6.4 Vital Signs, Clinical Observation & Functional (ADL) Assessment
Key Takeaways
Typical adult resting reference ranges are a heart rate of 60 to 100 beats per minute, a respiratory rate of 12 to 20 breaths per minute, and an oxygen saturation of 95% to 100%.
Accurate blood pressure needs 5 minutes of seated rest, a correctly sized cuff, a supported arm at heart level, feet flat, and no talking during the reading.
Respiratory rate is counted without telling the client, often while appearing to keep counting the pulse, because awareness changes breathing.
Basic activities of daily living (bathing, dressing, toileting, transferring, continence, feeding) differ from instrumental activities such as shopping, cooking, finances, and managing medications.
A Timed Up and Go test slower than about 12 to 13.5 seconds is commonly used to flag increased fall risk in older adults.
Vital Signs, Clinical Observation & Functional (ADL) Assessment
1. Why Observation, Vital Signs, and Function Are Tested
Three CKT-testable competencies sit at the start of every physical assessment: maintain clinically relevant observation (2.f), perform vital signs assessment (2.g), and assess abilities to perform activities of daily living (2.h). Together they establish a safety baseline, reveal conditions that change the treatment plan (or rule treatment out), and provide functional measures for goals and re-assessment (see 11.1 and 11.4).
2. Clinically Relevant Observation
Observation begins in the waiting room and continues throughout treatment:
- General appearance and behaviour: Distress, guarding, facial grimacing, fatigue, confusion, anxiety, or signs of intoxication (which affect capacity to consent).
- Movement: How the client stands from a chair, walks, removes a coat, and climbs onto the table; use of assistive devices.
- Skin and tissue: Colour (pallor, cyanosis, flushing, jaundice), bruising, edema, scars, lesions, rashes, and temperature differences.
- Breathing: Rate, depth, use of accessory muscles, audible wheeze, and ability to speak in full sentences.
- During treatment: Changes in colour, sweating, breathing, muscle guarding, or verbal and non-verbal signs of discomfort that call for modifying pressure or stopping.
Observations are recorded objectively in the "O" section of the SOAP note (for example, "client paused twice while climbing onto the table and used both hands to lift the right leg").
3. Vital Signs: Technique and Reference Ranges
| Vital sign | How to measure | Typical adult resting range | Findings that change the plan |
|---|---|---|---|
| Heart rate (pulse) | Radial pulse with two fingers; count 30 seconds and double if regular, or a full 60 seconds if irregular; note rhythm and strength | 60–100 beats/min (lower in trained athletes) | Resting rate above 100 or below 50 with symptoms, or a new irregular rhythm: refer; chest pain or fainting: 911 |
| Respiratory rate | Count chest rises for 30–60 seconds without telling the client (for example, keep your fingers on the pulse) | 12–20 breaths/min | Above about 24 or below 10, laboured breathing, or new shortness of breath: stop and refer; severe distress: 911 |
| Blood pressure | Seated 5 minutes, back supported, feet flat, legs uncrossed, arm supported at heart level, no talking; correctly sized cuff on bare arm | See 5.2 for thresholds (guidelines differ by method) | Readings of 180/120 mmHg or higher: no treatment and urgent medical referral; with chest pain, neurological signs, or shortness of breath: 911 |
| Temperature | Oral or tympanic thermometer | About 36.5–37.5°C | 38.0°C or higher (fever): postpone treatment |
| Oxygen saturation (SpO2) | Pulse oximeter on a warm finger without nail polish | 95–100% in healthy adults | Below about 92% at rest, or a drop with symptoms: refer (some clients with COPD have lower agreed targets) |
Measuring Blood Pressure Manually
- Choose a cuff whose bladder encircles about 80% of the arm (a cuff that is too small reads falsely high; too large reads falsely low).
- Place the cuff 2–3 cm above the antecubital fossa with the arm supported at heart level.
- Palpate the radial pulse and inflate until it disappears, then inflate a further 20–30 mmHg.
- Place the stethoscope over the brachial artery and deflate at about 2–3 mmHg per second.
