vital signs

Systolic vs. Diastolic Pressure

Systolic pressure represents the maximum pressure exerted when the heart contracts during systole to force blood into the aorta. Diastolic pressure represents the minimum pressure exerted during the relaxation phase (diastole) as the heart chambers fill with blood.

Tachypnea vs. Bradypnea

Tachypnea is a respiratory rate faster than $20\text{ breaths/min}$, whereas bradypnea is a respiratory rate slower than $12\text{ breaths/min}$.

Hyperthermia vs. Fever

In hyperthermia, the hypothalamic set point remains unchanged while heat-loss mechanisms fail. In a fever, there is an upward shift of the hypothalamic set point in response to pyrogens or infection.

Core vs. Surface Body Temperature

Core temperature measures deep tissues within the body (e.g., esophagus, pulmonary artery, urinary bladder, tympanic membrane). Surface temperature measures the temperature of the skin, subcutaneous fat, and tissue.

Acute vs. Chronic Pain

Acute pain has a rapid onset, short duration, a identifiable cause, and temporarily limits activities until healing occurs. Chronic pain persists beyond the point of healing (often lasting more than $6\text{ months}$), may lack a clear cause, is more diffuse, and leads to long-term interference with daily functioning.

Single-lumen vs. Double-lumen Stethoscope Tubing

Single-lumen tubing transmits sound from the chest piece to the ear piece through a single tube. Double-lumen tubing uses separate pathways for each ear, making it more sensitive to subtle body sounds.

Importance of Baseline Vital Signs

They evaluate circulatory, pulmonary, endocrine, and neurological functioning and serve as a baseline for comparison with subsequent measurements to detect unexpected changes.

Indications for Assessing Vital Signs

On admission, during changes in physical condition, before and after surgical or invasive procedures, and before and after administering medications that affect cardiovascular and respiratory functions.

Validating Unexpected Vital Sign Measurements

Re-assessing and double-checking unexpected data validates accuracy, ensuring precise reporting to the provider and guiding appropriate clinical interventions.

Documenting Intervention Responses

Evaluates intervention effectiveness, informs care plan adjustments, and facilitates continuity and quality of care among healthcare team members.

Client Privacy in Written Preparation

Student materials based on medical records must exclude all identifiable demographic information and contain only data necessary for safe, efficient care.

Five Rights of Delegation

Right task, right circumstance, right person, right directions and communication, and right supervision and evaluation to ensure safe client care.

Enhanced Infection Control for Vital Sign Equipment

Avoid sharing equipment between clients, use single-use disposable thermometers, and clean stethoscopes and BP cuffs according to facility policy and manufacturer instructions.

Basic Parts of a Nonelectric Stethoscope

A binaural assembly (ear tips and ear tubes) and a chest piece (diaphragm and bell).

Function of Stethoscope Ear Tips

They seal the ear canal and ensure proper acoustic sound transmission.

Stethoscope Diaphragm vs. Bell

The flat, drum-like diaphragm detects high-pitched sounds (e.g., lung sounds, normal heart sounds). The cupped bell detects low-pitched sounds (e.g., murmurs, extra heart sounds).

Purpose of Nonchill Rings on Stethoscopes

Provides a comfortable barrier between the cold metal chest piece and the client's skin.

Components of an Electronic Thermometer

A rechargeable battery-powered display unit, a thin wire cord, and color-coded temperature probes (blue tip for oral/axillary, red tip for rectal).

Elimination of Mercury Thermometers

Phased out due to environmental hazards and toxic risks associated with mercury exposure.

Disposable Thermometer Probe Covers

Prevents cross-contamination and transmission of microorganisms between clients.

Four Mechanisms of Heat Loss

Conduction (direct contact with cooler surfaces), convection (air currents), evaporation (sweat/lung moisture drying), and radiation (heat transfer without direct contact).

Thermoregulation Mechanisms

Shivering, sweating, vasoconstriction, and vasodilation controlled by the hypothalamus.

Temperature Reference Ranges by Site

Oral reference range is $36\text{--}38^\text{o}\text{C}$ ($96.8\text{--}100.4^\text{o}\text{F}$). Rectal readings average $0.5^\text{o}\text{C}$ ($0.9^\text{o}\text{F}$) higher, and axillary readings average $0.5^\text{o}\text{C}$ ($0.9^\text{o}\text{F}$) lower.

Thermoregulation Considerations in Older Adults

Lower average metabolic and physiological baseline temperatures, alongside a reduced ability to develop a fever in response to infection due to aging changes.

