Vital signs

What are the vital signs assessed in a general health assessment?

Temperature, pulse, respirations, blood pressure, oxygen saturation, and pain level.

Why are vital signs assessed?

They reflect health status, cardiopulmonary function, and overall body function. They are used to establish a baseline, monitor the patient's condition, evaluate responses to treatment, identify problems, and monitor risks for changes in health.

What findings may indicate the need for a rapid response team?

Acute change in mental status; stridor; respirations

What assessments and measurements are included with vital signs and general survey?

Height, weight, temperature, pulse, respirations, blood pressure, oxygen saturation, pain level, assessment for orthostatic hypotension, and Doppler pulse/BP if needed.

What equipment may be needed to obtain vital signs?

Scale, height bar, stethoscope, thermometer, watch with a second hand, sphygmomanometer, and pulse oximeter.

What should be done before measuring vital signs?

Have the patient rest for at least 5 minutes; ensure they have not eaten, drank, or smoked for at least 30 minutes; remove constrictive clothing from the upper arm; and note whether the patient is standing, sitting, or lying down.

What is assessed during the general survey?

Physical appearance and mobility. Assess overall appearance, hygiene and dress, skin color, body structure and development, behavior, facial expressions, level of consciousness, speech, posture, range of motion, and gait.

When does the general survey begin and end?

It begins with the first interaction with the patient and continues throughout the entire time the nurse is providing care.

What is the normal body temperature range given in the PowerPoint?

36.5°C–37°C or 97.7°F–98.6°F, depending on the route used.

How do rectal, tympanic, and temporal artery temperatures compare with oral temperature?

They are approximately 0.4–0.5°C or 0.7–1°F higher than oral temperature.

How does an axillary temperature compare with an oral temperature?

Axillary temperature averages about 0.5°C or 1°F lower than oral temperature.

What is a pulse?

A throbbing sensation that can be palpated over a peripheral artery or auscultated over the cardiac apex.

What is the normal adult pulse rate?

60–100 beats per minute.

What four characteristics should be assessed when palpating a pulse?

Rate, rhythm, strength, and elasticity.

What are tachycardia, bradycardia, and asystole?

Tachycardia = pulse >100 bpm; bradycardia = pulse <60 bpm; asystole = pulse of 0.

What is sinus arrhythmia?

A rhythm in which breathing affects heart rate: the heart rate increases during inspiration and decreases during expiration.

What should the nurse do if the radial pulse is irregular?

Assess the heart rate at the apical region of the heart for 1 full minute.

What counts as one respiration?

One inspiration plus one expiration equals one respiration.

What is the normal adult respiratory rate?

12–20 breaths per minute with a regular rhythm.

What are the important abnormal respiratory terms?

Dyspnea = difficulty breathing; bradypnea = respirations <12/min; tachypnea = respirations >20/min; apnea = 0 respirations; hyperventilation and hypoventilation are also abnormal findings.j

What does oxygen saturation measure, and what is the normal range in this PowerPoint?

SpO2 measures the percentage of hemoglobin filled with oxygen. The PowerPoint lists normal pulse oximetry as 92%–99%.

What oxygen saturation levels are concerning?

SpO2 <85% indicates inadequate oxygenation and a possible emergency. SpO2 85%–89% may be acceptable for some patients with specific chronic conditions such as emphysema.

What can cause inaccurate pulse oximetry readings, and what should be documented?

Circulation impairment and cold extremities can cause measurement errors. Document whether the patient was on room air or receiving oxygen.

What do systolic and diastolic blood pressure represent?

Systolic BP is the maximum pressure created during left ventricular contraction. Diastolic BP is the minimum pressure during left ventricular relaxation.

What factors contribute to blood pressure?

Cardiac output, peripheral vascular resistance, circulating blood volume, blood viscosity, and vessel wall elasticity.

What adult blood pressure ranges are given in the PowerPoint?

Systolic BP: 90–120 mm Hg. Diastolic BP: 60–80 mm Hg. The PowerPoint lists the adult average as 120/80 mm Hg.

What factors can influence blood pressure?

Age, gender, ethnicity, weight, diurnal cycle, body position, exercise, emotions, stress, medications, and smoking.

What are hypertension and hypotension?

Hypertension is elevated blood pressure. Hypotension is blood pressure below normal limits.

What should you know about BP measurement, Doppler, and documentation?

Use the appropriate cuff size. BP may be measured on the arm or thigh. If circulation is poor, a Doppler may be used and documented as systolic pressure over Doppler, such as 88/Doppler. Document where the BP was taken and whether the patient was lying, sitting, or standing.

What should the nurse do if an automatic vital-sign monitor gives a questionable reading?

Validate the reading using a manual method. Portable monitors may measure BP and SpO2, but questionable results should be confirmed manually.

What is the priority if a patient is sitting up and having difficulty breathing?

Call for assistance while taking vital signs. The patient may need a rapid response team, while the vital signs provide important baseline information for the responding team.