In Wilkinson's Fundamentals of Nursing, Volume 1, Chapter 18, the

nurse’s role in assessing and managing vital signs is crucial in monitoring a

client's health and identifying abnormalities. Here is a summarized
breakdown:

Nurse's Role in Assessing Vital Signs:

1. Accurate Measurement: Nurses must use correct techniques and

validated equipment to measure temperature, heart rate, respirations,
blood pressure, and pulse oximetry.
2. Critical Thinking: Nurses analyze trends in vital signs, assess the
context of the patient's condition, and correlate findings with overall
health status.
3. Timely Reporting: If abnormal findings are identified, nurses must
communicate these findings to the healthcare team promptly.

Classifying Assessment Findings & Management:

● Across the Lifespan:

○ Infants and older adults may have different baseline normal
ranges due to physiological differences.
○ For infants, respiratory and heart rates tend to be higher,
whereas older adults may present lower baseline values.
○ Abnormal findings, such as tachycardia or hypertension, are
compared against age-specific norms.
● Management Strategies:
○ When abnormalities like high blood pressure, irregular heart
rate, or altered respirations are detected, nurses may initiate
interventions such as medication, oxygen therapy, or lifestyle
adjustments, depending on the severity and context.

Plan of Care for a Client with Abnormal Vital Signs:

1. Assessment: Document initial vital sign readings and compare them

to baseline or standard age-specific norms.
 2. Diagnosis: Identify abnormal patterns, such as hypertension,
bradycardia, or hypoxemia.
3. Interventions:
○ Administer prescribed treatments (e.g., antihypertensives,
oxygen).
○ Non-pharmacological interventions, such as positioning for
better breathing, or advising on stress reduction.
○ Reassess vital signs frequently.
4. Evaluation: Continuously monitor the client’s response to
interventions and adjust care accordingly.

Client/Caretaker Education on Vital Signs:

1. Normal Ranges: Teach clients and caretakers the normal ranges for
vital signs based on age and individual health status.
2. Recognizing Abnormal Signs: Explain the importance of
recognizing symptoms like shortness of breath, rapid heart rate, or
dizziness, which might indicate abnormal vital signs.
3. Self-Monitoring Techniques: Educate clients on how to measure
their vital signs at home, including using devices like blood pressure
monitors or pulse oximeters.
4. When to Seek Help: Instruct clients on when to seek medical advice
if abnormal readings or concerning symptoms occur.

Exemplars:

● Temperature: Fever may require antipyretics or cooling interventions,

whereas abnormal hypothermia requires warming interventions.
● Heart Rate: Tachycardia might need medication, while bradycardia
may require monitoring or pacemaker consideration.
● Respirations: Increased respirations might indicate infection or
respiratory distress and require oxygen or ventilation support.
● Blood Pressure: Hypertension management might involve lifestyle
changes or medication, while hypotension may require fluids or
vasopressors.
 ● Pulse Oximetry: Low oxygen saturation may necessitate
supplemental oxygen.

This holistic approach ensures that the nurse not only manages abnormal
findings but also educates the client and caregivers for continued care at
home.

Learning Objectives:

1. Nurse’s Role in Assessing Vital Signs:

○ Nurses are responsible for measuring vital signs as per
provider's order, nursing judgment, client condition, or facility
standards. The assessment may involve delegating the task if
appropriate.
2. Classifying Abnormal Findings Across the Lifespan:
○ Abnormalities in temperature, heart rate, respirations, blood
pressure, and oxygen saturation are compared to age-specific
norms.
○ Management strategies vary depending on the client’s age and
condition (e.g., infants, adults, elderly).
3. Plan of Care for Abnormal Vital Signs:
○ Care plans for clients with abnormal vitals involve continual
assessment, prompt interventions (medications, oxygen
therapy), and evaluating the client's response.
4. Client/Caretaker Education:
○ Educating clients and caregivers on how to recognize abnormal
vital signs, self-monitoring, and understanding when to seek
help is critical.

Vital Signs Monitoring:

● Frequency of Monitoring: Depends on provider orders, nursing

judgment, client condition, or facility standards.
● Delegation: Can be delegated depending on the patient’s condition
and facility policy.
Temperature:

● Thermoregulation: Controlled by the hypothalamus, which balances

heat production and loss.
○ Heat Loss: Managed through sweating and vasodilation.
○ Heat Retention: Managed through shivering and
vasoconstriction.

Heart Rate/Pulse:

● Assessment: Check pulse over a peripheral artery or apical pulse

using a stethoscope.
○ Key factors: Rate, rhythm, quality, and equality.
○ Know the anatomical locations of heart sounds.

Respiratory Rate:

● Normal Adult Rate: 12-20 breaths per minute.

