Understanding Vital Signs in Nursing

Role of Vital Signs

• Vital signs provide data about basic body functions
• Vital signs are often the first data collected and reveal changes in health
• Nurses measure and interpret vital signs to identify health issues

Primary Vital Signs

• Temperature is a vital sign
• Pulse (heart rate) is a vital sign
• Respiration rate and oxygen saturation are vital signs
• Blood pressure is a vital sign
• Pain and consciousness levels are considered as additional vital signs for providing insights into a patient's condition.

1.1 Importance of Vital Signs

• Vital signs are fundamental indicators of health and physiological status
• Vital signs are regularly assessed to:
  • Monitor baseline health
  • Detect early signs of illness or injury
  • Evaluate a patients response to treatment
  • Determine the need for emergency interventions
• Regular monitoring allows timely intervention and prevents complications

1.2 Vital Sign Details

• Temperature is measured orally, rectally, axillary and tympanically
• Oral temperature normal range 36.5–37.5°C (97.7–99.5°F)
• Fever is considered to be a temperature of 100.4 or greater
• Infection should be considered when there is a fever
• Rectal temperature readings are considered most accurate.
• Oral temperature is measured by placing thermometer under the tongue and closing mouth until reading is complete
• Rectal temperature is measured by inserting a lubricated thermometer into the rectum about 1 inch for precise readings
• Axillary temperatures are measured ensuring the arm is held tightly against the body
• Tympanic temperatures are measured by gently inserting the thermometer into the ear canal.
• Temperature is affected by time of day, being lower in the morning and higher in the afternoon or evening
• Temperature is affected by activity level, physical activity can increase body temperature
• Temperature is affected by age, with older adults tending have lower temperatures
• Temperature is affected by environmental temperature, and hot or cold surroundings
• Temperature is affected by illness, infections cause fever, while hypothyroidism lowers body temperature

Pulse

• Resting heart rate normal range is 60–100 beats per minute (bpm)
• Pulse can be measured at the radial (wrist), carotid (neck), brachial (arm), and femoral (groin) arteries
• Radial artery measurements are most frequently used in clinical practice
• Pulse is measured by placing two fingers on the radial artery on the thumb side of the wrist
• Count the beats for 30 seconds and multiply by two to calculate the bpm
• If the pulse is irregular, count for a full minute
• Pulse rate is affected by Infants and children tend to have higher heart rates
• Pulse rate is affected by fitness and athletes may have lower resting heart rates
• Pulse rate is affected by emotional state, stress, anxiety, or excitement can raise the heart rate.
• Some medications, like beta-blockers, lower heart rate, while stimulants, increase it.

Respiration Rate

• Normal value: 12-20 breaths a minute
• Respiration rate is measured by observing the rise and fall of a patient's chest
• Count the number of breaths for 30 seconds and multiply by two.
• Each rise and fall of the chest counts as one breath
• Respiratory rates are affected by age, with rates tending to be higher in younger individuals and decrease with age
• Respiratory rates are affected by physical activity, exercise or physical exertion increases respiration rate
• Respiratory rates are affected by emotional state, stress or anxiety can increase breathing rate
• Respiratory rates are affected by drugs, with certain drugs, such as opioids, slowing down the respiratory rate
• Higher altitudes cause faster breathing as the body tries to compensate for lower oxygen levels.

Oxygen Saturation

• Normal value is 95–100%
• Oxygen saturation is measured using a pulse oximeter, a non-invasive device
• Attach the sensor to the patient's fingertip or earlobe
• Allow a few seconds for the device to provide a reading
• Record the oxygen saturation level displayed as a percentage
• Oxygen saturation is affected by altitude, and may be lower at high altitudes
• Oxygen saturation is affected by respiratory conditions, patients with chronic respiratory diseases like COPD may have lower baseline oxygen levels
• Nail polish can interfere with pulse oximeter readings

Blood Pressure

• Normal Systolic Values: 90–120 mmHg
• Normal Diastolic Values: 60–80 mmHg
• Normal Range: Less than 120/80 mmHg
• Blood pressure is measured by using a sphygmomanometer and a stethoscope
• However electronic blood pressure monitors are also commonly used
• Place the cuff around the upper arm at heart level
• Inflate the cuff until the brachial artery is occluded and no blood flow is heard
• Slowly deflate the cuff and listen for the first sound to get the systolic pressure
• Continue deflating until the sound disappears to get the diastolic pressure
• Record the measurement as systolic/diastolic
• Blood pressure is affected by age, and tends to increase with age
• Blood pressure is affected by activity level, and physical exertion raises blood pressure temporarily
• Blood pressure is affected by stress, which can cause temporary increases
• Blood pressure is affected by medications, such as antihypertensives, lower blood pressure
• Blood pressure is affected by a diet, with high salt intake increasing blood pressure

