Vital Sign Measurement Across The Lifespan 1st Canadian Edition 1539369683

Vital Sign Measurement Across the Lifespan - 1st Canadian edition
Vital Sign Measurement Across the Lifespan - 1st

Canadian edition
JENNIFER L. LAPUM, MARGARET VERKUYL, WENDY GARCIA, OONA

ST-AMANT, AND ANDY TAN
Vital Sign Measurement Across the Lifespan - 1st Canadian edition by Ryerson University is licensed under a Creative Commons Attribution 4.0
International License, except where otherwise noted.
Contents
Preface 1
About the Authors 2
Content Advisory Team 3
Customization 5
Level of Organization 6
Acknowledgements: eCampusOntario 7
Part I. Chapter 1: Introduction
1. Introduction 11
2. General Points to Consider in Vital Sign Measurement 12
Part II. Chapter 2: Temperature
3. What is Temperature? 19
4. Why is Temperature Measured? 20
5. Methods of Measurement 21
6. What are Normal Temperature Ranges? 22
7. Oral Temperature 24
8. Tympanic Temperature 27
9. Axillary Temperature 30
10. Rectal Temperature 32
11. Finding the Error Activity: Tympanic Temperature 34
12. Finding the Error Activity: Tympanic Temperature – Feedback 35
13. Try it Out 37
14. Try it Out: Oral Temperature 38
15. Try it Out: Tympanic Temperature 39
16. Try it Out: Axilla Temperature 40
17. Test Yourself 41
18. Test Yourself: Answers 43
19. Test Yourself: List in the Correct Order 45
20. Test Yourself: List in the Correct Order – Answers 47
21. Chapter Summary 49
Part III. Chapter 3: Pulse and Respiration
22. What is Pulse? 53

23. Why is Pulse Measured? 56
24. What Pulse Qualities are Assessed? 58
25. Radial Pulse 60
26. Carotid Pulse 62
27. Brachial Pulse 64
28. Apical Pulse 65
29. What is Respiration? 68
30. Respiration Technique 70
31. Finding the Error Activity: Radial Pulse 72
32. Finding the Error Activity: Radial Pulse – Feedback 73
33. Finding the Error Activity: Infant Apical Pulse 75
34. Finding the Error Activity: Infant Apical Pulse – Answer 76
35. Try it Out 78
36. Try it Out: Radial Pulse and Respiration 79
37. Try it Out: Apical Pulse 80
Part IV. Chapter 4: Oxygen Saturation
43. What is Oxygen Saturation? 91

44. How is Oxygen Saturation Measured? 92
45. What are Normal Oxygen Saturation Levels? 95
46. Oxygen Saturation Technique 96
47. Finding the Error Activity 1: Pulse Oximetry 98
48. Finding the Error Activity 1: Pulse Oximetry – Feedback 99
49. Finding the Error Activity 2: Pulse Oximetry 100
50. Finding the Error Activity 2: Pulse Oximetry – Feedback 101
51. Try it Out: Pulse Oximetry 103
Part V. Chapter 5: Blood Pressure
57. What is Blood Pressure? 111

58. Why is Blood Pressure Measured? 112
59. Factors That Influence Blood Pressure 113
60. What are Normal Blood Pressure Ranges? 115
61. How is Blood Pressure Measured? 117
62. Manual Blood Pressure Measurement 123
63. What Should the Healthcare Provider Consider? 128
64. Hypertension 129
65. Hypotension 133
66. Finding the Error Activity: Blood Pressure 135
67. Finding the Error Activity: Blood Pressure – Feedback 136
68. Try it Out 137
69. Try it Out: Two-step Blood Pressure 138
70. Try it Out: One-step Blood Pressure 139
72. Test Yourself – Answers 144
Part VI. Chapter 6: Knowledge Integration
76. Knowledge Integration 153

77. Case Study 1: Adult Client 154
78. Case Study 1: Adult Client (continued) 155
81. Case Study 2: Pediatric Client 160
82. Case Study 2: Pediatric Client (continued) 161
85. Case Study 3: Pregnant Adult Client 167
86. Case Study 3: Pregnant Adult Client (continued) 168
89. Case Study 4: Older Adult Client 173
90. Case Study 4: Older Adult Client (continued) 174
93. Case Study 5: Adolescent Client 181
94. Case Study 5: Adolescent Client (continued) 185
Part VII. Chapter 7: Conclusion
95. Conclusion 189

96. Printable Flashcards 192
97. References 195
This open access textbook was developed as an introductory resource to guide best practices in vital sign
measurement. Its intended audience is students in health-related post-secondary programs as well as healthcare
providers. The project was supported and funded by eCampusOntario. This book is best viewed via the online,
pressbooks format. However, a pdf format is made available.
About eCampusOntario
eCampusOntario is a not-for-profit corporation funded by the Government of Ontario. It serves as a centre of

excellence in online and technology-enabled learning for all publicly funded colleges and universities in Ontario
and has embarked on a bold mission to widen access to post-secondary education and training in Ontario.
This textbook is part of eCampusOntario’s open textbook library, which provides free learning resources in a
wide range of subject areas. These open textbooks can be assigned by instructors for their classes and can
be downloaded by learners to electronic devices or printed. These free and open educational resources are
customizable to meet a wide range of learning needs, and we invite instructors to review and adopt the resources
for use in their courses.
Preface | 1
About the Authors
Jennifer L. Lapum, RN, PhD, MN, BScN, Associate Professor, Ryerson University, Faculty of Community Services,
Daphne Cockwell School of Nursing, Toronto, ON, Canada
Margaret Verkuyl, NP:PHC, MN, Professor, Centennial College, School of Community and Health Studies,
Toronto, ON, Canada
Wendy Garcia, RN, MS, BScN, Instructor, Ryerson University, Faculty of Community Services, Daphne Cockwell
School of Nursing, Toronto, ON, Canada
Oona St-Amant, RN, PhD, MScN, BScN, Assistant Professor, Ryerson University, Faculty of Community
Services, Daphne Cockwell School of Nursing, Toronto, ON, Canada
Andy Tan, BScN student, Ryerson University, Faculty of Community Services, Daphne Cockwell School of
Nursing, Toronto, ON, Canada
Contact person
Dr. Jennifer L. Lapum

jlapum@ryerson.ca
415-979-5000 ex. 6316
350 Victoria St.
Toronto, ON, M5B 2K3
Daphne Cockwell School of Nursing
Ryerson University
Note to Educators Using this Resource
We encourage you to use this resource and would love to hear if you have integrated it into your curriculum.
Please consider notifying Dr. Lapum if you are using it in your course and if you are: identify the healthcare
discipline and the number of students.
2 | About the Authors

Content Advisory Team
Susan Albanese Cairns, RN, MHS, BScN, Instructor, Daphne Cockwell School of Nursing, Ryerson University,
Hospital for Sick Children, Critical Care Department
Sheilagh Callahan, RN, MScN, BScN, Professor, Sally Horsfall Eaton School of Nursing, George Brown College
Jimmy Chen, RN, MScN, Professor of Nursing, School of Community and Health Studies, Centennial College
Mark Fox, RMT, BEd., Professor of Massage Therapy, Centennial College
Patricia Lee, PT, MEd, BSc, Professor of Occupational Therapist Assistant & Physiotherapist Assistant Program,
School of Community and Health Studies, Centennial College
Janet O’Connell, RN, MAEd, Professor of Nursing & Year 2 Coordinator, School of Community and Health
Studies, Centennial College
Mary Sharpe, RM, PhD, MEd, Associate Professor, Midwifery Education Program, Ryerson University
Terrence M. Yau, MD, MSc, FRCSC, Angelo & Lorenza DeGasperis Chair in Cardiovascular Surgery Research,
Director of Research, Division of Cardiovascular Surgery, University Health Network, Professor of Surgery,
University of Toronto, Attending Cardiac Surgeon, Peter Munk Cardiac Centre
Student Advisory Team
Jessica Bregstein, BScN student, Ryerson, Centennial, George Brown Collaborative Nursing Degree Program,
Ryerson University
John Edwards, RMT, BScN student, Ryerson, Centennial, George Brown Collaborative Nursing Degree Program,
Ryerson University
Jill McKinlay, BA (Hons), BScN student, Ryerson, Centennial, George Brown Collaborative Nursing Degree
Program, Ryerson University
Christopher Nguyen, BSc, BScN student, Ryerson, Centennial, George Brown Collaborative Nursing Degree
Karen Owusu, BScN student, Ryerson, Centennial, George Brown Collaborative Nursing Degree Program,
Ryerson University
Mark Pezzetta, BSc (Hons), BScN student, Ryerson, Centennial, George Brown Collaborative Nursing Degree
Rezwana Rahman, BScN student, Ryerson, Centennial, George Brown Collaborative Nursing Degree Program,
Ryerson University
Renee Shugg, BScN student, Ryerson, Centennial, George Brown Collaborative Nursing Degree Program,
Ryerson University
Andy Tan, BScN student, Ryerson, Centennial, George Brown Collaborative Nursing Degree Program, Ryerson
University
Victoria Tos, BScN student, Ryerson, Centennial, George Brown Collaborative Nursing Degree Program,
Ryerson University
Medical Artists
Paige Jones
Hilary Tang, BScN student, Ryerson, Centennial, George Brown Collaborative Nursing Degree Program,
Ryerson University
Content Advisory Team | 3

Acknowledgments
Wendy Freeman, PhD, MSc, Director, Office of e-Learning, Associate Professor, Ryerson University, Faculty of
Communication and Design, Toronto, ON, Canada
John Hajdu, Mulitmedia author and production consultant, Ryerson University, Toronto, ON, Canada
Nada Savicevic, MA Interactive Design, MArch, BSc (Eng), Instructional Designer, Office of e-Learning, Ryerson
University, Toronto, ON, Canada
Ann Ludbook, MLIS, MA, BA, Copyright and Scholarly Engagement Librarian, Ryerson University, Toronto, ON,
Canada
Sally Wilson, MLS, BA, Web Services Librarian, Ryerson University, Toronto, ON, Canada
Adam Chaboryk, IT Accessibility Specialist, Digital Media Projects, Ryerson University
4 | Content Advisory Team

Customization
This textbook is licensed under a Creative Commons Attribution 4.0 International (CC-BY) license, which means
that you are free to:
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You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.
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No warranties are given: The license may not give you all of the permissions necessary for your intended use.
For example, other rights such as publicity, privacy, or moral rights may limit how you use the material.
Attribution
Part of the content of this textbook contains material from two Open Educational Resources (OERs). The OERs
adapted include:
© Apr 10, 2017 OpenStax Anatomy and Physiology. Textbook content produced by OpenStax Anatomy and
Physiology is licensed under a Creative Commons Attribution License 4.0 license. Download for free
at http://cnx.org/contents/7c42370b-c3ad-48ac-9620-d15367b882c6@12
© 2015 British Columbia Institute of Technology (BCIT). Licensed under a Creative Commons Attribution 4.0
International License Download this book for free at http://openbccampus.ca
For information about what was used and/or changed in this adaptation, refer to the statement at the bottom
of each page where applicable.
Content that is not taken from the above two OERs should include the following attribution statement:
© 2018 Ryerson University. Licensed under a Creative Commons Attribution 4.0 International License. Vital
Sign Measurement Across the LifeSpan (1st Canadian edition) by Jennifer L. Lapum, Margaret Verkuyl, Oona
St-Amant, Wendy Garcia, Andy Tan. Download this book for free at: http://pressbooks.library.ryerson.ca/
vitalsign/
Customization | 5
Level of Organization
Chapter 1: Introduction
Chapter 2: Temperature
Chapter 3: Pulse and Respiration
Chapter 4: Oxygen Saturation
Chapter 5: Blood Pressure
Chapter 6: Knowledge Integration
Chapter 7: Conclusion
Learning Outcomes
• Define the vital signs used in healthcare

• Integrate knowledge about anatomy and physiology with vital sign measurement
• Evaluate influencing factors related to vital sign measurement
• Synthesize knowledge about various methods and techniques of vital sign measurement across
the lifespan
• Integrate knowledge about alternative methods of vital sign measurements
• Assess normal and abnormal vital sign values
• Evaluate significance of vital sign findings
• Generate best interventions based on vital sign findings
6 | Level of Organization
Acknowledgements: eCampusOntario
Share
If you adopt this book, as a core or supplemental resource, please report your adoption in order for us to
celebrate your support of students’ savings. Report your commitment at www.openlibrary.ecampusontario.ca.
We invite you to adapt this book further to meet your and your students’ needs. Please let us know if you do! If
you would like to use Pressbooks, the platform used to make this book, contact eCampusOntario for an account
using open@ecampusontario.ca.
If this text does not meet your needs, please check out our full library at www.openlibrary.ecampusontario.ca.
If you still cannot find what you are looking for, connect with colleagues and eCampusOntario to explore creating
your own open education resource (OER).
About eCampusOntario
eCampusOntario is a not-for-profit corporation funded by the Government of Ontario. It serves as a centre of

excellence in online and technology-enabled learning for all publicly funded colleges and universities in Ontario
and has embarked on a bold mission to widen access to post-secondary education and training in Ontario.
This textbook is part of eCampusOntario’s open textbook library, which provides free learning resources in a
wide range of subject areas. These open textbooks can be assigned by instructors for their classes and can be
downloaded by learners to electronic devices or printed for a low cost by our printing partner, The University of
Waterloo. These free and open educational resources are customizable to meet a wide range of learning needs,
and we invite instructors to review and adopt the resources for use in their courses.
Acknowledgements: eCampusOntario | 7
8 | Acknowledgements: eCampusOntario
PART I
CHAPTER 1: INTRODUCTION
Chapter 1: Introduction | 9
1. Introduction
The purpose of this textbook is to help you develop best practices in vital sign measurement. It will provide you
with the opportunity to read about, observe, practice, and test vital sign measurement. Boxes with helpful tips
are provided throughout the chapters:
• Technique Tips provide helpful information about measurement techniques, and

• Points to Consider highlight key points to consider about vital sign measurements and findings.
A Chapter Summary and Printable Flashcards highlighting techniques for each vital sign measurement are
provided at the end of each chapter. These printable flashcards are all located together in the textbook’s
conclusion chapter.
You can review the full textbook or advance to sections that you have identified as areas you want to work
on. The textbook has a self-directed format and provides an interactive and engaging way for you to learn about
and develop competence in the measurement of vital signs while integrating knowledge about anatomy and
physiology.
You will learn about various vital signs including temperature, pulse, respiration, blood pressure, and oxygen
saturation. Measurement of vital signs is a foundational, psychomotor skill for healthcare providers and students
in post-secondary health-related programs such as nursing, medicine, pharmacy, midwifery, paramedics,
physiotherapy, occupational therapy, and massage therapy. These measurements provide information about a
person’s overall state of health and more specifically about their cardiovascular and respiratory status. These
measurements can also reveal changes in a client’s vital signs over time and changes in their overall state of
health. Proficiency in vital sign measurement is essential to client safety, care, and management. Measurements
can influence clinical decision-making related to therapeutic interventions.
This book is best viewed via the online, pressbooks format. However, a pdf format is made available.
Introduction | 11
2. General Points to Consider in Vital Sign
Measurement
Therapeutic Environment and Informed Consent
It is important to seek informed consent while creating a therapeutic and safe environment during all encounters
with clients. You will usually begin by introducing yourself by name and designation so the client knows who
you are. Next, explain what you are going to do and always ask permission to touch before beginning vital sign
measurement. For example, an appropriate introduction is:
“Hello, I am XXX (state first and last name). I am a XXX (state designation, e.g., I am a registered
nurse). Today, I am here to take your vital signs. It will involve me touching your arm, are you okay
with that?”
It is also important to ensure the client’s privacy by closing the curtains or the door to the room.
Infection Prevention and Control
Clean hands and clean equipment are essential to infection prevention and control when measuring vital signs.
Ensuring cleanliness helps reduce communicable and infectious diseases, particularly nosocomial infections,
which are infectious organisms acquired by a client while in hospital. Common infections include clostridium
difficile (C. diff), vancomycin-resistant enterococcus (VRE), and methicillin-resistant staphylococcus aureus
(MRSA).
Ensuring your hands are clean is the best way to prevent and control infection. Hand hygiene can include
cleansing with hand gel (see Figure 1.1) and hand washing. (see Figure 1.2). Use an alcohol-based sanitizer before
and after contact with clients. Place gel on your hands and rub all hand surfaces for at least fifteen seconds.
When washing hands using soap and water, wet your hands and apply soap. Rub all hand surfaces for about
fifteen seconds, then rinse your hands. If the tap is not automatic, then turn it off with a paper towel.
Points to Consider
Hand gel is the preferred method of hand hygiene because it kills more bacteria and is easily accessible
to healthcare providers. Soap and water is used when hands/gloves come into contact with bodily fluids.
12 | General Points to Consider in Vital Sign Measurement

Figure 1.1: Hand gel
General Points to Consider in Vital Sign Measurement | 13

Figure 1.2: Hand washing
Equipment
Healthcare providers always inspect equipment before use to ensure it is in good working condition. Equipment
(e.g., stethoscopes, pulse oximeters) can be cleaned with alcohol-based solutions to disinfect the surfaces.
Automated devices should be regularly serviced to ensure accuracy. Biomedical technicians/experts are
responsible for preventative maintenance and calibration to optimize functioning.
Pain Assessment
A pain assessment is conducted in conjunction with the measurement of vital signs because pain can influence
the findings. Pain can activate the sympathetic nervous system and increase pulse, respiration, and blood
pressure. Pain is a complex issue, and a comprehensive discussion of pain assessment is beyond the scope of this
e-book.
Briefly, because pain is subjective, self-reports are the most effective way to assess pain. The choice of pain
assessment tool depends on the client situation: healthcare providers frequently use a numeric rating scale such
as “rate your pain on a scale of 0 to 10 with zero being no pain and ten being the very worst pain that you have
ever felt.” The response is often recorded on the vital sign record and expanded on in the narrative notes. Another
common tool is the PQRSTU mneumonic in which each letter corresponds to a series of questions.
14 | General Points to Consider in Vital Sign Measurement

• P – Provocative/Palliative (e.g., what makes the pain worst? what makes the pain better?)
• Q – Quality/Quantity (e.g., can you describe what the pain feels like? how bad is the pain?)
• R – Region/Radiation (e.g., where is the pain located? does it radiate anywhere else?)
• S – Severity (as noted above, rate the pain on a scale of zero to ten)
• T – Timing (when did the pain begin? is it constant?)
• U – Understanding (what do you think is causing the pain?)
Order of Vital Sign Measurement
The order of vital sign measurement is influenced by the client situation. Healthcare providers often place the
pulse oximeter probe on a client while proceeding to take pulse, respiration, blood pressure, and temperature.
However, in some situations this order is modified and the healthcare provider needs to critically assess the
situation to prioritize the vital sign measurement order. For example, with newborns/infants, it is best to
proceed from least invasive to most invasive, so it is best to begin with respiration, pulse, oxygen saturation,
temperature and if required, blood pressure. In an emergency situation or if a person loses consciousness, it is
best to begin with pulse and blood pressure. Generally, it is important to conduct a complete set of vital signs
unless otherwise indicated.
Significance of Measurements
Determining the significance of vital sign measurements involves a process of diagnostic reasoning. The
healthcare provider analyzes client data and makes decisions about whether the vital signs are normal or
abnormal and whether the findings are significant: the following chapters provide normal vital sign ranges. The
healthcare provider also considers agency policy, if applicable, about vital sign ranges to assess any abnormal
variations and clinical significance. Additionally, the healthcare provider considers the client’s baseline vital signs
to obtain a better sense of the client’s ‘normal’ and allow comparison (e.g., of trends) over time. The diagnostic
reasoning process also involves considering other available objective and subjective data.
Documentation
Timely documentation of vital sign measurements is imperative as a form of communication, to observe trends
in vital sign measurements, and to ensure effective intervention when needed. Documentation occurs on paper-
based vital sign records or electronic systems depending on the agency. Healthcare providers follow the agency’s
documentation policy and the professional standards of practice. If using a vital sign record, healthcare providers
use the symbols noted on the legend of the record.
General Points to Consider in Vital Sign Measurement | 15

PART II
CHAPTER 2: TEMPERATURE
Chapter 2: Temperature | 17
3. What is Temperature?
Temperature refers to the degree of heat or cold in an object or a human body. In humans, the brain’s
hypothalamus acts as the body’s thermostat and is responsible for regulating its temperature (OER #2). See
Figure 2.1 of the hypothalamus.
The human body is constantly adapting to internal health states and environmental conditions, and the
hypothalamus is programmed to tell the body to generate heat if the body temperature is low. For example, the
hypothalamus can activate peripheral vasoconstriction and shivering (contraction of skeletal muscles) to prevent
a decrease in body temperature. The hypothalamus can also reduce heat if the body temperature is too high. For
example, it can activate peripheral vasodilation to increase heat loss and cause a person to perspire, which cools
the body.
Figure 2.1: Hypothalamus (Illustration credit: Hilary Tang)
_____________________________________________________________________
____
Part of this content was adapted from OER #2 (as noted in brackets above):
What is Temperature? | 19
4. Why is Temperature Measured?
Healthcare providers measure a client’s temperature because it can give information about their state of health
and influence clinical decisions. Accurate measurements and interpretation are vital so that hyperthermia and
hypothermia can be identified and appropriate interventions determined.
Hyperthermia refers to an elevated body temperature. It can be related to an internal or external source.
External sources that increase body temperature could include exposure to excessive heat on a hot day or being
in a sauna or hot tub. Internal sources that may increase body temperature include fever caused by an infection
or tissue breakdown associated with physical trauma (e.g., surgery, myocardial infarction) or some neurological
conditions (e.g., cerebral vascular accident, cerebral edema, brain tumour). Hyperthermia that is associated with
an infectious agent, such as a bacteria or virus (e.g., the flu) is referred to as febrile. Unresolved hyperthermic
body states can lead to cell damage.
Hypothermia refers to a lowered body temperature. It is usually related to an external source such as being
exposed to the cold for an extended period of time. Hypothermia is sometimes purposefully induced during
surgery, or for certain medical conditions, to reduce the body’s need for oxygen. Unresolved hypothermic body
states can slow cellular processes and lead to loss of consciousness.
20 | Why is Temperature Measured?

