Vital signs study notes

1.Name the vital signs

1. temperature
2. pulse
3. respiratory rate
4. blood pressure
5. pain
6. oxygen saturation( refers to
the amount of oxygen that's in
your bloodstream)

2.The most frequent measurements obtained by healthcare practitioners

vital signs
3.All the _______ are subject to change in response to a number of factors.
vital signs
4.Gives vital information to determine the patient's usual state of health (baseline), as well as
response to physical and psychological stress, and medical and nursing therapy.
vital signs
5.What are the basic techniques involved in taking vital signs?
1. inspection
2. palpation
3. auscultation

6.When are vital signs measured?

1. upon admission
2. whenever nursing judgement
dictates the need
3. when ordered by a physician
4. as dictated by facility policy
5. change in assessment (ex.
difficulty breathing)
6. before and after surgery
7. before and after
administration of meds that
affect cardiovascular,
respiratory, and that control
function
8. when patients general
physical assessment changes
9. before and after nursing
procedures that may alter VS
10. when the patient reports
nonspecific symptoms of
physical distress
11. before, during, and after
administration of blood, blood
products and chemotherapy

7.the hotness or coldness of a substance temperature

8.The difference between amount of heat produced by body processes and the amount of heat
lost to the external environment
body temperature
9.the temperature of deep tissues
core temperature
10.hyperthermia
the inability of the body to increase
heat loss or decrease heat production
11.hypothermia
the inability of the body to decrease
heat loss or increase heat production
12.When does heat stroke occur?
When hypothalmic regulation of body
temp is overwhelmed
13.Signs of heat stroke
1. high temperature
2. hot, dry skin

14.Heat stroke is the result of what?

Heat exhasution
15.Heat exhaustion results from what?
profuse fluid/electrolyte loss causing
fluid volume deficit
16.Signs of heat exhaustion
1. weakness
2. diziness
3. fainting
4. low BP
5. thirst

17.occurs when body parts are exposed to cold temperatures for long periods of time
frost bite
18.What is the body doing when frost bite occurs?
vasoconstriction occurs as the body
tries to retain heat, but sever
vasoconstriction deprives tissues of
oxygen with resulting tissue death and
damage
19.signs and symptoms of frost bite
1. numbness
2. tingling
3. discoloration

20.Acceptable range of body temp for best tissue function

96.8 to 100.4 F
21.The relationship between ___ ___ and ___ ___ must be maintained to regulate body temp
heat loss and heat production
22.heat production of body at rest
BMR
23.set point
the average temperature at which a
heating system operates
24.radiation
 the transfer of heat from one surface
to another without direct contact
25.conduction
transfer of heat from one object to
another by direct contact
26.example of conduction
bathing in cool water
27.convection
transfer of heat away by air movement
28.example of convection
a fan moving warm air away from skin
29.evaporation
transfer of heat energy when gas
becomes a liquid
30.diaphoresis
sweat glands under control of
sympathetic nervous system
31.standard area for measuring core temp
pulmonary artery
32.core areas for temp
1. ear
2. esophagus
3. urinary bladder

33.why does the tympanic membrane better reflect the core temp than other areas?
it is close to the hypothalamus
34.What is the average rectal temp?
99.6
35.rectal temp
reflects core temperature but lags
behind in times of rapid change
36.How far should a rectal thermometer enter a newborn?
1/4 inch
37.How far should a rectal thermometer enter an adult?
About 2 inches
38.What are some things to keep in mind when taking a rectal temperature?
1. Be careful of the size of the
thermometer, something too
big may cause bleeding
2. Keep in mind the vagus nerve-
if it is stimulated it causes
erythmea and the pulse will
plummet
3. You could scratch rectal tissue

39.Temporal artery as a core assessment of temp reflects rapid change in core

temperature

40.Peripheral sites for taking temperature

1. oral
2. axillary
 3. skin

41.What is the average oral temp?

