1. Chapter 17 Vital Signs

2. Terminology Related to Blood Pressure
Diastolic pressure: Measurement of the pressure exerted by the blood on the artery walls while the heart ventricles are not contracting (at rest); the lower of the two pressures; the bottom number of the BP
Systolic pressure: Measurement of the pressure exerted by the blood on the artery walls while the heart ventricles are contracting; the highest of the two pressures; the top number of the BP
Objective #1: Define various terms associated with assessment of the six vital signs.
Describe the following terms related to blood pressure:
Diastolic pressure
Systolic pressure
In addition, discuss other terms in italics or bolded within the chapter to help students understand terminology. Ensure that they understand the meanings of each.

3. Terminology Related to Abnormal Blood Pressure
Hypertension: The systolic BP consistently over 140 mm Hg or the diastolic BP consistently over 90 mm Hg
Hypotension: The BP suddenly falls 20 mm Hg to 30 mm Hg below the patient’s normal BP or falls below the low normal of 90/60 mm Hg
Objective #1: Define various terms associated with assessment of the six vital signs.
Describe the following terms related to blood pressure:
Hypertension
Hypotension

4. Terminology Related to Abnormal Blood Pressure (cont.)
Orthostatic hypotension or postural hypotension: When the position changes, it results in a systolic pressure drop of 15 to 25 mm Hg or the diastolic pressure falls 10 mm Hg
Pulse pressure: Measurement of the difference between the systolic and diastolic pressures, normally a point difference
Objective #1: Define various terms associated with assessment of the six vital signs.
Describe the following terms related to blood pressure:
Orthostatic hypotension
Pulse pressure

5. Terminology Related to Body Temperature
Afebrile: Without fever
Febrile: Fever
Hyperthermia: Fever
Hypothermia: Temperature below normal
Pyrexia: Fever, commonly above 105°F (40.5°C)
Objective #1: Define various terms associated with assessment of the six vital signs.
Describe the following terms related to body temperature:
Afebrile
Febrile
Hyperthermia
Hypothermia
Pyrexia

6. Terminology Related to Normal Apical Pulse
S1: As the ventricular contraction begins, the tricuspid and bicuspid valves (AV valves) slam shut; the first heart sound; the longer, lower-pitched sound; the lubb of “lubb dupp”
S2: As the ventricles begin relaxation, the pulmonary and aortic valves (semilunar valves) close; a shorter, sharper sound; the dupp of “lubb dupp”
Objective #1: Define various terms associated with assessment of the six vital signs.
Describe the following terms related to normal apical pulse: S1 S2

7. Terminology Related to Abnormal Pulses
Bradycardia: Heart rate below 60 bpm
Tachycardia: Heart rate above 100 bpm
Pulse deficit: The difference between the apical and radial pulse when the radial pulse is slower than the apical pulse
Objective #1: Define various terms associated with assessment of the six vital signs.
Explain the following terms related to abnormal pulses:
Bradycardia
Tachycardia
Pulse deficit

8. Term for Normal Respirations
Eupnea: Evenly spaced respirations of normal depth, between the rate of 12 and 20 breaths per minute
Objective #1: Define various terms associated with assessment of the six vital signs.
Explain the following term describing normal respirations:
Eupnea

9. Abnormal Respiratory Terms
Apnea: Respirations cease or are absent
Bradypnea: Respiratory rate below 12/minute
Tachypnea: Respiratory rate above 20/minute
Dyspnea: Labored or difficult breathing
Stertorous: Noisy, snoring, labored respirations that are audible without a stethoscope
Objective #1: Define various terms associated with assessment of the six vital signs.
Explain the following terms describing abnormal respirations:
Apnea
Bradypnea
Tachypnea
Dyspnea
Stertorous

10. Abnormal Respiratory Terms (cont.)
Hypoxemia: Decreased oxygen level in blood
Hypoxia: Decreased oxygen level in tissues
Orthopnea: Difficulty breathing unless in upright position
Stridor: An audible high-pitched crowing sound that results from partial obstruction of the airways
Objective #1: Define various terms associated with assessment of the six vital signs.
Explain the following terms describing abnormal respirations:
Hypoxemia
Hypoxia
Orthopnea
Stridor

11. Six Vital Signs Blood pressure (BP) Temperature (T) Pulse (P)
Respiration (R)
Oxygen saturation (SpO2)
Pain
Objective #2: Describe the six vital signs, their significance, and their normal ranges.
Review the five objective vital signs: blood pressure, temperature, pulse, respiration, and oxygen saturation, and the one subjective measurement: pain.
Tell your students that the normal range for adult blood pressure is between 90/60 mm Hg and 120/80 mm Hg, and when the systolic pressure rises above 120, it is considered to be pre-hypertension. (Refer to Table 17-1.)

