Vital Signs

Vital signs are an essential part of nursing care and provide important information about a client’s overall health status. The four main vital signs are:

1. Temperature: Normal body temperature ranges from 97.8°F to 99°F (36.5°C to 37.2°C). A fever is defined as a temperature above 100.4°F (38°C), while hypothermia is defined as a temperature below 95°F (35°C).
2. Pulse: The pulse rate is the number of times the heart beats per minute. The normal range for pulse rate is 60 to 100 beats per minute for adults. The pulse rhythm and quality should also be assessed.
3. Respiration: Respiration rate refers to the number of breaths a client takes per minute. The normal range for respiration rate is 12 to 20 breaths per minute for adults. Respiratory rhythm and depth should also be assessed.
4. Blood pressure: Blood pressure is the pressure of blood against the walls of arteries as the heart pumps it through the body. Normal blood pressure for adults is less than 120/80 mmHg.
5. Pain is assessed by the nurse by collecting and analyzing subjective and objective data. Pain is a subjective experience that cannot be scientifically proven to be or not be present. Current research clearly supports the fact that the client’s subjective complaints of pain are far more accurate than other indicators of pain, such as the client’s vital signs and behavioral changes such as crying and guarding the area of the body affected by the pain.

When measuring vital signs, it’s important to use proper techniques to ensure accuracy. Nurses should explain the procedure to the client, position them comfortably, and use appropriate equipment, such as a thermometer, sphygmomanometer, and stethoscope. Vital signs should be measured at regular intervals based on the client’s condition and care plan.

Abnormal vital signs can indicate a health problem, so it’s important for nurses to document and report any abnormal findings to the healthcare team. Nurses should also be aware of factors that can affect vital signs, such as medications, physical activity, and emotional state.

Temperature

Body temperature can be measured using various methods such as oral, rectal, ear, axillary, temporal and forehead depending on the thermometer used. However, oral temperature measurement is not recommended for neonates, infants, young children, and clients with confusion, agitation, and decreased level of consciousness. Similarly, rectal temperature measurement is not recommended for clients with seizure disorder, heart disease, or rectal disorder.

Respirations

A lower breathing rate can be a sign of various conditions including CNS depression due to opioids or damage, sedation from medication or as a planned procedure, and alkalosis. On the other hand, higher breathing rates can be caused by a fever, pain, acidosis, and anxiety.

The normal respiratory rates along the life span are as follows:

• Neonate: From 30 to 60 per minute
• Infant: From 30 to 60 per minute
• Toddler: From 20 to 40 per minute
• Pre School Child: From 22 to 30 per minute
• School Age Child: From 20 to 26 per minute
• Adolescent: The same as the adult from 16 to 22 per minute
• Adult: From 16 to 22 per minute

Pulses

Assessment of pulses involves both palpation and auscultation techniques. Peripheral pulses, including the radial, femoral, brachial, popliteal, dorsalis pedis, and posterior tibial, are assessed bilaterally through palpation, using the index and/or middle finger to count the beats and assess characteristics such as regularity, volume, and other features. For difficult-to-palpate pulses, a Doppler may be used. On the other hand, the apical pulse is assessed through auscultation, with the point of maximum intensity for adults located on the left side of the chest at the fifth intercostal space. This location may vary in other age groups, as well as in older adults due to an enlarged heart.

The normal parameters for pulse rates along the life span are:

• Neonate: From 80 to 180 beats per minute
• Infant: From 100 to 160 beats per minute
• Toddler: From 90 to 140 beats per minute
• Pre School Child: From 80 to 110 beats per minute
• School Age Child: From 70 to 100 beats per minute
• Adolescent: From 60 to 100 beats per minute
• Adult: From 60 to 100 beats per minute

Blood Pressure

The blood pressure is determined by the force of blood flow in the arteries, which is influenced by several factors including blood volume, peripheral vascular resistance, heart’s pumping action, and blood thickness. Systolic blood pressure measures the pressure during the heart’s contraction, while diastolic blood pressure measures the pressure when the heart is at rest. Typically, blood pressure is measured over the brachial artery above the antecubital space, and it’s the most common method of measurement.

The normal blood pressures along the life span are:

• Neonate: Diastolic from 40 to 50 mm Hg and systolic from 60 to 80 mm Hg
• Infant: Diastolic from 50 to 70 mm Hg and systolic from 74 to 100 mm Hg
• Toddler: Diastolic from 50 to 80 mm Hg and systolic from 80 to 112 mm Hg
• Preschool child: Diastolic from 50 to 78 mm Hg and systolic from 82 to 110 mm Hg
• School age child: Diastolic from 54 to 80 mm Hg and systolic from 84 to 120 mm Hg
• Adolescent: < 120/80
• Adult: < 120/80

Pain

Pain assessment is an important nursing skill that involves evaluating a patient’s pain level and providing appropriate interventions to manage pain. The goal of pain assessment is to identify the nature, location, and severity of pain, as well as any aggravating or alleviating factors, so that an effective pain management plan can be implemented.

There are various tools and methods that can be used to assess pain, including self-report scales, behavioral observation, and physiological indicators. Self-report scales are commonly used and involve asking patients to rate their pain on a numerical or visual analog scale, or to describe their pain using descriptive terms like throbbing or sharp. Behavioral observation involves assessing a patient’s physical expressions and movements that may indicate pain, such as grimacing or guarding. Physiological indicators, such as increased heart rate or blood pressure, can also be used to assess pain.

