Vital Signs:

T, P, R, BP; temperature, pulse, respiration, blood pressure

o 5th is SaO2
o take every 4 hours, more if needed
Temperature
Normal temperature is 36 C to 37.5 C (or 97 to 99.5 F); lowest in
morning, highest in late afternoon, regulated by hypothalamus,
o Core measurements: tympanic, rectal (also esophagus,
pulmonary artery, or bladder)
o Surface: oral (sublingual) and axillary (least reliable)
o Tympanic/rectal are core, oral is 1 degree below core, axillary
is 2 below core or 1 below oral, forehead is 5.5 below core
Primary source of heat is metabolism (also NE/E/TH), arteriovenous
shunts open/close to control heat loss (controlled by sympathetic
system)
o Also lost by breathing, sweating, excretion
o Ups and downs go with circadian rhythm
Very old/young most affected by environmental changes
o Hypothermia: low body temperature; can die below 93 F
o Hyperthermia: high body temperature
o Afebrile: without fever
o Febrile: fever (pyrexia), response to trauma/illness
o Neurogenic fever is from damage to hypothalamus, does not
respond to antipyretics; FUO (fever of unknown origin)
Pulse
Checking rate, quality, rhythm, and volume of blood ejected (SV)
o Rate is faster when young and slower when old
o 0 (absent pulse) 1+ (thready, not easily felt and disappears
with pressure) 2+ (weak) 3+ (normal) 4+ (bounding)
o CO= HR x SV (Normal is 3500 to 8000 mL)
Auscultate, use diaphragm of stethoscope for high frequency
(respiratory) sounds, bell is for low frequency (heart sounds, blood
in vessels)
o Inspiration cycle is 1/3 faster, louder) and expiration is 2/3
(slower, softer)
o Apical pulse taken when peripheral pulses are irregular,
difference is the pulse deficit and lets you know if not all
pulses are reaching limbs
Respiration
External respiration is the exchange of O/CO2 in alveoli/blood;
internal is exchange between blood/tissues
 o Respiratory centers in medulla/pons; activated by
chemoreceptors in aortic arch/carotid, stretch/irritant
receptors in lungs, and receptors in joints/muscles
o Increase in CO2 is most powerful stimulant
o Cerebral cortex allows voluntary control of breathing
Normal rate is 12-20 breaths a minute (eupnea)
o Tachypnea: >20, shallow
o Bradypnea: <12, regular depth
o Apnea: no breathing
o Dyspnea: difficult/labored breathing
Blood Pressure
The force against arterial walls, least BP at beginning of systole
o Highest BP is systolic, lowest is diastolic; difference is pulse
pressure
o Arterioles keep peripheral pressure, allow smooth blood flow
instead of spurts
o Vasoconstriction: renin-angiotensin-aldosterone increase
Na/H2O retention to give more blood volume and higher BP
o ADH, vasopressin is released during decreased blood
volume/pressure or increased osmolarity and increases blood
fluid
Hypertension is controlled with drugs (b-adrenergic blockers to
decrease CO, diuretics, vasodilators/Ca blockers, ACE inhibitors),
losing weight, low calorie/salt/fat diets, exercise; organs affected are
heart, brain, kidneys
Korotkoff sounds (1/5)
o Phase I: first appearance of faint but clear tapping (first sound
is systolic)
o Phase II: swishing sounds, nothing=auscultatory gap
o Phase III: loud sounds
o Phase IV: muffling sound, onset of diastolic
o Phase V: last sound before silence, second diastolic
measurement
Sphygomomanometer is calibrated in 2mmHG increments
SaO2: lower than 93% is dangerous, normal is 96%+ (smoker could
give false high)
False high: not calibrated at 0, viewing below eye level, releasing
valve too slowly, reinflating bladder during auscultation
False low: viewing above eye level, releasing valve too rapidly, not
putting stethoscope over artery, not pumping 30 mmHG above
Normal (120-100/80-60) prehypertensive (139-20/89-80) mild
hypertension/stage 1 (159-140/99-90) Stage 2 is moderate/severe
Pts on antihypertensive (below 140/90), with renal dx (130/80)
 Pulse pressure determined by SV and aortic artery compliance
o Increased compliance= smaller pule pressure; larger SV gives
larger PP at any compliance
Health Assessment
Palpation
o Dorsum (Back): temperature
o Palmar: texture, shape, fluid, size, consistency, pulsation
o Detect vibration of lungs with palm of hand or ulnar
surface (pinky side)
o Touch the area that hurts last
o Light (<1 cm/.5), moderate (1to 2 cm, .5 to .75), deep (2
cm, 1)
Percussion: assess location, size, shape, middle finger used as
hammer
o Tone is determined by density, more dense is quieter
o Tympany (gastric bubble), hyperressonance (emphysema,
pulmonary disease, air in lungs), resonance (normal lungs),
dullness (liver), flatness (muscle)
Auscultation: look at pitch (high/low), loudness (soft/loud),
quality (gurgling), duration (short/medium/long)
Inspection of skin:
o Erythema: redness of skin
o Cyanosis: blue/gray discoloration from lack of O
o Turgor: fullness/elasticity of skin
Angle between nail and base should be about 160 degrees
(greater than 180 is clubbing from lack of oxygen)
Alopecia is hair loss, hirsutism is excessive hair on face/body
Mental Status
Awareness: time, place, person (A&O x 3)
Level of consciousness: (awake/alert, lethargic, stuporous,
comatose)
Glasgow scale assesses if someone is in coma, standardized,
7 or less is coma; higher score is higher LOC
MMSE: mini mental status exam, total score of 30
o Orientation: year, month, date, day, time (1p for each
correct); state, country, town, building, floor (1p each);
5 each, 10 total
o Registration: name 3 objects, ask them to repeat (1
each), if incorrect, keep repeating until learned
o Attention/Calculation: serial 7s, subtract five times from
100 (1 each); OR spell world backwards (1/letter)
o Recall: repeat previous 3 objects (1 each)
 o Language: ask to identify two objects (1 point each); say
no ifs, ands, or buts (1 point total); follow 3 stage
command (1 point for each); write close your eyes
and ask to say and obey (1 point total); ask them to
write a sentence (1 point if sensible with subject and
verb); ask to copy intersecting pentagons (1 point)
Cranial Nerves: Oh, Oh, Oh The Teacher Ate Fish And Got Very
Sick, HA!
