Vital Signs and Pain Assessment in Nursing

Comprehensive practice flashcards covering vital signs measurement techniques, normal lifespan ranges, assessment equipment, respiratory patterns, blood pressure classifications, and pain assessment scales.

What are the standard normal vital sign ranges for an adult?

Temperature: 96.4-100.4°F; Pulse/Heart Rate: 60-100 BPM; Respirations: 12-20 per minute; Blood Pressure:

According to nursing guidelines, when should vital signs be assessed?

On admission to obtain baseline data; with a change in health status or symptoms; before and after procedures or surgery; before/after administering medications affecting the cardiovascular or respiratory systems; and before and after nursing interventions.

How do rectal, axillary, and tympanic body temperature readings compare to oral readings?

Oral baseline temperature range is 96.8-100.4°F (37°C core average). Rectal temperature is ~0.9°F higher than oral. Axillary and Tympanic temperatures are ~0.9°F lower than oral.

What do blue and red probe colors indicate on an electronic thermometer?

Blue probe indicates an oral temperature site; Red probe indicates a rectal temperature site.

What is the procedure and recommended insertion depth for taking an adult rectal temperature?

Lubricate the probe cover, insert 1-1.5 inches for adults aiming toward the umbilicus, and stop immediately if resistance is felt.

How does a chemical-dot single-use thermometer (such as Tempa-DOT) function?

It consists of disposable plastic strips applied to the skin containing color-changing dots that yield temperature readings in approximately 60 seconds.

What physical technique is required when taking a tympanic temperature?

Apply a disposable probe cover, pull the pinna back, up, and out, insert the probe gently at the proper angle, and wait for the audible signal.

What is considered best practice for temperature assessment in children under 2 years old?

Rectal temperature is considered best practice for children under 2 years old.

What are the features of temporal temperature measurement?

It measures blood flow heat from the temporal artery, is safe for all ages, and provides temperature readings close to rectal temperature.

How should a nurse count regular versus irregular radial pulse rates?

For a regular pulse, count beats for 30 seconds using finger pads and multiply by 2. For an irregular pulse, count for 1 full minute.

Where is the apical pulse located and how is it assessed?

It is located at the Point of Maximal Impulse (PMI) on the chest. Assess using the diaphragm of a stethoscope by listening for S1 and S2 sounds for 1 full minute.

What is a pulse deficit and what does it indicate?

A pulse deficit is the difference between the apical pulse rate and the radial pulse rate. It indicates inefficient cardiac contractions and occurs with irregular heart rhythms.

What are the numerical criteria for bradycardia and tachycardia in adults?

Bradycardia is defined as a pulse rate

What are the proper dimensions for sizing a blood pressure cuff?

Cuff width should equal 40% of arm circumference, and bladder length should equal 80% of arm circumference.

What local conditions contraindicate taking a blood pressure on a specific extremity?

Do not take blood pressure on an arm with a mastectomy side, a dialysis fistula or graft, an active IV site, or compromised skin integrity.

What do the first and fifth Korotkoff sounds signify when taking blood pressure?

The first sound signifies systolic blood pressure. The fifth sound (disappearance of sound) signifies diastolic blood pressure (use the fourth sound if no clear fifth sound is heard).

How is pulse pressure calculated and what is its normal range?

Pulse pressure is calculated as the difference between systolic blood pressure and diastolic blood pressure. Normal range is 30-50 mmHg.

What are the adult blood pressure classification ranges for Elevated, Stage 1, Stage 2, and Hypertensive Crisis?

Elevated: 120-129/

What changes define orthostatic hypotension?

A drop in systolic blood pressure of ≥ 20 mmHg or an increase in pulse rate of ≥ 20 bpm associated with a position change.

Why is the two-step blood pressure method performed?

It prevents underestimating true systolic pressure and avoids missing an auscultatory gap.

What is the normal adult respiratory rate and what method should be used to measure it?

Normal rate is 12-20 breaths/minute. Count for 1 full minute without telling the patient to avoid conscious alteration of breathing.

What are tachypnea and bradypnea?

Tachypnea is a respiratory rate >20 breaths/minute. Bradypnea is a respiratory rate <11 breaths/minute.

What are Cheyne-Stokes respirations?

A breathing pattern characterized by a gradual increase in rate and depth, followed by a gradual decrease, and then a period of apnea.

What characterizes Biot's respirations?

An irregular pattern with varying respiratory depth and rate interrupted by periods of apnea.

What characterizes Kussmaul's respirations?

Deep, gasping respirations at a rapid rate.

What physical signs indicate increased work of breathing?

Use of accessory muscles, nasal flaring, intercostal retractions, tripod positioning, restlessness, and changes in level of consciousness (LOC).

What physiological parameter does pulse oximetry measure?

It noninvasively measures oxygen saturation of hemoglobin (%SpO2), indicating oxygenation (not ventilation).

What patient factors can interfere with pulse oximetry readings?

Nail polish or artificial nails, patient movement, cold extremities, vasoconstriction, peripheral edema, hypotension, and abnormal hemoglobin.

Why is the pulse oximetry waveform important during assessment?

An accurate waveform confirms reading accuracy and reflects pulse strength.

What is considered the gold standard for pain assessment?

Patient self-report is the gold standard because pain is a subjective experience and the patient is the expert.

Identify the labeled parts of the stethoscope shown in the diagram.

Bell (top smaller side), Stem (metal connecting piece), and Diaphragm (bottom larger flat side).

Identify the labeled components of an aneroid sphygmomanometer shown in the diagram.

Cuff, Bladder, Tubing, Pressure Gauge, Bulb, and Air Release Valve.

Identify the pain assessment scale shown in this image and state its target population.

Wong-Baker FACES Pain Rating Scale, designed for pediatric patients to choose a face representing their pain level from 0 (NO HURT) to 10 (HURTS WORST).

Identify the pain assessment tool shown in this chart and list its parameters.

CRIES Pain Scale for neonates. Parameters evaluated (scored 0 to 2) are Crying, Requires O2, Increased vital signs, Expression, and Sleeplessness.

What are the normal vital sign values for a newborn according to the lifespan table?

Pulse: 100-160 bpm awake (as low as 70 in sleep); Respirations: 30-60 breaths/min; Temperature: 36.5-37.4 C; Systolic BP: 50-70 mmHg at birth (90 at day 10); Diastolic BP: 30-45 mmHg at birth (50 at day 10).