Vital Signs

Vital signs, also known as cardinal signs, are the clearest indicators of a client’s overall health status.
Standard vital signs include:
- Blood pressure.
- Pulse.
- Respiration.
- Temperature.
- Pain.
These signs provide baseline assessment data that is essential for the ongoing evaluation of a client’s condition. This baseline allows healthcare providers to easily identify deviations from the client’s normal state.

Measurement frequency varies based on the clinical environment and the stability of the client:
- Routine intervals: Generally measured every $4$ , $6$ , or $8$ hours ( $q4h$ , $q6h$ , $q8h$ ).
- Acute situations: May be assessed as frequently as every $5$ minutes, $15$ minutes, or every $1$ to $2$ hours.
- Other instances: Vital signs may be taken as needed ( $prn$ ), once weekly, or at longer intervals in stable or long-term care settings.
Vital signs should be taken whenever a clinician deems it appropriate based on professional judgement.

Equipment: Ensure all equipment is functioning correctly before use.
Baseline Knowledge: Understand the client’s normal ranges to identify meaningful deviations.
Context: Be aware of the client’s medical history, current therapies, and medications that may influence results.
Delegation: If vital sign measurement is delegated to another staff member, the nurse remains responsible for interpretation.
Patient Preparation: Since physical and emotional stress can alter vital signs, help the client relax before taking measurements.
Consistency: Develop and use a consistent system for obtaining vital signs to ensure accuracy and reliability.
Verification: If an unusual measurement is obtained or a finding is doubted, the measurement should be repeated.
Professionalism: If an abnormal finding occurs, stay calm and professional to avoid causing the client unnecessary anxiety.
Reporting: Inform the nurse in charge or a doctor regarding abnormal findings when necessary.

Normal adult temperature ranges are typically cited as $36.5–37.5\,^{\circ}\text{C}$ or more broadly as $36.0–38.0\,^{\circ}\text{C}$ .
Temperature variations by site:
- Rectal temperature is typically $0.5\,^{\circ}\text{C}$ higher than oral temperature.
- Axillary temperature is typically $0.5\,^{\circ}\text{C}$ lower than oral temperature.
Assessment Sites:
- Oral: The most common site; offers easy access and client comfort.
- Rectal: Considered the most reliable for core temperature.
- Tympanic: An easy and accessible site accurate for core readings.
- Axillary: Safe and non-invasive; suitable for newborns and unconscious clients.
Thermometer Types:
- Tympanic electronic thermometer.
- Electronic oral/rectal thermometer.
- Chemical strips.
- Temporal artery thermometer.
Temperature Conversion Formulas:
- Fahrenheit to Celsius: $C = (F - 32) \times \frac{5}{9}$
- Celsius to Fahrenheit: $F = (\frac{9}{5} \times C) + 32$

The normal pulse rate for adults is $60–100\,\text{bpm}$ .
Pulse Character Characteristics:
- Rate: The number of beats per minute.
- Rhythm: The pattern of the beats and intervals between them.
- Strength: The force of the pulse (e.g., weak, thready, bounding).
- Equality: Ensuring the pulse is the same on both sides of the body.

The normal respiratory rate for adults is $12–20\,\text{breaths per minute}$ .
Character Characteristics:
- Rate: Number of breaths per minute.
- Rhythm: Regularity of the breathing pattern.
- Depth: The degree of chest wall expansion (e.g., deep, normal, or shallow).
- Quality: The effort and sound of breathing (e.g., labored, gasping, or quiet).

Arterial Oxygen Saturation ( $SpO_2$ ):
- Measured using a pulse oximeter.
- Possible placement sites include the finger, toe, or earlobe.
Blood Pressure Definition:
- Blood pressure measures the force of blood against arterial walls.
- Systolic: Peak pressure during cardiac contraction.
- Diastolic: Minimal pressure during cardiac relaxation.
Blood Pressure Standards (Heart and Stroke):
- Low risk: $120 / 80\,\text{mmHg}$ .
- Medium risk: $121–134 / 80–84\,\text{mmHg}$ .
- High risk (Hypertension): $135+ / 85+\,\text{mmHg}$ .
- Hypertension.ca Standard: $\le 130 / 80\,\text{mmHg}$ .
Blood Pressure Equipment:
- Sphygmomanometer (Blood pressure cuff): Includes the cuff, bladder, manometer/gauge, tubing, bulb, and valve.
- Stethoscope: Used for auscultation of sounds.
- Automatic blood pressure devices.
General BP Guidelines:
- Check if the patient has taken their blood pressure medication.
- Ensure proper patient positioning and equipment function.

Orthostatic Hypotension Assessment Procedure:
1. The patient lies in bed for $5\,\text{minutes}$ ; take blood pressure while the patient is lying down.
2. Ask the patient to stand.
3. Take blood pressure after the patient has been standing for $2\,\text{minutes}$ .
Diagnostic Criteria for Orthostatic Hypotension:
- A drop in systolic BP greater than $20\,\text{mmHg}$ .
- A drop in diastolic BP greater than $10\,\text{mmHg}$ .
Nursing Care for Orthostatic Hypotension:
- Address the risk for falls.
- Notify the physician.
- Monitor orthostatic vitals before administering medications.
Pulse Pressure:
- The difference between the systolic and diastolic pressure.
- Normal range is approximately $30–50\,\text{mmHg}$ .

Onset / Origin: When and where did the pain start?
Provocative / Palliative: What brings the pain on? What were you doing? What makes it worse or better? Is it relieved with rest or worse with activity?
Quality: How does it feel? (e.g., sharp, dull, burning).
Region / Radiation: Where is the pain located? Does it spread anywhere else?
Severity Scale: How would you rate the pain on an intensity scale (e.g., $0–10$ )?
Timing / Treatment: What treatments have worked? Is the pain constant, dull, or intermittent?
Understanding: What does the client believe is causing the pain?
Values: What is the client's acceptable level for this pain? Are there any other concerns highighted by the client?