12. Significance of the Five Objective Vital Signs
Reveal how certain systems are functioning
Provide data regarding patient’s overall condition
Provide a baseline against which subtle changes can be measured
Objective #2: Describe the six vital signs, their significance, and their normal ranges.
Discuss the significance of the five objective vital signs.

13. Body Temperature Measured in either Fahrenheit or Celsius
Factors affecting the temp:
Environment
Time of day
Physical activity and exercise
Medications
Food or drink, smoking
Illness
Objective #2: Describe the six vital signs, their significance, and their normal ranges.
Discuss the types of thermometers and scales that are used to measure body temperature (Fahrenheit or centigrade [also known as Celsius]). Note the factors that affect body temperature. (Refer to Figures 17-5 and 17-6, and Box 17-4.)
Objective #6: Relate at least six factors that affect blood pressure, temperature, pulse, and respiration.
Discuss the types of thermometers and scales that are used to measure body temperature (Fahrenheit or centigrade [also known as Celsius]).
Note the factors that affect body temperature. (Refer to Figures 17-5 and 17-6, and Box 17-4.)

14. Routes Used for Taking Temperature
Oral: more accurate, most common route used
Tympanic
Axillary: 1°F lower than oral
Skin
Temporal artery
Rectal: most accurate, closer to core temp, 1°F higher than oral
Objective #2: Describe the six vital signs, their significance, and their normal ranges.
Note routes used for taking a patient’s temperature. (Refer to Table 17-2 and Skill 17-3.)
Tell your students that the normal range for core temperatures varies from 97°F to 99.6°F (36.1°C–37.5°C), with the average being 98.6°F (37°C).

15. Factors to Assess Regarding Respiratory Rate
Rate per minute
Depth
Rhythm
Pattern
Respiratory effort
Objective #2: Describe the six vital signs, their significance, and their normal ranges.
Discuss the method of assessing respirations with a watch. Note the assessments that are made. State that the normal range for adult respirations is 12 to 20 per minute. (Refer to Tables 17-6 and 17-7.)

16. Abnormal Breath Sounds
Adventitious
Wheezes
Crackles or rales
Rhonchi
Stridor (sometimes heard without the use of a stethoscope)
Objective #2: Describe the six vital signs, their significance, and their normal ranges.
Define abnormal breath sounds, including adventitious, wheezes, crackles or rales, rhonchi, and stridor. Point out that stridor may also be heard without a stethoscope.

17. Oxygen Concentration Abbreviated as SpO2 Normal is 96%-100%
Clip sensor can be applied to the fingertip, earlobe, bridge of the nose, or the toe if circulation to the feet is adequate
Objective #2: Describe the six vital signs, their significance, and their normal ranges.
Point out that normally 96% to 100% of the hemoglobin in arterial blood is bound with oxygen molecules. Note that this saturation level is measured with an electronic pulse oximeter by attaching the plastic clip sensor to the fingertip, earlobe, bridge of the nose, or, when circulation is adequate, the toe. (Refer to Skill 17-8.)

18. When to Assess Vital Signs
Admission to hospital
Each visit to a clinic or emergency room
Each home health or hospice visit
Every 8 hours or according to hospital policy
According to physician’s orders
When a patient complains of feeling unusual or different
When you suspect a change in condition
Objective #3: Identify times when vital signs should be assessed.
Note that there are designated times to assess vital signs, and most hospitals have a routine schedule of once every 8 hours unless the physician orders it more frequently. (Refer to Box 17-1.)

19. When to Assess Vital Signs (cont.)
When administering medications
Before, during, and after blood product transfusion
Before, during, and after surgical and diagnostic procedures
Every 4 hours when one or more vital signs are abnormal
Objective #3: Identify times when vital signs should be assessed.
Note that there are designated times to assess vital signs, and most hospitals have a routine schedule of once every 8 hours unless the physician orders it more frequently. (Refer to Box 17-1.)

20. When to Assess Vital Signs (cont.)
A second time when an assessment finding is different from the last assessment
Every 5 to 15 minutes if the patient’s condition is unstable
Objective #3: Identify times when vital signs should be assessed.
Note that there are designated times to assess vital signs, and most hospitals have a routine schedule of once every 8 hours unless the physician orders it more frequently. (Refer to Box 17-1.)

