S

Notes: Patient Centered Care - Vital Signs

Patient Centered Care: Vital Signs (Part II)

  • Overview

    • Patient Centered Care blends patient, family, and community in care decisions; values, preferences, beliefs, and culture are considered during care. (Source: Pearson, 2023).

    • Role of the nurse in accessing vital signs includes proper technique, site selection, interpretation, and communication to patients and families.

  • Terminology (key terms to know)

    • Afebrile, Febrile, Pyrexia

    • Apnea, Hyperthermia, Hypothermia

    • Bradicardia/Bradycardia, Tachycardia

    • Bradypnea, Eupnea, Dyspnea, Orthopnea

    • Dysrhythmia, Pulse deficit, Pulse pressure

    • Korotkoff sounds

    • Systolic pressure, Diastolic pressure

    • Hypertension, Hypotension

    • Orthopnea

    • Radial, Carotid, Brachial, Abdominal, Femoral, Popliteal, Posterior tibial, Dorsalis pedis (pulse sites)

  • Pharmacology flash cards (drug classifications that affect vital signs)

    • Anti-hypertensives (ACE inhibitors; ARBs/Angiotensin II receptor blockers/inhibitors/antagonists)

    • Anti-arrhythmics (e.g., beta-blockers; calcium-channel blockers; sodium-channel blockers)

    • Diuretics (thiazides)

    • Narcotics/analgesics

    • Vasopressors

  • Overview of vital signs (and additional common sign)

    • Temperature (T)

    • Pulse (P) / Apical heart rate

    • Respirations (R)

    • Blood pressure (BP)

    • Pulse oximetry (SpO2)

    • Pain as the often fifth sign

  • Normal vital signs for healthy adults (quick reference)

    • Oral temperature: T_{ ext{oral}} ext{ within } 96.4^ ext{-}99.4^ ext{°F}

    • Pulse rate: 60 ext{ to } 100 ext{ beats/min} ext{ (average ~80 bpm)}

    • Respirations: 12 ext{ to } 20 ext{ breaths/min}

    • Blood pressure: 120/80 ext{ mmHg (ideal systolic < 120 mmHg)}

  • Vital signs across the lifespan (summary table)

    • Newborn (Birth–28 days)

    • Temperature: 35.9^ ext{°C} ext{ to } 36.9^ ext{°C}; 97.7^ ext{°F} ext{ to } 99.5^ ext{°F}

    • Pulse: 120 ext{ to } 160 ext{ bpm}

    • Respirations: 30 ext{ to } 60 ext{ breaths/min}

    • BP: 60/40 ext{ mmHg}

    • Temperature method note: axillary

    • Infant (1 month – 12 months)

    • Temperature: 37.1^ ext{°C} ext{ to } 38.1^ ext{°C}; 98.7^ ext{°F} ext{ to } 100.5^ ext{°F}

    • Pulse: 80 ext{ to } 160 ext{ bpm}

    • Respirations: 20 ext{ to } 40 ext{ breaths/min}

    • BP: 85/37 ext{ mmHg}

    • Temperature method note: temporal/tympanic etc. (per table)

    • Toddler (1–3 years)

    • Temperature: 37.1^ ext{°C} ext{ to } 38.1^ ext{°C}; 98.7^ ext{°F} ext{ to } 100.0^ ext{°F}

    • Pulse: 80 ext{ to } 130 ext{ bpm}

    • Respirations: 25 ext{ to } 32 ext{ breaths/min}

    • BP: 89/46 ext{ mmHg}

    • Child (3–10 years)

    • Temperature: 36.8^ ext{°C} ext{ to } 37.8^ ext{°C}; 98.2^ ext{°F} ext{ to } 100.0^ ext{°F}

    • Pulse: 70 ext{ to } 115 ext{ bpm}

    • Respirations: 20 ext{ to } 26 ext{ breaths/min}

    • BP: 95/57 ext{ mmHg}

    • Preteen (10–13 years)

    • Temperature: 35.8^ ext{°C} ext{ to } 37.5^ ext{°C}; 96.4^ ext{°F} ext{ to } 99.5^ ext{°F}

    • Pulse: 65 ext{ to } 110 ext{ bpm}

    • Respirations: 18 ext{ to } 26 ext{ breaths/min}

    • BP: 102/61 ext{ mmHg}

    • Teen (13–20 years)

