Pepito, Alyssa Marie

BSN-1A

1. Describe factors that affect vital signs

➢ Temperature: Age, Diurnal variations (circadian rhythms), Exercise, Hormones, Stress and Environment
➢ Pulse: Age, Sex, Exercise, Fever and Medications
➢ Respirations: Exercise, stress, high environmental temperature and low oxygen increase respiratory rate, Low
environmental temperature, some medications, and increased intracranial pressure decrease respiratory rate
➢ Blood Pressure: Age, Exercise, Stress, Race, Sex, Medications, Obesity, Diurnal variations, Medical conditions,
Temperature
➢ Oxygen Saturation: Hemoglobin, Circulation, Activity and Carbon monoxide poisoning

2. Identify variations in normal body temperature, pulse, respirations, and blood pressure that occur from infancy to
old age

➢ Body temperature:
Normal body temperature can range from 97.8° F (36.5°C) to 99°F (37.2°C) for a healthy adult. Body temperature
may be abnormal due to fever (high temperature) or hypothermia (low temperature.

Babies and children- In babies and children, the average body temperature ranges from 97.9°F (36.6°C) to 99°F
(37.2°C).
Adults- Among adults, the average body temperature ranges from 97°F (36.1°C) to 99°F (37.2°C).
Adults over age 65 - In older adults, the average body temperature is lower than 98.6°F (37°C).

➢ Pulse rate:
➢ Respiration:

➢ Blood pressure:

3. Recognize when it is appropriate to delegate measurement of vital signs to unlicensed assistive personnel (UAP)

The nurse can delegate the measurement of vital signs to unlicensed assistive personnel if they conclude that the
patient's condition allows it and the NAP has the skills to measure the vital signs. Unlicensed assistive personnel are
paraprofessionals who assist individuals with physical disabilities, mental impairments, and other health care needs with
their activities of daily living.
4. Demonstrate beginning skills in assessing:

➢ Body temperature:
• Oral- This site is frequently used because it is very convenient and accessible. Food, fluids, or warm smoke
can affect mouth temperature. Thermometer is place under the tongue and close the lips around it.
• Rectal- Considered to be very accurate but inconvenient and unpleasant for patients. It is difficult for
patient who cannot turn to the side.
• Axillary- Preferred for newborns where we place the thermometer in the axilla while adducting the with
the arm of the patient.
• Tympanic membrane- where the thermometer where we insert the thermometer into the ear canal
• Skin/temporal artery- newer, noninvasive method in obtaining body temperature.

➢ Peripheral pulse
• Assess peripheral pulses by palpating with gentle pressure over the artery. Use the pads of first three
fingers.
• Note for rate, rhythm, symmetry and applitude (4= bounding, 3= increased, 2= normal, 1= weak, 0= absent
or nonpalpable)

Tachycardia- Excessively fast heart rate (over 100 bpm)

Bradycardia- Heart rate of less than 60 bpm in adults

➢ Apical and radial pulses

• Determine need to assess for pulse deficit. Irregular heart rate & signs &symptoms such as dyspnea,
fatigue, chest pain & palpitations may indicate cardiac funcntion.
• Assist patient to supine or sitting position.
• Locate apical and radial pulse sites. Auscultate apical pulse while 2nd provider padial pulse.
• Begins pulse count by calling out loud when to begin counting pulse.
• Complete a 60 second pulse count simultaneously. Sixty seconds is required when a discrepancy between
pulse sites is expected or when the rhythm is irregular.

➢ Blood pressure
• Direct (invasive monitoring)- requires the placement of a catheter into a peripheral artery, most
commonly the dorsal metatarsal or femoral artery in smaller patients, although any accessible artery
could be used.
• Indirect- involves collapsing the artery with an external cuff, providing an inexpensive and easily
reproducible way to measure blood pressure. The indirect method can be performed using a manual cuff
and sphygmomanometer, a manual cuff and doppler ultrasound, or with an automated oscillometric
device.
• Korotkoff sounds

Auscultatory- turbulent blood flow will occur when the cuff pressure is greater than the diastolic pressure and
less than the systolic pressure. The "tapping" sounds associated with the turbulent flow are known as Korotkoff
sounds.

Palpatory- Inflate the cuff rapidly to 70 mmHg, and increase by 10 mm Hg increments while palpating the radial
pulse. Note the level of pressure at which the pulse disappears and subsequently reappears during deflation will
be systolic blood pressure.

• Auscultatory gap- also known as the silent gap, is a period of diminished or absent Korotkoff sounds
during the manual measurement of blood pressure.
 ➢ Blood oxygenation using pulse oximetry

Infants:

• If an appropriate-sized finger or toe sensor is not available, consider using an earlobe or forehead sensor.
• The high and low pulse SpO2 levels are generally present at 95% and 80%, respectively, for neonates.
• The oximeter may be need to be taped, wrapped with an elastic bandage, or covered by stocking to keep
it in place.

Children:

• Instruct the child that the sensor does not hurt. Disconnect the probe whenever possible to allow for
movement.

Older adults:

• Use of vasoconstrictive medications, poor circulation, or thickened nails may make finger or toe sensors
inaccurate.
• Use a forehead or earlobe sensor if indicated.

5. Document appropriately vital signs findings

➢ Blood pressure: 90/60 mm Hg to 120/80 mm Hg

➢ Respiration: 12 to 20 breaths per minute
➢ Pulse: 60 to 100 beats per minute
➢ Temperature: 96.8°F to 99.5°F (36°C and 37.5°C); average 98.6°F (37°C)
➢ Oxygen saturation: Normal SpO2 95–100%

6. Value the important role of the nurse in assessing vital signs

The monitoring of vital signs is an essential part of nursing care. It is a time-consuming, tedious process in which
nurses measure and record thousands of normal vital signs throughout their careers. Nurses are often in charge of
overseeing vital sign monitoring and analyzing the data. Nurses bring a diverse set of skills and experience to the public's
benefit.