5. Methods of Measurement
Methods of measuring a client’s body temperature vary based on developmental age, cognitive functioning,
level of consciousness, state of health, safety, and agency/unit policy. The healthcare provider chooses the best
method after considering client safety, accuracy, and least invasiveness, all contingent on the client’s health
and illness state. The most accurate way to measure core body temperature is an invasive method through
a pulmonary artery catheter. This is only performed in a critical care area when constant measurements are
required along with other life-saving interventions.
Methods of measurement include oral, axillary, tympanic, rectal, temporal artery and dermal routes.
Oral temperature can be taken with clients who can follow instructions, so this kind of measurement is
common for clients over the age of four, or even younger children if they are cooperative. Another route other
than oral (e.g., tympanic or axillary) is preferable when a client is on oxygen delivered via a face mask because
this can alter the temperature.
For children younger than four, axillary temperature is commonly measured unless a more accurate reading is
required.
Rectal temperature is an accurate way to measure body temperature (Mazerolle, Ganio, Casa, Vingren, & Klau,
2011). The rectal route is recommended by the Canadian Pediatric Society for children under two years of age
(Leduc & Woods, 2017). However, this method is not used on infants younger than thirty days or premature
infants because of the risk of rectal tearing. If the rectal method is required, the procedure is generally only used
by nurses and physicians.
Temporal artery temperature is not a common method of measurement, but may be used in some agencies;
this process involves holding the device and sliding it over the skin of the forehead and then, down over the
temporal artery in one motion. Dermal strips can be placed on the forehead to measure skin temperature, but
are not yet widely used, and the accuracy of this method has not yet been verified.
Points to Consider
The accuracy of measurements is most often influenced by the healthcare provider’s adherence to the
correct technique.
The following pages detail the normal temperature ranges and techniques associated with each of the
temperature methods.
Methods of Measurement | 21
6. What are Normal Temperature Ranges?
The human body’s core temperature (internal body temperature) is measured in degrees Celsius (ºC) or
Fahrenheit (ºF). In Canada, degrees Celsius is most commonly used.
In adults, the normal core body temperature (referred to as normothermia or afebrile) is 36.5–37.5ºC or
97.7–99.5ºF (OER #2).
A wider temperature range is acceptable in infants and young children, and can range from 35.5–37.7ºC or
95.9–99.8ºF. Infants and children have a wider temperature range because their heat control mechanisms are
less effective. They are at risk for heat loss for many reasons including having less subcutaneous fat than adults,
a larger body surface area in comparison to weight (and larger head size in proportion to the rest of the body),
immature metabolic mechanisms (e.g., they may be unable to shiver), and limited ability to produce heat through
activity. They are also at risk of excessive heat production due to crying and restlessness as well as external
factors such as being wrapped in too many blankets.
Older adults tend to have lower body temperatures and are at risk for hypothermic states; reasons for this
may include having less subcutaneous tissue acting as insulation, loss of peripheral vasoconstriction capacity,
decreased cardiac output with resultant lowered blood flow to the extremities, decreased muscle mass resulting
in reduced heat production capacity, and decreased metabolic responses.
Points to Consider
It is important to monitor and regulate temperature in newborns and infants because of the
temperature fluctuations that place them at higher risk for hypothermia and hyperthermia, whereas
temperature changes in older adults are often minimal.
See Table 2.1 for normal temperature ranges based on method. The normal ranges vary slightly for each of
the methods. As a healthcare provider, it is important to determine the significance of the temperature by
considering influencing factors and the client’s overall state of health.
22 | What are Normal Temperature Ranges?

Table 2.1: Normal Temperature Ranges
Method Range
Oral 35.8–37.3ºC
Axillary 34.8–36.3ºC
Tympanic 36.1–37.9ºC
Rectal 36.8–38.2ºC
Other factors that influence temperature include diurnal rhythm, exercise, stress, menstrual cycle, and
pregnancy. The diurnal cycle causes a fluctuation of 1ºC, with temperatures lowest in the early morning and
highest in the late afternoon. During exercise, body temperature rises because the body is using energy to power
the muscles. Temperature can rise as a result of stress and anxiety, due to stimulation of the sympathetic nervous
system and increased secretion of epinephrine and norepinephrine. Body temperature varies throughout a
woman’s menstrual cycle due to hormonal fluctuations, rising after ovulation until menstruation by about
0.5–1ºC. Body temperature is slightly elevated during pregnancy as a result of increased metabolism and
hormone production such as progesterone.
_____________________________________________________________________
____
What are Normal Temperature Ranges? | 23

7. Oral Temperature
The normal oral temperature is 35.8–37.3ºC (OER #1) or 96.4–99.1ºF. Oral temperature measurement is common
and reliable because it is close to the sublingual artery. An oral thermometer is shown in Figure 2.2. The device
has blue colouring, indicating that it is an oral or axillary thermometer as opposed to a rectal thermometer,
which has red colouring.
Figure 2.2: Oral thermometer
Technique
Remove the probe from the device and place a probe cover (from the box) on the oral thermometer without
touching the probe cover with your hands. Place the thermometer in the client’s mouth under the tongue and
instruct client to keep mouth closed and not to bite on the thermometer (OER #1). Ensure the thermometer
probe is in the posterior sublingual pocket under the tongue, slightly off-centre. Leave the thermometer in place
for as long as is indicated by the device manufacturer (OER #1). The thermometer will beep within a few seconds
when the temperature has been taken: most oral thermometers are electronic and provide a digital display of the
reading. Discard the probe cover in the garbage (without touching the cover) and place the probe back into the
device. See Figure 2.3 of an oral temperature being taken.
24 | Oral Temperature
Figure 2.3: Oral temperature being taken
Technique Tips
Putting the probe cover on takes practice. You need to ensure that it snaps onto the probe. Sometimes
the device will turn off after you take the probe out of the device if you take too long to put the probe
cover on or insert it in the client’s mouth. If so, discard the probe cover and re-insert the probe into the
device to reset it. Then try again.
What should the healthcare provider consider?
Healthcare providers often measure the oral temperature, particularly when the client is conscious and can
follow directions. However, certain factors can lead to an inaccurate oral temperature, including recent
consumption of hot or cold food or a beverage, chewing gum, and smoking prior to measurement. Healthcare
providers should wait up to 15 minutes to take the oral temperature if the client is eating hot or cold food or
drinking a hot or cold beverage and about 5 minutes if the client is chewing gum or has just smoked. Alternatively,
a different method is used to measure temperature. Measurement of the oral temperature is not recommended
Oral Temperature | 25
for individuals who are unconscious, unresponsive, confused, have an endotracheal tube secured in the mouth,
and cannot follow instructions.
_____________________________________________________________________
____
© 2015 British Columbia Institute of Technology (BCIT). Clinical Procedures for Safer Patient Care by Glynda
Rees Doyle and Jodie Anita McCutcheon, British Columbia Institute of Technology. Licensed under a Creative
Commons Attribution 4.0 International License, except where otherwise noted. Download this book for free
at http://open.bccampus.ca
26 | Oral Temperature
8. Tympanic Temperature
The normal tympanic temperature is usually 0.3–0.6°C higher than an oral temperature (OER #1). It is accurate
because the tympanic membrane shares the same vascular artery that perfuses the hypothalamus (OER #1). A
tympanic thermometer is shown in Figure 2.4.
Figure 2.4: Tympanic thermometer
Technique
Remove the tympanic thermometer from the casing and place a probe cover (from the box) on the thermometer
tip without touching the probe cover with your hands. Only touch the edge of the probe cover (if needed), to
maintain clean technique. Turn the device on. Ask the client to keep head still. For an adult or older child, gently
pull the helix up and back to visualize the ear canal. For an infant or younger child (under 3), gently pull the lobe
down. The probe is inserted just inside the opening of the ear. Never force the thermometer into the ear and
do not occlude the ear canal (OER #1). Only the tip of the probe is inserted in the opening – this is important
to prevent damage to the ear canal. Activate the device; it will beep within a few seconds to signal it is done.
Discard the probe cover in the garbage (without touching the cover) and place the device back into the holder.
See Figure 2.5 of a tympanic temperature being taken.
Tympanic Temperature | 27
Figure 2.5: Tympanic temperature being taken
Technique Tips
The technique of pulling the helix up and back (adult) or the lobe down (child under 3) is used to
straighten the ear canal so the light can reflect on the tympanic membrane. If this is not correctly done,
the reading may not be accurate. The probe tip is gently inserted into the opening to prevent damage to
the ear canal. The ear canal is a sensitive and a highly innervated part of the body, so it is important not
to force the tympanic probe into the ear.
The tympanic temperature method is a quick and minimally invasive way to take temperature. Although research
has proven the accuracy of this method, some pediatric institutions prefer the accuracy of the rectal
temperature. The Canadian Pediatric Society found equal evidence for and against the use of tympanic
28 | Tympanic Temperature
temperature route (Leduc & Woods, 2017). It concluded that tympanic temperature is one option for use with
children, but suggested using rectal temperature for children younger than two, particularly when accuracy is
vital. The tympanic temperature is not measured when a client has a suspected ear infection. It is important to
check your agency policy regarding tympanic temperature.
_____________________________________________________________________
____
Tympanic Temperature | 29
9. Axillary Temperature
The normal axillary temperature may be as much as 1ºC lower than the oral temperature (OER #1). An axillary
thermometer is the same electronic device as an oral thermometer, and both have a blue end.
Technique
Remove the probe from the device and place a probe cover (from the box) on the thermometer without touching
the cover with your hands. Ask the client to raise the arm away from his/her body. Place the thermometer in
the client’s armpit (OER #1), on bare skin, as high up into the axilla as possible, with the point facing behind
the client. Ask the client to lower his/her arm and leave the device in place for as long as is indicated by the
device manufacturer (OER #1). Usually the device beeps in 10–20 seconds. Discard the probe cover in the garbage
(without touching the cover) and place the probe back into the device. See Figure 2.6 of an axillary temperature
being taken.
Figure 2.6: Axillary temperature being taken
30 | Axillary Temperature
The axillary route is a minimally invasive way to measure temperature. It is commonly used in children. It is
important to ensure that the thermometer is as high up in the axilla as possible with full skin contact and that
the client’s arm is then lowered down.
_____________________________________________________________________
____
Axillary Temperature | 31
10. Rectal Temperature
The normal rectal temperature is usually 1ºC higher than oral temperature (OER #1). A rectal thermometer has a
red end to distinguish it from an oral/axillary thermometer. A rectal thermometer is shown in Figure 2.7.
Figure 2.7: Rectal thermometer
Technique
First, ensure the client’s privacy. Wash your hands and put on gloves. For infants, lie them down in a supine
position and raise their legs up toward the chest. You can encourage a parent to hold the infant to decrease
movement and provide a sense of safety. With older children and adults, assist them into a side lying position.
Remove the probe from the device and place a probe cover (from the box) on the thermometer. Lubricate the
cover with a water-based lubricant, and then gently insert the probe 2–3 cm inside the rectal opening of an
adult, or less depending on the size of the client. The device beeps when it is done.
Measuring rectal temperature is an invasive method. Some suggest its use only when other methods are not
available (OER #1), while others suggest that the rectal route is a gold standard in the infant population because
of its accuracy. The Canadian Pediatric Society (Leduc & Woods, 2017) has referred to research indicating that
32 | Rectal Temperature
rectal temperatures may remain elevated after a client’s core temperature has started to return to normal, but
after reviewing all available evidence, still recommends measuring rectal temperature for children under the age
of two, particularly when accuracy is vital. Rectal temperature is not measured in infants under one month of
age or premature newborns.
_____________________________________________________________________
____
Rectal Temperature | 33
11. Finding the Error Activity: Tympanic
Temperature
Now you have an opportunity to find errors in measurement techniques. This first activity involves looking at an
image.
What error in technique is this healthcare provider making while taking the temperature of an adult client?
Figure 2.8: Error while taking the temperature of an adult
Go to the next page for information about the correct technique in measuring tympanic
temperature.
34 | Finding the Error Activity: Tympanic Temperature

12. Finding the Error Activity: Tympanic
Temperature – Feedback
An incorrect technique is being demonstrated in Figure 2.9 because the helix is not being pulled up and back.
For an adult/older child, the correct technique (Figure 2.10) involves gently pulling the helix up and back so that
the ear canal is visualized and the light can reflect off of the tympanic membrane.
Incorrect technique of taking tympanic temperature
Figure 2.9: Incorrect technique
Finding the Error Activity: Tympanic Temperature –

Feedback | 35
Correct technique of taking tympanic temperature
For an adult/older child, gently pull the helix up and back while stabilizing the client’s head with your hand.
Figure 2.10: Correct technique
36 | Finding the Error Activity: Tympanic Temperature – Feedback

13. Try it Out
Next, you have an opportunity to watch film clips on accurate measurement techniques. There are three
activities that involve film clips that you can watch, and then try out yourself. Check it out!
Try it Out | 37
14. Try it Out: Oral Temperature
Watch this short film clip 2.1 and see how oral temperature is taken correctly. After watching the clip, try the
technique yourself. You can watch the clip and practice as many times as you like.
Alternatively, if viewing textbook as a pdf, use this link: https://www.youtube.com/embed/
HVpjXk0B6SA?rel=0
An interactive or media element has been excluded from this version of the text. You can view it online
here: https://ecampusontario.pressbooks.pub/vitalsign/?p=62
Film clip 2.1: Oral temperature
38 | Try it Out: Oral Temperature

15. Try it Out: Tympanic Temperature
Watch this short film clip 2.2 and see how tympanic temperature is taken correctly. After watching the clip, try
the technique yourself. You can watch the clip and practice as many times as you like.
cVusEmUWTC8?rel=0
Film clip 2.2: Tympanic temperature
Try it Out: Tympanic Temperature | 39

16. Try it Out: Axilla Temperature
Watch this short film clip 2.3 and see how axilla temperature is taken correctly. After watching the clip, try the
Alternatively, if viewing textbook as a pdf, use this link: https://www.youtube.com/embed/m71ISuIJRlA?rel=0
Film clip 2.3: Axilla temperature
40 | Try it Out: Axilla Temperature

17. Test Yourself
Now that you have completed this chapter, it’s time to test your knowledge. Try to answer the following
questions (you may want to review parts of the chapter before answering). Write your answers down on a piece
of paper.
1. What is the most accurate way to take the temperature of a one-year-old client?
a. Oral temperature
b. Rectal temperature
c. Axillary temperature
d. Tympanic temperature
2. An adult client is drinking coffee. How should the healthcare provider measure the client’s temperature?
Select all that apply.
a. Take the client’s oral temperature right away
b. Take the client’s axillary temperature right away
c. Take the client’s tympanic temperature right away
d. Take the client’s rectal temperature in five minutes
e. Wait two minutes and take the client’s oral temperature
3. What is the best way to measure temperature in a client who is confused? Select all that apply.
a. Oral temperature
c. Axillary temperature
e. Temporal artery temperature
4. An infant’s tympanic temperature is 37.7°C. How should the healthcare provider respond?
a. Apply a cold compress
b. Re-take in the other ear
c. Recognize this as normal
d. Take a rectal temperature
5. How should the healthcare provider take the temperature of an adult client who is post-operation day
two following oral surgery?
a. Avoid measuring temperature
b. Take rectal temperature once a shift
c. Take tympanic temperature as necessary
d. Take oral temperature every four hours
Test Yourself | 41
Go to the next page to check your answers.
42 | Test Yourself
18. Test Yourself: Answers
1. What is the most accurate way to take the temperature of a one-year-old client?
a. Oral temperature
b. Rectal temperature **
c. Axillae temperature
Rationale: The correct answer is b (rectal temperature). Rectal temperature is the most accurate
measurement method for children under two years of age, who are not able to readily follow directions.
2. An adult client is drinking coffee. How should the healthcare provider measure the client’s temperature?
Select all that apply.
a. Take the client’s oral temperature right away
b. Take the client’s axillary temperature right away **
c. Take the client’s tympanic temperature right away **
d. Take the client’s rectal temperature in five minutes
e. Wait two minutes and take the client’s oral temperature
Rationale: The correct answers are b and c (take the client’s axillary or tympanic temperature right away).
Recent consumption of a hot drink or cold drink alters a client’s oral temperature. Thus, temperature is taken via
the axillary or tympanic route if a client has recently had a hot or cold drink. You can take an oral temperature if
you wait 15 minutes after hot drink consumption.
3. What is the best way to measure temperature in a client who is confused? Select all that apply.
a. Oral temperature
c. Axillary temperature **
d. Tympanic temperature **
e. Temporal artery temperature **
Rationale: The correct answers are c, d, and e (axillary, tympanic and temporal artery temperature). A client
who is confused often cannot follow directions, so they may not follow directions to close their mouth as
required when taking an oral temperature. Additionally, it is not safe to measure rectal temperature when a client
is confused. Thus, it is best to measure axillary, tympanic, or temporal artery temperature.
4. An infant’s tympanic temperature is 37.7°C. How should the healthcare provider respond?
a. Apply a cold compress
b. Re-take in the other ear
c. Recognize this as normal **
d. Take a rectal temperature
Rationale: The correct answer is c (recognize this as normal). A temperature of 37.7°C is normal for an infant,
so no further action is required.
5. How should the healthcare provider take the temperature of an adult client who is post-operation day
two following oral surgery?
a. Avoid measuring temperature
Test Yourself: Answers | 43

b. Take rectal temperature once a shift
c. Take tympanic temperature as needed **
d.Take oral temperature every four hours
Rationale: The correct answer is c (tympanic temperature). Taking oral temperature is avoided after oral
surgery, and taking rectal temperature is avoided in the adult population. Thus, the best method is to measure
tympanic temperature.
44 | Test Yourself: Answers

