S

Vital Signs and Patient-Centered Care - Study Notes

Definition

  • Patient Centered Care: Blends patient, family and community in patient care decisions. Values, preferences, beliefs, and culture are taken into consideration during the patient’s care. (Pearson, 2023).

Terminology

  • Afebrile
  • Apnea
  • Bradycardia
  • Bradypnea
  • Diastolic pressure
  • Dyspnea
  • Dysrhythmia
  • Eupnea
  • Febrile
  • Fever
  • Hypertension
  • Hyperthermia
  • Hypotension
  • Hypothermia
  • Korotkoff sounds
  • Orthopnea
  • Pulse deficit
  • Pulse pressure
  • Pyrexia
  • Systolic pressure
  • Tachycardia

Pharmacology Flash Card: Drug Classifications

  • Anti-hypertensive
  • ACE inhibitors
  • Anti-arrhythmic
  • Angiotensin II receptor blockers/inhibitors/antagonist (ARBs)
  • Beta-blocker
  • Calcium-channel blocker
  • Sodium-channel blocker
  • Diuretics/thiazides
  • Narcotic/analgesic
  • Vasopressors

Vital Signs (T, P, R, BP, O2Sat)

  • Temperature (T)
  • Pulse (P)
  • Apical heart rate
  • Respiration (R)
  • Blood pressure (BP)
  • Pulse oximetry (O2Sat)
  • Pain (often included as fifth sign)

Normal Ranges for Vital Signs for Healthy Adults

  • Oral temperature: 96.4-99.4^{ op} ext{F} = afebrile
  • Pulse rate: 60 ext{ to } 100 ext{ beats/min} (80 average)
  • Respirations: 12 ext{ to } 20 ext{ breaths/min}
  • Blood pressure: 120/80 ext{ mmHg} (ideally systolic < 120)

Normal Ranges Through the Lifespan (note: values can vary by resource)

  • Newborn (Birth-28 days):
    • Temperature: 35.9-36.9^{ op}C ext{ (97.7-99.5}^{ op}F)
    • Pulse: 120-160 ext{ beats/min}
    • Respirations: 30-60 ext{ breaths/min}
    • BP: 60/40 ext{ mmHg}
    • Measurement note: a = axillary temperature (a)
  • Infant (1 month - 12 months):
    • Temperature: 37.1-38.1^{ op}C ext{ (98.7-100.5}^{ op}F)
    • Pulse: 80-160 ext{ beats/min}
    • Respirations: 20-40 ext{ breaths/min}
    • BP: 85/37 ext{ mmHg}
    • Measurement note: b = temporal temperature (b)
  • Toddler (1-3 yrs):
    • Temperature: 37.1-38.1^{ op}C ext{ (98.7-100}^{ op}F)
    • Pulse: 80-130 ext{ beats/min}
    • Respirations: 25-32 ext{ breaths/min}
    • BP: 89/46 ext{ mmHg}
    • Measurement note: c = tympanic temperature (c)
  • Child (3-10 yrs):
    • Temperature: 36.8-37.8^{ op}C ext{ (98.2-100}^{ op}F)
    • Pulse: 70-115 ext{ beats/min}
    • Respirations: 20-26 ext{ breaths/min}
    • BP: 95/57 ext{ mmHg}
  • Preteen (10-13 yrs):
    • Temperature: 35.8-37.5^{ op}C ext{ (96.4-99.5}^{ op}F)
    • Pulse: 65-110 ext{ beats/min}
    • Respirations: 18-26 ext{ breaths/min}
    • BP: 102/61 ext{ mmHg}
  • Teen (13-20 yrs):
    • Temperature: 35.8-37.5^{ op}C ext{ (96.4-99.5}^{ op}F)
    • Pulse: 55-105 ext{ beats/min}
    • Respirations: 12-22 ext{ breaths/min}
    • BP: 112/64 ext{ mmHg}
  • Adult (20+ yrs):
    • Temperature: 35.8-37.5^{ op}C ext{ (96.4-99.4}^{ op}F)
    • Pulse: 60-100 ext{ beats/min}
    • Respirations: 12-20 ext{ breaths/min}
    • BP: 120/80 ext{ mmHg}
  • Footnotes: a) Temperature is axillary; b) Temperature is temporal; c) Temperature is tymanic; d) Temperature is oral.

