ATI Fundamentals For Nursing Chapter 27 - Vital Signs

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Vital Signs

are measurements of the body's most basic functions

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  • temperature
  • pulse
  • respiration
  • blood pressure

Most often assessed on vital signs are

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  • pain
  • oxygen saturation

In many healthcare facilities, these assessments are also considered vital signs and may also be measured depending on the reason the patient needs healthcare.

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antipyrectic

a substance or procedure that reduces fever

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aptnea

temporary or transient cessation of breathing

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auscultatory gap

temporary disappearance of sounds usually heard over the brachial artery, occurring when the cuff pressure is high and is gradually reduced, with the sounds again heard at a lower level of pressure (usually occurring in patients who have hypertension)

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axillary

pertaining to the axilla, the cavity beneath the junction of a forelimb and the body; also called the armpit or the underarm

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brachial pulse

beating or throbbing felt over the brachial artery, usually palpated in the antecubital space

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bradycardia

an abnormally slow pulse rate, usually fewer than 60 beats per minutes in an adult

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bradypnea

an abnormally slow respiratory rate, usually fewer than 12 breaths per minutes in an adult

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cardiac output

the amount of blood pumped into the arteries by the heart during one minute; the product of the heart rate and the stroke volume

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celcius

relating to the international thermometric scale on which 0° is the freezing point and 100° is the boiling point; centigrade

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centigrade

relating to the international thermometric scale on which 0° is the freezing point and 100° is the boiling point; Celsius

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core temperature

the amount of heat in the deep tissues and structures of the body, such as the liver

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diastolic pressure

the force exerted when the heart is at rest in between each beat; the lowest pressure exerted against the arterial walls at all times

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dyspnea

the sensation of difficult or labored breathing

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eupnea

normal respiration

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farenheit

relating to the temperature scale on which 32° is the freezing point and 212° is the boiling point

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fever

feverish; pertaining to a fever

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hypertension

a common cardiovascular disorder, often with no symptoms, in which the blood exerts an abnormal amount of force on the inside walls of the arteries persistently and blood pressure readings are persistently above 120/80 mmHg

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korotkoff sounds

a series of five sounds (four sounds followed by an absence of sound) heard during the auscultatory determination of blood pressure and produced by sudden distention of the artery because of the proximally placed pneumatic cuff

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orthopnea

ability to breathe without difficulty only when in an upright position (sitting upright or standing)

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orthostatic hypertension

a sudden drop in blood pressure resulting from a change in position, usually when standing up from a sitting or reclining position and often causing dizziness

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oximetry

determination of the oxygen saturation of arterial blood using a photoelectric device called an oximeter

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oxygen saturation

a clinical measurement of the percentage of hemoglobin that is bound with oxygen in the blood

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palpation

the application of the fingers with light pressure to the surface of the body to determine the condition of the underlying parts

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pulse deficit

the difference between the apical and the radial pulse rates. This condition may indicate a lack of peripheral perfusion for some of the heart contractions.

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pulse pressure

the difference between the systolic and the diastolic blood pressures

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radial pulse

beating or throbbing felt over the radial artery, usually palpated over the groove along the thumb side of the inner wrist

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S1

the first heart sound, heard when the atrioventricular (mitral and tricuspid) valves close

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S2

the second heart sound, heard when the semilunar (aortic and pulmonic) valves close

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Sim's position

a side-lying position with the lowermost arm behind the body and the uppermost leg flexed

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Stethoscope

a device used to convey sounds produced in the body to the listener's ears

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Stroke Volume

the amount of blood entering the aorta with each ventricular contraction

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systolic pressure

the amount of force exerted within the arteries while the heart is actively pumping or contracting; the maximum pressure exerted against the arterial walls

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tachycardia

an abnormally fast pulse rate, usually above 100 beats per minutes in an adult

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tachypnea

an abnormally fast respiratory rate, usually more than 20 breaths per minutes in an adult

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tympanic

pertaining to the ear canal or eardrum (tympanic membrane)

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vital signs

measurements of physiological functioning, specifically temperature, pulse, respirations, and blood pressure, but may also include pain and pulse oximetry

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1. Bainaural Assembly

  • Ear Tips
  • Ear Tubes
  • Tubing

2. Chest Piece

  • Bell ( for low-pitched sound)
  • Diaphragm ( for high-pitched sound)

Name the parts of a stethoscope

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  • Cuff
  • Tubing
  • Inflation Bulb
  • Pressure Monitoring Device

Name the parts of a blood-pressure cuff

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  1. The radial pulse is easy to find and is the most frequently checked peripheral pulse.
  2. To check the radial pulse with the patient supine, position the patient's arm along the side of the body or across the upper abdomen with the patient's wrist relaxed.
  3. Apply light pressure with the pads of the fingers in the groove along the radial or thumb side of the patient's inner wrist. Be careful not to apply too much pressure, as this can impair blood flow.
  4. If the pulse is regular, count for 30 seconds, then multiply that number by 2.

    If the pulse is irregular, count for 1 full minute.