21. When to Reassess Vital Signs
After administering IV medications
Change in level of consciousness
Unstable postoperative condition
Uncontrolled bleeding
Pale, cold, and clammy skin
Whenever you detect or suspect a change in patient condition
Whenever a serious condition is suspected
Whenever your instinct says to reassess
Objective #3: Identify times when vital signs should be assessed.
Point out that there are times when the nurse should assess a patient’s vital signs or reassess them after someone else has already taken them.

22. Guidelines for Assessing Vital Signs
Use an organized and systematic approach
Use the appropriate equipment for each patient
Be familiar with the normal ranges for different ages
Compare vital signs with previous vital sign range for that specific patient
Know the patient’s medical history, meds, and therapies
Objective #4: Summarize the guidelines for vital sign assessment.
Review the guidelines for assessing vital signs.

23. Guidelines for Assessing Vital Signs (cont.)
Understand and interpret the vital sign findings
Record and communicate significant vital sign changes to the physician and next shift nurse
Minimize environmental effects on vital signs
Objective #4: Summarize the guidelines for vital sign assessment.
Review the guidelines for assessing vital signs.
Discussion Point: Brainstorm with the class to decide when the LPN should assess vital signs instead of delegating the task. Give examples of situations in which vital signs should be reassessed.

24. Four Circulatory Qualities
Strength of the heart contraction or pumping action of the heart
Blood viscosity or thickness
Blood volume
Peripheral vascular resistance or elastic recoil ability of the blood vessel walls
Objective #5: Outline the four circulatory qualities and how they determine blood pressure.
Tell your students that blood pressure is the measurement of the pressure or tension of the blood pushing against the walls of the arteries in the vascular system. Discuss the four circulatory qualities that determine blood pressure.
Emphasize that the amount of blood ejected from the heart in one contraction is known as the stroke volume, and the volume of blood pumped from the heart in a full minute is termed the cardiac output. Point out that the greater the cardiac output, the higher the blood pressure will be. Conversely, the lower the cardiac output, the lower the pressure will be.

25. Normal Percentage of RBCs in Plasma
Newborns: 49% to 54%
Children: 35% to 49%
Adult females: 37% to 47%
Adult males: 40% to 54%
(Test to measure this percentage: hematocrit)
Objective #5: Outline the four circulatory qualities and how they determine blood pressure.
Discuss how the hematocrit, or percentage of red blood cells (RBCs) in the plasma, can affect blood pressure.

26. Korotkoff Sounds
First sound: Clear, rhythmic tapping sound, gradually increasing in intensity
Second sound: Soft, swishing or murmuring sound, representing turbulent blood flow
Third sound: Sharper, crisper rhythmic sound
Fourth sound: Softening or muffling of rhythmic sound
Fifth sound: Silence
Objective #5: Outline the four circulatory qualities and how they determine blood pressure.
Teach your students the proper procedure for the assessment of blood pressure and describe the equipment used, including a stethoscope and BP cuff or sphygmomanometer. Demonstrate the procedure. (Refer to Skill 17-1, Box 17-2, and Figures 17-1 through 17-4.)
Review the Korotkoff sounds heard when assessing blood pressure.
Student Assignment: Collect the equipment needed to assess vital signs. Include the various types of thermometers and sphygmomanometers to familiarize the students with the differences. Divide the class into five groups and have them take turns assessing each other’s vital signs. Rotate the necessary equipment from group to group so everyone has a chance to use each assessment tool.

27. Factors Affecting Blood Pressure, Pulse Rate, & Respiration
Age, race, obesity
Exercise, rest, level of hydration
Circadian rhythm
Anxiety
Medications
Nicotine and caffeine
Hemorrhage, increased intracranial pressure
Illness
Objective #6: Relate at least six factors that affect blood pressure, temperature, pulse, and respiration.
Talk about how the cardiac and respiratory systems work so closely together, that something affecting one of them generally affects the other.
Review the factors that affect blood pressure, pulse, and respirations: including age, sex, race, exercise, rest, circadian rhythm, anxiety, medications, nicotine and caffeine, obesity, level of hydration, hemorrhage, illness, and increased intracranial pressure.

28. Effects of Hypertension on the Body
Gradual loss of elasticity in arterial walls results in less stretch and recoil
Heart has to work harder to pump blood through the cardiovascular system
Objective #7: Contrast the effects of hypertension and hypotension on the body.
Point out that hypertension is the term used to describe a systolic consistently above 140 or a diastolic consistently over 90. Discuss the effects of hypertension on the body.

29. Risk Factors for Hypertension
Family history
Smoking
Chronically high stress level
Moderate to heavy alcohol consumption
Obesity
Elevated cholesterol levels in blood
Objective #7: Contrast the effects of hypertension and hypotension on the body.
Review the risk factors for hypertension. (Refer to Box 17-3.)

