Vital Signs Review - Measuring, Thermoregulation, Pulse, Respiration, and Blood Pressure (Dr. Murdock)

Flashcards covering key concepts from the Measuring Vital Signs lecture, including thermoregulation, pulse, respiration, and blood pressure, plus documentation, sites, patterns, and clinical interpretation.

What are vital signs and what do they indicate?

Vital signs—temperature, pulse, respiration, blood pressure, pain, oxygenation, and emotional distress—reflect a patient’s physiological functioning and health; each patient has a baseline that should be used to detect changes in context.

When should vital signs be measured?

On admission; at the beginning of a shift; at provider office/clinic visits; before, during, and after surgeries or procedures; to monitor effects of meds/activities; and whenever a patient’s condition changes.

What are the commonly used frequencies for taking vital signs in different care settings?

Hospital: every 4–8 hours; Home health: every visit; Clinic: every visit; Skilled nursing facilities: weekly–monthly.

How are normal and abnormal vital signs documented?

On the facility flowsheet; a nurse’s note for abnormal findings with associated symptoms, interventions taken, and the results.

What is thermoregulation?

The body's process of maintaining a stable internal temperature; the hypothalamus detects changes and triggers mechanisms to conserve or dissipate heat.

What are core temperature sites vs surface temperature sites?

Core: deep within the body (viscera) and rectal (order required); tympanic membrane. Surface: oral, axillary, and forehead.

What is a normal body temperature for adults and how much does it vary?

There is no universal normal value; for adults, oral ~36.7–37.0°C (98–98.6°F), rectal ~37.2–37.6°C (99–99.6°F); slight variations are common and continuous elevation requires evaluation.

What is fever (pyrexia) and what do febrile/afebrile mean?

Fever: oral >37.8°C (100°F) or rectal >38.3°C (101°F); febrile means fever is present; afebrile means no fever.

What are the phases of a fever?

Initial phase (onset) with rising temp and chills; second phase (course) with fever at a new set point; third phase (defervescence/crisis) with temp returning to normal and diaphoresis.

What are pyrogens and the hypothalamic set point?

Pyrogens stimulate fever by signaling the hypothalamus to raise the body's thermostat (set point); when the stimulus is removed, the set point returns to normal (reset value).

What are fever patterns?

Intermittent: fever to normal within 24 hours; Remittent: fluctuations above normal for 24 hours; Constant: always above normal with minor fluctuations; Relapsing: fever periods alternating with normal temperatures.

What temperature sites should you use and what documentation is needed?

Choose a patient-specific site; rectal temperature requires an order; document site and value (e.g., 99.7°F Axillary); include conversion between Fahrenheit and Celsius when needed.

How do you convert Fahrenheit to Celsius and Celsius to Fahrenheit?

F to C: (F − 32) × 5/9; C to F: (C × 9/5) + 32.

What is the normal pulse rate for adults and what do bradycardia and tachycardia mean?

Normal: 60–100 bpm; Bradycardia:

What factors influence the pulse rate?

Developmental level; sex; exercise; food intake; emotions/stress; fever; disease; blood loss; position changes; medications.

What pulse assessment sites are used and which is most common for routine vitals?

Apex (apical) and peripheral pulses; radial (most common for routine vitals); brachial (infants CPR); carotid (brain circulation); temporal; dorsalis pedis; posterior tibial; femoral; popliteal; avoid bilateral carotids.

What is a pulse deficit and why is it important?

A difference between radial and apical pulses; indicates potential serious issues such as atrial fibrillation and should be reported promptly.

What data should you collect and how should you document the pulse rate?

Document rate, rhythm, and quality; count for 1 minute if slow or irregular; rate in bpm; rhythm: regular/irregular; irregular may need ECG; pulse volume on a 0–3 scale; assess bilateral equality (carotid should not be checked bilaterally).

What is respiration and its mechanical and chemical aspects?

Respiration is the exchange of O2 and CO2; mechanical aspect is pulmonary ventilation (breathing).

What is a normal respiratory rate?

12–20 breaths per minute; normality varies with age, exertion, emotions, and other factors.

How does the body regulate respiration?

A slight rise in CO2 or H+ stimulates respiration; PaO2 below 80 mmHg triggers peripheral chemoreceptors; breathing is involuntary but controllable by the patient.

What are the mechanics of breathing?

Inspiration: diaphragm contracts; expansion of the chest and lungs; Expiration: diaphragm and chest muscles relax; air expelled.

List factors that influence respiration.

Developmental level; exercise; pain; stress/anxiety; smoking; fever; hemoglobin/altitude; disease; medications; position.

What data should you collect for respiration and how should you document it?

Rate, depth, rhythm, effort; breath sounds; chest/abdominal movement; include pulse oximetry and ABGs when appropriate.

Breath sounds: what are the common types and their meanings?

Normal; wheezes (high-pitched expiratory); rhonchi (low-pitched gurgling); crackles (popping/bubbling); stridor (inspiratory, often obstruction); stertor (snoring-like).

What are signs of oxygenation problems and how are they measured?

Hypoxia signs: pallor, cyanosis, restlessness, confusion, dizziness, fatigue, tachycardia, tachypnea, BP changes; cough types; ABGs (invasive) vs pulse oximetry (noninvasive; normal SpO2 95–100%).

What is blood pressure and why is it important?

The force exerted on artery walls; essential for tissue perfusion; systolic is the peak during heart contraction; diastolic is the pressure during heart relaxation.

What are normal BP ranges and the category definitions?

Normal

What factors influence blood pressure beyond the numbers?

Cardiac output, peripheral resistance, blood volume, arterial size/compliance; age, sex, family history, lifestyle (sodium, smoking, obesity, alcohol), exercise, diurnal variation, medications, diseases, genetics.

What cuff size and placement considerations are important for BP?

Cuff should cover two-thirds of the upper arm; width ~40% of arm; bladder length ~80% of arm; use the larger cuff if unsure; record cuff size with the reading.

Which BP site should be avoided and what are alternatives?

Avoid arms with IVs, dialysis fistulas, skin grafts, casts, or dressing; alternatives include forearm, thigh, or calf (note lower-extremity systolic may be 20–30 mmHg higher).

What are auscultation and palpation methods for BP?

Auscitation is most common; palpation used when auscultation is difficult; palpation with auscultation helps ensure accuracy and detect auscultatory gaps (loss and return of sound up to 30 mmHg).

What are hypotension and orthostatic hypotension definitions and risk factors?

Hypotension: systolic ≤90 mmHg or diastolic ≤60; Orthostatic hypotension: drop ≥10 mmHg within 2–5 minutes of standing; risk factors include older age, dehydration, pregnancy, blood loss, certain medications.

What are modifiable and nonmodifiable risk factors for hypertension?

Modifiable: smoking, overweight/obesity, sedentary lifestyle, unhealthy diet, high cholesterol, stress, heavy alcohol use; Nonmodifiable: family history, age, race; other factors include diurnal variation and kidney disease.

How should you evaluate vital signs in practice?

Evaluate against known norms and the patient’s trends; consider medications, diagnoses, procedures, environment, and activity; assess for additional clinical signs to determine action.

Who usually obtains vital signs and who interprets them?

Unlicensed assistive personnel often obtain VS; the nurse reviews trends and decides on actions; students should consult instructors when unsure; ultimate responsibility lies with the nurse.