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Measuring and Interpreting Vital Signs

Objectives:
Upon completion of this article, you will be able to:
1. Define the terms associated with measuring and interpreting vital signs.
2. Describe the normal and abnormal vital sign values.
3. Explain the methods of measuring a patients vital signs.

Case Study
Its about noon, and you, your partner, and an EMT student have just finished eating lunch at a
local beach front restaurant. Walking back to your ambulance, you notice several people on
the beach, standing in a circle and looking down. One of the bystanders notices you and yells,
Please, come quick! Something is wrong with this guy! The three of you run quickly to the
group. As you approach, the bystanders begin to part, and you notice a middle-aged male
lying on his back, apparently unconscious. Your partner quickly notifies dispatch of the incident
via radio and then returns to your ambulance to gather the necessary equipment. You and the
EMT student approach the man and attempt to ask him his name. When he does not respond,
you gently shake him, and the man begins to stir and opens his eyes briefly but does not
respond verbally. The patient appears to be breathing regularly and does not appear to have
any visible life-threatening injuries. The man then asks you where he is and why you are
looking at him. You attempt to reassure the patient and identify yourself, telling him you are
there to help. You then ask the man if you can check him out to make sure he is okay; he
agrees. You look at your EMT student and ask him what he thinks you should do next. He
replies in a questioning tone, Take his vital signs? You know that this answer is correct, but the student appears to be unsure. Does he truly understand
why it is important to obtain a baseline set of vitals? You decide to take this opportunity to explain how to correctly measure and interpret vital signs.

Introduction
In order to properly assess a patient, we must quickly and thoroughly gather numerous bits of information pertaining to the patients condition. The most
important information is gathered from the patients body itself. Such data is commonly known as vital signs, which when properly measured and
interpreted are the keys to effective patient assessment and treatment. In order to use this information properly, we must first establish what the patients
initial or baseline vital signs are and determine if they are within the normal ranges of a healthy person for that age group. Once this has been
accomplished, we begin to treat our patient based on our findings. Finally, we reassess the vital signs as needed; this allows us to determine whether our
treatment efforts are beneficial or need to be altered.
After you obtain a baseline set of vital signs, it is imperative that you continue to reassess them periodically. As a general rule of thumb, a stable patients
vital signs should be reassessed every fifteen minutes, while the unstable patients vital signs should be reassessed every five minutes. This article will cover
common terms associated with measuring and interpreting vital signs as well as the proper methods of measuring and interpreting a patients respiratory
rate, blood pressure, pulse rate, body temperature, pulse oxygen levels, level of consciousness, and blood sugar levels. However, it will not attempt to
address treatment issues related to abnormal findings.

Respiratory System

Youll find the definitions of


new and unfamiliar words

When measuring a patients respiratory rate, we are in effect ensuring that the patient is taking enough oxygen into his or
and phrases in the text in the
her body, which directly affects the patients oxygen saturation levels and energy production requirements of the body. We
section Common Terms
first begin by measuring a patients respiratory rate and observing the breathing rhythm/pattern. Both tasks can be
following the main text.
performed simultaneously fairly easily. Two of the easiest and most common methods of measuring a patients respiratory
rate are through touch and observation. Touch may be the easiest method but is often the least effective due to the patients ability to alter his or her
respiratory rate and breathing patterns, whether consciously or unconsciously. When obtaining a patients respiratory rate through touch, place a hand
lightly on the patients chest and count the number of times the patients chest rises for either thirty seconds or one minute. Observation is often the more
effective method of evaluating the patients respiratory rate and breathing patterns due to the patients lack of awareness to your observations; the natural
breathing pattern and respiratory rate of the patient, therefore, more accurately reflects his or her current condition. Regardless of the method used to
measure your patients respiratory rate, ensure that you record your findings. Commonly, respiratory rates are recorded as RR and then the number of
respirations. For example, a patient that completes sixteen respiratory cycles in one minute would be recorded as RR16 BPM.
Respiratory rates vary with each patient and are affected by overall health and conditioning as well as age. Simply put, there is no exact number of
respirations per minute that can be considered normal. Therefore, normal ranges have been established and are listed by age and range in the following
table.

Age
Newborn
1 Year
3 Years
5 Years
7 Years
10 Years
15 Years
Adult

Normal Respiratory Rates1


Breaths Per Minute
40-60
30-40
25-30
20-25
20-25
15-20
15-20
12-20

When counting the patients respiratory rate, consider the rhythm/pattern, depth, quality, and effort of his or her breathing. While assessing the patients
breathing rhythm/pattern, consider whether it was equal on both sides of the chest (left and right lungs) or concentrated on one side. Did both the left and
right sides of the chest expand and contract equally and simultaneously, or did one rise first and the other more slowly? While counting the number of
respirations, watch the patients breathing pattern. Is it within normal limits? If not, is it fast (tachypnea), slow (bradypnea), or nonexistent (apnea)? Keep
in mind that certain conditions, such as a high fever, fear, pain, hypoxia, acidosis, alkalosis, and stimulant use (cocaine, methamphetamine, caffeine, etc.),
will cause a patients respiratory rate to increase dramatically, while chronic depression, depressants (alcohol, Diazepam, etc.), and narcotic drug use
(heroin, other opiates, etc.), whether naturally occurring or synthetic, will cause the patients respiratory rate to slow well below the normal range or even
stop altogether.
Evaluate the depth of respirations. Does the patients chest wall appear to be rising and falling appropriately? Is it moving normally, and does it appear to
be within normal ranges, or is the movement excessive (deep) or limited (shallow)? Remain observant for other abnormal respiratory patterns, such as
hyperpnea, Cheyne-Stokes, Biots, Kussmauls, apneustic, and agonal breathing patterns, which are indicative of both medical and traumatic causes.
Additionally, you should remain alert for several modified forms of respiration, such as coughing, sneezing, hiccoughing, sighs, and yawns. While the
modified forms of respiration are common, they may also indicate signs of illness.