30. Damage Caused by Untreated Hypertension
Brain, in the form of a stroke
Heart, in the form of congestive heart failure or myocardial infarction (heart attack)
Kidneys, resulting in kidney failure
Retinas of the eyes, resulting in loss of vision
Objective #7: Contrast the effects of hypertension and hypotension on the body.
Note the damage that can be caused if hypertension is left untreated.
Tell your students that when BP suddenly falls 20 mm Hg to 30 mm Hg below the patient’s normal BP or falls below the low normal of 90/60 mm Hg, it is considered hypotension.
Discuss the assessment of orthostatic hypotension. Point out that if a patient becomes faint due to hypotension, the initial treatment is to lay the person in a modified Trendelenburg position. (Refer to Skill 17-2.)
Student Assignment: Ask your students to research one of the five objective vital signs and write a brief report stating normal values for the assessment for different age groups. Have them prepare a patient teaching plan for a patient with hypertension.

31. Peripheral Pulse Sites
Temporal: Used when radial not accessible
Carotid: Used in cardiac arrest
Brachial: Measures BP
Radial: Used for pulse rate assessment
Femoral: Determines leg circulation
Popliteal: Determines leg circulation
Posterior tibialis: Determines foot circulation
Dorsalis pedis: Determines foot circulation
Objective #8: Describe how and where to assess peripheral pulses.
Teach your students that the heart’s four chambers rhythmically contract and relax, and with each contraction of the ventricles, oxygenated blood is forced out of the left ventricle through the aorta to be delivered to the body’s arteries. Define stroke volume as the amount of blood discharged from the left ventricle with each contraction.
Discuss the peripheral pulse sites that can be palpated by applying gentle fingertip pressure over the artery against the underlying bone. Note when these sites are used. (Refer to Figure 17-8 and Skill 17-5.)

32. Peripheral Pulse Assessment
Strength:
Absent or 0
Weak or 1+ (may also be thready)
Strong or 2+
Bounding or 3+
Equality:
Equal strength bilaterally
Weaker than opposite side
Objective #8: Describe how and where to assess peripheral pulses.
Review the three characteristics of the pulse, including rate, rhythm, and volume (strength). Note that the normal range for adults is 60 to 100 bpm. (Refer to Table 17-4.)
Explain that when assessing the peripheral pulses, as long as the rate of the radial pulse was assessed, the remaining peripheral pulses are generally not counted but are assessed only for strength and equality from side to side to ensure there is adequate circulation to the extremities.
Discuss scales used to measure peripheral pulse volume and the use of a Doppler to determine if blood flow is present in absent pulses. (Refer to Table 17-5 and Skill 17-6.)
Student Assignment: Divide the class into pairs and have the students practice taking each other’s pulses at peripheral pulse sites.

33. Regulation of Vital Signs
Brain:
Medulla: Heart rate, vasomotor centers that help control diameter of blood vessels affecting temp and thereby BP, and respiratory center regulating breathing
Pons: Has 2 breathing centers that work with medulla to control respirations
Hypothalamus: Temperature by sweating and muscle shivering, autonomic nervous system affecting pulse rate and constricting/dilating vessels, circadian rhythm
Objective #9: Distinguish how the body regulates each vital sign.
Brain:
Medulla: Heart rate, vasomotor centers that help control diameter of blood vessels affecting temp and thereby BP, and respiratory center regulating breathing
Pons: Has 2 breathing centers that work with medulla to control respirations
Hypothalamus: Temperature by sweating & muscle shivering, autonomic nervous system affecting pulse rate and constricting/dilating vessels, circadian rhythm
Explain to your students that the hypothalamus has capabilities to increase heat production by causing muscles to shiver and to conserve body heat by constricting vessels in the body’s outer surface layers and extremities. Note that this vasoconstriction helps to redirect the majority of blood flow to the vital organs, primarily the brain and heart, to maintain adequate core temperature.
Again, note that because the heart and lungs work together to provide circulation of nutrients and oxygen, the factors that affect the BP and heart rate generally affect the respiratory rate as well.
Student Assignment: Ask students to select an abnormal assessment finding for one vital sign. Have them write a brief report explaining one possible etiology with accompanying pathophysiology that might result in the abnormal finding.

34. Characteristics of Pain to Be Assessed
Site or location
Characteristics
Constant or intermittent?
Sharp, dull, stabbing, aching, cramping, or burning
Severity of pain using a pain scale that is appropriate for age and comprehension
Objective #10: Describe how to assess pain.
Distinguish between acute and chronic pain. Note the characteristics of pain that should be assessed.
Tell your students that nurses should use a pain scale such as a scale of 0 to 10, with 0 being “no pain” and 10 being “worst pain you can imagine” when assessing the patient’s pain. Discuss the various pain scales available for use with children too young to use a number scale and patients who cannot read or comprehend the number scale.