Note: Values/ranges may differ between resources; the table reflects ranges used at Holy Name Hospital.

When to Assess Vital Signs

  • On admission to any health care facility or institution
  • Based on facility or institutional policy and procedures
  • Any time there is a change in the patient’s condition
  • Any time there is a loss of consciousness
  • Before and after any surgical or invasive diagnostic procedure
  • Before and after activity that may increase risk (e.g., ambulation after surgery)
  • Before administering medications that affect cardiovascular and/or respiratory function

Temperature

  • Definition: Body temperature is the balance between heat produced by the body and heat lost to the environment; measured in degrees.
  • Normal range: 96.4-99.4^{ op}F; Average 98.6^{ op}F; 100^{ op}F or greater usually equals fever.
  • SITES for measurement: ext{Oral (sublingual)}, ext{Axillary (armpit)}, ext{Tympanic}, ext{Temporal}, ext{Rectal}
  • Rectal is considered the most accurate in many settings.
  • Equipment for assessing temperature: electronic/digital thermometers, tympanic thermometers, disposable single-use thermometers, temporal artery thermometers, automated monitoring devices.
  • Types of thermometers used: electronic/digital; tympanic membrane; disposable; temporal artery; automated monitoring devices.
  • Types of fever/pyrexia:
    • Febrile: a fever
    • Hyperpyrexia: fever ext{≥} 106^{ op}F or greater (medical emergency)
    • Intermittent: temp returns to normal at least once every 24 hours
    • Remittent: temp fluctuates several degrees but never returns to normal
    • Sustained/continuous: temp remains above normal with minimal variation
    • Relapsing/recurrent: returns to normal for days with episodes of fever lasting several days
    • Hyperthermia: mechanisms controlling temp fail
    • Neurogenic: hypothalamic damage
    • FUO: fever of unknown origin
  • Factors affecting body temperature:
    • Circadian rhythms (~every 24 hours)
    • Age and gender
    • Physical activity
    • State of health
    • Environmental temperature
  • Effects of fever (signs/symptoms):
    • Increased RR and pulse
    • Loss of appetite
    • Headache
    • Hot, dry skin; flushed face
    • Thirst; muscle aches; fatigue
    • Fever blisters (herpes type I) in young children
    • May provoke seizures in young children; confusion in older adults
  • Treatment of fever:
    • Determine the cause
    • Administer antipyretics
    • Oral fluids
    • Cool sponge bath or cool packs
    • Hypothermia/cooling blanket as needed

Pulse

  • Pulse physiology: Regulated by autonomic nervous system via the sinoatrial node
    • Parasympathetic stimulation decreases heart rate
    • Sympathetic stimulation increases heart rate
  • Pulse rate definition: number of heartbeats per minute in a peripheral artery
  • Peripheral pulse characteristics:
    • Rate: normal 60-100 bpm; tachycardia >100 bpm; bradycardia <60 bpm
    • Amplitude/quality: strong or weak
    • Rhythm: regular or irregular
    • Stroke volume: volume ejected with each heartbeat
  • Pulse amplitude (conceptual): relation to CO and arterial health
  • Factors affecting pulse:
    • Age and biological sex
    • Physical activity
    • Fear and stress
    • Medications
    • Disease
  • Pulse sites for palpation:
    • Temporal, Carotid, Brachial, Radial, Dorsalis pedis, Posterior tibial, Popliteal, etc. (List).
  • Apical heart rate: technique details
    • Client supine; locate 5th intercostal space, midclavicular line (adult); child at 4th intercostal space
    • Stethoscope over apex; listen for lub-dub; count for 1 full minute; report in beats per minute
  • Pulse deficit: difference between heart rate (apical) and peripheral pulse rate; common in Afib or ectopic beats

Apical Heart Rate (technique)

  • Patient position: supine
  • Locate apex: 5th intercostal space, midclavicular line (adult); 4th intercostal space (child)
  • Stethoscope over apex; listen for heart sounds (lub-dub) = 1 beat
  • Count for a full minute; report as beats per minute
  • Pulse deficit = HR − peripheral pulse rate; suggests irregular rhythm (e.g., Afib)