Pain assessment should be individualized and take into account the patient’s cultural background, age, cognitive status, and ability to communicate. For example, nonverbal or cognitively impaired patients may require alternative pain assessment methods, such as facial expression scales or observational scales.

Once pain is assessed, appropriate interventions can be implemented to manage the pain, such as pharmacological interventions (e.g., analgesics), non-pharmacological interventions (e.g., relaxation techniques), or a combination of both. It is important to regularly reassess pain levels to determine the effectiveness of the interventions and make necessary adjustments.

Effective pain assessment and management is essential for promoting patient comfort, improving quality of life, and preventing adverse outcomes associated with untreated pain.

There are several ways of assessing pain. These pain assessment methods include:

• The PQRST method of pain assessment which includes precipitating events, the quality of pain (dull, sharp, deep, superficial, burning, aching, or stabbing?), region and location of the pain, the severity of the pain, and the triggers and timing of the pain.

The PQRST method is a useful way for nurses to assess pain. The PQRST method consists of:

• P: Precipitation: What precipitated the pain symptoms? What things precipitate an increase in the amount of pain and what things precipitate a relief from the pain?
• Q: Quality: What is the quality of the pain? Is it dull, sharp, deep, superficial, burning, aching, or stabbing?
• R: Region: Where is the pain? What region or area is painful? Does the pain travel and radiate to another area of the body like the jaw and your leg?

• S: Severity and Symptoms: What is the intensity of the pain on a scale of 1 to 10 with 1 being minimal pain and 10 as the most intense pain? What other symptoms are you experiencing in addition to the pain?
• T: Triggers and Timing: What triggers and starts your pain? What triggers make the pain worse and more severe? When did the pain begin? Tell me about the timing of the pain. How long does the pain last? How often does the pain appear?

• Using a standardized pain assessment scale specifically for adults, children and infants, such as the CRIES and McGill Pain Assessment tools
• Using a graphic or numerical pain rating scale with faces and on a scale from 0 to 10, for example
• The assessment of behavioral signs and symptoms of pain such as tachycardia, hypertension and diaphoresis

Evaluating Invasive Monitoring Data

Invasive monitoring is an important part of a registered nurse’s duties, which involves evaluating and monitoring data such as increased intracranial pressure, pulmonary artery pressure, and other hemodynamic monitoring data. Intracranial pressure (ICP) refers to the pressure within the cranial cavity or skull, where the normal contents include the brain, cerebrospinal fluid, and blood. Since the skull is rigid and bony, an increase in intracranial pressure can lead to hypoxia, impaired cerebral perfusion, and compression of the cerebral arteries, which can be life-threatening if left untreated.

Increased Intracranial Pressure

Several neurological insults can cause increased intracranial pressure, such as closed head injury, cerebral tumor, epidural hematoma, subdural hematoma, subarachnoid hematoma, spina bifida, infections and abscesses, hydrocephalus, cerebral infarct, and status epilepticus.

The normal range for intracranial pressure is 5-15 mmHg, and increased ICP occurs when the volume of the cranial cavity increases. Under normal circumstances, cerebral perfusion pressure is necessary to adequately perfuse the brain, which can be mathematically calculated by subtracting the actual intracranial pressure from the mean arterial blood pressure.

Cerebral perfusion pressure = The mean arterial pressure – The intracranial pressure

The normal cerebral perfusion pressure, under normal circumstances, should range from 60 to 100 mm Hg.

Some of the signs and symptoms of increased intracranial pressure include:

• A widening pulse pressure
• Decreased level of consciousness
• A headache
• Vomiting
• Seizures
• Decorticate or decerebrate posturing

Abnormal rigid bodily posturing can manifest in two forms: decorticate and decerebrate posturing. Decorticate posturing is marked by clenched fists on the chest and inward-turned arms, while decerebrate posturing is characterized by an arched backward head, extended legs and arms, and upward-pointed toes. Both types of posturing can occur on one or both sides of the body.

• Dilated and sluggish pupils
• Neurological sensory and motor losses
• Visual disturbances
• Cheyne-Stokes respirations: Cheyne-Stokes respirations are signaled with the classical signs of rapid, deep breathing with periods of apnea and abnormal posturing.
• Cushing’s reflex: Cushing’s reflex is a late sign of increased intracranial pressure. It is characterized with bradycardia, hypertension and a widening pulse pressure, which is the mathematical difference between the systolic and diastolic blood pressure. For example, the pulse pressure is 40 when a client’s blood pressure is 120/80 (120-80= 40) and the pulse pressure will rise to 90 when the client’s blood pressure changes to 160/70 (160-70=90). This rise is referred to as a widening pulse pressure.

Hemodynamic Monitoring

Hemodynamic monitoring is a method of obtaining real-time information about a patient’s blood pressure, pulmonary artery pressure, pulmonary artery wedge pressure, central venous pressure, cardiac output, intra-arterial pressure, mixed venous oxygen saturation, and other relevant data. This allows healthcare providers to have up-to-date and accurate information on the patient’s hemodynamic status. For example:

• Central Venous Pressure: 1 to 8 mm Hg
• Cardiac Output: 4 to 7 L/min

In summary, measuring and interpreting vital signs is an essential nursing skill that requires proper techniques, attention to detail, and awareness of normal ranges and potential abnormalities. Nurses play a crucial role in monitoring and assessing vital signs to ensure timely and appropriate interventions to promote the health and well-being of their clients.