35. VS Documentation Blood Pressure: BP-134/74 Temperature:
Oral route: 98.6°F
Tympanic route: T 98.6°F
Axillary route: ax 97.6°F
Rectal route: R 99.6°F
Objective #11: Document correctly the assessment of vital signs.
Explain the typical recording sequence: BP, T, P, R, SpO2, pain.
Discuss the correct format for documenting each vital sign, including the position of systolic and diastolic numbers, the route and scale for temperature, and the characteristics of pulse and respirations, whether or not the SpO2 was measured with supplemental oxygen in use or just on room air, versus just recording the numerical values.

36. VS Documentation (cont.)
Pulse:
P-64 reg, 1+
Respirations:
R-15 reg, even
Oxygen Saturation:
SpO2-96% w/O2 4L/m perN/C
Pain:
Denies pain.
Objective #11: Document correctly the assessment of vital signs.
Explain the typical recording sequence: BP, T, P, R, SpO2, pain.
Discuss the correct format for documenting each vital sign, including the position of systolic and diastolic numbers, the route and scale for temperature, and the characteristics of pulse and respirations, whether or not the SpO2 was measured with supplemental oxygen in use or just on room air, versus just recording the numerical values.

37. VS Documentation (cont.)
BP-128/66; T-ax 97.6°F; P-70 reg, 1+; R-17 reg, even; SpO2-98% Room air; Rt shoulder Pain 1-2
Some chart formats only allow:
BP-128/66, T-97.6, P-70, R-17, SpO2-98%, Pain1-2
In this case, document the additional characteristics and data in the narrative section of chart.
Objective #11: Document correctly the assessment of vital signs.
Explain the typical recording sequence: BP, T, P, R, SpO2, pain.
Discuss the correct format for documenting each vital sign, including the position of systolic and diastolic numbers, the route and scale for temperature, and the characteristics of pulse and respirations, whether or not the SpO2 was measured with supplemental oxygen in use or just on room air, versus just recording the numerical values.
Talk about the various chart forms and their differences for vital sign recording: electronic charting, graphic sheets, nurse’s notes, etc.

38. Health Conditions Affecting VS
Hypertension
Arteriosclerosis
Congestive heart failure
Hemorrhage
Shock
Infection
COPD
Objective #12: Discuss how various health conditions may affect vital signs.
Talk about various health conditions and diseases that can affect each of the vital signs. Include things such as hypertension, arteriosclerosis, congestive heart failure, hemorrhage, shock, infection, and COPD. Add any other you feel should be included.

39. Possible Interventions?
FOR:
Elevated Temperature
Newly identified “bounding” pulse with elevated BP
Slowing pulse and rising BP in a patient with a head injury
Vital signs that are significantly different than last reading
Objective #13: Identify nursing interventions regarding vital signs appropriate in specific scenarios.
Discuss various scenarios of vital sign assessment that commonly occur, such as elevations of temperature, a newly identified “bounding” pulse with elevated BP, tachypnea, or slowing of pulse and increasing BP in a patient with head injury.
Talk about possible nursing interventions for each scenario.
Expound how further assessment is often the key to catching problems before they are serious.

40. Information in the Connection Features
Clinical Connection
Knowledge
Laboratory and Diagnostic
Supervision/Delegation
People and Places
Patient Teaching
Post Conference
Objective #14: Discuss information found in the Connection features in this chapter.
Divide students into groups and have each group take one of the Connection features.
Ask the group to share the information in the feature with the class and to discuss ways that it can apply in a broader sense to their practice of nursing. 40

41. Information in the Safety Features
Why are the particular safety features so important that they are highlighted as safety issues?
What could happen if those safety guidelines are not followed?
Objective #15: Identify specific safety issues.
Remind students to review the red safety features within the chapter. Point out to them that the information in those safety features is very important (and that they might see a related test question).
Ask the students why those particular items were so important that they were highlighted as safety issues. What could happen if those safety guidelines are not followed? 41

42. Information in the Skills Procedures
Review the steps of each of the skills procedures.
Make sure you understand why the steps are important.
What could happen if each of the steps are not followed or are followed out of order?
Objective #16: Answer questions about the skills in this chapter.
Ask students questions about the steps of performing the skills and the rationales for those steps. Ensure that students understand why they do what they do during the skills procedures. (Refer to Skills 17-1 through 17-8.) 42