19. Test Yourself: List in the Correct Order
List the steps below in the correct order for each of the following techniques. Write your list on a piece of paper.
Oral Temperature Technique
• Place the thermometer in the mouth under the tongue in the posterior sublingual pocket (slightly off-
centre) and instruct client to keep mouth closed and not to bite on the thermometer
• Remove the probe from the device and place a probe cover (from the box) on the oral thermometer without
touching the cover with your hands
• Note the temperature on the digital display of the device
• Remove the thermometer when the device beeps
• Place the probe back into the device
• Discard the probe cover in the garbage (without touching the cover)
Tympanic Temperature Technique
• Turn the device on

• Remove the tympanic thermometer from the casing and place a probe cover (from the box) on the
thermometer tip without touching the cover with your hands
• Activate the device
• Gently insert the probe into the opening of the ear
• For an adult or older child, gently pull the helix up and back to visualize the ear canal. For an infant or
younger child (under 3), gently pull the lobe down.
• Discard the probe cover in the garbage (without touching the cover) and place the device back into the
holder
Axillary Temperature Technique
• Place the thermometer in the client’s armpit as high up as possible into the axillae, on bare skin, with the
point facing behind the client, and ask the client to lower his/her arm
• Remove the probe from the device and place a probe cover (from the box) on the thermometer without
• Ask the client to raise the arm away from his/her body
• Discard the probe cover in the garbage (without touching the cover) and place the probe back into the
device
Rectal Temperature Technique
• Remove the probe from the device and place a probe cover on it
• Lubricate the cover
• Ensure the client’s privacy and wash your hands and put on gloves
Test Yourself: List in the Correct Order | 45

• Position the client appropriately
• Gently insert the probe 2–3 cm inside the rectal opening of an adult, or less depending on the size of the
client
• Discard the probe cover in the garbage (without touching the cover) and place the probe back into the
device
• Remove your gloves and wash your hands
Go to the next page to see the correct order of steps for these techniques.
46 | Test Yourself: List in the Correct Order

20. Test Yourself: List in the Correct Order –
Answers
The steps are listed in the correct order for each of the following techniques. These are printable flashcards to
help you memorize and practice the techniques.
1. Remove the probe from the device and place a probe cover (from the box) on the oral thermometer without
2. Place the thermometer in the mouth under the tongue in the posterior sublingual pocket (slightly off-
centre) and instruct the client to keep mouth closed and not to bite on the thermometer
3. Remove the thermometer when the device beeps
4. Note the temperature on the digital display of the device
5. Discard the probe cover in the garbage (without touching the cover)
6. Place the probe back into the device
1. Remove the tympanic thermometer from the casing and place a probe cover (from the box) on the
2. Turn the device on
3. For an adult or older child, gently pull the helix up and back to visualize the ear canal. For an infant or
younger child (under 3), gently pull the lobe down
4. Gently insert the probe into the opening of the ear
5. Activate the device
7. Discard the probe cover in the garbage (without touching the cover) and place the device back into the
holder
1. Remove the probe from the device and place a probe cover (from the box) on the thermometer without
2. Ask the client to raise the arm away from his/her body
3. Place the thermometer in the client’s armpit as high up as possible into the axillae on bare skin, with the
point facing behind the client, and ask the client to lower arm
5. Discard the probe cover in the garbage (without touching the cover) and place the probe back into the
device
Test Yourself: List in the Correct Order – Answers | 47

1. Ensure the client’s privacy and wash your hands and put on gloves
2. Position the client appropriately
3. Remove the probe from the device and place a probe cover on it
4. Lubricate the cover with a water-based lubricant
5. Gently insert the probe 2–3 cm inside the rectal opening of an adult, or less depending on the size of the
client
6. Note the temperature on the digital display of the device when it beeps
device
8. Remove your gloves and wash your hands
48 | Test Yourself: List in the Correct Order – Answers

21. Chapter Summary
Temperature is an important vital sign because it provides current data about the client’s health and illness state.
Changes in body temperature act as a cue for healthcare providers’ diagnostic reasoning.
There are many ways to measure temperature. In determining the best method, the healthcare provider
considers agency policy, the client’s age and health and illness state, and the reason for taking the temperature.
Healthcare providers must use the correct technique when measuring temperature, because this can influence
client data.
When determining the relevance of the temperature, the healthcare provider considers the client’s baseline
data and the situation. Diagnostic reasoning about temperature always involves considering additional data
including other vital sign measurements and subjective and objective client data.
Chapter Summary | 49
PART III
CHAPTER 3: PULSE AND RESPIRATION
Pulse and respiration are discussed together in this chapter because these vital signs are taken in succession.
Chapter 3: Pulse and Respiration | 51

22. What is Pulse?
Pulse refers to a pressure wave that expands and recoils the artery when the heart contracts/beats. It is palpated
at many points throughout the body. The most common locations to accurately assess pulse as part of vital
sign measurement include radial, brachial, carotid, and apical pulse as shown in Figure 3.1. The techniques vary
according to the location, as detailed later.
What is Pulse? | 53
Figure 3.1: Radial, brachial, carotid and apical pulse (Illustration credit: Hilary Tang)
The heart pumps a volume of blood per contraction into the aorta. This volume is referred to as stroke volume.
Age is one factor that influences stroke volume, which ranges from 5–80 mL from newborns to older adults.
Pulse is measured in beats per minute, and the normal adult pulse rate (heart rate) at rest is 60–100 beats per
minute (OER #1, OER #2). Newborn resting heart rates range from 100–175 bpm. Heart rate gradually decreases
until young adulthood and then gradually increases again with age (OER #2). A pregnant women’s heart rate is
slightly higher than her pre-pregnant value (about 15 beats). See Table 3.1 for normal heart rate ranges based on
age.
Table 3.1: Heart Rate Ranges
Age Heart rate (beats per minute)
Newborn to one month 100–175
One month to two years 90–160
Age 2–6 years 70–150
Age 7–11 years 60–130
Age 12–18 years 50–110
Adult and older adult 60–100
Points to Consider
The ranges noted in Table 3.1 are generous. It is important to consider each client and situation to
determine whether the heart rate is normal. For example, heart rate is considered in the context of a
client’s baseline heart rate. The healthcare provider also considers the client’s health and illness state and
determinants such as rest/sleep, awake/active, and presence of pain. You can expect higher pulse values
when a client is in a stressed state such as when crying or in pain; this is particularly important in the
54 | What is Pulse?
newborn. It is best to complete the assessment when the client is in a resting state. If you obtain a pulse
when the client is not in a resting state, document the circumstances (e.g., stress, crying, or pain) and
reassess as needed.
_____________________________________________________________________
____
Commons Attribution 4.0 International License, except where otherwise noted. Download this book for free at
http://open.bccampus.ca
Physiology is licensed under a Creative Commons Attribution License 4.0 license. Download for free at
http://cnx.org/contents/7c42370b-c3ad-48ac-9620-d15367b882c6@12
What is Pulse? | 55
23. Why is Pulse Measured?
Healthcare providers measure pulse because it provides information about a client’s state of health and
influences diagnostic reasoning and clinical decision-making.
Tachycardia
Tachycardia refers to an elevated heart rate, typically above 100 bpm (OER #2) for an adult. Developmental
considerations are important to consider, such as higher resting pulse rates in infants and children. For adults,
tachycardia is not normal in a resting state but may be detected in pregnant women or individuals experiencing
extreme stress (OER #2). Tachycardia can be benign, such as when the sympathetic nervous system is activated
with exercise and stress. Caffeine intake and nicotine can also elevate the heart rate. Tachycardia is also
correlated with fever, anemia, hypoxia, hyperthyroidism, hypersecretion of catecholamines, some
cardiomyopathies, some disorders of the valves, and acute exposure to radiation (OER #2).
Bradycardia
Bradycardia is a condition in which the resting heart rate drops below 60 bpm (OER #2) in adults. In newborns, a
resting heart rate below 100 bpm is considered bradycardia. However, a sleeping neonate’s pulse may be as low as
90 bpm. People who are physically fit (e.g., trained athletes) typically have lower heart rates (OER #2). If the client
is not exhibiting other symptoms, such as weakness, fatigue, dizziness, fainting, chest discomfort, palpitations,
or respiratory distress, bradycardia is generally not considered clinically significant (OER #2). However, if any of
these symptoms are present, this may indicate that the heart is not providing sufficient oxygenated blood to the
tissues (OER #2). Bradycardia can be related to an electrical issue of the heart, ischemia, metabolic disorders,
pathologies of the endocrine system, electrolyte imbalances, neurological disorders, prescription medications,
and prolonged bedrest, among other conditions (OER #2). Bradycardia is also related to some medications, such
as beta blockers and digoxin.
Points to Consider
It is vital that healthcare providers assess clients with tachycardia or bradycardia to determine whether
the findings are significant and require intervention.
_____________________________________________________________________
____
56 | Why is Pulse Measured?

Why is Pulse Measured? | 57

24. What Pulse Qualities are Assessed?
The pulse rhythm, rate, force, and equality are assessed when palpating pulses.
Pulse Rhythm
The normal pulse rhythm is regular, meaning that the frequency of the pulsation felt by your fingers follows an
even tempo with equal intervals between pulsations. If you compare this to music, it involves a constant beat
that does not speed up or slow down, but stays at the same tempo. Thus, the interval between pulsations is
the same. However, sinus arrhythmia is a common condition in children, adolescents, and young adults. Sinus
arrhythmia involves an irregular pulse rhythm in which the pulse rate varies with the respiratory cycle: the heart
rate increases at inspiration and decreases back to normal upon expiration. The underlying physiology of sinus
arrhythmia is that the heart rate increases to compensate for the decreased stroke volume from the heart’s left
side upon inspiration.
Points to Consider
If a pulse has an irregular rhythm, it is important to determine whether it is regularly irregular (e.g.,
three regular beats and one missed and this is repeated) or if it is irregularly irregular (e.g., there is
no rhythm to the irregularity). Irregularly irregular pulse rhythm is highly specific to atrial fibrillation.
Atrial fibrillation is an arrhythmia whereby the atria quiver. This condition can have many consequences
including decreased stroke volume and cardiac output, blood clots, stroke, and heart failure.
Pulse Rate
The pulse rate is counted by starting at one, which correlates with the first beat felt by your fingers. Count for
thirty seconds if the rhythm is regular (even tempo) and multiply by two to report in beats per minute. Count for
one minute if the rhythm is irregular.
Pulse Force
The pulse force is the strength of the pulsation felt when palpating the pulse. For example, when you feel a
client’s pulse against your fingers, is it gentle? Can you barely feel it? Alternatively, is the pulsation very forceful
and bounding into your fingertips? The force is important to assess because it reflects the volume of blood, the
heart’s functioning and cardiac output, and the arteries’ elastic properties. Remember, stroke volume refers to
the volume of blood pumped with each contraction of the heart (i.e., each heart beat). Thus, pulse force provides
an idea of how hard the heart has to work to pump blood out of the heart and through the circulatory system.
Pulse force is recorded using a four-point scale:
• 3+ Full, bounding
58 | What Pulse Qualities are Assessed?

• 2+ Normal/strong
• 1+ Weak, diminished, thready
• 0 Absent/non-palpable
Practice on many people to become skilled in measuring pulse force. While learning, it is helpful to assess pulse
force along with an expert because there is a subjective element to the scale. A 1+ force (weak and thready) may
reflect a decreased stroke volume and can be associated with conditions such as heart failure, heat exhaustion,
or hemorrhagic shock, among other conditions. A 3+ force (full and bounding) may reflect an increased stroke
volume and can be associated with exercise and stress, as well as abnormal health states including fluid overload
and high blood pressure.
Pulse Equality
Pulse equality refers to whether the pulse force is comparable on both sides of the body. For example, palpate
the radial pulse on the right and left wrist at the same time and compare whether the pulse force is equal.
Pulse equality is assessed because it provides data about conditions such as arterial obstructions and aortic
coarctation. However, the carotid pulses should never be palpated at the same time as this can decrease and/
or compromise cerebral blood flow.
What Pulse Qualities are Assessed? | 59

25. Radial Pulse
Technique
Use the pads of your first three fingers to gently palpate the radial pulse (OER #1). The pads of the fingers are
placed along the radius bone, which is on the lateral side of the wrist (the thumb side; the bone on the other
side of the wrist is the ulnar bone). Place your fingers on the radius bone close to the flexor aspect of the wrist,
where the wrist meets the hand and bends. See Figure 3.2 for correct placement of fingers. Press down with
your fingers until you can best feel the pulsation. Note the rate, rhythm, force, and equality when measuring the
radial pulse (OER #1).
Figure 3.2: Correct placement of fingers
Technique Tips
Note the first beat felt in your fingers as “1” and then continue to count. Alternatively, start counting at
“0” when your watch is at zero and then continue to count.
60 | Radial Pulse
You may need to adjust the pressure of your fingers when palpating the radial pulse if you cannot feel the pulse.
For example, sometimes pressing too hard can obliterate the pulse (make it disappear). Alternatively, if you do
not press hard enough, you may not feel a pulse. You may also need to move your fingers around slightly. Radial
pulses are difficult to palpate on newborns and children under five, so healthcare providers usually assess the
apical pulse or brachial pulse of newborns and children.
Points to Consider
You can use a Doppler ultrasound device if you are struggling to feel the pulse and are concerned about
perfusion into the limbs. This is a handheld device that allows you to hear the whooshing sound of the
pulse. The Doppler device is also used following surgery or insertion of a central line to assess blood flow.
These devices are most commonly used when assessing peripheral pulses in the lower limbs, such as the
dorsalis pedis pulse or the posterior tibial pulse. See Film clip 3.1 for use of a Doppler device. The doppler
device is also used to locate the brachial pulse and assess blood pressure in infants.
Film clip 3.1: Use of doppler device
Alternatively, if viewing textbook as a pdf, use this link: https://www.youtube.com/embed/cn3aA0G1mgc?rel=0
_____________________________________________________________________
____
Radial Pulse | 61
26. Carotid Pulse
May be taken when radial pulse is not present or is difficult to palpate (OER #1).
Technique
Ask the client to sit upright. Locate the carotid artery medial to the sternomastoid muscle (between the muscle
and the trachea at the level of the cricoid cartilage, which is in the middle third of the neck). With the pads
of your three fingers, gently palpate the carotid artery, one at a time. See Figure 3.3 for correct placement of
fingers.
Although other pulses can be taken simultaneously to assess equality, the carotid pulses are NEVER taken at the
same time. Gently palpate one artery at a time so that you do not stimulate the vagus nerve and compromise
arterial blood flow to the brain. Avoid palpating the upper third of the neck, because this is where the carotid
sinus area is located. You want to avoid pressure on the carotid sinus area because this can lead to vagal
stimulation, which can slow the heart rate, particularly in older adults.
62 | Carotid Pulse
Technique Tips
Never palpate the carotid pulses simultaneously as this will reduce and/or compromise cerebral blood
flow.
_____________________________________________________________________
____
Carotid Pulse | 63
27. Brachial Pulse
Brachial pulse rate is indicated during some assessments, such as with children, in whom it can be difficult to
feel the radial pulse. A Doppler can be used to locate the brachial pulse if needed.
Technique
The brachial pulse can be located by feeling the bicep tendon in the area of the antecubital fossa. Move the pads
of your three fingers medial (about 2 cm) from the tendon and about 2–3 cm above the antecubital fossa to locate
the pulse. See Figure 3.4 for correct placement of fingers along the brachial artery.
It can be helpful to hyper-extend the arm in order to accentuate the brachial pulse so that you can better feel it.
You may need to move your fingers around slightly to locate the best place to most accurately feel the pulse. You
will usually need to press fairly firmly to palpate the brachial pulse.
64 | Brachial Pulse
28. Apical Pulse
Apical pulse is auscultated with a stethoscope over the chest where the heart’s mitral valve is best heard. In
infants and young children, the apical pulse is located at the fourth intercostal space at the left midclavicular
line. In adults, the apical pulse is located at the fifth intercostal space at the left midclavicular line (OER #1). See
Figure 3.5 below.
Figure 3.5: Apical Pulse (Illustration credit: Hilary Tang)

