Vital signs nursing foundations

What are the normal adult vital-sign ranges?

• Temperature: 97.8–99°F (36.5–37.2°C)

• Pulse: 60–100 bpm

• Respirations: 12–20/min

• BP: 120/80 mmHg

• SpO₂: 95–100%

• Pain: 0–10 scale

Why are vital signs important?

They establish a patient's baseline, identify changes in physiological function, and help guide clinical decision-making and intervention.

What should the nurse do before taking vital signs?

Perform hand hygiene and identify the patient. Hand hygiene comes before every measurement.

How long should hand hygiene take?

At least 20–30 seconds, covering all surfaces including the wrists

What is the order of vital signs from fastest to slowest changing?

Respirations → Pulse → SpO₂ → Blood Pressure → Temperature.

Which vital sign changes the fastest?

Respirations. They are highly sensitive to O₂, CO₂, and pH changes and can change within seconds.

When should vital signs be assessed?

• On admission

• With any change in health status

• With chest pain, feeling hot, or feeling faint

• Before/after surgery or invasive procedures

• Before/after medications affecting respiratory or cardiovascular function

• Before/after nursing interventions that may affect vital sign

What is the normal adult temperature range according to the lecture?

97.6–99.6°F

What happens to temperature in older adults

Older adults tend to have a lower baseline temperature, approximately 95.9–99.5°F, and may have a blunted fever response(reduced).

Why is a blunted fever response important in older adults?

A serious infection may not cause a significant temperature spike as it might in a younger adult.

Which temperature site is the most accurate?

Rectal temperature

When should rectal temperature be avoided?

Avoid with diarrhea, rectal disease, or neutropenia

Which common temperature site is least accurate?

Axillary.

What are the temperature sites from the lecture?

• Oral

• Rectal

• Tympanic

• Temporal

• Axillary

What is fever/pyrexia?

condition in which the hypothalamus cannot hold its set point, often associated with bacteria or viruses. Mild elevation can help immunity but increases oxygen demand

What is hyperthermia?

The body cannot lose heat or reduce heat production. Malignant hyperthermia is a hereditary reaction to certain anesthetics.

What temperature defines heatstroke in the lecture?

104°F or higher. It results from prolonged heat exposure and is a medical emergency.

What causes heat exhaustion?

Profuse sweating, causing water and electrolyte loss.

What is hypothermia?

he body cannot compensate for cold exposure, causing the core temperature to drop

What happens during frostbite?

Ice crystals form inside cells, causing permanent tissue and circulatory damage

What is the normal adult resting pulse?

60–100 bpm.

How do you count a regular pulse?

count for 30 seconds and multiply by 2.

How do you count an irregular pulse?

Count for the full 60 seconds.

What three characteristics of a pulse should be assessed?

Rate, rhythm, and quality/strength

What does a pulse strength of 0 mean?

Absent.

What does a pulse strength of 1+ mean?

Diminished

What does a pulse strength of 2+ mean?

brisk/expected (normal)

What does a pulse strength of 3+ mean?

Increased/strong

What does a pulse strength of 4+ mean?

Full volume/bounding.

What is a pulse deficit?

The difference between the apical rate and radial rate. With some dysrhythmias, the heart contracts without producing a palpable radial pulse, so the apical rate is higher than the radial rate.

How is a pulse deficit measured accurately?

Two clinicians simultaneously measure the apical(heart) and radial pulses.

What does the parasympathetic nervous system do to pulse?

Lowers pulse rate

What does sympathetic stimulation do to pulse?

Raises pulse rate; it can be triggered by exercise, fever, caffeine, and volume changes.

What happens to pulse with hemorrhage?

Pulse increases as a compensatory response.

What happens to pulse with hypothermia?

Pulse decreases

What medication example decreases pulse?

Beta blockers.

What is the normal adult respiratory rate?

12–20 breaths/minute.

How should respirations be counted?

Watch the chest rise and fall for a full minute and count without making the patient aware, because awareness can change the breathing pattern.

What is tachypnea?

An abnormally fast respiratory rate: >20 breaths/minute in an adult.

What is bradypnea?

