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The new edition of Standard Highway Signs will contain the details for all signs and pavement markings in the 11th Edition of the MUTCD, expanded sign design guidelines, and details for symbolic traffic and lane-control signal indications. It is taking some additional time to prepare the publication, and information is expected to be posted in the coming months.

The Federal Highway Administration has developed the design details of the signs added in the 2009 Edition of the MUTCD and signs whose designs have been modified in the 2009 MUTCD. The new designs are provided in the form of a Supplement to the 2004 Edition of Standard Highway Signs.

These links represent the current version of Standard Highway Signs and the 2012 Supplement to the 2004 Standard Highway Signs. The 2012 Supplement contains the new and revised sign designs adopted in the 2009 Edition of the MUTCD. Where a sign design is included in the 2012 Supplement, its previous design in the 2004 Standard Highway Signs is superseded. Together, these two documents are a companion to the 2009 Edition of the MUTCD.

Undimensioned, full-size layouts for selected signs are provided for use by sign fabricators in the electronic fabrication process. These full-size layouts are made available in vector-based PDF and EPS formats that can be used directly with electronic vinyl cutting equipment.

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Vital signs are an objective measurement of the essential physiological functions of a living organism. They have the name "vital" as their measurement and assessment is the critical first step for any clinical evaluation. The first set of clinical examinations is an evaluation of the vital signs of the patient. Triage of patients in an urgent/prompt care or an emergency department is based on their vital signs as it tells the physician the degree of derangement that is happening from the baseline. Healthcare providers must understand the various physiologic and pathologic processes affecting these sets of measurements and their proper interpretation. If we use a triage method where we select patients without determining their vital signs, it may not give us a reflection of the urgency of the patient's presentation.[1] The degree of vital sign abnormalities may also predict the long-term patient health outcomes, return emergency department visits, and frequency of readmission to hospitals, and utilization of healthcare resources.

Traditionally, the vital signs consist of temperature, pulse rate, blood pressure, and respiratory rate. Even though there are a variety of parameters that may be useful along with the traditional four vital sign parameters, studies have only found pulse oximetry and smoking status to have significance in patient outcomes.[2] Pulse oximetry sometimes helps to clarify the patient's physiological functions, which would sometimes be unclear by checking just the traditional vital signs. The inclusion of smoking status has the premise that the patient will be provided counseling by the provider on quitting smoking. In the past, some health care systems in the United States had used "pain as the fifth vital sign'. This approach is being abandoned due to the unintended opioid crisis that the country is currently facing.[3]

Patient safety is a fundamental concern in any health care organization, and early detection of any clinical deterioration is of paramount importance whether the patient is in the emergency department or on the hospital floor. The early detection of changes in vital signs typically correlates with faster detection of changes in the cardiopulmonary status of the patient as well as up-gradation of the level of service if needed. Vital signs assessment currently uses electronic equipment, but there is evidence that, outside of the intensive care units, respiratory rate assessment through observation, leading to insufficient, subjective, and unreliable results.[4]

In a case-control study conducted by Rothschild and colleagues, early warning criterion among patients on the medical floor, the presence of respiratory rate over 35/min (OR=31.1) was most strongly associated with a life-threatening adverse event.[5] Early warning score (EWS) tools, mostly using vital sign abnormalities, are critical in predicting cardiac arrest and death within 48 hours of measurement, even though the effect on in-hospital health outcomes and utilization of resources remains unknown.[5]

It seems intuitive that the higher the frequency of vital sign measurement, the faster the chances of clinical deterioration are detected. There is variability between institutes within and across nations depending on the acuity of clinical condition, any active intervention carried out, the amount of staff availability, cost issues, organizational practices, and leadership styles. The weighted average score deduced from the vital sign measurements (i.e., an early warning score) is used to determine the timing of the next observation sets.[4][5]

The most common sites of measuring the peripheral pulses are the radial pulse, ulnar pulse, brachial pulse in the upper extremity, and the posterior tibialis or the dorsalis pedis pulse as well as the femoral pulse in the lower extremity. Clinicians measure the carotid pulse in the neck. In day-to-day practice, the radial pulse is the most frequently used site for checking the peripheral pulse, where the pulse is palpated on the radial aspect of the forearm, just proximal to the wrist joint. Parameters for assessment of pulse include its rate, rhythm, volume, amplitude, and rate of increase, besides its symmetry The rate of the pulse is significant to measure for assessing the physiological and pathological processes affecting the body. The normal range used in an adult is between 60 to 100 beats/minute with rates above 100 beats/minute and rates below 60 beats per minute, referred to as tachycardia and bradycardia, respectively. The age-specific heart rate given for the pediatric age range appears in table -2.

Blood pressure is an essential vital sign to comprehend the hemodynamic condition of the patient. Unfortunately, though, there are a lot of inter-person variabilities when measuring it. Many times, the basic measurement techniques are not followed and lead to erroneous results.

Since vital signs are an indication of the changes in physiological processes, they tend to change with age. With age, core body temperature tends to be lower, and the ability of the body to change with different kinds of stressors becomes minimized. Even subtle variation from the core body temperature can be a significant finding as fever in an older patient often indicates a more severe infection and is associated with increased rates of life-threatening consequences.[12]

There can be a decrease in response to changes in the oxygen and carbon dioxide at the molecular level along with anatomical changes resulting due to stiffness of muscles and compliance of the chest wall. Respiratory rate sometimes might be the most neglected of the vital signs reported in hospitalized patients but is more sensitive than other vital signs in picking up a critically ill patient.[13]

Accurately measuring vital signs is a clinical skill that needs time and practice to refine. A review of literature is abundant about the inter-observer variability observed and reported secondary to lack of this skill. Clinicians should be wary of this and always re-check the vital signs themselves if there is a profound or unexpected change. Clinics and organizations should continuously strive to check and educate their nursing and ancillary staff to sharpen these skills.

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