Measuring Vital Signs

One of the very first practical skills that students of the medical sciences learn is
how to take vital signs. Measuring vital signs is important: This information
shows healthcare practitioners how the body is functioning and alert to possible
medical conditions, many of which are present without signs or symptoms.

Why is it so important to know how to take vital signs? What sort of data is
gathered during the vital signs process and what does this tell us about the patient?
How do healthcare professionals collect vital signs and ensure accuracy? We can
answer these questions by taking a look at each of these measurements and
learning the processes by which they are collected and documented. We also
discuss the monitoring equipment used and provide the numerical ranges that are
considered normal in the adult population.

What are Vital Signs?

Vital Signs
Vital signs are measures of various physiological status, in order to assess the
most basic body functions. When these values are not zero, they indicate that a
person is alive.
All of these vital signs can be observed, measured, and monitored. This will
enable the assessment of the level at which an individual functioning. Normal
ranges of measurements of vital signs change with age and medical condition.
Vital signs serve as a communicator of patient status and are used to monitor acute
to chronic disease, and everything in between. Vital signs are useful in detecting
or monitoring medical problems. Vital signs can be measured in a medical setting,
at home, at the site of a medical emergency, or elsewhere.
Vital signs should be taken when the individual is at rest and hasn’t eaten, drank,
smoked or exercised within the last 30 minutes.

Vital Signs
Are measurements of the body's most basic functions:
1. Body temperature (Temp).
2. Pulse / heart rate.
3. Respiration.
4. Blood pressure (BP).

When to Assess Vital Signs

1. Upon admission to any healthcare agency.
2. Based on agency institutional policy and procedures.
3. Any time there is a change in the patient’s condition.
4. Before and after surgical or invasive diagnostic procedures.
5. Before and after activity that may increase risk.
6. Before and after administering medications that affect cardiovascular or
respiratory functioning.
Procedure
1. Identify the client properly and explain what you are going to do, why it is
necessary, and how he can cooperate.
2. Wash hand and observe other appropriate infection control procedure
3. Provide for client privacy.
4. Place the client in the appropriate position

ASSESSING BODY TEMPERATURE (AXILLARY TEMPERATURE)

1. Wipe the armpit with tissue paper or ask the client to do it if able
2. Wipe the thermometer from bulb to stem with alcoholized cotton ball.
3. Place the thermometer on the client’s opposite side.
4. Wait for appropriate amount of time. (While waiting for the time, the nurse
can now assess the other vital signs.)
5. Remove the thermometer and wipe with the tissue if necessary.
6. Read the temperature.
7. Wipe the thermometer with alcoholized cotton ball from stem to bulb. Return
to container.

ASSESSING A PERIPHERAL PULSE (RADIAL PULSE)

1. Palpate and count the pulse. Place two or three middle fingers lightly and
squarely over the pulse point.
2. Count for one full minute and note the pulse rhythm and volume.

ASSESSING RESPIRATION
1. Asses after taking pulse, keep fingers on wrist. Observe the chest movements
while supposedly taking radial pulse. So pt is unaware you are counting
respiration.
2. Count the respiratory rate for 1 full minute. An inhalation and an exhalation is
counted as one respiration. Observe the depth, rhythm, and character or
respiration.
IMPORTANT NOTE :
- (Nurse must not tell the patient that he or she will assess his respiration because
the patient can control his breathing so that will give a wrong assessment).
- a complete cycle of an inspiration composes one respiration .

ASSESSING BLOOD PRESSURE

1. Apply the BP cuff with arm hyper extended.
2. Palpate brachial artery with left hand, Insert stethoscope earpieces and
position diaphragm directly over the brachial pulse.
3. Turn the knob on the air pump clockwise to close the valve.
4. Inflate cuff till pulsation disappears and add 30 mmHg
5. Gently turn the knob on the air pump counter-clockwise to open the valve and
deflate the cuff.
6. As the dial pointer falls, watch the number and listen for a thumping sound.
7. Note the number shown where the first thump is heard (systolic pressure).
8. Note the number shown where the last thump is heard (diastolic pressure).
9. Deflate and remove cuff.
10. Document the reading, written as systolic/diastolic, and note any unusual
observations.

Normal vital sign ranges for average healthy adults (at rest) are:
 Blood pressure: 90/60 mm Hg to 120/80 mm Hg
 Breathing: 12 to 18 breaths per minute
 Pulse: 60 to 100 beats per minute
 Temperature: 97.8°F to 99.1°F (36.5°C to 37.3°C)/average 98.6°F (37°C)

For the most accurate readings, it is best that the person not smoke, drink coffee,
or exercise vigorously within 30 minutes before taking vitals. Don’t be shy about
taking multiple readings a few minutes apart – be sure to write down all of the
results. And don’t forget to record the date and time along with any other
important details. Vital signs are written using the LOINC internationally accepted
standard coding system – take care to record vital signs using the correct and
consistent format.

Always wash your hands before and after engaging with an individual to take vital
signs. As well, ensure that all supplies are cleaned and sanitized per manufacturer
instructions and stored away in the proper place. By following these instructions
and practicing carefully, you’ll be able to read vital signs just like a pro.