An abnormally slow respiratory rate: <12 breaths/minute in an adult

What three things should be assessed in addition to respiratory rate?

Rhythm, depth, and effort.

What is eupnea?

Normal respiratory rhythm and depth

How do opioids, anesthetics, and sedatives affect respirations?

They depress respiratory rate

How do anxiety and exercise affect respirations

hey increase respiratory rate and depth through sympathetic stimulation

How does pain affect respiration?

Chest or abdominal pain can cause shallow breathing as the patient splints the painful area

What is the normal SpO₂ range?

95–100%

What does SpO₂ measure?

The percentage of hemoglobin bound with oxygen in the arteries

What SpO₂ level is considered a clinical emergency in most patients?

Below 90%

What is the important SpO₂ exception for COPD patients?

A COPD patient may have a baseline SpO₂ as low as 88%

What can cause an inaccurate pulse-ox reading?

• Nail polish

• Cold fingers

• Patient movement

What does blood pressure represent?

The force of blood pushing against arterial walls.

What does systolic BP represent?

The top number; pressure during ventricular contraction.

What does diastolic BP represent?

The bottom number; pressure during ventricular relaxation.

What factors can increase blood pressure?

• Stress/anxiety

• Pain

• Exercise

• Certain medications such as decongestants

• Excess fluid volume

• Stiff/narrowed arteries

What factors can decrease blood pressure?

• Blood loss

• Dehydration

• Diuretics/antihypertensive medications

• Severe infection/sepsis

• Sudden position change/orthostatic hypotension

What is the most important equipment consideration when measuring BP?

Correct cuff size. Cuff size has a major effect on accuracy

What happens if the BP cuff is too small?

It produces a falsely HIGH BP reading.

What happens if the BP cuff is too large?

It produces a falsely LOW BP reading.

Where should the patient's arm be positioned when measuring BP?

The arm should be at heart level. Incorrect positioning can skew the reading

What is the recommended patient position/environment for BP measurement?

Patient should be resting, in a warm, quiet environment, with feet flat on the floor

When is manual BP preferred over electronic BP?

Manual BP is preferred with:

• Irregular heart rate

• Tremors

• Hemodynamic instability

• Shivering

• Seizures

• Peripheral vascular obstruction

• Inability to cooperate

• SBP <90 mmHg

What should you do if an electronic BP reading doesn't match how the patient looks or feels?

Confirm the reading manually before acting on i

What are the lecture's criteria for orthostatic hypotension?

A decrease in:

• SBP ≥25 mmHg OR

• DBP ≥10 mmHg
  PLUS

• HR increase ≥10 bpm

when moving from lying to sitting/standing

What can orthostatic hypotension indicate?

Hypovolemia or failure of the autonomic nervous system's protective reflexes

What symptoms should you watch for with orthostatic hypotension

• Dizziness

• Weakness

• Blurred vision

• Syncope

What can be delegated regarding vital signs?

Routine vital signs on a stable patient can often be delegated to a trained UAP/CNA, according to facility policy

What cannot be delegated by the RN?

Interpretation of vital signs, recognizing/acting on abnormal findings, first assessment after a procedure/change in condition, and care of unstable/critical patients.

What are the Five Rights of Delegation?

• Right Task

• Right Circumstance

• Right Person

• Right Direction

• Right Supervision

What should be documented when taking vital signs?

• Vital-sign values

• Associated/precipitating symptoms

• Interventions initiated

• Explanation and nursing action when values are outside anticipated outcomes

What should the nurse do when an abnormal vital sign is identified?

Do something to correct/address the abnormality and document the nursing action.

A patient says, “I can't catch my breath.” Which vital sign should the nurse check first?

Respirations / SpO₂.

A patient is pale, sweaty, and feels faint. Which vital sign should be checked first?

Blood pressure

A patient's skin feels very warm and they report chills. Which vital sign should be checked first?

Temperature.

A medication has been administered that can slow the heart rate. Which vital sign should the nurse assess?

Pulse

A trauma patient is bleeding heavily. Which vital sign should be checked first?

Blood pressure, then pulse

A patient suddenly becomes confused and disoriented. Which vital sign should the nurse assess?

SpO₂, because the confusion may indicate possible hypoxia