What 4 things are assessed when taking vital signs?

What is often assessed along with

vital signs?

temperature\n pulse\n respiration\n blood pressure\n\n(pain is often assessed

with vital signs)

What is the primary purpose of taking vital signs?

to monitor essential physiologic

function of vital organs

In addition to monitoring vital organ function, what other purpose does taking vital signs
serve? evaluates health status and gives us baseline information regarding health
How long should you wait before assessing a person's vital signs who was active? about
15 minutes
Guidelines are in place when assessing vital signs to offer a range for reference.
However, when assessing an individual patient what must you also consider?

trends or

patterns established by that particular patient

Observing trends in Vital Signs allows the nurse to do what 4 things?

clinical

problem solving\n make decisions about treatments/interventions\n evaluate effectiveness of

medications and treatments\n evaluate the response to illness
What are 5 occasions when vital signs are taken?

on admission\n per hospital

routine or physician's order\n before and after surgery or diagnostic procedure, medications or
nursing interventions affecting VS\n before, during, and after blood/blood product
transfusion\n when there is a change in client's condition or a report of physical distress

True/false:\n\nA nurse must obtain a doctor's order to take vital signs.

False\n\nA

nurse can use his/her own judgment to take vital signs. REMEMBER You have to take them
minimally according to policy or orders, but can access more often using YOUR judgment!
(def)\n\nthe heat of the body determined by the balance of heat produced and heat lost
body temperature
Body temperature is stated in what two degrees?

Fahrenheit or Celsius

What are two examples of temperature methods used to detect core temperature?
Tympanic and rectal
What are two examples of temperature methods used to detect surface temperature?
Oral and axillary
What part of the brain is the thermoregulatory center?

hypothalamus

The hypothalamus receives messages from ___________ ____________. thermal

receptors
What type of regulatory response would you see when the nerve cells in the
hypothalamus become heated?

Compensatory mechanisms, such as sweating and

vasodilation to promote heat loss

What type of reaction might you see in the body when the hypothalamus detects a low
body temperature?

shivering and vasoconstriction

How does vasoconstriction apply to body temperature?

vasoconstriction conserves

body heat
Temperature deep in the body is referred to as what?

core temperature

What is the primary source of heat production in the body? metabolism

(def)\n\nheat production at rest

BMR

True/False:\n\nShivering decreases body temperature.

False\n\nShivering is the

body's mechanism of INCREASING body temperature.

What are the 4 methods of heat transfer?

radiation\n conduction\n convection \n

evaporation
Heat loss caused by sitting in a cold room is an example of what mechanism of heat
transfer?

radiation

(def)\n\ndiffusion of heat by electromagnetic waves radiation

Heat loss caused by taking a cool bath is an example of what mechanism of heat transfer?
conduction
(def)\n\ntransfer of heat through direct contact

conduction

Heat loss caused by using an electric fan to cool off is an example of what mechanism of
heat loss?

convection

(def)\n\ntransfer of heat via air currents

convection

Heat loss caused by sweating and respiration is an example of what mechanism of heat
transfer?

evaporation

(def)\n\nthe conversion of liquid to vapor

evaporation

(def)\n\nraised body temperature; fever

pyrexia

Pyrexia is described as a fever over ______ F or _______ C.

100.4 F or 38 C

(def)\n\nthe condition of having a body temperature greatly above normal hyperthermia

(def)\n\nthe condition of having a subnormal temperature

hypothermia

To be classified as hypothermia, the body's temperature must be lower than _____ F or

______ C.

96.8 F or 36 C

What is the normal value for an oral temperature?

97.6 to 99.6 F or 36.5 to 37.5 C

How much higher is a rectal temperature vs. an oral temperature? 1 F or 0.5 C

How much lower is an axillary temperature vs. and oral temperature?

1 F or 0.5 C

True/False:\n\nA tympanic temperature is 0.5 F higher than an oral temperature.

What are the 4 types of thermometers?

