NURSING 1F03 Lecture 6: Week 6 Vital-Signs
7 May 2018
School
Department
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Professor
Sunday, November 1, 2015
1
1I02 Week 8- Vital Signs
Guidelines for Incorporating Vital Signs into Practice:
• nurse caring for client is responsible for vital sign measurements and measurement of
special vital signs may require assistive personnel; nurse must assist vital signs for
making decisions about interventions
• equipment should be functional and appropriate for the size and age of patient
• equipment should be selected based on client’s condition and characteristics (e.g., an
adult-size blood pressure cuff should not be used for a child)
• know the client’s usual range of vital signs; a client’s usual values may differ from the
acceptable range for that age and physical state and can serve as a baseline for
detecting change in the patient’s condition over time
• nurse must know client’s medical history, therapies, and prescribed medications
(some medications can cause vital sign changes)
• nurse must control or minimize environmental factors that can affect vital signs (e.g.,
taking temperature in a warm or humid room)
• nurse must follow the procedure properly and be organized in measuring the signs;
organization facilities efficiency (e.g., respirations can be assessed while taking oral
temperature)
• nurse must approach client in a calm and caring manner to measure vital signs
• nurse must collaborate with physician based on the client’s condition to decide
frequency of vital sign assessment
- in the hospital physicians order minimum frequency for assessment of signs
- after a surgery or treatment vital signs need to be measured more frequently
- in a clinic our outpatient setting signs need to be measure before practitioner
examines client and after any invasive procedures
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Sunday, November 1, 2015
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• vital signs need to be measured for prescribing medication
- cardiac drugs are given within a range of pulse or blood pressure values
- antipyretics are given when body temperature is elevated
- no need to give medication if conditions are within the set range of values
• nurse must analyze results of vital sign measurements; a client’s ongoing health
status and physical signs and symptoms must also be considered while making
analysis about vital signs
• nurse must verify, communicate, and document changes in a client’s vital signs;
abnormalities in vital signs means that another nurse or physician must repeat the
measurement
• nurse must develop a teaching plan to instruct the client or caregiver in vital sign
assessment
When to Take Vital Signs
• on admission or with homelier visit
• before and after surgical procedure
• before and after an invasive diagnostic procedure
• before, during, and after administration off medications that affect cardiovascular,
respiratory, and temperature control function
• when client’s general physical condition changes (e.g., loss of consciousness,
increased pain)
• before and after nursing interventions influencing a vital sign (e.g., before a client on
bed rest ambulates, before a client performs ROM exercises)
• when client reports nonspecific symptoms of physical distress (feeling different or
funny)
• According to orders or facility standards
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Sunday, November 1, 2015
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• Order is the MINIMUM, nurses can ALWAYS assess vital signs if needed
• As often as every 3-5 minutes, or once a month
Vital Signs Acceptable Ranges
Temperature
Range: 36- 38
deg (96.8-100.4 F)
Degrees Celsius
Fahrenheit
Advantages
Disadvantages
average
oral/tympanic
37
98.6
Accessible-
requires no
position change
Provides accurate
surface
temperature
readings
reflects rapid
change in core
temperature
Affected by
ingestion of fluids
or foods, smoke,
and oxygen
delivery
should not be used
with clients who
have oral surgery,
trauma, history of
epilepsy
should not be used
with small children
and infants, or
unconscious
clients
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