VITAL SIGNS LISTENING GUIDE
Measuring Vital Signs
 The four vital signs of body function are:
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_____________________
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_____________________
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_____________________
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_____________________
 MEASURING AND REPORTING VITAL SIGNS
 Vital signs:
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Are measured to detect changes in normal body function
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Tell about responses to treatment
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Often signal life-threatening events
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Are part of the assessment step in the nursing process
 Vital signs are measured:
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During physical ______________________
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When the person is ____________________ to the nursing center
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As often as required by the person’s____________________
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____________ and ______________ surgery
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Before and after complex __________________ or __________________tests
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After some care measures, such as ___________________
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After _______________ or other injury
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When drugs affect the ______________or circulatory system
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When there are complaints of pain, dizziness, lightheadedness, shortness of breath, rapid heart
rate, or not feeling well
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As stated on the ___________ _____________
 ______________________is essential when you measure, record, and report vital signs.
 Unless otherwise ordered:
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Take vital signs with the person ____________ or _________________.
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The person is at________________when vital signs are measured.
 Report the following at once:
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Any vital sign that is ________________ from a prior measurement
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Vital signs above the normal range
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Vital signs below the normal range
 If you cannot measure vital signs, __________________________________.
 BODY TEMPERATURE IS THE AMOUNT OF HEAT IN THE BODY.
 Thermometers are used to measure _____________________.
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It is measured using the _____________(F)and centigrade or _______(C) scales.
 Temperature sites are the __________, _________, _________, tympanic membrane, and temporal
artery.
 _______________means an elevated body temperature.
 Always report temperatures that are above or below the normal range.
 These types of thermometers are used:
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Glass thermometers
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Electronic thermometers
 Some have oral and rectal probes
 _________________ membrane thermometers (Ear)
 ____________________ artery thermometers (Temple)
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Digital
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Disposable oral thermometers
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Temperature-sensitive tape
 A PULSE IS FELT EVERY TIME THE HEART BEATS.
 Pulse sites
Pulse Site
Location
Used For
Carotid
Heart
Front of the elbow
Use a stethoscope
Radial
Behind the knee
Ankle
Assessment
Dorsalis Pedis
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The temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis
(pedal) pulses are on each side of the body.
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The _______________________ pulse is used most often.
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The carotid pulse is taken during _____________and other emergencies.
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The apical pulse is felt over the _____________________.
 This pulse is taken with a stethoscope.
 To use a stethoscope:
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Wipe the earpieces and diaphragm with antiseptic _____________before and after use.
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Place the earpiece tips in your ears.
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Place the diaphragm over the artery.
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Prevent noise.
 The pulse rate is the number of heartbeats or pulses felt in 1 ______________
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The rate varies for each age-group.
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The adult pulse rate is between _____________________ beats per minute.
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Report abnormal pulses to the nurse at once.
 Fast heart rate______________________
 Slow heart rate_____________________
 The rhythm of the pulse should be regular.
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An ____________________ pulse occurs when the beats are not evenly spaced or beats are
skipped.
 Force relates to pulse strength.
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A forceful pulse is described as strong, full, or bounding.
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Hard-to-feel pulses are described as weak, thready, or feeble.
 You must count pulses accurately.
 You must report and record the pulse rate accurately.
 The apical pulse is on the _________________ side of the chest slightly below the nipple.
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It is taken with a ______________________.
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Count the apical pulse for ________________________.
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Count each lub-dub as one beat.
 The apical and radial pulses should be equal.
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To see if the apical and radial pulses are equal, __________ staff members are needed.
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The pulse________________ is the difference between the apical and radial pulse rates.
 RESPIRATIONS
 Respiration means breathing air into __________________and out of _______________ the lungs.
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________________ enters the lungs during inhalation.
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____________ _______________ leaves the lungs during exhalation.
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The chest rises during inhalation and falls during exhalation.
 The healthy adult has _________________ respirations per minute.
 Respirations are normally quiet, effortless, and regular.
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______ _________ of the chest rise and fall equally.
 Count respirations when the person is at____________.
 Count respirations right after taking a pulse.
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Keep your fingers or stethoscope over the pulse site.
 To count respirations, watch the chest rise and fall.
 BLOOD PRESSURE
 Blood pressure is controlled by:
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The force of heart contractions
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The amount of blood pumped with each heartbeat
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How easily the blood flows through the blood vessels
 The period of heart muscle contraction is called _________________.
 The period of heart muscle relaxation is called __________________.
 Blood pressure is measured in millimeters (mm) of mercury (Hg).
 The_______________ pressure is recorded over the _________________ pressure.
 Blood pressure has normal ranges:
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Systolic pressure—less than __________ mm Hg
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Diastolic pressure—less than __________ mm Hg
 _________________—blood pressure measurements that remain above a systolic pressure of 140 mm
Hg or a diastolic pressure of 90 mm Hg
 _______________ —when the systolic blood pressure is below 90 mm Hg and the diastolic pressure is
below 60 mm Hg
 A stethoscope and a ___________________________ are used to measure blood pressure.
 Blood pressure is normally measured in the _____________________ artery.
 QUALITY OF LIFE
 You must protect the right to privacy when measuring vital signs.
 Always keep resident information confidential.
 The right to personal choice is important.