Vital Signs.
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Chapter 5
Vital Signs
Copyright © 2018, Elsevier Inc. All rights reserved.
Copyright © 2018, Elsevier Inc. All rights reserved.
This chapter reviews three procedures and five skills: measuring body temperature, assessing radial pulse, assessing apical pulse, assessing radial-apical pulse, assessing respirations, assessing arterial blood pressure, assessing blood pressure electronically, and measuring oxygen saturation.
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Vital Signs
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Copyright © 2018, Elsevier Inc. All rights reserved.
| Reveal changes in patient condition |
| Include temperature, pulse, blood pressure, respirations, oxygen saturation |
| Sometimes pain is included |
| Performed during routine physical assessment |
Copyright © 2018, Elsevier Inc. All rights reserved.
- Vital signs
- Indicate whether body systems are functioning normally.
- Reveal sudden changes in a patient’s condition.
- Reveal changes that occur progressively over time.
- Any difference between a patient’s normal baseline measurement and present vital signs may indicate a need for therapies/medical interventions.
- Pain, a subjective symptom, is often referred to as a vital sign.
- Vital signs are included in routine physical assessment.
[Ask students: what are some examples of how vital sign measurements can be used? Discuss.]
- Always obtain a baseline measurement of vital signs on first contact with a patient to serve as a basis for comparison with later vital sign measurements.
- Frequency of vital sign measurements depend on the specific patient’s condition; you apply clinical judgement to decide which vital sign to measure, when to obtain measurements and the frequency of assessments.
[Review with students Box 5-1, When to Take Vital Signs.]
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- Be culturally sensitive when taking vital sign measurements
- Protect patient privacy
- Observe patient cultural norms
- Be considerate of patient anxiety
Patient-Centered Care
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Copyright © 2018, Elsevier Inc. All rights reserved.
Copyright © 2018, Elsevier Inc. All rights reserved.
- Privacy
- Vital sign measurements require removing clothing or exposing areas considered inappropriate or offensive to patients from other cultures.
- Be sensitive to each patient’s need for privacy and observe cultural norms.
- Provide privacy when performing apical pulse assessment, especially for traditional female patients and elders from Asian, Middle Eas
Chapter 30
Vital Signs
Copyright © 2017, Elsevier Inc. All Rights Reserved.
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As indicators of health status, vital sign measurements indicate the effectiveness of circulatory, respiratory, neural, and endocrine body functions. Because of the importance of these functions, these measurements are referred to as vital signs.
Pain, a subjective symptom, is often called the fifth vital sign and is frequently measured with the others.
Measurement of vital signs provides data to determine a patient’s usual state of health (baseline data). Many factors, such as the temperature of the environment, the patient’s physical exertion, and the effects of illness cause vital signs to change, sometimes outside an acceptable range.
An alteration in vital signs signals a change in physiological function and the need for medical or nursing intervention.
Vital signs and other physiological measurements are the basis for clinical decision making and problem solving.
Measuring is your responsibility
Equipment use; ensure it is working properly
Know patient’s usual range and medical Hx
Control environmental factors
Use systematic approach
Collaborate to decide frequency
Used for administering medications
Analyze results, identify significant findings
Instruct patient in vital sign assessment
Guidelines for Measuring Vital Signs
Copyright © 2017, Elsevier Inc. All Rights Reserved.
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Know expected values of vital signs. interpret your patient’s values, communicate findings appropriately, and begin interventions as needed.
[Review Box 30-1, Vital Signs: Acceptable Ranges for Adults, with students.]
Use the following guidelines to incorporate measurements of vital signs into nursing practice:
Measuring vital signs is your responsibility. You may delegate measurement of vital signs in selected situations, but you must review results and interpret their significance.
Assess equipment to ensure that it is working correctly and provides accurate findings.
Select equipment on the basis of the patient’s condition and characteristics (e.g., do not use an adult-size blood pressure [BP] cuff for a child).
Know the patient’s usual range of vital signs.
Know your patient’s medical history, therapies, and prescribed medications. Some illnesses or treatments cause predictable changes in vital signs. Some medications affect one or more vital signs.
Control or minimize environmental factors that affect vital signs.
Use an organized, systematic approach when taking vital signs.
Each procedure requires a step-by-step approach to ensure accuracy.
On the basis of the patient’s condition, collaborate with health care providers to decide the frequency of vital sign assessment.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.
