Nursing Vital Signs Summary

Vital Signs Overview

  • Fundamental to nursing practice; provide information on vital organs' condition.
  • Key physiological observations include:
    • Respiration
    • Oxygen saturation
    • Blood pressure
    • Pulse
    • Level of consciousness
    • Temperature
    • Pain

Assessment Timing

  • Assess upon admission, or with change in health status (e.g. chest pain).
  • Before & after procedures/activities that may alter vital signs.
  • General frequency: every 6 hours (more infrequent in aged care, e.g. monthly).

Importance of Monitoring

  • Competent nurses utilize critical thinking when assessing vital signs.
  • Recognizing deterioration hinges on abnormal vital signs, which may prelude severe events like cardiac arrest.

Respirations & Oxygen Saturation

  • Respiration:
    • Involves inspiration (intake of air) and expiration (breathing out).
    • Normal Rates:
    • Adult: 12-20 bpm
    • Infant: 30-60 bpm
    • Child: 20-30 bpm
    • Adolescent: 16-19 bpm
  • Oxygen Saturation:
    • Monitored via pulse oximeter; normal SpO2 range is 95%-100%.
    • Below 90% is critical.

Heart Rate Assessment

  • Pulse Rate:
    • Adult: 60-100 bpm
    • Infant: 120-160 bpm
    • Factors that affect heart rate include exercise, emotion, and medications.
  • Categories:
    • Bradycardia: < 60 bpm
    • Tachycardia: > 100 bpm.

Blood Pressure Measurement

  • Indicates the pressure exerted by blood through arteries, recorded as systolic and diastolic (e.g., 120/80 mmHg).
  • Normal ranges for adults:
    • Systolic: 90-139 mmHg
    • Diastolic: 60-89 mmHg.
  • Hypertension: > 140/90 mmHg; Hypotension: < 90/60 mmHg.

Level of Consciousness

  • Ranges from alertness to coma; assessed using ACVPU scale.
  • Normal signs include being awake, alert, and oriented.

Temperature Assessment

  • Normal temperature range: 36 - 37.5 ℃.
  • Influenced by method of measurement, age, and time of day.

Pain Assessment

  • Defined as the subjective experience of discomfort; assessed via tools like the Visual Analogue Score.

Documentation & Best Practices

  • Accurate documentation is crucial for tracking health changes and essential for nursing practice.
  • Follow clear guidelines to ensure communication, planning, and care audit are consistent.