Pediatric Temperature Route Selection

Axillary and temporal methods are preferred for infants because they are non-invasive; rectal routes are avoided unless prescribed due to the risk of mucosal perforation.

Oral Temperature Contraindications and Delays

Contraindicated in unconscious, confused, or seizure-prone clients, and those with oral trauma or oxygen masks. Delay measurement by $15\text{--}30\text{ minutes}$ if the client consumed hot/cold food, smoked, or chewed gum.

Tympanic Thermometer Technique and Contraindications

Pull pinna back, up, and out for adults (down and back for young children), angle probe into the ear canal, and wait $2\text{--}5\text{ seconds}$. Contraindicated in ear pain, discharge, lesions, or severe earwax buildup.

Temporal and Axillary Thermometer Placement

Temporal scans across the forehead and temporal artery area exposed to air. Axillary probe is centered deep in the axilla with the arm held firmly against the side.

Chemical Dot Thermometers

Inexpensive, unbreakable, single-use temperature indicators useful in isolation settings to prevent cross-contamination.

Hyperthermia Manifestations and Interventions

Core temperature of $104^\text{o}\text{F}$ ($40^\text{o}\text{C}$) or higher, dizziness, nausea, tachycardia. Interventions include moving to a cool environment, removing excess clothing, applying cool packs to neck/axillae/groin, using fans, and IV fluids as ordered.

Fever Management Nursing Interventions

Reduce room temperature, remove excess blankets, encourage fluid intake, limit physical exertion, keep linens dry, and administer prescribed antipyretics.

Initial Signs of Mild Hypothermia

Uncontrolled shivering, impaired fine motor skills, and decreased peripheral vision.

Actions for Elevated Temperature Readings

Assess for signs of infection, notify the healthcare provider, implement fever reduction measures, and document reading, route, interventions, and client response.

Radial Pulse Assessment Significance

Provides quick information about cardiovascular status and peripheral arterial circulation as the most accessible peripheral pulse site.

Point of Maximal Impulse (PMI) Location

Located at the fifth intercostal space at the left midclavicular line in adult clients.

Heart Sounds S1 and S2

S1 ('lub') is caused by the closure of the tricuspid and mitral valves. S2 ('dub') is caused by the closure of the aortic and pulmonic valves.

Causes of Bradycardia

Hypothyroidism, hyperkalemia, elevated intracranial pressure, cardiac conduction abnormalities, or specific medications.

Bounding Pulse Characteristics

Indicates hypervolemia or increased stroke volume; pulse feels full, forceful, and is difficult to obliterate with finger pressure.

Indications for a Full 60-Second Pulse Count

Required whenever the pulse rhythm is irregular, baseline rate is abnormal, or when assessing apical pulse prior to administering cardiac medications.

Pulse Deficit Clinical Significance

The numerical difference between apical and radial pulse rates. Indicates inefficient cardiac contractions that fail to transmit a pulse wave to peripheral arteries (e.g., in atrial fibrillation).

Procedure for Assessing Apical-Radial Pulse Deficit

Two clinicians simultaneously count the apical and radial pulse for $60\text{ seconds}$ using the same timepiece with the client supine or seated, then calculate the difference.

Nursing Actions for Abnormal Pulse Readings

Assess for associated symptoms (dizziness, chest pain, cyanosis, diaphoresis), compare peripheral pulses bilaterally, notify the provider if unexpected, and document findings.

Factors Influencing Cardiac Output and Blood Pressure

Blood pressure increases with higher cardiac output, increased blood volume, elevated blood viscosity, and increased peripheral vascular resistance due to decreased vessel elasticity.

Adult Blood Pressure Categories

Normal: <$120/80\text{ mmHg}$; Elevated: $120\text{--}129/<80\text{ mmHg}$; Stage 1 HTN: $130\text{--}139\text{ mmHg}$ systolic or $80\text{--}89\text{ mmHg}$ diastolic; Stage 2 HTN: $\text{s } \frac{140}{90}\text{ mmHg}$ or higher; Hypertensive Emergency: >$180/120\text{ mmHg}$.

Pediatric Hypertension Criteria

Diagnosed when blood pressure measurements are at or above the 95th percentile for age, sex, and height on three separate clinical visits.

Nonpharmacological Hypertension Interventions

Sodium restriction, regular aerobic exercise, stress reduction strategies, weight management, and smoking cessation.

