Nursing Vital Signs Assessment

Vital Signs Observation and Pain Assessment

• The course is titled PDN24 Foundations of Nursing Therapeutics I
• The intended learning outcomes include identifying the time for assessing vital signs, describing the factors influencing vital signs, differentiating normal and abnormal vital signs, describing nursing interventions for abnormal findings, analyzing the advantages and disadvantages of temperature measuring methods, describing the mechanics and regulation of breathing, assessing pain levels of verbal and nonverbal clients, calculating the Modified Early Warning Score (MEWS), and correlating response actions to risk levels.
• The content includes what vital signs are, body temperature, pulse, respirations, blood pressure, oxygen saturation, pain, and the Modified Early Warning Score (MEWS).

Body Temperature

• Body temperature reflects the balance between heat produced and heat loss from the body, measured in both Fahrenheit (°F) and Celsius (°C).
• Average normal temperatures for healthy adults are presented for different measuring methods (oral, rectal, tympanic, axillary, and temporal).
• Assessment of body temperature includes identifying patient identity, observing signs of fever or hypothermia, noting the measurement site and device, and considering previous baseline temperature.
• Possible nursing diagnoses include hyperthermia, hypothermia, risk for imbalanced body temperature, ineffective thermoregulation, and risk for perioperative hyperthermia.
• Planning involves the patient, equipment, and environment
• Implementation details include methods for oral, rectal, tympanic, axillary, and temporal temperature measurement.
• Evaluation involves comparing the temperature with the previous baseline.

Pulse

• A pulse is a wave of blood created by the contraction of the heart's left ventricle.
• Pulse rate is measured in beats per minute (bpm), and normal ranges are given for adults (60-100 bpm).
• Normal pulse rhythm is regular and evenly spaced.
• Affecting factors like age, sex, exercise, fever, medications, hypovolemia, stress, and position changes are cited.
• Apical and peripheral pulse types exist for assessing newborns, infants and children. Indicates when to use an apical (at heart) or peripheral (at fingertips) pulse.
• Assessment details for both types are included, covering symptoms, patient identity, alterations, and potential nursing diagnoses.
• Planning involves the patient, equipment, and environment
• Implementation includes various methods and instructions to take an apical and peripheral pulse
• Evaluation involves comparing the pulse rate with the previous baseline.

Respirations

• Respirations involve inhalation (intake of air), exhalation (breathing out gases), and ventilation (movement of air).
• Two types of breathing, costal and diaphragmatic.
• Costal breathing involves external intercostal muscles and other accessory muscles.
• Diaphragmatic breathing involves contraction and relaxation of the diaphragm.
• The mechanics and regulation of breathing are controlled by centers in the medulla oblongata and pons, with chemoreceptors in the medulla and carotid/aortic bodies responding to changes in oxygen, carbon dioxide, and hydrogen levels.
• Affecting factors like exercise, stress, medical conditions, medications, position changes, and environment temperature are considered.
• Normal respiration rates and rhythm (evenly spaced regular breathing) for adults are presented.
• Assessment details include altered respiration, patient identity, and alterations.
• Possible diagnoses may include impaired gas exchange, ineffective breathing patterns, and ineffective airway clearance.
• Planning involves the patient, equipment, and environment.
• Implementation details for performing respiration assessments are detailed.
• Evaluation involves comparing the respiration rate with the previous baseline, and correlating this with SpO2 and ABG measurements.

Blood Pressure

• Blood pressure measures the force exerted by blood against arterial walls, in millimeters of mercury (mmHg).
• Systolic pressure is the pressure during ventricular contraction, while diastolic pressure is the pressure when ventricles relax.
• Mean arterial pressure (MAP) is derived from the average blood pressure
• Affecting factors such as age, gender, exercise, stress, ethnicity, temperature, medications, obesity, fluid status, and smoking are documented.
• Assessment details include altered blood pressure, patient identity and variations. Potential associated diagnoses include decreased cardiac output, deficient volume, excess volume, and ineffective tissue perfusion.
• Planning involves the patient, equipment, and environment .
• Implementation details include proper cuff size and position, inflation, and deflation procedures, and also how and where to place stethoscope.
• Evaluation involves comparing the blood pressure with the previous baseline.

Oxygen Saturation

• Oxygen saturation reflects the percentage of hemoglobin binding sites occupied by oxygen in arterial blood.
• Normal values are 95-100%, and abnormal findings are <95%, with life-threatening levels being lower than 90%.
• Assessment covers symptoms related to altered oxygen saturation, patient identification, and variations. Possible diagnoses may include impaired gas exchange, ineffective breathing pattern, and ineffective airway clearance.
• Planning involves the patient, equipment, and environment.
• Implementation details involve using pulse oximeters and appropriate sensor placement
• Evaluation involves comparing the saturation result with previous baseline values.

Pain Assessment

• "Pain is an unpleasant subjective sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage"
• The assessment involves location, quality (description), intensity, pattern, precipitating and alleviating factors, coping resources, and the affective response to pain.
• It covers observation techniques involving facial expression, rhythmic body movement, immobilization, BP, pulse, RR, diaphoresis, and pallor.
• Numerical rating scale (NRS), verbal rating scale (VRS), and visual analogue scale (VAS) for evaluating pain intensity are included.

Modified Early Warning Score (MEWS)

• This is a validated tool to trigger timely and appropriate interventions.
• It assists staff in recognizing clinical deterioration and notifying senior staff.
• Specific patient factors for inclusion and exclusion are included for use of the tool.
• Includes algorithms to determine risk levels according to various parameters.

Test your knowledge on essential nursing practices regarding vital signs. This quiz covers differentiation, analysis, and interventions required for assessing various vital signs and understanding their implications. Perfect for nursing students looking to strengthen their clinical skills.