Vital Signs, Measurement & Related Concepts

Vocabulary flashcards summarizing key terms and definitions from the lecture on vital signs, temperature regulation, pulse, respiration, blood pressure, and related assessment techniques.

Vital Signs (VS)

Cardinal measurements (temperature, pulse, respirations, blood pressure) that indicate basic body function.

Fifth Vital Sign

Pain level (or comfort level) routinely assessed with the traditional four vital signs.

Baseline Vital Signs

Initial set of vital signs obtained on admission, used for comparison with future readings.

Pyrexia

Elevation of body temperature above normal; fever.

Febrile

Having or showing symptoms of a fever.

Hyperthermia

Abnormally high body temperature, often defined as >105 °F (40.6 °C).

Hypothermia

Core body temperature below normal; dangerous when <93.2 °F (34 °C).

Core Temperature

Temperature of deep body tissues; remains relatively constant and is measured rectally or tympanically.

Surface Temperature

Temperature of the skin; varies with environment and is measured orally or axillary.

Intermittent Fever

Fever that alternates between febrile and afebrile states at least once every 24 h.

Remittent Fever

Fevers that vary several degrees but do not return to normal until recovery.

Constant (Sustained) Fever

Fever that remains elevated with little fluctuation.

Signs of Elevated Temperature

Flushed skin, thirst, anorexia, irritability, headache, diaphoresis, chills, possible convulsions (in children).

Age Effect on Temperature

Infants have unstable, higher normal ranges; older adults often have lower baseline temps (~95 °F in cold weather).

Exercise & Temperature

Physical activity increases body temperature; prolonged heavy exercise may raise temp to 103–105 °F.

Circadian Rhythm & Temperature

Lowest body temperature occurs between 1 AM–4 AM; peaks late afternoon (4–6 PM).

Hormonal Influences on Temperature

Ovulation and menopause cause variations, often increasing body temperature.

Stress & Temperature

Physical or emotional stress can elevate body temperature.

Environmental Temperature

Extreme hot or cold surroundings can raise or lower body temperature.

Oral Thermometer Contraindications

Not used for unconscious, disoriented, infants, mouth-breathers, post-oral surgery, or seizure patients.

Rectal Thermometer Contraindications

Avoid after rectal surgery, with hemorrhoids, cardiac conditions, spinal cord injuries, or neonates.

Glass Thermometer Color Code

Blue or clear tip for oral/axillary; red tip for rectal use.

Electronic Thermometer

Battery-operated device with disposable probe covers for rapid oral, rectal, or axillary readings.

Tympanic Thermometer

Infrared device measuring temperature of the eardrum (core); quick and minimally invasive.

Temporal Artery Thermometer

Infrared scanner swept across forehead to read temperature over temporal artery.

Chemical Disposable Thermometer

Heat-sensitive strip placed on skin; color change indicates approximate temperature.

Pulse

Recurrent arterial wave produced by heart contraction; assessed for rate, rhythm, and volume.

Normal Adult Pulse Rate

60–100 beats per minute (average 80 bpm).

Tachycardia

Heart rate greater than 100 bpm in adults.

Possible Causes of Tachycardia

Exercise, fever, pain, hypovolemia, stress, medications like atropine or epinephrine.

Bradycardia

Heart rate less than 60 bpm in adults.

Pulse Dysrhythmia

Irregular rhythm or disturbance in normal heartbeat pattern.

Pulse Deficit

Difference between apical and radial pulse rates; indicates ineffective cardiac contractions.

Pulse Volume 0

Absent pulse; no palpable pulsation.

Pulse Volume 1+

Thready pulse; difficult to feel, disappears with slight pressure.

Pulse Volume 2+

Weak pulse; stronger than thready, disappears with light pressure.

Pulse Volume 3+

Normal pulse; easily felt, obliterated with moderate pressure.

Pulse Volume 4+

Bounding pulse; strong and spring-like even with moderate pressure.

