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Vital Signs

Table of Contents
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CLINICAL PROTOCOLS
Temperature, Pulse & Respirations..................................................................................1
Blood Pressure ................................................................................................................ 2
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Core Clinical Service Guide
Section: Vital Signs
September 1, 2012
VITAL SIGNS
When reviewing vital signs in each of the age groups, be alert for signifcant changes and
compare with normal values for each of the signs. For best results, when taking vital signs of
infants, respirations are counted frst before the infant is disturbed, the pulse next and the
temperature last. When taking temperatures, the use of non-mercury thermometers is
recommended.
TEMPERATURE
(Birth to Adult)
NORMAL RESTING PULSE
(Birth to Adult)
RESPIRATIONS
(Birth to Adult)
(Birth to 10)
Temperature between .!"
#$$.! F is considered low-grade
fever. %f the temperature is
taken rectally, a temperature is
not considered a fever until it is
above #$$.&
• Temperature between
#$#"#$' is considered a mild
fever.
• Temperature between
#$'"#$( is considered a
moderate fever.
• Temperature around #$&
or above is considered a high
fever, and delirium or
convulsions may occur.
(11 Year to Adult)
• Temperature above #$$.&
is considered a fever.
• %f temperature is taken
rectally, it would register one
degree higher and a reading
of #$# would be considered a
fever.
• Temperature between
#$#"#$' is considered a mild
fever.
• Temperature between
#$'"#$( is considered a high
fever, and delirium or
convulsions may occur.
Ma!a"e#e!t
)ssess the patient to determine
if other signs or symptoms are
present *i.e., +ushed face, hot,
dry skin, low output and highly
concentrated urine, disinterest
in eating, constipation, diarrhea,
or vomiting. ,lder children or
adolescents may complain of
sore throat, headaches, aching
all over, nausea, constipation, or
diarrhea-.
.etermine if elevated
temperature could be post
immuni/ation *see %mmuni/ation
0ewborn--------#$$"#1$
2 months"# year $"#($
'"( years----------!$"#'$
&"3 years----------1$"##$
#$ years")dult---2$"#$$
Ma!a"e#e!t
The apical heart rate is
preferred in children. To count
the rate, place stethoscope on
the anterior chest at the ffth
intercostal space in a
midclavicular position. 4ach
5lub-dub6 sound is one beat.
7ount the beats for one full
minute. While counting the
rate, note whether the rhythm
is regular or irregular.
8ulse rates may be checked at
sites other than the apex, for
example, the carotid, brachial,
radial, femoral, and dorsalis
pedis sites. 7ompare the
distal and proximal pulses for
strength. )lso record whether
the pulse is normal, bounding
*very strong-, or thready
*weak-.
When reviewing the resting
heart or pulse rate in each of
the age groups, if the rate is
not within the normal limits9
• :epeat to confrm.
• :eview history for
appropriate age group to
determine if patient is
taking medication that may
alter the heart rate or if the
patient is active in sports or
exercise programs *i.e.,
runner, ;ogger, football,
basketball, tennis, etc.-.
• %f heart or pulse rate is
outside the normal range
and there is no appropriate
The procedure for
measuring a child<s
respiratory rate is
essentially the same as for
an adult. =owever, keep in
mind these points.
• >ince a child<s
respiration rate is
diaphragmatic, observe
abdominal movement to
count the respiration
rate.
• )bdominal
movement in a child will
be irregular.
• 7ount for one full
minute.
Nor#al Re$iratio! Rate
(Birth throu"h Adult)
0ewborn---------($"2$
2 months--------'&"(2
# year------------'$"&$
'"( years--------'$"($
&"2 years--------#2"''
2"#$ years------#2"'$
##"'$ years----#'"'$
Ma!a"e#e!t
)ssess the patient to
determine if other signs or
symptoms of respiratory or
cardiac distress are present.
%f a child has any acute
distress *retractions,
cyanosis, whee/ing,
irritability-, refer
immediately for a medical
evaluation.
Page 1 of 3
Core Clinical Service Guide
Section: Vital Signs
September 1, 2012
>ection-, or related to
underlying condition, being
treated at the ?=.. %f not, seek
medical consultation and@or
refer for medical evaluation.
Fever in an infant ( months and
younger is of greater
signifcance and medical
consultation or referral should
occur.
rationale, refer for medical
evaluation.