Apical pulse rate is indicated during some assessments, such as when conducting a cardiovascular assessment
and when a client is taking certain cardiac medications (e.g., digoxin) (OER #1). Sometime the apical pulse is
auscultated pre and post medication administration. It is also a best practice to assess apical pulse in infants and
Apical Pulse | 65
children up to five years of age because radial pulses are difficult to palpate and count in this population. It is
typical to assess apical pulses in children younger than eighteen, particularly in hospital environments. Apical
pulses may also be taken in obese people, because their peripheral pulses are sometimes difficult to palpate.
Technique
Position the client in a supine (lying flat) or in a seated position. Physically palpate the intercostal spaces to locate
the landmark of the apical pulse. Ask the female client to re-position her own breast tissue to auscultate the
apical pulse. For example, the client gently shifts the breast laterally so that the apical pulse landmark is exposed.
See Figure 3.6 below. Alternatively, the healthcare provider can use the ulnar side of the hand to re-position the
breast tissue and auscultate the apical pulse. Ensure draping to protect the client’s privacy.
Either the bell or diaphragm are used to auscultate the client’s heart rate and rhythm. There is a pediatric-
size stethoscope for infants. Typically, apical pulse rate is taken for a full minute to ensure accuracy; this
is particularly important in infants and children due to the possible presence of sinus arrhythmia. Upon
auscultating the apical pulse, you will hear the sounds “lub dup” – this counts as one beat. Count the apical pulse
for one minute. Note the rate and rhythm.
Figure 3.6: Female client re-positioning her breast in order to auscultate the apical pulse
Listen to Audio clip 3.1 and count the apical pulse. For practice, we have made this clip 30 seconds so you will
need to multiply it by two to report it as beats per minute (but remember, the most accurate measurement is
to count the apical pulse for one minute). The reported apical rate in Audio clip 3.1 is: 60 bpm (30 x 2) with a
regular rhythm
66 | Apical Pulse
Audio clip 3.1: Counting apical pulse rate
Alternatively, if viewing textbook as a pdf, use this link: https://www.youtube.com/embed/yL4E_6PaPgg?rel=0
Although pulses are best measured at rest, sometimes this is not possible. It is important to document other
factors such as when a person is in pain or an infant/child is crying.
Technique Tips
Feel the intercostal spaces to accurately locate the apical pulse and obtain a physical landmark. There
is a space below the clavicle, but the first intercostal space is located below the first rib. You can also
slide your fingers down the manubrium where it meets the sternum: this is called the sternal angle (angle
of Louis). The second rib extends out from the sternal angle.
_____________________________________________________________________
____
Apical Pulse | 67
29. What is Respiration?
Respiration refers to a person’s breathing and the movement of air into and out of the lungs (OER #2). The
respiratory system provides oxygen to body tissues for cellular respiration, removes the waste product carbon
dioxide, and helps maintain acid–base balance (OER #2). Inspiration is the process that causes air to enter the
lungs, and expiration is the process that causes air to leave the lungs (OER #2). A respiratory cycle (or one breath
while you are measuring respiratory rate) is one sequence of inspiration and expiration (OER #2).
Respiration is assessed for quality, rhythm, and rate.
The quality of a person’s breathing is normally relaxed and silent. Healthcare providers assess use of accessory
muscles in the neck and chest and indrawing of intercostal spaces (also referred to as intercostal tugging), which
can indicate respiratory distress. Respiratory distress can also cause nasal flaring, and the person often moves
into a tripod position. The tripod position involves leaning forward and placing arms/hands and/or upper body
on one’s knees or on the bedside table.
Respiration normally has a regular rhythm. A regular rhythm means that the frequency of the respiration
follows an even tempo with equal intervals between each respiration. If you compare this to music, it involves a
constant beat that does not speed up or slow down, but stays at the same tempo.
Respiratory rates vary based on age. The normal resting respiratory rate for adults is 10–20 breaths per minute
(OER #1). The normal respiratory rate for children decreases from birth to adolescence (OER #2). Children
younger than one year normally have a respiratory rate of 30–60 breaths per minute, but by the age of ten, the
normal rate is usually 18–30 (OER #2). By adolescence, the respiratory rate is usually similar to that of adults,
12–18 breaths per minute (OER #2). Respiratory rates often increase slightly over the age of sixty-five.
Estimated respiratory rates vary based on the source. Table 3.2 lists a generous range of normal respiratory
rates based on age. It is important to consider the client and the situation to determine whether the respiratory
rate is normal. Healthcare providers take into consideration the client’s health and illness state and determinants
such as rest/sleep, awake/active, presence of pain, and crying when assessing the respiratory rate.
68 | What is Respiration?
Table 3.2: Respiratory Rate Ranges
Age Rate (breaths per minute)
Newborn to one month 30–65
One month to one year 26–60
1–10 years 14–50
11–18 years 12–22
Adult and older adult 10–20
_____________________________________________________________________
____
What is Respiration? | 69
30. Respiration Technique
Technique
The respiratory rate is counted after taking the pulse rate so that the client is not aware that you are taking
it (OER #1). Once you have finished counting the pulse, leave your fingers in place and then begin assessing
respiration. Observe the chest or abdomen rise and fall. One respiration includes a full respiratory cycle
(including both inspiration and expiration). Thus, the rise and the fall of the abdomen or chest is counted as
one full breath. Count for 30 seconds if the rhythm is regular or for a full minute if irregular (OER #1). Report
the respiration as breaths per minute, as well as whether breathing is relaxed, silent, and has a regular rhythm.
Report whether chest movement is symmetrical.
Assess the movement of the chest with adults, and the movement of the abdomen with newborns and infants.
Adults are normally thoracic breathers (the chest moves) while infants are normally diaphragmatic breathers (the
abdomen moves). Some adults are abdominal breathers. Breathing rates are counted for one minute with infants
because the respiratory rhythm (tempo) can vary significantly. For example, the breathing rates of infants can
speed up and slow down with some short periods of apnea (pauses in breathing).
When assessing respiration, ensure that thick and bulky clothing is removed so you can clearly see the rise and
fall of the chest or abdomen. Although respiratory rates are best counted at rest, sometimes this is not possible
(e.g., in an emergency situation and with a child who is crying). In this case, document the situation. While
assessing respirations, it is important to note signs of respiratory distress, which can include loud breathing,
nasal flaring, and intercostal retractions. See Figure 3.7 for signs of respiratory distress. These signs require
further assessment and intervention.
70 | Respiration Technique
Figure 3.7: Signs of respiratory distress (Illustration credit: Paige Jones)
_____________________________________________________________________
____
Respiration Technique | 71
31. Finding the Error Activity: Radial Pulse
Now you have an opportunity to find errors in measurement techniques. This activity involves looking at an
image.
What error in technique is this healthcare provider making while measuring the radial pulse of a client?
Figure 3.8: Error in technique while measuring the radial pulse
Go to the next page for information about the correct technique for measuring radial pulse.
72 | Finding the Error Activity: Radial Pulse

32. Finding the Error Activity: Radial Pulse –
Feedback
As per Figure 3.8, an incorrect technique is being demonstrated because the pads of the three fingers are being
placed on the ulnar side of the wrist. The correct technique (Figure 3.9) to palpate the radial pulse involves
placing the pads of the three fingers along the radius which is on the lateral side of the wrist (the thumb side).
The pads of the fingers are placed on the radius bone close to the flexor aspect of the wrist.
Incorrect placement of fingers
Figure 3.8: Incorrect placement of fingers
Correct placement of fingers
While palpating the pulse, gently place the pads of your three fingers along the radial bone at the flexor aspect
of the wrist (the thumb side).
Finding the Error Activity: Radial Pulse – Feedback | 73

74 | Finding the Error Activity: Radial Pulse – Feedback

33. Finding the Error Activity: Infant Apical Pulse
Now you have an opportunity to find errors in measurement technique. This activity involves looking at an image.
What error in technique is this healthcare provider making while measuring the apical pulse of an infant?
Figure 3.10: Error in technique while measuring the apical pulse
Go to the next page for information about the correct technique for measuring apical pulse in an
infant.
Finding the Error Activity: Infant Apical Pulse | 75

34. Finding the Error Activity: Infant Apical Pulse
– Answer
As per Figure 3.11, an incorrect technique is being demonstrated because the stethoscope is placed on the
incorrect side of the chest. The correct technique (Figure 3.12) to auscultate the apical pulse of an infant is to
place the stethoscope at the left midclavicular line in the fourth intercostal space.
Incorrect placement of stethoscope
Figure 3.11: Incorrect placement of stethoscope
Correct placement of stethoscope
While taking the apical pulse of an infant, place the stethoscope at the fourth intercostal space at the left mid-
clavicular line.
76 | Finding the Error Activity: Infant Apical Pulse – Answer

Figure 3.12: Correct placement of stethoscope
Finding the Error Activity: Infant Apical Pulse – Answer | 77

35. Try it Out
Next, you have an opportunity to watch film clips on accurate measurement techniques. There are two activities
that involve two film clips that you can watch and then try out yourself. Check it out!
78 | Try it Out
36. Try it Out: Radial Pulse and Respiration
Watch this short film clip 3.2 and see how to measure radial pulse and respiration correctly. After watching the
clip, try the technique yourself. You can watch the clip and practice as many times as you like.
yxSoB3BiDLo?rel=0
Film clip 3.2: Pulse and respiration measurement
Try it Out: Radial Pulse and Respiration | 79

37. Try it Out: Apical Pulse
Watch this short film clip 3.3 and see how to measure an apical pulse correctly. After watching the clip, try the
JJ9VEymVl8Q?rel=0
Film clip 3.3: Correct measurement of apical pulse
80 | Try it Out: Apical Pulse

38. Test Yourself
of paper.
1. What is the apical pulse rate?
Listen to the audio clip of the apical pulse. Count the pulse for 30 seconds and report the rate as beats per
minute (NOTE: although this clip only allows you to count for 30 seconds, remember, it is best to count the
apical pulse for one minute).
Audio clip 3.2: Apical pulse
Alternatively, if viewing textbook as a pdf, use this link: https://www.youtube.com/embed/znhbVRZRLfM?rel=0

Listen to the audio clip of the apical pulse. Count the pulse for 30 seconds and report the rate as beats per
Audio clip 3.3: Apical pulse
Alternatively, if viewing textbook as a pdf, use this link: https://www.youtube.com/embed/Hxd68qJfzhQ?rel=0
3. How should a healthcare provider respond when a newborn has an apical heart rate of 120 beats per
minute?
a. Re-take the rate at the brachial location
b. Document the rate and assess it as normal
c. Document the rate and identify it as tachycardia
d. Notify the physician and identify it as bradycardia
4. Which findings should be of most concern to the healthcare provider in an adolescent client?
Test Yourself | 81
a. Pulse 40 bpm and respiration 34
b. Respiration 16 and pulse 82 bpm
c. Pulse 68 bpm and sinus arrhythmia
d. Pulse 2+, 78 bpm, and regular rhythm
5. Match the findings that are typically normal for the person listed:
Sinus arrhythmia Athlete
Bradycardia Newborn
Abdominal breather Adolescent
82 | Test Yourself
Listen to the audio-clip of the apical pulse. Count the pulse for 30 seconds and report the rate as beats per
The pulse rate is 76 bpm (38 x 2) with a regular rhythm

The pulse rate is 114 bpm (57 x 2) with a regular rhythm
2. How should a healthcare provider respond when a newborn has an apical heart rate of 120 beats per
minute?
a. Re-take the rate at the brachial location
b. Document the rate and assess it as normal **
c. Document the rate and identify it as tachycardia
d. Notify the physician and identify it as bradycardia
Rationale: The correct answer is b (document the rate and assess it as normal). An apical heart rate of 120
bpm falls within the normal range for newborns. Newborns have a faster apical heart rate than adults because
they have smaller and less muscular hearts. As a result, their stroke volume (volume of blood per contraction) is
smaller than that of adults and their hearts must beat faster to pump sufficient blood, oxygen, and nutrients to
the body.
3. Which findings in an adolescent client is of most concern to a healthcare provider?

a. Pulse 40 bpm and respiration 34 **
b. Respiration 16 and pulse 82 bpm
c. Pulse 68 bpm and sinus arrhythmia
d. Pulse 2+, 78 bpm, and regular rhythm
Rationale: The correct answer is a (pulse 40 bpm and respiration 34). In adolescents, a pulse of 40 bpm is
low and a respiration rate of 34 is high. All of the other findings are normal for adolescents, including sinus
arrhythmia, which is common in children and adolescents.
4. Match the findings that are typically normal for the person listed:
Bradycardia——————-Athlete
Abdominal breather———Newborn
Sinus arrhythmia————Adolescent
Rationale: Bradycardia (low pulse) is common in athletes because their hearts are more muscular and pump
a larger stroke volume per contraction. As a result, the heart contracts/beats less to pump sufficient blood,
oxygen and nutrients. Newborns are abdominal breathers, meaning that the abdomen moves up and down when
breathing, as opposed to the thorax. Sinus arrhythmia is common in adolescents. It involves an irregular pulse
rhythm in which the pulse rate varies with the respiratory cycle; the heart speeds up at inspiration and decreases
back to normal upon expiration. The underlying physiology of sinus arrhythmia is that the heart rate increases
to compensate for the decreased stroke volume from the left side of the heart upon inspiration.

Radial Pulse Technique
• Note the rate, rhythm, force, and equality when measuring the radial pulse
• Use the pads of your first three fingers to gently palpate the radial pulse along the radius bone close to the
flexor aspect of the wrist
• Press down with your fingers until you can best feel the pulsation
Carotid Pulse Technique
• Gently palpate the carotid artery one at a time

• Note the rate, rhythm, force, and equality when measuring the carotid pulse
• Locate the carotid artery medial to the sternomastoid muscle in the middle third of the neck
• Ask the client to sit upright.
Apical Pulse Technique
• Physically palpate the intercostal spaces to locate the landmark of the apical pulse
• Ask the client to lay flat in a supine position
• Note the rate and rhythm
• Auscultate the apical pulse
Brachial Pulse Technique
• Move your fingers medial from the tendon and about one inch above the antecubital fossa to locate the
brachial pulse
• Palpate the bicep tendon in the area of the antecubital fossa
• Note the rate and rhythm
Respiration Technique
• Count for 30 seconds if the rhythm is regular or for a full minute if it is irregular
• Observe the rise and fall of the chest or abdomen
• Leave your fingers in place when you are done counting the pulse, and then begin assessing respiration
• Report the respirations as breaths per minute, as well as whether breathing is relaxed, silent, and has a
regular rhythm

Test Yourself: List in the Correct Order | 85
Answers
1. Use the pads of your first three fingers to gently palpate the radial pulse along the radius bone close to the
2. Press down with your fingers until you can best feel the pulsation
3. Note the rate, rhythm, force, and equality when measuring the radial pulse
1. Ask the client to sit upright

2. Locate the carotid artery medial to the sternomastoid muscle in the middle third of the neck
3. Gently palpate the carotid artery one at a time
4. Note the rate, rhythm, force, and equality when measuring the carotid pulse
1. Ask the client to lay flat in a supine position

2. Physically palpate the intercostal spaces to locate the landmark of the apical pulse
3. Auscultate the apical pulse
4. Note the rate and rhythm
1. Palpate the bicep tendon in the area of the antecubital fossa

2. Move your fingers medial from the tendon and about one inch above the antecubital fossa to locate the
pulse
1. Leave your fingers in place when you are done counting the pulse, and then begin assessing respiration
2. Observe the rise and fall of the chest or abdomen
3. Count for 30 seconds if the rhythm is regular or for a full minute if it is irregular
4. Report respiration as breaths per minute, as well as whether breathing is relaxed, silent, and has a regular
rhythm
86 | Test Yourself: List in the Correct Order – Answers

42. Chapter Summary
Measurement of pulse and respiration is important because these vital signs provide current data about the
client’s health and illness state. Changes in pulse and respiration act as cues for healthcare providers’ diagnostic
reasoning.
Pulse can be measured in many locations. When determining the best location, healthcare providers consider
the client’s age and health and illness state, as well as the reason for taking the pulse.
When determining the relevance of pulse and respiration data, healthcare providers consider the client’s
baseline data and the situation. Diagnostic reasoning about pulse and respiration always considers additional
information, including other vital sign measurements and subjective and objective client data.
Chapter Summary | 87
PART IV
CHAPTER 4: OXYGEN SATURATION
Chapter 4: Oxygen Saturation | 89

43. What is Oxygen Saturation?
Oxygen saturation refers to the percentage of hemoglobin molecules saturated with oxygen. Hemoglobin
molecules can each carry four oxygen molecules; the oxygen binds or attaches to hemoglobin molecules. Oxygen
saturation provides information about how much hemoglobin is carrying oxygen, compared to how much
hemoglobin is not carrying oxygen.
Why is Oxygen Saturation Measured?
Healthcare providers measure oxygen saturation because it provides information about a client’s state of health.
The body’s tissues and organs require oxygen for metabolism, and oxygen saturation can reveal whether there
is sufficient oxygen in the blood or whether the client is in a state called hypoxemia (insufficient oxygen in the
blood).
Oxygen saturation levels can influence clinical decisions about whether the client is receiving sufficient
oxygen and/or requires supplemental oxygen. Oxygen saturation levels are also monitored during and after
surgeries and treatments and to assess a client’s capacity for increased activity.
What is Oxygen Saturation? | 91

44. How is Oxygen Saturation Measured?
Oxygen saturation can be measured using a pulse oximetry device, which is a non-invasive method to measure
arterial oxygen saturation level. See Figure 4.1 for a pulse oximeter. In critically ill clients, a more invasive and
continuous monitoring system is used to measure arterial blood gases through an arterial line. An arterial line is a
catheter that is inserted into an artery, usually the radial artery. It provides a way to access blood gases including
arterial oxygen saturation (SaO2). Here, we focus on pulse oximetry because it is identified as a vital sign.
Figure 4.1: A pulse oximeter

A pulse oximetry device includes a sensor that measures light absorption of hemoglobin and represents
arterial SpO2 (OER #1). Oxyhemoglobin and unoxygenated hemoglobin absorb light differently. The sensor
measures “the relative amount of light absorbed by oxyhemoglobin and unoxygenated (reduced) hemoglobin”
and compares the amount of “light emitted to light absorbed” (Jarvis, 2014, p. 164). This comparison is then
converted to a ratio and is expressed as a percentage of Sp02.
92 | How is Oxygen Saturation Measured?

Points to Consider
A pulse oximeter reading reflects arterial oxygen saturation levels, as opposed to venous oxygen
saturation levels, because the device only measures light absorption of pulsatile flow: the ‘p’ in Sp02
refers to pulse or pulsatile flow. If pulsatile flow is limited or obstructed, an oxygen saturation level will
not be accurate. For example, the compression of a blood pressure cuff will obliterate the pulsatile flow
so blood pressure and pulse oximetry should not be taken simultaneously on the same limb.
The sensor is attached using various devices. One is a spring-loaded clip attached to a finger or toe as shown in
Figure 4.1. It is used when an intermittent measurement is required. However, this clip is too large for newborns
and young children, so for this population, the sensor is taped to a finger or toe. See Figure 4.2. This technique
is also used for clients who require continuous monitoring.
Figure 4.2: Pulse oximeter with sensor taped around finger

An earlobe clip is another useful device for clients who cannot tolerate the finger or toe clip or have a condition
that could affect the results, such as vasoconstriction and poor peripheral perfusion. Another type of device is
taped across the forehead and left in place for continuous monitoring. See Figure 4.3.
How is Oxygen Saturation Measured? | 93

Figure 4.3: Pulse oximeter with device across forehead
_____________________________________________________________________
____
94 | How is Oxygen Saturation Measured?

