Vital Signs, Physical Examination & Palpation

This lesson picks up patient inspection where Lesson 2 left off — from the doorway observation of the patient's color, through the core vital signs and breathing patterns, into a head-to-toe physical exam, and finishing with the hands-on palpation techniques you'll use every day.

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General Clinical Presentation — Color

The first thing you notice about a patient is often their color. Learn to name what you see.

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Vital Signs

Temperature

Normal Ranges

Fever (Febrile)

Fever is an elevation of the body's temperature. It isn't one pattern — it's a family of patterns:

Diaphoresis (profuse sweating) or night sweats can occur with fever.

Common causes:

• Infection (most common)
• Dehydration
• Reactions to substances, drugs, or protein breakdown

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Pulse

Pulse can be seen on the monitor or evaluated for rate, rhythm, and strength through palpation.

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Blood Pressure

Blood pressure is the force exerted against the wall of the arteries as blood moves through them.

• Systolic pressure — peak force exerted during contraction of the left ventricle. Normal: 90 – 140 mmHg
• Diastolic pressure — force remaining during relaxation of the ventricles. Normal: 60 – 90 mmHg
• Normal BP: 120/80 mmHg

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Breathing Rates & Patterns

Count chest rise and fall to obtain rate:

• 30 seconds × 2
• 20 seconds × 3
• 15 seconds × 4

Normal Resting Adult

• 12 – 18 breaths per minute (bpm)
• Eupnea — normal respiratory rate, rhythm, and depth

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Rate-Based Patterns

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Hyperpnea

Increased rate and depth of breathing. Caused by metabolic disorders.

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Kussmaul's

Labored breathing with increased respiratory rate and volume.

Cause: late stages of severe metabolic acidosis. The patient becomes "air hungry," and the desperate gasping characteristic of Kussmaul's breathing appears involuntary.

Video references:

• Kussmaul's breathing — example 1
• Kussmaul's breathing — example 2
• Kussmaul's breathing — example 3

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Cheyne-Stokes

Gradually increasing then decreasing in depth and rate, with periods of apnea in between.

Causes:

• Stroke
• Traumatic brain injuries
• Brain tumors
• Carbon dioxide poisoning
• Metabolic encephalopathy
• First-time high-altitude sickness
• Normal side effect of IV morphine administration

Video references:

• Cheyne-Stokes — short clip
• Cheyne-Stokes — example 2
• Cheyne-Stokes — example 3

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Biot's

Irregular breathing with long periods of apnea. Each breath has the same depth — this is the distinguishing feature from Cheyne-Stokes.

Causes:

• Increased intracranial pressure
• Damage to the medulla oblongata by stroke (CVA) or trauma
• Pressure on the medulla due to herniation
• Prolonged opioid abuse

Video reference:

• Biot's breathing — short clip

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Ataxic

A completely irregular breathing pattern with irregular pauses and unpredictable periods of apnea. As breathing continues to deteriorate, ataxic breathing begins to merge with agonal respirations.

Causes:

• Damage to the medulla oblongata secondary to trauma or stroke
• Usually indicates a very poor prognosis

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Apneustic

Prolonged gasping inspiration followed by an extremely short, insufficient expiration.

Cause: damage to the upper part of the pons.

Video reference:

• Apneustic breathing

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Position-Related Breathing Patterns

Paroxysmal Nocturnal Dyspnea (PND)

Sudden onset of difficulty breathing that occurs when a sleeping patient is lying flat.

• Caused by the gradual transfer of fluid in the lower extremities to the lungs
• Associated with coughing
• Relieved when the patient assumes an upright position

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Physical Examination

A full inspection works top-down: Head and Neck → Chest → Hands.

Head and Neck — Face

Facial expressions help determine distress, pain, alertness, mood, and general character.

• Look for signs of cyanosis around the lips
• Pursed-lip breathing — a classic COPD finding
• Excessive sweating (diaphoresis)

Head and Neck — Eyes

The eye exam is part of the neurologic assessment.

• Check for normal pupillary reflex — PERRLA (Pupils Equal, Round, Reactive to Light, and Accommodation)
• Cranial nerves II and III must be intact for normal reflexes
• Head trauma, tumor, CNS disease, and certain medications can cause abnormal findings

Neck

Inspection of the neck helps identify tracheal deviation, jugular venous pressure (JVP), and accessory muscle use.

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Chest — Pattern, Effort, and Configuration

Assess the pattern and effort of breathing alongside the thoracic configuration.

Normal Chest Configuration

• The normal A-P (anteroposterior) diameter is less than the transverse diameter
• An increased A-P diameter is a sign of COPD — aka barrel-chested

Abnormal Chest Configurations

Abnormal Spinal Configurations

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Hands — Digital Clubbing

A sign of pulmonary disease caused by chronic hypoxemia. Clubbing is present when the angle of the nail bed and skin increases.

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Palpation

Palpation is the use of the hands to feel for body movement, lumps, masses, and skin characteristics. This section covers three targets: the chest, the pulse, and blood pressure.

Chest Palpation

During chest palpation, you're looking for:

• Asymmetrical chest movements
• Estimating thoracic expansion
• Assessing skin and tissue
• Vocal fremitus

Vocal vs. Tactile Fremitus

• Vocal fremitus — vibrations created by the vocal cords during phonation, transmitted down the tracheobronchial tree and through the alveoli to the chest wall.
• Tactile fremitus — what you feel on the chest wall as the patient talks.

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Pulse Palpation

Assess the pulse for rate, rhythm, and force.

Rate

Rhythm

Force

Paradoxical Pulse ("Pulsus Paradoxus")

Pulse/blood pressure varies with respiration — systolic pressure drops more than 10 mmHg during inhalation at rest.

Caused by:

• Severe air trapping
• Cardiac tamponade
• Status asthmaticus

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How to Palpate a Pulse

1. Place the pads of the index and middle fingers lightly over the pulse point
2. Compress until maximum pulsation is felt
3. Evaluate rhythm and strength
4. Count beats felt to obtain rate — 30 s × 2, 20 s × 3, or 15 s × 4

Frequently Used Sites

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Trachea Palpation

Useful to palpate the trachea for deviation — a shift of the trachea to one side. Depress the index finger into the suprasternal notch and palpate.

Video reference:

• Trachea palpation demonstration

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Blood Pressure

Patient Positioning

• Seat the patient for at least 5 minutes prior to taking the measurement
• Have the patient sit comfortably with their arm resting on a table, so the midpoint of the upper arm is at heart level
• Ensure the patient does not cross their legs before or during measurement

Cuff Selection & Placement

• Use the correct cuff size — the bladder should encircle 80% of the arm
• A cuff too large or too small results in false high measurements
• Place the cuff mid-way between the shoulder and the elbow
• The markings on the cuff should be centered over the brachial artery

Taking the Measurement

1. Position and secure the gauge so it can be easily seen and read
2. Locate the brachial artery by palpation, then place the stethoscope on the artery
3. Close the valve and inflate the cuff
4. Inflate to 70 mmHg, then continue increasing until the pulse can no longer be felt
5. Release pressure slowly, listening carefully and watching the gauge
6. Note the point where the first sound is heard — this is the systolic value
7. Note the point where the last sound or change in sound is heard — this is the diastolic value
8. Release pressure completely after the diastolic value is obtained

Retry Rules

• If unsure of the reading, completely deflate the cuff for at least 30 seconds before reattempting
• Do NOT allow the cuff to remain inflated for longer than 20 seconds

Video reference:

• Manual blood pressure measurement walkthrough