CBR MIDTERMS • Rale- An abnormal, discontinuous, nonmusical
sound heard on auscultation of the chest, primarily
ASSESSMENT OF VITAL SIGNS
KEY TERMS
• Anoxia- Absence of oxygen in the tissues.
• Apical pulse- The pulse that is found when a
stethoscope is placed on the chest wall over the
apex of the heart; also may be found by palpation.
• Apnea- The absence of breathing.
• Arrhythmia- Variation from the normal rhythm.
• Auscultation- Listening for sounds produced
within the body by using the unaided ear or a
stethoscope.
• Bradycardia- A slow heartbeat (i.e., pulse rate less
than 60 beats/min); may be a normal finding in a
well-conditioned person or an abnormal finding.
• Cardiac output- The amount of blood that is
pumped from the heart during each contraction.
• Diaphoresis- Profuse perspiration.
• Diastole- The period when the least amount of
pressure is exerted on the walls or the arteries
during the heartbeat; usually indicates the resting
phase of the heart.
• Dyspnea- Labored or difficult breathing
• Dysrhythmia- Disturbance of rhythm.
• Ectopic- Arising or produced abnormally.
• Expiration- The passive phase of respiration when
the person breathes out; also referred to as
exhalation.
• Fever- Body temperature that is above the normal
level; also referred to as pyrexia.
• Hypertension- Abnormally high blood pressure.
• Hypotension- Abnormally low blood pressure.
• Inguinal- Pertaining to the groin.
• Inspiration- The active phase of respiration when
the person breathes in; also referred to as
inhalation.
• Intubation- The insertion of a tube into the larynx
to maintain an open airway.
• Korotkoff’s sounds- Sounds heard during
auscultatory determination of blood pressure;
believed to be produced by the vibratory motion of
the arterial wall as the artery suddenly distends
when compressed by a pneumatic blood pressure
cuff; the origin of the sound may be within the blood
passing through the vessel or within the wall itself
• Occlude- To fit close together; to close tight; to
obstruct or close off.
• Orthopnea- A condition in which breathing is
easier when the person is seated or standing.
• Pulse- A palpable wave of blood produced in the
walls of the arteries with each heartbeat or
contraction.
• Pulse oximeter- A medical device that measures
levels of blood oxygen saturation, monitors pulse
rate, and calculates heart rate.
during inhalation; also called a crackle.
• Rectal- Pertaining to the rectum or the distal
portion of the large intestine.
• Respiration- The act of breathing. • SOB Shortness
of breath.
• Sphygmomanometer- An instrument used to
measure blood pressure; it may use a mercury
column or an enclosed air-pressure spring system.
• Stethoscope- An instrument used to convey
sounds produced in the body of a person to the ears
of the examiner; it is comprised of a diaphragm,
tubing, and earpieces.
• Syncope- A temporary suspension of
consciousness caused by cerebral anemia; fainting.
• Systole- The period when the greatest amount of
pressure is exerted on the walls of the arteries
during heartbeat; usually indicates the contractile
phase of the heartbeat.
• Tachycardia- An abnormally fast heartbeat (i.e., a
pulse rate greater than 100 beats/min).
• Vital signs- Measurement of a person’s body
temperature, heart and respiration rates, and blood
pressure; also referred to as cardinal signs.
VITAL / CARDINAL SIGNS
• Indicators of general health and physiologic status:
- Temperature
- Pulse
- Blood Pressure
- Respiration
- Pain
• Baseline measurement at rest should be
established:
- monitor changes in values and the causative
factor of these changes (abnormal)
- establish goals of treatment
- assess patient’s response to treatment, or
effectiveness of treatment
• General Factors affecting changes in VS:
- amount of physical activity
- environmental temperature
- age
- emotional status
- physiologic status of the person (illness,
trauma, meds)
(1) BODY TEMPERATURE
• Degree of heat within the body
• Unit of measurement: Celsius or Fahrenheit
• Guidelines:
- Monitor changes in body temp. before,
during, and after exercise
 - Sites: oral, rectal, axillary, inguinal,
forehead, temporal, ear canal
- Rectal: most accurate
- Axillary/Inguinal: least, due to air currents

• Apical Pulse- Monitored through auscultation

(stethoscope)

• Guidelines
o Radial and Carotid – commonly used sites;
easily accessed
o Apical – when the peripheral sites are difficult
to palpate
o Descriptions:
- Rate
- Rhythm
- Volume
o Apical and radial pulses may differ (peripheral
arterial disease); must be evaluated
simultaneously
o Pulse deficit: difference between apical and
radial
o If (+) pulse deficit, use apical pulse for
evaluation
• Strong and regular- indicates even beats with a
good force to each beat.
• Weak and regular- indicates even beats with a
poor force to each beat.
(2) PULSE
• Irregular- indicates that both strong and weak
• the movement of blood in an artery
beats occur during the period of measurement.
• indirect measure of the contraction of the left • Thready- indicates a weak force to each beat and
ventricle of the heart
irregular beats.
• indicates the rate at which the heart is beating
• Tachycardia- indicates a rapid HR (>100
• Unit of measurement: beats per minute or bpm beats/min).
• Bradycardia- indicates a slow HR (<60 beats/ min)
(2) PULSE OXIMETRY
• measures the level of blood oxygen saturation,
monitors pulse rate, and calculates HR
• Pulse oximeter device is placed over the fingertip
of the forefinger or ring finger (or at times the
earlobe)
• Normal: 95%-100%
• Hypoxemia: < 90%
• 3 Types
o Stationary digital pulse oximeter • The width of the bladder should be 40% of the
- Usually used in hospitals (ICU), with alarm circumference of the midpoint of the limb (refer to
system when abnormal reading is noted table 3-7).
o Handheld pulse oximeter • The length of the bladder is also important and
- Consist of a finger probe, and a handheld should be approximately twice the width of the
unit to display results bladder, or 80% of the arm circumference.
o Finger pulse oximeter
- What is commonly used now
- Finger probe with digital display of results

(3) BLOOD PRESSURE

• It is the force exerted by the blood against any unit
area of the vessel wall
• Device: Sphygmomanometer + Stethoscope
• Composed of: SYSTOLIC (contraction) and
DIASTOLIC (rest)
• Listening for Korotkoff’s sounds with a
stethoscope can identify the various phases of a
person’s BP (Phase I and V – most important to
identify)

(4) RESPIRATION
• Performed by Observation or Touch
• Unit of measurement: breaths per minute (bpm)
or cycles per minute (cpm)
• Descriptions:
o Rate- # of bpm
o Rhythm- regularity pattern
o Depth- amount of air exchanged with
respiration
o Character- deviations from the
normal/resting/quiet respiration
(5) PAIN
• an unpleasant sensory and emotional experience
associated with actual or potential tissue damage or
described in terms of such damage
• Pain screening or evaluation:
o Not limited to Intensity / scale
o Causes, location, duration, description
o Others:
- effects to lifestyles, work, sleeping pattern
- Effectiveness of medication