Vital Signs and Lab Reference Intervals

Question 1

Vital signs

Answer 1

Includes temperatura, pulse, respirations, BP, oxygen saturation and pain assessment.
May be delegated to AP but the nurse is responsible for interpretation.

Question 2

When vital signs are measured

Answer 2

• Initial contact
• Physical assessment
• Before and after invasive diagnostic procedure or surgical procedure
• During adm of medication that affects the cardiac, respiratory or temperature controlling functions
• Before, during and after blood transfusion
• Whenever a client’s condition changes (or verbalizes)
• Whenever a intervention may affect a client’s condition
• When a fever or known infection is present (check every 2 to 4 hours)

Question 3

Temperature

Answer 3

Normal range in fahrenheit: 97.5 to 99.5.
Conversion F to C: F - 32 x 5/9 = C
Conversion C to F: C x 9/5 + 32 = F
Temp may fluctuate during first year because mechanism is not fully developed.
Temp decreases before ovulation and increase during ovulation.
Pregnancy: body temp may stay at high normal because of increase in metabolic rate.
Stress increases hormone secretion leading to increase in temp.
Illness due to infective agents and inflammatory response.
The inability to obtain a temp should not be ignored (may be hypothermia)

Question 4

Methods of temperature measurement

Answer 4

Oral, rectal, axillary, tympanic, temporal artery

Question 5

Pulse Grading Scale

Answer 5

4+ strong and bounding
3+ full pulse, increased
2+ normal, easily palpable
1+ weak, barely palpable
0 absent, not palpable

Question 6

Pulse Points and Locations

Answer 6

• temporal artery
• carotid artery
• apical pulse
• brachial pulse
• radial pulse
• ulnar pulse
• femoral pulse
• popliteal pulse
• posterior tibial pulse
• dorsalis pedis pulse

Question 7

Pulse deficit

Answer 7

In this condition, the peripheral pulse rate (radial) is less than the ventricular contraction rate (apical)
Indicates that cardiac contractions are ineffective, failing to send pulse waves to the periphery.

Question 8

Respirations

Answer 8

RR: 12 to 20 rpm
An increased level of carbon dioxide or a lower level of oxygen in the blood results in an increase in RR.
Head injury or increased intracranial pressure will depress the respiratory center in the brain, resulting in shallow or slowed breathing.
Medications such as opioid analgesics depress resp.
Additional factors that can affect: exercise, pain, anxiety, smoking and body position.

Question 9

Blood pressure

Answer 9

BP is the force on the walls of an artery exerted by the pulsating blood under pressure from the heart.
To obtain orthostatic vital sign, check BP in supine, sitting and standing. Wait 1 - 3 min after changing positions to check.
- BP tends to increase with age progress
- stress results in sympathetic stimulation that increases BP
- high BP is higher among african americans
- antihypertensive meds and opioids can decrease BP
- BP is typically lower in the morning and gradually increases during the day
- after puberty, males tend to have higher BP and after menopause, women tend to have higher.
- smoking, activity and body weight tend to affect BP

Question 10

Hypertension categories

Answer 10

Normal: less than 120/80 mmHg.
Elevated: systolic between 120-129 or diastolic less than 80 mmHg.
Stage 1: systolic between 130-139 or diastolic between 80-89 mmHg.
Stage 2: systolic at least 140 or diastolic at least 90.
Hypertensive crisis: systolic over 180 and/or diastolic over 120 mmHg.

Question 11

Pulse oximetry

Answer 11

Normal value 95-100%
Factors that affect light transmission: sensor movement, nail polish, hypotension, anemia, or peripheral vascular disorders.
A sensor may be placed on finger, toe, nose, earlobe or forehead.

Question 12

Pain assessment

Answer 12

Numerical, descriptive, visual analog and faces.

Question 13

Conventional nonpharmacological interventions

Answer 13

Cutaneous stimulation
- heat, cold, pressure and vibration (may require prescription)
Transcutaneous electrical nerve stimulation (TENS)
- application of a battery-operated device that delivers a low electrical current to the skin and underlying tissues to block pain (may require prescription)
Binders, slings and other supportive devices
Complementary and alternative therapies:
- acupuncture and acupressure, biofeedback, chiropractic manipulation, distraction techniques, guided imagery, meditation, herbal, hypnosis, humor, massage, relaxation and repositioning, spiritual measures, therapeutic touch.

Question 14

Pharmacological interventions for pain: Nonsteroidal antiinflammatory drugs (NSAIDs) and acetylsalicylic acid (aspirin)
**AINES, AAS

Answer 14

Contraindicated if the client has gastric irritation or ulcer disease or an allergy.
Bleeding is a concern.
Instruct the client to take oral doses with food or milk.
NSAIDs can amplify the effects of anticoagulants.
Hypoglycemia may result for the client taking ibuprofen and oral antidiabetic agent.
A high risk of toxicity exists if the client is taken ibuprofen with calcium channel blocker.

