Exam 1 Study Guide — Module 2: Vital Signs, Skin, Head & Neck, Senses, Breast-Part A

What are the 5 vital signs, and what does each one tell you?

• Temperature — body heat balance (infection, environment)
- Pulse — heart rate, rhythm, and strength
- Respirations — breathing rate, rhythm, depth, effort
- Oxygen saturation (SpO₂) — % of hemoglobin carrying oxygen
- Blood pressure (BP) — force of blood against artery walls
(Pain is assessed with them in the general survey.)

What are the expected ADULT vital sign ranges?

• Temperature: 36–38 °C (96.8–100.4 °F), average 37 °C (98.6 °F)
- Pulse: 60–100/min
- Respirations: 12–20/min
- SpO₂: 95–100%
- BP: under 120 systolic AND under 80 diastolic
Values exactly at the edge still count as expected.

What are the expected PULSE ranges across the lifespan?

• Newborn (birth–4 wk): 110–160
- Infant (1–12 mo): 90–160
- Toddler (1–2 yr): 80–140
- Preschool (3–5 yr): 70–120
- School age (6–12 yr): 60–110
- Adolescent (13–18 yr): 50–100
- Adult (18+): 60–100
Pattern: fastest at birth, slows through childhood.

What are the expected RESPIRATORY RATE ranges across the lifespan?

• Newborn (0–28 days): 30–60
- Infant (1 mo–1 yr): 25–60
- Toddler (1–3 yr): 25–30
- Preschool (3–6 yr): 20–25
- School age (6–12 yr): 20–25
- Adolescent (12–20 yr): 16–20
- Adult (20+): 12–20
Note: age brackets differ from the pulse table.

How does temperature differ in older adults?

• Baseline often lower: 35–36.1 °C (95–97 °F)
- Fevers are weaker, so infection is easy to miss
- Suspect infection when temp is ABOVE 37.2 °C (99 °F) OR more than 1.1 °C (2 °F) above the client's baseline

What are the 7 steps of the universal response to ANY abnormal vital sign?

1. VERIFY — recheck, check equipment, manual method or full 1-min count
2. LOOK for other signs — dizziness, chest pain, confusion, shortness of breath
3. FIX modifiable causes (pain, anxiety, activity, caffeine, nicotine) → recheck in 15–30 min
4. SAFETY — sit upright, fall precautions, oxygen if prescribed
5. NOTIFY the provider, compare with baseline and trends
6. PREPARE for emergency care if severe
7. DOCUMENT readings, interventions, and client response (= evaluation)

Why do vital sign trends matter?

• A trend can show a change in condition even when each single reading looks okay
- Example: BP 132/84 → 122/76 → 110/70 → 98/62 over 8 hours = report the downward trend
- Trends also show whether an intervention worked (evaluation)

When should vital signs be measured?

• At the start of every health care encounter
- Per unit policy (often after surgery, every 4 or 8 hr on general units)
- Before/after certain medications and blood products
- Whenever the client's condition changes
- Whenever the nurse senses something is wrong

What are the delegation rules for vital signs?

• RN can delegate to another RN, an LPN, or assistive personnel (AP)
- LPN can delegate to another LPN or AP
- AP COLLECTS and REPORTS BACK
- The NURSE INTERPRETS and ACTS (verify, assess, notify)
Five Rights of Delegation: right task, circumstance, person, directions/communication, supervision/evaluation

Which factors RAISE BP, pulse, and respiratory rate?

• Exercise / recent activity
- Pain
- Anxiety, fear, "white coat" nerves
- Caffeine
- Nicotine
- Fever (raises pulse and RR)
Fix: let the client rest, address the cause, recheck in 15–30 min.

Which conditions LOWER BP or pulse?

• Dehydration or blood loss → ↓ BP (pulse ↑ to compensate)
- Heart failure → ↓ BP
- Hypothyroidism → ↓ pulse
- Excellent fitness (athletes) → ↓ pulse (expected)
- Sleep → ↓ pulse

How do common MEDICATIONS affect vital signs?

• Beta blockers (-olol, e.g., metoprolol): ↓ HR, ↓ BP — can MASK a fast heart rate from bleeding or infection
- Opioids / sedatives: ↓ RR, ↓ BP, pinpoint pupils
- Antipyretics (acetaminophen, ibuprofen): ↓ temp — can MASK fever
- Diuretics / antihypertensives: ↓ BP → orthostatic hypotension risk
- Decongestants / stimulants: ↑ HR, ↑ BP
- Digoxin: ↓ HR — take apical pulse 1 full min before giving

What are the key TEMPERATURE terms and numbers?