True

mixture of gallium, indium and tin

enclosed in plastic\n electronic \n chemical\n temperaturesensitive tape

What type of thermometer requires you to shake it down and hold it at eye level to read?
Mixture
What type of thermometer has a pencil like probe with a cover?

electronic

Chemical thermometers that are disposable plastic strips are used for what two methods
of assessment?oral and axillary
What type of thermometer would be applied to the skin and changes color according to
the skin temperature? temperaturesensitive tape
What is the most commonly used method of temperature assessment?

oral

How long should you wait to take a temperature after a patient has eaten, drank or
smoked?

30 minutes

How long does it take to take an oral temperature using a gallium thermometer?

35

minutes
What are some contraindications to taking an oral temperature?

mouth breathing\n

uncooperative \n seizures\n unconscious\n younger than 6 years old\n nasal/oral surgery or

trauma
What is the most accurate method of assessing temperature?

rectal

What PPE should be donned when taking a rectal temperature?

gloves

True/False:\n\nLubricant is not required for taking a rectal temperature.

false you

should always lubricate the tip of the thermometer

Rectal thermometers should be inserted towards the ___________. umbilicus
How far should a rectal thermometer be inserted in adults? children? infants?

adults

1.5 inches\nchildren 1 inch\ninfants 1/2 inch

How long must you hold a rectal gallium thermometer in place?

24 minutes

What are some contraindications in assessing rectal temperature? rectal/prostate

surgeries or disorders\n diarrhea or impacted stool\n serious heart disease\n newborns
Why would you not want to assess the temperature rectally in a patient with serious heart
disease?

vagal stimulation may sow the heart rate

Why would you not want to assess the temperature rectally in a newborn? you could
perforate the rectal wall
What is the safest and least invasive method of assessing temperature?

axillary

How long must you hold a gallium thermometer in place to assess axillary temperature?
810 minutes
Would the tympanic method of assessing temperature provide you with an accurate
surface or core temperature? core
________, __________, or __________ processes may cause fever.

Infection,

inflammatory, or immunologic processes

(def)\n\na substance, typically produced by a bacterium, that produces fever when
introduced or released into the blood.pyrogens
What happens to the body's setpoint temperature when endogenous pyrogens are
introduced into the blood?

the hypothalamus raises the body's setpoint in response to the

pyrogens being present

What are some beneficial consequences of fever?

stimulate the body to produce

WBCs\n decreases iron in blood plasma which suppresses bacterial growth\n increases
production of interferon, a virusfighting substance
What are some harmful consequences of fever?

increases BMR, P and R rates\n

excessive sweating may lead to dehydration\n prolonged fever may result in tissue catabolism,
muscle wasting, aching, negative nitrogen balance, weight loss, apathy, delirium and
withdrawl\n fever over 41 C may lead to seizures or neurological complications
Fever above _____ C may lead to seizures or neurological complications. 41
What are the 3 phases of the febrile episode? chill phase\n plateau phase\n fever
break

During which phase of the febrile episode is heat conserved? During which phase is heat
lost?

During the "chill phase" heat is conserved. During the "fever break" heat is lost.
During which phase of the febrile episode does the setpoint rise?

Chill phase

Why does the client experience chills and shivering during the "chill phase" of the Febrile
Episode?

because the body is trying to conserve heat

What occurs during the plateau phase of the Febrile Episode?

Chills subside and the

client experiences a warm and dry feeling because the new temperature setpoint is reached
During which phase of the Febrile Episode would a patient experience vasodialation?
Fever break
Why does a client experience sweating (diaphoresis) during the "fever break" phase of
the Febrile episode? because the setpoint decreases, and the body is attempting to lose heat or
return to its normal setpoint
What is the proper way to clean a thermometer prior to use? What about after use?
Prior to use, clean from the bulb to your hand (clean to dirtiest). After use, clean from
hand to bulb (clean to dirtiest)
Which temperature route best reflects the core body temperature? rectal is said to be
most accurate
When assessing a client with fever, you should always assess for causality as well. What
are some examples of situations that may cause fever?
environment (exposure to extreme heat/cold)

dehydration\n infection\n

What other assessment measures should be done for a client experiencing fever?
monitor all vitals (not only fever)\n assess for causality \n assess skin color and temperature
\n determine phase of febrile episode\n assess comfort level
Which of the following symptoms of fever would adversely affect an already weakened
patient?\n\nincrease WBCs\nincrease BMR\nsuppress bacterial growth\ndecrease level of
iron in the blood

