Vital Signs Measurement: Comprehensive Study Notes

Supplies & Initial Preparation

• Gather all necessary equipment before entering patient room:

  • Stethoscope (bell + diaphragm) connected to a manual sphygmomanometer (blood-pressure cuff)

  • Thermometer appropriate for the chosen route (temporal, oral, tympanic, rectal, axillary)

  • Portable or bedside pulse-oximeter probe

  • Wristwatch or clock with a second hand (for pulse/respirations timing)

  • Non-sterile gloves

  • Disinfectant wipe(s) for reusable devices

• Perform hand hygiene immediately before contact; don additional PPE if patient is on isolation/ contact precautions.

• Enter room, introduce yourself (name + role) & obtain consent: “I’m Sarah, a nurse here. I’d like to take your vital signs—is that okay?”

• Confirm TWO patient identifiers from the ID band and verbal response (name, date of birth).

Components of a Full Vital-Sign Set

• Core vitals measured each session:

  • Blood Pressure (BP)

  • Heart Rate / Pulse (HR)

  • Respiratory Rate (RR)

  • Temperature (T)

• Adjuncts collected at the same time:

  • Pain rating (often called the “5th vital sign”)

  • Peripheral oxygen saturation (SpO_2)

Pain Assessment (5th Vital Sign)

• Always start with pain—quick & can influence remaining vitals.

• Standard adult scale: 0 \text{ (no pain)} \rightarrow 10 \text{ (worst imaginable pain)}

• If rating >0, follow with OLDCART-style probes:

  • O: Onset

  • L: Location (“Where is the pain?”)

  • D: Duration / constant vs intermittent

  • C: Character (“burning, stabbing, radiating?”)

  • A: Aggravating/relieving factors

  • R: Radiation

  • T: Timing / severity trend

• Document BOTH number and patient’s descriptors. High pain may elevate HR, BP, RR.

• Example given: patient rates pain as 8; nurse must explore details and chart accordingly.

Oxygen Saturation (SpO_2)

• Equipment: finger probe (portable or monitor-attached)

  • Place on warm, pink fingertip/nail bed ⇢ best capillary flow.

  • Avoid cold, cyanotic, or polish-covered nails if possible.

• Activate device, wait for reading:

  • Demonstrated value: 97\% SpO_2 (displays HR as well—verify later manually).

• Normal adult range: 95\% \text{–} 100\% at sea level.

• Clean reusable probe with disinfectant after removal.

• Chart numerical SpO2 and please whether pt is on room air or supplemental

Body Temperature

• Adult oral reference: 98.6^{\circ}\text{F} but physiologic range 97^{\circ}\text{F} \text{–} 99^{\circ}\text{F}.

• Fever (adult): >100.4^{\circ}\text{F} orally.

• Route‐dependent offsets (memorize 1-degree rule):

  • Rectal & Tympanic ≈ Oral +1^{\circ}\text{F}

  • Axillary & Temporal ≈ Oral -1^{\circ}\text{F}

• Demonstrated technique: Temporal Artery Scanner

  1. Apply disposable probe cover.

  2. Ensure forehead dry & free of hair.

  3. Place probe mid-forehead, press/hold button, glide to hairline.

  4. If forehead diaphoretic (sweaty) → sweep to hairline then behind ear lobe (post-auricular) for vascular compensation.

  5. Read display; clean probe head.

• Always note route in documentation: e.g., “T = 98.2^{\circ}\text{F} (temporal).”

Pulse / Heart Rate

• Preferred site in adults: Radial artery (thumb-side wrist over radius bone).

• Patient position: seated or supine; arm supported at heart level.

• Palpation method:

  • Use index + middle + ring fingers; never the thumb (thumb has its own pulse).

  • Apply light pressure—just enough to feel pulsations.

• Parameters to record ("RRS"):

  • Rate: count beats for 30\text{ s} ×2 if regular; 1 full min if irregular.

  • Rhythm: regular vs irregular (arrhythmia noticed ⇢ full-minute count & possibly apical auscultation).

  • Strength (0–3+ scale)

  • 0 = absent

  • 1+ = weak/thready

  • 2+ = normal (expected)

  • 3+ = bounding

• Stated example: HR =82 bpm, regular, 2+.

• Normal adult range: 60 \text{–} 100\,\text{bpm}.