45. What are Normal Oxygen Saturation Levels?
The normal oxygen saturation level is 97–100% (OER #1).
Older adults typically have lower oxygen saturation levels than younger adults. For example, someone older
than 70 years of age may have an oxygen saturation level of about 95%, which is an acceptable level.
It is important to note that the oxygen saturation level varies considerably based on a person’s state of health.
Thus, it is important to understand both baseline readings and underlying physiology associated with certain
conditions to interpret oxygen saturation levels and changes in these levels.
• People who are obese and/or have conditions such as lung and cardiovascular diseases, emphysema,
chronic obstructive pulmonary disease, congenital heart disease and sleep apnea tend to have lower
oxygen saturation levels.
• Smoking can also influence the accuracy of pulse oximetry in which the the SpO2 is low or falsely high
depending on whether hypercapnia is present. With hypercapnia, it is difficult for the pulse oximeter to
differentiate oxygen in the blood from carbon monoxide (caused by smoking).
• Additionally, oxygen saturation levels may decrease slightly when a person is talking.
• Oxygen saturation may remain normal (e.g., 97% and higher) for people with anemia. However, this may not
indicate adequate oxygenation because there are less hemoglobin to carry an adequate supply of oxygen
for people who have anemia. The inadequate supply of oxygen may be more prominent during activity for
people with anemia.
• Falsely low oxygen saturation levels may be associated with hypothermia, decreased peripheral perfusion,
and cold extremities. In these cases, an ear lobe pulse oximeter device or arterial blood gases would
provide a more accurate oxygen saturation level. However, arterial blood gases are usually only taken in
critical care or emergency settings.
Points to Consider
In practice, the SpO2 range of 92–100% is generally acceptable for most clients. Some experts have
suggested that a SpO2 level of at least 90% will prevent hypoxic tissue injury and ensure client safety
(Beasley, et al., 2016).
_____________________________________________________________________
____
What are Normal Oxygen Saturation Levels? | 95

46. Oxygen Saturation Technique
Technique
The pulse oximeter probe is clipped onto or taped around a client’s finger, as shown in Figure 4.4. The device
displays an oxygen saturation level and a pulse within a few seconds. Palpate the client’s radial pulse (taken for
30 seconds if regular and one minute if irregular) while the oximeter is attached to the finger. The healthcare
provider can have confidence in the accuracy of the measurement of the oxygen saturation level if the pulse
displayed on the oximeter coincides with the radial pulse.
Figure 4.4: Measuring oxygen saturation
Points to Consider
Nail polish or artificial nails can interact with the absorption of light waves and influence the accuracy
of the SpO2 measurement when using a probe clipped on the finger. Remove nail polish or use an
alternative method.
96 | Oxygen Saturation Technique

Many factors can influence accuracy when measuring oxygen saturation levels via pulse oximetry. Certain
conditions, including poor circulation and peripheral vasoconstriction, can lead to inaccurate oxygen saturation
measurements when the device is attached to a finger or toe. Vasoconstriction involves narrowing of the vessels,
so blood flow is reduced to the peripheries. This can reduce the accuracy of the reading and reduce the
oximeter’s capacity to detect a signal. Readings may also be inaccurate (low) if a client’s hands or feet are cold or
they have poor circulation. In cases like these, use an alternate method of measurement, like clipping a device to
the earlobe or taping it to the forehead.
The healthcare provider cannot have confidence in measurement accuracy when the radial pulse does not
coincide with the pulse displayed on the oximeter. It is also important to note that the pulse oximeter device
cannot provide an accurate reading when oxygen saturation is below 75% (Shah & Shelley, 2013). Oxygen
saturation levels in the 70s indicate that a client is decompensating and immediate intervention is required. Thus,
it is important to confirm accuracy via additional assessments, such as assessing for respiratory distress, drawing
arterial blood gases and/or checking for machine error.
The significance of the oxygen saturation level is interpreted in the context of the client’s baseline
measurements, other data including vital signs and other objective and subjective findings, and the client’s
overall health and wellness state.
Oxygen Saturation Technique | 97

47. Finding the Error Activity 1: Pulse Oximetry
Now you have an opportunity to find errors in measurement techniques. The first activity involves watching a
short film clip. Check it out!
What error in technique is this healthcare provider making while measuring oxygen saturation in Film clip
4.1?
bbm3hOPFjQg?rel=0
Film clip 4.1 Oxygen saturation taken incorrectly
Go to the next page for information about the correct technique for measuring oxygen saturation.
98 | Finding the Error Activity 1: Pulse Oximetry

48. Finding the Error Activity 1: Pulse Oximetry –
Feedback
In the film clip 4.1, the healthcare provider did not confirm the accuracy of the pulse displayed on the pulse
oximeter with the radial pulse. Healthcare providers always assess the radial pulse and ensure that it coincides
with the pulse displayed on the oximeter to ensure the accuracy of the oxygen saturation level.
Finding the Error Activity 1: Pulse Oximetry – Feedback | 99

49. Finding the Error Activity 2: Pulse Oximetry
Now you have an opportunity to find errors in measurement techniques by looking at an image.
What error in technique is this healthcare provider making while measuring oxygen saturation?
Figure 4.5: Error in technique while measuring oxygen saturation
Go to the next page for information about the correct technique for measuring oxygen saturation.
100 | Finding the Error Activity 2: Pulse Oximetry

50. Finding the Error Activity 2: Pulse Oximetry –
Feedback
An incorrect technique is demonstrated in Figure 4.6 because the healthcare provider is using the pulse
oximeter device on a client who has nail polish on her fingers. Nail polish can affect accuracy, so healthcare
providers remove nail polish when pulse oximetry is measured on the fingers. Alternatively, the pulse oximetry
could be measured using a device attached to the earlobe. The correct technique is demonstrated in Figure 4.7 in
which the nail polish is removed. It is also important to note that healthcare providers need to ensure the radial
pulse aligns with the pulse displayed on the pulse oximeter.
Incorrect technique of measuring pulse oximetry
Figure 4.6: Error in technique while measuring oxygen saturation
Finding the Error Activity 2: Pulse Oximetry – Feedback | 101

Correct technique of measuring pulse oximetry
Figure 4.7: Correct technique of measuring pulse oximetry
102 | Finding the Error Activity 2: Pulse Oximetry – Feedback

51. Try it Out: Pulse Oximetry
Next, you have an opportunity to watch a short film clip on accurate measurement techniques. Watch this
film clip 4.2 to see how to measure oxygen saturation correctly using a pulse oximeter. After the clip, try the
6KTG1lWQ8bs?rel=0
Film clip 4.2: Oxygen saturation taken correctly
Try it Out: Pulse Oximetry | 103

52. Test Yourself
questions. Write your answers down on a piece of paper.
1. Match each person with the estimated SpO2.

Healthy adolescent 92% SpO2
Adult with lung disease 95% SpO2
80-year-old adult 97% SpO2
2. A client’s oxygen saturation is measured via pulse oximetry using a finger probe. The radial pulse does
not coincide with the pulse displayed on the oximeter. How should the healthcare provider respond?
a. Notify the most responsible provider
b. Document the findings in the client’s chart
c. Assume the client has hypoxic tissue injury
d. Repeat the measurements using an earlobe probe
3. The physician asks for an oxygen saturation report on a client who has peripheral limb tremors. What is
the best location to place the probe?
a. Ear
b. Toe
c. Finger
d. Thumb
4. A person’s oxygen saturation is 89% and the pulse displayed on the pulse oximeter is aligned with the
radial pulse. How should the healthcare provider respond?
a. Give oxygen to the client
b. Raise up the head of the client’s bed
c. Ask the client, “are you having any difficulty breathing?”
d. Note this finding as normal and continue with assessment
104 | Test Yourself

1. Match each person with the estimated SpO2.
Healthy adolescent——————97% SpO2
Adult with lung disease————-92% SpO2
80-year-old adult——————–95% SpO2
2. A client’s oxygen saturation is measured via pulse oximetry using a finger probe. The radial pulse does
not coincide with the pulse displayed on the oximeter. How should the healthcare provider respond?
a. Notify the most responsible provider
b. Document the findings in the client’s chart
c. Assume the client has hypoxic tissue injury
d. Repeat the measurements using an earlobe probe **
Rationale: The correct answer is d (repeat the measurements using an earlobe probe). Repeat the
measurements using an ear probe. The O2 saturation reading is inaccurate when the palpable pulse does not
coincide with the pulse displayed on the pulse oximeter. This could be caused by conditions related to poor
circulation and/or peripheral vasoconstriction. The best action is to use an alternate method to obtain the O2
saturation such as an earlobe probe.
3. The physician asks for an oxygen saturation report on a client who has peripheral limb tremors. What is
the best location to place the probe?
a. Ear **
b. Toe
c. Finger
d. Thumb
Rationale: The correct answer is a (ear). Tremors can affect the ability of the pulse oximeter to accurately read
the pulsations and oxygen saturations. The toe, finger, and thumb are all affected by the tremors. Therefore, it is
best to use the earlobe to measure O2 saturation.
4. A person’s oxygen saturation is 89% and the pulse displayed on the pulse oximeter is aligned with the
radial pulse. How should the healthcare provider respond?
a. Give oxygen to the client
b. Raise up the head of the client’s bed
c. Ask the client, “are you having any difficulty breathing?” **
d. Note this finding as normal and continue with assessment
Rationale: The correct answer is c (ask the client, “are you having any difficulty breathing?”). Ask the client
if he/she is having any difficulty breathing. This oxygen saturation is considered abnormal. Further assessments
need to be completed prior to an intervention. The first assessment starts with the respiratory system including
a subjective assessment of the client’s breathing and whether he/she is having difficulty breathing. The context
of the client’s current health state will determine how you proceed with interventions.

List the steps below in the correct order. Write your list on a piece of paper.
• turn oximeter on
• remove client nail polish
• clean oximeter probe with alcohol swab
• take radial pulse (30 seconds if regular and one minute if irregular)
• ensure radial pulse is aligned with pulse displayed on the oximeter
• clip or tape probe onto a client’s finger
• report or document findings

– Answers
The steps are listed in the correct order below. These are printable flashcards to help you memorize and
practice the techniques.
1. remove client nail polish

2. clean oximeter probe with alcohol swab
3. clip or tape probe onto a client’s finger
4. turn oximeter on
5. take radial pulse (30 seconds if regular and one minute if irregular)
6. ensure radial pulse is aligned with pulse displayed on the oximeter
7. document or report findings

56. Chapter Summary
Measuring oxygen saturation via pulse oximetry is a non-invasive way to quickly assess a client’s oxygen level.
The results reflect a person’s oxygenation status and provide data for healthcare providers’ diagnostic reasoning.
The sensor can be attached in many ways, including clipping and taping probes to the finger, toe, earlobe,
and forehead. The type and location of the apparatus is selected based on the client’s age, the presence
of vasoconstriction, the adequacy of peripheral perfusion, whether intermittent or continuous monitoring is
required, and the client’s health and illness state.
When determining the relevance of the oxygen saturation reading, healthcare providers consider the client’s
health and wellness state. Specifically, they consider other data related to oxygenation including respiratory
quality, rate, and rhythm; pulse; skin colour and temperature; and the client’s subjective description of ease
or difficulty breathing. Decreases in oxygen saturation readings are potentially life-threatening and require
immediate intervention.
108 | Chapter Summary

PART V
CHAPTER 5: BLOOD PRESSURE
Chapter 5: Blood Pressure | 109

57. What is Blood Pressure?
Blood pressure is the force of blood exerted against the arterial walls, and is reported in millimetres of mercury
(mm Hg). Try turning your kitchen tap on just a little bit, and then full blast. Compare the varying forces of water
pressure as you adjust the tap. This comparison will give you a better sense of blood pressure.
The pressure against the arterial walls (the blood pressure) changes depending on whether the heart is
contracting and pushing blood out into the arteries or whether the heart is in a resting phase and filling with
blood. There is always force against the arterial walls, even when the heart is in a resting phase. The systolic
pressure is the maximum pressure on the arteries during left ventricular contraction (systole) (OER #1). The
left ventricle is a lower chamber of the heart responsible for pumping blood out to the body. The diastolic
pressure is the resting pressure on the arteries between each cardiac contraction (OER #1) when the heart’s
chambers are filling with blood (diastole).
Stroke volume is the amount of blood ejected from the left ventricle in a single contraction. Stroke volume
provides information about the functioning of the heart. Stroke volume is influenced by age and typically ranges
from 5–80 mL. Newborns have a stroke volume of about 5 mL per contraction while adults have a stroke volume
of about 30–70 mL per contraction; the stroke volume increases as individuals grow and their hearts become
stronger and can pump more volume per contraction. Direct measurement of stroke volume involves an invasive
approach in which a catheter is passed into the pulmonary artery via a large neck vein; this monitoring device is
only used during critical care situations.
Indirect measurement of stroke volume involves assessing the pulse pressure, which is the difference between
the systolic and diastolic values and signifies the force required by the heart each time it contracts. For example,
if someone’s blood pressure is 120/80 mm Hg, the pulse pressure is 40 mm Hg. A higher pulse pressure can
indicate arterial stiffness, which often happens as a result of aging or cardiovascular disease. A higher pulse
pressure can also be indicative of aortic valvular insufficiency where the diastolic pressure is unusually low and
the systolic pressure is mildly elevated or unchanged. A lower pulse pressure can be a marker of poor heart
function, where cardiac output is decreased.
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What is Blood Pressure? | 111

58. Why is Blood Pressure Measured?
• A person’s blood pressure provides insight into the functioning of the body
• Healthy body functioning is influenced by healthy blood pressure
• The findings can provide information about the integrity of arteries and heart functioning, which can lead
the healthcare provider to conduct additional assessments
• High blood pressure can cause the arteries to become weak and damaged and cause the heart to become
weak and enlarged
• Low blood pressure can decrease perfusion of nutrients and oxygen to the body’s cells, influencing ability
to function and potentially to cellular death
• Chronic high blood pressure can contribute to conditions such as vascular disease, myocardial infarction,
cerebral stroke, kidney disease, and dementia
112 | Why is Blood Pressure Measured?

59. Factors That Influence Blood Pressure
Five factors influence blood pressure:
1. Cardiac output
2. Peripheral vascular resistance
3. Volume of circulating blood
4. Viscosity of blood
5. Elasticity of vessels walls
Blood pressure increases with increased cardiac output, peripheral vascular resistance, volume of blood,
viscosity of blood and rigidity of vessel walls.
Blood pressure decreases with decreased cardiac output, peripheral vascular resistance, volume of blood,
viscosity of blood and elasticity of vessel walls.
Cardiac Output
Cardiac output is the volume of blood flow from the heart through the ventricles, and is usually measured in
litres per minute (L/min). Cardiac output can be calculated by the stroke volume multiplied by the heart rate.
Any factor that causes cardiac output to increase, by elevating heart rate or stroke volume or both, will elevate
blood pressure and promote blood flow. These factors include sympathetic stimulation, the catecholamines
epinephrine and norepinephrine, thyroid hormones, and increased calcium ion levels. Conversely, any factor
that decreases cardiac output, by decreasing heart rate or stroke volume or both, will decrease arterial pressure
and blood flow. These factors include parasympathetic stimulation, elevated or decreased potassium ion levels,
decreased calcium levels, anoxia, and acidosis.
Peripheral Vascular Resistance
Peripheral vascular resistance refers to compliance, which is the ability of any compartment to expand to
accommodate increased content. A metal pipe, for example, is not compliant, whereas a balloon is. The greater
the compliance of an artery, the more effectively it is able to expand to accommodate surges in blood flow
without increased resistance or blood pressure. Veins are more compliant than arteries and can expand to
hold more blood. When vascular disease causes stiffening of arteries (e.g., atherosclerosis or arteriosclerosis),
compliance is reduced and resistance to blood flow is increased. The result is more turbulence, higher pressure
within the vessel, and reduced blood flow. This increases the work of the heart.
Volume of Circulating Blood
Volume of circulating blood is the amount of blood moving through the body. Increased venous return stretches
the walls of the atria where specialized baroreceptors are located. Baroreceptors are pressure-sensing receptors.
As the atrial baroreceptors increase their rate of firing and as they stretch due to the increased blood pressure,
the cardiac centre responds by increasing sympathetic stimulation and inhibiting parasympathetic stimulation
to increase HR. The opposite is also true.
Factors That Influence Blood Pressure | 113

Viscosity of Blood
Viscosity of blood is a measure of the blood’s thickness and is influenced by the presence of plasma proteins and
formed elements in the blood. Blood is viscous and somewhat sticky to the touch. It has a viscosity approximately
five times greater than water. Viscosity is a measure of a fluid’s thickness or resistance to flow, and is influenced
by the presence of the plasma proteins and formed elements within the blood. The viscosity of blood has a
dramatic effect on blood pressure and flow. Consider the difference in flow between water and honey. The more
viscous honey would demonstrate a greater resistance to flow than the less viscous water. The same principle
applies to blood.
Elasticity of Vessel Walls
Elasticity of vessel walls refers to the capacity to resume its normal shape after stretching and compressing.
Vessels larger than 10 mm in diameter are typically elastic. Their abundant elastic fibres allow them to expand as
blood pumped from the ventricles passes through them, and then to recoil after the surge has passed. If artery
walls were rigid and unable to expand and recoil, their resistance to blood flow would greatly increase and blood
pressure would rise to even higher levels, which would in turn require the heart to pump harder to increase the
volume of blood expelled by each pump (the stroke volume) and maintain adequate pressure and flow. Artery
walls would have to become even thicker in response to this increased pressure.
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All content on this page was adapted from OER #2:
114 | Factors That Influence Blood Pressure

60. What are Normal Blood Pressure Ranges?
Blood pressure is reported in mm Hg, in which the systolic is the numerator and diastolic is the denominator.
See Table 5.1 for an overview of estimated normal blood pressure for age.
Table 5.1: Estimated Normal Blood Pressure for Age
Age Normal Systolic Range Normal Diastolic Range

Newborn to 1 month 45–80 mm Hg 30–55 mm Hg
One to 12 months 65–100 mm Hg 35–65 mm Hg
Young child (1–5 years) 80–115 mm Hg 55–80 mm Hg

Older child (6–13 years) 80–120 mm Hg 45–80 mm Hg
Adolescent (14–18 years) 90–120 mm Hg 50–80 mm Hg

Adult (19–40 years) 95–135 mm Hg 60–80 mm Hg
Adult (41–60 years) 110–145 mm Hg 70–90 mm Hg
Older adult (61 and older) 95–145 mm Hg 70–90 mm Hg
Points to Consider
The average blood pressure for an adult is 120/80 mm Hg. However, this is only an average and the
healthcare provider needs to consider acceptable ranges for individual clients. For example, in adults,
normal blood pressure can range from 95–145/60–90 mm Hg. The healthcare provider considers the
client’s baseline blood pressure and the client’s current health state in conjunction with subjective data
and other objective data. For example, a blood pressure of 90/50 mm Hg may be normal for a healthy,
asymptomatic 20-year-old adult.
Factors that influence blood pressure include age, sex, ethnicity, weight, exercise, emotions/stress, pregnancy,
and diurnal rhythm as well as medication use and disease processes.
• The general pattern is that blood pressure rises with age, so normal variations tend to be higher for older
adults.
• Blood pressure is similar in childhood for males and females. After puberty, females have lower blood
pressure than males, whereas after menopause females have higher blood pressure than males.
• Research has revealed that ethnicity may be a predictor of blood pressure, but this causation is not
necessarily biological, but rather sociocultural. When determining risk for high blood pressure, it is
important to consider ethnicity as a contributing factor.
• The diurnal cycle influences blood pressure to be lower in the morning and increase throughout the day
until early evening. Try it out: take your blood pressure when you wake up in the morning and then again in
late afternoon, and note the difference. This is one reason why healthcare providers document the time a
What are Normal Blood Pressure Ranges? | 115

client’s blood pressure is taken.
• Blood pressure can be higher in people who are obese because the heart has to work harder to perfuse the
body’s tissues.
• The sympathetic nervous system is stimulated by exercise, stress, anxiety, pain, anger, and fear, which
increases blood pressure. Blood pressure returns to baseline within five minutes of rest following activity.
Try it out. Have a peer take your blood pressure. Then, run on the spot or do some other cardiac activity
for five minutes. Have the peer take your blood pressure again, and then lie down and rest for five minutes.
Take the blood pressure again. Note the changes.
• Blood pressure varies throughout the duration of pregnancy. It decreases about halfway through the first
trimester until mid-pregnancy due to progesterone effects that relax the walls of blood vessels, causing
decreased peripheral vascular resistance. It returns to pre-pregnancy values toward the end of pregnancy.
Points to Consider
‘White coat syndrome’ refers to elevated blood pressure due to nervousness or anxiety when clients
have their blood pressure taken by a healthcare provider. This occurs in approximately 20% of clients.
Key message: have the client take their blood pressure at home with an automatic home blood pressure
cuff and compare the findings. Alternatively, you can ask the client to sit quietly and leave the room while
an automatic cuff takes a client’s blood pressure. The automatic cuff can be programmed to take three
measurements and the blood pressure documented is an average of the three readings.
116 | What are Normal Blood Pressure Ranges?