Abnormal Breathing Pattern


Hyperpnea

Abnormal Breathing Patterns2,3


Description
Common Causes
Normal respiration rate, but abnormally
Hypoxia, sepsis
deep

Kussmauls

Respiratory rate gradually increases and


then decreases, with periods of apnea
Gasping (rapid, deep breaths), with
short periods of apnea between sets
Rapid or slow, deep breathing

Apneustic

Long inhalation with short exhalations

Agonal

Slow, shallow, irregular respirations

Cheyne-Stokes
Biots (cluster respirations)

Modified Respiration
Cough
Sneeze
Hiccough
Sigh/Yawn

Anoxia, brain stem injury, cerebral


hemorrhage, stroke, heart failure
Increased intracranial pressure, stroke
Diabetic ketoacidosis
Brain injury, temporarily by certain drug
usage
Anoxia, organ failure, sepsis, death

Modified Forms of Respiration


Definition
Forceful exhalation used to remove an irritant
from the larynx, trachea, or bronchi
Forceful exhalation used to remove an irritant
from the nasal passageways
Caused by a diaphragmatic spasm
Bodys natural mechanism used to attempt to
re-inflate an improperly inflated alveoli

A patients quality of breathing may be described as normal, shallow, labored, or noisy. A patient is said to be breathing normally when there is no apparent
use of accessory muscles while either inhaling or exhaling, and the depth of the breaths appear to be within normal ranges. Shallow breathing is observed
when a patients chest wall moves only slightly; often, shallow breathing is accompanied by tachypnea and has the appearance of panting or
hyperventilation. Remain alert for abnormal or noisy breathing; abnormal sounds can be heard either on inspiration or expiration. These sounds include
crowing, gurgling, snoring, stridor, or wheezing.

Sounds
Crowing

Gurgling (coarse crackles)


Snoring
Stridor
Wheezing

Noisy, Abnormal Breath Sounds4.5


Description
Common Causes
During both inhalation and exhalation
Edema and/or foreign body obstruction of
(however, most obvious during
the upper airway
exhalation)
A low-pitched, loud, bubbling or gurgling Pulmonary edema, pneumonia, and
sound during and continuing into the first terminal illness, with a depressed cough
part of expiration
reflex associated with the upper airways
Gurgling, growl-like sound
Partially obstructed upper airway
High-pitched, harsh sound heard on
Upper airway obstruction
inspiration
Whistling sound heard during both
Brochoconstriction, foreign body
inhalation and exhalation (however,
obstruction of the airway, and edema
most obvious during exhalation)
within the airway

Additionally, you should asses your patients respirations for effort. How much work does it take for the patient to breathe? Breathing is normally a simple
process and requires little to no work; however, at times, a patients suffering from one form of respiratory distress or another may actually require work at
taking enough air into the lungs with each breath. This is known as labored breathing and is apparent by the use of accessory muscles, such as the
sternocleido mastoid, the scalene muscles, and the pectoralis minor muscles. Many times, you may able to identify a patient in respiratory distress in the
first few seconds of your interaction by noting his or her speech, posture, and position. A person not in respiratory distress will normally be able to converse
with you in a normal manner and in complete sentences without stopping to catch his or her breath. A healthy patient, depending on his or her complaint,
will normally be in a normal position with an average posture. However, the patient that is in distress may appear to be anxious, restless, or have an

altered mental status. At times, he or she may have difficulty speaking more than one to two words at a time without stopping to breathe (one-to-two-word
dyspnea). You should note the patients position and posture. Is the patient sitting extremely upright and leaning forward, with the head and chin thrust in
front of the chest and the weight of the upper body placed on his or her arms and back? If so, this is known as the tripod position, or sniffing position, and
allows for easier usage of the accessory breathing muscles. It is a key indicator of respiratory distress. Often, these patients will have pursed lips and nasal
flaring as they attempt to maintain pressure within their chests. Finally, remain alert for shortness of breath or difficulty in breathing when a patient lies
down (orthopnea) or sits up (platypnea).

Blood Pressure
Blood pressure is an important measure of the force that is being exerted on the walls of the blood vessels and when properly interpreted provides
important clues as to whether or not the patients cardiac system is functioning properly. Blood pressure is recorded as two measurements, the systolic and
diastolic, and is recorded in millimeters of mercury, which is written as mmHg. The systolic blood pressure is the first number recorded and is the higher of
the two; it indicates the peak pressure or force the heart places on the walls of the blood vessels as the blood is pumped through the body with each
heartbeat. A normal, healthy adults systolic blood pressure is in the range of 120 mmHg. The diastolic pressure is the second, lower number and indicates
the level of lowest pressure the blood places on the walls of the blood vessels when the heart is relaxed between beats. A normal healthy adults diastolic
blood pressure is in the range of 80 mmHg. Therefore, a typical patients blood pressure should be in the range of 120/80 mmHg.
When noting the patients blood pressure, document which location was used as well as the patients position sitting, prone, or standing. Also, you may
take the patients pulse pressure as needed. The pulse pressure is the difference between the systolic and diastolic blood pressures measured. (Note: When
obtaining the normal blood pressure range for children under three years old, use this formula: 80 + (age X 2) = normal systolic blood pressure for that
age, +/- 10 mmHg; dividing normal systolic blood pressure number by 2/3 = normal diastolic blood pressure.)
Blood pressure is commonly obtained via the standard sphygmomanometer (blood pressure cuff) and stethoscope or, in emergency situations, by palpation.
The blood pressure cuff is constructed with an inflatable bladder enclosed in an outer nylon covering that is fastened and secured around a patients arm or
leg via hook and loop fasteners and has a small rubber hand pump (bulb) with two tubes. The pump has an adjustable valve to allow air to enter or exit
from one of the tubes but enables the pressure to build within the bladder. The first tube then runs from the pump into the bladder. As the air enters the
bladder, it moves into the second tube, which is connected to a calibrated pressure gauge that displays the pressure within the bladder in millimeters of
mercury or mmHg. Blood pressure cuffs come in three sizes: pediatric, adult, and extra large. A properly sized cuff will cover two-thirds of the patients
upper arm. Ensure that you utilize a properly sized cuff to determine valid blood pressure measurements. A cuff that is too large may provide false lower
readings while a cuff that is too small may provide readings that are too high. Note that the pediatric cuff may be used for very small adults and the extra
large cuff may be used if you must attempt to measure the patients blood pressure via his or her thigh. When attempting to measure the patients blood
pressure from the thigh, ensure that the cuff is approximately 40 percent of the circumference of the patients thigh. Additionally, digital
sphygmomanometers are available but may not be as accurate as manual sphygmomanometers.
The stethoscope is used to amplify the sounds of the patients blood rushing through the blood vessels. At times it may be difficult to auscultate the taps and
thumps associated with measuring blood pressure, and you may need to rely on watching the pressure gauge to obtain an accurate reading.
When measuring a patients blood pressure:
1. Identify the site that you are going to use to obtain the patients blood pressure. The most common area is an arm; however, should both arms be
injured, or if the cuff is too large, you may utilize the patients thigh. At times, you may encounter a morbidly obese patient, and you may attempt to
use the patients forearm. Do not take a patients blood pressure on an injured extremity, an arm that has an established IV or shunt, or on the at-risk
arm of a woman who has had a mastectomy. If they have had breast cancer in both breasts, blood pressure should be taken on the thigh.
2. Remove clothing that covers the site that you are attempting to use. While it is possible with practice to leave light clothing on the site and still obtain
the patients blood pressure, it may not be accurate and is not recommended.
3. Measure the patient to ensure that you are using the properly sized cuff.
4. When using the arm, palpate the brachial artery and place the lower edge of the cuff one inch above the elbow. When using the thigh, palpate the
popliteal artery and place the cuff mid-thigh. When using the forearm, palpate the radial artery and place the cuff mid-forearm. While placing the cuff,
ensure that the center of the cuff is placed directly over the artery (note that the center is normally marked with a line or an arrow).

