3 Vital Signs & Findings

temperature, pulse, respirations, blood pressure
**+ sO2
(TPR & BP)

you wait 15 mins after smoking, eating, drinking (oral) and 15 minutes after coming from the cold

36.5 - 37.5

35.9 - 38.1

0.5 lower

0.5 higher

>38

60 - 100bpm

>100 bpm (trauma, anemia, infection, fever, pain, fear, anxiety, shock)

<60 bpm

absence of pulse

regular (evenly spaced intervals) vs irregular (varied interval between beats)

auscultate apical pulse for 1 minute

5th intercostal space, midclavicular space using diaphragm of stethoscope

0 non-palpable/absent
1+ weak/diminishedarely palpable
2+ strong
3+ full, increased
4+ bounding

60-100 bpm (adult); regular; 2+; no deficit, artery feels smooth and resilient

should be smooth, straight, resilient

12-20 breaths/min

12-24 breaths/min

normal RR, rhythm, effort, no use of accessory muscles

>20 breaths/min (rapid, persistent, fever, exercise, anxiety)

difficulty breathing

deeper and more rapid

decreased respiratory rate

absence of spontaneous breathing for more than 10 secs

shallow, moderate, deep?

use of accessory muscles?

>92-100%

12-20 breaths per minute, regular, easy, no accessory muscles used, SpO2 > 92%

low pitched sounds

high pitched sounds

120/80

low <90
low expected: 90-120
high expected: 130-140
high 140-150

low <60
60-80
high >90

[SBP + (2x DBP)] / 3

systolic - diastolic pressure

-Acute change
-Agitation, restlessness
-Newnresponsive chest pain
-sudden changes in ABCs
-Increased shortness of breath; stridor!
-RR <10 or >32/min
-O2 sat <92% when no other pathology
-HR <55 or >120 bpm
-SBP <100 or >170 mmHg
-drop of >30 mmHg
-Temperature <35 or >39.5 C
-Oral Temperature >37.5-38 in neutropenic patients/transplant