• Expected: 36–38 °C (96.8–100.4 °F)
- Fever: above 38 °C (100.4 °F)
- Hyperthermia: 40 °C (104 °F) or higher
- Hypothermia: below 35 °C (95 °F) — ATI writes "below 30 °C," which is actually SEVERE hypothermia
- Older adult — suspect infection: above 37.2 °C (99 °F) or 1.1 °C above baseline
- Febrile = has a fever. Afebrile = no fever.
- Daily pattern: lowest early morning, highest late afternoon

What is the difference between FEVER and HYPERTHERMIA?

FEVER
- Brain's thermostat (hypothalamic set point) is RAISED, usually by infection
- Client shivers and feels cold because the body is making heat to reach the new set point
- Actions: find the infection source, notify, bring the temp down
HYPERTHERMIA
- Set point is NORMAL — the body can't get rid of heat (hot/humid environment, poor sweating)
- Signs: dizziness, weakness, thirst, nausea → untreated: hypotension, fainting, confusion, organ failure
- Actions: physical cooling (antipyretics don't fix it)

What are the 4 ways the body loses heat?

• CONDUCTION — direct contact with a cooler surface (cooling blanket, cold pack, cold exam table)
- CONVECTION — moving air (a fan)
- EVAPORATION — moisture evaporating (sweat, wet skin, sponge bath)
- RADIATION — heat moving to a nearby cooler surface WITHOUT touching (standing by a cold window)

What are the nursing actions for HYPERTHERMIA?

1. Move the client to a cooler place
2. Remove extra clothing
3. Cold packs to the NECK, AXILLAE, and GROIN
4. Fan (convection)
5. IV fluids as prescribed
6. Frequent temperature checks
7. Notify the provider of changes

What are the stages and actions for HYPOTHERMIA?

MILD/EARLY — shivering, decreased motor skills, poor perfusion
→ Warm the room, add clothing layers, COVER THE HEAD, warming blanket. Infants: radiant warmer.
PROGRESSING — confusion, poor concentration, dilated pupils, loss of consciousness
→ Warming blanket + WARMED IV fluids as prescribed
SEVERE (emergency) — loss of deep tendon reflexes, coma, high risk of cardiac arrest
→ Emergency care, frequent core temps, notify if temp isn't rising

What are the 5 temperature sites, with pros and cons?

• ORAL — easy, any position | inaccurate within 30 min of eating, drinking, smoking, not for young children
- TYMPANIC (ear) — fast, reflects core | inaccurate with earwax or ear infection, hard under age 3, remove hearing aids
- TEMPORAL (forehead) — fast, all ages, reflects rapid core changes | affected by sweat, hats, hair
- AXILLARY (armpit) — safe, all ages | SLOWEST, doesn't reflect rapid core changes, affected by room temp
- RECTAL — MOST RELIABLE | injury risk, avoid with diarrhea, hemorrhoids, rectal surgery, bleeding disorders

How do you position the ear for a tympanic temperature?

• Over age 3 (and adults): pull the pinna UP and BACK
- Age 3 and under: pull the pinna DOWN and BACK
- Insert snugly, angled toward the jaw, then scan
- Check for earwax or infection first

When is an ORAL temperature inaccurate?

• Within 30 minutes of eating or drinking anything hot or cold
- Within 30 minutes of smoking
- In newborns, infants, and young children
Fix: wait 30 minutes, or use another site (tympanic or temporal).

What are the steps for a RECTAL temperature?

1. Two identifiers, privacy, gloves
2. Red-tip rectal probe with a cover
3. Lubricate the first 2.5 cm (1 in)
4. Adults and older children: LEFT side-lying. Infants: supine, knees to abdomen.
5. Have the client take a deep breath
6. Insert toward the umbilicus — adult 3.5 cm (1.5 in), infant/child 1.2 cm (½ in)
7. Hold in place, remove gently, perianal care, remove gloves, hand hygiene, disinfect probe

What are the steps for ORAL and AXILLARY temperatures?

ORAL: probe cover on → confirm nothing hot/cold/smoked in 30 min → probe in the POSTERIOR SUBLINGUAL POCKET beside the frenulum → lips closed → hold until the beep
AXILLARY: dry the skin → probe in the CENTER of the axilla → arm down against the body → hold until the beep

How do you take a TEMPORAL artery temperature?