● Abnormal Patterns:
○ Apnea: No breathing.
○ Bradypnea: Slow breathing.
○ Tachypnea: Fast breathing.
○ Cheyne-Stokes and Biot’s: Abnormal breathing patterns.
● Effort: Dyspnea (difficulty breathing), Orthopnea (difficulty breathing
when lying down).

Hypoventilation & Hyperventilation:

● Hypoventilation: Decreased rate/depth leading to CO2 retention

(seen in COPD, anesthesia).
● Hyperventilation: Excessive breathing causing CO2 loss (seen in
anxiety, hypoxia).

Pulse Oximetry:

● Normal: 95%-100%.
● Cause for Concern: Below 90%.

Blood Pressure:
 ● Definition: Pressure exerted on arterial walls during cardiac
contraction.
○ Factors: Cardiac output, vascular resistance, blood volume.
● Cuff Sizing: Ensure appropriate size to avoid errors.
● Lower Extremity Blood Pressure: Systolic BP in the lower
extremities is usually 20-30 mmHg higher than in the upper
extremities.

Abnormal Blood Pressure:

● Hypotension: Systolic BP <90 mmHg, diastolic <50 mmHg.

Orthostatic hypotension may occur when transitioning from lying to
standing.
● Hypertension: Diagnosed if BP >140/90 mmHg on two or more
occasions. May present with fatigue, headaches, or vision changes.

This document emphasizes the importance of accurate assessment,

appropriate management, and continuous education in handling vital signs,
which are foundational to patient care.

● Vital signs are measured to monitor a patient's health condition.

● There are five main vital signs: temperature, heart rate, respiration
rate, blood pressure, and pulse oximetry.
● Vital signs can be measured manually or electronically, and the
frequency of measurement depends on the patient's condition and
facility standards.
● Body temperature is regulated by the hypothalamus, which senses
changes in temperature and triggers mechanisms to either increase
or decrease heat production.
● Heart rate and pulse can be measured at peripheral arteries or by
auscultating the apical pulse.
● Respiratory rate is measured by counting breaths per minute, and
abnormal rates or rhythms can indicate respiratory problems.
● Blood pressure is the pressure of blood against arterial walls during
cardiac contraction and is measured using a sphygmomanometer.
 ● Hypotension and hypertension are abnormal blood pressure readings
that can indicate underlying health conditions.

Vital Signs Questions:

1. Normal Heart Rate for an Adult: 60-100 beats per minute.

2. Normal Respiratory Rate for an Adult: 12-20 breaths per minute.
3. Why Does the Body Sweat with a Fever?: The body sweats during
a fever as a mechanism to cool down. When body temperature rises,
the hypothalamus stimulates sweat production and vasodilation to
dissipate heat.
4. Causes of a High Heart Rate:
○ Stress or anxiety
○ Fever
○ Exercise
○ Medications (e.g., stimulants)
○ Heart conditions like arrhythmias
5. Pulses Not Checked Bilaterally at the Same Time: The carotid
pulse should not be checked bilaterally simultaneously due to the risk
of reducing blood flow to the brain.
6. Why Check Most Pulses Bilaterally?: Checking pulses bilaterally
helps assess whether blood flow is equal on both sides of the body.
7. When to Listen to Apical Pulse for a Full Minute: When an
irregular pulse is detected or when assessing clients with cardiac
conditions, the apical pulse should be counted for a full minute.

Matching:

● Dyspnea: Difficulty breathing

● Autonomic Nervous System: Affects both pulse and blood pressure
● Apnea: Absence of respirations
● Hypertension: Blood pressure greater than 120/80
● Bradycardia: Pulse rate less than 60 beats per minute
● Tidal Volume: Amount of air moving in and out with each breath
● Hypothalamus: The body's thermostat
 ● Tachycardia: Pulse greater than 100 beats per minute

Multiple Choice Questions:

1. Stroke Volume: The amount of blood ejected from each ventricle

with each heartbeat.
2. Causes of Falsely High Blood Pressure Readings:
○ A blood pressure cuff that is too small
○ The arm positioned below the heart
3. Opioid Analgesic Effect on Vital Signs: Most likely to cause a
decreased respiratory rate.
4. Temperature After Hot Tea: Wait 15 minutes before checking the
client’s temperature.
5. Proper Blood Pressure Assessment: Inflate the cuff to 30 mm Hg
higher than the point you last palpated a pulse.
6. Pulse Quality for Congestive Heart Failure: A weak, thready pulse
corresponds to a 1+ pulse quality.
7. Normal Respiratory Rate for Adults: 12-20 breaths per minute.
8. Verifying a Slow Radial Pulse: You can check the apical pulse for a
full minute to verify accuracy.
9. Expected Vital Sign Changes in a Long-term Smoker with
Pneumonia:
○ Increased respiratory rate (tachypnea)
○ Possible low oxygen saturation (hypoxia)
○ Fever due to infection
○ Possible tachycardia