- The first clear tapping sound (Korotkoff phase I) is the systolic pressure; the point where sounds disappear (phase V) is the diastolic pressure.
- Record the reading, the arm used, the position, and the time. Automated devices are acceptable when validated and used with the same preparation.
When Should an RMT Take Vital Signs?
- At the initial visit as a baseline for clients with cardiovascular, respiratory, renal, or endocrine conditions, or those taking medications that affect heart rate or blood pressure.
- Before systemic hydrotherapy or vigorous treatment in clients with cardiovascular disease.
- Whenever a client reports symptoms such as dizziness, chest discomfort, palpitations, headache, or shortness of breath.
- After positional changes in clients prone to orthostatic hypotension (a drop of 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing defines orthostatic hypotension).
4. Assessing Activities of Daily Living (ADLs)
Function links impairment to what matters to the client.
- Basic ADLs (self-care): bathing, dressing, toileting, transferring, continence, and feeding (the Katz Index groups these six).
- Instrumental ADLs (IADLs): more complex tasks needed to live independently—shopping, cooking, housekeeping, laundry, managing medications and finances, using the telephone, and transportation (the Lawton scale).
- Methods: Ask what the client can no longer do or does with difficulty; observe tasks directly (sit-to-stand, reaching to a shelf, putting on a jacket, stepping onto a stool); and use standardized questionnaires such as the Patient-Specific Functional Scale, Neck Disability Index, Oswestry Disability Index, or QuickDASH (11.4).
- Fall-risk screening: The Timed Up and Go (TUG) test times the client rising from a chair, walking 3 metres, turning, returning, and sitting. Times slower than about 12 to 13.5 seconds are commonly used to flag increased fall risk in community-dwelling older adults. A positive screen calls for safer transfers (11.7), a fall-prevention home program, and possible referral.
Functional findings become SMART goals (for example, "dress independently without shoulder pain within 4 weeks") and are re-measured at re-assessment.
5. Clinical Vignette
A 66-year-old client taking a beta-blocker and a diuretic arrives for treatment of chronic low back pain. He reports feeling light-headed when he stood up from the waiting room chair. Seated after 5 minutes of rest, his blood pressure is 132/78 mmHg and his pulse is 58 and regular. After standing for 3 minutes, his blood pressure is 108/70 mmHg and he feels dizzy. The 24 mmHg systolic drop meets the definition of orthostatic hypotension. The therapist treats him side-lying rather than prone, uses slow position changes, has him sit on the edge of the table for 1–2 minutes before standing, documents the readings, and suggests he review the symptom with his physician because medications are a likely contributor.
When measuring blood pressure manually, which technique produces the most accurate reading?
After 5 minutes of seated rest, with back and arm supported, arm at heart level, feet flat, and a correctly sized cuff on bare skin
Measure immediately on arrival with the client standing, the arm hanging at the side, and the cuff over a thin sleeve
Ask the client to describe their symptoms during the reading so the therapist can record pain and pressure together
Use the smallest cuff available so that it fits snugly, and deflate quickly at about 10 mmHg per second so the reading is not prolonged
Why is a client's respiratory rate counted without telling them it is being measured?
Because clients usually change their breathing rate and depth once they know it is being observed
Because privacy legislation prohibits telling clients that their breathing is being assessed
Because informing the client would require a separate signed consent form for each vital sign
Because respiratory rate must always be counted while the client is asleep on the table
Which task is an instrumental activity of daily living (IADL) rather than a basic ADL?
Feeding oneself once food is prepared
Transferring from the bed to a chair
Managing medications and paying bills
Dressing the upper and lower body
Before a full-body treatment, a client's blood pressure is 186/122 mmHg on two seated readings. She has no chest pain, neurological symptoms, or shortness of breath. What is the appropriate action?
Proceed with a vigorous full-body treatment to help her relax, then re-measure the blood pressure at the end of the session
Do not treat; explain the readings and arrange urgent same-day medical assessment, calling 911 if symptoms develop
Treat only the lower limbs, because blood pressure readings are not relevant to massage of the legs
Apply hot packs to the neck and shoulders before massage to lower her blood pressure through vasodilation
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