Mosby: Mosby’s Nursing Video Skills
Student _________________________________________ Date ___________________
Instructor _______________________________________ Date ___________________PERFORMANCE CHECKLIST FOR OBTAINING BLOOD PRESSURE BY THE
ONE-STEP METHODS U NP Comments
1. Performed hand hygiene.
2. Provided for patient’s privacy.
3. Verified health care provider’s orders.
4. Gathered necessary equipment and supplies.
5. Checked patient’s baseline reading, determined
best site for use.
6. Introduced self to patient and family.
7. Identified patient using two identifiers.
8. Positioned patient and patient’s arm
appropriately.
9. Exposed upper arm fully.
10. Ensured blood pressure cuff was appropriate
the appropriate size.
11. Palpated patient’s brachial artery in the
anticubital space.
12. Positioned cuff properly above artery,
wrapped fully deflated cuff properly around
upper arm.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.
13. Cleaned earpieces, diaphragm, and bell of
stethoscope with alcohol swabs.
14. Placed earpieces in ears, ensured sounds were
clear and not muffled.
15. Positioned monometer properly, stood no
more than one yard away from it.
16. Placed bell or diaphragm chestpiece over
brachial artery, did not let chestpiece touch
cuff or patient’s clothing.
17. Closed valve on pressure bulb, inflated cuff
properly above patient’s usual systolic
pressure.
18. Released pressure valve slowly, let
manometer indicator fall appropriately, noted
point at which fist clear sound was heard.
19. Deflated cuff slowly, noted pressure where
sound disappeared.
20. Listened appropriately after last sound, let
remaining air escape.
21. Took blood pressure again in 2 minutes, used
second set of measurements as baseline.
22. Removed cuff from patient’s arm, repeated
process on other arm if appropriate.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.
23. Helped patient to comfortable position,
covered arm again, discussed findings with
patient.
24. Cleaned the earpieces, diaphragm, and bell of
stethoscope with alcohol swabs.
25. Placed perso
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.
Mosby: Mosby’s Nursing Video Skills
Student _________________________________________ Date ___________________
Instructor _______________________________________ Date ___________________PERFORMANCE CHECKLIST FOR OBTAINING BLOOD PRESSURE BY THE
ONE-STEP METHODS U NP Comments
1. Verified health care provider’s orders.
2. Gathered necessary equipment and supplies.
3. Performed hand hygiene.
4. Provided for patient’s privacy.
5. Checked patient’s baseline reading, determined
best site for use.
6. Introduced self to patient and family, identified
patient using two identifiers, compared
identifiers with information on patient’s ID
bracelet.
7. Positioned patient and patient’s arm
appropriately.
8. Exposed upper arm fully.
9. Ensured blood pressure cuff is appropriate the
appropriate size.
10. Palpated patient’s brachial artery in the
anticubital space.
11. Positioned cuff properly above artery,
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.
wrapped fully deflated cuff properly around
upper arm.
12. Positioned manometer properly, stood no
more than one yard away from it.
13. Palpated brachial artery distal to cuff while
inflating cuff with other hand.
14. Noted point at which pulse disappeared,
inflate cuff appropriately past that point,
slowly deflated cuff.
15. Noted point at which pulse disappeared.
16. Fully deflated cuff, waited 30 seconds.
17. Cleaned earpieces, diaphragm, and bell of
stethoscope with alcohol swabs.
18. Placed earpieces in ears, ensured sounds were
clear and not muffled.
19. Placed bell or diaphragm over stethoscope,
did not let chestpiece touch cuff or patient’s
clothing.
20. Closed valve on pressure bulb properly, quick
inflated cuff to the proper pressure.
21. Released valve on pressure bulb, let
manomemter fall properly, noted point at
which the first clear sound is heard.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.
22. Continued to deflate cuff slowly, noted
pressure at which sound disappears.
23. Listened after last sound, let remaining air
escape quickly, discussed findings with
patient, removed cuff.
24. Took patient’s BP aga
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.
Student __________________________________________________ Date ________________________
Instructor ________________________________________________ Date ________________________
PERFORMANCE CHECKLIST FOR ASSESSING APICAL-RADIAL PULSE
S U NP Comments
1. Verified the health care provider’s orders.
2. Gathered the necessary equipment and supplies.
3. Performed hand hygiene.
4. Introduced self to the patient and family.
5. Provided for the patient’s privacy.
6. Identified the patient using two patient identifiers.
7. Checked for factors that suggest a possible pulse deficit.
Obtained the help of a second health care provider.
