Vital signs and physical assessment

Foundations assessment items ask whether you measured the right vital the right way and whether the sequence of your hands matches the organ. Chest-pain perfusion mapping and focused stroke neuro exams stay in Acute coronary syndromes and Stroke and neuro assessment — this chapter owns vital-sign craft, general technique, and drug-level timing.

Vital signs that change the plan

A vital sign is a decision tool, not a chart decoration. Tachycardia with fever means something different from tachycardia with bleeding. Hypotension with cool clammy skin is perfusion failure until proven otherwise. Always pair the number with symptoms, baseline, and trend — a “normal” BP that is 40 points below the client’s usual is a finding.

Orthostatic vitals catch volume depletion and drug effects. Have the client lie, measure, sit, measure, stand, measure on the protocol clock, and stop if they nearly syncope. Teaching is slow position change, dangle, and call for help — not “push through the dizziness.”

• Avoid BP on AV fistula arms, post-mastectomy/lymph-node sides as taught, and traumatized limbs.
• Correct cuff size: too small falsely elevates BP; too large falsely lowers it.
• Count irregular pulses for a full minute; use apical when the stem demands accuracy (digoxin, irregular rhythm).

General assessment techniques

Inspection costs nothing and finds asymmetry, color, effort of breathing, and devices. Palpation follows for temperature, tenderness, and masses — start light. Percussion maps density. Auscultation hears air and blood flow. For the abdomen specifically, auscultate after inspection and before percussion/palpation so you do not create bowel sounds with your hands.

1. Inspect first everywhere.
2. Abdomen: inspect → auscultate → percuss → palpate.
3. Save deep palpation of surgical or tender abdomens for last / as ordered.

Pain assessment is part of every set of vitals that matters: location, quality, severity, timing, what worsens and relieves. Reassess after interventions. The distractor is documenting a pain score and walking away while the client still cannot breathe or is clutching the chest — those stems belong to the cardiac and respiratory chapters once you recognize the emergency.

Therapeutic drug monitoring

Some drugs need blood levels because the gap between help and harm is narrow — digoxin, vancomycin, aminoglycosides, and similar agents on exams. A trough is usually drawn immediately before the next dose (lowest level). A peak is drawn after a dose or infusion finishes on a drug-specific clock. If timing is wrong, the lab number cannot guide the next dose safely.

Nursing responsibilities: hold or give as parameters say, draw from the correct line (not from the same lumen that is infusing the drug when that contaminates the sample), label time accurately, and notify for levels outside the ordered band with the clinical picture attached. Lithium and other psych levels also appear in mental-health stems — same timing discipline.

Priority map