1. Skin dry, hair brushed away, no hat or scarf
2. Start at the center of the forehead
3. Slide across to the hairline with the button HELD DOWN
4. Touch behind the earlobe, then release

How is temperature documented?

• Value + units (°C or °F) + ROUTE
- Related findings and actions
Example: "T 38.9 °C (102 °F) tympanic. Skin warm, flushed. Client reports chills. Provider notified."

What are the 8 pulse sites and where is each?

• Temporal — above and in front of the ear's tragus
- Carotid — side of the neck
- Brachial — inner arm just above the elbow (top of the antecubital fossa)
- Radial — inner wrist below the base of the thumb (ROUTINE site)
- Femoral — midway between the symphysis pubis and the anterior superior iliac spine (supine)
- Popliteal — center of the back of the knee (supine)
- Posterior tibial — inner ankle, between the Achilles tendon and medial malleolus
- Dorsalis pedis — top of the foot

What is the PULSE STRENGTH scale?

• 0 — ABSENT, nonpalpable → use a Doppler
- 1+ — WEAK/diminished, easily obliterated
- 2+ — NORMAL (expected)
- 3+ — INCREASED/strong, can still be obliterated with pressure
- 4+ — BOUNDING, CANNOT be obliterated
Also compare left vs. right, and upper vs. lower limbs.

How do you count a pulse?

• Use the pads of 2–3 fingers, gentle pressure (too much blocks it, too little misses it)
- REGULAR rhythm: count 30 sec × 2
- IRREGULAR rhythm: count a FULL 60 sec + check the apical pulse
- NEVER palpate both carotids at the same time (can cause fainting)
- Never use your thumb (it has its own pulse)

What do you do if a pulse is NOT palpable?

1. Use a Doppler ultrasound stethoscope: apply gel, place the probe gently, rotate to find the sound, count 1 full minute
2. Check perfusion: skin temperature, color, capillary refill
3. Notify the provider of any pulse that needed a Doppler

Where is the APICAL pulse, and how do you take it?

• Adults/adolescents: 5th intercostal space, LEFT midclavicular line (point of maximal impulse, PMI)
- Young children (under 7): 4th intercostal space, just left of the midclavicular line
- Use the diaphragm
- One "lub-dub" = one beat
- Count a FULL 1 MINUTE
- Document rate, rhythm, and location

What are the 5 heart auscultation points ("APE To Man")?

• AORTIC — 2nd intercostal space, RIGHT sternal border
- PULMONIC — 2nd intercostal space, LEFT sternal border
- ERB'S POINT — 3rd intercostal space, left sternal border
- TRICUSPID — 4th intercostal space, left sternal border
- MITRAL (apex, PMI) — 5th intercostal space, left midclavicular line

What is an APICAL–RADIAL PULSE DEFICIT?

• HOW: two nurses, same watch, start together, count a full 1 minute (one apical, one radial)
- MATH: deficit = apical − radial (e.g., 112 − 96 = 16)
- WHY: some beats are too weak to reach the wrist, so radial can never be higher than apical
- CAUSES: atrial fibrillation, coronary artery disease
- ACTION: document the deficit as a number, notify the provider
- EMERGENCY if with chest/back pain, sweating, cyanosis, dizziness

What is TACHYCARDIA — causes and actions in order?

DEFINITION: adult pulse ABOVE 100/min
CAUSES: exercise, anxiety, caffeine, nicotine, fever, medications, heart electrical problems
ACTIONS:
1. Verify the reading
2. Address causes — rest, relaxation (meditation, yoga, guided imagery)
3. Recheck in 15–30 min
4. Valsalva maneuver ("bear down as if having a bowel movement") — slows the heart through the vagus nerve
5. Still high → NOTIFY the provider and DOCUMENT
TEACH: limit caffeine/nicotine, smoking cessation, count the radial pulse

What is BRADYCARDIA — causes and actions?

DEFINITION: adult pulse BELOW 60/min
CAUSES: very fit athletes (EXPECTED), hypothyroidism, heart failure, heart muscle damage, beta blockers
CONCERNING when symptomatic: dizziness, fatigue, shortness of breath, chest pain, confusion
ACTIONS: change positions slowly, take medications as prescribed, report changes, teach radial pulse counting and when to call the provider

What is an ARRHYTHMIA, and what do you do?

• An irregular rhythm OR a rate outside the expected range
- Action: auscultate the APICAL pulse for a FULL minute to confirm, then notify the provider

How is the pulse documented?

