Vitals Check Off

What do you do before entering a patients room?

• Verify provider order

• Gather Supplies

What do you do once you enter a patients room?

• Assess patient for factors that might affect pulse and resp. rate (Med history, disease process, age, exercise, medications)

• Perform appropriate hand hygiene and PPE

• Identify patient using two identifiers

• Explain procedures

• Ensure privacy

Assessing pain

• Ask if pain is currently present

• Assess current level using 0-10 pain scale

• Assess response to any previous interventions

• Assess for any signs or symptoms of pain

• Assess characteristics of pain

• Physically assess sight of pain

What is PQRSTU?

Pain, Quality (sharp, dull, etc.), Radiation, Severity (how intense), Timing, You

Temperature

• Apply probe cover

• place probe under tongue and instruct patient to close mouth and keep probe in place

• After beep record temp

• Dispose of probe cover

• Normal range is 96.8-99.5

Oxygen Saturation (SpO2)

• Assess presence of nail polish, skin integrity, moisture, hypothermia

• Assess capillary refill. If more than 3 seconds, select alternative site

• Appropriately apply O2 sensor and report accurate interpretation and result (whether within range of 95-100 or not)

Radial Pulse

• Make sure patient is in supine or sitting position with wrist extended straight or forearm across chest or upper abdomen with palm down

• Rate strength of pulse (0: absent, 1: weak, 2: normal, 3: strong, 4: bounding) and pattern (regular or irregular)

• Compares pulse bilaterally (pulse feels equal)

• Regular pulse is between 60-100 bpm

Respiratory Rate

• Ensure patient’s chest is visible and forearm is in relaxed position across the lower chest/upper abdomen

• Notes rate (12-20), pattern (regular or irregular), and effort (labored or unlabored breathing)

Blood pressure

• Note systolic palp

• Report final BP reading

• Normal systolic: 90-119

• Normal diastolic: 60-79

Results and Documentation

• Documents patient’s response

• Reports any needs for intervention

• Identifies values outside of normal