Hi! I'm Joanna Jackson, and this lesson is
about changes and abnormalities in vital signs.
Vital signs measure the bodies functions.
They provide medical staff with a
picture of what's going on inside of a
person's body. Let's start with pulse.
The expected range for pulse of an adult is
60 to 100 beats per minute at rest.
For infants, the expected pulse is
120 to 160 beats
The average pulse for 12 to 14-year-old
child is 80 to 90 beats
per minute. In addition to the rate, the
nurse should assess the rhythm
and strength of the pulse. As with all vital signs,
there's no exact normal. Every patient will have
a different and unique baseline to be used
as a measure for comparison.
Let's talk about abnormalities with pulse.
We'll begin with bradycardia.
This means an abnormally low pulse rate. Usually
slower than 60 beats per minute.
Nursing interventions include, assessing the
patient for injury, positioning,
chronic pain, or medications that may have
decreased the pulse. As always, if you get
an abnormal pulse, recheck it just to be sure.
Then we have tachycardia. This is an
abnormally high body pulse rate. Average is
higher than 100 beats per
minute. Nursing interventions include assessing
the patient for injury, pain, an
positioning, or medications that might increase
the pulse. Assess and monitor all
vital signs. Notify the provider and
document any findings. Next let's talk about
dysrhythmia. This is an irregular heart rhythm.
Sometimes this is found while
assessing a radial pulse or while using a
stethoscope. Assess the patient for
injury, assess and monitor all vital signs,
administer appropriate medications in
order to maintain a proper heart rhythm,
and notify the provider as soon as
possible, and document your findings.
Next we'll talk about temperature. An oral
temperature should remain within the
range of 96.8
to 100.4. The average is 98.6. Rectal
temperatures are usually
about 0.5 to 0.8 higher than the
Axillary and tympanic temperatures are usually
0.5 to 0.9 lower than oral temperatures.
Please remember as with all vital signs, there
is no exact normal. Every patient
will have a different and unique baseline.
Now let's talk about abnormalities
with temperature. Hypothermia refers to an
abnormally low body temperature.
Nursing interventions include create a warm
environment, provide blankets, oral
and IV fluids, and assess the vital signs
regularly. Be prepared for
life-saving measures and notify the
provider and document the findings.
Hyperthermia refers to an abnormally
high body temperature.
Nursing interventions include provide oral
and IV fluids, administer fever reducing
medications like acetaminophen, as ordered,
keep linens and clothing dry, prevent shivering
but do not warm the patient, notify the provider,
and document your findings. A fever
alone is typically not harmful in adults
unless it exceeds 102 degrees
Fahrenheit. Now we will review respirations.
The expected rate for adults is
12 to 20 respirations per minute.
Newborns have rates of 30 to 60 respirations
per minute. And it's normal for
them to have brief periods of apnea. School-age
children have respiration
rates of 20 to 30 respirations per minute.
Altered depths are described as
deep or shallow. A regular rhythm is expected
in adults. Occasional changes in
rhythm are not abnormal. Oxygen saturation
is typically between 90% and
100%, but may vary due to illnesses like COPD.
Again, with all vital
signs, there is no exact normal. Every patient
will have a different and unique
baseline to use for comparison. One abnormality
related to respirations is
hypoxemia. This is an
abnormally low oxygen in the blood. In hypoxemia,
oxygen saturation is usually
below 90%. Nursing interventions include
confirming the vital sign by retaking it,
just to be sure it's correct and not a
malfunction of the equipment.
Assess the patient's positioning, oxygen
equipment, and surrounding environmental
factors. Now we will review blood pressure.
Normal blood pressure is
120 over 80. Infant's blood pressure is
much lower but increases
with age. Again, with all vital signs, every
patient will be different and unique.
One abnormality related to blood pressure is
hypotension. This is an abnormally
low blood pressure.
Nursing interventions include confirm the
vital sign as abnormal
and not an equipment error, assess the patient's
positioning, assess for related
symptoms and abnormal vital signs, and educate
the patient about calling for
assistance to avoid falling and assist
them with ambulation.
Now let's review hypertension. This is an
abnormally high blood pressure.
Nursing interventions include confirming the
vital sign is actually abnormal and
not an equipment error, assessing the patient's
positioning, administering medications as
ordered, and educating the patient on lifestyle,
diet changes, and stress as
those are related to hypertension.
Here are some important tips to help you obtain
the proper vital sign. Gather all your equipment
before beginning. Know which
abnormal vital signs are an emergency, and which
require further monitoring.
Always, always document your findings. Recheck abnormal
vital signs to ensure the abnormal
results. Here are some quick ways to remember this
content. Say the information out loud.
Practice talking to friends or in the mirror
as if you were the nurse
explaining a procedure to a patient. Make up
funnier quirky acronyms about
medications or processes that will help you
remember them. For example, the
nursing process can be remembered as ADPIE.
Assess, diagnose, plan, implement,
and evaluate. Visualize the information. In the
example ADPIE, visualize an apple pie
with the letters AD on it. The NCLEX
will be as easy as pie.
Here are some quick tips for success. When in
doubt, assess, diagnose, plan, and then
implement. Always assess before taking any action.
If two answers feel correct, do
your best to pick the one that is most correct.
And remember, opposites attract.
If two answers are complete opposites, one of
the answers is probably correct.