NURS 258 Lecture Notes - Lecture 1: Vital Signs 1, Vital Signs, Auscultation
Introduction to Physical Assessment and Vital Signs
Learning Outcomes:
• Explain physiological mechanisms for the normal regulation of blood pressure,
pulse, temperature, and respiration.
• Identify normal vital sign values across the lifespan.
• Describe factors that cause variations in blood pressure, pulse, temperature and
respirations.
• Discuss the nursing responsibilities in assessing blood pressure, pulse,
temperature, and respiration.
• Describe the equipment necessary to assess vital signs.
• Identify sites for assessing blood pressure, pulse, and temperature.
• Measure vital signs in an organized, accurate manner.
• Document and report vital signs correctly.
QSEN Competency Category: Safety, Patient-Centered Care
Learner Level: Beginning
Preparation:
Reading:
• Jarvis: Chapter 8 (Read the following sections: Cultivating your senses; Inspection;
Palpation; Auscultation; A clean field; The infant; The toddler; The preschool child; The
school-aged child; The adolescent; The aging adult)
• Potter: Chapter 30 (Read the following: Page 487; Box 30-1; Guidelines for measuring
vital signs; Body temperature: Physiology; Factors affecting body temperature: all subsections
stop at hyperthermia; Sites stop at Nursing Diagnosis box (pg. 494); Health promotion stop at
heatstroke; Pulse; Table 30-2; Assessment of pulse; Table 30-3; Character of the pulse including
Table 30-4; Respiration; Assessment of ventilation through Table 30-6; Blood pressure (all
subsections); Table 30-7; Factors influencing blood pressure (all subsections); Table 30-8;
Hypertension; Hypotension; Measurement of blood pressure & BP equipment; Auscultation;
Assessment in children through pg 507; Skill 30-1; Skill 30-2; Skill 30-3; Skill 30-5 (we will be
doing the one-step method)).
Bring to Lab:
• Laptop computer
• Watch with a second hand
• Stethoscope
Outline for Theory
Physical Assessment
1. Skills required for physical assessment (in this order)
A. Inspection
i. Starts the moment you meet the person
ii. Careful observation – make sure to look at the whole patient
iii. Compare right & left side of body – making sure things are equal
B. Palpation– hot/cold, dry/wet, swelling, lumps, does the pt have any pain
i. Light – one hand, circle around abdomen, texture, warmth, moisture, tenderness,
pulsations
ii. Deep – more common in the abdomen or find masses
C. Percussion – tapping on the skin (nurses do not do)
i. Assesses underlying organs – determines if there is fluid/dense, difference in
sounds
ii. Size & density
D. Auscultation
i. Ear pieces toward nose
ii. Diaphragm – high-pitched, hold firmly (large side), used most of the time,
breathing, bowel sounds, lung
iii. Bell – soft, low pitched, hold lightly, more listened for heart sounds (heart
murmur)
iv. Sizes- Infant, Pediatric, Adult (small, med, LG, XL)
iv. Warm hands
vi. Directly on skin
vii. Alcohol off end piece and ear pieces between pts
2. Setting
A. Exam Room/Hospital Room – warm, private, good lighting, equipment handy
3. A safer environment
A. National Patient Safety Goals for Patient Care – improve accuracy of pt. ID, 2 forms,
verify with pt. ID bracelet or HER***On D2L – review***
i. Improve accuracy of patient identification
ii. Reduce the risk of health care associated infections
a. Nosocomial infection – hospital acquired infection, comes from
nurses/doctors/aids inside hospital setting
b. Hand washing – before and after each pt. encounter, in presence of pt.,
after contact with body fluids or contaminated equip., after removing
gloves, after using the bathroom, before and after eating
c. Alcohol-based hand rub – in place of soap and water unless: hands
visibly soiled or pt. has C. diff (GI infection), rub until dry
d. Clean equipment with each pt. contact
4. The infant
A. Position – parent hold as much as possible
B. Prep - 1 to 2 hours after feeding
C. Sequence- do less invasive assessments first (lung sounds), do more invasive
assessments last (ear)
5. The toddler
A. Position – parent hold as much as possible
B. Prep – instruct parents on comfort holds, give them options of either A or B
C. Sequence – non-threatening is first (example pt comes in with broken arm)
6. The preschool child
A. Position – ask if child wants to sit on exam table or parents lap