61. How is Blood Pressure Measured?
Blood pressure is measured in many ways including manual, automatic, cellular phone applications, and arterial
catheters. Whatever method is used, blood pressure must be measured using validated equipment. Studies have
repeatedly demonstrated that blood pressure is often not measured accurately in clinical practice, particularly
when using the auscultatory/manual method. It is important to ensure correct technique to obtain an accurate
measurement.
Points to Consider
Take blood pressure in both arms when you measure a client’s blood pressure for the first time. A small
difference in blood pressure between the arms is often normal. Differences of greater than 10 mm Hg
systolic between the arms are investigated further because this finding has been associated with vascular
disease and mortality outcomes. Measure subsequent blood pressures in the arm with the higher blood
pressure.
Client Positioning
Blood pressure is generally taken in a sitting or supine position with the bare arm at heart level (OER #1). Certain
health states prevent some clients from sitting, such as clients who are critically ill, unstable, or postoperative.
Thus, healthcare providers document the client’s positioning (e.g., sitting, supine, standing). If sitting, the feet
are placed flat on the floor with the back resting comfortably against a chair. The healthcare provider checks to
ensure that the client’s legs are not crossed, because this can increase blood pressure. The client sits resting for
five minutes before you take the blood pressure. This waiting period is not feasible when the client’s condition
is deteriorating or a STAT blood pressure is required.
Cuff Types and Sizes
Manual and automatic blood pressure measurement involves using a blood pressure cuff with a
sphygmomanometer. Many cuff sizes are available to fit newborns, children, adults, people with small and larger
arms, and people with cone-shaped arms. The cuff is typically wrapped around the upper arm. However, there is
also a cuff that can be placed on the thigh when the arm is not feasible. See Figure 5.1 of varying blood pressure
cuff sizes.
How is Blood Pressure Measured? | 117

Figure 5.1: Varying blood pressure cuff sizes
It is important to choose a cuff size that matches the client’s arm size, rather than their age. See Table 5.2
about cuff sizing. See Film Clip 5.1 of a demonstration of accurate cuff sizing.
Table 5.2: Cuff Sizing
Cuff Sizing
The width of the cuff is 40% of the person’s arm circumference
The length of the cuff’s bladder is 80–100% of the person’s arm circumference
Film clip 5.1: Accurate cuff sizing
Alternatively, if viewing textbook as a pdf, use this link: https://www.youtube.com/embed/uNTMwoJTfFE?rel=0

Before placing the blood pressure cuff on the client’s arm, palpate the brachial artery just above the antecubital
118 | How is Blood Pressure Measured?

fossa medially (OER #1). To do this, palpate the bicep tendon at the antecubital fossa. Move 2 cm medially from
the tendon and 2–3 cm above the antecubital fossa. Press firmly to feel the brachial pulse. Wrap the blood
pressure cuff securely and evenly around the client’s upper, bare arm (not over clothing) with the cuff’s artery
marker aligned with the brachial artery.
Technique Tips
Thigh blood pressure is indicated when blood pressure cannot be taken on the arm, such as when
clients have bilateral amputation or burns. Thigh blood pressure is also done on children and adolescents
with unusually high blood pressure in the arm and to compare differences between upper and lower
extremities. In such cases, coarctation of the aorta (a congenital narrowing of the aorta) is possible. The
thigh systolic blood pressure is 10–40 mm Hg higher than the arm systolic blood pressure, while the
thigh diastolic blood pressure is approximately the same as the arm. To obtain thigh blood pressure, the
client must be in prone position. Place the cuff around the bottom third of the client’s thigh. The cuff’s
artery line is aligned with the popliteal artery. The popliteal artery can be located in the popliteal fossa.
Palpate the medial tendon and move the pads of your three fingers lateral to the tendon. Press your
fingers into the femur or tibia bone. Continue with the same process as noted above in terms of taking
blood pressure.
Blood Pressure Methods
Manual blood pressure measurement is taken using a blood pressure cuff with a sphygmomanometer and a
stethoscope. See Figure 5.2. This technique is detailed on next page.

Figure 5.2: Blood pressure cuff with a sphygmomanometer and a stethoscope
Automatic blood pressure cuffs are a digital way to measure blood pressure. See Figure 5.3. After positioning
the client and the blood pressure cuff on the arm, press the start button on the monitor. The cuff is automatically
inflated and then, deflates at a rate of 2 mm Hg per second. The monitor has a digital display that shows the blood
pressure reading when done. Automatic cuffs can be programmed to take a series of blood pressure readings in a
row. If the healthcare provider is concerned about an initial high blood pressure reading on a client, the accuracy
of the blood pressure is verified with the following actions:
• have the client sit in a room by themselves

• quiet the room
• dim the lights
• allow the client to sit quietly, without talking
• then take three measurements, a few minutes apart, with the automatic cuff. The blood pressure displayed
is an average of the three readings.

Figure 5.3: Automatic blood pressure cuffs
Clients can monitor their own blood pressure at home with an automatic digital blood pressure monitoring
device. Clients are advised to use a device that meets the standards of the Association for the Advancement of
Medical Instrumentation, the requirements of the British Hypertension Society protocol, or the International
Protocol for Validation of Automated Blood Pressure Measuring Devices. The cuff is applied around the client’s
upper arm or wrist. Similar to the automatic cuff noted above, the client presses the start button and the
cuff inflates and deflates based on programmed levels displaying a digital reading. Clients are encouraged to
document their blood pressure or use a device with data-recording capabilities to increase the reliability of their
reported home blood pressure monitoring. These data can be shared with the client’s primary care provider.
Arterial catheters are an invasive way to measure blood pressure and are only used in critical care situations
when continuous blood pressure monitoring and arterial blood gas draws are required. This involves insertion
of a catheter (similar to an intravenous) into the artery. The catheter is connected to a pressure transducer and
monitor that provide a digital blood pressure reading.
Cellular phone applications have been developed to measure blood pressure, but the accuracy of this
technology is still being investigated.
Points to Consider
Avoid using an automatic blood pressure cuff if the systolic pressure is less than 90 mm Hg in an adult,

the pulse is rapid or the rhythm is irregular, and/or the client is experiencing shivers or tremors. It is
best to also complete a manual blood pressure measurement to validate the accuracy of the automatic
blood pressure measurement.
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62. Manual Blood Pressure Measurement
A healthcare provider uses a stethoscope and a blood pressure cuff with a sphygmomanometer to measure blood
pressure manually. The stethoscope is used to listen to the blood pressure sounds, which are called Korotkoff
sounds.
Stethoscope Usage and Korotkoff Sounds
The stethoscope is used on bare skin so that a client’s clothing does not affect the sounds. The stethoscope does
not make sounds louder; it simply blocks out extraneous noises so you can better hear the Korotkoff sounds.
These sounds are heard through a stethoscope applied over the brachial artery when the blood pressure cuff
is deflating. You will not hear anything when you first place the stethoscope over the brachial artery, because
unobstructed blood flow is silent. The Korotkoff sounds appear after you inflate the cuff (which compresses the
artery/blood flow) and then begin to deflate the cuff. The Korotkoff sounds are the result of the turbulent blood
caused by the inflated cuff compressing the artery and oscillations of the arterial wall when the heart beats
during cuff deflation.
Here are a few tips:
• Use a high quality stethoscope with durable, thick tubing. Avoid stethoscopes with long tubing because this
can distort sounds.
• Ensure quiet surroundings so that you can better hear the Korotkoff sounds.
• Make sure that the slope of the stethoscope earpieces point forward or toward your nose.
• Use a stethoscope that has both bell and diaphragm capacity. See Figure 5.4 for bell and diaphragm.
Manual Blood Pressure Measurement | 123

Figure 5.4: Stethoscope with bell and diaphragm (Illustration credit: Hilary Tang)
124 | Manual Blood Pressure Measurement

• Cleanse the stethoscope prior to use including the ear pieces and the bell and diaphragm.
• The bell of the stethoscope is suggested because it is used for low-pitched sounds like blood pressure.
However, some healthcare providers use the diaphragm for several reasons: that is how they learned to
take blood pressure; they believe this helps them hear the Korotkoff sounds better; and the diaphragm
covers a larger surface area than the bell.
• Hold the bell lightly against the skin with a complete seal or hold the diaphragm firmly against the skin with
a complete seal.
• You must ensure that the bell or diaphragm is open before using. See Film Clip 5.2 on how to open and
close the bell and diaphragm.
Film clip 5.2: Opening and closing the bell and diaphragm
Alternatively, if viewing textbook as a pdf, use this link: https://www.youtube.com/embed/rp_4h-tCmvs?rel=0
Determining Maximum Inflation Pressure
Healthcare providers determine the maximum inflation pressure before they take blood pressure. The maximum
inflation pressure is the number on the sphygmomanometer that the cuff is inflated to when measuring blood
pressure. If you do not determine the maximum pressure inflation, an auscultatory gap could go unrecognized,
and as a result the blood pressure could be underestimated (lower than the actual value).
An auscultatory gap is a silent interval when the Korotkoff sounds go absent and then reappear while you are
deflating the cuff during blood pressure measurement. This gap is an abnormal finding and can occur due to
arterial stiffness and arteriosclerotic disease. It is typically observed in people with a history of hypertension
who have been treated with prolonged antihypertensive medication.
To determine the maximum inflation pressure, start by palpating the brachial or radial pulse while inflating the
cuff. Inflate the cuff 30 mm Hg past the point when you obliterate the pulse (ie., you no longer feel the pulse). If
you still cannot feel the pulse, use that value to start auscultating – that value is the maximum inflation pressure
number.
When taking blood pressure, if an auscultatory gap is observed, document the first systolic sound and diastolic
sound only. Report the presence of an auscultatory gap in narrative notes.
Points to Consider
Generally, auscultatory gaps do not interfere with automatic blood pressure measurements (Fech, et

al., 2012). However, if a client’s blood pressure reading is suspiciously high or low, the healthcare provider
takes blood pressure manually.
Blood Pressure Measurement Techniques
For novices, it is a good idea to start with the two-step technique and then move onto the one-step technique
as you develop your skills.
Two-step technique
First step: Determining maximum pressure inflation
Palpate the radial or brachial artery, inflate the blood pressure cuff until the pulse is obliterated, and then
continue to inflate 20–30 mm Hg more (OER #1). Note this number – it is considered the maximum pressure
inflation. Next, deflate the cuff quickly.
Second step: Measure blood pressure
Now, you can start to measure blood pressure. Place the bell of the cleansed stethoscope over the brachial artery
(OER #1) using a light touch and complete seal. Inflate the cuff to the maximum pressure inflation number (OER
#1). Open the valve slightly. Deflate the cuff slowly and evenly (OER #1) at about 2 mm Hg per second. See Film
Clip 5.3 which focuses on the speed of the needle when deflating the blood pressure cuff.
Note the points at which you hear the first appearance of Korotkoff sounds (systolic blood pressure) (OER #1)
and the last Korotkoff sound before it goes silent (diastolic blood pressure). These sounds are called Korotkoff
sounds and vary in quality from tapping, swooshing, muffled sounds, and silence. The pressure at which the
first Korotkoff sound is noted signifies the systolic pressure, while the pressure at which the last Korotkoff
sound is heard before it goes silent marks the diastolic pressure. See Audio Clip 5.1 to listen to Korotkoff
sounds and noting systolic and diastolic blood pressure. Alternatively, if viewing textbook as a pdf, use this
link: https://www.youtube.com/embed/lPlYNt8cVnI?rel=0
Film clip 5.3: Deflation rate of sphygmomanometer
Alternatively, if viewing textbook as a pdf, use this link: https://www.youtube.com/embed/QbGPzUluT5c?rel=0
126 | Manual Blood Pressure Measurement

One-step technique: Determining maximum pressure inflation and taking blood pressure
Palpate the radial or brachial artery, inflate the blood pressure cuff until the pulse is obliterated, and then
continue to inflate 20 to 30 mm Hg more (OER #1). Place the bell of the cleansed stethoscope over the brachial
artery (OER #1) using a light touch with a complete seal. Open the valve slightly. Deflate the cuff slowly and
evenly (OER #1) at about 2 mm Hg per second. Note the points at which you hear the first Korotkoff sound
(systolic blood pressure) (OER #1) and the last Korotkoff sound (diastolic blood pressure) before it goes silent.
These sounds are called Korotkoff sounds and vary in quality from tapping, swooshing, muffled sounds, and
silence. The first Korotkoff sound is the systolic pressure, and the diastolic pressure is the last Korokoff sound
before the sounds go silent.
Audio clip 5.1: Korotkoff sounds with blood pressure of 122/76 mm Hg

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63. What Should the Healthcare Provider
Consider?
Manual blood pressure is reported in even numbers. Healthcare providers always measure blood pressure with
pulse because these vital signs are closely related and data from both are needed to make accurate and informed
clinical decisions.
What Should You Do if You Cannot Feel the Brachial Pulse?
• To locate the brachial pulse, palpate the bicep tendon, move medially about 2 cm, and move up about 2–3
cm
• Use three fingers including your index and middle finger to feel for the pulse
• You will usually need to press fairly firmly to palpate the brachial pulse and may need to modify the
pressure. If you press too hard, you will obliterate the pulse (make it disappear) and if you press too lightly,
you will not be able to feel the pulse
• You may need to reposition your fingers to find the best place to feel the pulse along the brachial artery
• Place the client’s arm with the palm up and elbow extended. You can flex the elbow in varying degrees to
relax the muscle and accentuate the pulse
• Cup your opposite hand under the client’s elbow
What Should You Do if You Cannot Hear the Korotkoff Sounds?
• Use your bell and make full contact with skin

• Make sure the bell is positioned over the brachial artery
• Ensure the room is quiet
• Concentrate on expected sounds (swooshing, tapping, muffled sounds)
• Try different earbuds (hard or soft) on your stethoscope
Common Errors When Taking Blood Pressure
Many errors must be avoided when measuring blood pressure. Failure to determine maximum pressure inflation
can produce a falsely low systolic reading. Deflating the cuff too slowly can produce a falsely high diastolic, and
deflating the cuff too quickly can produce a falsely low systolic or falsely high diastolic reading. Inaccurate cuff
sizes for the client’s arm size and shape can result in measurement error: a cuff that is too narrow or too loose
can produce a falsely high blood pressure. A falsely low blood pressure can result from the arm being positioned
above the level of the heart and a falsely high blood pressure can result from the arm being positioned below the
level of the heart.
128 | What Should the Healthcare Provider Consider?

64. Hypertension
Chronically elevated blood pressure is known clinically as hypertension. It is defined as chronic and persistent
blood pressure measurements of 140/90 mm Hg or above (OER #2). However, the specific measurement in
which hypertension is diagnosed depends on many factors. As per Hypertension Canada (Leung, et al., for
Hypertension Canada, 2017), some of these factors include whether it is the first or second visit to have
blood pressure assessed and whether the blood pressure is assessed using automatic or manual measurement
devices. It is always important to look at the most current guidelines related to hypertension. See Table 5.3 for
the guidelines related to management, including monitoring and treatment, recommended by Hypertension
Canada (Leung, et al., for Hypertension Canada, 2017).
Hypertension is typically a silent disorder, so hypertensive clients may not recognize the seriousness of their
condition and not adhere to their treatment plan. The result is often a heart attack or stroke. Hypertension
may also lead to an aneurysm (ballooning of a blood vessel caused by a weakening of the wall), peripheral
arterial disease (obstruction of vessels in peripheral regions of the body), chronic kidney disease, or heart failure.
(OER#2)
Common errors in measurement and natural fluctuations in blood pressure can result in readings that
erroneously suggest hypertension. Some of the errors are due to the operator (i.e., the healthcare provider) and
others are due to client anxiety and situational determinants. As a healthcare provider, it is important to review
your technique to assess possible measurement errors and assess the client for factors that could elevate blood
pressure. If the client’s blood pressure is elevated, repeat the measurement for accuracy and take the blood
pressure in the opposite arm.
Because hypertension is a silent disorder, healthcare providers measure blood pressure at regular intervals.
The intervals depend on the client’s health status and risk factors. Before a diagnosis of hypertension is made,
blood pressure is monitored over days, weeks, or months either in the office using an automatic blood pressure
machine, or at home using an ambulatory blood pressure machine.
Clients demonstrating features of a hypertensive urgency or emergency (e.g., hypertensive encephalopathy,
acute coronary syndrome, acute ischemic stroke, intracranial hemorrhage) are diagnosed as hypertensive and
treated immediately.
Points to Consider
It is important to note the distinction between elevated blood pressure and a diagnosis of
hypertension. See Table 5.3 below for more information on making a determination of hypertension,
which precipitates intervention.
Guidelines to Determine Hypertension
Hypertension Canada (Leung, et al., for Hypertension Canada, 2017) states that when assessing chronic high
blood pressure, readings must be done under the following conditions:
Hypertension | 129
• No acute anxiety, stress, or pain
• No caffeine, smoking, or nicotine in the preceding 30 minutes
• No use of substances containing adrenergic stimulants such as phenylephrine or pseudoephedrine (may be
present in nasal decongestants or ophthalmic drops)
• Bladder and bowel comfortable
• No tight clothing on arm or forearm
• Quiet room with comfortable temperature
• Rest for at least five minutes before measurement
• Ask the client to stay silent prior and during the procedure
Technique Tips
If one of the above conditions is not met, the blood pressure is still taken, but the healthcare provider
must take it into consideration. If the blood pressure is elevated, it needs to be repeated to assess the
possibility of hypertension.
See Table 5.3 for the guidelines related to management, including monitoring and treatment, recommended
by Hypertension Canada (Leung, et al., for Hypertension Canada, 2017). These recommendations are based on
in-office visit one. At least two or more readings are taken during the same visit. If assessing blood pressure
manually, the first reading is discarded and the latter two readings are averaged.
130 | Hypertension
Table 5.3: Hypertension Canada Guidelines
Finding Management
Visit 1 Office BP
MeasurementsManual
BP averaged reading
Annual follow-up appointments are recommended so that trends and/or increases in blood
pressure are assessed.
≥130–139/85–89 mm Hg
(high-normal)
A health history and physical examination are performed.
Visit two is scheduled within one month of visit one.
Visit 1 Office BP If clinically indicated, diagnostic tests are scheduled prior to visit two to assess
MeasurementsManual cardiovascular risk factors (see Table 5.4 for modifiable and non-modifiable risk factors) and
BP averaged reading search for target organ damage (e.g., cerebral vascular, eyes, kidneys, coronary arteries).
≥140/90 mm Hg (high) External, modifiable factors that can increase blood pressure are assessed and removed if
possible (certain prescription drugs and other substances like sodium, licorice root, alcohol,
Automatic BP reading and street drugs).
≥135/85 mm Hg (high)
Out of office blood pressure measurements (e.g., ambulatory or home blood pressure
measurements) are performed before visit two. White coat syndrome/hypertension is
diagnosed if the out of office blood pressure measurements are within the normal range, and
pharmacologic treatment is not initiated.
Visit 1 Office BP
MeasurementsAutomatic
or manual BP averaged
reading Hypertension is diagnosed and immediate intervention is required.
>180/110 mm Hg
The healthcare provider assesses a client’s cardiovascular risk factors for atherosclerosis and hypertension.
These risk factors are categorized as modifiable and non-modifiable. See Table 5.4 for an overview of risk factors
adapted based on Hypertension Canada guidelines (Leung, et al., for Hypertension Canada, 2017)
Table 5.4: Modifiable and Non-modifiable Risk Factors
Non-modifiable Modifiable
• Smoking
• Stress and anxiety
• Sedentary lifestyle (little or no physical
activity)
• Age 55 years or older
• Poor dietary habits (high sugar, high
• Male sex and postmenopausal women
sodium, high fat, high cholesterol)
• Family history of cardiovascular disease that began in men younger
• Abdominal obesity/overweight
than 55 years and in women younger than 65 years
• Dysglycemia and dyslipidemia
• Non-adherence to treatment plans (e.g.,
medication, diet, exercise regimen)
• Alcohol intake
Hypertension | 131
_____________________________________________________________________
____
132 | Hypertension
65. Hypotension
A number of factors can cause hypotension (low blood pressure). Hypotension is considered less than 95/60
mm Hg in a normotensive adult. However, low blood pressure measurements are always interpreted in the
context of a client’s baseline and past blood pressure readings as well as their current health state. Common
symptoms associated with hypotension are lightheadedness, loss of consciousness, blurry vision, clammy skin,
and fatigue.
Orthostatic Hypotension
Orthostatic hypotension is a drop in blood pressure when the client moves from lying to sitting to a standing
position.
Have you ever stood up quickly and felt dizzy for a moment? This is because, for one reason or another, blood
is not getting to your brain so it is briefly deprived of oxygen. When you change position from sitting or lying
down to standing, your cardiovascular system has to adjust for a new challenge, keeping blood pumping up into
the head while gravity is pulling more and more blood down into the legs. The reason for this is a sympathetic
reflex that maintains the output of the heart in response to postural change. This sympathetic reflex keeps the
brain well oxygenated so that cognitive and other neural processes are not interrupted. Sometimes this does not
work properly. If the sympathetic system cannot increase cardiac output, then blood pressure into the brain will
decrease, and a brief neurological loss can be felt. This can be brief, such as a slight ‘wooziness’ when standing
up too quickly, or could lead to a loss of balance and neurological impairment for a period of time. The name
for this is orthostatic hypotension, which means that blood pressure falls below the homeostatic set point when
standing. It can be the result of standing up faster than the reflex can occur, which may cause a benign ‘head
rush,’ or it may be the result of an underlying cause.
There are two basic reasons why orthostatic hypotension occurs. First, blood volume is too low and the
sympathetic reflex is not effective. This hypovolemia may be the result of dehydration or medications that
affect fluid balance, such as diuretics or vasodilators. The second underlying cause of orthostatic hypotension
is autonomic failure. Several disorders can result in compromised sympathetic functions, ranging from diabetes
to multiple system atrophy (a loss of control over many systems in the body), and addressing the underlying
condition can improve the hypotension. Orthostatic hypotension is more common with advancing age and can
be aggravated by antihypertensive medications.
How to Assess Orthostatic Hypotension
Orthostatic hypotension is assessed by measuring orthostatic or postural blood pressure and pulse changes. This
procedure is done by assessing when the client moves from supine to sitting to standing. There are variations in
how this procedure is done in terms of timing. Here is a common way to proceed:
1. The client rests supine for three minutes.