Increase BMR this results in an increase in caloric intake, weight loss,

and increases need for oxygen

What are 2 nursing interventions that will decrease heat production in a client with fever?
limit physical activity\n promote rest
What are 2 nursing interventions that will increase heat loss in a client with fever?
remove external covers\n keep linens and clothing dry
What can be done to meet the increased BMR needs of a febrile patient? (2)

Administer O2 as ordered\n Provide adequate nutrition and fluids

How can you promote client comfort in a febrile patient? (4)

frequent oral

care\n control environmental temperature\n bed bath\n change linens

During the systolic phase of the cardiac cycle, the left ventricle ejects approximately how
many mL of blood into the aorta?

6070 mL

How is Pulse or Heart Rate measured?

by counting the number of palpable pulse

beats per minute

What is the adult normal range for pulse?
What does palpate mean?

feel

60100 bpm

What body system regulates the pulse rate? Autonomic Nervous System
Would the parasympathetic Vagus nerve increase or slow the pulse rate?

slows the

pulse rate
What is increased via the sympathetic nervous system to increase pulse?

epinephrine

and norepinephrine
How long should "you" count the pulse?

30 seconds\n\n(multiply results by 2)

What are some factors affecting P or HR?

age\n sex\n activity\n fever\n

medications\n hemorrhage\n stress\n position changes\n vagal stimulation\n pain

Which would you expect to have a higher pulse, a 6 month old female or a 22 year old
male? 6 month old female
Do men or women have a higher pulse rate? women
How long should you wait to take a pulse after activity?

30 minutes

Would an athlete have a higher or lower than average heart rate?

lower

A patient is in recovery after surgery. You observe an increase in heart rate followed by a
sudden, drastic decrease. What would this be indicative of?hemmorrhage
Would medications increase or decrease heart rate? It depends on the medication
What effect does stress have on heart rate? it increases it
Does the body's position affect heart rate?

Yes, for example standing after lying will

result in a decrease in blood pressure

Will pain increase or decrease heart rate?

increase

Where is the vagus nerve located in the body?

In the GI tract, extending from the

mouth to the anus

How does straining to have a bowel movement, gagging or vomiting affect heart rate?
It decrease heart rate due to vagal nerve stimulation
Where are the vagal receptors located in the body? Carotid artery sinus in the upper
third of the neck
The carotid artery sinus houses vegal receptors. How does this affect our procedure for
taking a carotid pulse?

We palpate the carotid artery in the lower half of the neck

What are 2 methods for assessing pulse?

palpation\n auscultation

What fingers should be used to assess the pulse? Which should be avoided?

Middle

3 to palpate (pads of fingertips more sensitive); avoid using the thumb

What are 2 tools used to ausculate pulse?

stethoscope\n doppler ultrasound

What are the 6 major Peripheral pulses?

Carotid\n Radial\n Brachial\n

Femoral\n Popliteal\n Pedal pulses

What is the most accurate peripheral pulse? carotid pulse
True/false:\n\nYou should never check both carotid pulses at the same time.

True

palpation of both at the same time could hinder blood flow to the brain
What type of pulse assessment is used in CPR?

Carotid

Where should you place your fingers when assessing a carotid pulse?
trachea and the sternocleidomastoid muscle on the LOWER half of the neck

between the

What is the most common type of pulse assessment?

What pulse assessment is used in infant CPR?

Radial

brachial pulse

True/False:\n\nAssessing both dorsalis pedis pulses at the same time is necessary to

check for equal rates. False both pulses would be checked to assess equal volume or
synchronized beats
What site for pulse assessment is used when taking blood pressure?Brachial
What pulse locations would be assessed when checking for circulation?

femoral\n

popliteal\n pedal pulses (dorsalis pedis, posterior tibial)

Which location would yield a higher blood pressure rating, the brachial or popliteal
pulse? popliteal yields higher results
How long should you auscultate a central pulse?

a full minute

What is the next assessment step if you detect an abnormal peripheral pulse?
ausculate the apical pulse
A nurse is caring for a patient with CV disease. What type of pulse assessment would be
standard on this patient?

apical pulse

What is the standard location of the apical pulse?

