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.