• PERIPHERAL: rate, rhythm, strength (0–4+), equality (L vs. R)
- APICAL: rate, rhythm, location
Example: "Apical pulse 112/min irregular at 5th ICS L MCL. Radial 94/min. Pulse deficit 18. Provider notified."

How do you count respirations correctly?

• DON'T tell the client — keep your fingers on the wrist as if still taking the pulse
- Position: sitting or head of bed at 45–60°
- 1 breath = 1 inspiration + 1 expiration
- REGULAR: 30 sec × 2
- IRREGULAR, unexpected rate, or ill client: FULL 60 sec
- Also note DEPTH, RHYTHM, and EFFORT

What are the respiratory patterns, their descriptions, and causes?

• EUPNEA — normal rate and rhythm
- TACHYPNEA — FAST, often shallow → pain, anxiety, fever, pneumonia, asthma
- BRADYPNEA — SLOW → opioids/sedatives, alcohol, increased intracranial pressure, hypothyroidism, shock
- APNEA — breathing STOPS → opioid toxicity, trauma, neuro problems (persistent = respiratory arrest)
- CHEYNE-STOKES — CYCLES shallow → deep → shallow, then APNEA → brain injury, stroke, increased ICP, heart failure, dying
- KUSSMAUL — DEEP, FAST, REGULAR, no pauses → diabetic ketoacidosis (DKA), kidney failure
- RETRACTIONS — skin pulls INWARD between/below ribs or above the sternum → increased work of breathing

What is eupnea?

Breathing at a normal rate and rhythm for the client's age.

What is tachypnea?

Respiratory rate ABOVE the expected range, often shallow. Can cause dizziness and tingling hands.

What is bradypnea?

Respiratory rate BELOW the expected range. Signs: dizziness, fatigue, weakness, confusion, poor coordination.

What is apnea?

Breathing stops. Persistent apnea = respiratory arrest = emergency.

What is Cheyne-Stokes breathing?

An IRREGULAR, CYCLICAL pattern: breaths grow deeper, then shallower, followed by a pause (apnea), then the cycle repeats.
Causes: brain injury, increased intracranial pressure, stroke, heart failure, dying.
Memory: C = Cycles, CNS, Cardiac.

What is Kussmaul breathing?

REGULAR but abnormally DEEP and RAPID breathing, often labored, with NO pauses.
Cause: severe metabolic acidosis — especially diabetic ketoacidosis (DKA) — and kidney failure. The body is blowing off acid.
Memory: K = Ketones.

What are retractions?

Tissue pulling INWARD during inspiration (neck, below the sternum, below or between the ribs) as accessory muscles are used. Means increased work of breathing → report.

What are the nursing actions for TACHYPNEA?

1. Find and treat the cause:
• Pain → pain relief, repositioning, ice or heat
• Asthma → bronchodilator, upright position
• Anxiety → calming, slow breathing
2. Sit the client UPRIGHT
3. Reevaluate the respiratory rate

What are the nursing actions for BRADYPNEA?

1. Find and treat the cause:
• Opioid toxicity → NALOXONE as prescribed
• Increased intracranial pressure → raise head of bed slightly, medications to reduce brain swelling
2. Monitor respiratory rate, SKIN COLOR, and SpO₂
Priority framework: ABCs (breathing).

How are respirations documented?

• Breaths per minute + pattern
- Depth, rhythm, effort
- Any positioning or interventions
Example: "RR 24/min, shallow, regular. Mild intercostal retractions. HOB raised to 45°."

What are the oxygen terms SaO₂, SpO₂, hypoxemia, hypoxia, and dyspnea?

• SaO₂ — arterial oxygen saturation (% of hemoglobin carrying oxygen), measured in arterial blood
- SpO₂ — SaO₂ ESTIMATED by pulse oximetry, expected 95–100%
- HYPOXEMIA — low oxygen in the BLOOD ("-emia" = blood)
- HYPOXIA — not enough oxygen reaching the TISSUES
- DYSPNEA — difficult or labored breathing (shortness of breath)

What SpO₂ values matter?

• 95–100%: expected
- Below 90%: HYPOXIA → emergency (ATI)
- Always compare with the client's previous readings (trend)

What are the steps for measuring SpO₂?

1. Choose a well-perfused site — capillary refill under 2 sec
2. Prepare: clean, dry, intact skin. REMOVE dark nail polish or artificial nails.
3. Choose the probe to match the site (finger, earlobe clip, adhesive)
4. Attach the probe, client keeps still, check for a CONSISTENT WAVEFORM
5. COMPARE the oximeter pulse with the RADIAL pulse — if they don't match, MOVE the probe
6. Wait 10–30 sec for a stable reading
7. Set alarm limits for continuous monitoring
8. Compare with previous readings

Which SpO₂ site should be used for each client?

