Learning Objectives
By the end of this section, you will be able to:
- Describe the steps involved for preparing to obtain vital signs
- Understand how and when to monitor vital signs
- Discuss the importance of using critical judgment when validating data
- Explain proper techniques for documenting data
A vital sign is a marker of physiological homeostasis and are essential in the analysis of monitoring patient progress. Vital signs include the body temperature, pulse, respiratory rate, and blood pressure. Vital signs are gathered during the initial encounter with the patient to establish a baseline and routinely thereafter, according to condition, to assess disease progression or resolution. When vital signs are abnormal, a patient’s plan of care is typically altered. When vital signs are taken routinely, the healthcare team can analyze them to observe the response to treatments or disease progression. The combination of multiple vital sign measurements over a period of time also provides the typical and normal ranges for an individual patient. These individualized ranges are the vital sign trends. The vital signs provide a snapshot of the circulatory, respiratory, and neurological status of the patient.
Preparing to Obtain Vital Signs
Prior to obtaining vital signs, the nurse should gather the necessary equipment, check the patient’s vital sign trends and pertinent history, and verify the healthcare provider’s orders regarding frequency and parameters. To complete the vital signs, the nurse must obtain a thermometer, stopwatch, stethoscope, pulse oximeter, and blood pressure cuff. Many of these items may be present on the facility’s vital sign machine. Some facilities keep designated vital sign equipment at the patient’s bedside. At times, vital signs are obtained via an electronic monitoring device either continually (such as in critical care units) or scheduled (Figure 15.14). When these devices are used, it is the nurse’s responsibility to manually collect the data received.
Figure 15.14 A vital sign machine shows a patient’s pulse, heart rate, and blood pressure. (credit: Senior Airman Callie Norton/McChord, Public Domain)
Reviewing the patient’s vital sign trends could provide valuable information for the nurse. For example, if the patient’s health record indicates that their heart rate is typically around 65 beats per minute, then the nurse checks it and finds it to be 96 beats per minute, further investigation may be warranted. Although this value is normal for the population in general, it is not normal for that patient.
Health history may influence obtaining vital signs. For example, a mastectomy would prevent the nurse from obtaining blood pressure on that arm due to the risk of lymphedema, and a wound might prevent placement of blood pressure cuff. Oral trauma would change the route of obtaining the temperature, and a wound over the wrist may interfere with the palpation of a pulse. Being prepared prior to entering the room will prevent errors.
Life-Stage Context
Older Adults and Normal Temperature Ranges
The normal temperature range in older adults tends to be on the lower end of the normal adult temperature ranges. As we age, our metabolic rate gradually decreases which, in turn, causes a gradual decline in our temperature. When caring for an older adult, a temperature on the high end of normal could indicate a fever, and even a serious infection, since their trends are lower (Hernandes Júnior & Sardeli, 2021).
Monitoring Vital Signs
The frequency at which a nurse should obtain vital signs is determined by the stability of the patient, facility protocols, and healthcare provider orders. Heart rate, respiratory rate, blood pressure, and oxygen saturation may be monitored continuously in critical settings or with patients who are unable to manage their airways or sufficiently perfuse their body. It is important to note that the nurse can use nursing judgment to recheck vital signs at any time despite the frequency noted in the orders. The orders indicate the minimum frequency by which the nurse should take the patient’s vital signs. Any change in the patient’s status such as a new complaint or new assessment finding would prompt the nurse to obtain a set of vital signs. Whenever a nurse feels that the practitioner needs to be updated on the patient’s status, the nurse should obtain a complete set of vital signs to communicate a thorough picture of the patient to the practitioner.