2. Take blood pressure and pulse in supine position.
3. The client sits up with feet dangling.
4. Take blood pressure and pulse within two minutes of position change.
5. The client stands up.
6. Take blood pressure and pulse within two minutes of position change.
Hypotension | 133
How to Evaluate the Findings
Normal variation is a 10 mm Hg decrease in blood pressure from lying to standing and an increase in pulse of
10–15 bpm.
A decrease in blood pressure from lying to standing of systolic ≥ 20 mm Hg or diastolic ≥ 10 mm Hg is identified
as orthostatic hypotension.
An increase in pulse from lying to standing of ≥ 20 bpm is identified as orthostatic pulse.
Technique Tips
The healthcare provider determines the maximum inflation pressure in the supine position and then
uses this same number throughout all readings. If a client is unable to stand during the orthostatic blood
pressure assessment, have them sit and dangle their legs. To ensure safety, have a safe place for the client
to land/sit if dizzy. Leave the blood pressure cuff on the whole time.
_____________________________________________________________________
____
The content under the sub-title “Orthostatic Hypotension” was adapted from OER #2 (as noted in brackets
above):
134 | Hypotension
66. Finding the Error Activity: Blood Pressure
Now you have an opportunity to find the errors in measurement techniques. The first activity involves watching
a short film clip. Check it out!
What errors in technique is this healthcare provider making while taking blood pressure?
Film clip 5.4: Errors in blood pressure measurement
Alternatively, if viewing textbook as a pdf, use this link: https://www.youtube.com/embed/-

NYfBuZMmXo?rel=0
Go to the next page for information about the correct technique for taking blood pressure.
Finding the Error Activity: Blood Pressure | 135

67. Finding the Error Activity: Blood Pressure –
Feedback
In the previous film clip, a number of measurement errors were made. It is important to ensure the following
techniques:
• Perform hand hygiene before and after

• Correct cuff placement must be determined by palpating the brachial artery.
• Maximum pressure inflation must be determined before a blood pressure can be accurately taken.
• The cuff is securely fastened around the arm so that only one finger can be placed between the cuff and
the client’s arm. The cuff should not be moveable.
• The stethoscope is cleansed before using.
• The client should sit still with feet placed flat on the floor while having the blood pressure taken.
136 | Finding the Error Activity: Blood Pressure – Feedback

68. Try it Out
Next, you have an opportunity to watch film clips on accurate measurement techniques. There are two activities
that involve two film clips about blood pressure measurement techniques. Watch each of them and then try it
out yourself.
Please note: The first film clip refers to the two-step blood pressure approach. This approach is used for
learners. As you become more proficient, you can try the one-step blood pressure approach.
Check it out!
Try it Out | 137

69. Try it Out: Two-step Blood Pressure
Watch this teaching video of a film clip that shows the two-step blood pressure approach. This approach is best
used when you are first learning how to take blood pressure. Watch the clip and then try it out!
Film clip 5.5: Two-step blood pressure approach
Alternatively, if viewing textbook as a pdf, use this link: https://www.youtube.com/embed/UbW4viRRvd4?rel=0
138 | Try it Out: Two-step Blood Pressure

70. Try it Out: One-step Blood Pressure
Watch this teaching video of a film clip that shows the one-step blood pressure approach. After you become
proficient in the two-step approach, you can move on to the one-step blood pressure approach. Watch the clip
and then try it out!
Film clip 5.6: One-step blood pressure approach
Alternatively, if viewing textbook as a pdf, use this link: https://www.youtube.com/embed/OLdz13c7_vo?rel=0
Try it Out: One-step Blood Pressure | 139

71. Test Yourself
of paper.
1. Watch and listen to the Korotkoff sounds while blood pressure is taken in audio clip 5.2. What is the
systolic and diastolic blood pressure?
Audio clip 5.2: Korotkoff sounds
Alternatively, if viewing textbook as a pdf, use this link: https://www.youtube.com/embed/q j6X2nQhqyI?rel=0
Audio clip 5.3: Korotkoff sounds
Alternatively, if viewing textbook as a pdf, use this link: https://www.youtube.com/embed/5jIpNADLKHk?rel=0
3. Which one of the two images below (Figure 5.5 or Figure 5.6) demonstrates the correct way of putting the
ear pieces of the stethoscope in your ears?
140 | Test Yourself

Figure 5.5
Test Yourself | 141

Figure 5.6
4. The bell of the stethoscope is best used to hear Korotkoff sounds.

a. True
b. False
5. In a blood pressure measurement of 110/70, the first number is the ________.

a. systolic pressure
b. diastolic pressure
c. pulse pressure
d. mean arterial pressure
(from OER#2)
6. A healthy elastic artery ________.

a. is compliant
b. reduces blood flow
c. is a resistance artery
d. has a thin wall and irregular lumen
(From OER#2)
142 | Test Yourself

7. Which of the following symptoms may be a result of orthostatic hypotension?
a. Fatigue
b. Nocturia
c. Dizziness
d. Chest pain
8. The healthcare provider assesses an older client’s blood pressure for the first time at a walk-in clinic. The
healthcare provider obtains a reading of 164/84. What should the healthcare provider do first?
a. Take the client’s pulse
b. Provide education to the client
c. Inform the most responsible provider
d. Repeat the blood pressure on the other arm
9. A woman’s pre-pregnancy pulse and blood pressure are 72 bpm and 112/78. Which findings are of most
concern to the healthcare provider?
a. Pulse 82 bpm and BP 108/70 at the end of the first trimester
b. Pulse 68 bpm and BP 118/82 in the first half of the first trimester
c. Pulse 90 bpm and BP 104/68 at the beginning of the second trimester
d. Pulse 90 bpm and BP 138/88 towards the latter half of the final trimester
Test Yourself | 143

72. Test Yourself – Answers
1. Watch and listen to Korotkoff sounds while blood pressure is taken in audio clip 5.2. What is the systolic and
diastolic blood pressure?
104/84 mm Hg
(NOTE: you should aim to obtain a measurement within 2-4 mm Hg. In this testing environment, it may depend
on the quality of your computer speakers. In actual practice, the stethoscope’s quality is a main determinant of
accuracy)
118/76 mm Hg
(NOTE: you should aim to obtain a measurement within 2-4 mm Hg. In this testing environment, it may depend
on the quality of your computer speakers. In actual practice, the stethoscope’s quality is a main determinant of
accuracy)
3. Which one of the two images below (Figure 5.5 or Figure 5.6) demonstrates the correct way of putting the
ear pieces of the stethoscope in your ears?
144 | Test Yourself – Answers

The correct way
Figure 5.5: Stethoscope in the ears the correct way
Test Yourself – Answers | 145

The incorrect way
Figure 5.6: Stethoscope in the ears the incorrect way

Rationale: The slope of the stethoscope’s ear pieces are inserted at the same angle as the ear canal (e.g.,
pointing forward or pointing toward the nose) as shown in Figure 5.6. The action shown in 5.7 is incorrect as the
ear pieces are pointed straight into the ears.
4. True or False: The bell of the stethoscope is best used to hear Korotkoff sounds.
Rationale: The correct answer is true. You can use the bell or diaphragm to take a blood pressure, but the best
way to hear the Korotkoff sounds is with the bell because it is better at picking up low-pitch vascular sounds.
5. In a blood pressure measurement of 110/70, the first number is the ________.

a. systolic pressure **
b. diastolic pressure
c. pulse pressure
d. mean arterial pressure
(from OER#2)
Rationale: The correct answer is a (systolic pressure). When documenting the blood pressure, the first sound
146 | Test Yourself – Answers

heard is the systolic pressure and the last sound heard is the diastolic pressure. Thus, the systolic measurement
is reported as the numerator.
6. A healthy elastic artery ________.

a. is compliant **
b. reduces blood flow
c. is a resistance artery
d. has a thin wall and irregular lumen
(From OER#2)
Rationale: The correct answer is a (is compliant). Arteries are able to expand and contract to adjust to pressure
and volume changes.
7. Which of the following symptoms may be a result of orthostatic hypotension?

a. Fatigue
b. Nocturia
c. Dizziness **
d. Chest pain
Rationale: The correct answer is c (dizziness). With orthostatic hypotension, the blood vessels fail to constrict
effectively when the client moves to an upright position. This causes a decrease in blood flow to the brain.
8. The healthcare provider assesses an older client’s blood pressure for the first time at a walk-in clinic. The
healthcare provider obtains a reading of 164/84. What should the healthcare provider do first?
a. Take the client’s pulse
b. Provide education to the client
c. Inform the most responsible provider
d. Repeat the blood pressure on the other arm **
Rationale: The correct answer is d (repeat the blood pressure on the other arm). An abnormal blood pressure
needs to be repeated to determine accuracy before making a clinical decision.
9. A woman’s pre-pregnancy pulse and blood pressure are 72 bpm and 112/78. Which findings are of most
concern to the healthcare provider?
a. Pulse 82 bpm and BP 108/70 at the end of the first trimester
b. Pulse 68 bpm and BP 118/82 in the first half of the first trimester
c. Pulse 90 bpm and BP 104/68 at the beginning of the second trimester
d. Pulse 90 bpm and BP 138/88 towards the latter half of the final trimester **
Test Yourself – Answers | 147

Two-step blood pressure technique
• Now, you can start blood pressure so place the bell of the cleansed stethoscope over the brachial artery
using a light touch and complete seal.
• Open the valve slightly.
• Deflate the cuff quickly.
• Palpate the radial or brachial artery, inflate the blood pressure cuff until the pulse is no longer felt, and
then continue to inflate 20–30 mm Hg more: this is the maximum pressure inflation.
• Inflate the cuff to the maximum pressure inflation number.
• Deflate the cuff slowly and evenly at about 2 mm Hg per second.
• Note the points at which you hear the first appearance of Korotkoff sound (systolic blood pressure) and the
last Korotkoff sound before it goes silent (diastolic blood pressure).
One-step blood pressure technique
• Place the bell of the cleansed stethoscope over the brachial artery using a light touch, but with an airtight
seal.
• Open the valve slightly.
• Palpate the radial or brachial artery, inflate the blood pressure cuff until the pulse is no longer felt, and
then continue to inflate 20–30 mmHg more.
• Deflate the cuff slowly and evenly at about 2 mm Hg per second.
• Note the points at which you hear the first appearance of Korotkoff sound (systolic blood pressure) and the

Answers
1. Palpate the radial or brachial artery, inflate the blood pressure cuff until the pulse is no longer felt, and
2. Deflate the cuff quickly.
3. Now, you can start blood pressure so place the bell of the cleansed stethoscope over the brachial artery
4. Inflate the cuff to the maximum pressure inflation number.
5. Open the valve slightly.
6. Deflate the cuff slowly and evenly at about 2 mm Hg per second.
7. Note the points at which you hear the first appearance of Korotkoff sound (systolic blood pressure), and the
2. Place the bell of the cleansed stethoscope over the brachial artery using a light touch, but with an airtight
seal.

75. Chapter Summary
Blood pressure measurement is important because it provides objective data about the client’s health and illness
state. Changes in blood pressure act as a cue for healthcare providers’ diagnostic reasoning. Blood pressure
fluctuates with internal and external factors. Therefore, it is important to take more than one measurement
before making clinical decisions.
It is always important to ensure correct techniques when taking blood pressure.
In determining the relevance of the blood pressure reading, the healthcare provider considers the client’s
baseline blood pressure, previous readings, and health status. The blood pressure reading is always taken in
conjunction with a pulse. Diagnostic reasoning takes into account blood pressure, pulse, and subjective and
objective client data.
150 | Chapter Summary

PART VI
CHAPTER 6: KNOWLEDGE INTEGRATION
Chapter 6: Knowledge Integration | 151

76. Knowledge Integration
In healthcare, knowledge integration involves drawing upon and synthesizing client data to inform diagnostic
reasoning and clinical decision-making. Healthcare providers are continually evaluating whether vital sign
measurements are normal or abnormal. The analysis takes into consideration the client’s baseline vital sign
measurements as well as the client’s age and health and illness state. Additionally, healthcare providers pay
attention to trending, which involves looking at vital signs across time to detect changes. If abnormalities are
identified, healthcare providers consider the client context including other subjective and objective data to
differentiate relevant from irrelevant data. The analysis of client data influences evidence-informed clinical
decision-making in which healthcare providers identify priority actions and treatment options.
This chapter presents five case studies based on what you learned in Chapters 1–5. The case studies are
intended to provide an opportunity for you to critically think about client data in the context of a client situation.
You will integrate your knowledge about normal and abnormal vital signs and engage in diagnostic reasoning to
determine priority actions and next steps based on the client data.
Case Study 1: Adult client
Case Study 2: Pediatric client
Case Study 3: Pregnant adult client
Case Study 4: Older adult client
Case Study 5: Adolescent client
Layout
Data about each case study are provided with a series of critical thinking questions. The answers are provided
on the page following the questions. You will need paper and a pen to write down your answers. For some of the
case studies, you will be directed to download a blank vital sign record.
Go to the next page to start Case Study 1.
Knowledge Integration | 153

77. Case Study 1: Adult Client
Initial Assessment Data
• Biographical data: Adult client

• Reason for seeking care: Vomiting and diarrhea
• History of presenting illness: Vomited x 4 daily x 3 days, diarrhea x 6 daily x 3 days, currently severely
nauseated and dizzy, tolerating sips of clear fluid
• Past history: No medications, no illnesses
Think about the client data and try to answer the following questions. Write your answers on a piece of paper.
1. What infection control measures should the healthcare provider implement?

2. What method should be used to measure temperature for this adult client?
3. What pulse and blood pressure readings should be taken for this adult client?
154 | Case Study 1: Adult Client

78. Case Study 1: Adult Client (continued)
1. What infection control measures should the healthcare provider implement?
Use correct handwashing techniques before and after your assessment.
2. What method should be used to measure temperature for this adult client?
Temperature is best taken using the tympanic or axillary route; because the client is nauseated, the oral route
could stimulate the gag reflex.
3. What pulse and blood pressure readings should be taken for this adult client?
Orthostatic vital signs (pulse and blood pressure) should be taken because this client is at risk for hypovolemia.
The client may be dehydrated as a result of the vomiting and diarrhea and lack of fluid intake. Return to the
chapter on blood pressure for more information on hypovolemia and its effects on vital signs.
Next, see and read the vital sign record below. On a piece of paper, write down each of the client’s vital sign
readings, and if applicable, the route used and the client’s position.
Case Study 1: Adult Client (continued) | 155

156 | Case Study 1: Adult Client (continued)
Go to the next page to view the vital sign readings based on the record above.

Vital Sign Measurements
0800 hours, May 1, 2018
• Temperature 37.9°C tympanic

• Pulse Lying 92 bpm (radial)
◦ regular rhythm, force 1+, weak and thready, equal radial pulses
• RR 22 bpm irregular rhythm
• BP lying 122/78 mm Hg
• 02 saturations 96%
0802 hours, May 1, 2018
• Pulse sitting 110 bpm (radial)

• BP sitting 112/72 mm Hg
0804 hours, May 1, 2018
• Pulse standing 120 bpm (radial)

• BP standing 98/68 mm Hg
Questions to Reflect On
1. Which findings are considered abnormal for this adult client? What medical terminology is used to define/
label these findings?
2. What further assessment should the healthcare provider do based on this adult client’s findings?
3. What actions should the healthcare provider take based on this adult client’s findings?
158 | Case Study 1: Adult Client (continued)

• The temperature is higher than expected: hyperthermia/febrile (> 37.3°C)

• The pulse in lying position is within normal limits, but in the sitting and standing position, the pulse is
elevated and is identified as tachycardia (> than 100 bpm)
• The pulse increased more than 20 bpm and the systolic BP decreased more than 20 mm Hg when the client
moved from lying to standing, indicating orthostatic hypotension
• The pulse is weak and thready at 1+ force, which is abnormal
• The respiration rate is high: tachypnea (> 20 bpm)
• The oxygen saturations are slightly low (< 97%)
2. What further assessment should the healthcare provider do based on this adult client’s findings?
Continue to assess for signs of dehydration:
• Dry mucous membranes

• Poor skin turgor
• Decreased and concentrated urine output
3. What actions should the healthcare provider take based on this adult client’s findings?
• Notify the most responsible provider such as the physician or nurse practitioner.
• If you are the most responsible provider, discuss and initiate treatments such as fluid rehydration.

