Vital Sign Notes
Heart Rate
We what to determine the heart rate, rhythm, and quality.
•Rate = number of beats in 30 sec X 2
•Rhythm = regular, irregular
•Quality = strong, weak
Verbal Report Example: “The heart rate is eighty beats per minute, regular, and strong.”
Written Report Example: HR = 82/min, reg, strong
Blood Pressure
We want to determine a systolic and diastolic pressure by auscultation.
•Alternatively, we can determine a blood pressure by palpation, which gives us the
systolic pressure only!
Blood pressure by auscultation:
•Systolic pressure = The pressure at which you first hear the pulse as you are
releasing pressure from the BP cuff.
•Diastolic pressure = The pressure at which the pulse goes away.
Blood pressure by palpation:
•Systolic pressure = The pressure at which you first feel a pulse.
Verbal Report Example: “The patient's blood pressure is 124/76 mmHg.”
Verbal Report Example: “The patient's blood pressure is 120 mmHg by palpation.”
Written Report Example: BP = 134/82mmHg
Respiratory Rate
We want to determine our patient’s respiratory rate (RR), tidal volume (TV), and effort.
•Respiratory Rate = number of breaths in 30 sec X 2.
•TV = shallow, normal, deep
•Effort = labored or unlabored
Verbal Report Example: “The respiratory rate is six per minute, shallow, and labored.”
Written Report Example: RR = 12/min, GTV, unlabored (GTV = good tidal volume)
Pulse Oximetry
We want to determine the patient’s oxygen saturation. Normal is typically around
96-98% or so. It is uncommon for a human breathing atmospheric air to have a oxygen
saturation of 100%. The AHA considers anything below 94% to be of concern, so you
should, too!
Verbal Report Example: “The patient’s oxygen saturation is 98% on room air, and 100%
on oxygen at 2 lpm via nasal cannula.”
Written Report Example: SpO2 = 98% RA.