    • Temperature: 35.8^ ext{°C} ext{ to } 37.5^ ext{°C}; 96.4^ ext{°F} ext{ to } 99.5^ ext{°F}

    • Pulse: 55 ext{ to } 105 ext{ bpm}

    • Respirations: 12 ext{ to } 22 ext{ breaths/min}

    • BP: 112/64 ext{ mmHg}

    • Adult (≥20 years)

    • Temperature: 35.8^ ext{°C} ext{ to } 37.5^ ext{°C}; 96.4^ ext{°F} ext{ to } 99.4^ ext{°F}

    • Pulse: 60 ext{ to } 100 ext{ bpm}

    • Respirations: 12 ext{ to } 20 ext{ breaths/min}

    • BP: 120/80 ext{ mmHg}

    • Footnotes: a = axillary temperature; b = temporal; c = tympanic; d = oral

  • When to assess vital signs

    • On admission to any health care facility

    • Based on facility policy/procedures

    • Any time there is a change in patient’s condition

    • Any time there is loss of consciousness

    • Before/after surgical or invasive diagnostic procedures

    • Before/after activity that may increase risk (e.g., ambulation after surgery)

    • Before administering meds that affect cardiovascular/respiratory function

  • Temperature (T)

    • Definition: difference between heat produced by body and heat lost to environment; measured in degrees

    • Normal range: 96.4^ ext{°F} ext{ to } 99.4^ ext{°F}; average about 98.6^ ext{°F}

    • Fever: T ext{ ≥ } 100^ ext{°F} (usually indicates fever)

    • Sites for measurement: Oral (sub-lingual), Axillary, Tympanic, Temporal, Rectal (anus) – Rectal is most accurate

    • Core body temperature refers to internal organs (heart, liver, brain, blood)

    • Equipment for assessing temperature: electronic/digital thermometers; tympanic; disposable single-use; temporal artery; automated monitoring devices

    • Types of thermometers (brief): listed as various types; visual cue indicates multiple thermometer types

    • Types of fever/pyrexia:

    • Febrile: fever

    • Hyperpyrexia: fever ≥ 106^ ext{°F} (medical emergency)

    • Intermittent: normal at least once every 24 hours

    • Remittent: fluctuates several degrees; never normal

    • Sustained/continuous: above normal with minimal variation

    • Relapsing/recurrent: returns to normal then fever again

    • Hyperthermia: dysregulation where body temp control fails; includes neurogenic fever (hypothalamus involvement) and FUO (fever of unknown origin)

    • Factors affecting temperature: circadian rhythm (~24 hr), age/gender, physical activity, health status, environmental temperature

    • Effects of fever: ↑ RR, ↑ pulse, ↓ appetite, headache, hot/dry skin, flushed face, thirst, muscle aches, fatigue, fever blisters; seizures in young children; delirium/confusion in older adults; treatment focuses on cause, antipyretics, fluids, cooling methods

    • Treatments: antipyretics, oral fluids; cool sponge bath; cooling blanket for hypothermia/cooling

  • Pulse physiology and assessment

    • Pulse regulated by autonomic nervous system via sinoatrial node

    • Parasympathetic: decreases HR; Sympathetic: increases HR

    • Pulse rate = number of contractions per minute in a peripheral artery

    • Normal pulse rates vary with lifespan; generally decrease from birth to adulthood

    • Peripheral pulse characteristics:

    • Rate: Normal 60 ext{ to } 100 ext{ bpm}; Tachycardia >100 ext{ bpm}; Bradycardia <60 ext{ bpm}

    • Amplitude/quality: strong vs weak

    • Rhythm: regular vs irregular

    • Stroke volume: volume ejected with each heartbeat

    • Factors affecting pulse: age/biological sex; physical activity; fear/stress; medications; disease

    • Pulse sites (most common): temporal, carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial

    • Apical heart rate:

    • Patient supine; locate 5th intercostal space, midclavicular line (apex)

    • Child: 4th intercostal space

    • Stethoscope over apex; listen for lub-dub; count for 1 full minute

    • Report as beats per minute

    • Pulse deficit: difference between heart rate (apical) and peripheral pulse rate; common in Afib or ectopic beats

  • Respirations and respiration-related concepts

    • Ventilation: movement of air in/out of lungs; inhalation vs exhalation

    • Diffusion: exchange of O2 and CO2 between alveoli and blood

    • Perfusion: exchange of O2/CO2 between blood and tissue cells

    • 1 inhale + 1 exhale = 1 respiration

    • Rate/depth of breathing changes with tissue demands; controlled by medulla/pons; carbon dioxide is a primary stimulant for breathing

