NR 302 Week 4 Edapt

Grace J.
August 11, 2025August 11, 2025
CU BSN, NR-302

Student Name

Chamberlain University

NR-302: Health Assessment I

Prof. Name

Date

Week 4 Edapt – NR 302 Vital Signs

Pulse Rate

Pulse rate is influenced by various physiological and demographic factors. Typically, newborns and children have a faster heart rate, which gradually slows as individuals age. After puberty, females often have a slightly higher resting pulse compared to males due to hormonal influences and body composition differences (McKinney et al., 2022).

If an abnormal pulse rate is detected—either high or low—it is essential to confirm the reading. This verification is best achieved by assessing the apical pulse for a complete minute. Only after confirming the abnormality should the healthcare provider be notified. Before doing so, a focused cardiovascular assessment should be performed, and the findings should be documented. Previous heart rate and rhythm trends can be obtained from the patient’s electronic health record (EHR), making it unnecessary to contact family members for such information.

Abnormal Assessment Findings – Physiology of Blood Pressure

Blood pressure measurement reflects the force of circulating blood against arterial walls. The systolic pressure is recorded during ventricular contraction, while the diastolic pressure represents the pressure in arteries when the ventricles are relaxed. The difference between these two readings is termed pulse pressure, which provides insight into cardiac function and arterial elasticity.

Key Blood Pressure Concepts:

Term	Definition
Systolic Pressure	Pressure during ventricular contraction
Diastolic Pressure	Pressure during ventricular relaxation
Pulse Pressure	Difference between systolic and diastolic pressures
Korotkoff Sounds	Sounds heard when auscultating BP; Phase 1 marks systolic, last sound indicates diastolic
Auscultatory Gap	Temporary disappearance of sounds, often linked to peripheral blood flow reduction

What Are Vital Signs?

Vital signs are indicators of a patient’s basic physiological status and include temperature, pulse, respiration, and blood pressure.

Vital Sign Finding	Clinical Term	Normal/Abnormal Classification
95.1 °F (35.1 °C)	Hypothermia	Abnormal – low temperature
HR 110 bpm (adult)	Tachycardia	Abnormal – high pulse
RR 20 breaths/min (adult)	Normal	Within range
BP 144/98 mm Hg (adult)	Hypertension	Abnormal – high BP

When Should Vital Signs Be Taken?

Vital signs should be measured at specific times to ensure patient safety and to detect clinical changes promptly:

On admission to a healthcare facility
As prescribed by the healthcare provider
Before and after surgical or diagnostic procedures
Before and after medications that may influence cardiovascular, respiratory, or thermoregulatory functions
When there is a change in the patient’s general condition
Before and after interventions such as ambulation or tracheal suctioning

Temperature

Body temperature is regulated by the hypothalamus, located in the brain, which maintains a balance between heat production and loss. Temperature is documented in Fahrenheit (°F) or Celsius (°C) depending on institutional policies.

Pulse

The pulse is a rhythmic expansion and contraction of an artery caused by the ejection of blood from the left ventricle. In healthy adults, the normal resting pulse rate ranges between 60 and 100 bpm, with an average of about 80 bpm.

For infants, the apical pulse should be auscultated for a full minute. During cardiopulmonary resuscitation (CPR), the carotid artery is the preferred site for pulse assessment in adults.

Pulse Variations

Pulse rate can be influenced by age, gender, emotional state, physical activity, body temperature, and certain medications.

Common Variations:

Condition	Definition	Possible Causes
Tachycardia	HR > 100 bpm	Fever, exercise, shock, medications, pain
Bradycardia	HR < 60 bpm	Beta-blockers, heart block, athlete’s conditioning
Dysrhythmia	Irregular rhythm	Cardiac conduction abnormalities

If a pulse is too weak to palpate, a Doppler ultrasound device can detect and amplify the sound for accurate measurement.

Respirations

The medulla oblongata in the brainstem controls respiratory rate and rhythm. Activities that increase metabolism—such as fever, exercise, or stress—raise the body’s oxygen demand and, consequently, the respiratory rate.

Parameter	Normal Adult Value	Notes
Respiratory Rate	12–20 breaths/min	Increased rate = tachypnea; decreased rate = bradypnea
Tidal Volume	~500 mL	Varies by age, size, and lung health
Rhythm	Regular	Occasional sighing is normal
Breath Sounds	Not audible normally	Abnormal sounds may indicate airway obstruction or lung pathology

The ideal time to assess respirations is immediately after counting the pulse, when the patient is unaware to prevent altered breathing patterns.

Blood Pressure

Blood pressure measurement should be avoided in certain circumstances, such as:

On the side of a recent mastectomy with lymph node removal
On an arm with burns, a cast, or an active IV line
On an arm with a dialysis shunt

Selecting the correct site helps prevent discomfort, injury, and inaccurate readings.

Oxygen Saturation

Oxygen saturation (SpO₂) measures the percentage of hemoglobin molecules carrying oxygen. Normal readings are ≥95% on room air. Inaccurate results can occur due to:

Nail polish or artificial nails
Cold extremities
Poor device placement
Motion artifacts

If accuracy is questioned, reposition the sensor and recheck.

Pain Assessment

Pain assessment begins with open-ended questions, allowing patients to describe their discomfort. After gathering descriptive details, a standardized pain scale should be used (e.g., numeric, visual analog, or Wong-Baker Faces scale). Accurate assessment is crucial for targeted interventions and improving patient comfort.

Impact of Vital Signs on Social Determinants of Health

Abnormal vital signs can be influenced by, or contribute to, broader social and environmental factors:

Determinant	Potential Influence on Vital Signs
Food insecurity	Malnutrition affecting BP, HR, and temperature
Housing insecurity	Poor living conditions leading to respiratory issues
Financial insecurity	Delayed treatment or inability to afford medication
Limited healthcare access	Late detection of chronic conditions
Water contamination	Gastrointestinal illness impacting hydration status
Poor air quality	Increased respiratory rate, reduced oxygenation

Health Education Based on Vital Signs

Education topics should focus on:

Treatment adherence for conditions like hypertension
Risk reduction strategies such as sodium restriction
Self-monitoring techniques (home BP measurement, pulse checks)
Lifestyle changes—exercise, diet, and smoking cessation

Nursing Application: Vital Signs – When to Notify the Provider

Notify the healthcare provider after confirming abnormal findings if:

Temperature rises above baseline (possible infection)
Absent pulse verified with Doppler
New or worsening shortness of breath
Significant BP change from baseline
SpO₂ < 90% despite interventions
Pain exceeding the patient’s stated goal

Treating Hypertension

Non-pharmacological interventions are first-line for Stage 1 hypertension and include:

Reducing sodium intake to decrease vascular volume
Encouraging a diet rich in fruits, vegetables, and lean protein
Promoting regular aerobic exercise
Weight management and limiting alcohol

Skin and Nails

Braden Scale

The Braden Scale for Predicting Pressure Sore Risk® evaluates:

Sensory perception
Moisture
Activity
Mobility
Nutrition
Friction and shear

It does not assess circulation or skin turgor.

Function of the Skin

The integumentary system:

Regulates temperature
Acts as a barrier against trauma and infection
Produces vitamin D
Allows for sensory perception
Excretes metabolic waste
Adjusts to internal and external environmental changes

Skin Cancer

According to the Skin Cancer Foundation (2020), 1 in 5 Americans will develop skin cancer before 70 years old.
Types:

Squamous cell carcinoma
Basal cell carcinoma
Melanoma (most dangerous, highest mortality rate)