Week 5 lecture - vital signs

Week 5 Nursing Notes: Vital Signs Assessment

Learning Objectives

By the end of this week, you should be able to:

  • Discuss the rationale, knowledge, and skills required for vital signs assessment.

  • State the normal parameters of respiration, oxygen saturation, pulse, blood pressure, level of consciousness, temperature, and pain across the lifespan.

  • Identify factors that may affect accurate measurement of vital signs.

  • Discuss pain assessment tools used in assessing pain.

  • Demonstrate appropriate documentation and reporting of vital signs.

1. Introduction to Vital Signs

Definition & Importance

  • Vital signs are physiological indicators that provide information about the condition of vital organs.

  • They include:

    • Respiration

    • Oxygen saturation

    • Pulse (Heart Rate)

    • Blood pressure

    • Level of consciousness

    • Temperature

    • Pain

When to Assess Vital Signs?

  • On admission

  • When there is a change in health status, e.g., symptoms like chest pain or dizziness.

  • After an incident, accident, or injury.

  • Before & after procedures that may alter vital signs, such as:

    • Surgery or invasive procedures

    • Medication administration (e.g., antihypertensives, Ventolin)

    • Nursing interventions (e.g., ambulation, exercise)

  • Frequency of measurement:

    • Hospital: At least every six hours (ACSQHC, 2022).

    • Aged care: Monthly.

Clinical Reasoning in Vital Signs Assessment

  • Competent nurses use critical thinking to detect and interpret abnormal signs.

  • Early changes in vital signs often occur before serious conditions such as cardiac or respiratory arrest.

  • Recognizing deterioration requires knowledge, skill, and vigilance in assessment.

2. Respirations & Oxygen Saturation

Respiration Process

  • Inspiration: Air intake into the lungs.

  • Expiration: Air is exhaled.

  • Ventilation: Exchange of O₂ & CO₂ in alveoli.

  • Types of breathing:

    • Costal (thoracic) – Upper chest movement (common in women).

    • Diaphragmatic (abdominal) – Abdomen movement (common in men and children).

Assessing Respirations

  • Observe one full respiratory cycle (inspiration + expiration).

  • Normal respiratory rates (bpm):

    • Adult: 12-20

    • Infant: 30-60

    • Child: 20-30

    • Adolescent: 16-19

  • Factors influencing respiration:

    • Exercise, pain, smoking, anaemia, medications, anxiety, infection.

Respiratory Patterns key term

  • Eupnoea – Normal breathing.

  • Bradypnoea – Slow breathing rate.

  • Tachypnoea – Fast breathing rate.

  • Apnoea – Absence of breathing.

  • Cheyne-Stokes – Alternating deep and shallow breathing with apnoea (common at end of life).

Signs of Respiratory Distress

  • Tracheal tug, nasal flaring, use of accessory muscles, cyanosis (late sign).

  • Stridor (harsh inspiratory sound), wheezing (high-pitched sound), grunting (expiratory effort).

Oxygen Saturation (SpO₂) & Pulse Oximetry

  • Normal SpO₂: 95-100%

  • SpO₂ < 90% is life-threatening.

  • Factors affecting accuracy:

    • Movement, dark nail polish, poor circulation, anaemia, carbon monoxide poisoning.

3. Heart Rate (Pulse)

Definition & Sites

  • Pulse is the wave of arterial blood caused by left ventricular contraction.

  • Palpated at pressure points (e.g., radial, carotid, brachial, femoral, dorsalis pedis).

Assessing Pulse

  • Rate (bpm):

    • Adult: 60-100

    • Infant: 120-160

    • Child: 75-110

    • Adolescent: 60-90

  • Rhythm: Regular or irregular.

  • Strength (Volume): Strong, weak, bounding, or thready.

  • Equality: Compare both sides.

  • Elasticity: Normally smooth & soft.

Abnormal Pulse Terms

  • Bradycardia – HR < 60 bpm.

  • Tachycardia – HR > 100 bpm.

  • Arrhythmia/Dysrhythmia – Irregular rhythm.

4. Blood Pressure (BP)

Definition & Measurement

  • Force exerted by blood against arterial walls.

  • Measured in mmHg, recorded as systolic/diastolic (e.g., 120/80 mmHg).

Normal BP Ranges

  • Adults:

    • Systolic 90-139 mmHg

    • Diastolic 60-89 mmHg

Factors Affecting BP

  • Age, exercise, stress, medications, obesity, hydration, disease.

Hypertension (High BP)

  • BP > 140/90 mmHg.

  • Risk factors: Smoking, obesity, stress, high-fat diet, genetics.

  • Nursing intervention: Monitor, lifestyle changes, medication education.

Hypotension (Low BP)

  • BP < 90/60 mmHg.

  • Symptoms: Dizziness, cold skin, syncope (fainting).

  • Interventions: Slow position changes, hydration, BP monitoring.

Orthostatic Hypotension

  • Drop in BP upon standing (≥20 mmHg systolic or 10 mmHg diastolic).

  • Causes: Medications, dehydration, prolonged bed rest, heart conditions.

5. Level of Consciousness (ACVPU)

  • A – Alert.

  • C – Confused (WA does not use this).

  • V – Responds to verbal stimulus.

  • P – Responds to pain.

  • U – Unresponsive.

6. Temperature

  • Normal range: 36.0 – 37.5°C

  • Pyrexia (Fever): >37.5°C.

  • Hypothermia: <35°C.

  • Measurement sites:

    • Core: Tympanic (ear), rectal.

    • Surface: Oral, axillary, skin.

7. Pain Assessment

  • Definition: "Pain is whatever the patient says it is" (McCaffery, 1968).

  • Assessment tools:

    • Visual Analogue Scale (VAS) – 0 (no pain) to 10 (worst pain).

    • PQRST Method:

      • P – Provokes (What causes pain?)

      • Q – Quality (Sharp, dull, throbbing?)

      • R – Radiation (Where is the pain?)

      • S – Severity (Pain scale 0-10)

      • T – Time (When did it start?)

8. Documentation & Reporting

  • Why?

    • Communication of findings.

    • Tracking changes in baseline data.

  • Best Practices:

    • Use Adult Observation & Response Chart (AORC).

    • Graph data for clear trends.

    • Use colour-coded systems to indicate deterioration.

    • Electronic Medical Records (EMR) ensure consistency.

Summary

  • Accurate vital sign assessment prevents patient deterioration.

  • Early detection of abnormalities improves patient outcomes.

  • Documentation must be precise and timely.

Case study

  1. Comment on each of the assessment findings.  Are they within normal range?

  2. Consider the patient history. Use appropriate terminology when answering

  3. Are any of his vital signs in escalation zones? What action might you need to take?

  1. from 18:00 - 22:00

6am his rep rate is high consider underservallince

hr undersruvallince

02 - senior nurse review

his blood pressure is low

bp - low

high temp

This can be an indication on infection