Chapter 6 Vital Signs

Patient-Centered Care Changes in vital signs indicate a patient’s response to physical, environmental, and psychological stressors. Nursing clinical judgment determines: which vital signs to measure how often to measure them safe delegation practices. Vital signs help determine if additional assessment is needed. Vital signs must be measured correctly, interpreted, acted on, and reported.

Safety Clean vital sign equipment before and after use with each patient. Routinely inspect vital sign equipment to keep in working order. The biomedical department inspects for electrical safety. Know how to use each device and ask for instruction if unsure.

Skill 6.1 Measuring Body Temperature Identify factors that may affect temperature. Assess for signs and symptoms of infection. Determine baseline value. Select appropriate measurement site and device. Maintain patient privacy. Maintain device position until reading is obtained. Return device to charging unit.

Skill 6.2 Assessing Pulse: Apical Identify factors that may affect pulse such as medications, treatments, exercise, or anxiety. Assess for altered cardiac function. Determine baseline value. Determine appropriate measurement site and device.

Skill 6.3 Assessing Pulse: Radial Identify factors that may affect pulse. Obtain pulse after patient is at rest for 5 to 10 minutes. Determine baseline value. Position with relaxed lower arm and wrist extended. Maintain privacy. Use moderate pressure to feel radial pulse. 30 seconds for rapid, slow, or regular pulses Multiply by 2. 60 seconds for irregular pulses

Skill 6.4 Assessing Respirations Identify factors that may affect respirations. Determine baseline value. Place patient in position of comfort. Position patient so chest is visible. Maintain privacy. Observe and count a complete respiratory cycle (one inspiration and one expiration). 30 seconds for regular respirations Multiply by 2. 60 seconds for irregular rhythm or rate less than 12 or greater than 20

Skill 6.5 Assessing Blood Pressure Identify factors that may affect blood pressure. Have patient rest in a sitting position for 5 minutes before measuring blood pressure. Determine that patient has not smoked or ingested caffeine for 30 minutes. Determine appropriate extremity, blood pressure cuff size, and latex allergy status. Determine baseline value. Use appropriate cuff size with arm relaxed at heart level. Use one-step or two-step method.

Procedural Guideline 6.1 Assessing Pulse: Apical-Radial Pulse Deficit A pulse deficit exists when there is a difference in pulse rates taken from two different sites. One health care provider auscultates apical pulse while a second provider simultaneously obtains radial pulse. Count for 60 seconds and compare apical and radial rates. If pulse count differs by more than 2, a pulse deficit exists. Report findings to health care provider

Procedural Guideline 6.2 Assessing Blood Pressure Electronically Electronic blood pressure machines are used in health care facilities and public places. Determine appropriateness for use of electronic measurement (e.g., patient condition). Select appropriate cuff size for patient extremity. Follow manufacturer’s directions to obtain reading. If unable to obtain reading, verify machine function. Compare electronic reading with auscultatory measurement to verify accuracy of electronic result.

Procedural Guideline 6.3 Measuring Oxygen Saturation Pulse oximetry noninvasively measures arterial blood oxygen saturation. Assess for factors that may alter oxygen saturation. Determine patient’s baseline measurement. Select appropriate site with adequate circulation and no interfering factors. Attach sensor to monitoring site. Correlate pulse rate with patient’s radial pulse. Compare result with baseline and previous values.