Question 15

Pharmacological interventions for pain: Acetaminophen (tylenol)

Answer 15

Contraindicated in clients with hepatic or renal disease, alcoholism, or hypersensitivity.
Monitor the client for signs of hepatic damage and liver function parameters.
Risk of hepatotoxicity if taken for more than 10 days (adult) or 5 days (child).
The antidote is acetylcysteine.

Question 16

Pharmacological interventions for pain: Opioides

Answer 16

• Suppress pain impulses but can also suppress respiration and coughing by acting on the center located in the medulla of the brainstem.
• clients with impaired renal or liver function may only tolerate low doses, assess for allergy.
• IV route produces faster effect but lasts shorter.
• opioids, which produce euphoria and sedation, can cause physical dependence.
• adm 30 to 60 minutes before painful activities.
• monitor RR, if <12 withhold medication and notify PHCP.
• monitor BP, if hypo withhold and notify.
• monitor HR, if brady withhold and notify.
• Encourage activities: turning, deep breathing and incentive spirometry to help prevent atelectasis and pneumonia.
• monitor level of consciousness.
• monitor intake and output, assess urine retention; also constipation is common.
• instruct oral doses with food or milk.
• assess effectiveness 30 min after.
• have opioid antagonist (nalaxone), oxygen and resuscitation equipment available.

Question 17

Pharmacological interventions for pain: Codeine sulfate (opioid)

Answer 17

• also used in low doses as a cough supressant.
• may cause constipation.
• common medications in this class: hydrocodone and oxycodone.

Question 18

Pharmacological interventions for pain: Hydromorphone (opioid)

Answer 18

• primary concern is respiration depression.
• other effects include drowsiness, dizziness, and orthostatic hypotension.
• monitor VS, specially RR and BP.

Question 19

Pharmacological interventions for pain: Morphine sulfate (opioid)

Answer 19

• used to ease acute pain resulting from myocardial infarction or cancer, for dyspnea resulting from pulmonary edema, and as perioperative medication.
• major concern is respiratory depression, but postural hypotension, urine retention, constipation and pupillary constriction may also occur.
• may cause nausea and vomiting by increasing vestibular sensitivity.
• contraindicated in severe respiratory disorders, head injuries, severe renal disease or seizure activity and in the presence of increased intracranial pressure.
• monitor for urine retention, bowel sounds and pupil (pinpoint may indicate overdose).

Question 20

Serum sodium

Answer 20

• maintains osmotico pressure and acid-base balance, and assists in the transmission of nerve impulses.
• is absorbed from the small intestine and excreted in the urine.
• normal reference: 135-145 mEq/L
• elevated: dehydration, impaired renal function, increased dietary or IV intake, primary aldosteronism, use of corticosteroid therapy.
• below: addison’s disease, decreased dietary, diabetic ketoacidosis, diuretic therapy, excesive loss from the GI, excessive perspiration, water intoxication.

Question 21

Serum potassium

Answer 21

• prolonged use of tourniquet before venous sampling can increase the blood level of K+.
• regulates cellular water balance, electrical conduction in muscle cells, and acid-base balance.
• obtains through dietary and kidneys preserve or excrete depending on need.
• used to evaluate cardiac, renal, GI function and the need for IV replacement.
• normal reference: 3.5-5.0 mEq/L
• elevated: acute kidney injury, chronic kidney disease, addison’s, dehydration, diabetic ketoacidosis, excessive dietary or IV intake, massive tissue destruction, metabolic acidosis.
• below: burns, cushing’s, deficient dietary intake, diarrhea, diuretic, GI fistula, insulin adm, pyloric obstruction, starvation, vomiting.
• clients with elevated WBC counts and platelet may have falsely elevated K+ levels.

Question 22

Activated partial thromboplastin time (aPTT)

Answer 22

• evaluates how well the coagulation sequence is functioning.
• test screens for deficiencies and inhibitors of all factors except VII and VIII.
• is usually used to monitor the effectiveness of heparin therapy and screen for coagulation disorders.
• normal reference 30-40 seconds.
• if the client is receiving heparin, draw the blood 1 hour before the next dose. Also, should be 1.5 to 2.5 times normal.
• elevated: deficiency of one or more factors, hemophilia, heparin therapy, liver disease.
• if longer than 100 sec initiate bleeding precautions.

