Taking and Interpreting Vitals - NCLEX-PN

An overlarge blood pressure cuff will often result in a blood pressure reading that is artificially low. It is important that the nurse chooses the appropriate blood pressure cuff size for each individual patient.

The chest-piece of the stethoscope is made up of two components designed for auscultation: the bell and the diaphragm. The bell is dome-shaped and used for auscultation of low-pitched sounds, while the diaphragm is used to auscultate high-pitched sounds.

When taking a patient's blood pressure, the diaphragm alone should be used to listen at the antecubital fossa. The bell, used for low-pitched sounds, would not give the examiner accurate enough information to assess systolic or diastolic pressure.

Normal adult blood pressure is anywhere from 90-120 mmHg systolic over 60-80 mmHg diastolic. 120-140 mmHg over 80-90 mmHg would be considered pre-hypertension, while anything over that would be considered either stage I or stage II hypertension.

A patient with a one-time high blood pressure reading can not be diagnosed as hypertensive. A diagnosis of hypertension requires at least three measurements of blood pressure over 140/90 mmHg on at least two separate visits to health care provider.

Stage II hypertension is defined as a blood pressure equal to or greater than 160 mmHg systolic over 100 mmHg diastolic, taken at three different times on at least two separate occasions. Stage I hypertension is systolic blood pressure of 140-160 mmHg or diastolic blood pressure of 90-100 mmHg, while prehypertension is defined as a systolic blood pressure of 120-140 mmHg or diastolic blood pressure of 80-90 mmHg.

While most examiners remember to take the pulse, temperature, and blood pressure while assessing their patient's vitals, overall visual appearance is also an important part of an individuals vitals. Does the patient appear ill? Anxious? Are there any noticeable issues with hygiene or bizarre dress or movements? Are there any signs of pallor, jaundice, or cyanosis? All of these observations can be quickly noted in a patient's chart when taking vitals.

Tachycardia is the term used to describe a faster than normal heart rate. A heart rate of more than 100 beats per minute is considered tachycardic. Bradycardia is used to describe a slower than normal heart rate. Less than 60 beats per minute is considered bradycardia.

Afebrile is a term used to describe a patient who does not have a fever. Clinically, a fever is defined as a temperature greater than 100.4 Fahrenheit. Blood pressure, heart rate, and respiratory rate do not tell you if the patient has a fever.

The following scale applies to the amplitude of a pulse when palpated at the radial artery:

3+ is an increased or bounding pulse

2+ is a normal pulse

1+ is a weak pulse

0 is an absent pulse

The most appropriate location for assessing the pulse of an infant is the brachial artery, which travels from the axilla down the ventral surface of the upper arm to the cubital fossa. The popliteal and radial pulses are difficult to palpate on an infant due to their size, and the carotid artery can be difficult to palpate due to an infant's shorter, thicker neck.

Normal adult respiratory rate is 12-20 breaths per minute. A respiratory rate below 12 is defined as bradypnea, while a respiratory rate above 20 is considered tachypnea.

Infants have the highest respiratory rate of any age group. A normal infant respiratory rate is 30-60 breaths per minute.

A normal respiratory rate in a child aged 1-6 years is 24-34 breaths per minute. This is significantly higher than an adult normal respiratory rate, which is 12-20 breaths per minute.

Infants have the highest heart rate of any age group. Normal heart rate for an infant under one year of age is 100-160 bpm.

Normal heart rate for a child aged 6-12 is 70-120 bpm. This is moderately higher than normal heart rate for an adult, which is 60-100 bpm.

Proper cuff size is very important for accurate blood pressure assessment. The correct way to determine proper blood pressure cuff size is to wrap the cuff around the arm, then note the area covered by the inflatable bladder. The inflatable bladder should cover approximately 80% of the circumference of the forearm while its width should cover approximately 40%.

An overlarge blood pressure cuff will often result in a blood pressure reading that is artificially low. It is important that the nurse chooses the appropriate blood pressure cuff size for each individual patient.

The chest-piece of the stethoscope is made up of two components designed for auscultation: the bell and the diaphragm. The bell is dome-shaped and used for auscultation of low-pitched sounds, while the diaphragm is used to auscultate high-pitched sounds.

When taking a patient's blood pressure, the diaphragm alone should be used to listen at the antecubital fossa. The bell, used for low-pitched sounds, would not give the examiner accurate enough information to assess systolic or diastolic pressure.