Vital Signs & Nursing Practice

• Vital signs are a cornerstone of nursing practice for information about a patient's health
• Accurate measurement, interpretation, and understanding of the factors influencing vital signs are critical to ensuring effective patient care
• By routinely monitoring vital signs, nurses can detect early signs of illness, evaluate the effectiveness of treatment, and initiate appropriate interventions

Pain

• Pain is the "5th vital sign" given its significant impact on a patient’s well-being and health outcomes
• Pain is subjective and relies on patient self-reporting.
• Assessment and management of pain is crucial for holistic care, improving patient comfort, and enhancing recovery

Pain Assessment

• Unlike traditional vital signs like temperature or blood pressure, there is no instrument that directly measures pain
• Pain is assessed based on patient communication and standardized tools
• Nurses use these tools to evaluate both the intensity and the characteristics of the pain
• Numeric Rating Scale (NRS): Patients rate their pain on a scale from 0 (no pain) to 10 (worst pain imaginable).
• Visual Analog Scale (VAS): Patients mark their pain intensity on a 10 cm line from “no pain” to “worst pain imaginable.”
• Wong-Baker Faces Pain Scale: Patients choose a face that represents their level of pain
• Verbal Descriptor Scale (VDS): Patients choose words such as "mild," "moderate," or "severe".

Characteristics of Pain Assessment

• Nurses gather the following information
• Location: Where is the pain located?
• Intensity: How severe is the pain?
• Quality: What does the pain feel like
• Duration: How long has the pain been present, and is it constant or intermittent?
• Aggravating/Relieving Factors: What makes the pain worse or better?
• Effect on Functioning: How does the pain impact daily activities, movement, sleep, and emotional well-being?

Pain Management

• Effective pain management is vital for promoting healing, improving quality of life, and preventing complications such as chronic pain or emotional distress
• Unrelieved pain leads to physical consequences like increased blood pressure and rapid heart rate, and emotional issues like anxiety or depression
• Pain should be treated promptly through medications, physical therapies, or non-pharmacological interventions

Charting Vital Signs

• Accurate documentation of vital signs is a critical component of nursing care
• It serves as a record for ongoing patient monitoring, helps detect early signs of clinical deterioration, and guides medical interventions
• Proper charting ensures that all healthcare professionals have access to up-to-date information about the patient's status

Reporting Abnormal Findings Vital Signs

• Abnormal vital signs indicate patient deterioration, requiring immediate attention
• Report changes to the healthcare team member to prevent serious complications

Key Elements When Charting Vital Signs

• Temperature: Record the numerical value, the unit (°C or °F), and the method used (oral, rectal, axillary, or tympanic).
• Example: 37.2°C (Oral)
• Pulse: Note the rate (beats per minute), rhythm (regular or irregular), and strength (weak, normal, strong).
• Example: 78 bpm, regular, strong
• Respiration Rate: Record the number of breaths per minute and any abnormalities in the breathing pattern (e.g., labored, shallow).
• Example: 16 breaths/min, normal
• Blood Pressure: Document both the systolic and diastolic readings, as well as the position of the patient (sitting, standing, lying) if relevant.
• Example: 118/76 mmHg (sitting)
• Oxygen Saturation (SpO₂): Record the percentage value and whether supplemental oxygen is being used.
• Example: 98% on room air
• Pain: Use the pain scale selected and note the patient’s reported pain level along with any descriptive characteristics.
• Example: Pain 7/10, sharp, intermittent, in lower back

Guidelines for Accurate Charting

• Chart vital signs immediately after measurement
• Use the same measurement methods for comparisons over time
• Include all relevant information like patient position or interventions
• Use clear and objective language with precise numbers and descriptions

Identifying Abnormal Vital Signs

• Temperature: Fever (≥38°C or 100.4°F) or hypothermia (≤36°C or 96.8°F) may indicate infection or systemic issues
• Pulse: Bradycardia (below 60 bpm) or tachycardia (above 100 bpm) indicates cardiac/electrolyte issues
• Respiration Rate: Bradypnea (less than 12 breaths/min) or tachypnea (more than 20 breaths/min) points to respiratory/metabolic problems
• Blood Pressure: Hypotension (systolic 140 mmHg) indicate fluid balance disorders
• Oxygen Saturation: A reading below 95% indicates hypoxemia, below 90% requires intervention
• Pain: Uncontrolled or escalating pain suggests worsening condition

Steps to Reporting Abnormal Findings

• Verify the Data: Recheck the abnormal value to rule out measurement error
• Notify the Physician or Nurse Practitioner and provide the abnormal finding, baseline values, and symptoms
• Use ISBARR: Identification, Situation, Background, Assessment, Recommendation, Readback
• ISBARR aids succinct handoff
• Document findings and responses in the chart