5. With the cuff in place, make sure that the pressure gauge is where you can read it easily and that the tubes are free of the cuff itself.
6. Place your stethoscope over the artery that you are using, ensuring that you apply light pressure so that you are able to hear the sounds of the blood
flowing through the artery. (Make sure that you do not place your fingers or thumb over the bell of the stethoscope, as this will interfere with its ability
to amplify sounds.)
7. Ensure that the valve near the pump is closed, and then inflate the cuff to approximately 30 mmHg above the point the pulse disappears or 180
mmHg, whichever is lower.
8. Slowly release the valve so that the needle within the pressure gauge falls at a rate of 2 to 3 mmHg per second.
9. As the needle falls slowly, it will begin to bounce as blood begins to spurt through the artery; simultaneously, you will hear Korotkoff sounds (snapping
or tapping). The first sound is the patients systolic blood pressure.
10. Continue to release the pressure at the same rate until you begin to hear a slight rushing and/or thumping sound as blood begins to flow more freely
through the patients arteries. Once this rushing and/or thumping sound is barely audible or disappears completely, you can note the patients diastolic
blood pressure.
11. Release the valve completely, and remove the cuff.
12. If you were unable to obtain the patients blood pressure, let the patient relax for about a minute, allowing the blood pressure to renormalize, and then
attempt to take it again.

Palpation
In emergency situations, you can obtain minimum systolic blood pressure without any equipment by palpating three locations: the carotid artery, the radial
artery, and the femoral artery. If you can feel a patients carotid pulse, then the patient has a minimum systolic blood pressure of 60 mmHg; if you are able
to feel the patients radial pulse, then the patient has a minimum blood pressure of 80mmHg. Similarly, if you are able to feel a femoral pulse, the patients
systolic blood pressure is at least 70mmHg. Diastolic blood pressures cannot be measured by palpation; therefore, blood pressures obtained by palpation
are annotated as systolic/P.
Now that we have obtained the patients blood pressure, we must determine what is normal. Like the vital signs, normal depends on the patients age,
health, genetics, conditioning, mental state, and even diet. It is not uncommon to find a twenty-two-year-old who is athletic with a blood pressure
somewhere near 100/60 mmHg or a sixty-two-year-old who lives a sedentary lifestyle with a blood pressure of 160/100 mmHg. While both are abnormal
for the population in general, they are perfectly normal for these patients.

Age
Newborn
1 Year
3 Years
5 Years
7 Years
10 Years
15 Years
Adult

Normal Blood Pressures by Age1


Systolic/Diastolic Blood Pressures
80/40 mmHg
82/44 mmHg
86/50 mmHg
90/52 mmHg
94/54 mmHg
100/60 mmHg
110/64 mmHg
120/80 mmHg

Abnormal Blood Pressure Findings


While not everyones blood pressure will be the same, and it can be hard to determine what is normal, there are some general guidelines for abnormal
blood pressures. A high systolic blood pressure indicates an increased level of stress on the blood vessels when the heart is attempting to pump blood into
the bloodstream, while a high diastolic blood pressure indicates that the blood vessels have only a minimal chance to relax between heartbeats. Increased
blood pressure may indicate a traumatic injury to the head or a medical condition such as atherosclerosis. However, occasional high blood pressure is
common, especially if the patient is anxious, nervous, or has recently exercised or eaten. Often, seeing a medical professional, such as a doctor, nurse, or

paramedic, may cause the patients stress level to increase significantly and cause the blood pressure to rise for a short period of time. This is commonly
referred to as white coat syndrome. It should be noted that a significant long-term increase in blood pressure may cause the blood vessels to rupture.
Slightly lower than normal blood pressure may indicate a significant loss of blood or bodily fluids, decreased cardiac function, or loss of vascular tone, while
a significant decrease in blood pressure indicates decompensated shock.
Abnormal Blood Pressures Findings
Abnormal Blood Pressures Findings
Common Causes
Cardiovascular disease, certain drugs such as
Hypertension
stimulants, head injuries, genetics, and obesity
Certain drugs such as depressants, poisoning, shock,
Hypotension
and severe head injuries
Cardiac tamponade, heart failure, tension,
Narrowed pulse pressure
pneumothorax, and shock
Fever, hot weather, exercise, anxiety, anemia,
Widened pulse pressure
pregnancy, cardiovascular disorders, and increased
intracranial pressure
Hypovolemia; some drugs, such as diuretics, calcium
channel blockers, angiotensin-converting enzyme
Orthostatic hypotension
(ACE) inhibitors, angiotensin II receptor blockers,
nitrates, and beta blockers

Pulse
The pulse rate is an indicator that is used to determine whether a patients cardiac and circulatory systems are functioning within normal ranges. The pulse
that we are able to feel is a result of the pressure wave that occurs as blood is forced through the arteries and the walls of the arteries expand and contract.
A patients pulse is most easily felt at a site where an artery is close to the surface of the skin and near a firm structure, such as a bone, muscle, or solid
organ; these are known as pulse points. The three easiest and most common locations to obtain a patients pulse rate are the carotid artery (the neck), the
radial artery (the wrist), and the posterior tibial artery (the ankle). However, the brachial, ulnar, femoral, and dorsalis pedis arteries may be used as well.
(A word of caution: Should you attempt to palpate a patients carotid pulse, ensure that you apply firm pressure to only one side of the neck and remain
alert for any change in mental status).
When attempting to take an infants or small childs pulse rate, it is often difficult to palpate their carotid and radial pulses; therefore, the brachial artery is
often used. Commonly, a patients pulse rate is recorded as P-80 BPM. To measure a patients pulse rate, first determine if he or she is responsive or
unresponsive. A responsive patients pulse rate is most commonly taken at the radial artery in an uninjured arm while the patient is supine or seated. If the
patient has sustained injuries to both arms, you may utilize other pulse points as needed. The unresponsive patients pulse is commonly taken at the carotid
artery. When attempting to take the patients pulse, ensure that you apply firm, even pressure with the fingertips of your first two fingers until you feel
pulsations. Additionally, ensure that you do not attempt to use your thumb to palpate the patients pulse, as your own pulse will interfere with your
measurement. At times, you may need to adjust the position of your fingers to be able to palpate the patients pulse. Make sure that you are able to
actually feel the pulsations and have not completely stopped the blood from flowing.
When assessing an infants or small childs pulse rate, place him or her supine and then gently raise the arm above his or her head and press firmly on the
brachial artery. Next, palpate the pulse point for thirty seconds and then multiply the results by two to obtain the one-minute pulse rate, or simply count the
pulsations for one minute and record your findings. A normal healthy adults pulse rate is between 60 and 100 beats per minute; however, a patient in
excellent physical condition may have a lower than normal pulse rate. As with most vital signs, the normal range changes with age.

