Vital Signs: Measurement and Variations

Vital Signs Charting

• Charting involves recording vital signs details, including blood pressure site (e.g., right arm or leg) and temperature measurement method (e.g., oral, temporal).
• It is important to note the blood pressure number and site on the chart.
• Accurate recording of the temperature measurement method is essential.
• Accurate charting of vital signs is crucial for patient care.

Age-related Variations in Vital Signs

• Age significantly impacts vital signs; therefore, these variations are important to know for accurate assessment.
• Neonates typically have higher heart and respiratory rates compared to adults.
• Blood pressure norms vary across different age groups.
• Older adults may have elevated blood pressure due to age-related vessel changes.
• Age-specific normal ranges should be considered when assessing vital signs.

Temperature Measurement Methods

• Body temperature can be measured through oral, rectal, axillary, and tympanic methods.
• Rectal temperatures are generally one degree warmer than oral temperatures.
• Axillary temperatures are usually one degree cooler compared to oral temperatures.
• The appropriate method should be selected based on the patient's condition.
• Proper technique is essential when measuring rectal temperature to prevent injury.

Pulse Measurement and Grading

• Pulse locations include radial, ulnar, brachial, femoral, popliteal, dorsalis pedis, and posterior tibialis.
• Use a grading scale from 0 (absent) to 4+ (bounding) to document pulse quality.
• Pulses should be compared for symmetry.
• Both carotid pulses should not be measured simultaneously.

Apical pulse assessment

• The apical pulse is assessed at the point of maximum impulse (PMI) at the apex of the heart.
• Assessment should occur for one full minute, in particular for clients that are on Digoxin
• Accurate placement of the stethoscope at the PMI is crucial.
• The regularity and rate of the pulse should be assessed over a full minute.
• If there are irregularities, ensure listening for the full minute to capture them.

Orthostatic hypotension

• Orthostatic hypotension is characterized by a drop of 25 mmHg in systolic pressure when moving from lying to sitting or standing.
• A drop of 10 mmHg in diastolic pressure when moving from lying to sitting or standing also indicates orthostatic hypotension.
• Blood pressure should be monitored in different positions when orthostatic hypotension is suspected.
• Patients should be advised to rise slowly from lying or sitting positions.
• If dizziness occurs upon standing, the patient should sit or lie down immediately to prevent falls.

Blood pressure measurement techniques

• Manual measurement using a sphygmomanometer is a technique for measuring blood pressure accurately.
• Automated machines may not be accurate for clients presenting with irregular pulses.
• Blood pressure is usually higher in the lower extremities, compared to the arms.
• With irregular pulses, manual measurement is preferred.
• Ensure that the cuff placement and size are correct for accurate readings.
• Where a client has a dialysis shunt or mastectomy, avoid using the affected arm for blood pressure measurement.

Objective and Subjective Data in Nursing Assessment

• Signs are objective data perceived by the nurse through observation, measurement, and physical examination.
• Symptoms are subjective data reported by the patient.
• Examples of signs include rashes, altered vital signs, and abnormal lung or heart sounds.
• Examples of symptoms include pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety.
• It is important to encourage the full description of symptoms by the client.
• Onset, course, and character of symptoms should be assessed.
• Identify any factors that aggravate or alleviate symptoms.

Disease and Diagnosis

• Disease is a pathological condition of the body that disrupts its structure or function.
• Diagnosis which involves assessing signs and symptoms, can formulate a patient problem statement.
• Nurses rely on their assessment to formulate a patient problem statement.

Origins of Diseases

• Diseases can originate from hereditary, congenital, inflammatory, degenerative, infectious, deficiency, metabolic, neoplastic, traumatic, environmental, and autoimmune causes.
• Hereditary diseases are genetically inherited.
• Congenital diseases result from factors affecting the fetus.
• Inflammatory diseases involve inflammation of tissues.
• Degenerative diseases involve deterioration of body functions.
• Infectious diseases are caused by pathogens.
• Deficiency diseases are caused by a lack of essential nutrients.
• Metabolic diseases affect the body's metabolism.
• Neoplastic diseases are caused by abnormal cell growth.
• Traumatic diseases result from physical injury.
• Environmental diseases are caused by external factors.
• Autoimmune diseases occur when the immune system attacks the body.