Respiratory Rate

• Perform surreptitiously without prompting patient (prevents conscious alteration).

• Keep fingers at radial pulse site → appear to be still counting pulse while actually observing respirations.

• Parameters ("RDR"):

  • Rate: 12 \text{–} 20\,\text{breaths·min}^{-1} (adult norm)

  • Depth: labored vs unlabored, shallow vs deep

  • Rhythm: regular vs irregular

• Counting rule mirrors pulse:

  • 30\text{ s} \times 2 if rhythm regular.

  • 60\text{ s} if irregular or if patient on life-support.

• Visual/ tactile aids:

  • Watch lateral chest rise/fall from side.

  • Light hand on back to feel movement.

• Each “rise + fall” =1 respiration.

Blood Pressure Measurement (Manual/Auscultatory Method)

1. Patient positioning

   • Seated or supine; arm at heart level; legs uncrossed; palm up.

2. Cuff sizing & placement

   • Width ≈ 40\% of upper-arm circumference; bladder length \geq 80\%.

   • Align arterial indicator arrow over brachial artery in antecubital fossa; lower cuff edge \approx 2\,\text{in} above crease.

3. Locate & palpate brachial artery for reference.

4. Estimate systolic pressure (palpatory method)

   • Inflate cuff while palpating brachial pulse until pulse disappears.

   • Note gauge reading (example \approx100\,\text{mmHg}) = estimated systolic.

5. Wait 30–60 s (allows arm reperfusion).

6. Auscultatory measurement

   • Place stethoscope bell or diaphragm over brachial artery (light contact; avoid artery occlusion).

   • Inflate cuff to estimated systolic + 30 mmHg (here 100+30 =130\,\text{mmHg}) to circumvent potential oscillatory gap (silent interval, common with hypertension—can cause under-estimation of SBP).

   • Deflate at \approx2\,\text{mmHg·s}^{-1}.

   • Korotkoff sounds:

     • Phase I (first tapping) = Systolic BP (SBP)

     • Phase V (sound disappears) = Diastolic BP (DBP)

   • Example reading: \text{BP}=104/78\,\text{mmHg}.

7. Fully open valve, deflate cuff, remove.

8. Clean cuff if non-disposable; document BP and arm/position (e.g., “L arm, seated”).

ACC/AHA 2017 Classification

• Normal: SBP <120 and DBP <80

• Elevated: SBP 120\text{–}129 and DBP <80

• Hypertension Stage 1: SBP 130\text{–}139 or DBP 80\text{–}89

• Hypertension Stage 2: SBP \ge140 or DBP \ge90

Hygiene & Equipment Care

• Perform hand hygiene before and after patient contact.

• Disinfect all reusable devices (stethoscope earpieces, cuff, temporal scanner, pulse-ox probe) with approved wipes.

• Replace probe covers and gloves per facility policy.

Clinical / Ethical / Practical Insights

• Pain control is both a physiologic and ethical imperative; untreated pain elevates vitals and complicates recovery (e.g., post-operative tachycardia, hypertension).

• Correct cuff sizing and oscillatory-gap technique avert misclassification of hypertension → prevents overtreatment or undertreatment.

• Temporal scanning behind the ear when forehead is sweaty underscores the importance of accounting for environmental/ patient factors that skew readings.

• Sequential order (pain → SpO_2 → T → HR → RR → BP) saves time and improves accuracy; respirations counted covertly; BP last to avoid white-coat elevation influencing other measures.

• Documentation accuracy underpins legal records, continuity of care, billing, and public-health statistics.

Quick Reference Cheat-Sheet

• HR: 60!–!100 bpm (2+ normal strength)

• RR: 12!–!20 breaths/min, unlabored

• Temp: Oral 97^{\circ}\text{F}!–!99^{\circ}\text{F}; Fever >100.4^{\circ}\text{F}

• SpO_2: 95\%!–!100\% (room air)

• BP: <120/<80 normal per ACC/AHA 2017

• Pain scale: 0!–!10 (document number + description + location)

End-of-Procedure Checklist

• Remove PPE if worn → hand hygiene.

• Ensure patient comfort & call-light within reach.

• Report abnormal findings immediately per facility escalation protocol.

• Chart all values with units, routes, arm used, patient position, and any pertinent observations (e.g., “RR irregular, uses accessory muscles”).