Age
Newborn

Normal Pulse Rates by Age1


Range
120-160 BPM

1 Year
3 Years
5-10 Years
15 Years
Adult

80-140 BPM
80-120 BPM
70-115
70-90 BPM
60-100 BPM

While you are counting the patients pulse rate, you will also need to evaluate the pulse for strength and regularity. When assessing the strength of a
patients pulse, ask yourself whether it feels normal or is more rapid and/or stronger than normal. If its the latter, this is known as a bounding pulse rate.
Many times, you are able to observe a patients bounding pulse rate in the carotid artery, as the artery visibly pulsates similar to that of an athlete who
exerts himself or herself. At times, you may feel a light, fine pulse that is almost impalpable; this is known as a thready pulse. Next, you will need to assess
the patients pulse for regularity. Is the patients pulse rate regular or irregular? A normal healthy adults pulse can be felt at regular intervals and can even
seem to be felt at predictable intervals. At times, you may find that a patients pulse has varying intervals. When this is found, the patients pulse rate is
said to be irregular. At times, you will find that a patient has a faster (tachycardic) or slower (bradycardic) than normal pulse rate. A patients pulse rate is
recorded as the number of beats per minute, strength, and regularity. So if you were able to feel 80 pulsations in one minute at regular intervals, it would
be recorded as P-80 BPM strong/regular.

Abnormal Pulse Rate Findings


While there is no exact normal rate for most vital signs, pulse rates have a normal range by age group. Should you come into contact with a patient that
has a pulse rate outside the normal range, it is considered an abnormal finding. A faster than normal pulse rate is known as tachycardia and is commonly
caused by respiratory distress, certain drugs such as stimulants, fear, pain, fever, hypoxia, hypovolemia, shock, and dysrhythmias. A slower than normal
pulse rate is known as bradycardia; it is commonly caused by opiates, head injuries, hypoxia, hypothermia, and certain drugs such as depressants. You will
also find that a patients pulse may be bounding, thready, or irregular. A bounding pulse rate may indicate hypertension, increased intra-cranial pressure, or
heat stroke, while a thready pulse may be caused by congestive heart failure, hypovolemia, or shock. Patients with an irregular pulse may be suffering from
cardiac dysrhythmias and must be evaluated further.

Abnormal Pulse Rates


Bradycardia
Tachycardia
Irregular
Weak
Bounding

Abnormal Pulse Rates1


Common Causes
Certain drugs such as depressants and opiates, head
injuries, hypoxia, and hypothermia
Respiratory distress, certain drugs such as stimulants,
fear, pain, fever, hypoxia, hypovolemia, shock, and
dysrhythmias
Dysrhythmias
Congestive heart failure, hypovolemia, shock
Hypertension, increased intracranial pressure, and
heat stroke

Body Temperature
Body temperature is a key indicator of health in a patient. By simply obtaining a patients temperature and determining if it is within normal ranges, you are
able to gather important facts in regards to possible infections, medical conditions, drug usage, and environmental injuries. The normal healthy patients
body temperature should be within plus or minus one degree of 98.6F. While it is common for a persons body temperature to change throughout the day, it
will generally remain within this range. Anything outside of this range should be considered abnormal. In emergency situations, quickly inspect the patient
for signs of abnormal body temperature. Place the back of your gloved hand on the patients forehead and attempt to evaluate his or her external skin
temperature; this will provide you with important clues that will aid you in your patient assessment. Is he or she sweating or shivering? Is the environment
hot or cold? Keep in mind that a normal patient should not normally be sweating unless exposed to high temperatures or exertion. The skin should feel dry

and slightly warm to the touch.


As time permits, we will need to obtain a more accurate reading of the patients body temperature. You are probably familiar with the four most common
methods: the mercury-filled glass thermometer, the disposable plastic strip thermometer, the electronic thermometer, and the digital ear thermometer.
While mercury-filled glass thermometers and disposable plastic strip thermometers are not commonly used by emergency responders, we must be aware
that they are still used by the public. Mercury-filled thermometers are a non-disposable, small glass or plastic tube (casing) filled with mercury, which are
slowly being phased out. The major issue with these thermometers is that should a casing break, the mercury can leak out and become deadly if ingested.
Additionally, many of these thermometers are difficult to read, resulting in invalid readings. Next, we have the disposable plastic strip thermometer, which is
a small piece of plastic with a color-changing strip attached to it that is designed to be placed on the forehead to obtain a reading. While they are extremely
easy to use and read, they are unreliable and inaccurate and are not recommended for medical use. Both electronic thermometers and digital ear
thermometers are widely used by emergency responders due to their proven reliability, quickness, and accuracy. Electronic thermometers use probes that
are attached to the tip to read the patients bodily temperature, which is displayed on an LED screen. Digital ear thermometers use an infrared light in the
ear canal to measure the bodys internal temperature, which is displayed on an LED screen. Common locations used to obtain a patients body temperature
are listed in the following table.
Body Temperature Accuracy Table

Location

Mercury-filled
Glass
Thermometer
Accuracy

Disposable
Plastic
Thermometer
Accuracy

Electronic
Thermometer
Accuracy

Digital Ear
Thermometer
Accuracy

Forehead

N/A

LOW

N/A

N/A

Ear

N/A

N/A

N/A

HIGH

Oral

MODERATE

N/A

HIGH

N/A

Axillary

LOW

N/A

LOW

N/A

Rectum

HIGH

N/A

HIGH

N/A

Each thermometer is slightly different, and you must ensure that you review the operators manual prior to use. Most mercury-filled glass thermometers
and electronic thermometers must remain in their recommended locations for up to three minutes prior to obtaining an accurate reading. The electronic
thermometer will often beep to signal that it has obtained the body temperature. Should you attempt to obtain a patients temperature axillary (under the
patients armpit), you may need to leave the thermometer in place for up to five minutes. The disposable plastic thermometers are often left in place for
one to three minutes, and the digital ear thermometers can obtain an accurate body temperature within one second when properly used. Once obtained,
you should find that the average healthy adults body temperature is within plus or minus one degrees of 98.6F. However, a persons temperature commonly
changes from body location to body location as well as from time to time. The age and overall health of your patient will affect the body temperature as
well.
Average Body Temperature6
Age Group

In Fahrenheit

Less than 3 months

99.4

3 months to 1 yr

99.6

1-5 yrs

99.2

5-13 yrs

98.2

Over 13 yrs

98.6

Rectal temperatures may be one degree higher than oral temperatures, while axillary temperatures may one degree lower.

