BSN Nursing Assessment Techniques Quiz

Assessing Vital Signs

• Begin the assessment by speaking with the client about their normal pulse rate.
• Palpate a peripheral pulse by placing the first two fingers on the pulse point with moderate pressure.
• Count the pulse rate for a full minute, noting the regularity (rhythm).

Pulse

• Normal pulse rate: 60-100 bpm.
• Bradycardia: less than 60 bpm.
• Tachycardia: greater than 100 bpm.
• Rhythm: pattern of beats (regular/irregular).
• Pulse volume: strength or size of the pulse.
• Bounding/full pulse: strong pulse, volume higher than normal.
• Thready/weak pulse: diminished strength, lacks fullness.
• Imperceptible pulse: cannot be felt or heard.

Breathing and Ventilation

• Normal breathing is active and passive.
• Women breathe thoracically, while men and young children breathe diaphragmatically.
• Assess breathing after taking pulse, while still holding the hand, so the patient is unaware.
• Ventilation: movement of air in and out of the lungs.
• Symmetrical breathing: sides of the chest normally rise and fall together.
• Asymmetrical breathing: rise and fall are not together.
• External respiration: interchange of O2 and CO2 between the alveoli and the pulmonary blood.
• Internal respiration: interchange of O2 and CO2 between the circulating blood and body tissues.

Arteries

• An artery is straight, smooth, soft, and pliable/elastic.
• Elastic artery contains collagen and elastin filaments, which gives it the ability to stretch in response to each pulse.
• Artery wall elasticity reflects expansibility and deformities.

Pulse Locations

• Popliteal pulse: located behind the knee in the popliteal fossa with the patient's knee flexed.
• Dorsalis pedis pulse: located on the dorsum of the foot with the foot plantar flexed.
• Palpate for this pulse halfway between the middle of the patient's ankle and the space between the great toe and the second toe.
• Posterior tibial pulse: located on the inner side of the ankle slightly below the medial malleolus.

Respiration and Blood Pressure

• Absence of bilateral equality affects blood pressure.
• Each time the heart beats, pressure is created that may indicate cardiovascular disorder.

Terminologies

• Rate: number of beats per minute (bpm).
• Rhythm: pattern of beats (regular/irregular).
• Dysrhythmia or arrhythmia: random, irregular beats or predictable pattern of irregular beats.

Assessing Pulse Rate

• Allow 5 minutes of rest before taking vital signs.
• The goal is to completely meet the patient's needs.

Temperature

• Normal temperature: 36.5 - 37.7 °C.
• Balance between the heat produced by the body and heat lost from the body.
• Two kinds of temperature: surface temperature and core temperature.
• Surface temperature fluctuates in response to the environment.
• Core temperature remains relatively constant.
• Temperature is lowest in the morning (4am-6am) and highest during the evening.

Vital Signs

• Temperature (T), pulse (P), and respiratory (R) rates, and blood pressure (BP) are the "cardinal signs".
• The "taking of vital signs" refers to the measurement of these signs.
• Vital signs are the first step in the physical examination.
• Clinical measurements that provide data that reflect the status of several body systems, including cardiovascular, peripheral vascular, neurologic, and respiratory systems.
• Pain is considered the 5th vital sign.