Vital Signs
The 6th vital sign
Pain
If drainage is present in the eyes, ears, or nose, assess for
Color, odor, consistency/characteristics, amount
This pulse grading is used to describe an increased, strong, or full pulse
These sounds can be heard without a stethoscope and is a high-pitched crowing sound.
Stridor
A bluish coloration in the skin, oral mucosa and/or nail beds related to a lack of oxygen to the tissues
Cyanosis
Body temperature less than 95F (35C)
Hypothermia
Assessment of orientation deficit
Person, place, time, situation
You assess this by applying pressure to the patient's digit then releasing, and observing the reaction
Capillary Refill
These breath sounds are continuous, low-pitched sounds that can be heard with inspiration and expiration. These can sometimes be cleared with coughing.
Rhonchi
Bleeding under the skin caused by trauma or injury
Ecchymosis
A blood pressure of 160/90 mm Hg. What is this called?
Hypertension
Documentation for the observation noted for the pupils reaction when a light is shined in the patient's eyes and when a patient looks at a distant object and then a close object.
PERRLA
When assessing these pulses, you will assess one at a time
Carotid Pulse
Whistling, high-pitched musical sounds made when air flows through narrowed airway passages. Can be heard on inspiration, expiration, or both.
Wheezes
Yellowish color of the skin and/or eyes related to an increase level of bilirubin and seen in liver disorders
Jaundice
The patient reports dizziness when going from a sitting to a standing position
Orthostatic Hypotension
Facial drooping, unequal movements, or slurred speech is indicative of what conditions?
Cranial nerve or central nervous system injury; stroke
Located at the left fifth intercostal space along the midclavicular line.
Apical Pulse; Point of Maximal Impulse (PMI)
This breath sound is a low-pitched, coarse, grating tone that is heard on inspiration and expiration
Pleural Friction Rub
Fluid accumulation in the interstitial spaces
Edema
Normal Vital Signs
Temp: 96.8F-100.4F (36C-38C)
HR: 60-100 bpm
SpO2: > 95%
RR: 12-20 breaths/min
BP: <120/80 mm Hg
The term used for crossed eyes
Strabismus
The names of the peripheral pulses that are palpated noting their rate, rhythm, and strength
Radial pulses, brachial pulses, femoral pulses, popliteal pulses, posterior tibial pulses, and dorsalis pedis pulses
This breath sound is an intermittent rattling, popping, or bubbling sound that can be fine and high-pitched or coarse and low-pitch. These sounds are not cleared by coughing.
Crackles or rales
Assessed by pinching a large fold of skin on the anterior chest, indicative of hydration status