    • Respiratory patterns:

    • Eupnea: normal, unlabored; 12 ext{ to }20 ext{ breaths/min}

    • Tachypnea: increased rate

    • Bradypnea: decreased rate

    • Apnea: no respiration

    • Dyspnea: difficult/labored breathing

    • Orthopnea: change in breathing with position (sitting/standing)

  • Lung sounds and auscultation

    • Basic lung sounds:

    • Vesicular: normal sounds over most lung fields

    • Bronchovesicular: posterior chest between scapulae and center of chest

    • Bronchial: anterior chest over large airways

    • Tracheal: over the trachea

    • Adventitious sounds:

    • Wheeze: expiratory, airway obstruction (e.g., asthma)

    • Rhonchi: coarse, low-pitched sound due to mucus in large airways; cleared by coughing

    • Crackles (rales) – coarse/low-pitched: pathologies (e.g., chronic bronchitis, pneumonia, edema); louder/longer/low-pitched than fine crackles

    • Crackles – fine: high-pitched, in lower bases (CHF, pneumonia, atelectasis)

    • Stridor: loud, high-pitched sound due to upper airway obstruction (louder in neck)

    • Pleural friction rub: non-musical, short, bi-phasic explosive sound from inflamed pleural surfaces rubbing

    • Normal vs adventitious sounds: practice distinguishing breath sounds; document onset, location, and timing within the breath cycle

  • Lung auscultation: systematic approach

    • Systematic approach: begin just above clavicles; move down to xiphoid process; compare right/left sides along chest wall (anterior and posterior views)

  • Stethoscope basics and use

    • Parts of the stethoscope: dual-head chest piece (diaphragm and bell); eartips; binaural springs; flexible tubing; headset

    • Proper placement and fit:

    • Observe the ear-tube angle; ears should fit tightly in the ear canal; misplacement degrades sound quality

    • Listener should have a proper seal; diaphragm over the area of interest

  • Pulse oximetry (SpO2)

    • Non-invasive measurement of oxyhemoglobin saturation in arterial blood

    • Normal range: 94 ext{ to }100 ext{ \%}

    • In COPD patients, normal range may be lower: around 88 ext{ to }92 ext{ \%}

    • Detects hypoxia; document with patient condition

  • Blood pressure (BP)

    • Definition: force of moving blood against arterial walls; measured in ext{mmHg}

    • BP components:

    • Systolic pressure: P_{ ext{sys}}; ventricles contract; pressure rises

    • Diastolic pressure: P_{ ext{dia}}; ventricles relax; pressure falls

    • Pulse pressure: difference P{ ext{sys}} - P{ ext{dia}}

    • Korotkoff sounds: used to determine systolic and diastolic pressures with a stethoscope

    • BP measurement steps (key principles):

    • Client seated comfortably with back supported; feet flat on floor

    • Arm supported at heart level; cuff sized appropriately; bladder over brachial artery

    • Use appropriate cuff size; avoid talking; wait at least 5 minutes after activity

    • Inflate cuff slowly; listen for first Korotkoff sound (systolic); continue until sounds disappear (diastolic, or auscultatory gap considerations)

    • Factors affecting BP:

    • Age, gender, race; circadian rhythm; recent food intake; exercise; weight; emotional state; body position; drugs/medications

    • Equipment for BP assessment:

    • Stethoscope + sphygmomanometer; Doppler ultrasound; electronic/automated devices

    • BP cuff sizes and placement:

    • Three cuff sizes available; cuff should be placed 2–3 cm above antecubital fossa; artery alignment with index marker over brachial artery; stethoscope over brachial artery

    • Alternative sites include brachial, radial, popliteal, dorsalis pedis, posterior tibial, and others for auscultation when needed

    • Phases of Korotkoff sounds (brief summary):

    • Phase I: first faint, clear tapping sounds; systolic pressure

    • Phase II: muffled/swishing sounds; possible auscultatory gap (up to ~40 mmHg); beware misreading diastolic pressure when gap exists

    • Phase III: distinct, louder sounds as artery opens

    • Phase IV: abrupt muffling with blowing quality; onset often considered diastolic in adults

    • Phase V: sounds disappear; last audible sound marks second diastolic pressure

    • After Phase V, cuff is deflated and blood flow returns to normal

    • BP measurement sites: radial artery; brachial artery; (and with cuff placement) popliteal, dorsalis pedis, posterior tibial