Question 23

Prothrombin time (PT) and international normalized ratio (INR)

Answer 23

• prothrombin is a vitamin K-dependent glycoprotein produced by the liver that is necessary for fibrin clot formation.
• the PT measures the amount of seconds it takes to form a clot.
• used to monitor response to warfarin or to screen for dysfunction of the extrinsic cloting system resulting from liver disease, vit K deficiency or disseminated intravascular coagulation.
• the INR is a frequently used test to measure the effects of some anticoagulants.
• diets high if leafy vegetables can increase the absorption of vit K, which shortens the PT.
• PT: 11 to 12.5 sec
• INR: 0.81 to 1.20 sec
• elevated: deficiency of factors I, II, V, VII or X; liver disease; vit K deficiency; warfarin therapy.

Question 24

Platelet Count

Answer 24

• function in hemostatic plug formation, clot retraction, and coagulation factor activation.
• produced by the bone marrow.
• normal reference: 150,000 to 400,000 mm3.
• elevated: acute infections, chronic granulocytic leukemia, chronic prancreatitis, cirrhosis, collagen disorders, polycythemia, postsplenectomy, high altitudes, and chronic cold weather.
• below: acute leukemia, chemotherapy, disseminated intravascular coagulation, hemorrhage, infection, systemic lupus erythematosus, thrombocytopenic purpura.

Question 25

Hemoglobin and hematocrit

Answer 25

• fasting is not required
• hemoglobin main component of erythrocytes and serves as the vehicle for oxygen and carbon dioxide. Elevated in chronic obstructive pulmonary diasease, high altitudes and polycythemia. Below in anemia and hemorrhage.
• hematocrit represents red blood cell mass (volume percentage). Elevated in dehydration, high altitudes, polycythemia. Below in anemia, bone marrow failure, leukemia, overhydration.
• normal reference:
  Hb male 14 - 18 g/dL; female 12 - 16 g/dL
  Ht male 42 - 52 %; female 37 - 47%

Question 26

Lipids

Answer 26

Abstain from food and liquids (except water) for 12-14 hours, and alcohol for 24 hours before test.
Normal reference:
Cholesterol < 200 mg/dL
HDL > 60 md/dL
LDL < 100 mg/dL
Triglycerides MALE 40-160 mg/dL
FEMALE 35-135 mg/dL

Question 27

Fasting blood glucose

Answer 27

• formed from the digestion of carbohydrates and the conversion of glycogen by the liver.
• main source of cellular energy and is essential for brain and erythrocyte function.
• fast for 8 to 12 hours.
• instruct the client with DM to withhold morning insulin or oral hypoglycemic med until after the blood is drawn.
• reference: 70 - 99 mg/dL
• elevated: acute stress, cerebral lesions, cushing’s, DM, hyperthyroidism, pancreatic insufficiency.
• below: addison’s, insulin overdose, hepatic disease, hypothyroidism, pancreatic tumor, pituitary hypofunction, postdumping syndrome.

Question 28

Glycosylated hemoglobin (HgbA1C)

Answer 28

• is a blood glucose bound to hemoglobin.
• is a reflection of how well blood glucose levels have been controlled for the past 3 to 4 months.
• fasting is not required.
• normal reference: < 6%
• elevated: poorly controlled DM, nondiabetic hyperglycemia.
• below: chronic blood loss, chronic kidney disease, pregnancy, sickle cell anemia.

Question 29

Renal function: Serum Creatinine

Answer 29

• increased levels indicate a slowing of the glomerular filtration rate.
• instruct to avoid excessive exercise for 8 hours and excessive red meat for 24 before test.
• normal male: 0.6 to 1.2 mg/dL (53-106 mcmol/L)
• normal female: 0.5 to 1.1 mg/dL (44-97 mcmol/L)
• elevated in renal disease.
• below in diseases with decreases muscle mass such as muscular dystrophy and myasthenia gravis.

Question 30

Renal function: blood urea nitrogen (BUN)

Answer 30

• substance formed in the liver through an enzymatic protein process breakdown and is filtered through the renal glomeruli, with a small amount reabsorbed in the tubules and the remainder excreted in the urine.
• normal: 10 to 20 mg/dL
• elevated indicates slowing of the glomerular filtration rate. Occurs in burns, dehydration, GI bleeding, fever, stress, renal disease, shock, ITU.
• below: fluid overload, malnutrition, severe liver damage, syndrome of inappropriate antidiuretic hormone.

Question 31

White blood cell (WBC) count

Answer 31

• normal ref: 5000 to 10000 mm3.
• Neutrophils (60-70%) is usually associated with a bacterial infection. When there is a shift to the left, it means that an increased number of immature neutrophilis is present in the blood (bastoes). A shift to the right means that cells have more than the usual number of nuclear segments (liver disease, down’s syndrome, megaloblastic and pernicious anemia).
• Lymphocytes (20-25%): usually elevates on viral infections.
• Monocytes (3-8%): viral and bacterial infections.
• Eosinophilis (2-4%): parasits, asthma and allergy.
• Basophilis (0.5-1%): allergy process and chronic inflammation.