81. Case Study 2: Pediatric Client
• Biographical data: 18-month-old child

• Reason for seeking care: Febrile
• History of presenting illness: Fever x 2 days, today rash appeared consisting of red spots over the client’s
body
1. What infection control measures need to be taken when interacting with this child and taking the child’s
vital signs?
2. What developmental considerations need to be considered when taking the child’s vital signs?
160 | Case Study 2: Pediatric Client

82. Case Study 2: Pediatric Client (continued)
1. What infection control measures need to be taken when interacting with this child and taking the child’s
vital signs?
The toddler has a fever and an unknown rash, therefore needs to be isolated in a private room, and the healthcare
provider must wear a surgical mask, gown, and gloves (contact and droplet precautions). The toddler requires
vital signs equipment for use with that client only.
2. What developmental considerations need to be considered when taking this child’s vital signs?
• An apical pulse is taken for a full minute due to the client’s age.
• An axillary temperature is taken because it is minimally invasive. A rectal temperature may be performed to
check for accuracy considering that the client is febrile.
• The SpO2 saturation is taken via ear sensor or a taped finger sensor because the pulse oximeter clip is too
large for a young child’s finger.
1700 hrs, June 12, 2018
• Temperature: 39.8°C axilla

• Pulse: 170 bpm (apical) cyclical increases with inspiration, force 2+, regular rhythm
• RR 30 bpm, regular rhythm
• Spo2 saturation 98%
Print the blank vital sign record and document the findings noted above. Then, go to the next page
to see the findings properly documented on the vital sign record.
Vital Sign Record – Blank (pdf)
Case Study 2: Pediatric Client (continued) | 161

162 | Case Study 2: Pediatric Client (continued)

Try to answer the following questions. Write your answers on a piece of paper.
1. Which vital sign findings are considered abnormal for this child? What medical terminology is used to
define/label these findings?
2. What are the healthcare provider’s actions based on this child’s findings?

1. Which vital sign findings are considered abnormal for this child? What medical terminology is used to
• The temperature is high: hyperthermia or pyrexia/febrile.

• The heart rate is elevated: tachycardia.
• Sinus arrhythmia is considered normal in the pediatric population.
2. What are the healthcare provider’s actions based on these findings?
• Remove external clothing from the client (down to a diaper) to reduce fever.
• Provide cool fluids or popsicles to reduce fever.
• Promote fluid intake to reduce fever and maintain hydration.
• Ensure safety and observe the child due to the risk of febrile seizures that can occur with high body
temperatures.
• Report to the most responsible provider if you are not the most responsible provider.

85. Case Study 3: Pregnant Adult Client
• Biographical data: Pregnant adult client (age 32)

• Reason for seeking care: Shortness of breath at a prenatal visit
• History of health/illness: 36 weeks pregnant
1430 hrs, August 14, 2018
• T 37.1°C axilla
• RR 14 (shallow breathing)
• P 92 (radial), regular rhythm, 2+ force, Sp02 97%
• BP 134/90 mm Hg (right arm, sitting position)
Baseline vital signs (pre-pregnancy)
• RR 14
• P 84, regular rhythm, 2+ force, Sp02 97%
• BP 124/74 mm Hg (right arm)
1. What needs to be considered when interpreting the vital signs findings of this pregnant client?
2. Which vital sign findings are considered abnormal for this pregnant client? What medical terminology is
used to define/label these findings?
Case Study 3: Pregnant Adult Client | 167

(continued)
1. What needs to be considered when interpreting the vital signs findings of this pregnant client?
• Even though the client’s reason for seeking care is shortness of breath, the Sp02 saturation is within the
normal range and the respiratory rate is in the normal range. In the third trimester, it is common for the
fetus to push against the diaphragm, causing it to raise and put pressure on the lungs resulting in the
pregnant woman feeling short of breath.
• When measuring respiration, the healthcare provider assesses the depth of breathing: breathing is usually
shallow in later-term pregnancy.
• Always take a fetal heart rate when taking a pregnant woman’s vital signs.
2. Which vital sign findings are considered abnormal for this pregnant client? What medical terminology is
used to define/label these findings?
The blood pressure is elevated because the systolic pressure is 134 and the diastolic pressure is 90. Healthcare
providers should first repeat the blood pressure reading for accuracy. They should also review the pregnant
woman’s blood pressure levels pre-pregnancy and during previous pregnancies to determine the significance
of these values. These considerations are important because slightly high systolic and diastolic blood pressure
levels in later-term pregnant women can require an urgent referral for an obstetrical assessment.
The blood pressure is repeated on both arms after the client is at rest for five minutes to confirm accuracy.
1435 hrs, August 14, 2018
• BP 132/90 mm Hg right arm in sitting position, P 92 (radial)

• BP 128/88 mm Hg left arm in sitting position, P 88 (radial)
Try to answer the following questions. Write your answers on a piece of paper.
1. Which blood pressure do you record?

2. Is the variation between the arms of concern?
168 | Case Study 3: Pregnant Adult Client (continued)

(continued)
1. Which blood pressure do you record?
The blood pressure readings that were taken after the woman rested for five minutes should be recorded. Record
both the right arm and left arm reading in the narrative notes and the highest blood pressure reading on the
vital sign record (e.g., the right arm reading of 132/90). Whenever a reading is elevated, consider repeating the
measurement for confirmation.
2. Is the variation between the arms of concern?
The difference between the two arms is not significant. A difference below 10 mm Hg between arms is normal.
1430 hrs, August 14, 2018
• RR 14 (shallow breathing)
• P 92 radial in sitting position, regular rhythm, 2+ force, Sp02 97%
• BP 134/90
1435 hrs, August 14, 2018
• BP 132/90 mm Hg right arm, P 92

• BP 128/88 mm Hg left arm, P 88
Print the blank vital sign record and document the woman’s vital signs. Then, go to the next page
to see accurate documentation of vital signs.
Case Study 3: Pregnant Adult Client (continued) | 169

(continued)
Case Study 3: Pregnant Adult Client (continued) | 171

89. Case Study 4: Older Adult Client
• Biographical data: Older adult client

• Reason for seeking care: Assess blood pressure at a blood pressure clinic
• History of health/illness: Healthy
1050 hrs, September 7, 2018
• Sitting BP: 160/94 mm Hg right arm

• Pulse: 72 bpm (radial), 2+, regular rhythm
2. What factors might cause the blood pressure reading to be higher than normal in this adult client?
3. What is the healthcare provider’s next action based on the findings of this adult client?
Case Study 4: Older Adult Client | 173

90. Case Study 4: Older Adult Client (continued)
1050 hrs, September 7, 2018
• Sitting BP: 160/94 mm Hg right arm

• Pulse: 72 bpm (radial), 2+, regular rhythm
1. Which findings are considered abnormal for this adult client? What medical terminology is used to
• The blood pressure is elevated: hypertension (without diagnosis).
2. What factors might cause the blood pressure reading to be higher than normal in this adult client?
• Operator error
• Anxiety, stress, or pain
• Caffeine, smoking, or nicotine in the preceding 30 minutes
• Recently took adrenergic stimulants such as phenylephrine or pseudoephedrine
• Bladder and bowel discomfort
• Tight clothing on arm or forearm
• Noisy, cold room
• Taken immediately after activity
• Movement during the pressure reading
3. What are the healthcare provider’s next actions based on the findings of this older client?
• Retake the blood pressure to ensure accuracy

• Take blood pressure in the other arm
• Have client sit in a room by themselves and then do the following:
◦ ensure the room is quiet

◦ dim the lights
◦ allow the client to sit quietly for five minutes, without talking
◦ then take three measurements, a few minutes apart, with the automatic cuff (with an automatic cuff,
the blood pressure documented is the average of the three readings).
After the healthcare provider followed the above procedures, the results were:
September 7, 2018
1058 hrs Sitting BP: 156/92 mm Hg right arm P 70 bpm (radial)
1100 hrs Sitting BP: 148/90 mm Hg left arm
174 | Case Study 4: Older Adult Client (continued)

Automatic Cuff
5 mins later (1105 hrs)
Sitting BP: 150/86 mm Hg right arm P 66 bpm
Print the blank vital sign record and document the adult client’s vital sign readings. Then, go to
the next page for a sample vital sign record of these findings.
Case Study 4: Older Adult Client (continued) | 175

See accurate documentation of findings on vital sign record.
What are the healthcare provider’s actions based on the findings for this adult client?

Go to the next page to check your answer.

What are the healthcare provider’s actions based on the findings for this adult client?
• Notify primary care provider.

• If you are the primary care provider, anticipate two visits for blood pressure readings within one month of
this visit, or home blood pressure monitoring.

93. Case Study 5: Adolescent Client
• Biographical data: Adolescent client (age 17)

• Reason for seeking care: Post-op surgery
• History of health/illness: Healthy
• Client had abdominal surgery and was transferred from the recovery room to the surgical floor. Lethargic
and oriented x 3. Awakes when name is called and responds to questions appropriately. Client rates pain 2/
10. The healthcare provider assesses client’s vital signs every 30 minutes x 2 hours.
Case Study 5: Adolescent Client | 181

Vital Sign Record
182 | Case Study 5: Adolescent Client

Case Study 5: Adolescent Client | 183
Think about the client data documented on the vital sign record and try to answer the following questions.
Write your answers on a piece of paper.
1. Review the vital sign record and identify the trends that you see.
2. What should the healthcare provider’s next action be?
184 | Case Study 5: Adolescent Client

94. Case Study 5: Adolescent Client (continued)
1. After reviewing the vital sign record, identify the trends that you see.
The trends include a significant decrease in blood pressure, increase in pulse, and decrease in pulse force over
90 minutes. There is an increase in respiratory rate and a decrease in oxygen saturation. The temperature is
slightly elevated, which is a common finding post-surgery. The temperature remained stable over the 90-minute
period.
The changes in the above vital signs suggest hypovolemic shock, particularly in the context of recent
abdominal surgery. Hypovolemic shock is a life-threatening condition that occurs with significant fluid loss
such as blood. As part of diagnostic reasoning, healthcare providers recognize the indicators of hypovolemic
shock as a decrease in blood pressure and an increase in pulse. The change in the respiratory rate is a
compensating mechanism for blood loss and decreasing oxygen saturation: physiological factors stimulate
increased respiratory rate to meet the oxygen demands of tissues as a result of decreasing blood pressure.
2. What should the healthcare provider’s next actions be?
This condition is a medical emergency that requires immediate intervention.
• Notify the most responsible provider (if you are not the most responsible provider).
• Anticipate fluid rehydration and continue to monitor the client closely.
Case Study 5: Adolescent Client (continued) | 185

PART VII
CHAPTER 7: CONCLUSION
Chapter 7: Conclusion | 187

95. Conclusion
As you become more proficient in measuring vital signs and interpreting the findings, you should remember a
few key points.
There are many methods to take vitals signs. The correct technique is essential to obtaining an accurate
measurement.
Vital sign measurements have very little meaning on their own. Healthcare providers engage in critical thinking
and correlate these measurements with subjective and other objective data. Thinking critically about these
measurements will best inform clinical decision-making. Healthcare providers look holistically at the person and
their health and wellness state to determine whether vital sign measurements are within normal limits for this
individual person.
It is also essential to acknowledge that clients may have additional information that can provide insight into
their body, which may influence the technique and location for measuring vital signs and the significance of the
findings. Sharing findings with clients is also a good opportunity for health promotion teaching.
Points to Consider
It is important to document vital signs in a timely manner. The healthcare provider reports any
abnormal and unexpected findings to the most responsible provider. For example, students should share
the findings with their preceptor or clinical instructor in a timely manner.
Conclusion | 189
Figure 7.1: Cells (Illustration credit: Hilary Tang)
190 | Conclusion
Artist Statement – Cells
The human body is a messy phenomenon. From the organ to the cell, the brain to the neurotransmitter, like
clockwork, everything is constantly happening. Down to our very core, the tiniest components are working in
conjunction, harmoniously, to let us eat, breathe, and move. Without our constant consciousness, we are living.
What an organized chaos our bodies are.
Conclusion | 191
96. Printable Flashcards
TEMPERATURE
1. Remove the probe from the device and place a probe cover (from the box) on the oral thermometer without
2. Place the thermometer in the mouth under the tongue in the posterior sublingual pocket (slightly off-
centre) and instruct the client to keep mouth closed and not to bite on the thermometer
3. Remove the thermometer when the device beeps
5. Discard the probe cover in the garbage (without touching the cover)
6. Place the probe back into the device
1. Remove the tympanic thermometer from the casing and place a probe cover (from the box) on the
2. Turn the device on
3. For an adult or older child, gently pull the helix up and back to visualize the ear canal. For an infant or
younger child (under 3), gently pull the lobe down
4. Gently insert the probe into the opening of the ear
5. Activate the device
7. Discard the probe cover in the garbage (without touching the cover) and place the device back into the
holder
1. Remove the probe from the device and place a probe cover (from the box) on the thermometer without
2. Ask the client to raise the arm away from his/her body
3. Place the thermometer in the client’s armpit as high up as possible into the axillae on bare skin, with the
point facing behind the client, and ask the client to lower arm
device
1. Ensure the client’s privacy and wash your hands and put on gloves
2. Position the client appropriately
3. Remove the probe from the device and place a probe cover on it
192 | Printable Flashcards

4. Lubricate the cover with a water-based lubricant
5. Gently insert the probe 2–3 cm inside the rectal opening of an adult, or less depending on the size of the
client
6. Note the temperature on the digital display of the device when it beeps
device
8. Remove your gloves and wash your hands
PULSE AND RESPIRATION
1. Use the pads of your first three fingers to gently palpate the radial pulse along the radius bone close to the
2. Press down with your fingers until you can best feel the pulsation
3. Note the rate, rhythm, force, and equality when measuring the radial pulse
1. Ask the client to sit upright

2. Locate the carotid artery medial to the sternomastoid muscle in the middle third of the neck
3. Gently palpate the carotid artery one at a time
4. Note the rate, rhythm, force, and equality when measuring the carotid pulse
1. Ask the client to lay flat in a supine position

2. Physically palpate the intercostal spaces to locate the landmark of the apical pulse
3. Auscultate the apical pulse
1. Palpate the bicep tendon in the area of the antecubital fossa

2. Move your fingers medial from the tendon and about one inch above the antecubital fossa to locate the
pulse
1. Leave your fingers in place when you are done counting the pulse, and then begin assessing respiration
2. Observe the rise and fall of the chest or abdomen
3. Count for 30 seconds if the rhythm is regular or for a full minute if it is irregular
4. Report respiration as breaths per minute, as well as whether breathing is relaxed, silent, and has a regular
rhythm
Printable Flashcards | 193

OXYGEN SATURATION
Pulse oximter
1. Remove client nail polish

2. Clean oximeter probe with alcohol swab
3. Clip or tape probe onto a client’s finger
4. Turn oximeter on
5. Take radial pulse (30 seconds if regular and one minute if irregular)
6. Ensure radial pulse is aligned with pulse displayed on the oximeter
7. Document or report findings
BLOOD PRESSURE
2. Deflate the cuff quickly.
3. Now, you can start blood pressure so place the bell of the cleansed stethoscope over the brachial artery
4. Inflate the cuff to the maximum pressure inflation number.
2. Place the bell of the cleansed stethoscope over the brachial artery using a light touch, but with an airtight
seal.
194 | Printable Flashcards

97. References
Beasley, R., Chien, J., Douglas, J., Eastlake, L., Farah, C., King, G., Moore, R., Pilcher, J., Richards, M., Smith, S., &
Walters, H. (2016). Target oxygen saturation range: 92–96% versus 94–98%. Respirology, 22(1), 200–202
Fech, T., Penrod, J., Battistone, M., Sawitzke, A., & Stults, B. (2012). The prevalence and clinical correlates of an
auscultatory gap in systemic sclerosis patients. International Journal of Rheumatology, doi: 10.1155/2012/590845
Jarvis (2014). Physical Examination & Health Assessment (2nd Canadian edition). Elsevier Canada: Toronto
Leduc, D., & Woods, S., (2017). Canadian Paediatric Society Position Statement: Temperature measurement in
paediatrics. Retrieved from: http://www.cps.ca/en/documents/position/temperature-measurement
Leung, A.A., Daskalopoulou, S.S., Dasgupta, K., McBrien, K., Butalia, S., Zarnke, K., … Rabi, D. for Hypertension
Canada. (2017). Hypertension Canada’s 2017 Guidelines for Diagnosis, Risk Assessment, Prevention, and
Treatment of Hypertension in Adults. Canadian Journal of Cardiology, 33 (5), 557–576
Mazerolle, S., Ganio, M., Casa, D., Vingren, J., & Klau, J. (2011). Is oral temperature an accurate measurement of
deep body temperature? A systematic review. Journal of Athletic Training, 46(5), 566–573.
Shah, A., & Shelley, K. (2013). Is pulse oximetry an essential tool or just another distraction? The role of the
pulse oximeter in modern anesthesia care. J Clin Monit Comput, 27, 235–242. DOI 10.1007/s10877-013-9428-7
References | 195

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Vital Sign Measurement Across the Lifespan - 1st Canadian edition

Vital Sign Measurement Across the Lifespan - 1st

JENNIFER L. LAPUM, MARGARET VERKUYL, WENDY GARCIA, OONA

About the Authors 2

Content Advisory Team 3

Part I. Chapter 1: Introduction

Part II. Chapter 2: Temperature

22. What is Pulse? 53

Part IV. Chapter 4: Oxygen Saturation

43. What is Oxygen Saturation? 91

Part V. Chapter 5: Blood Pressure

57. What is Blood Pressure? 111

Part VI. Chapter 6: Knowledge Integration

76. Knowledge Integration 153

Part VII. Chapter 7: Conclusion

95. Conclusion 189

eCampusOntario is a not-for-profit corporation funded by the Government of Ontario. It serves as a centre of

Dr. Jennifer L. Lapum

Note to Educators Using this Resource

2 | About the Authors

Student Advisory Team

Content Advisory Team | 3

4 | Content Advisory Team

• SHARE – copy and redistribute the material in any medium or format

Under the Following Terms

• Define the vital signs used in healthcare

eCampusOntario is a not-for-profit corporation funded by the Government of Ontario. It serves as a centre of

• Technique Tips provide helpful information about measurement techniques, and

Infection Prevention and Control

12 | General Points to Consider in Vital Sign Measurement

General Points to Consider in Vital Sign Measurement | 13

14 | General Points to Consider in Vital Sign Measurement

Order of Vital Sign Measurement

General Points to Consider in Vital Sign Measurement | 15

Figure 2.1: Hypothalamus (Illustration credit: Hilary Tang)

20 | Why is Temperature Measured?

22 | What are Normal Temperature Ranges?

What are Normal Temperature Ranges? | 23

Figure 2.2: Oral thermometer

What should the healthcare provider consider?

Figure 2.4: Tympanic thermometer

What should the healthcare provider consider?

Figure 2.6: Axillary temperature being taken

Figure 2.7: Rectal thermometer

What should the healthcare provider consider?

Figure 2.8: Error while taking the temperature of an adult

34 | Finding the Error Activity: Tympanic Temperature

Incorrect technique of taking tympanic temperature

Figure 2.9: Incorrect technique

Finding the Error Activity: Tympanic Temperature –

Figure 2.10: Correct technique

36 | Finding the Error Activity: Tympanic Temperature – Feedback

Film clip 2.1: Oral temperature

38 | Try it Out: Oral Temperature

Film clip 2.2: Tympanic temperature

Try it Out: Tympanic Temperature | 39

Film clip 2.3: Axilla temperature