Vital Signs & Pain Assessment

General Survey Components

Physical appearance, body structure, mobility, behavior, and measurements.

Infant Weight Measurement

Use a platform scale for safety when weighing infants.

Infant Length Measurement

Measure length flat up to two years of age.

Older Adult Weight Changes

Weight decreases due to loss of subcutaneous fat.

Vital Signs List

Temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation.

Temperature Regulation

Regulated by the hypothalamus to balance heat production and loss.

Euthermia

Normal body temperature of approximately 37°C or 98.6°F.

Hypothermia

Body temperature below 36°C or 96.8°F due to prolonged cold exposure.

Hyperthermia

Body temperature above 37.8°C or 100°F caused by infection or heat.

Oral Temperature Consideration

Ensure no liquids, solids, or smoking for 15 minutes before measuring.

Rectal Temperature Route

The most accurate temperature route, measured 1 inch into an adult rectum.

Tympanic Temperature Route

Measured in the ear canal by pulling the adult pinna up and back.

Temporal Temperature Route

Measured by sliding a probe across the forehead and behind the ear.

Bradycardia

A heart rate of less than 60 beats per minute.

Tachycardia

A heart rate of greater than 100 beats per minute.

Pulse Force 3+

Full and bounding pulse.

Pulse Force 2+

Normal pulse.

Pulse Force 1+

Weak and thready pulse.

Pulse Force 0

Absent pulse.

Assessing Irregular Pulse

Count the pulse for a full 60 seconds.

Adult Respiratory Rate

Normal range is 12 to 24 breaths per minute, averaging 20.

Systolic Blood Pressure

Maximum pressure on the artery during left ventricular contraction.

Diastolic Blood Pressure

Elastic recoil pressure between each heart contraction.

Pulse Pressure

The difference between systolic and diastolic blood pressures.

Mean Arterial Pressure (MAP)

The average blood pressure over the cardiac cycle.

Hypertension

Systolic blood pressure above 130 or diastolic above 80.

Hypotension

Systolic blood pressure below 100 accompanied by symptoms.

BP Cuff Size Error

A cuff that is too large, small, or loose causes a falsely high reading.

Korotkoff Sounds

Sounds produced by turbulent blood flow used to determine blood pressure.

Pulse Oximetry Normal Range

Normal oxygen saturation is 97% to 99% on room air.

Infant Blood Pressure Assessment

Do not measure BP in infants; start at 3 years of age.

Acute Pain

Short-term, self-limiting pain associated with an injury or incident.

Chronic Pain

Persistent pain lasting longer than 6 months, managed rather than cured.

Gold Standard for Pain Assessment

The patient's self-report.

Behavioral Cues for Pain

Nonverbal signs like grimacing, moaning, guarding, and restlessness.

Physiological Pain Response

Sympathetic nervous system stimulation causing increased heart rate, blood pressure, and respiratory rate.

Pain Assessment Tool Selection

Choose based on developmental age, verbal ability, and cognitive level.