Vital Signs

What are the four traditional vital signs?

Temperature, pulse, respirations, and blood pressure.

What is often considered the fifth vital sign?

Pain.

What additional measurement is commonly assessed with vital signs?

Pulse oximetry/SpO₂.

When should vital signs be assessed?

On admission, according to facility policy, with changes in condition, after loss of consciousness, before/after surgery or invasive procedures, around risk-increasing activity, and before medications affecting cardiovascular or respiratory function.

What is the normal adult temperature range?

Approximately 35.8–37.5°C (96.4–99.5°F).

What is the normal adult pulse rate?

60–100 beats/minute.

What is the normal adult respiratory rate?

12–20 breaths/minute.

What is the normal adult blood pressure?

What is the normal SpO₂ range listed in the lecture?

90–100%.

What is the primary source of body heat?

Metabolism.

What increases heat production?

Hormones, muscle movement, exercise, thyroid hormone, and shivering.

What hormones help increase heat production?

Epinephrine and norepinephrine.

What is the primary source of heat loss?

The skin.

What are the four methods of heat transfer?

Radiation, convection, evaporation, and conduction.

What is radiation?

Transfer of heat from the body to the environment without direct contact.

What is convection?

Transfer of heat through movement of air or fluid.

What is evaporation?

Heat loss when liquid changes into vapor.

What is conduction?

Transfer of heat through direct contact.

What factors affect body temperature?

Circadian rhythm, age/gender, physical activity, health status, and environmental temperature.

What are common temperature measurement sites?

Oral, rectal, axillary, tympanic, and temporal artery.

What are the adult temperature ranges by route?

Oral: 35.9–37.5°C; rectal: 36.3–38.1°C; axillary: 35.4–36.9°C; tympanic: 36.8–38.3°C; temporal: 36.3–38.1°C.

When should you wait before taking an oral temperature?

After eating, drinking, or smoking.

How do you convert Fahrenheit to Celsius?

Subtract 32, then multiply by 5/9.

How do you convert Celsius to Fahrenheit?

Multiply by 9/5, then add 32.

What does afebrile mean?

Without fever.

What does pyrexia mean?

Fever/febrile.

What is an intermittent fever?

Temperature returns to normal at least once every 24 hours.

What is a remittent fever?

Temperature stays above normal but fluctuates.

What is a sustained/continuous fever?

Temperature remains above normal with minimal variation.

What is a relapsing/recurrent fever?

Temperature returns to normal for one or more days, followed by one or more episodes of fever.

What are common manifestations of fever?

Loss of appetite, headache, hot/dry skin, flushed face, thirst, muscle aches, fatigue, increased pulse/respirations, and fluid/electrolyte/acid-base imbalances.

What fever complications are especially important in children and older adults?

Children may experience febrile seizures; older adults may develop confusion or delirium.

What is the goal of fever treatment?

Increase comfort and prevent complications.

How can fever be treated?

Treat the underlying infection when present, use antipyretics, cooling measures, increased fluids, and appropriate nutrition.

What is hypothermia?

Core body temperature below 35°C (95°F).

What are effects of hypothermia?

Poor coordination, slurred speech, poor judgment, amnesia, hallucinations, stupor, decreased respirations, weak/irregular pulse, and decreased blood pressure.

How is hypothermia treated?

Rewarming.

What regulates heart rate?

The autonomic nervous system through the sinoatrial (SA) node.

What does parasympathetic stimulation do to heart rate?

Decreases heart rate.

What does sympathetic stimulation do to heart rate?

Increases heart rate.

What is pulse rate?

The number of contractions felt over a peripheral artery in one minute.

What characteristics are assessed when evaluating a pulse?

Rate, amplitude/quality, rhythm, and volume.

What is tachycardia?

An abnormally increased heart rate.

What is bradycardia?

An abnormally decreased heart rate.

What does pulse amplitude/quality describe?

The strength of the pulse.

What does pulse rhythm describe?

Whether the pulse is regular or irregular.

What does pulse volume refer to?

The amount of blood ejected with each heartbeat, or stroke volume.