Abnormal Body Temperature and Common Causes


While the normal body temperature is said to be 98.6 F, the normal range is actually 97.6F to 99.6F. We will first look at high temperatures, commonly
known as fevers. The medical term for a fever is pyrexia, which is defined as any body temperature above 99.6F. A fever is a symptom of an illness that is
commonly caused by either a viral or bacterial infection, but it can also be caused by toxins such as certain drugs, cancers, or autoimmune diseases. It
should be noted that if a patient is exposed to extreme heat or overexertion, that individual is in danger of developing hyperthermia and should be treated
quickly to avoid disastrous consequences. Often, patients with increased body temperatures will be warm or hot to the touch and have a flushed skin color.
Patients with higher than normal body temperatures may perspire and/or remove their clothing inappropriately in an attempt to cool their bodies. A
low-grade temperature between 99.7F and 101.0F may indicate pneumonia, the common cold, a mild infection, or even drug usage, such as a central
nervous system stimulant or similar drugs. A mid-grade temperature between 101.0F and 104.0F may indicate a more severe infection or other medical
issue. It is not uncommon to find that influenza sufferers have body temperatures as high as 104.0F.7 A high fever is indicated above 104.0F and may be the
result of brain damage, cancer, or an uncontrolled infection. Should a patients internal temperature reach 107.6F or higher, brain damage and death will
quickly follow unless emergency treatment is begun.
In healthy adults, anything below 97.6F is considered abnormal. As the body continues to cool, hypothermia may set in. Hypothermia is commonly defined
as a drop in a bodys core temperature to below 95F. Hypothermia may be the result a patients body being exposed to cold temperatures, normally below
70F. Hypothermia may be hastened by wind; heat loss due to prolonged lying or sitting on a cold surface or immersion in cold water; a medical condition,
such as hypothyroidism, uremia, cardiac arrest, diabetic ketoacidosis, or other disease; and certain drugs, such as narcotics, central nervous system
depressants, or alcohol. Patients suffering from low body temperatures often present with a cold or cool exterior skin temperature, possibly bluish skin, and,
in severe cases, confusion and difficulty walking. Should a patients internal body temperature drop below 96F, many thermometers will not register a body
temperature, and treatment to attempt to re-warm should begin. Patients with an extremely low-core temperature may appear to be deceased, but with
appropriate treatment, they can recover.1

Oxygenation Levels
Commonly called the fifth vital sign, pulse oxygenation provides the emergency responders with vital baseline information regarding the level of oxygen in
the circulating arterial blood supply. Additionally, pulse oximetry allows responders to quickly assess if their treatment efforts are effective and allows for
redirection of efforts as needed. Assessing a patients pulse oxygenation level is accomplished by the use of a pulse oximeter. Pulse oximeters come in
numerous designs. Among the most commonly found in emergency settings are a small, non-disposable clip-like device containing two separate sides, each
of which has a small diode (probe) that emits a red and infrared light through a thin area of the body, such as a fingertip or earlobe; and a small, Band-Aid
sized disposable adhesive or hook and loop strip with two sides, each with a small diode, that may be attached to a fingertip, earlobe, or, in the event of a
small child, around the foot.
Once the pulse oximeter is attached, it will send the red and infrared lights through the area that it is attached to and measure the change in light waves as
they pass from one diode through the patients body and bloodstream, where they are altered slightly due to the oxygen molecules, and then to the other
diode, resulting in the pulse oxygen level. Attempt to ensure that the area that you wish to place the pulse oximeter is generally free of dirt, grease, and
oils; additionally, should the patient have nail-polished fingertips, remove the nail polish or select another site. Although a pulse oximetry is unable to
determine if the patients body is effectively metabolizing the oxygen molecules, it does provide the level of oxygen within the bloodstream and therefore
helps determine the need for supplemental oxygen. Your oxygen saturation findings are recorded as SaO2. The normal healthy adults oxygen saturation
levels should be 96 percent to 100 percent at normal room air. Should the patients oxygen saturation level be below 96 percent, you must consider the
need for supplemental oxygen, and should the SaO2 level drop below 90 percent, respiratory failure may be imminent.8

Capnography
Capnography has been called the vital sign of ventilation. By reading the amount of carbon dioxide in a patients exhaled breath, excess or a lack of carbon
dioxide can be detected immediately. Carbon dioxide levels directly affect the patients ventilation status, while indirectly affecting the circulation and
certain metabolic processes of the body. An article in the American Journal of Medical Electronics shows evidence of the use of capno processes as early as
1962.22 Much like other technologies, capnography has advanced to where it is now portable, making it useful for pre-hospital use.10
Definitions:11
Capnogramthe graphical representation, or waveform, of ETCO2.
Capnographythe measurement and numerical display of ETCO2.
Capnometrythe numeric measurement of CO2.
End-tidal carbon dioxide (ETCO2)the maximum concentration of exhaled carbon dioxide. Maximum concentration indicates the amount of carbon
dioxide in the bottom of the lungs, measured at the end of an exhalation. This is measured in percentages.
PETCO2 Partial pressure (amount) of end-tidal carbon dioxide. This is measured in mmHg.
PaCO2Partial pressure (amount) of carbon dioxide in arterial blood gases.
In the blood, carbon dioxide and oxygen, along with other gases, are measured as partial pressures of the total gas volume. Capnography measures the
partial pressure of carbon dioxide as it leaves the body via exhalation.11
Capnography does not provide the exact same information as an arterial blood gas (ABG) reading. In healthy patients, PETCO2 (capnography) and PaCO2
(from arterial blood gases) vary by 2 to 7% without the needle stick and in real time (i.e., as the changes are happening). In unhealthy patients, the
difference can vary greatly. Still, this makes capnography perfect for in-hospital telemetry and for bouncing down a highway in an ambulance. The PaCO2 in
a healthy adult should range between 35 to 45 mmHg. This correlates to an ETCO2 reading of 5 to 6%.12
Capnography is useful for the following actions:12
Detecting the correct placement of endotracheal tubes
Recognizing the disconnection of a patient from mechanical ventilation
Identifying the patients attempts to breathe while paralyzed
Assessing the effectiveness of CPR; carbon dioxide may be absent in the lungs if CPR compressions are not effective. (Note: A high dose of adrenaline
nulls this reading.)
Early detection of malignant hyperpyrexia, especially after ingestion of the drug Ecstasy
Routine monitoring of the adequacy of ventilation and the effects of intermittent positive pressure ventilation (IPPV) and CPAP
Early detection of hypoventilation and hyperventilation
Determining acidosis
Capnography can prove to be a valuable diagnostic tool for recognizing the following symptoms:12
Apneaindicated by a flatline waveform, no breath sounds, and no effort to breath.
Increased airway obstructionindicated by a flatline waveform, with a soundless effort to breath and response to airway maneuvers.
Bronchospasm indicated by a sloped waveform, with increased CO2.
Laryngospasmindicated by a flatline waveform; airway movement is possible but only via positive pressure ventilations (BVM, ventilator).