the apex of the heart (usually heard

loudest at the 5th intercostal space, midclavicular line)

Where should you begin your count when assessing a pulse?
What two sounds correlate with cardiac cycle?

always start at 0

systole and diastole (S1 and S2)

What anatomical landmarks should you follow to locate the apical pulse? locate the
suprasternal notch, angle of Louis, which is level with the 2nd ICS\n\n count rib spaces down to
the 5th ICS, midclavicular line
What is the purpose of detecting an apicalradial pulse?

to assess if there is a pulse

deficit
When assessing apicalradial pulse, what might you deduct if the radial pulse produced is
diminished or absent? that the left ventricle contraction is weak
A ________ __________ occurs when the apical pulse is greater than the peripheral
pulse. pulse deficit
What does a pulse deficit indicate?

poor peripheral circulation/perfusion

What are the 5 things that you should assess the pulse for? rhythm \n amplitude
(volume)\n rate\n elasticity \n equality
(def)\n\nthe pattern or spacing between pulse beats; may be regular or irregular
An irregular rhythm in pulse is known as what?

rhythm

dysrhythmia

The strength or force of a pulse is known as what? amplitude (volume)

The amplitude of a pulse is measured on a scale from 0 to +3. Describe each individual
measurement. 0 = absent\n+1 = difficult to feel (weak); easy to obliterate \n+2 = normal; easy to
feel; obliterates with stronger force\n+3 = strong, bounding; difficult to obliterate
(def)\n\nthe number of heart beats per minute

rate

How long should you count a regular rhythm pulse? 30 seconds (multiply by 2)

How long should you count an irregular rhythm pulse?

60 seconds

A pulse lower than 60 is called what?bradycardia

A pulse greater than 100 is called what?

tachycardia

Describe normal and abnormal elasticity of arteries. normal = soft, pliable \nabnormal =
hard, twisted, tortuous
How do you determine the equality of a pulse?

assess the left and right pulse at the

same time
What type of changes should be reported immediately?

absent, weak, thready

pulse\n pulse deficit \n significant change in resting pulse\n change in volume or rhythm\n
cool, pale skin
A nurse assesses a patient's radial pulse at 88. She/he finds it easy to feel and puts
moderate force to obliterate the pulse. Upon further examination, she/he finds that the artery
feels soft and pliable and that the rhythm is regular. How is this information documented?
radial 88/m regular, +2 smooth
True/False:\n\nWhen performing an apicalradial pulse, it is imperative that both nurses
starts their individual watches at the exact same time to ensure an accurate count. False\n\nAn
apicalradial pulse requires that both nurses use the SAME watch!
What are some pulse/blood pressure changes you may expect to see in the elderly?
loss of compliance (elasticity)\n Blood pressure may be higher to compensate for the
loss of arterial compliance \n after activity, it takes longer for the pulse to return to "resting"
state

True/false:\n\nThe elderly usually have a higher heart rate. False \n\nWhile blood
pressure may be higher to compensate for compliance issues, heart rate is usually the same.
(def)\n\nthe act of breathing (exchange of gases) for 1 minute;
What is the average length of inspiration? Expiration?

respiration

Inspiration = 11 1/2

seconds\nExpiration = 23 seconds
What 3 muscles 'may' be used in respiration? diaphragm\n intercostals\n accessory
What is the major muscle of respiration?

diaphragm

What muscle(s) would you expect to be used when a patient is having difficulty
breathing?

diaphragm\n intercostals\n accessory (ex. neck muscles)

What are the 3 processes of respiration?

ventilation \n diffusion\n perfusion

(def)\n\nmechanical movement of respiration; the act of breathing ventilation

(def)\n\nthe movement of O2 and CO2 between alveoli and RBCs diffusion
(def)\n\nthe distribution of RBCs from pulmonary capillaries to the rest of the body
perfusion
Neural regulation of respiration involves what 2 parts of the brain? medulla
oblongata \n cerebral cortex
You observe a client's respiration without their knowledge. What part of the brain is
likely controlling the breathing that you document? medulla oblongata responsible for
involuntary, automatic control of breathing

What part of the brain would likely be controlling breathing if the patient was aware that
you were counting their respiration rate?

cerebral cortex voluntary control of respirations

What structures detect the presence of CO2 and O2 in the blood? chemoreceptors
located in the aorta and carotid arteries
What 4 things should you assess when observing respirations?

rhythm\n rate\n

effort/ease\n depth
Rhythm of respirations should be recorded as either ________ or _______.

regular

or irregular
If you cannot see the chest rise/fall when assessing respirations, how should you position
the client?

place the client's arm over their abdomen

In the "Assessment of Vital Signs", at what point should you assess respirations?
immediately after taking their pulse
How long should you count respirations?