What do pulse strength grades mean?

0 = absent; +1 = diminished; +2 = normal; +3 = bounding.

What is the most common pulse site?

Radial artery.

When should a pulse be counted for a full 60 seconds?

When the rhythm is irregular.

What is ventilation?

Movement of air into and out of the lungs.

What is inhalation?

Breathing air into the lungs.

What is exhalation?

Breathing air out of the lungs.

What is diffusion?

Gas exchange between the alveoli and circulating blood.

What is perfusion?

Gas exchange between circulating blood and tissue cells.

Where are the respiratory centers located?

In the medulla and pons.

What activates the respiratory centers?

Impulses from chemoreceptors.

What is the most powerful respiratory stimulant?

An increase in carbon dioxide.

What is eupnea?

Normal, unlabored breathing.

What is tachypnea?

Increased respiratory rate.

What is bradypnea?

Decreased respiratory rate.

What is apnea?

Periods when no breathing occurs.

What is dyspnea?

Difficult or labored breathing.

What is orthopnea?

Difficulty/changes in breathing associated with sitting or standing.

What should be assessed when counting respirations?

Rate, depth, and pattern.

How should respirations be counted?

Observe chest rise and fall discreetly so the patient does not consciously change their breathing.

What is blood pressure?

The force of moving blood against arterial walls.

What is systolic pressure?

The maximum pressure when the left ventricle contracts and ejects blood.

What is diastolic pressure?

The lowest pressure when the heart rests between beats.

What is pulse pressure?

The difference between systolic and diastolic pressure.

How do you calculate pulse pressure?

Systolic pressure − diastolic pressure.

What is the pulse pressure for 120/80 mmHg?

40 mmHg.

What are the main mechanisms involved in short-term BP regulation?

Neural and humoral mechanisms.

How does cardiac output affect blood pressure?

The strength of heart contractions affects blood pressure.

What do baroreceptors do?

Monitor pressure and signal the cardiovascular center of the brain.

What does the renin-angiotensin-aldosterone system (RAAS) do?

Raises blood pressure.

What factors affect blood pressure?

Age, race, circadian rhythm, biologic sex, food intake, weight, exercise, emotional state, body position, and medications.

What is the most common artery used for BP measurement?

Brachial artery.

What artery can be used for a lower-extremity BP?

Popliteal artery.

What equipment can measure BP?

Stethoscope/sphygmomanometer, Doppler ultrasound, or electronic/automated devices.

What are Korotkoff sounds?

Sounds heard through a stethoscope during manual blood pressure measurement.

What does the first Korotkoff sound indicate?

Systolic pressure.

What indicates diastolic pressure?

The change or cessation of Korotkoff sounds.

How should the patient be positioned for BP measurement?

Seated when possible, with feet flat and arm supported at heart level.

Should the patient talk during BP measurement?

No.

Why is cuff size important?

An incorrect cuff size can produce an inaccurate BP reading.

What is hypotension?

Blood pressure below 90/60 mmHg.

What can cause hypotension?

Disease, medication side effects, or inability to maintain normal BP.

What is orthostatic hypotension?

A drop in BP caused by an inadequate physiologic response to a change in position, especially when standing.

What can cause orthostatic hypotension?

Dehydration, blood loss, or neurologic, cardiovascular, or endocrine problems.

Why is pain often considered the fifth vital sign?

It is routinely assessed along with other vital signs.

When should pain be assessed?

At every vital-sign assessment.

What pain scale is commonly used for adults who can self-report?

0–10 Numeric Rating Scale.

What do 0 and 10 represent on the numeric pain scale?

0 = no pain; 10 = worst pain possible.

What pain scale can be used for children or patients who cannot communicate pain numerically?

Wong-Baker FACES.

What should be documented when assessing pain?

Location, quality, severity, aggravating factors, and relieving factors.

What should the nurse do after a pain intervention?

Reassess the patient's pain.

What is pulse oximetry?

A noninvasive measurement of oxygen saturation in arterial blood.

What does SpO₂ represent?

Arterial oxygen saturation.

Where is a pulse oximeter commonly placed?

Finger.