How it Works
Capnography is the continuous analysis and recording of carbon dioxide concentrations in exhaled respiratory gases. As with the pulse oximeter, an infrared
light passes through the expiratory carbon dioxide and is read by a sensor. Either a spectrometer or an infrared analyzer detects (senses) the percentage of

light waves absorbed by the carbon dioxide.10


PETCO2 correlates to the partial pressure of carbon dioxide in the blood (PaCO2), but only if ventilation and perfusion are stable. If either are unstable, a
V/Q (ventilation/perfusion) mismatch occurs, and the PETCO2 and PaCO2 correlation changes, making the PETCO2 less reliable. This can occur with
hypovolemia or a pulmonary embolism.
Note: An oxygen mask may lower the reading by 10% or more.

Capnogram
The capnogram waveform begins before exhalation and ends with inspiration, meaning that breathing out comes before breathing in. It is important to note
that the referenced documentation, as well as common capnography devices, interchanges the terms PETCO2 and ETCO2.

Capnogram Waveform13
The normal capnogram waveform is nearly rectangular, with each section representing the amount of CO2 in the exhalation process. Exhalation begins with
alveolar emptying of CO2, which then mixes with dead-space gases. The plateau at the top represents the rich mixture of CO2 released by the alveoli. The
peak before the drop represents ETCO2, with the quick drop representing inhalation.
An increase in height in the waveform indicates an increase in ETCO2, while a drop in the height indicates a drop in ETCO2 levels. If ETCO2 readings are
elevated, then CO2 levels are elevated; if ETCO2 levels are low, then the body is not producing adequate amounts of CO2.

Intubation
Capnography is a reliable way to insure endotracheal (ET) tube placement.14,15

Capnogram Showing an ET Tube in the Esophogus16


If a patient is intubated properly, with the tube through the vocal cords, a normal waveform will appear on the capnogram. Should the tube becomes
dislodged, the waveform changes immediately, allowing for timely correction.
An intubated patient who is not adequately paralyzed or is completely comatose may try to breathe around the ET tube. The movement of the diaphragm is
indicated by a notch or a curare cleft in the waveform.

Capnogram in Real Time17


Note: A cleft can also indicate a partial disconnection of a mainstream sensor. ALWAYS check the equipment before a determination is made.

Airway Blockages
Capnography can detect an obstructed or partially obstructed airway. Airway blockages release CO2 at a slower rate, causing a slope in the waveform. This
type of capnogram waveform is loosely identified as a shark fin. The sharper the slope, the more severe the airway occlusion.

Capnogram Shark Fin Waveform18

Hyperventilation
Since the width of the waveform represents the expiratory time, faster ventilations will compress the waveform, while slower ventilations will widen the
waveform.

Capnogram Hyperventilation Waveform19


Hyperventilation lowers ETCO2 values. Since ETCO2 relates closely to the carbon dioxide levels in the blood, low levels may also indicate metabolism
failure. Low carbon dioxide is a state of respiratory alkalosis, which can result in metabolic acidosis.

Hypoventilation
An ETCO2 reading of less than 35 mmHg equals hyperventilation/hypocapnia (alkaline), while an ETCO2 greater than 45 mmHg represents hypoventilation /
hypercapnia (acid). Too much CO2 means too little oxygen.

Capnogram Hypoventilation Waveform20


Other factors that cause an increase in ETCO2 include medications, rising body temperature, CO2 absorption, foreign body airway obstruction, and reactive
airway disease. Responses from ACLS medications may cause changes in the capnogram.21

Errors
Like other machines and electronics, capnography units can fail or have errors. Always check the patency of the circuit before making a decision based upon
capnography. Use this in conjunction with other assessment tools. Remember to treat the patient, not the monitor.

Additional Vital Signs That Should Be Measured


While the next two topics, level of consciousness and blood glucose levels, are not traditionally known as vital signs, they can provide even more keys to a
patients condition and, when used properly, will greatly assist you in the assessment and treatment of your patients.

Level of Consciousness
Perhaps the most important considerations are level of consciousness and mental status. These are normally evaluated within the first few seconds of
contact with your patient. A patients level of consciousness is assessed by evaluating responsiveness to you, while mental status is assessed by determining
the patients orientation to his or her surroundings and events.9 An unresponsive or disoriented patient may be experiencing a severe life-threatening
condition and needs immediate treatment time is of utmost importance. Responsiveness is evaluated by utilizing the simple mnemonic of AVPU.
A Alert, the patient is alert and awake (eyes are open) and is able to respond to questions. The patient is
alert, but may not be orientated to person, place, time, and event.
V Verbal, the patient is able to respond to verbal stimulus when spoken to (i.e. the patients eyes may be
closed but may open when asked questions, or the patient may respond inappropriately).
P Pain, if the patient is not alert and does not respond to verbal stimuli, attempt to obtain a reaction to
pain from your patient. Common methods for adults are the sternal rub, pinching the earlobes or
fingertips. Does the patient awaken or moan? Or does he or she attempt to stop the painful stimuli, such
as trying to move or push the object away? Was the movement intentional or reactionary? If the patient
responds, then he or she is responsive to pain.
U Unresponsive, the patient is non-responsive to all attempts to elicit a response.

