Master Vital Signs - Adult with Picmonic for Nursing RN

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Neurovascular Assessment 6 P's

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The Nursing Process

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Vital Signs - Adult

Vitals Sign of Adults

Picmonic

Vital signs are an important part of a nurse's physical assessment. It should be done on a routine basis to watch for trends that could indicate the patient's condition might change. Vital signs should also be done whenever the nurse suspects or observes a change in the patient. Using the right equipment that is functioning properly is necessary for proper treatment to take effect. It is important to remember that every person is unique, and everyone has his or her own baseline.

8 KEY FACTS

The human body maintains the body temperature between 96.8°-100.4°F (36°-38°C). A variety of factors can influence one's temperature: infection, sepsis, trauma, medicine, and hormone imbalance. It is important to alert the provider when the temperature is out of range. Warm blankets can be used to warm a patient up, or ice packs, medicine, fan, and an ice bath can be used to cool a patient down.

Rectal temperature typically is about one degree higher than the oral temperature. Therefore, one must subtract a degree from the measured rectal temperature before it can be compared to the standard temperature range (96.8°-100.4°F). This route is typically only done when the oral and axillary route cannot be used. Do not insert the thermometer too far into the rectum to avoid perforation of the bowel.

Axillary temperature typically is about one degree lower than the oral temperature, because of the exposure to the environment. Therefore, one must add a degree to the measured axillary temperature before it can be compared to the standard temperature range (96.8°-100.4°F). This route is best used with newborns and unconscious patients.

Respiration is defined as the body’s ability to move oxygen into the blood and into the cells at the same time removing CO2 from the body. However, there are some key terms that are involved in respiration. Ventilation is the movement of air/gas in and out of the lungs, also called respiratory rate. Diffusion is the movement of oxygen and CO2 between the air/gas and the blood. Lastly, perfusion is the body's ability to take the oxygenated red blood cells to the rest of the body.

Oxygen saturation is the measurement of the body’s ability to diffuse and perfuse. A pulse oximeter has a light-emitting diode (LED) that reads light reflected from hemoglobin molecules. The most common areas to attach the sensor are the fingers, toes, or earlobes. It is important to remember, if a patient has nail polish on, is hypothermic, experiencing vasoconstriction, peripheral edema, or has abnormal hemoglobin levels. the sensor reading may not be accurate.

The pulse is the palpable sensation that can be felt after the heart contracts. The pulse rate is the total beats per minute that is felt or auscultated. Common areas to palpate for a pulse are the radial, carotid, and femoral arteries. If there is a dysrhythmia or there is a weak pulse, the apical pulse should be checked. The apical pulse can be check by auscultating between the fourth and fifth intercostal space at the left midclavicular line.

When the heart contracts and the blood is pushed out, there is a force placed on the artery walls. The force exerted on the artery wall can be measure by taking one's blood pressure. Two types of pressure are being measure with the blood pressure. The systolic, which is the high pressure (range from 90-120mm Hg) caused by the heart contracting and blood being pushed into the aorta. The other type is the diastolic, the low pressure (range from 60-80 mm Hg). This measures the amount of continuous pressure on the artery walls after contraction of the heart and the ventricles relax. For healthy adults, a blood pressure less than 120/80 is normal per the ACC/AHA. It is important to use the correct blood pressure cuff, because using an incorrect size can alter blood pressure reads.

Pain is often referred to as the fifth vital sign. It should always be assessed while taking the patient’s temperature, pulse, blood pressure, and respirations. Pain can have a variety of effects on a patient both physical and psychological. If a patient has pain, their care plan needs to address the problem adequately.

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