Sphygmomanometer Components and Cuff Sizing

Includes cuff, bladder, inflation bulb, release valve, and manometer gauge. Cuff width must be $40Tool$ of arm circumference and bladder length must encircle at least $80Tool$ of the arm.

Aneroid Manometer Calibration Requirement

Requires recalibration every $6\text{ months}$ because thermal and mechanical changes can alter internal metal expansion and accuracy.

Two-Step Manual Blood Pressure Method

Palpate brachial pulse, inflate cuff until pulse disappears to estimate systolic pressure, deflate, wait $30\text{ s}$, reinflate cuff to $30\text{ mmHg}$ above estimated level, and slowly deflate to auscultate.

Korotkoff Sounds Overview

Five distinct sound phases produced by blood flow turbulence through a partially compressed artery; Phase 1 marks systolic pressure and Phase 5 marks diastolic disappearance.

Lower Extremity Blood Pressure Assessment

Used when upper arms are inaccessible. Cuff is placed over the thigh and the popliteal artery behind the knee is auscultated.

Impact of Crossed Legs on BP Assessment

Crossing legs at the knees increases muscle contraction and vascular resistance, artificially elevating systolic reading.

Orthostatic Hypotension Definition and Causes

A drop in systolic BP by >$20\text{ mmHg}$ or diastolic BP by >$10\text{ mmHg}$ (or pulse increase of $20/\text{min}$) upon standing. Caused by hypovolemia, prolonged bed rest, aging, or antihypertensives.

Emergency Management of Severe Hypotension

Place client in trendelenburg or supine position, initiate fluid resuscitation, administer prescribed vasopressors, and monitor vital signs closely.

Documentation Standards for Blood Pressure

Record systolic/diastolic values, limb/site used, client position (lying, sitting, standing), any presence of symptoms, and interventions performed.

Respiratory Mechanics: Inspiration and Expiration

Inspiration is active: diaphragm moves downward and intercostals contract to expand chest volume. Expiration is passive: diaphragm moves upward and intercostals relax to reduce chest volume.

Central Neural Regulation of Breathing

The medulla oblongata senses increased arterial carbon dioxide levels and responds by increasing respiratory rate and depth.

Shallow Respirations and Tidal Volume Estimation

Shallow breathing results from pain, chest injuries, or neuromuscular disease. Tidal volume can be estimated visually by observing chest wall expansion depth and symmetry.

Atypical Breathing Patterns (Cheyne-Stokes, Biot's, Kussmaul)

Cheyne-Stokes: alternating deep, shallow, and apneas (heart failure, increased ICP). Biot's: irregular breaths with sudden apneas (CNS damage). Kussmaul: deep, rapid, gasping breaths (diabetic ketoacidosis).

Opioid Medications Effect on Respiration

Depresses the brainstem respiratory center, causing bradypnea and reduced tidal volume.

Expected Oxygen Saturation Reference Range

Normal reference range for SpO2 in healthy adults is $95\text{--}100Tool$.

Pulse Oximetry Indications and Placement

Indicated in respiratory distress, post-op recovery, and oxygen therapy. Placed on highly vascular sites like fingers, toes, earlobes, or forehead/bridge of nose.

Pulse Oximetry Artifacts and Inaccuracies

Inaccurate readings can be caused by nail polish/fake nails, hypothermic vasoconstriction, peripheral edema, low perfusion, severe anemia, motion, or bright ambient light.

Oxygen Therapy & Nebulizer Documentation Requirements

Document SpO2 level, sensor location, delivery device and flow rate, breath sounds before/after therapy, nebulizer medication delivered, and client response.

Cancer-Related Pain Characteristics

Unique pain that can present as acute, chronic, or breakthrough pain stemming from direct tumor progression, organ compression, or treatment toxicity.

Pain Assessment Tool Selection Criteria

Choice depends on client's age, developmental stage, cognitive function, and communication capacity. Consistency in using the same tool over time is key.

Developmental Pain Assessment Tools

Numeric rating scale ($0\text{--}10$) for teens/adults; FACES/OUCHER for young children; CRIES ($3\text{-point scale}$) for neonates; Verbal Descriptor Scale for cognitively impaired or older adults.

Nonverbal Indicators of Pain

Facial grimacing, restlessness, guarding, moaning, crying, diaphoresis, and sudden increases in HR, BP, or respiratory rate.

Scheduled vs. PRN Analgesic Administration

Scheduled administration maintains therapeutic blood levels to prevent pain escalation, whereas PRN dosing responds only after pain returns.