Vital sign assessment includes heart rate, respiratory rate, blood pressure, oxygen saturation, respiratory effort, capillary refill time and temperature. 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 with the exception of oxygen saturation reading and automatic blood pressure (BP) readings. See considerations under blood pressure section below. 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.

Pain is another key indicator of patient well-being and should therefore be assessed and documented along with vital signs.

Heart Rate

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. heart rate should be taken for one full minut

Respiratory Rate and Respiratory Effort

Respiratory rate should be taken for one full minute. Auscultation with a stethoscope will increase the ability to hear shallow breaths.

Respiratory rhythm and depth should be evaluated using a manual assessment and observation of the patient's respiratory pattern. Visualization of the chest wall effectively enables the evaluation of accessory muscle use. Respiratory effort is described in the table below.

Normal

Normal effort no in-drawing, no apnea

Mild

Mild increased respiratory effort, nasal flaring, mild-in-drawing

Moderate

Moderately increased rep. effort, nasal flaring, marked in-drawing with multiple muscle groups

Severe

Greatly increased respiratory effort, in-drawing, audible grunt, nasal flaring, head bobbing,tracheal tug, accessory muscle use, apneas

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. When using an electronic BP device, validated the reading 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.

Vital Signs Ranges

Age

Heart Rate

Respiratory Rate

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 Temperature

Measuring a patient's temperature using a consistent route is important to ensure accurate trending. Oral and rectal routes are more reliable and are the recommended routes for evaluating temperature. Axilla temperature should only be used when there are contraindications to the recommended routes. For guidelines on the appropriate routes for intermittent temperature monitoring, please refer to the Vital Signs and Monitoring policy

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 temperature route including rectal surgery, rectal abnormalities, bradycardia related to vagal stimulation, blood disorders and anti-coagulation therapy which can result in bleeding, oncology and neutropenic patients at risk of infection, 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 patient temperatures in the NICU are monitored by the axillary route Temperature Ranges

Method

Range (C)

Oral

36.5- 37.5

Rectal

37.0 - 37.8

Axillary

36.1 - 37.1

Note:

The above temperature ranges have been arrived at from variety of sources and should be interpreted and managed in the context of the patient's age, illness, and clinical picture. The literature demonstrates that here is no single agreement of what specific temperature reading consists a fever. Premature and small term infants may not be able to generate an elevated temperature in response to infections.

Oxygen Saturation

Oxygen saturation is measured using a pulse oxymeter device and an appropriate probe affixed to the patient.