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NR 224-Week 2 Edapts
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NR 224 Edapt Week 2Vital Signs
Introduction to Vital Signs
Vital signs serve as a starting point in assessing the overall functioning of the body and are a snapshot of a point in time that
reflects the immediate status of a baseline or trends of the values over time. Vital signs include the measurement of temperature,
pulse, respirations, blood pressure, and O2 saturation.
There are normally five vital signs that are measured: temperature, pulse, respirations, blood pressure, and pain. Oxygen
saturation is also frequently included.
The nurse must be able to do the following:
Measure vital signs correctly.
Use the equipment needed for vital sign measurements correctly.
Understand what the vital signs tell you about the client.
Be organized and use a systematic approach when measuring vital signs.
Delegate vital sign measurements to other healthcare providers.
Analyze and interpret trends over time.
Respond to changes in vital signs quickly and appropriately.
Communicate and document findings accurately.
Vital signs alone are not enough to evaluate body functioning or determine problem-solving steps. Vital signs are one set of clues
used in collaboration with other physiological measurements and assessment findings for the basis of problem solving and
indication of basic body functioning.
Abnormal Vital Signs
The client’s baseline range of vital signs, which may or may not typically run in the normal range, in comparison to
current findings.
The client’s health history, therapies, and prescribed and over-the-counter medications as these may predictably affect
one or more vital signs; the impact of vital sign measurements on medication administration, and vice versa. Some
medications are only given when a particular vital sign is within a particular range. And some medications are
contraindicated when certain vital signs are within a certain range.
Environmental factors may falsely affect vital signs (such as the effect of a warm, humid room on the client's
temperature).
Ensure that the vital sign equipment is working correctly prior to measurement in order to provide accurate findings,
and select the correct equipment for the client’s condition and characteristics (such as age and size).
An acute episode of anxiety can cause the physiologic response of an increased pulse rate.
A low heart rate means the body is receiving less blood/perfusion, which can cause decreased cardiac output.
Ineffective, rapid respirations result in a decrease in serum oxygen and impaired gas exchange.
A client who has had a surgical procedure is likely to be in acute pain, which impacts vital sign results.
A decreased pulse oximetry indicates insufficient oxygen in the blood and, therefore, ineffective peripheral tissue
perfusion.
Vital Signs With Pediatric Clients
The client’s age, gender, activity, medication, and health status influence their vital signs.
Compared with adults, in infants and children:
pulse and respirations run higher
blood pressure runs lower
, brachial and apical pulse are the best sites for assessing pulse
respirations tend to be less regular in infants
Vital signs in older adults are influenced by aging.
Delegating Vital Signs
Vital sign measurements are the nurse’s responsibility. However, when appropriate, nurses may delegate them to unlicensed
nursing assistant personnel after the nurse has determined that the client’s condition is stable. The nurse must review the vital
sign data and use nursing knowledge to follow the nursing process based on the data obtained.
The skill of apical pulse measurement cannot be delegated. The nurse completes the vital signs upon admission to establish
baseline vital signs and to assess the client’s stability before delegating.
Determining Client Health by Monitoring Vital Signs
Recall from previous knowledge that:
Vital signs and other physiological measurements often provide the basis for problem solving.
Careful technique ensures accurate findings.
Temperature, pulse, respirations, blood pressure, and oxygen saturation are usually assessed at the same time at set
intervals.
The ability to obtain accurate measurements of vital signs is critical because vital signs are an indication of basic body
functioning.
It is appropriate to begin the physical assessment by obtaining this data.
The skills required to measure vital signs are simple, but the simplicity should never reduce the critical value of the
task.
Changes in vital signs signal a change in physiological function and can change based on many factors, such as:
environmental temperature
physical exertion
effects of illness
Assessment of vital signs provides:
cues for identifying nursing diagnoses, implementing planned interventions, and evaluating outcomes
monitoring of a client’s condition, identification of problems, and evaluation of intervention responses
data used to determine a client’s health status and need for medical or nursing interventions
Considerations for Vital Signs
Vital signs are interrelated. A rise in temperature of one degree Fahrenheit may cause an increase in the pulse rate by four beats
per minute. Respiratory rates and blood pressure readings also increase with a rise in temperature. When blood pressure falls
because of a hemorrhage, the pulse and respirations increase to compensate.
Client Condition
A client's condition determines when, where, how, and by whom vital signs are measured.
The frequency of vital sign measurements is kept to a minimum but will likely be increased as the client's condition
worsens and becomes more acute.
The nurse is responsible for judging whether more frequent assessments are necessary.