o I. Olfactory: smell
o II. Optic: vision
o III. Oculomotor: pupil constriction, opens eyelid
o IV. Trochlear: Downward/Inward movement of eye
o V. Trigeminal: chews, feels face, cornea
o VI. Abducens: Lateral eye movement
o VII. Facial: smiles, spits, cries, taste
o VIII. Acoustic: hearing
Vestibulocochlear: Romberg tests balance (eyes closed, losing
balance= + Romberg), whisper test
o IX. Glossopharyngeal: tastes, salivates, swallows
o X. Vagus: swallowing/speaking
o XI. Spinal Accessory: shrugs shoulders
Inspect for atrophy/asymmetry of trapezius/SCM
muscles, strength
o XII. Hypoglossal: moves tongue
Deep tendon reflexes: strike quadriceps tendon right below
patella; 0 (none) 1+ (low normal) 2+ (normal) 3+ (brisker
than average) 4+ (hyper)
Flaccidity (decreased muscle tone) spasticity (increased
muscle tone)
Kyphosis is hunchback, lordosis is arched, scoliosis is S shaped
curve
Signs of musculoskeletal disease are pain, redness, swelling
(edema)
o Muscle strength: 0 (no contraction) 1 (trace contraction)
3 (can move muscle but not against resistance) 4 (move
muscle group against some resistance but weak) 5
(normal, moves against resistance)
Periodontal disease is marked by gingivitis and degeneration of
periosteum, pockets between teeth with pus filled gums
o Tartar: plaque/dead bacteria hard deposits
o Stomatitis: inflammation of oral mucosa
o Glossitis: inflamed tongue due to deficiencies or B12, folic
acid, iron
 o Cheilosis: ulcerated lips due to vitamin B deficiencies
(riboflavin)
PRN: as needed care
Antiembolism stockings used for deep vein thrombosis,
pulmonary embolism, or to prevent phlebitis
o Increases velocity of blood flow in superficial/deep veins,
improves venous valve function in legs promoting venous
return to heart
o Take off for 30 minutes every eight hours
Pain
Acute: quick onset, protective
Chronic: persistent, remission and exacerbation
o With cancer, is malignant; when healed, nonmalignant
Cutaneous: superficial, on skin or underlying tissues
Somatic pain: deep, in tendons/ligaments/bones/nerves
Visceral pain: from organs, poorly localized, referred pain
Intractable: pain resistant to therapy and persists
Psychogenic: physical cause cannot be identified
COLD ERA (character of pain, onset, location, duration,
exacerbated, relief, associated symptoms problem)
Activation of pain receptors (nociceptors) is transduction
o Bradykinin: vasodilator, releases histamine
o Prostaglandins: stimuli to CNS
o Substance P: sensitizes nerve receptors
o Serotonin: vasoconstrictor
o A fibers are fast/localized, C are slow and are burning
visceral pain
Body Mechanics
Labyrinthine sense: in inner ear, stimulated by body movement,
protects you before you fall
Proprioreceptor/kinesthetic sense: location of a limb
Isotonic: aerobic
Isometric: muscle contraction without shortening, people in cast
Isokinetic: weights
Position:
o Hi-fowlers: 90 degrees
o Low/semi-Fowlers: 30 degrees
Cranial nerves 8: need vision, be able to go somewhere without
looking, cerebellum to be function; innervates thoracic spin up to
shoulders
For neuro/MS tests, use observation (inspection/palpation), for
heart use everything but percussion
 Different between flaccidity and atrophy is circumference does
not change
Doppler only gives systolic BP, used for edema