Child: From 70 to 100 beats per minute
  • Adolescent: From 60 to 100 beats per minute
  • Adult: From 60 to 100 beats per minute

Blood Pressure

Blood pressure results from the pressure of the blood flow as it moves through the arteries. The blood pressure is what it is as the result of a combination of the blood volume, the peripheral vascular resistance, the pumping action of the heart and the thickness, or viscosity, of the blood.

Systolic blood pressures reflect the pressure that occurs with the heart's contraction and diastolic blood pressure reflects the pressure that is exerted when the heart is at rest. Blood pressures are measured most commonly over the brachial artery just above the client's antecubital space.

The normal blood pressures along the life span are:

  • Neonate: Diastolic from 40 to 50 mm Hg and systolic from 60 to 80 mm Hg
  • Infant: Diastolic from 50 to 70 mm Hg and systolic from 74 to 100 mm Hg
  • Toddler: Diastolic from 50 to 80 mm Hg and systolic from 80 to 112 mm Hg
  • Preschool child: Diastolic from 50 to 78 mm Hg and systolic from 82 to 110 mm Hg
  • School age child: Diastolic from 54 to 80 mm Hg and systolic from 84 to 120 mm Hg
  • Adolescent: < 120/80
  • Adult: < 120/80

Applying a Knowledge of Client Pathophysiology When Measuring Vital Signs

Nurses apply a knowledge of the client's pathophysiology when they are assessing vital signs.

As stated above, temperatures are a function of bodily heat losses and bodily heat production. Among other things, bodily temperatures gains and abnormal body temperatures can result from pathophysiological changes of the brain, the central nervous system, pathologies of the hypothalamus, the inflammatory process, endocrine hormones, and external environmental temperatures such as extremes of hot or cold which can cause hyperthermia and hypothermia, respectively.

Pathophysiologically, alterations and abnormalities of the cardiovascular system, the parasympathetic nervous system and the autonomic nervous system can lead to an abnormal pulse in terms of number of beats per minute, the regularity of the pulse, the volume of the pulse, and other characteristics of the pulse.

Pathophysiological alterations affecting the brain stem and the baroreceptors in the carotid arteries, and the aorta, as well as pathophysiology of the respiratory system can lead to alterations in terms of the client's respirations.

Similarly, pathophysiological changes in terms of cardiac rate, systemic vascular resistance, and venous return can lead to alterations in terms of the client's blood pressure.

Evaluating Invasive Monitoring Data

In addition to monitoring noninvasive data like vital signs, registered nurses also monitor and evaluate invasive monitoring data such as increased intracranial pressure, pulmonary artery pressure and other hemodynamic monitoring data.

Increased Intracranial Pressure

The pressure within the cranial cavity or skull is known as intracranial pressure (ICP). The normal contents of the skull include the brain, cerebrospinal fluid and blood. Because the skull, after infancy, is a boney and rigid structure without any ability to expand and contract when necessary, increased intracranial pressure in the skull will lead to impaired cerebral perfusion, hypoxia, and the compression of the cerebral arteries. Increased intracranial pressure can be a life threatening situation when it is not treated and reversed.

Increased intracranial pressure can increase when many neurological insults including a closed head injury, a cerebral tumor, an epidural hematoma, a subdural hematoma, a subarachnoid hematoma, spina bifida, infections and abscesses, hydrocephalus, a cerebral infarct, and status epilepticus.

The normal range for intracranial pressure ranges from 5 to 15 mmHg. Increased ICP occurs when the volume of the cranial cavity increases. Under normal circumstances, the pressure that is necessary to adequately perfuse the brain is known as cerebral perfusion pressure which can be mathematically calculated by subtracting the actual intracranial pressure from the mean arterial blood pressure, as shown below.

Cerebral perfusion pressure = The mean arterial pressure – The intracranial pressure

The normal cerebral perfusion pressure, under normal circumstances, should range from 60 to 100 mm Hg.

Brain herniation occurs when intracranial pressure increases to the point where the boney, rigid skull can no longer accommodate for this increased pressure without successful treatment. The types of brain herniation that can occur are a downward, lateral, and medial displacements, which are referred to as central transtentorial, transtentorial, and cingulated herniation, respectively.

Some of the signs and symptoms of increased intracranial pressure include:

  • A widening pulse pressure
  • Decreased level of consciousness
  • A headache
  • Vomiting
  • Seizures
  • Decorticate or decerebrate posturing
  • Dilated and sluggish pupils
  • Neurological sensory and motor losses
  • Visual disturbances
  • Cheyne-Stokes respirations: Cheyne-Stokes respirations are signaled with the classical signs of rapid, deep breathing with periods of apnea and abnormal posturing.
  • Cushing's reflex: Cushing's reflex is a late sign of increased intracranial pressure. It is characterized with bradycardia, hypertension and a widening pulse pressure, which is the mathematical difference between the systolic and diastolic blood pressure. For example, the pulse pressure is 40 when a client's blood pressure is 120/80 (120-80= 40) and the pulse pressure will rise to 90 when the client's blood pressure changes to 160/70 (160-70=90). This rise is referred to as a widening pulse pressure.

