Vital Signs Overview for Nursing

Study Notes

Vital Signs

Temperature:
- Axillary: Best for babies.
- Temporal/Tympanic: Common for children and adults.
- Rectal: Used for core temperature only.
Pulse:
- Newborn: 110-160 bpm.
- Adult: 60-100 bpm (decreases with age).
- Increased by: Fever, pain, anxiety, activity, stimulants.
- Decreased by: Sleep, medications, certain medical conditions (e.g., heart block).
Respiration Rate (RR):
- Measured for a full minute, assessing rate, depth, pattern, and effort.
- Normal: >12 breaths/minute (except during sleep).
- Decreased by: Opioids, benzodiazepines, anesthesia.
Blood Pressure:
- Increased by: Pain, stimulants, fluid overload (FVO).
- Decreased by: Dehydration, fluid volume deficit (FVD), shock.
Oxygen Saturation: Measures oxygen levels in the blood.
Pain (6th Vital Sign): Assessed using OPQRST:
- O: Onset
- P: Provocation/Palliation
- Q: Quality
- R: Radiation
- S: Severity
- T: Timing

Physical Assessment

Purpose: Gathering patient health data, identifying problems, and guiding care planning.
Techniques:
- Inspection: Observing the patient.
- Palpation: Feeling for abnormalities (masses, tenderness, temperature changes).
- Percussion: Tapping to assess underlying structure (e.g., dullness, resonance).
- Auscultation: Listening to sounds (heart, lungs, bowels).
Abdomen Assessment:
- Inspect, auscultate, percuss, palpate (essential order to avoid altering bowel sounds).
General Impression:
- Appearance: Posture, facial expression, hygiene, tone.
- Position: Patient's posture and movement.
- Distress Level: Patient's pain or discomfort.
- Mental Status: Speech, thoughts, alertness.
HEENOT (Head, Eyes, Ears, Nose, Throat):
- Cranial Nerve Assessment.
- PEARRLA: Pupils Equal and Reactive to Light and Accommodation.
- EOMI: Extraocular Movements Intact.
- Tongue and mucosa: Assess hydration.
- Palate: Check for pallor (anemia) or jaundice.
Chest/Thorax:
- Cardiac: Listening for heart sounds (S1, S2, S3, S4, murmurs), palpating PMI.
- Chest Wall: Assessing for crepitus, tactile fremitus, and chest expansion.
- Lungs: Listening for abnormal sounds (rhonchi, wheezes, crackles, pleural friction rub).
Abdomen:
- Four quadrants: Inspect and palpate for abnormalities.
- Percussion Sounds:
  - Flat: Over bone.
  - Dull: Over solid organ.
  - Tympany: Over hollow organ.
Extremities:
- CSMP: Color, Sensation, Mobility, Perfusion (assess color, temperature, capillary refill, pulses).
- 6 Ps of Compartment Syndrome: Pain, Pressure, Paresthesias, Paralysis, Pulselessness, Pallor.
- Chronic Arterial Insufficiency: Pale, cold, thin skin, no hair growth, pain with elevation.
- Chronic Venous Insufficiency: Edema, brownish skin, ulcers.
Skin: Checking for pallor, jaundice, cyanosis, erythema.

Focused Assessments

Purpose: Concentrating on specific problems, injuries, or complaints.
Prioritizing care based on urgency.
Common Assessments: Pulses, perfusion, pain, inspecting injury then palpating (avoid worsening damage).

Shock vs. Increased Intracranial Pressure (ICP)

Shock:
- Signs: Tachycardia, tachypnea (shallow), hypotension, restlessness, anxiety, pale, cool, clammy skin, decreased urine output.
Increased ICP:
- Signs: Bradycardia, bradypnea, hypertension (widening pulse pressure), unequal/dilated pupils, anxiety, restlessness, headache; Cushing's triad: Hypertension, bradycardia, irregular respirations.

Fluid Volume Balance

Fluid Volume Deficit (FVD):
- Signs: Tenting/poor skin turgor, dry/cracked tongue, tachycardia, tachypnea, hypotension.
- Pediatrics: Sunken fontanelles, sunken orbits.
Fluid Volume Overload (FVO):
- Signs: Edema, crackles, JVD, weight gain, tachycardia, tachypnea, hypertension.
- Pediatrics: Bulging fontanelles, orbital edema.

Description

This quiz covers essential aspects of vital signs, including temperature, pulse, respiration rate, blood pressure, and oxygen saturation. It also delves into the importance of pain assessment as the '6th vital sign' using the OPQRST method. Test your knowledge on these critical indicators of health!