Major Peripheral Pulse Sites

Carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial.

Apical Pulse

Actual beating of the heart heard at the apex, typically fifth intercostal space, mid-clavicular line.

Stethoscope Diaphragm

Flat circular side transmitting high-pitched sounds (e.g., breath, normal heart tones).

Stethoscope Bell

Cup-shaped side transmitting low-pitched sounds (e.g., heart murmurs).

Respiration

Process of inhaling oxygen and exhaling carbon dioxide; assessed for rate, depth, rhythm, and quality.

Normal Adult Respiratory Rate

12–20 breaths per minute.

Tachypnea

Rapid breathing rate >20 breaths/min in adults.

Bradypnea

Slow respiratory rate <12 breaths/min in adults.

Dyspnea

Difficult or labored breathing.

Apnea

Absence of spontaneous breathing.

Orthopnea

Ability to breathe only in upright sitting or standing position.

Cheyne–Stokes Respiration

Alternating periods of apnea and deep, rapid breathing; seen in critically ill or dying patients.

Kussmaul Respiration

Deep, labored breathing pattern often associated with metabolic acidosis or diabetic ketoacidosis.

Stertorous Breathing

Snoring or sonorous respirations caused by partial obstruction of upper airway.

Rales (Crackles)

Bubbling or rattling lung sounds caused by air passing through fluid or mucus.

Hyperventilation

Ventilation rate and depth exceed metabolic needs, often from emotional stress.

Hypoventilation

Ventilation insufficient for metabolic needs, causing CO₂ retention.

Factors Increasing Respirations

Fever, exercise, anxiety, acute pain, hypoxia, metabolic acidosis.

Factors Decreasing Respirations

Narcotic analgesics, brain injury, hypothermia, metabolic alkalosis.

Blood Pressure (BP)

Force exerted by circulating blood on arterial walls; recorded as systolic/diastolic mm Hg.

Systolic Pressure

Peak pressure during ventricular contraction; first Korotkoff sound heard.

Diastolic Pressure

Pressure in arteries during cardiac relaxation; last Korotkoff sound heard.

Normal Adult BP Range

90/60 to 139/89 mm Hg (preferred <120/80 mm Hg).

Hypertension

Persistent BP ≥140/90 mm Hg; called primary when cause is unknown.

Hypotension

BP below normal (<90/60 mm Hg) that may cause dizziness or fainting.

Orthostatic (Postural) Hypotension

Drop of ≥25 mm Hg systolic and ≥10 mm Hg diastolic when moving to upright position.

Pulse Pressure

Difference between systolic and diastolic pressures; normal about 40 mm Hg.

Aneroid Sphygmomanometer

Mechanical gauge and inflatable cuff used to measure BP.

Korotkoff Sounds

Five phases of arterial sounds heard while measuring BP with stethoscope.

Auscultatory Gap

Temporary disappearance of Korotkoff sounds between systolic and diastolic readings; may cause under-estimation of systolic BP.

Proper BP Cuff Size

Bladder width ~40% of limb circumference and length encircling 80% of arm; wrong size causes inaccurate readings.

Effect of Small BP Cuff

Leads to falsely high blood pressure reading.

Effect of Large BP Cuff

Leads to falsely low blood pressure reading.

Pulse Oximetry

Non-invasive measurement of arterial oxygen saturation (SpO₂) using a light sensor on finger, ear, or toe.

Height and Weight Measurements

Assist in growth assessment, drug dosage calculations, and monitoring fluid balance; taken same time, same scale, similar clothing.

Body Mass Index (BMI)

Weight-to-height ratio used to assess body fat and nutritional status.

Pain Assessment (Fifth VS)

Evaluation of pain intensity, quality, location, frequency, and duration.

Licensed Practical/Vocational Nurse Role

Collect vital signs data, recognize deviations, report abnormalities, and contribute to care plan adjustments.