8. Explained to the patient that two people will be assessing
heart function at the same time. Helped the patient into
a supine or sitting position, and exposed the sternum
and left side of the chest.
9. Located the apical and radial pulse sites. Had the second
health care provider palpate the radial pulse while they
auscultated the apical pulse.
10. Counted the pulse rate simultaneously for a full 60
seconds.
11. Stopped counting and compared findings.
12. Subtracted the radial rate from the apical rate.
13. Helped the patient into a comfortable position.
Discussed findings with the patient as needed.
14. Performed hand hygiene.
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Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.
15. Assessed for other signs and symptoms of decreased
cardiac output.
16. Reported the presence of a pulse deficit and any related
symptoms to the nurse in charge or to the health care
provider.
17. Helped the patient into a comfortable position, and
placed toiletries and personal items within reach.
18. Placed the call light within easy reach, and made sure
the patient knows how to use it to summon assistance.
19. Raised the appropriate number of side rails and lowered
the bed to the lowest position.
20. Disposed of used supplies and equipment. Left the
patient’s room tidy.
21. Removed and disposed of gloves. Performed hand
hygiene.
22. Documented and reported the patient’s response and
expected or unexpected outcomes.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.
Mosby: Mosby’s Nursing Video Skills
Student _________________________________________ Date ___________________
Instructor _______________________________________ Date ___________________PERFORMANCE CHECKLIST FOR ASSESSING APICAL PULSE
S U NP Comments
1. Verified health care provider’s orders.
2. Gathered necessary equipment and supplies.
3. Performed hand hygiene.
4. Provided patient’s privacy.
5. Introduced self to patient and family.
6. Identified patient using two identifiers.
7. Assessed for factors that can affect apical pulse
rate and rhythm.
8. Used gloves if necessary.
9. Helped patient into appropriate position.
10. Located PMI properly.
11. Slid fingers down to ICS, then to the fifth
intercostals space, then over to the left
midclavicular line.
12. Felt PMI as a light tap reflecting apex of the
heart.
13. Located PMI if not where expected.
14. Warmed diaphragm of stethoscope in palm of
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.
hand, cleaned with alcohol, allowed to dry.
15. Placed diaphragm over PMI, auscultated for
normal S1 and S2 sounds.
16. Looked at watch once sounds were heard
with regularity, took pulse properly.
17. Replaced patient’s gown and bed linen
helped patient to comfortable position,
discussed findings as appropriate.
18. Cleaned earpieces and diaphragm with
alcohol after each use, discarded swab
appropriately.
19. Placed personal items within reach.
20. Placed call light within reach, ensured patient
knew how to use it.
21. Raised top side rails and lowered bed to
ensure patient safety.
22. Disposed of used supplies and equipment, left
patient’s room tidy.
23. Removed and disposed of gloves if worn,
performed hand hygiene.
24. Compared patient’s apical pulse rate and
rhythm with baseline and acceptable range.
25. Documented and reported patient’s response
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.
and outcomes.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.
Mosby: Mosby’s Nursing Video Skills
Student _________________________________________ Date ___________________
Instructor _______________________________________ Date ___________________PERFORMANCE CHECKLIST FOR ASSESSING RADIAL PULSE
S U NP Comments
1. Verified health care provider’s orders.
2. Gathered necessary equipment and supplies.
3. Performed hand hygiene.
4. Provided patient’s privacy.
5. Introduced self to patient and family.
6. Identified patient using two identifiers.
7. Assessed for factors that can affect pulse rate
and rhythm.
8. Used gloves if necessary.
9. Helped patient into appropriate position.
10. Placed fingers properly on patient’s inner
wrist, extended or flexed wrist until strongest
pulse is felt.
11. Pressed against radius until pulse was
obliterated, relaxed pressure until pulse is
palpable.
12. Rated strength of pulse properly.
13. Note regularity and rate of rhythm properly.
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Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.
14. Helped patient to comfortable position,
placed personal items within reach.
15. Placed call light within reach, ensured patient
knows how to use it.
16. Raised appropriate number of side rails and
lowered bed to ensure patient safety.
17. Disposed of used supplies and equipment, left
patient’s room tidy.
18. Removed and disposed of gloves if worn,
performed hand hygiene.
19. Discussed finding with patient as needed.
20. Compared patient’s pulse rate and character
with baseline and acceptable range.
21. Documented and reported patient’s response
and outcomes.
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