98.6 F
42.Contraindications to oral temp
1. unconsciosness
2. confused patients
3. oral wounds

43.What is the benefit of taking an oral temp?

it is an accessible site, no need to
move clothing
44.Average axillary temp
97.6 F
45.What are some considerations to keep in mind when taking axillary temp?
1. direct skin to skin contact
2. go straight up into the armpit
3. restrict movement of the
patient

46.skin strips
used to measure peripheral temp,
swipe across the forehead
47.Types of thermometers
1. Glass, mercury- cheap &
accurate, dangerous
2. Electronic- battery powered
unit
3. Disposable strips- little dots on
a strip

48.Pulse
palpable, bounding of blood flow
noted at various points on the body
49.Do we use arteries or veins for pulse?
Arteries
50.Name the pulse sites
1. temporal
2. carotid
3. apical
4. brachial
5. ulnar
6. radial
7. popliteal
8. femoral
9. dorsalis pedis
10. posterior tibialis

51.For how long should you assess pulse?

30 seconds, then multiply by 2
52.Are there any exceptions to the length of time you should assess pulse?
 Yes, count for 60 seconds if it is
irregular
53.dysrythmia
an abnormal pulse rhythm
54.2 types of dysrythmia
1. regular irregularity
2. irregular irregularity

55.How is a pulse deficit created?

An efficient contraction of the heart
fails to transmit a pulse wave to the
peripheral pulse site
56.Pulse deficits are frequently associated with what?
Dysrythmias
57.The strength or amplitude of the pulse reflects what?
The volume of blood ejected with each
heart contraction
58.Besides regular and irregular, what else can characterize the rhythm of a pulse?
1. thready
2. bounding
3. strong
4. weak

59.Thready pulse
somewhere between strong and weak
60.Bounding pulse
you can see it through the skin
61.What might a bounding pulse indicate?
1. rigid blood vessels
2. high blood volume

62.How would you assess equality of pulses?

Assess all symmetrical pulses
simultaneously and bilaterally
63.What artery should you NEVER assess bilaterally?
Carotid
64.Which pulse only gets rate and rhythm assessment?
Apical
65.Tachycardia
Abnormally fast heart rate
66.Bradycardia
Abnormally slow heart rate
67.Respirations
the mechanism the body uses to
exchange gases between the
atmosphere and the blood and the
blood and the cells
68.ventilation
movement of gases in and out of the
lungs
69.diffusion
movement of oxygen and carbon
dioxide between the alveoli and RBCs
70.perfusion
distribution of RBC to and from the
pulmonary capillaries
71.hypercarbia
Elevated levels of carbon dioxide
72.hypoxemia
low levels of oxygen
73.Ventilatory depth can be classified in 3 ways. Name them.
1. Deep
2. Shallow
3. Normal

74.For how long should respiration be counted in the normal, healthy adult?
30 seconds, multiply by 2
75.For how long should respiration be counted in a child?
1 minute
76.For how long should respiration be counted in an adult with irregular respiratory rate or
rhythm?
1 minute
77.Apnea
absence of respirations
78.Tachypnea
rapid respirations
79.What does diffusion and perfusion measure?
oxygen saturation levels in the blood
80.Should be 95-100%
SaO2 (saturated oxygen)
81.Should be 70%
SvO2 (venous saturation)
82.What does the pulse oximeter measure?
SpO2, a reliable estimate of SaO2
levels
83.When might the pulse oximeter be inaccurate?
1. When someone is wearing nail
polish
2. When someone has acrylic
nails
3. Low temperature

84.Blood pressure
the lateral force of on the walls of an
artery by the pulsing blood under
pressure from the heart
85. Hearts contraction forces blood under ____ pressure into the ____. high, aorta
86.Systolic blood pressure
peak of maximum pressure when
ejection occurs
87.Diastolic blood pressure
minimal pressure exerted on arterial
walls at all times
88.Pulse pressure
the difference between sbp and dbp,
usually around 30-40 mmHg
89.Sphygmomanometer
tool used to assess blood pressure
90.2 types of Sphygmomanometer
Aneroid- what you're used to seeing,
just the cuff, require periodic
recalibration
Mercury- usually wall or cart mounted,
not many of these left
91.How big should the cuff be?
1. Should cover 80-100% of the
arm
2. 2/3 from shoulder to elbow

92.Where should the arm be when taking BP?

