Vital Signs in Nursing

Vital Signs

• Vital signs are essential to reflect the patient's body physiological status and provide information/baseline data.
• The nurse is responsible for measuring, interpreting, and making decisions about care based on vital signs.
• Knowledge of normal ranges, environmental factors, and systematic approach is necessary to accurately measure vital signs.

When to Assess Vital Signs

• On admission to obtain baseline data
• When a client has a change in health status or reports symptoms
• Before and after nursing interventions that could affect vital signs
• Before and after medication administration that could affect the respiratory or cardiovascular systems
• Before and after surgery or an invasive procedure
• Frequency of vital signs assessment varies depending on the medical doctor's order, nursing judgment, client condition, and facility standards.

Observation Prior to Vital Signs Measurement

• Take a minute to observe the client's overall condition, looking for signs of anxiety, pain, or upset.
• Note the client's dress and hygiene.
• The exam begins as soon as you lay eyes on the client.

Purpose of Vital Signs Measurement

• To detect abnormal body temperature (hypothermia or hyperthermia)
• To detect fever
• To monitor the effectiveness of a fever-reducing medicine
• To plan for pregnancy by determining if a woman is ovulating

Temperature

• Normal body temperature ranges from 36.5°C to 37.5°C
• Thermoregulation is the maintenance of physiologic core body temperature by balancing heat generation with heat loss.
• Factors affecting body temperature include:
  • Circadian rhythms
  • Age
  • Hormones
  • Stress
  • Environmental temperature
  • Exercise or physical activity
  • Pyrexia (fever)

Pulse

• Normal pulse rate ranges from 60-100 beats per minute
• Pulse can be measured at the radial, femoral, popliteal, or dorsalis pedis arteries.
• Methods of measuring pulse include:
  • Using two hands to feel the femoral pulse
  • Placing fingers on the back of the knee to feel the popliteal pulse
  • Palpating the dorsalis pedis artery on the dorsal surface of the foot

Respiration

• Respiration is controlled by the respiratory centers in the medulla oblongata and the Pons of the brain, as well as chemo receptors located centrally in the medulla and peripherally in the carotid and aortic bodies.
• Respiration involves chemical exchange, diffusion, and perfusion.
• Respiratory rate is the number of breaths a person takes per minute.
• Normal respiratory rate ranges from:
  • 12-20 breaths per minute for adults
  • 20-25 breaths per minute for young children
  • Up to 40 breaths per minute for infants

Factors Affecting Respiratory Rate

• Age
• Physical activity and exercise
• Stress
• Pain
• Fever and metabolic rate
• Lung disease and respiratory condition
• Medications
• Environmental factors
• Hormonal factors
• Sleep

Variations in Respiration Rate

• Eupnea: normal respiratory rate in depth and rate
• Bradypnea: slow respiration rate less than 12 breaths per minute