Abnormal Level of Consciousness Findings


A normal healthy adult will be alert, awake, and will respond easily to questions, while patients suffering from illness or traumatic injuries may not be able
to do so. Abnormal findings may include: extreme drowsiness, stupor, obtundation, or coma. Should your patient not respond to you verbally, you will need
to attempt to assess the level of consciousness further. First, begin by gently shaking the patient; if this fails, attempt to elicit a response by pinching the
patients earlobe or fingertips. Should this also fail, you can attempt to remove the patients shoes, if necessary, and run an object such as a pen cap over
the bottom of his or her foot. If this attempt fails, try a sternal rub. If the patient awakens or attempts to stop the painful stimuli by withdrawing or
attempting to push the offending hand or object away, he or she is responsive to pain. Note what action caused a response, if any, and if the movement
appeared to be either voluntary or involuntary. Common causes of altered levels of consciousness include: head trauma, hypoxemia, hypoglycemia, stroke,
cardiac failure, and both legal and illegal drug use.
As time allows, consider utilizing the Glasgow Coma Scale to more fully assess a patients level of consciousness. A GCS score of 13 to 15 indicates a mild
head injury. A score of 9 to 12 indicates a moderate head injury. A score of 8 or lower indicates a severe head injury.
Glasgow Coma Scale
Criteria/Score
Eye Opening
4
3
2
1
Verbal Response
5
4
3
2
1
Motor Response
6
5
4
3
2
1

Adult

Child

Spontaneous
Responds to voice
Responds to pain
None

Spontaneous
Responds to voice
Responds to pain
None

Oriented
Confused
Inappropriate
Incomprehensible
None

Appears oriented
Irritable cry
Cries to pain
Grunts/moans to pain
None

Obeys commands
Localized pain
Withdrawals from pain
Flexation response to pain
Extension response to pain
None

Normal movement
Withdrawals from pain
Withdrawals from pain
Flexation response to pain
Extension response to pain
None

Orientation is evaluated as you obtain the patients history and includes person, place, time, and event. Simply ask the patient the following questions:
1.
2.
3.
4.

What is your name?


Where are you?
What is the current date and time?
What happened?

Phrase your questions in an understandable format, and assess a patients orientation in relation to his or her age. You should not expect most
four-year-olds to tell you what time it is; however, the average fourteen-year-old should be able to tell you an approximate time. A fully alert and oriented
patient is documented as AOX4. A patient that is oriented to only two of the four questions would be documented as AOX2, and then you would specify your
findings in the patient report.

Blood Glucose Levels


Blood glucose levels (or blood sugar levels) refer to the amount of glucose that is within the patients bloodstream and available for the bodys cells to use
as energy. As emergency responders, from time to time you may come into contact with patients who are acting abnormally for no apparent reason; they
may be combative or comatose or just in a stupor. When facing a patient like this, ensure that you are able to approach him or her safely, and attempt to
look for signs of medical alert jewelry, medications, or other items, such as a glucometer, that may indicate an illness such as diabetes or possibly a
psychological-related problem. If you cannot approach the patient safely, wait for law enforcement backup to assist. Once you have made contact with the
patient safely, you should attempt to obtain the patients blood glucose levels. Obtaining a blood glucose level is a fairly simple process that takes less than
a minute. Below is a general guideline for the use of a glucometer. Follow the glucometer manufacturers instructions and all local medical protocols prior to
use.
1. Ensure that the glucometer is in working order in accordance with the manufacturers directions, and ensure that the units batteries are fresh and will
not fail on you when needed.
2. Utilize all body substance isolation protocols necessary, and identify the site from which you wish to obtain a blood sample; this is generally the palmar
side of the tip of one of the patients fingers. In infants, you should avoid the fingers and utilize the tip of a toe or heel to avoid injury. Do not use a site
that has a recent puncture wound or other damage.
3. Clean the site with an alcohol preparation pad and allow the site to dry.
4. Remove the lancet and test strip from their packaging, and insert the lancet into the withdrawal site; make sure that the lancet has entered the skin at
a sufficient depth to allow a blood drop to form. Once that happens, remove the lancet.
5. As needed, milk the finger to create a blood drop large enough to be placed on the test strip as directed in the manufacturers instructions.
6. Insert the test strip into the glucometer and wait for a reading.
7. Apply pressure to the withdrawal site and place a small bandage over it, as needed.
8. Record your findings as milligrams per deciliter. For example, if the test result returns a number of 100, it would be recorded as 100 mg/dl.
Now that we have discussed the common way to obtain a blood glucose level, we must know what the normal blood glucose level is for a healthy adult.
First, you must understand that as with most vital signs there is not an exact measurement for the normal level of blood glucose, as the blood glucose
level alters with diet, exercise, and how recently the patient last ate. There is, however, a normal range based on a patients age.

Age Group
Infant
Under 2 Yrs
2-50 Yrs
Over 50 Yrs

Average Blood Glucose Levels


Milligrams Per Deciliter (mg/dl)
40-90
60-100
70-105
Up to 126

Abnormal Blood Glucose Findings


While assessing the patients blood glucose, remain alert for the other vital signs, as they may indicate either hypoglycemia, which is an abnormally low
blood glucose level, or hyperglycemia, which is an abnormally high blood glucose level. Findings at or below 60 mg/dl should be considered a
life-threatening emergency and treated as such. Some of the common findings associated with both hypoglycemia and hyperglycemia are found in the
following table.

Vital Signs
Respirations
Blood Pressure
Pulse Rate
Body Temperature

Abnormal Blood Glucose Levels


Hypoglycemia
Hyperglycemia
Normal to Rapid
Rapid and Deep
Normal to Low
Normal to Low
Rapid
Rapid and Weak
Pale, Moist and Clammy
Warm and Dry

Level of Consciousness
Breath Odor

Altered
Normal

Varies
Sweet and Fruity

Case Study Conclusion


As you continue to evaluate the patients mental status, you begin to quickly explain to the student that you will need to determine several key indicators of
the patients health. In order to do this, you will measure and then interpret the patients vital signs which include: respirations, blood pressure, pulse rate,
body temperature, pulse oxygen level, level of consciousness, and blood glucose level. Your partner arrives with your medical bag and you go to work, first
directing the student to monitor the patients respirations while you and your partner obtain the patients blood pressure, pulse rate, body temperature, and
pulse oxygen levels. Next, all of you compare your findings so far: RR = 26 BPM, equal and bilateral; BP = 120/80 mmHg; PR = 120 BPM regular/strong;
body temperature = 99.0F/clammy; and a pulse oxygen level of 98 percent on normal room air. When compiled with your initial findings that the patient
was unconscious and not fully alert, you suspect that the patient may be suffering from low glucose levels. You then walk your student through the proper
steps of using a glucometer to obtain the patients blood glucose level. You quickly learn that his blood glucose level is 52 mg/dl and begin immediate
treatment for hypoglycemia. The patients level of consciousness quickly improves, and after a short discussion, he agrees to go with you to the hospital for
further evaluation.