Intracranial pressure is assessed and monitored with invasive and noninvasive tests. A CT scan can diagnose and monitor intracranial pressure and invasive direct monitoring of the intracranial pressure can be done with a intraventricular catheter, also referred to as a ventriculostomy, which is placed into the lateral ventricle of the brain, a subarachnoid bolt and an epidural bolt. Some of these devices also drain excess intracranial fluid to relieve the pressure.

The treatments of increased intracranial pressure are often dependent on the cause of the increase and the severity of the increased intracranial pressure. In addition to the identification and treatment of an underlying disorder when possible, some of the medications that are used include intravenous osmotic diuretics, like mannitol, to remove fluid, corticosteroids to reduce edema, and anticonvulsant medications to prevent seizures. At times, a barbiturate coma may be induced to preserve brain functioning by decreasing the metabolic demands of the brain. Life saving measures, including cardiopulmonary resuscitation and mechanical ventilation may be indicated.

Decorticate posturing is abnormal rigid bodily posturing that is characterized with the tight clenching of the fists on the chest while the arms are turned inward; and decerebrate posturing is rigid and abnormal bodily posturing that is characterized with the extension and arching backward of the client's head while the arms and the legs are extended and the toes are point upward. These abnormal posturings can be unilateral or bilateral.

Hemodynamic Monitoring

Hemodynamic monitoring provides health care providers with current data and information relating to the client's blood pressure, pulmonary artery pressures, pulmonary artery wedge pressure, central venous pressure, cardiac output, intra-arterial pressure, mixed venous oxygen saturation and other data.

The normal values for hemodynamic monitoring measurements are as below:

  • Pulmonary Artery Systolic Pressure: 15 to 26 mm Hg
  • Pulmonary Artery Diastolic Pressure: 5 to 15 mm Hg
  • Pulmonary Artery Wedge Pressure: 4 to 12 mm Hg
  • Central Venous Pressure: 1 to 8 mm Hg
  • Cardiac Output: 4 to 7 L/min
  • Mixed Venous Oxygen Saturation: 60% to 80%
  • Right Atrium Pressure: 0 to 8 mm Hg
  • Right Ventricle Peak Systolic: 15 to 30 mm Hg
  • Right Ventricle End Diastolic: 0 to 8 mm Hg
  • Pulmonary Artery Mean: 9 to 16 mm Hg
  • Pulmonary Artery Peak Systolic: 15 to 30 mm Hg
  • Pulmonary Artery End Diastolic: 4 to 14 mm Hg
  • Pulmonary Artery Occlusion Mean: 2 to 12 mm Hg
  • Left Atrium Mean: 2 to 12 mm Hg
  • Left Atrium A Wave: 4 to 16 mm Hg
  • Left Atrium V Wave: 6 to 12 mm Hg
  • Left Ventricle Peak Systolic: 90 to 140 mm Hg
  • Left Ventricle End Diastolic: 5 to 12 mm Hg
  • Brachial Artery Mean: 70 to 150 mm Hg
  • Brachial Artery Peak Systolic: 90 to 140 mm Hg
  • Brachial Artery End Diastolic: 60 to 90 mm Hg

Invasive hemodynamic monitoring systems include a pressure transducer, a monitor, pressure tubing, a pressure bag and a flush device. Some even permit access to draw arterial blood gases. For example, a pulmonary artery catheter consists of a proximal lumen which measures the central venous pressure and it can also be used for the administration of intravenous fluids and to draw venous blood samples, a distal lumen that measures the pulmonary wedge, the pulmonary artery systolic, and the pulmonary artery diastolic pressures, a thermistor that measures the cardiac output, and a balloon inflation port that measures the pulmonary artery wedge pressure when it is briefly inflated.

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Alene Burke, RN, MSN

Alene Burke, RN, MSN

Alene Burke RN, MSN is a nationally recognized nursing educator. She began her work career as an elementary school teacher in New York City and later attended Queensborough Community College for her associate degree in nursing. She worked as a registered nurse in the critical care area of a local community hospital and, at this time, she was committed to become a nursing educator. She got her bachelor’s of science in nursing with Excelsior College, a part of the New York State University and immediately upon graduation she began graduate school at Adelphi University on Long Island, New York. She graduated Summa Cum Laude from Adelphi with a double masters degree in both Nursing Education and Nursing Administration and immediately began the PhD in nursing coursework at the same university. She has authored hundreds of courses for healthcare professionals including nurses, she serves as a nurse consultant for healthcare facilities and private corporations, she is also an approved provider of continuing education for nurses and other disciplines and has also served as a member of the American Nurses Association’s task force on competency and education for the nursing team members.

Alene Burke, RN, MSN

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