30 seconds

What is the normal range for respirations?

1220 breaths per second

(def)\n\nregular respirations between 1220; no effort required to breath

(def)\n\nrespirations below 12 breaths per minute
(def)\n\nrespirations above 20 per minute

bradypnea

tachypnea

(def)\n\nabsence of breathing apnea

(def)\n\ndifficulty breathing; shortness of breath

dyspnea

(def)\n\nbreathing done with great effort and difficulty

labored

eupnea

(def)\n\nshortness of breath (dyspnea) which occurs when lying flat, causing the person
to have to sleep propped up in bed or sitting in a chair

orthopnea

What 3 descriptions are used to describe varying depths of respirations?

full\n

hypoventilation\n hyperventilation
What description would you use to describe breathing that was very shallow and
undetectable by chest or abdomen movements?

hypoventilation

If a client is experiencing hypoventilation, how might you have to observe respiration

depth? observe shoulders or use stethoscope
(def)\n\nvery deep movement of the chest/abdomen when breathing
hyperventilation
What do you do if a client sighs or yawns while counting respirations?

You count that

as a breath, both are part of the normal breathing cycle

Rapid, deep breathing as seen with diabetes ketoacidosis is known as what?
Kussmaul
Respirations that go from shallow > deeper > shallow > apnea, as seen in head
injuries are known as what? CheyneStokes
Totally erratic respirations displaying no pattern (often seen when death is imminent) are
known as what?

agonal

How does exercise influence respirations?

increases the rate

How does acute pain influence respirations? increases the rate and rhythm

How does anxiety influence respirations?

increases the rate and depth

How does smoking influence respirations? increases the rate at rest

What body position offers full expansion of the chest cavity, easing breathing?
upright/straight
What change in respirations would you expect to see in a client who receives narcotics?
slower rate
How might a neurological injury affect respirations? decreases rate; changes rhythm
What occurs to respirations when a client has low hemoglobin function?

the rate

increases
What effect does the decrease in the arterial elasticity of elderly clients have on their
respiration rate?

respirations are shallower and slightly faster

A nurse assesses the respiration rate of an 83 year old black female at 23 per minute.
Why is this not an immediate cause of concern?

Respiration rate in elderly clients is often

higher due to the decrease in elasticity of arteries/veins

Arterial blood pressure measure what?

arterial wall pressure created as blood flows

through the arteries throughout the cardiac cycle

BP is written as a fraction consisting of what 2 parts?

systolic BP\ndiastolic BP

What is the systolic and diastolic blood pressures of a BP 120/80? systolic =

120\ndiastolic = 80

Which BP, systolic or diastolic, is the pressure created as the left ventricle ejects blood?
systolic
Which BP, systolic or diastolic, is when the heart relaxes? diastolic
(def)\n\nthe difference in systolic and diastolic BP pulse pressure
What is the normal range of pulse pressure? 3050 mm Hg
What might be the cause of an abnormal pulse pressure?

neurological or cardiac

dysfunction
What is the range of normotensive BP? Prehypertensive? Hypertensive Stage 1 and 2?
normontensive 90/60 139/89\nprehypertensive 120/80 139/89\nhypertensive stage 1
140/90 159/99\nhypertensive stage 2 160/100 and above
A blood pressure below 90/60 in an adult who's BP is normally higher than that is termed
what? hypotension
For a blood pressure below 90/60 to be considered hypotensive, what must be present?
symptoms or a significant change
(def)\n\nvolume of blood (stroke volume) pumped by the heart in one minute
Cardiac Output (CO)
(def)\n\nresistance to blood flow determined by the tone of vascular musculature and the
diameter of blood vessels

Peripheral resistance

(def)\n\namount of blood circulating within the vascular system

(def)\n\nthickness of blood

viscosity

blood volume

(def)\n\nability of arteries to stretch elasticity

What measures the ratio of blood cells to plasma?