Nurse-patient relationship initiation

• Introducing yourself and your role to the patient is a great of initiating the relationship.
• Explaining the purpose of the visit and procedures helps to develop the interaction.
• Communicating trustworthiness and discretion is vital.
• The nurse must introduce themselves, explain their role, and communicate the purpose of their visit.
• This helps in building trust and ensures the patient feels comfortable sharing personal information.
• The procedures also need to be explained in a way that the patient understands.
• The patient needs to know that their information is confidential.
• If a patient refuses an assessment, respect their decision and find an alternative solution.

OPQRSTUV method for pain assessment

• Onset: focus on when did the pain start?
• Provocative/Palliative: focus on what makes the pain worse or better?
• Quality: focus on asking them to describe the pain (sharp, dull, etc.).
• Region/Radiation: focus on asking them where is the pain and does it radiate?
• Severity: focus on what the severity of the pain is on a scale?
• Timing: focus on how long does the pain last?
• Understanding: focus on what the patient thinks is causing it?
• Value: focus on what a patient's goals are for care?
• The OPQRSTUV method is used to gather detailed information about a patient's pain, which helps in planning appropriate interventions.
• Make sure all aspects of the pain are covered during assessment.
• Use the patient's description to guide further questioning.

Review of systems

• General symptoms: Any current symptoms?
• Skin and skeletal: Any issues with skin or bones?
• Head: Headaches or unusual sensations?
• Eyes, ears, nose, mouth: Any problems?
• Endocrine: Hormonal issues?
• Reproductive: Any reproductive health concerns?
• Respiratory and cardiac: Breathing or heart issues?
• Gastrointestinal and genitourinary: Digestive or urinary problems?
• Neurologic and psychiatric: Mental health and neurological status?
• The review of systems is a systematic approach to assess each body system, ensuring no aspect of the patient's health is overlooked.
• Conduct the review in a private setting to maintain confidentiality.
• Be thorough and systematic in questioning.

Glasgow Coma Scale (GCS)

• The Glasgow Coma Scale is an objective measurement of the level of consciousness.
• It assesses eye opening, verbal response, and motor response.
• Eye opening: spontaneous eye opening scores a 4.
• Verbal response: oriented verbal response scores a 5.
• Motor response: obeying commands scores a 6.
• A total score of 15 indicates no brain trauma.
• A score of 8 or less indicates severe brain injury.

Skin Turgor and Hydration

• Skin turgor assesses the hydration status of a patient.
• Decreased skin turgor indicates dehydration.
• Increased skin turgor indicates edema.

Lung Sounds and Auscultation

• Auscultation of lung sounds involves listening to different locations of the lungs to find normal and abnormal sounds.
• Crackles indicate fluid in the bronchioles and alveoli.
• Wheezes indicate narrowed passageways.
• Stridor indicates an obstruction in the upper airway.
• Pleural friction rub indicates inflammation of the pleural sac.

Assessment of gastrointestinal system

• The gastrointestinal system is evaluated through inspection, auscultation, and palpation.
• Inspect the abdomen for shape, contour, lesions, scars, lumps, or rashes.
• Auscultate for bowel sounds in all four quadrants, using the diaphragm of the stethoscope.
• Palpate lightly to check for masses or rigidity.
• Chart all visible marks on the abdomen, such as scars or tattoos.
• Listen for at least four minutes before declaring absent bowel sounds.

Assessment of genitourinary system

• Evaluation of the genitourinary system can be done through inspection during perineal care.
• Whilst providing perineal care, check for lesions, lice, or discharge in genital areas.
• Retract and replace the foreskin when cleaning an uncircumcised male.

Assessment of extremities for edema

• Check the extremities for temperature, edema, and signs of blood clots.
• Assess temperature and palpate for edema.
• Use the pitting edema scale to classify swelling.
• To detect the presence of blood clots, avoid using Hohmann's sign.
• Compare both calves for size and signs of blood clots.
• If encountering suspected blood clots, assess for pain, redness, swelling, and heat.

SBAR communication tool

• Situation: Describe the current situation.
• Background: Provide background information.
• Assessment: Share your assessment.
• Recommendation: Offer recommendations.
• SBAR is used to ensure clear and concise communication.
• This is useful during handoffs with other healthcare professionals.