• Adults and children: FINGER (most common)
- Poor peripheral circulation (cold fingers): EARLOBE (more reliable)
- Forehead adhesive probe: children and adults
- Newborns and young infants: adhesive probe on the FOOT, ANKLE, WRIST, or PALM — snug but not tight
- Restless child or confused adult: earlobe, toe, or foot

What causes FALSE or unreliable SpO₂ readings?

• Dark nail polish or artificial nails
- Movement
- Cold, poorly perfused fingers
- Carbon monoxide poisoning (falsely HIGH)
- DARKER SKIN TONES — may read falsely HIGH and hide hypoxemia → always check the whole clinical picture (CO5)

What are the nursing actions for LOW SpO₂, from least to most intensive?

1. Sit the client UPRIGHT / raise the head of the bed
2. DEEP BREATHING and COUGHING to clear secretions
3. SUPPLEMENTAL OXYGEN and medications (bronchodilators) as prescribed
4. NOTIFY the provider
5. MONITOR SpO₂, mental status, capillary refill, skin color
6. If severe: continuous monitoring, lung sounds, high-flow oxygen, intubation equipment ready

What are the signs of low oxygen (hypoxia)?

• EARLY: restlessness, anxiety, new confusion, ↑ heart rate, ↑ respiratory rate
- Dyspnea, frequent cough
- Cyanosis (late)
- Causes: pneumonia, chronic lung disease, hypothermia, poor perfusion (low cardiac output)

How is SpO₂ documented?

• Percentage
- ROOM AIR or oxygen device + flow rate
- Site
Example: "SpO₂ 90% RA, L index finger, waveform consistent, oximeter HR matches radial."

What are the adult BLOOD PRESSURE categories (American Heart Association)?

CATEGORY — SYSTOLIC — DIASTOLIC
- Normal — under 120 AND under 80
- Elevated — 120–129 AND under 80
- Stage 1 hypertension — 130–139 OR 80–89
- Stage 2 hypertension — 140 or higher OR 90 or higher
- Hypertensive emergency (notify NOW) — above 180 AND/OR above 120
- Hypotension (no baseline) — under 90 OR under 60
RULE: classify by the HIGHER category. "OR" means either number alone is enough.

How do you classify a BP when the two numbers fall in different categories?

Use the HIGHER category.
Examples:
- 126/84 → systolic "elevated," diastolic Stage 1 → STAGE 1
- 118/82 → diastolic 82 → STAGE 1
- 124/76 → ELEVATED (diastolic under 80)
- 142/72 → systolic 142 → STAGE 2
- 138/78 → systolic 138 → STAGE 1

What is needed to DIAGNOSE hypertension?

At least TWO elevated readings on TWO or more separate occasions. One high reading is not a diagnosis, and the provider (not the nurse) diagnoses.

What is the correct ORDER of steps for a manual blood pressure?

1. Explain, remove bulky clothing (don't roll a tight sleeve — falsely high)
2. Position: seated, back supported, FEET FLAT, LEGS UNCROSSED (or supine)
3. Arm at HEART LEVEL, palm up, elbow slightly flexed, supported
4. PALPATE the BRACHIAL artery
5. Apply the correct-size cuff (covers 80% of the upper arm), artery marker over the brachial artery
6. Gauge at zero, at eye level
7. No baseline? TWO-STEP method to estimate the systolic, then wait 1 min
8. Stethoscope over the brachial artery, inflate 30 mm Hg ABOVE the estimated systolic
9. Deflate at 2–3 mm Hg PER SECOND
10. Read the systolic and diastolic, remove the cuff, clean equipment

What is the TWO-STEP method for blood pressure?

Used when there is NO baseline:
1. Palpate the brachial pulse while inflating the cuff
2. Note where the pulse DISAPPEARS, then inflate 30 mm Hg more
3. Deflate slowly — where the pulse RETURNS = ESTIMATED SYSTOLIC
4. Deflate fully and WAIT 1 MINUTE
5. Then auscultate: inflate to 30 mm Hg above the estimated systolic

What sounds mark the systolic and diastolic pressures?

• SYSTOLIC = the FIRST faint, clear TAPPING sound (first Korotkoff sound)
- Sounds muffle, then...
- DIASTOLIC = the point where sounds completely DISAPPEAR
Example: tapping at 136, muffles at 88, gone at 82 → record 136/82.