    • Commonly used arterial sites for auscultation depend on limb positioning and accessibility

    • Nursing responsibilities in BP assessment:

    • Proper equipment use; correct sites; determine frequency of assessment; knowledge of lifespan normal values; actions for abnormal findings; when to notify HCP; documentation; patient/family education on self-monitoring

  • Practice and assessment questions (examples with rationale)

    • Q1: Normal pulse rate range for adolescents/adults

    • Answer: 60 ext{ to } 100 ext{ bpm}

    • Rationale: matches standard adult/adolescent range

    • Q2: Pulse site at inside of elbow

    • Answer: brachial

    • Rationale: brachial pulse is at the inner elbow; temporal is at the head; radial is at the wrist; femoral is in the groin

    • Q3: Actions for accurate BP measurement (select all that apply)

    • Correct: B) Use an appropriately sized cuff; E) Allow the client to rest at least 5 minutes

    • Incorrect: standing position; cuff placement below elbow; talking during measurement

    • Q4: If pulse is irregular, next action

    • Correct: C) Assess the pulse for one full minute

    • Rationale: accurate rate/rhythm requires full-minute count; other actions may be warranted but the first step is full minute assessment

    • Q5: Orthostatic hypotension teaching point

    • Correct: C) Instruct to change positions slowly to allow time for blood vessels to adjust

    • Rationale: gradual positional changes prevent sudden BP drops

  • Practical implications and clinical connections

    • Emphasize patient-centered care when taking vital signs: explain procedures to patients; respect comfort, privacy, and preferences; tailor home monitoring education to patient literacy

    • Recognize the interdependence of vital signs with overall patient status: fever can elevate HR and RR; dehydration affects BP and pulse; lung sounds guide respiratory assessment and infection/inflammation management

    • Understanding phases of Korotkoff sounds reduces measurement error (e.g., auscultatory gap can lead to underestimation of systolic or overestimation of diastolic pressures)

  • Real-world relevance and ethical/practical considerations

    • Accurate vital signs support timely diagnosis, monitoring of disease progression, and assessment of treatment effectiveness

    • Home monitoring education should consider patient safety, interpretation limits, and when to seek professional help

    • Cultural, linguistic, and education-level considerations affect how vital signs information is communicated and understood

  • Summary of key formulas and numerical references (LaTeX)

    • Normal adult ranges:

    • T_{ ext{oral}} ext{ approx } 96.4^ ext{°F} ext{ to } 99.4^ ext{°F}

    • P ext{ (pulse)}: 60 ext{ to } 100 ext{ bpm}

    • R ext{ (respirations)}: 12 ext{ to } 20 ext{ breaths/min}

    • BP: 120/80 ext{ mmHg}

    • Lifespan table (highlights)

    • Newborn: T ext{ around } 97.7^ ext{°F} ext{ to } 99.5^ ext{°F}; P: 120 ext{–}160 ext{ bpm}; R: 30 ext{–}60; BP: 60/40

    • Infant: T: 98.7^ ext{°F} ext{ to } 100.5^ ext{°F}; P: 80 ext{–}160; R: 20 ext{–}40; BP: 85/37

    • Toddler: T: 98.7^ ext{°F} ext{ to } 100^ ext{°F}; P: 80 ext{–}130; R: 25 ext{–}32; BP: 89/46

    • Child: T: 98.2^ ext{°F} ext{ to } 100^ ext{°F}; P: 70 ext{–}115; R: 20 ext{–}26; BP: 95/57

    • Preteen: T: 96.4^ ext{°F} ext{ to } 99.5^ ext{°F}; P: 65 ext{–}110; R: 18 ext{–}26; BP: 102/61

    • Teen: T: 96.4^ ext{°F} ext{ to } 99.5^ ext{°F}; P: 55 ext{–}105; R: 12 ext{–}22; BP: 112/64

    • Adult: T: 96.4^ ext{°F} ext{ to } 99.4^ ext{°F}; P: 60 ext{–}100; R: 12 ext{–}20; BP: 120/80

  • References (for context)

    • ATI Fundamentals for Nursing; Auscultation resources; Korotkoff sounds; learning tools for BP basics

    • Classical texts: Taylor & Bartlett; Thompson on health assessment

    • Patient-centered care principles and clinical guidelines aligned with the content above