NRS Vital Signs

Apical Pulse

HR felt at the apex of the heart

Apical Pulse Location

located medially to the midclavicular line at the fifth intercostal space

Apnea

Absence of spontaneous respirations

Axillary Temperature

Body temperature obtained in the axilla with arm held to side of body

Blood Pressure

A measurement of the force circulating blood exerts on the interior walls of blood vessels

Bradycardia

HR less than the expected reference range

Bradypnea

Respiratory rate less than expected range

Cardiac Output (CO)

volume of blood ejected by the heart ventricles in 1 min

Cardiac output formula

Stroke Volume x HR

Cheyne-Stokes

Breathing pattern of cycles that begin with rapid, shallow breaths, increase to deep breaths, ending with periods of apnea

Contractility

The force required to eject blood from the left ventricle

Diastole

Heart relaxes and the chambers of the heart fill with blood

Doppler ultrasound stethoscope (DUS)

A stethoscope fitted with an audio unit and a transducer that amplifies the vascular or other sounds of the body

dorsalis pedis pulse

Beating or throbbing palpated or heard with a doppler over the dorsalis pedis artery located on the dorsal side of the foot; it is used to assess quality of perfusion

Dyspnea

Difficult or labored breathing

eupnea

Respiratory rate and rhythm that are within the expected reference range

hypertension

A blood pressure that is above the expected reference range

hyperthermia

An uncontrolled elevation in body temperature where the body cannot lose heat as fast as it is gained, usually caused by environmental or metabolic factors

Difference from fever and hyperthermia

The Hypothalamic set point is unchanged with hyperthermia

hypotension

A blood pressure that is below the expected reference range

hypothermia

Condition in which the body temperature is abnormally low due to the body losing heat faster than it is produced

hypoxia

Below normal level of oxygen in body tissue

Korotkoff sounds

Sounds created by movement of blood through a partially compressed vessel during a manual blood pressure assessment

Kussmaul respirations

Deep, rapid respirations.

orthostatic hypotension

A decrease in blood pressure that occurs upon standing, especially from a lying or sitting position. A significant drop in the blood pressure caused by a change in position

oxygen saturation

The percentage of hemoglobin that is saturated with oxygen

peripheral vascular resistance

The total resistance to flow of blood in the vascular bed

preload

The blood remaining in the left ventricle at the end of diastole that causes it to stretch

Pulse

Rythmic throbbing or beating caused by the expansion and contraction of the arteries in response to the ejection of blood from the left ventricle

pulse deficit

Difference between apical and radial pulse rates. This difference indicates a decrease in ventricular contraction or peripheral perfusion

pulse oximeter

A noninvasive device used to measure oxygen saturation

respiratory rate

The number of breaths taken per minute

sphygmomanometer

Instrument used to measure arterial blood pressure

stroke volume (SV)

Volume of blood ejected by the left ventricle during one contraction

systole

Contraction of the heart. Blood is driven into the aorta and pulmonary arteries

tachycardia

Heart rate above the expected reference range

tachypnea

Respiratory rate greater than expected range

temporal thermometer

A thermometer that uses infrared scanning of the temporal artery to determine body temperature

vital signs

A reflection of the body's physiological function. Includes pulse, blood pressure, respiratory rate, oxygen saturation and sometimes pain level

Normal BP

120/80

Elevated BP

120-129/80

High BP Stage I

130-139/80-89

High BP Stage II

140+/90+

Hypertensive Emergency

180+/+120

Newborn (4 weeks) pulse

110-160

Infant 1 month-1 year pulse

90-160

Toddler (1-2 years) pulse

80-140

Preschool (3-5 years) pulse

70-120

School age (6-12) pulse

60-110

Adolescent (13-18 years) pulse

50-100

Adult 18+ pulse

60-100

Newborn (4 weeks) Respiration rate

30 to 60/min

Infant (1 month-1year) Respiration rate

25 to 60/min

Toddler (1-3 years) Respiration rate

25 to 30/min

Preschool (3-6 years) Respiration rate

20 to 25/min

School-age (6 to 12 years) Respiration rate

20 to 25/min

Adolescent (12 to 20 years) Respiration rate

16 to 20/min

Adult (20 years and older) Respiration rate

12 to 20/min

Normal Body temp

36° C to 38° C (96.8° F to 100.4° F)