Page 2 of 3
Core Clinical Service Guide
Section: Vital Signs
September 1, 2012
BLOO% PRESSURE REA%INGS IN &'IL%REN (
A%OLES&ENTS
Alood pressure measurement for a child is basically the same as for an adult. The i)e
o* the +lood $reure ,u- i e.tre#el/ i#$orta!t. Whether manual or electronic
eBuipment is being used, the si/e of the blood pressure cuC is determined by the si/e of
the child<s arm or leg. Denerally, the width of the bladder cuC is two thirds of the length
of the long bone of the extremity on which the blood pressure is taken. The length of
the bladder cuC should be about three-fourths the circumference of the extremity and
should not overlap. %f the bladder of the cuC is too small, the pressure will read
extremely highE if it is too large, the pressure will be falsely low.
A"e 0Nor#al 00Sta"e I
Mild
'/$erte!io
!
00Sta"e II
Moderate
'/$erte!io
!
00Sta"e III
Se1ere
'/$erte!io
!
234 Year For results above normal, follow >tage %% guidelines
>ystolic #$1"### ##'
.iastolic 2#"1$ 1#
536 /ear
>ystolic ###"##3 ##2"#'# #''"#' F#'
.iastolic 2#"1$ 1#"11 1!"!3 F!3
10317 Year
>ystolic ##'"##2 ##1"#'3 #'2"#(( F#((
.iastolic 2&"13 12"!# !'"! F!
12314 Year
>ystolic ##2"#'( #'&"#(3 #(2"#&( F#&(
.iastolic 23"12 11"!3 !2"! F#
15318 Year
>ystolic ##!"#'2 #'1"#&# #&'"#& F#&
.iastolic 1$"1 !$"# '"1 F1
0Sour,e9 #odi:ed *ro# Natio!al
'eart; Lu!" ( Blood
I!titute3Betheda< M%
00Sour,e9 #odi:ed *ro# the A#eri,a!
A,ade#/ o* Pediatri,
Ma!a"e#e!t *or A+!or#al Blood Preure Readi!"
Sta"e I (Mild '/$erte!io!)
#. :epeat to confrm
'. )ssess for obesity and anxiety
(. :eview for underlying causes, including medications, underlying illnesses, pain,
etc.
&. =ealth education to include9
a. Aasic nutrition
b. 4xercise for older children and adolescents
c. Gonitor weekly at ( diCerent times within # month to confrm baseline
valuesE then monitor at routine visits.
Sta"e II a!d III (Moderate to Se1ere '/$erte!io!)
#. :epeat to confrm
'. =ealth and nutrition education
(. :efer for medical evaluation
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Core Clinical Service Guide
Section: Vital Signs
September 1, 2012
&LASSI=I&ATON AN% MANAGEMENT O= BLOO% PRESSURE =OR A%ULTS
A"e 18 a!d Older
BP
&lai:,at
io!
SBP
##'"
%BP
##'"
Ma!a"e#e!t0
0ormal H#'$ )nd H!$ #. 4ncourage lifestyle modifcations *i.e., weight
reduction, dietary sodium reduction, aerobic
physical activity, moderation of alcohol
consumption, and smoking cessation-.
'. :echeck A8 every year
8rehypertension #'$"#( ,r !$"! #. 8rescribe lifestyle modifcations.
'. 7onfrm A8 in contralateral arm.
(. :efer for medical evaluation.
>tage #
=ypertension
#&$"#3 ,r $" #. 8rescribe lifestyle modifcations.
'. 7onfrm hypertension in contralateral arm.
(. )ssess risk factors.
&. :efer for medical evaluation.
3. 8rovide or refer for medical nutrition therapy.
>tage '
=ypertension
F#2$ ,r F#$$ #. 8rescribe lifestyle modifcations.
'. 7onfrm hypertension in contralateral arm.
(. )ssess risk factors.
&. :efer for medical evaluation.
3. 8rovide or refer for medical nutrition therapy.
Sour,e9 Se1e!th Re$ort o* the >oi!t Natio!al &o##ittee o! Pre1e!tio!<
%ete,tio!< E1aluatio!< a!d Treat#e!t o* 'i"h Blood Preure (>N&?);
I)ny hypertension in a pregnant woman could signal the onset of pregnancy-induced
hypertension or other complications and should be immediately brought to the attention
of the clinical provider.
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Core Clinical Service Guide
Section: Vital Signs
September 1, 2012