Assessing Client Status
Nurses measure vital signs to assess a client's status as part of:
baseline, admission, and routine physical assessments
a review of or change in a client's condition
, before, during, and after certain medications and/or blood administration
a healthcare provider's order and in preparation for a healthcare provider's exam
a facility's standard of practice and policy
before, during, and after an invasive procedure and/or nursing interventions that impact a vital sign
Delegating Vital Sign Measurements
Vital sign measurements are the nurse's responsibility. However, when appropriate, they may be delegated to unlicensed
nursing assistant personnel after the nurse has determined that the client's condition is stable.
The nurse must review the vital sign data and use nursing knowledge to follow the nursing process based on the data
obtained.
Note: A nurse cannot delegate the skill of measuring an apical pulse.
Interrelated Vital Signs
An increased temperature may cause an increased pulse rate.
An increased temperature may cause an increased respiratory rate.
An increased temperature may cause an increased blood pressure.
A decreased blood pressure may cause an increased pulse rate.
A decreased blood pressure may cause an increased respiratory rate.
Normal Ranges of Vital Signs
Vital sign monitoring is a fundamental component of nursing care. As you learn to assess vital signs, it is important to know
the normal values so that you will be able to recognize and respond to abnormal vital signs. Review the image shown here for
the acceptable ranges of vital signs in adults.
A client’s age, gender, activity, medications, and health status influence vital signs.
Compared with adults, in infants and children:
pulse and respirations run higher
blood pressure runs lower
brachial and apical pulse are the best sites for assessing pulse
respirations tend to be less regular in infants
Vital signs in older adults are influenced by aging.
Assessing Vital Signs
Compared with adults:
The pulse rate tends to run higher in infants and children.
The respiratory rate tends to run higher in infants and children.
The blood pressure tends to run lower in infants and children.
The apical and brachial pulse are the best sites for assessing pulse in infants and children.
The respirations tend to be less regular in infants.
Analyzing Vital Signs
These are typical factors that impact vital sign measurements:
The client’s baseline range of vital signs, which may or may not typically run in the normal range.
The client’s health history, therapies, and prescribed and over-the-counter medications as these may predictably affect
one or more vital signs.
Environmental factors may falsely affect vital signs (such as the effect of a warm, humid room on the client’s
temperature).
Some medications are only given when a particular vital sign is within a particular range. And some medications are
contradicted when certain vital signs are within a certain range.
, Vital sign equipment must be working correctly before measurements in order to provide accurate findings.
Equipment must be selected correctly for the client’s condition and characteristics (such as age and size).
Priority Hypothesis and Documentation
There are many causes for abnormal vital signs that the nurse can act upon. Possible nursing diagnoses focus on when a
client’s vital signs are abnormal, including:
risk for imbalanced body temperature (hyperthermia or hypothermia)
ineffective thermoregulation
activity intolerance
anxiety
decreased cardiac output
deficient or excess fluid volume
impaired gas exchange
acute pain
ineffective peripheral tissue perfusion
risk of injury
It is very important to accurately record and report vital sign measurements in the client’s electronic medical record (EMR ).
Inform the healthcare provider of abnormal vital signs and subsequent follow-up assessment data you obtain.
Document the route and site used to obtain temperature, blood pressure, pulse, and oxygen saturation.
Document when vital signs are abnormal for the client’s expected values by recording the finding, any intervention, and
client response.
Early Warning Scores (EWS) are used by many healthcare organizations. When vital sign measurements are entered
into the EMR, this system identifies subtle changes which may be the first signs of a change in the client’s condition
and alerts nurses.
Documenting Vital Signs
Inform the healthcare provider of abnormal vital signs and subsequent follow-up assessment data you obtain.
Document the route and site used to obtain temperature, blood pressure, pulse, and oxygen saturation. Document when
vital signs are abnormal for the client’s expected values by recording the finding, any intervention, and client response.
Documentation is important but not until after priority nursing actions have been taken, such as analyzing the vital
signs and notifying the healthcare provider when appropriate.
Early warning scores (EWS) are used by many healthcare organizations. When vital sign measurements are entered into
the electronic health record (EHR ), EWS identifies subtle changes, which may be the first signs of a change in the
client’s condition, and alerts nurses. The nurse should never ignore the EWS and an EWS warning does not require a
healthcare provider to be notified. Further assessment would be the next step to determine the proper course of action.
Obtaining Vital Signs
The client’s baseline range of vital signs may or may not typically run in the normal range. The client’s health history, therapies,
and prescribed and over-the-counter medications may predictably affect one or more vital signs. Some medications are only given
when a particular vital sign is within a particular range. And some medications are contradicted when certain vital signs are
within a certain range.
This blood pressure is the baseline for this client. It is elevated in terms of the standard parameters but, for this client, it is
normal and there are no additional cues for concern. Before giving the medication as ordered, the nurse would still complete the
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