Hematocrit

A patient's hematocrit test indicates a high number of RBCs in ratio to blood plasma.
How would you expect this to affect the blood's viscosity? the blood would be thicker than
normal
How does age affect BP?

Higher age = lower elasticity, buildup of plaque in arteries

How does stress affect BP?

stress stimulates flight or fight response (sympathetic

system) and increases vasoconstriction

What are the differences in BP between males and females? Males have higher blood
pressure than females until menopause when it tends to equal out
What race tends to have higher BP? African Americans
Would you expect to see a higher BP in the morning or evening? Why?

Higher BP in

evening when metabolic rate peaks

True/False:\n\nMedications may increase or decrease BP.

True

How long should you wait to take the BP of a person who was exercising. Why? 30
minutes because exercise does increase BP (although the change is NOT as dramatic as pulse
changes)
A client is diagnosed with diabetes mellitus. What type of BP reading would you expect
to see in this client?

BP will be high, probable hypertension

Would you expect a higher or lower BP in an obese patient?higher

True/False:\n\nSmoking and/or high alcohol consumption results in higher BP

True

What are 3 known complications of hypertension? CVA\n Kidney Failure\n

Eyesight problems
Although hypertension is commonly asymptomatic, what symptoms are associated with
this disorder? headaches\n nosebleeds\n flushing\n fatigue
What are some symptoms of hypotension? dizziness\n confusion\n fainting\n
decreased urine output\n chest pain\n clamminess\n skin mottling\n pallor\n increased
heart rate
To be diagnosed with hypertension, the client's BP must be measures ____ or more times
and averaged out.

Orthostatic hypertension is a side effect of many ___________ medications.

hypertensive
(def)\n\na drop in BP of 20 or more systolic or 10 or more diastolic when you change
from a sitting/lying position to a standing position orthostatic hypertension
What type of method would be used to directly assess BP? an arterial line
What are 3 methods of assessing BP?palpatory (systolic only)\nausculatory (systolic and
diastolic)\nelectronic (systolic and diastolic)
How would you document a palpatory BP? value/p
The width of a BP cuff should be ______ % of the circumference of the midpoint of the
limb on which the cuff is used.

4050%

If a BP cuff is too narrow, what will happen to the reading? What if it is too wide?
too narrow = false high\ntoo wide = false low
What are 2 types of sphygmomanometers? aneroid (dial) or mercury
The sounds heard when listening to the blood pressure are called what?

Korotkoff's

sounds
What sound indicates the systolic BP when ausculating?

K1

What sound indicates the diastolic BP when ausculating?

K5 (adults) K4 (children)

What are examples of situations where you would not take the BP from the arm?
mastectomy \n recent blood drawn\n stroke deficit\n IV\n A line\n Shunt for dialysis \n
surgery or any deviation to the hand, arm, shoulder, or axilla
If you take a BP using the leg, what deviation do you expect to see in the reading? expect
the systolic to be 2030 higher
Why should you always palpate systolic pressure prior to taking BP?

to avoid

misreading due to an auscultory gap

What are the follow up recommendations for the following:\n\nNormal BP,
Prehypertension, Hypertension Stage I, Hypertension Stage II

Normal recheck in 2

years\nPrehypertension Recheck in 1 year\nStage I Hypertension Confirm in 2

months\nStage II Hypertension Confirm in 1 month
What is the protocal for a BP of 180/100 or greater? Treat immediately to 1 week
depending on clinical situation

When checking BP, the cuff should be inflated to _____ mercury above the palpated
systolic pressure.

30

Where should you position the stethoscope when assessing BP in the arm? over the
brachial artery
How far above the brachial artery should the cuff be positioned?

1 inch

When taking BP, what point indicates Systolic pressure?

when the 1st sound is heard

When taking BP, what point indicates Diastolic pressure?

when the sound disappears

What is the very 1st step in the blood pressure procedure? Wash hands
When releasing the valve of the BP cuff, what is the desired rate that the mercury will fall
every second? 23 mm