At the level of the heart
93.How far should you pump past your palpated estimate?
30 mmHg
94.Contraindications to the taking of BP in a particular arm
1. An arm with an IV
2. Arm with vascular
insufficiency
3. Injured, fractured or wounded
arm
4. Arm recently out of surgery

95.How do you take BP if both arms are contraindicated?

Use a thigh cuff, placing the
stethoscope over the popliteal artery
96.In which arm should you check blood pressure upon the initial assessment of your patient?
both
97.How would I check for postural hypotension?
Take BP sitting and standing
98.What should you notate with respect to BP?
1. position
2. arm
3. size of cuff

99.Korotkoff sounds
1. faint woosh or tapping
(systolic)
2. muffled/swishing
3. loud, distinct tapping
4. abrupt muffling
5. last sound heard (systolic)

Korotkoff sounds are generated

when a blood pressure cuff
changes the flow of blood through
the artery.

100.Ausculatory gap
 a period of diminished or absent
korotkoff sounds during the manual
measurement of BP.
101.Misinterpreting the ausculatory gap could lead to what?
1. underestimation of systolic BP
2. overestimation of diastolic BP

102.Why are patients still experiencing pain?

1. Reluctance of nurses to
administer pain meds
2. Reluctance of patients to take
pain meds
3. Inadequate knowledge of pain
management by healthcare
workers

103..What can unrelieved pain do to the healing process?

Delay and prolong it.
104.JCAHO
Joint Commission on Accreditation of
Healthcare Organizations
Introduced pain as the 5th vital sign
105.What questions should we ask our patient about pain?
1. pattern? if so, does it vary?
2. when was it most intense in
the last 24 hrs
3. what makes it better/worse?
4. taking any meds? are they
helping or causing adverse
side affects?
5. does it interfere with your
daily activities?

106.When should we reassess pain?

regularly and at specific times (i.e.
after medication)
1.when taking a blood pressure, what exactly are you measuring
of the blood against the walls of the
arteries

2.The difference between the diastolic & the systolic measurements is called

pulse pressure
3.why is the diastolic pressure lower that the systolic pressure?
with diastolic your hear is at rest
4.List 4 factors that influence blood pressure
1. Volume
2. Peripheral resistance
3. Vessel elasticity
4. Blood Viscosity
5.What is considered "normal" blood pressure?
120/80 or under
6.what may occur if the blood pressure cuff is too large/small?
Small-raise blood pressure
Large-reads it low
7.List 4 symptoms of hypertension
1. Blurred vision
2. Shortness of breath (Dyspnea)
3. Vertigo
4. Angina
5. Headache
6. Flushing
7. Nose bleeds (epistasis)
8. Palpitation's
8.Explain what could happen if the diastolic pressure is allowed to remain over 90min.
Rupture of the blood vessel or stroke
9.Blood pressure is measured in mm of ______
Mercury (Hg)
10.What are you looking for when measuring an orthostatic blood pressure?
Dehydration
11.Where do you take your blood pressure at?
Brachial Pulse
12.What increases blood pressure
- Jogging
- Stress
- Anxiety
13.What won't raise your blood pressure?
sleeping
14.When your taking ones Blood Pressure where should your arm be placed?
aligned with your heart
15.High Blood Pressure, what would you have?
- Renal/Kidney failure
- You would have blood in your urine
-Breaking filters in your kidneys from
high Bp will cause blood in your urine
16.Secondary Hypertension
-high blood pressure that's caused by
another medical condition.