Clinical Judgment Measurement Model
Take Action: Change in Patient Status
A nurse is caring for a gentleman recovering from a total knee replacement, postoperative day 2. The healthcare provider has ordered vital signs every four hours, physical therapy, pain medications, and a resumption of home medications. Since surgery, he has been doing well in physical therapy, and his pain has been controlled with IV ketorolac (Toradol) and oral acetaminophen (Tylenol). He last received ketorolac at 0430. His last set of vital signs were obtained two hours ago at 0400:
- Temperature 98.1°F (36.7°C)
- Pulse 68 beats per minute
- Respiratory rate 16 breaths per minute
- Blood pressure 119/58 mm Hg
This morning, he stated that his pain has been getting worse, not better, since his last dose of pain medicine. He also asked for Tylenol for a headache.
After noting the change in the patient’s condition, the nurse needs to take action. Even though it is not time to obtain the ordered vital signs, nursing judgment dictates the need to get another set of them. The vital signs are as follows:
- Temperature 99.8°F (37.7°C)
- Pulse 84 beats per minute
- Respiratory rate 22 breaths per minute
- Blood pressure 132/64 mm Hg
After administering the dose of acetaminophen, the nurse contacts the healthcare provider to report the change in the patient’s condition and the updated vital signs.
Postoperatively, vital signs are monitored according to a facility’s protocol, with more frequent vital signs obtained initially after the procedure, which then is progressively spaced out to the unit protocol frequency (Table 15.4). This postoperative protocol is used because of the anesthesia and medication’s effects and the nature of the procedure. Anesthesia and medication may cause respiratory depression and other reactions, among other complications. The procedure itself could have caused bleeding or damage to a body area. More frequently measured vital signs may show subtle changes, which can then be used to determine the healthcare team’s course of action.
| Protocol | Time | Data |
|---|---|---|
| Immediately | 1015 | |
| Every fifteen minutes for the first hour | 1030 1045 1100 1115 | |
| Every thirty minutes for two hours | 1145 1215 1245 1315 | |
| Every hour for four hours | 1415 1515 1615 1715 | |
| Revert to unit protocol’s or healthcare practitioner’s orders |
Table 15.4 Example of Postoperative Vital Sign Orders
Consider this scenario: A patient has arrived from the operating room after an emergency appendectomy. The unit postoperative vital sign protocol is as follows: Obtain vital signs on arrival to the unit, then every fifteen minutes × one hour, every thirty minutes × two hours, every hour × four hours, every four hours throughout admission. Following is an example of why vital sign monitoring is so important in discovering subtle changes and performing interventions to prevent complications.
| Time | Data | Observations/Interventions |
|---|---|---|
| 1015 | HR 67, BP 108/62, O2 98, RR 14 | Patient sleepy; arrived to unit |
| 1030 | HR 72, BP 112/68, O2 98, RR 18 | Wife at bedside |
| 1045 | HR 82, BP 120/74, O2 98, RR 20 | Patient reporting pain; pain meds given |
| 1100 | HR 64, BP 102/58, O2 94, RR 12 | Patient resting with lower O2 and RR; order obtained for 2 L O2 via nasal cannula |
| 1115 | HR 66, BP 108/62, O2 95, RR 14 | Patient resting comfortably |
| 1145 | HR 76, BP 112/68, O2 95, RR 16 | Patient reporting pain; nonpharmacological interventions done |
| 1215 | HR 72, BP 110/68, O2 95, RR 16 | Patient resting comfortably |
| 1245 | HR 70, BP 108/64, O2 92, RR 14 | Patient encouraged to use incentive spirometer/cough and deep breathe |
| 1315 | HR 76, BP 112/64, O2 92, RR 12 | Practitioner made aware of O2 saturation; nasal cannula increased to 4 L O2 |
| 1415 | HR 74, BP 110/62, O2 94, RR 14 | Reinforced the importance of incentive spirometer use; raised the head of the bed for better lung expansion |
| 1515 | HR 78, BP 112/62, O2 96, RR 16 | Encouraged continuation of incentive spirometer use; nasal cannula decreased to 2 L O2 |
| 1615 | HR 76, BP 107/62, O2 96, RR 16 | Encouraged continuation of incentive spirometer use |
| 1715 | HR 78, BP 110/68, O2 97, RR 16 | Encouraged continuation of incentive spirometer use |
Through vital sign monitoring, the nurse was able to identify possible postoperative atelectasis (partial collapse of the lung from anesthesia) and begin interventions to halt progress into possible pneumonia.
