Why are vital signs checked?
- Monitor body systems
- detect changes in health status
- evaluate effectiveness of interventions
- identify life threatening warning signs
When are vital signs checked?
Performed on a regular basis.
What is the frequency of taking vital signs determined by?
- physician and/or nursing judgment
- clients condition
- facility standards
How often should you check the vital signs for:
Stable patient, post surgical patient, critical/unstable patient
Stable- every 4-8 hrs
Post surgery- every 15-60 min
Critical/unstable- every 5 min
How to interpret vital signs
- Compare patient values to normal values
2. Compare patients values to previous values
- Oral (under the tongue)- most common site
- ear (tympanic)- used for adults and children
- forehead (temporal)- infants/small children
- axillary (axilla of arm)- healthy newborns
- Rectal- do NOT use for newborns, patients with low white counts, spinal cord injuries, quadriplegics, diarrhea, rectal surgeries
Ways to take temperature
How to change F -> C
(F-32) x 5/9
How to change C -> F
(C x 9/5) + 32
What is the apical pulse and where do you find it?
Apical pulse- most accurate site for checking pulse. Found at apex of the heart at point of maximal impulse (PMI).
How long should apical pulse be counted for?
1 minute
- temporal- side of head at temple
- carotid- side of neck below jaw
- brachial- inner side of elbow
- radial- thumb side of inner wrist (MOST COMMON PERIPHERAL SITE)
- femoral- bend of leg at groin
- popliteal-behind knee, inner side
- posterior tibial- below inner ankle
- dorsialis pedis- top of foot
8 peripheral pulse locations
Temperature: 95.9- 99.5 F (35.5 - 37.5 C)
Pulse: 60-100 BPM
Respirations 12-20 BPM
Blood pressure: systolic- 90-120 mmHG
diastolic- 60-80 mmHG
Pulse oximetry- > 95% saturation of peripheral oxygen
normal ranges of vital signs for adults
What number is systolic when writing blood pressure? What number is diastolic
Systolic = top Diastolic = bottom
What is the peak phase of BP? What is the Resting phase?
Systolic = peak phase Diastolic = resting phase
What is the proper name for a blood pressure measurer
Sphygmomanometer
What is hypertension? When is it diagnosed? How Mmkay times does it need to be tested?
- When blood pressure is higher than normal
- Diagnosed when:
Systolic is > 140 mmHg OR diastolic > 90 mmHG
- Tested on two or more separate occasions
What is primary/essential hypertension? What percentage of hypertension does it account for?
- Primary/essential hypertension- diagnosed when there is no known cause for the disease
- 90%
Nurses can delegate the activity of taking vital signs. True or false
TRUE
If a nurse delegates the responsibility of taking vitals to someone else, what is SHE responsible for?
- Interpretation of vital signs
- Vital sign trends
- decisions based on abnormal findings
What is the most frequent assessment you’ll make as a nurse?
Vital signs