Respirations

  • Ventilation: movement of air in and out of the lungs
  • Inhalation (in) and Exhalation (out)
  • Diffusion: exchange of O2 and CO2 between alveoli and blood
  • Perfusion: exchange of O2/CO2 between blood and tissue cells
  • Note: 1 inhalation + 1 exhalation = 1 respiration
  • Rate and depth of breathing:
    • Regulated by respiratory centers in the medulla & pons
    • Chemoreceptors stimulate respiration; ↑ CO2 is the strongest respiratory stimulant
  • Respiratory rates:
    • Eupnea: normal, unlabored; ~12-20 breaths/min; 1 respiration per ~4 heartbeats (approx.)
    • Tachypnea: increased rate
    • Bradypnea: decreased rate
    • Apnea: no breathing
    • Dyspnea: labored breathing
    • Orthopnea: worsened when lying down or flat; improves when sitting/standing

Basic Lung Sounds

  • Normal (breathing):
    • Vesicular sounds: heard over most of lung fields
    • Bronchovesicular: posterior chest between scapulae and center chest
    • Bronchial: anterior chest over large airways
    • Tracheal: over trachea
  • Adventitious sounds:
    • Wheeze: expiratory; airway obstruction (e.g., asthma)
    • Rhonchi: coarse, low-pitched; mucus in larger airways; usually cleared by coughing
    • Crackles/rales: coarse/low-pitched; associated with pathologies (e.g., chronic bronchitis, pneumonia, edema); louder/longer/ lower pitch than fine crackles
    • Crackles (fine): high-pitched; at lower bases (CHF, pneumonia, atelectasis)
    • Stridor: loud, high-pitched; upper airway obstruction
    • Pleural friction rub: non-musical, brief, rubbing/cracking sounds from inflamed pleural surfaces

Normal Respirations and Lung Sounds

  • See respiratory auscultation resources
  • Each inhale (inspiration) and exhale (expansion) counts as one respiration
  • Visual/diaphragm movement and airway passage during auscultation

Systematic Approach to Auscultation

  • Begin above the clavicle and move downward to below the xiphoid process
  • Auscultate on both the right and left sides of the chest wall; follow a systematic pattern (anterior and posterior views)

Stethoscope

  • Parts and usage (summary):
    • Eartips, ear plugs; dual head chestpiece with tunable diaphragm/bell; headest; binaural spring
    • Observe ear-tube angle, place ear tubes correctly for sound quality
    • Correct placement ensures accurate sound transmission; incorrect placement can degrade acoustics

Pulse Oximetry

  • Non-invasive method to measure oxygen saturation (SpO2)
  • Measures oxyhemoglobin saturation in arterial blood
  • Can detect hypoxia
  • Normal: 94-100 ext{ %}
  • COPD history: normal range may be 88-92 ext{ %}

Blood Pressure (BP)

  • Definition: The force of moving blood against arterial walls; measured in mmHg
  • BP is recorded as a fraction: Systolic pressure over Diastolic pressure (DP)
  • Pulse pressure: difference between systolic and diastolic pressures
    • ext{Pulse pressure} = ext{Systolic} - ext{Diastolic} = SP - DP

Assessing Blood Pressure

  • Use Korotkoff sounds with a stethoscope
  • First sound corresponds to systolic pressure (top number)
  • Change or cessation of sounds corresponds to diastolic pressure (bottom number)
  • Common sites: brachial artery; also radial, popliteal, etc. depending on context
  • Practical notes:
    • Client should be seated with feet flat; back supported
    • Quiet environment; avoid talking during measurement
    • Allow rest for at least 5 minutes if possible

Factors Affecting Blood Pressure

  • Age, gender, race
  • Circadian rhythm
  • Food intake
  • Exercise
  • Weight
  • Emotional state
  • Body position
  • Drugs/medications

Equipment for Assessing Blood Pressure

  • Stethoscope and sphygmomanometer
  • Doppler ultrasound (when auscultation is difficult)
  • Electronic or automated BP devices

Parts of a Sphygmomanometer; Cuff Sizes

  • Three cuff sizes to fit different arm circumferences
  • Proper cuff placement ensures accuracy

