4 Vital Signs Measurement and Pain Assessment Across the Lifespan
4 Vital Signs Measurement and Pain Assessment Across the Lifespan
Learning Objectives
- Obtain accurate vital signs using correct techniques.
- Recognize deviations from normal when assessing vital signs.
- Document vital signs accurately.
- Identify the age-appropriate tools to assess a patient for pain.
- Obtain pain history.
- Describe the different types of pain.
- Document the Pain Assessment finding
I. Overview of Vital signs and Pain:
Vital signs are used to obtain specific physiological statistical measurements. There are five vital signs that are routinely taken including temperature, heart rate also called pulse rate, respiration, blood pressure, and oxygen saturation (Perry, Potter, & Ostendorf, 2014). These measurements are used to monitor the hemodynamic status of the patient. Previously taken vital signs, at home or at a health care facility, are documented as part of the subject data obtained during the health history interview. This data is important as it provides each patient’s vital signs ranges/parameters. A distinct change in vital signs from normal levels may indicate that further investigation and closer monitoring is needed at home or at a facility by health care personnel, or admission to the hospital is needed.
The first set of vital signs taken by the nurse in any setting is used as a starting point to determine patient care and these are frequently called the baseline vital signs. These are completed as ordered by the health care provider upon admission to the hospital. Changes in any of the five vital signs may indicate that the patient’s conditioning is improving or worsening.
Each of the five vital signs is written in a specific manner and is associated with a unit. Temperature is written in Celsius or Fahrenheit and it is measure in degrees also written as º. Heart rate is measure as beats per minute also written as BPM. Respirations are written as breath per minute also written as BPM. Blood Pressure is measured in millimeters of mercury written mmHg. There is a specific order in which vital signs are documented: Temperature, pulse/heart rate, respiration rate, blood pressure, and lastly pulse oximeter reading: T, P, R, BP, Pulse ox
Vital signs are the first part of a thorough, comprehensive health assessment and are completed prior to obtaining the rest of the patient’s health history, or prior to performing an objective examination or physical assessment. Accurate measurement of vital signs is necessary but it is also important for the nurse to learn the significance of each vital sign to the current patient status. This is essential to developing sound nursing clinical reasoning and decision-making.
II. Anatomy and Physiology of Vital Signs
Temperature refers to the degree of heat or cold in an object or a human body. In humans, the brain’s hypothalamus acts as the body’s thermostat and is responsible for regulating its temperature.
Hypothalamus (Illustration credit: Hilary Tang)
Temperature regulation:
Humans