Which arms should NOT be used for blood pressure?

• Mastectomy with lymph node removal on that side (lymphedema risk)
- Dialysis AV fistula or shunt
- Central line
- Peripheral IV
- Recent surgery or acute injury (fracture, cast)
- Severe edema
NOT a contraindication: a TATTOO.
Alternatives: forearm, THIGH (popliteal, reads 20–30 mm Hg HIGHER), conical cuff for large cone-shaped arms.

Which errors cause FALSELY HIGH vs. FALSELY LOW blood pressure?

FALSELY HIGH
- Cuff too SMALL/narrow or too tight
- Arm BELOW heart level
- Arm unsupported
- Legs crossed
- Tight sleeve rolled up
- No rest after activity, pain, anxiety, caffeine, nicotine
- White coat effect
FALSELY LOW
- Cuff too LARGE/wide or too loose
- Arm ABOVE heart level
Memory: a small cuff squeezes harder → high.

When should a MANUAL cuff be used instead of an automated device?

• The device shows an error
- The reading is unexpectedly high or low
- The client has an IRREGULAR heart rhythm
- A reading needs verification
Wrist monitors, wearables, and phone apps are not for clinical use.

What is white coat syndrome?

BP rises from anxiety in a health care setting. Fix: build rapport, let the client rest, slow breathing, then recheck.

What are ORTHOSTATIC vital signs — steps, positive result, and teaching?

STEPS: BP (and pulse) LYING → SITTING → STANDING
POSITIVE (orthostatic hypotension): within 1 min of sitting or standing,
- SYSTOLIC drops 20 or more, OR
- DIASTOLIC drops 10 or more
(Either alone is enough.) Recheck at 3 min if symptomatic or delayed drop. Report.
CAUSES: dehydration, hypotension, heart failure, nervous system disorders, BP medications
TEACH: change positions slowly, raise head of bed slightly, avoid long lying/sitting, stay hydrated, avoid temperature extremes, sit if dizzy (fall risk)

What are the nursing actions for HYPERTENSION?

1. Look for modifiable causes (pain, anxiety, activity, caffeine)
2. Rest, build rapport, slow deep breaths
3. RECHECK in 15–30 min
4. Still high → DOCUMENT and NOTIFY the provider
5. Above 180/120 → notify IMMEDIATELY (hypertensive emergency)
HEALTH PROMOTION: exercise, stress reduction, LOW-SODIUM diet, weight loss if needed, antihypertensive teaching (adverse effects, when to call)
Complications if untreated: heart attack, stroke, kidney failure, vision loss.

What are the signs and actions for HYPOTENSION?

DEFINITION: under 90/60 when no baseline is available
CAUSES: dehydration, blood loss, shock, sepsis, medications
SIGNS: dizziness, nausea, blurred vision, ↑ PULSE, fatigue
ACTIONS: oral fluids, IV fluids if prescribed, compression stockings, review medications, FALL PRECAUTIONS

What are the signs of SHOCK, and what does the nurse do?

SIGNS:
- Cold, PALE skin
- RAPID, WEAK pulse
- RAPID breathing
- LOW BP
CAUSES: major blood loss, heart failure, sepsis
ACTION: carry out prescribed interventions IMMEDIATELY — rapid IV fluids or blood, medications to raise BP and contractility.
NOT shock: warm, flushed skin with a slow, bounding pulse.

How is blood pressure documented?

• Value in mm Hg + SITE (which arm) + client POSITION
- Interventions and the client's response
Example: "BP 142/88 mm Hg, R arm, seated. Rested 10 min with slow breathing. Recheck 128/78 mm Hg, R arm, seated."

How does BP change across the lifespan?

• LOWEST in newborns (about 64/41)
- Rises through childhood → adult levels in adolescence
- Rises slightly through adulthood
- Decreases slightly in older adulthood
- Routine BP starts after age 3
- Pediatric hypertension: at or above the 95th percentile for age on 3 separate visits

What techniques are used for a skin assessment, and in what ORDER?

TECHNIQUES: INSPECTION and PALPATION only (no percussion or auscultation)
ORDER:
1. COLOR (inspect)
2. TEXTURE and MOISTURE (inspect + palpate)
3. TEMPERATURE (back of hands, both sides)
4. MOBILITY/TURGOR, then EDEMA and pitting
5. INTEGRITY and LESIONS (measure in cm)
6. NAILS and CAPILLARY REFILL
Memory: see → feel surface → feel deeper → zoom in.

