Vital Signs Basics
What are the five cardinal vital signs traditionally monitored in patients?
Temperature, pulse, respiration, blood pressure, and oxygen saturation.
Whose responsibility is it to ensure accurate measurement of vital signs, even when delegated?
The Nurse
What physiological process produces heat as a by-product in the body?
Metabolism.
What does the pulse rate measure?
The number of cardiac cycles per minute.
What two measurements make up a blood pressure reading?
Systolic and diastolic pressures.
Why should equipment be cleaned between uses?
To reduce the risk of infection.
Which additional vital sign is considered a standard of care in many settings?
Pain.
Why is it essential to choose the correct equipment size, such as a blood pressure cuff?
To ensure accurate measurements.
Name one mechanism the body uses to lose heat.
Radiation, conduction, convection, or evaporation.
Name other common sites to check for a pulse other than the radial site?
Carotid, brachial, or apical pulse.
What device is used to measure blood pressure?
A sphygmomanometer.
What should be monitored to prevent skin breakdown during blood pressure measurements?
Rotate sites and avoid repeated use on the same area.
Why are vital signs important in patient care?
They are essential for monitoring conditions, identifying problems, and evaluating responses to interventions.
What should a nurse do if there’s a significant change in a patient’s vital signs?
Communicate it promptly to the healthcare provider.
Which factor does NOT influence body temperature: age, time of day, or hair color?
Hair color
What is the normal respiratory rate for an adult?
12-20 breaths per minute.
Define orthostatic hypotension.
A drop in blood pressure upon change in position
When should abnormal findings in vital signs be reported?
Immediately
Name a factor that could alter a patient’s vital signs.
Environmental temperature, physical exertion, medications, or illness.
Name two actions a nurse should take to prepare for accurate vital sign measurement.
Ensure equipment is functioning properly and provide patient privacy.
How does the body respond to cold temperatures to maintain core temperature?
Through mechanisms like shivering and vasoconstriction.
What term is used to describe a respiratory rate above the normal range?
Tachypnea
What is a normal oxygen saturation range as measured by pulse oximetry?
95-100%.
Why might a care plan need to be adjusted based on vital sign trends?
To address changes in the patient's health condition.
How does knowing a patient's baseline vital signs assist healthcare providers?
It helps identify changes that might indicate clinical deterioration.
How often should vital signs be taken, and what determines this frequency?
It depends on the patient’s condition and should be decided in collaboration with healthcare providers.
Why is the rectal site often more accurate for measuring core temperature?
Because it reflects the body’s core temperature more precisely than surface sites.
What might an irregular pulse rhythm (dysrhythmia) indicate?
It may indicate a need for further evaluation due to potential cardiac issues.
Name factors that can interfere with the accuracy of a pulse oximeter reading.
Cold extremities, patient movement, or nail polish.
Name one environmental factor to control for an accurate vital sign assessment.
Room temperature.