Potter/Perry Chapter 29: Vital Signs

acceptable temperature range for adults

36C- 38C (96.8F - 100.4F)

acceptable oral/tympanic temperature for adults

98.6F

acceptable rectal temperature for adults

99.5F

acceptable axillary temperature for adults

97.7F

acceptable pulse ranges for adults

60 -100 beats/min

acceptable respiration ranges for adults

12 - 20 breaths/min

acceptable blood pressure (BP) ranges for adults

normal oxygen saturation (SpO2) for adults

greater or equal to 95%

When to measure VSs...

-on admission to a health care facility

-when assessing a patient during home care visits

-routine schedule according to the provider's order or hospital std. practice

-before, during, and after a surgical procedure, invasive diagnostic procedure, a transfusion of blood products, the administration of medication or therapies that affect cardiovascular, respiratory, or temperature-control functions

-when a patient's general physical condition changes (e.g. loss of consciousness, increased pain)

-before and after nursing interventions influencing a vital sign

-when a patient reports nonspecific symptoms of physical distress (e.g. feeling "funny" or "different")

What are the factors affect body temperature?

Age, exercise, hormone level, circadian rhythm, stress, environment, etc.

heatstroke

body temperature of 40C (104F) or more. It is a dangerous heat emergency with a high mortality rate.

Signs and symptoms: giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances.

The most important sign of heatstroke is hot, dry skin.

heat exhaustion

It occurs when profuse diaphoresis results in excess water and electrolyte loss.

sustained fever

a constant body temp. continuously above 30C (100.4F) that has little fluctuation

intermittent fever

temperature returns to acceptable value at least once in 24h

remittent fever

fever spikes and falls without a return to normal temp. levels

relapsing fever

periods of febrile and periods with acceptable temp. values (febrile episodes and periods of normothermia are often longer than 24h)

Where is the best site for assessing an infant's or young child's pulse?

brachial or apical

acceptable ranges of heart rate for adults

60 - 100 beats/min

acceptable ranges of respiratory rate for adults

12 - 20 bpm

acceptable range of oxygen saturation

95% - 100%

prehypertension blood pressure

Systolic 120 - 139 mm Hg or Diastolic 80 - 89 mm Hg

hypertension blood pressure

Systolic >140 and diastolic >90 mm Hg

what can cause false-low readings during BP assessment

-cuff too wide

-arm above heart level

what can cause false-high readings during BP assessment

-cuff to narrow or too short

-cuff wrapped too loosely or unevenly

-arm below heart level

-arm not supported

what can cause false-high diastolic readings during BP assessment

-inflating or deflating cuff too slowly

A 52-year-old woman is admitted with dyspnea and discomfort in her left chest with deep breaths. She has smoked for 35 years and recently lost over 10 pounds. Her vital signs on admission are: HR 112, BP 138/82, RR 22, tympanic temperature 36.8°C (98.2°F), and oxygen saturation 94%. She is receiving oxygen at 2 L via a nasal cannula. Which vital sign reflects a positive outcome of the oxygen therapy?

A) Temperature: 37°C (98.6°F)

B) Radial pulse: 112

C) Respiratory rate: 24

D) Oxygen saturation: 96%

E) Blood pressure: 134/78

D) Oxygen saturation: 96%

A 56-year-old patient with diabetes admitted for community acquired pneumonia has a temperature of 38.2°C (100.8°F) via the temporal artery. Which additional assessment data are needed in planning interventions for the patient's infection? (Select all that apply.)

A) Heart rate

B) Presence of diaphoresis

C) Smoking history

D) Respiratory rate

E) Recent bowel movement

F) Blood pressure in right arm

G) Patient's normal temperature

H) Blood pressure in distal extremity

A, B, D, G

(You need to determine the patient's usual temperature to evaluate the degree of temperature elevation. Heart rate and respiratory rate increase with temperature. The presence of diaphoresis may contribute to fluid volume deficit from hyperthermia.)

A 55-year-old widowed patient was in a motor vehicle accident and is admitted to a surgical unit after repair of a fractured left arm and left leg. She also has a laceration on her forehead. An intravenous (IV) line is infusing in the right antecubital fossa, and pneumatic compression stockings are on the right lower leg. She is receiving oxygen via a simple face mask. What sites do you instruct the nursing assistant to use for obtaining the patient's blood pressure and temperature?

A) Right antecubital and tympanic membrane

B) Right popliteal and right axillae

C) Left antecubital and oral

D) Left popliteal and temporal artery

B (Right popliteal and right axillae)

(The only extremity that does not have a compromised artery to auscultate is the right lower leg after the sequential device is removed. The tympanic membrane and temporal artery are affected by facial surgery and oxygen mask.)

A patient has been transferred to your unit from the respiratory intensive care unit, where he has been for the past 2 weeks recovering from pneumonia. He is receiving oxygen via 4 L nasal cannula. His respiratory rate is 26 breaths/min, and his oxygen saturation is 92%. In planning his care, which information is most helpful in determining your priority nursing interventions?

A) Activity order

B) Medication list

C) Baseline vital signs

D) Patient's perception of dyspnea

C (Baseline vital signs)

(Knowledge of baseline vital signs is needed to prioritize care.)