What tools are used for a skin assessment?

• Penlight — direct lighting
- Centimeter ruler — measure unexpected findings
- Gloves — ONLY if moisture, weeping, or bleeding is present

What questions belong in a focused SKIN health history?

• Changes in skin or nails? New or changing MOLES?
- Rashes, ITCHING, bruising, lumps, scars, lesions?
- SORES THAT WON'T HEAL?
- History of allergies or skin problems — onset, cause, treatment?
- Sun exposure and SUNSCREEN use?
- PERSONAL or FAMILY history of skin cancer?
- How do you CARE for your skin and nails?
- Do you self-check moles?
- Effect on self-care, work, social life?

What are the 3 layers of the skin?

• EPIDERMIS (top) — keratin and melanocytes, barrier and skin color
- DERMIS (middle) — collagen, blood vessels, nerves, hair follicles, resists tearing, allows stretch
- SUBCUTANEOUS (bottom) — fat, temperature regulation, cushioning
Skin functions: protection, temperature regulation, sensation, waste excretion, vitamin D production.

What creates skin color?

• MELANIN — brown
- CAROTENE — yellow
- VASCULAR BED (blood flow) — red
Expected: even color, consistent with genetic background.

How do color changes appear in LIGHTER vs. DARKER skin, and where do you look?

• CYANOSIS (low oxygen) — lighter: bluish | darker: dull/ashen → check ORAL MUCOSA, LIPS, NAIL BEDS
- PALLOR (anemia, poor circulation) — lighter: white | darker: YELLOW-BROWN or ASHEN GRAY → check lips, mucosa, nail beds
- JAUNDICE (↑ bilirubin) — lighter: yellow | ALL clients: SCLERA and HARD PALATE, darker skin: also palms/soles
- ERYTHEMA (inflammation) — lighter: red | darker: purplish → PALPATE for WARMTH
- ECCHYMOSIS (bruise) — purple → blue → yellow | darker: hard to see, palpate swelling
- PETECHIAE (tiny bleeds) — red-purple pinpoints | check mucosa

What is cyanosis?

A bluish color of the skin or mucous membranes caused by low oxygen in the tissues. In darker skin, check the oral mucosa, lips, and nail beds.

What is pallor?

Unusual paleness from anemia or poor circulation. In darker skin it looks yellow-brown or ashen gray.

What is jaundice?

Yellow skin or eyes from high bilirubin (a red blood cell breakdown product), usually from liver disease. Check the sclera and hard palate in all clients.

What is erythema?

Redness from inflammation. In darker skin it may look purplish, so palpate for warmth.

What is ecchymosis?

A bruise: blood under the skin, larger than 3 mm. Reddish-purple, then blue and yellow as it heals.

What are petechiae?

Tiny (1–3 mm) reddish-purple pinpoint spots from small bleeds in the skin. Can signal infection, trauma, or a bleeding/platelet problem.

What is purpura?

Petechiae and ecchymoses covering an area. Causes: infection, bleeding disorder.

What are hyperpigmentation and hypopigmentation?

• HYPERpigmentation — MORE melanin: freckles, melasma (pregnancy), age spots (solar lentigines), café au lait spots, tan lines
- HYPOpigmentation — LESS melanin: scars, stretch marks
- VITILIGO — patchy TOTAL loss of pigment (more noticeable in darker skin)

What do skin TEXTURE and MOISTURE findings mean?

EXPECTED: smooth, uniformly dry, oil ranges from xerosis (dry) to seborrhea (oily), acne in adolescence, wrinkles with aging
UNEXPECTED:
- DIAPHORESIS (heavy sweating) → fever, SHOCK, severe PAIN, ANXIETY, thyroid, activity
- Diaphoresis + PALLOR → CARDIAC red flag (ATI: heart failure)
- Rough, dry, flaky → DEHYDRATION, THYROID disease
- Roughness alone → irritation or trauma
- Velvety, unusually smooth → THYROID disease

What is diaphoresis?

Excessive, heavy sweating. Causes: fever, shock, severe pain, anxiety, thyroid disorder, activity. With pallor = cardiac red flag.

What is xerosis?

Abnormally dry skin.

How do you assess skin TEMPERATURE, and what do findings mean?

TECHNIQUE: BACK (dorsal surface) of the hands, BOTH sides at the same time, arms then legs, moving downward, compare sides
- Generalized WARM → fever (infection)
- Localized WARM → inflamed joint, trauma, infection, sunburn
- Generalized COOL → poor whole-body perfusion: SHOCK, cardiac arrest
- Localized COOL (one limb) → reduced blood flow: CLOT, arterial disease → URGENT
EXPECTED: about as warm as your hands, consistent across the body.