Assessing radial pulse rate

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  1. Determining an apical pulse involves locating the point of maximal impulse (PMI), placing the bell or diaphragm of your stethoscope at this site, and listening for 1 minute.
  2. Expose the patient's sternum and the left side of the chest.
  3. Locate the PMI. Slide your fingers down each side of the angle of Louis to the second intercostal space.
  4. Move your fingers down the left side of the sternum to the fifth intercostal space and laterally to the left midclavicular line and the PMI.
  5. Place the diaphragm of your stethoscope over the PMI and auscultate for normal S₁ and S₂ heart sounds. You will usually hear them as "lub-dub." If the apical pulse is regular, count for 30 seconds, then multiply that number by 2. If the apical pulse is irregular or the patient is taking cardiovascular medications, count for 1 full minute to ensure an accurate measurement.

Assessing apical pulse rate

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  1. To determine the pulse deficit, take the radial and the apical pulses simultaneously.
  2. Position the patient either in a supine or a sitting position and expose the patient's sternum and the left side of the chest.
  3. Using the appropriate anatomical landmarks, locate the radial and the apical pulses.
  4. Start counting on command and count the pulse rates simultaneously for 1 full minute. Stop counting on command.
  5. To calculate the pulse deficit, subtract the radial pulse rate from the apical pulse rate.

Assessing pulse deficit

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insert the probe about an inch and a half into the patient's anus

-An insertion depth of 1.5 inches (3.5 cm) ensures sufficient exposure of the probe to the blood vessels in the rectal wall. Positioning the probe against the blood vessels enables to measure heat maximally and accurately.

When taking an adult patient's temperature rectally, it is important to:

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Have the head of the bed elevated 45 to 60 degrees

-This is a comfortable position for most patients and it allows full ventilatory movement. Also, any type of discomfort can increase respiratory rate.

When assessing a patient's respiration, it is recommended that the patient

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the pulse pressure

The difference between a patient's systolic and diastolic blood pressures is called:

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A respiratory rate of 30/min

An oral temp. of 100 F indicates a fever but this degree of elevation in body temp is rarely a situation that requires immediate attention

You have assessed a 45 yr old patient's vital signs. Which of the following assessment values requires immediate attention?

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You might not hear a fifth Korotkoff sound

-Most clinicians consider the fifth Korotkoff sound, which is actually the disappearance of sound, an adult patient's diastolic pressure. However, with some patient's, there is no distinct fifth sound. You hear sounds all the way to 0 mm Hg. For these patients, you would record the fourth Korotkoff sound as the diastolic blood pressure.

When taking a patient's blood pressure, why is it important to notice the pressure on the manometer when you hear the fourth Korotkoff sound or phase?

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Observe the patient's chest movements while appearing to assess his pulse

-You are mostly likely to observe the true respiratory pattern (rate, rhythm, and depth) when the patient is unaware that he is being assessed. When patients know their respiration is being observed, it is common for them to alter their respiratory pattern either voluntarily or involuntarily.

You are assessing the vital signs of a newly admitted patient. To establish an accurate baseline of the patient's respiration you

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An elevated pulse rate

-A fever increases metabolic rate and peripheral vasodilation, resulting in an increased pulse rate.

You are assessing a patient's vital signs. the patient has a temp. of 102 degrees F. Which of the following do you expect to find?

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Semilunar Valves close

-The second heart sound, S2, is generated by the closure of the semilunar valves (the aortic and pulmonic valve) and signals the start of diastole. S2 is the "dub" heard in the normal "lub-dub" sound.

When auscultating a patient's apical pulse, you listen until you hear the S1 and S2 heart sounds clearly and regularly. S2 is produced when the

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- patient is 60 lbs overweight
-patient is reporting a stuffy nose
-patient is taking digoxin
-patient had a mastectomy 2 years ago

When preparing to measure the vital signs of a patient, you should recognize that which of the following will affect the methods that you will use? (Select all that apply)

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Gently pulling the pinna back and upward

-A tympanic thermometer is probably not the best choice when the patient's ears show signs of infection, inflammation, or trauma because of the risk of further damage, pain, or contamination. But the device would still register temperature accurately.

You are preparing to use a tympanic thermometer. Which of the following steps has the highest priority in the accurate use of this piece of equipment for measuring body

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at the fifth intercostal space at the left midclavicular line

-To locate the point of maximal impulse, first located the angle of Louis - bony prominence just below the suprasternal notch. Slide you fingers down each side of the angle of Louis to locate the second intercostal space. Gently move your fingers down the left side of the sternum to the fifth intercostal space and laterally to the left midclavicular line. You have found the PMI.

To auscultate a patient's apical pulse accurately, you position the bell or the diaphragm on your stethoscope over the point of maximal impusel, which is located

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observe the degree of chest wall movements during inspiration and expiration

-You determine the depth of respiration subjectively by evaluating how much chest wall movement you can observe. The movement is generated by the movement of the diaphragm and intercostal muscles as the patient breathes. With shallow respiration, for example, you will observe very little movement. Deep respiration involves full expansions for the lungs which is usually quite visible

The best way to determine the depth of a patient's respiration is to

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in the posterior linguinal pocket lateral to the midline

-The heat produced by superficial blood vessels in the right and left posterior sublingual pocket is what generates an accurate oral temperature reading. Inserting the probe sideways into the back of the area under the tongue on the left or the right will access this area....

You are measuring a patient's temp. orally. You place the covered probe