Proper Placement of BP Cuff

  • Place cuff above antecubital fossa (2–3 cm above)
  • Align arterial marker with brachial artery
  • Place stethoscope over brachial artery
  • Ensure limb is at heart level

Korotkoff Phases (BP Auscultation)

  • Phase I: first faint, clear tapping sounds – systolic pressure
  • Phase II: muffled/swishing sounds; may disappear (auscultatory gap up to ~40 mmHg)
  • Phase III: distinct, louder sounds as flow increases
  • Phase IV: distinct muffling with a soft, blowing quality
  • Phase V: last sound heard before silence; diastolic pressure
  • After Phase V, cuff is deflated and blood flow resumes

Blood Pressure Assessment Sites

  • Radial artery: seated, arm supported, cuff placed above wrist; auscultate radial
  • Brachial artery: arm at heart level; cuff placed above elbow; auscultate brachial
  • Dorsalis pedis or Posterior tibial arteries: cuff placed above the knee; auscultate either artery
  • Popliteal artery: cuff placed above the knee; auscultate popliteal

Nursing Responsibilities

  • Proper use of equipment
  • Appropriate assessment sites
  • Frequency of assessment
  • Knowledge of normal values through the lifespan
  • What to do with abnormal findings
  • When to notify the healthcare provider
  • Documentation of findings and patient response
  • Patient and family education on self-monitoring

Video Review (Optional resources)

  • https://www.youtube.com/watch?v=GUWJ-6NL5-8
  • https://www.youtube.com/watch?v=BHXVHOQ0HYC

Practice Questions

  • Question 1: The nurse would expect the normal pulse rate for adolescents and adults to be in what range?
    • A. 40-80 beats/min
    • B. 100-130 beats/min
    • C. 60-100 beats/min
    • D. 90-120 beats/min
    • Answer: C. 60 – 100 beats/min.
    • Rationale: Normal pulse rate for adolescents and adults ranges from 60 to 100 bpm.
  • Question 2: The nurse would use what pulse site if using the inside of the elbow?
    • A. Temporal
    • B. Radial
    • C. Femoral
    • D. Brachial
    • Answer: D. Brachial
    • Rationale: Brachial site is at the inner elbow; temporal is at the head, radial at the wrist, femoral at the groin.
  • Question 3: The nurse is preparing to assess the vital signs of a client. What actions would the nurse perform to ensure an accurate measurement of the client’s blood pressure? Select All That Apply.
    • a. Place the client in a standing position during measurement.
    • b. Use a cuff that is appropriate for the size of the client's arm.
    • c. Place the cuff below the client’s elbow.
    • d. Inflate the cuff slowly while the client is talking.
    • e. Allow the client to rest for at least 5 minutes before measuring.
    • Answer: B, E
    • Rationale: Properly sized cuff, seated with back supported and feet uncrossed, cuff above elbow, quiet environment, and rest before measurement improve accuracy.
  • Question 4: The nurse is assessing a client’s pulse and notes it is irregular. What would be the nurse’s next action?
    • Options: Document as normal; Count for 30 seconds x 2; Assess for one full minute; Notify the provider immediately.
    • Answer: Assess the pulse for one full minute.
    • Rationale: An irregular pulse requires a full-minute assessment to determine rate and rhythm; may necessitate notification depending on findings.
  • Question 5: The nurse is educating a client newly diagnosed with orthostatic hypotension. What statement would be included?
    • A. Quick changes in position to improve blood flow.
    • B. It is normal to feel dizzy when changing position.
    • C. Change positions slowly to allow time for vessels to adjust.
    • D. Stop taking prescribed medication.
    • Answer: C. Instruct the client to change positions slowly to allow time for the blood vessels to adjust.
    • Rationale: Gradual position changes help the vascular system adjust to postural changes.

References

  • ATI Fundamentals for Nursing (edition 11.0)
  • Auscultation of lung sounds and murmurs (Patfyz.Medic.Upjs.Sk)
  • Korotkoff sounds | how to take a manual blood pressure (YouTube resource)
  • Learning tools: blood pressure basics (YouTube)
  • Taylor, C. Lynn & Bartlett, J. L. (2023). Fundamentals of nursing: the art and science of nursing care. (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
  • Thompson, J. (2022). Essential health assessment. F. A. Davis, Philadelphia, PA.