Chapter 10: Vital Signs

Question 1

How often are vitals taken?

Answer 1

Really depends on the hospital, unit, patient, etc.
At least every 8 hours

Question 2

Temperature

Answer 2

Normal range: 35.8 C to 37.3 C (96.4 F to 99.1 F)
Make sure to write down the route of temperature (oral, axillary, tympanic, temporal, rectal)

Question 3

Pulse

Answer 3

Rate: 60-100 beats more minute
Rhythm: regular or arrhythmia
Force: amplitude (0 = absent; 1+ = thready; 2+ = normal; 3+ bounding)

Question 4

Respirations

Answer 4

Normal: 12-20
Don’t draw attention to your assessment because the patient may change their breathing pattern

Question 5

Blood Pressure

Answer 5

Normal: 120/80
Document the position they’re in and which arm you use (keep arm restrictions into consideration)

Question 6

Systolic Pressure

Answer 6

Maximum pressure felt on the artery during left ventricular contraction (systole)

Question 7

Diastolic Pressure

Answer 7

Elastic recoil, or resting, pressure that blood exerts constantly between each contraction (diastole)

Question 8

Pulse Pressure

Answer 8

Difference between the systolic and diastolic pressure; reflects stroke volume (SV)

Question 9

Mean Arterial Pressure (MAP)

Answer 9

Pressure forcing blood into the tissues, averaged over cardiac cycle

Question 10

What are factors that influence BP?

Answer 10

Age: increases with age
Gender: men tend to have higher BP
Diurnal rhythm: BP tends to be lower in the morning than in the evening

Question 11

Orthostatic BP

Answer 11

Drop in BP when changing positions (sitting to standing); indicates a fall risk

Question 12

Oxygen Saturation (SpO2)

Answer 12

Measures how saturated with hemoglobin
Normal: 95-100
Patients with COPD have a lower baseline (88)
Document how they are receiving air (normal or intervention)

Question 13

Pain

Answer 13

Subjective; however, we use a scale to try to obtain some type of objective reading
Scale: 0-10 (or faces for children, nonverbal patients, etc)