-affect your kidneys, arteries, heart or

endocrine system. Secondary

18.Systolic Pressure
the highest pressure level that occurs
when the heart is contracting & the 1st
hear beat is heard (heart relaxation)
TOP
19.Diastolic Pressure
The bottom number, which is also the
lower of the two numbers, measures
the pressure in the arteries between
heartbeats (when the heart muscle is
resting between beats and refilling
with blood).
20.Pulse pressure
-The numeric difference between your
systolic and diastolic blood pressure
- if your resting blood pressure is
120/80mm Hg, your _______ ______
is 40
21.What measures blood pressure?
- Sphygmomanometer
- Cuff
22.Orthostatic Bp
Dehydration
standing up = Higher Bp
Siting = middle Bp
Laying down = lower Bp
25.Cuff to small
Bp will rise
26.Cuff to big
Bp will be lower
27.Essential Hypertension
a common form of hypertension that
occurs in the absence of any evident
cause, is marked hemodynamically by
elevated peripheral vascular
resistance, and has multiple risk
factors
28.Blood Pressure is a reflection of the pressure of blood against the walls of
arteries
29.The difference between the systolic & diastolic pressure is the
Highest & Lowest
30.Blood pressure is recorded as a fraction, w/a ______ tor (top) & the _________ reading being
the denominator (bottom)
Systolic Pressure
__________________
Diastolic Pressure
31._________ is the amount of blood in the arteries
Blood Pressure
32.A(n) _______ is the instrument used to measure the pressure of blood in the arteries.
Sphygmomanometer
33.___________ is the contraction of the heart
Systolic
34.__________ describes the relaxation of the heart
Diastolic
35.Describe some common signs & symptoms of hypertension
•Severe headache
• Fatigue or confusion
• Vision problems
• Chest pain
•Difficulty breathing
• Irregular heartbeat
• Blood in the urine
•Pounding in your chest, neck, or ears
36.4 Errors in blood pressure
1. Cuff is not the right size
2 You’ve incorrectly positioned your
 patient’s body
3 You’ve placed the cuff incorrectly
4. You’re not factoring in electronic
units correctly
1.Baseline
a record of initial measurements taken
upon admission against which future
recordings are compared.
2.Sensorium
Level of consciousness-or mental
status orientation to time,place, and
person
3.Trend
Multiple measurement over time or a
trend
provide a clearer clinical evaluation
4.Hypoxemia
low oxygen level in the arterial blood
5.Differential diagnosis
When signs and symptoms are share
by many diseases and the exact cause
is unclear
6.Oriented X 3
Oriented to time place and person)
conscious, alert and oriented)
Alert Oriented X 3
7.Hyperthermia
elevated body temp above normal
hyperpyrexia- (41.5 °C (106.7 °F)
8.Febrile
Temperature elevation caused by
disease is called fever
increases metabolism,causing both
increased 02 consumption, and C02
production which can cause increased
metabolism and circulation resulting
increased ventilation to maintain
homeostasis
9.Afebrile
without fever or normal temp

10.Apical pulse
The auscultated directly over the apex
over the heart
left side of the chest at the 5th
intercostal space at the midcalvicular
line
11I:E ratio
Inspiratory and expiratory breaths
12.Hypothermia
abnormally low body temperature
13.Tachycardia
 fast heart rate over 100bpm
14.Bradycardia
heart rate less than 60bpm
15.Pulsus Paradoxus
blood pressure decreasing more that
10mmHg upon inspiration (normally
only 2-8mmHg) typically seen in pts
with air trapping like asthma
16.FUO
fever of unknown origin
17.Tachypnea
fast breathing
18.Bradypnea
slow breathing
19.Systolic pressure
The arterial peak force exerted during
contraction of the left ventricle
20.Diastolic pressure
The force occurring when the heart is
relaxed
21.Pulse pressure
The difference between systolic and
diastolic pressure (normal 35-40)
Ex 120/80=40
22.Pack/Year Hx
determined by the multiplying the
number of packs smoked per day by
the number of years smoked
half pack a day for 20 years 30/20=1.5
x 20=30yrs
15 cigarettes per day for 20yrs
15/20=0.75 x 20yrs =15pk yrs
23.Minute Volume
gas inhaled and exhaled over 1 minute
24.Hypertension
b/p persistently higher than 140/90
associated with escalating risk for
development of heart, vascular and
renal disease