How do you assess skin TURGOR, and what do findings mean?

TECHNIQUE: pinch a skin fold on the ANTERIOR CHEST BELOW THE CLAVICLE
- MOBILITY = how easily it rises
- TURGOR = how quickly it returns (hydration)
EXPECTED: rises easily, returns flat quickly
TENTING (stays up) → SEVERE DEHYDRATION or significant weight loss
OLDER ADULTS: return is slower from lost elasticity (expected), so turgor is less reliable → check other hydration data.

What is tenting?

Pinched skin that stays elevated instead of returning flat. Means poor turgor from severe dehydration or significant weight loss.

What is edema, and what does its pattern suggest?

DEFINITION: excess fluid in the interstitial (between-cell) spaces
- BILATERAL / generalized → CENTRAL cause: HEART or KIDNEY failure
- UNILATERAL / localized → LOCAL cause: infection, trauma, clot
- Collects in DEPENDENT areas: feet, ankles, sacrum (raises pressure injury risk)
- Stretches skin → makes darker skin look lighter → can MASK jaundice or cyanosis

How do you assess and grade PITTING edema?

TECHNIQUE: inspect legs/feet → press the top of the foot, release, look for a pit → if pitting, repeat over the tibia → repeat on the other leg
GRADES:
- 1+ — barely detectable
- 2+ — about 4 mm
- 3+ — about 6 mm
- 4+ — 8 mm or deeper, persists a long time
Write "2+", not "+2".

What are the PRIMARY skin lesions and their size rules?

(New change to intact skin. 1 cm cutoff, 2 cm for solid deep lesions.)
- MACULE — flat color change, under 1 cm (freckle)
- PATCH — flat color change, over 1 cm (vitiligo)
- PAPULE — raised solid, under 1 cm (wart, raised mole)
- PLAQUE — raised solid, over 1 cm (psoriasis)
- NODULE — solid, deeper, under 2 cm
- TUMOR — solid, deeper, over 2 cm
- WHEAL — irregular raised swollen area (hives, insect bite)
- VESICLE — fluid blister, under 1 cm (chickenpox, shingles)
- BULLA — fluid blister, over 1 cm (burn blister)
- PUSTULE — pus-filled (acne, impetigo)
- CYST — enclosed sac of fluid or semisolid (sebaceous cyst)

What are the SECONDARY skin lesions?

(A primary lesion that changed over time)
- LICHENIFICATION — thickened skin from chronic scratching
- CRUST — dried exudate (scab)
- SCALE — white/silvery flakes of shed skin (psoriasis, eczema)
- FISSURE — linear crack into the dermis (very dry heels, mouth corners)
- EROSION — top layer (epidermis) only, moist, NO bleeding
- ULCER — epidermis + DERMIS, MAY BLEED (pressure injury, poor blood flow)
- EXCORIATION — linear scratch or abrasion
- KELOID — scar overgrowth beyond the wound edges

What is the difference between an EROSION and an ULCER?

• EROSION — loss of the EPIDERMIS only, moist, does NOT bleed (chickenpox, cold sore)
- ULCER — goes into the DERMIS, MAY bleed (pressure injury, poor limb blood flow)

What is a keloid?

A scar that overgrows beyond the original wound edges, smooth and rubbery. Can appear months to years after injury.

What must be documented for every skin lesion?

• COLOR
- HEIGHT (flat or raised)
- SHAPE / border
- SIZE in CM (no coin or household comparisons)
- LOCATION and LATERALITY (side)
- DISTRIBUTION (single or generalized)
- DRAINAGE (color, amount, odor)
Example: "L forearm: 0.8 cm raised dark-brown lesion, irregular border, no drainage."

What does ABCDE stand for in skin cancer screening?

For PIGMENTED lesions:
- A — ASYMMETRY: halves don't match
- B — BORDER: irregular (notched, scalloped, blurred)
- C — COLOR: multiple colors in one lesion
- D — DIAMETER: over 6 mm (pencil-eraser size)
- E — EVOLVING: changing size, color, shape, or symptoms (itching, bleeding) — MOST SENSITIVE sign
RULE: 2 or more features → high risk → refer for BIOPSY.

What is the "ugly duckling" sign?

A mole that looks or acts different from the client's other moles (itches, burns, bleeds). A warning sign for melanoma, most useful in clients with many moles.