Summary
Vital signs, when properly measured and interpreted are the keys to effective patient assessment and treatment. We must first establish what the patients
initial or baseline vital signs are and determine if they are within the normal ranges of a healthy person for that age group. Once this has been
accomplished, we begin to treat our patient based on our findings. Finally, we reassess the vital signs as needed; this allows us to determine whether our
treatment efforts are beneficial or need to be altered.
Common Terms1
Before we move on to refreshing our knowledge of the proper methods of measuring vital signs and then
interpreting them, we must ensure our familiarity with common terms associated with the processes.
Apnea The lack or absence of breathing.
AVPU A memory aid that assists in determining levels of consciousness in a patient. The letters refer to the
stimulus that a patient responds to: Alert, alert to Verbal stimulus, alert to Painful stimulus, and
Unresponsive.
Biots breathing pattern An abnormal breathing pattern characterized by rapid, deep breathing (gasps) with
short pauses between groups of breaths. Among its many causes are head injuries.
Bradypnea Decreased respiratory rate.
Breathing The mechanical and passive process of taking air into the lungs.
Capnography - The monitoring of the concentration of exhaled carbon dioxide in order to determine the
adequacy of ventilation.
Cheyne-Stokes breathing pattern Gradual increase and decrease in respirations with periods of apnea. This
is commonly caused by increased intracranial pressure and/or brain stem injury.
Crackles (also known as rales) The fine, rattling breath sounds (crackling) indicative of fluids within the
smaller airways of the lungs.
Dyspnea More commonly known as shortness of breath. Some patients may be able to speak one or two
words and then need to stop to catch their breath. This is known as one-to-two-words dyspnea and is
commonly observed in emphysema patients.
Eupnea Normal respiratory (breathing) rate and pattern.
Hyperglycemia An abnormally high amount of blood glucose in the circulatory system; also known as high
blood sugar.

Hypertension Blood pressure above the normal limits. Common causes include cardiovascular disease,
certain drugs such as stimulants, a head injury, genetics, and obesity.
Hyperthermia A severe condition that occurs as a result of the bodys inability to dissipate heat. This is
commonly due to excessive exposure to heat or extreme exertion.
Hyperventilation Characterized by rapid, deep breathing and gasping resulting in a reduction of carbon
dioxide levels within the bloodstream.
Hypoglycemia An abnormally low amount of blood glucose in the circulatory system; also known as low
blood sugar.
Hypotension Blood pressure below the normal limits. Common causes include certain drugs such as
depressants, poisoning, shock, and a severe head injury.
Hypothermia A severe condition that occurs as a result of the bodys inability to regulate heat due to
excessive heat loss. This is commonly caused by excessive exposure to a cool or cold environment.
Korotkoff sounds The sounds that are heard while taking a patients blood pressure, which is caused by the
blood as it begins to flow back through the arteries. The first sound is a snapping or tapping, which indicates
the patients systolic blood pressure. The diastolic blood pressure is measured when you are no longer able
to hear the second sound, a rushing or thumping, which occurs as blood begins to flow unrestricted through
the arteries.
Kussmuals breathing pattern An abnormal breathing pattern indicated by fast, deep respirations. This is
commonly caused by renal failure, metabolic acidosis, and diabetic ketoacidosis.
Narrowed pulse pressure A difference of less than 30 mmHg between the patients systolic and diastolic
blood pressures. Common causes include cardiac tamponade, heart failure tension, pneumothorax, and
shock.
Nasal flaring The enlargement of the external nares that occurs as the patient breathes, indicative of
respiratory distress.
Obtundation A decreased level of consciousness often due to heavy drug usage.
Orthopnea The difficulty in breathing that occurs when the patient is lying down.
Orthostatic hypotension A sudden, dramatic fall in blood pressure that happens when a patient stands.
Common causes include: hypovolemia and certain drugs, such as diuretics and calcium channel blockers,
angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, nitrates, and beta
blockers.
Platypnea Shortness of breath that occurs when the patient is sitting up.
Pleural fremitus A vibration of the chest wall caused by pleural rubbing that may be felt by palpation.
Postural hypotension See orthostatic hypotension.
Pulse points Areas of the body where arteries are close to the skin and adjacent to firm structures, such as
bones, muscles, and solid organs. Examples of pulse points include: the carotid artery (in the neck); the
radial and ulnar arteries (in the wrists); the femoral artery (groin area); and the posterior tibial and dorsalis
pedis arteries (in the ankles).
Pulse pressure The difference between the systolic and diastolic blood pressures.
Pyrexia A medical term for an abnormally high body temperature, more commonly known as a fever.
Rales (also known as crackles) The fine, rattling breath sounds (crackling) indicative of fluids within the
smaller airways of the lungs.
Respiration The process that involves the distribution and use of gases, oxygen, and carbon dioxide
occurring at several levels.
Retractions The visible sinking of the chest wall with inspiration caused by the usage of the respiratory
accessory muscles. Retractions occur supraclavicularly (at the collar bone), intracostally (between the ribs),
and subcostally (below the ribs).

Rhonchi The rattling sounds heard in the larger airway associated with excessive mucus production.
Sniffing position See tripod position.
Sphygmomanometer Blood pressure cuff.
Spirometer An instrument that is used to test lung capacity and to screen patients with dyspnea.
Spontaneous respirations Respirations that are spontaneous, independent, and without effort.
Stridor A harsh, high-pitched sound heard during inspiration, often indicative of an upper airway
obstruction.
Tachypnea Increased respiratory rate.
Tracheal deviation The trachea is shifted to the left or right of midline due to air in the plural space.
Tracheal deviation during inspiration indicates a pneumothorax on that side. Movement to one side without
effect of inspiration indicates a tension pneumothorax on the opposite side due to the trachea being displaced
away from the injury. Tracheal deviation may be hard to observe in the pre-hospital setting.
Tracheal tugging A visible tightness of the neck (tracheal) area resulting from dyspnea due to foreign body
airway obstruction.
Tripod position (also known as sniffing position) A position commonly observed in a patient having difficulty
breathing. Patients will usually be sitting extremely upright and leaning forward, with the head and chin
thrust in front of the chest and the weight of their upper body placed on their arms and back.
Vital signs The key signs used to asses a patients vital functions, which include a patients respiratory rate,
blood pressure, pulse rate, body temperature, and pulse oxygenation levels as well as level of
consciousness, mental status, and blood glucose level.
Wheezing A high-pitched whistling sound caused by constriction or obstruction of the airways.
Widened pulse pressure A difference of more than 50 mmHg between the patients systolic and diastolic
blood pressures. Common causes include fever, hot weather, exercise, anxiety, anemia, pregnancy,
intracranial pressure (ICP), or certain cardiovascular disorders.
Authors Robert Provost, Barbara Power, Copyright CE Solutions. All Rights Reserved.

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