Different settings and their protocols may also affect the frequency of the vital signs. In intensive care units, which are those units where the patients are in critical condition, even more frequent assessment may be necessary depending on patient condition and medications. In long-term care settings, vital signs are obtained every eight to twelve hours. In home health environments or when individuals are instructed to monitor their vital signs at home, they are typically done once each day and at the same time each day. Doing them at the same time each day helps the individual to make monitoring vital signs a habit. Another reason to do them at the same time each day is to prevent fluctuations due to the individual’s normal routine and time of day. Heart rate would be expected to be lower first thing in the morning and higher as the day progresses.
If there is a change in a patient’s condition, the nurse must obtain another set of vital signs, even if the last set was obtained only one hour prior. Changes in the patient’s condition refer to something experienced by the patient or observed by the nurse or family members—that is, anything that is concerning to any of the parties. The checked vital signs can help to alleviate the patient’s or family’s fears, but they may also provide the data that need to be conveyed to the healthcare provider to determine the next actions.
Validating Data
After the nurse obtains vital signs, it is imperative to compare these against the normal ranges for the patient’s age and the patient’s trends. Generally, if the results fall within both ranges, the vital signs are documented according to protocol. If the results fall outside of the normal ranges or the patient’s trends, the nurse will need to validate them, that is, to repeat the measurement of the vital sign in question. At times, these abnormal results reflect the clinical situation of the patient, but at other times, the abnormalities may be a result of operator or equipment error.
When an abnormal vital sign is obtained, whether outside of the normal ranges or outside of the patient’s trends, the nurse should recheck that vital sign. If the temperature reading is abnormal, the nurse may try another thermometer or use another route. Changing equipment will allow the nurse to ensure that the abnormal reading was not caused by equipment malfunction. If the equipment malfunction is noted, the nurse should report it, take the equipment out of use, notify biomed/tech to check the equipment, and label the equipment as “do not use.”
The nurse may also just have to verify that the steps were completed accurately in obtaining the temperature. For an abnormal blood pressure reading, it may be necessary to recheck on the opposite arm. Automatic and digital vital sign equipment has preset limits for results it is able to provide. For example, some digital thermometers will give an error screen if the result is greater than 105°F (40.5°C). If a patient’s results are outside of these limits, a manual method for obtaining that vital sign will be necessary. Any abnormal results warrant a reassessment of that vital sign. The nurse must also assess the patient for any signs of distress or deterioration. There are times when abnormal results do not indicate an emergency or need for intervention. Vital signs may be abnormally high when the patient is excited, nervous, or has experienced physical activity, such as physical therapy. They also may be lower due to the comforting presence of family or friends.
Documenting Data
After vital signs are obtained and validated, the nurse must document these results. Most healthcare facilities use the electronic health record for patients, but some facilities still use paper flowsheets. Documentation is required to track the patient’s trends and response to treatments and to communicate with the healthcare team. For temperature, the nurse will chart the degrees in Fahrenheit or Celsius (according to agency policy) and the method used to obtain the temperature (i.e., oral, axilla, tympanic). When charting the pulse, the result will be in beats per minute. The nurse will also document the site or method used for the pulse (i.e., radial pulse or continuous pulse oximeter). The respiratory rate will be documented in breaths per minute, and the method of assessment should be noted (i.e., visual or stethoscope). Blood pressure requires two numbers to be documented, the systolic and the diastolic pressures. The nurse will also specify which extremity was used and if the blood pressure was manually or automatically obtained. For an abnormal result, whether the charting system flags the vital sign or not, the action should be documented. For example, the action may be that a medication was administered, that the patient’s position was changed, or that the healthcare provider was alerted.