Hyperthermia range

equal to or greater than 40° C (104° F)

Hypothermia range

core temp less than 30° C (86° F)

Orthostatic hypotension range

Drop in systolic pressure of at least 20 mm Hg, or a drop in diastolic pressure of at least 10 mm Hg, within 1 min of movement

Tympanic temperature can be inaccurate in children under 3 years of age

due to the angle of the eustachian tube.

Baseline Vital Signs

Obtained by nurse for assessment, rerecordings may be delegated to AP

For clients with respiratory infections nurses should

Count rate for 1 min

Counting respiratory rate in healthy patients

count the rate for 15 seconds and multiply by 4 to determine the rate per minute

When taking BP the bladder cuff should be released at

2-3 mmHG per second

BP cuffs should have a width that’s

80% circumference of patients arm

Hypotension range

systolic BP less than 90 mm Hg or a diastolic BP less than 60 mm Hg.

BP using the thigh cuff

40% of the circumference of the thigh

What artery should be palpated when getting thigh BP

Popliteal

BP in the thigh is ___ then that of the arm

Higher

Respiration Rate can be obtained by

counting for 15 seconds and multiply by 4.

For apical pulse

Count for 1 min

For children 7 years and younger apical pulse is collected at

4th intercostal space to the left of the sternum

In clients with end-tidal carbon dioxide (ETCO₂) monitors, values outside of the expected reference range

(35 to 45 mm Hg) or those trending low or high warrant concern

cutaneous stimulation

therapy applied to the skin such as heat and cold, touch, massage, acupuncture, acupressure, or TENS

Cold therapies should be applied for

20-30 min at a time, checking the area frequently to avoid damage to the skin or nerves

Transcutaneous electronic stimulation (TENS)

Unit emits low-voltage electrical impulses to the skin over painful areas

Opioids

Most common pain medications, which have the risk of sedation and depression, such as morphine, hydromorphone, and fentanyl.

Opiates

natural opioids that come directly from the opium poppy (codeine and morphine)

Semisynthetic opioids

Created from natural opiates (eg. heroin, hydrocodone, oxycodone, and hydromorphone.)

Synthetic opioids

Manufactured products that include fentanyl, fentanyl analogs, and tramadol

Opioid Medications can be given

Mouth (PO), intramuscular (IM) injection, intravenous (IV) injections given intermittently or as continuous drips (for comfort care), per rectum (PR), and topically (TOP)

Patient-controlled analgesia (PCA)

A computerized pump controlled by the client capable of delivering pain medication through a syringe to their IV line.

Nonsteroidal anti-inflammatory drugs (NSTAIDs)

Reduce inflammation and fever. Includes ibuprofen, aspirin, diclofenac, celecoxib, ketorolac, and naproxen.

NSTAIDs can

Enhance bleeding if given concurrently with anticoagulants or antiplatelets

Sucrose

Can be given to sick infants to manage pain

Adjuvant analgesics

Aid in pain relief by working on underlying pain generators, such as antidepressants, corticosteroids, and botulinum toxin

SBIRT (Screening, Brief Intervention, and Referral to Treatment)

Used for patients with opioid addiction

If given a range order 2mg to 4mg Q4 hours

The nurse cannot split the dose to give 2 mg every 2 hr instead of 4 mg every 4 hr. Although the math might seem equal, this is not how the dose was prescribed

Capnography

Measuring carbon dioxide) can assist with identifying OIVI

To check for opioid-induced ventilatory impairment (OIVI)

Respiratory rate, Oxygen saturation, and Capnography

Diaphoretic

Sweating heavily

Justice

Clients be treated fairly in regard to their pain management regardless of age, ethnicity, or history, such as substance use disorder or limited social and economic resources