Chapter 2. Patient Assessment
2.4 Vital Signs
Temperature, pulse, respiration, blood pressure (BP), and oxygen saturation (SpO2), are measurements that indicate a person’s hemodynamic status. These are the five vital signs most frequently obtained by healthcare practitioners (Perry, Potter, & Ostendorf, 2018). Vital signs can reveal important information about a person’s health status including changes in a patient’s condition. As such the nurse’s responsibility is to consider patterns and trends in vital signs in anticipation of changes in health status, need for further investigation, and intervention (Perry, Potter & Ostendorf, 2018). Checklist 15 outlines the steps to take when checking vital signs.
Checklist 15: Vital SignsDisclaimer: Always review and follow your agency policy regarding this specific skill.
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Safety considerations:
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Steps |
Further Information |
Normal Values |
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| 1. Temperature: | Oral temperature: Place the thermometer in the mouth under the tongue and instruct patient to keep mouth closed. Leave the thermometer in place for as long as is indicated by the device manufacturer.
Axillary temperature: Usually 1ºC lower than oral temperature. Place the thermometer in patient’s armpit and lower the patient’s arm over the probe. Leave it in place for as long as is indicated by the device manufacturer. Tympanic membrane (ear) temperature: Usually 0.3°C to 0.6°C higher than an oral temperature. The tympanic membrane shares the same vascular artery that perfuses the hypothalamus. Do not force the thermometer into the ear and do not occlude the ear canal. Rectal temperature: Usually 1ºC higher than oral temperature. Use only when other routes are not available. On adults, insert the probe approximately 3.5 cm into rectum toward the umbilicus. Use lubricant. |
Normal (oral) = 35.8ºC to 37.5ºC
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| 2. Pulse (a.k.a. heart rate): | Pulses can be found at many points on the body and all could theoretically be used to assess heart rate. When palpating pulses use moderate pressure, as too much pressure can impair blood flow and occlude the vessel. In some agencies scales are used to document the strength of the pulse from bounding (+4); strong (+3); weak (+2); thready (+1); absent (0).
If a pulse is regular, a 30 second count multiplied by two is generally acceptable. If a pulse is irregular, count for 60 seconds Common pulses for assessment include: Radial pulse: Use the pads of your first three fingers to gently palpate the radial pulse at the inner lateral wrist. Apical pulse: Taken as part of a focused cardiovascular assessment and when the heart rate is irregular. Apical pulses are assessed using a stethoscope placed over the 4th–5th intercostal space of the midclavicular line on the left side on adults. For accuracy, an apical heart rate should be taken for a full minute. When giving medications that are dependent on the