4 Vital Signs Assessment

2024 Kent State Foundations of Assessment and Communication Exam 1

Blood Pressure

Represents the force exerted by blood against the arterial walls

normal Blood Pressure

120/80

borderline hypertension Blood Pressure (stage 1)

130/80

stage 2 hypertension Blood Pressure

140/90

Hypertensive crisis Blood Pressure

180/120 or greater

hypotensive Blood Pressure

less than 90/60

systolic pressure and diastolic pressure

top number - Systolic
bottom number - Diastolic

orthostatic hypotension

A drop in blood pressure by 20mmHg or more due to a sudden change of posture.

peripheral vascular resistance affect Blood Pressure

increased BP

blood volume affect Blood Pressure

low fluid volume = drop BP and increase heart rate

Blood Viscosity effect on Blood Pressure

Increases blood pleasure with thicker blood
(pumping molasses / water)

Who has a higher Blood Pressure? Males or Females… Until when?

Men do until women complete menopause then it evens out

What race has higher Blood Pressure

African Americans

T/F Blood Pressure stays the same through out the day

False, it is lower in the morning and increases throughout the day

Anxiety, Pain, and exercise affect Blood Pressure

Increasing

pulse pressure

difference between systole and diastole

normal pulse pressure

30-50

Measuring orthostatic Hypotension

Take BP when pt is lying down, sitting, and then standing with 1-3 minutes of rest in between measurements

What is the 1st Korotkoff sound?

systolic pressure, first ventricular contraction

What is the 5th Korotkoff sound?

Last sound you here, diastole, heart is at rest

What happens if the Blood Pressure cuff is too tight on pt?

False high reading

What happens if BP cuff is too loose on pt?

low reading

T/F when a pt has a change in health status before calling the doctor the nurse must re-take the pt's VS

True

When to take vital signs

• admission / discharge
• physical assessment
• routine monitoring
• general physical condition changes (e.g., loss of consciousness or increased intensity of pain)
• Before and after surgery or invasive procedure
• ongoing care to detect improvements

5 vital signs

Temp, pulse, respirations (Pulse Ox), BP, and pain

How often should a nurse be taking a pt's vitals?

Usually once a shift, based on physicians orders but nurses are responsible for judging if a Pt's vitals need re-assessed sooner

What things should be considered when taking a pt's vs

illnesses, physical condition, and age can affect vs

T/F vital sign assessment can be delegated but, the interpretation of Vital Signs and the decision of interventions cannot be delegated!

True

Average oral temperature

98.6 F, 37C
children older than 4 years

Average tympanic temperature

99.5 F, 37.5C
3 mo and older

Average rectal temperature

99.6 F, 37.5 C
not used on babies

Average axillary temperature

97.6 F, 36.5 C
for newborns and infants

Average temporal temperature

98.7 F, 37.1C

Average infrared tempature

97 F, 36.1 C

Neural control of body temp regulation

hypothalamus senses body temp and signals when to adjust

methods body thermoregulate when cold

Increased BMR
Voluntary movement
Shivering
All increase body heat

Body heat loss methods

Radiation
Conduction
Convection
Evaporation

Radiation (body temp)

Transfer of heat that is lost when the body is in a cold environment

Conduction (body temp)

transfer of heat from body to another surface (being in cold water)

Convection (body temp)

dispersion of heat through wind currents (fan)

Diaphoresis

sweating

age affect body temp

Skin becomes thinner as we age, decrease in circulation and lowering body temp

hormones affect body temp

Women's Body temp goes up during ovulation and low during menstruation (low progesterone)

circadian rhythm affect body temp

body temp lower in the morning, increase throughout the day

hyperthermia temp (F & C)

102.2 F / 39 C

severe fever temp

greater than 104 F / 40 C

Treatment of a fever

Antipyretics (Tylenol) and a hypothermia blanket

heat stoke caused by

fever of 106-113 F, environment weather, medications, excessive exercise, high humidity

Signs and Symptoms of a heat stroke

hot and dry skin, confusion, muscle cramps, elevated pulse and low bp

hypothermia body temp

less than 95 F / 35 C

Signs and Symptoms of hypothermia

uncontrolled shivering, memory loss, poor judgement, low pulse, resp, and BP. Cyanosis (blue)

Pulse

Number of ventricular contractions that occur within one minute

normal pulse rate

60-100 bpm in an adult

Bradycardia

less than 60 bpm

Tachycardia

greater than 100 bpm

different when assessing vitals on a pt with an irregular rhythm

Take pulse for a full minute

detect arrhythmia/Dysrhythmia

EKG or ECG

Pulse strength of 0

pulse is absent, requires doppler for confirmation
(pulse present with doppler only)

Pulse strength of 1

weak, hardly feel it

Pulse strength of 2

normal, average pulse

Pulse strength of 3

bounding, usually high BP

T/F to test for pulse equality you should check both sides

True

Where should you assess the pulse

the radial pulse inner wrist /thumb side

How do you take an apical pulse

find 5th intercostal space, auscultate with stethoscope and count for 60 seconds

When and Where does one take an apical pulse

when pulse is not normal
Point of Maximum impulse (PMI)

T/F is patient is obese or big breasted and an apical pulse must be taken it should be taken over the breast

False, ask patient if it is okay to lift breast and take pulse under the breast

Where is the dorsalis pedis pulse?

top of foot

Where is the posterior tibial pulse?

inside ankle

other common pulse sites?

Temporal, carotid, brachial, femoral, popliteal

When should the carotid pulse be taken

in emergency situations only

fever affect pulse

increased

hypothermia affect pulse

it decreases it

sudden pain affect pulse rate

it increases it
not with chronic pain

medications affect pulse rate

narcotics decrease it, epinephrine increases it

Normal respiration rate

12-20 respirations per minute

Tachypnea

greater than 20 breaths/min

Bradypnea

less than 12 breaths per minute

Dyspnea

difficulty breathing

Apnea

No breathing

Orthopnea

difficulty breathing when lying down

Hyperventilation

increase in rate and depth of respirations

Most important VS to take care of first

Respirations, airway

Ventilation

movement of air in and out of the lungs

Ventilation is assessed by

Respiratory Rate

Diffusion (respiratory)

movement of O2 and CO2 between alveoli and RBCs

Diffusion assessed by

blood O2 saturation

Perfusion (respiratory)

distribution of RBCS to and from capillaries, if not good extremities will turn blue
O2 saturation

Breath depth types (4)

shallow/ deep
labored/unlabored

altitude affect respiration

increased rate and depth, improve O2 supply

smoking affect respiration rate

increases

Body temp affect of respiration rate

increased metabolism = increased respritory rate

normal pulse oximetry

90%-100%

direct measurement of an o2 saturation

arterial blood gas (ABG) invasive

peripheral vascular disease affect pulse ox measurement

causes thick discolored nails, cant take pulse ox without invasive measures

Hypotension and Hypothermia affect o2 reading

poor circulation causes inaccurate reading

T/F pulse ox monitor not pick up o2 sat if pt has CO poisoning

True, must use ABG

Assessing Pain

pain assessment chart
also Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Treatment

OLDCART

O-Onset
L-Location
D-Duration
C-Characteristic
A-Aggravating Factors
R-Relieving Factors
T-Treatment

Pain assessment (other than OLDCART)

Intensity on a pain scale
Observed behavior effects
Effect on ADL's

unit blood pressure measured in

millimeters of mercury / mmHg