During a patient's routine annual physical, she tells you that she has noted that her heart feels like it's " racing, " usually in the later morning, early afternoon, or just before she goes to bed. Her radial pulse rate is 68 beats/min and regular; her blood pressure is 134/82 mm Hg. What additional information is helpful in evaluating the patient's racing heart? (Select all that apply.)

A) Dietary habits

B) Medication list

C) Exercise regimen

D) Age, weight, and height

A, B

(Dietary habits may include caffeine fluids and foods that stimulate heart rate. Medication list may include pharmacological agents that increase or decrease heart rate.)

You observe a nursing student taking a blood pressure (BP) on a patient. The patient's BP range over the past 24 hours is 132/64 to 126/72 mm Hg. The student used a BP cuff that was too narrow for the patient. Which of the following BP readings made by the student is most likely caused by the incorrect choice of BP cuff?

A) 96/40 mm Hg

B) 110/66 mm Hg

C) 130/70 mm Hg

D) 156/82 mm Hg

D (156/82 mm Hg)

(When you use a blood pressure cuff that is too narrow or short, your patient will most likely have a BP reading that is higher than it really is; you will get a false-high reading.)

As you are obtaining the oxygen saturation on a 19-year-old college student with severe asthma, you note that she has black nail polish on her nails. You remove the polish from one nail, and she asks you why her nail polish had to be removed. Your best reply is:

A) Nail polish attracts microorganisms and contaminates the finger sensor.

B) Nail polish increases oxygen saturation.

C) Nail polish interferes with sensor function.

D) Nail polish creates excessive heat in sensor probe.

C (Nail polish interferes with sensor function.)

(Nail polish reduces light transmission and can alter oxygen saturation measurement.)

A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical record indicates tympanic temperatures of 38.7°C (101.6°F) (0400), 36.6°C (97.9°F) (0800), 36.9°C (98.4°F) (1200), 37.6°C (99.6°F) (1600), and 38.3°C (100.9°F) (2000). How would you describe this pattern of temperature measurements?

A) Usual range of circadian rhythm measurements

B) Sustained fever pattern

C) Intermittent fever pattern

D) Resolving fever pattern

C (Intermittent fever pattern)

A patient presents in the clinic with dizziness and fatigue. The nursing assistant reports a very slow radial pulse of 44. What is your priority intervention?

A) Request that the nursing assistant repeat the pulse check

B) Call for a stat electrocardiogram (ECG)

C) Assess the patient's apical pulse and evidence of a pulse deficit

D) Prepare to administer cardiac-stimulating medications

C (Assess the patient's apical pulse and evidence of a pulse deficit)

(Your priority is to assess the patient first. The nurse cannot delegate vital signs to an unstable patient. Therefore first you determine if the patient has a pulse deficit. Calling for a stat electrocardiogram and preparing to administer cardiac-stimulating medications require notification of the health care provider and occur after you assess the patient.)

Which of the following patients is most at risk for tachycardia?

A) A healthy professional tennis player

B) A patient admitted with hypothermia

C) A patient with a fever of 39.4°C (103°F)

D) A 90-year-old male taking beta blockers

C (A patient with a fever of 39.4°C (103°F))

(Patients with a fever have a high heart rate. A healthy athlete has a low heart rate because of conditioning. Hypothermia slows the heart. Beta-blockers reduce heart rate.)

Which of the following patients is at most risk for tachypnea? (Select all that apply.)

A) Patient just admitted with four rib fractures

B) Woman who is 9 months' pregnant

C) Adult who has consumed alcoholic beverages

D) Adolescent awaking from sleep

A, B

(Rib fractures would cause splinting and pain to increase respiratory rate. Pregnancy impedes diaphragmatic excursion, causing shallow, frequent breaths.)

The following blood pressures, taken 6 months apart, were recorded from patients screened by the nurse at the assisted living facility. Which patient should be referred to the healthcare provider for hypertension evaluation?

A) 120/80, 118/78, 124/82

B) 128/84, 124/86, 128/88

C) 148/82, 148/78, 134/86

D) 154/78, 118/76, 126/84

C (148/82, 148/78, 134/86)

(The definition of hypertension requires two elevated blood pressure measurements in a row. All of the other choices describe prehypertension.)

A patient is admitted for dehydration caused by pneumonia and shortness of breath. He has a history of heart disease and cardiac dysrhythmias. The nursing assistant tells you his admitting vital signs. Which measurement should you reassess? (Select all that apply.)

A) Right arm BP: 120/80

B) Radial pulse rate: 72 and irregular

C) Temporal temperature: 37.4°C (99.3°F)

D) Respiratory rate: 28

E) Oxygen saturation: 99%

B, D, E

(An irregular pulse may be the result of a complication of heart disease and requires the assessment of the apical rate. A respiratory rate of 28 is abnormal, yet the oxygen saturation is normal. Both oxygen saturation and respiratory rate would be expected to be outside of the acceptable range.)

A patient returns to your postoperative unit following surgery for right shoulder rotator cuff repair. The licensed practical nurse (LPN) reports that she had difficulty obtaining the patient's heart rate from his right radial pulse. What is your best response?

A) Assess the patient's apical pulse to obtain the heart rate.

B) Obtain the heart rate from right and left radial sites.

C) Obtain the heart rate using the oximeter probe.

D) Perform a complete assessment of all pulses.

D (Perform a complete assessment of all pulses.)

(When an LPN reports that one pulse is difficult to obtain, first you need to assess the patient yourself and compare the quality of all pulses.)