Chapter 4 - VITAL SIGNS for Nursing 101
1. Discuss the importance of accurately assessing vital signs.
They indicate basic body functioning
It is appropriate to begin physical assessment by obtaining these data
Provide basis for problem solving
Enables identification of nursing diagnoses to implement planned interventions and to evaluate
success when vital signs have returned to normal values.
2. Identify guidelines for vital signs measurement
Measure vital signs correctly
Understand and interpret the values
Communicate findings appropriately
Begin interventions as needed
3. Accurately assess Oral temperature assessment
- most accessible site; comfortable for patient; does not need any position changes
- do not use for patients who could be injured by thermometer, who are unable to hold
thermometer properly, or who might bite down on thermometer.
- do not use for infants or small children
- do not use for disoriented or unconscious patients; patient who just had oral surgery; patients
with trauma to face or mouth
- do not use in patients who breathe only with mouth open
, - do not use in patients with history of convulsions or patients experiencing a chill
4. Accurately assess Rectal temperature assessment
- argued to be more reliable when oral temperature cannot be obtained
- use sensitivity because it is embarrassing
- do not use in patients after rectal surgery ; patients who have a rectal disorder such as tumors or
hemorrhoids; or patients who cannot be positioned for proper thermometer placement such as
those in traction
- there is risk of body fluid exposure, and lubrication is required
5. Accurately assess Axillary temperature assessment
- safe method because it is noninvasive
- least accurate
6. Accurately assess Tympanic Temperature Assessment
- noninvasive, accurate, safe
- provides core reading; lessens need to handle newborns, which aids in preventing heat loss
- excessive cerumen has the possibility to interfere with accurate reading;
- continuous measurement of temperature is not possible
- new disposable probe cover necessary for each patient.
, 7. Describe the procedure for determining the respiratory rate
Prepare hand hygiene, introduce self to patient, identify the patient (takes away patient anxiety)
Explain procedure (seeks cooperation and assistance from patient
Assemble all necessary supplies
Provide privacy (decreases patient's anxiety)
If patient has been active, wait for 5 to 10 minutes
Be sure patient is in a comfortable position, head of bed elevated to 45 to 60 degrees. (Discomfort
causes rapid breathing. Erect sitting position promotes full ventilation
Place fingertip as if to obtain a radial pulse because patients alter respiratory rate when being
observed.
Observe respiratory rate for 60 seconds (ensures accuracy). One inhalation and one exhalation =
one respiration.
Provide patient comfort
Document results
8. Normal Vital Sign limits for healthy adults
Heart Rate: 60 - 100
Respiratory Rate: 12-20
Blood Pressure: Systolic 100-120, Diastolic 70-80
100/70 through 120/80
Temperature: Oral and Tympanic: 98.6; Rectal 99.5, Axillary 97.6
Normal Range 97 to 99.6
9. Factors that affect Vital Sign Readings
Age
1. Discuss the importance of accurately assessing vital signs.
They indicate basic body functioning
It is appropriate to begin physical assessment by obtaining these data
Provide basis for problem solving
Enables identification of nursing diagnoses to implement planned interventions and to evaluate
success when vital signs have returned to normal values.
2. Identify guidelines for vital signs measurement
Measure vital signs correctly
Understand and interpret the values
Communicate findings appropriately
Begin interventions as needed
3. Accurately assess Oral temperature assessment
- most accessible site; comfortable for patient; does not need any position changes
- do not use for patients who could be injured by thermometer, who are unable to hold
thermometer properly, or who might bite down on thermometer.
- do not use for infants or small children
- do not use for disoriented or unconscious patients; patient who just had oral surgery; patients
with trauma to face or mouth
- do not use in patients who breathe only with mouth open
, - do not use in patients with history of convulsions or patients experiencing a chill
4. Accurately assess Rectal temperature assessment
- argued to be more reliable when oral temperature cannot be obtained
- use sensitivity because it is embarrassing
- do not use in patients after rectal surgery ; patients who have a rectal disorder such as tumors or
hemorrhoids; or patients who cannot be positioned for proper thermometer placement such as
those in traction
- there is risk of body fluid exposure, and lubrication is required
5. Accurately assess Axillary temperature assessment
- safe method because it is noninvasive
- least accurate
6. Accurately assess Tympanic Temperature Assessment
- noninvasive, accurate, safe
- provides core reading; lessens need to handle newborns, which aids in preventing heat loss
- excessive cerumen has the possibility to interfere with accurate reading;
- continuous measurement of temperature is not possible
- new disposable probe cover necessary for each patient.
, 7. Describe the procedure for determining the respiratory rate
Prepare hand hygiene, introduce self to patient, identify the patient (takes away patient anxiety)
Explain procedure (seeks cooperation and assistance from patient
Assemble all necessary supplies
Provide privacy (decreases patient's anxiety)
If patient has been active, wait for 5 to 10 minutes
Be sure patient is in a comfortable position, head of bed elevated to 45 to 60 degrees. (Discomfort
causes rapid breathing. Erect sitting position promotes full ventilation
Place fingertip as if to obtain a radial pulse because patients alter respiratory rate when being
observed.
Observe respiratory rate for 60 seconds (ensures accuracy). One inhalation and one exhalation =
one respiration.
Provide patient comfort
Document results
8. Normal Vital Sign limits for healthy adults
Heart Rate: 60 - 100
Respiratory Rate: 12-20
Blood Pressure: Systolic 100-120, Diastolic 70-80
100/70 through 120/80
Temperature: Oral and Tympanic: 98.6; Rectal 99.5, Axillary 97.6
Normal Range 97 to 99.6
9. Factors that affect Vital Sign Readings
Age
