Vital Signs Skills Assessment

Standard

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Vital Signs are another skills assessment that we have to do in nursing school soon. The following links are to videos from ATI that explain each procedure on obtaining vital signs:

 

 

Radial Pulse

Notes 

  • Normal: 60 – 100
  • Bradycardia: < 60 (Can be a result of Hyperkalemia, as well as other conditions)
  • Tachycardia: > 100 (Can be a result of CHF, Dehydration, etc.)
  • Pulse Strength:
    • Bounding = 4 +
    • Full or Strong = 3 +
    • Normal and Expected = 2 +
    • Diminished or Barely Palpable = 1 +
    • Absent = 0

Documentation Example

  • Radial pulse 72, 2 + and regular

 

Apical Pulse (Also see the other post here with an excellent video)

Notes

  • S1: Tricuspid and Mitral Valves close. End of ventricular filling. Low pitched and dull sound: “Lub”
  • S2: Pulmonic and Aortic Valves close. End of systolic contraction. Higher pitched and shorter sound: “Dub”

Documentation Example

  • Apical pulse 72; S1, S2 clear without rubs or murmurs noted.

Respiratory Rate

Notes

  • Bradypnea – Regular breathing, but slow , < 12 breaths/min.
  • Tachypnea – Regular breathing, but abnormally rapid, > 20 breaths/min.
  • Hyperpnea – Respirations labored, increased in depth, and increased in rate, > 20 breaths/min. Normal during exercise.
  • Apnea – Respirations cease for several seconds. Persistent cessation results in respiratory arrest.
  • Normal Adult Range – 12 – 20

Documentation Example

  • RR 18, regular rate and rhythm, depth normal

 

Blood Pressure (One Step Method)

 

Blood Pressure (Two Step Method)

Documentation Example

  • Palpated: BP RA 90/-, palpated, supine
  • Auscultated: BP RA 120/80 mm Hg, sitting

Notes

  • Systolic (top #): Measures pressure in arteries when heart beats (heart muscles contract)
  • Diastolic (bottom #): Measures pressure in arteries between heartbeats (when heart muscle resting between beats and refilling w/blood)
  • Normal: 120/80 mm Hg
  • AHA recommendation for healthy blood pressure Retrieved from: http://www.socalmds.com/blog.php?categories=Hypertension

Blood-Pressure-Chart-Health

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