25.Hypotension
b/p less than 95/60
26.Hypervolemia
overall low fluid volume

27.Apnea absence of spontaneous ventilation

28.Dyspnea
difficulty or labored breathing or
discomfort with breathing
29.Hyperpnea
increased depth of breathing
30.Hypopernea
decreased depth of breathing
31.Orthopnea
shortness of breath while lying flat (pt
usually has to sleep upright)
32.Hypoventilation
decreased rate of breathing
33.Hyperventilation
increased rate of breathing
34.Pulse deficit
difference between palpated pulse and
apical auscultated pulse
35.Holter monitor
portable device for cardiac monitoring
1.Where is a tympanic temperature taken?
ear canal
2.A temperature taken in the armpit is documented as a(n)__________temperature.
axillary
3.A temperature that is within the normal range is called_________.
afebrile
4.You should never use your_______to feel the pulse.
thumb
5.Where is the radial pulse located?
wrist
6.Which pulse is on top of your foot?
dorsalis pedis
7.Which temperature is considered febrile?
100.6F
8.What color temperature handle should be used for an axillary temperature?
blue
9.The normal pulse rhythm should be?
normal
10In which order should you document vital signs?
T-P-R-BP
11.How long should you wait to take a temperature after someone has eaten, drank or smoked?
15 minutes
12.How long should you count a pulse for?
1 min(60sec)
13.What might cause hyperventilation?
mental stress

14.Should you use an electronic(automatic)blood pressure cuff on someone who has a bleeding
disorder?
No, can cause increased pressure
resulting in bleeding
15.The number on the top is called?
Systolic
16.When the heart rate is slower than normal it is called?
Bradycardia-Brady means slow-Tachy
means fast
17.Which pulse is found along the trachea?
carotid
18.Which pulse is found next to the front of the ears?
 temporal
19.Which pulse is found behind the knee?
popliteal
20.A person's temperature is usually higher in the morning?
False
1.Normal Temp
96.8 - 99.5 F or. 36 - 37.5 C
2.Pyrexia
Raised body temp above normal range
3.Hyperthermia
Fever
4.Hyperpyrexia
Very high fever
5.Febrile
Patient with fever
6.Afebrile
Put without fever
7.Where do we take the temperature at?
Oral
tympanic- ear
temporal
rectal- most accurate
axillary- used for newborns
8.Pulse measures what?
Heart rate/ cardiac output
9.most common site used to take the pulse?
Radial
10.Pulse lets us know the heart rate and quality. Ex?
Weak, strong,full, threads, or absent
11.Pulse normal range is
60-100 and count for 30 seconds x2 if
normal.
Ireegular count for 1 minute
12.Places to check the pulse?
Temporal
carotid
brachial
radial
ulnar
Apical
femoral
popliteal
dorsal pedis
posterior tibial
13.Apical pulse
 Count for 1 minute
fmid-clavicular 5th intercoastal
14.Average pulse is?
72 bpm
15.Tachycardia
Over 100 bpm
16.Bradycardia
Less than 60 bpm in adults
17.Respirations
12-20 breaths/minute
30seconds x2
if abnormal 1 minute
18.Eupnea
Normal breaths
19.Apnea
Absence of breathing
20.Bradypnea
Slow breaths
less than 12 breaths/minute
21.Thachypnea
Fast breathing
more than 20 breaths/minute
22.Hyperventilation
Deep, fast breathing
23.Hypoventilation
Shallow, respirations
24.Cheyne strokes
Near death breathing
breathing deep, slow, the stopping
25.Dyspnea
Labored
use of intercoastal muscles, flaring of
nostrils, and neck
26.Orthopnea
Put needs to be ina specific position to
breath
-usually upright
27.Respiration sounds can be?
Wheezing,bubbling, stridor
28.Blood pressure
<120-80
29.Systolic
Contraction of ventricles
30.Dyastolic
Ventricles at rest and filling
31.Measured in?
mmHg
32.Prehypertension
120 - 139 / 80 -89
33.Hypertension Stage 1
140-159 / 90-99
34.Hypertension stage 2
Greater than 160 and 100
35.Hypertension
Contributes to heart attack
usually asymptomatic
persistently above normal
primary = unknown cause
secondary = known cause
36.Hypotension
Blood pressure below normal
Orthostatic hypotension is BP that
decreases when the patient sits or
stands
caused by analgesics, bleeding, severe
burns, dehydration