A) Question: How important for you to develop the skills and competencies in assessing the vital signs? 

B. INSTRUCTION: Before assessing the vital signs of your patient, you were instructed by your clinical facilitator to provide rationale or explanation of the importance of assessing those. With this, how will you give rationale in each component of vital sign? Explain using layman's terms as if you are talking to your patient.

1. Blood Pressure -
2. Respiratory Rate -
3. Pulse Rate -
4. Temperature -
5. Saturated Oxygen -

C. Analyze the case below.

On first day of your clinical duty, you are task by your clinical supervisor to the assess the complete vital sign of your patient. Patient detail:

• ? 64-year-old male patient diagnose of ankle sprain.
• ? Patient was able to ambulate (walk) independently with the use of axillary crutches.
• ? Able to comprehend, speak clearly and very compliant
• ? Patient has a history of hypertension
• Upon checking the initial vital signs, the findings are: BP: 160/90
• PR: 87
• RR: 23
• Temp: 35 deg. Celsius
• O2 Sat: 99%

 

1. Include step-by-step processes of blood pressure, respiratory rate, pulse rate, temperature, and oxygen saturation
2. What are the considerations in assessing each component of the vital signs? (blood pressure, respiratory rate, pulse rate, temperature, and oxygen saturation) Ex: applicable measurement of cuff, type of thermometer, etc.
3. What are the unit of measurement for each vital sign? (blood pressure, respiratory rate, pulse rate, temperature, and oxygen saturation)
4. Documentation of the patient for each vital sign (blood pressure, respiratory rate, pulse rate, temperature, and oxygen saturation)
5. Interpretations and findings of the patient for each vital sign (blood pressure, respiratory rate, pulse rate, temperature, and oxygen saturation)

 

A. In assessing vital signs, it is imperative that every nurse know the proper way of taking it. Moreover, it will be the baseline of the condition of the patient and to know the initial signs and symptoms.

B.

1. Blood Pressure - The pressure or force of blood that flows between your blood vessels. The rationale behind taking the blood pressure is to know how your heart and blood vessels are performing. The higher the pressure means the increase of workload of your heart.
2. Respiratory Rate - The number of breaths you take in and out for one whole minute. It is also important to take the respiratory rate of the patient this will exhibit if the patient is having a hard time to breath.
3. Pulse Rate - The number of beats of your heart per minute. The reason why you should take the pulse rate is to know the patients heart performance. The increase or decrease of PR can be a symptom of an underlying disease.
4. Temperature - The measurement of your core or surface temperature.
5. Saturated Oxygen - The amount of oxygen present in your body.

C.

1. When using a sphygmomanometer in checking blood pressure, assess first the patients arm and skin. Check for any fistula or skin damage avoid putting the cuff in where the skin is damage or there is fistula or graft. Make sure the cuff is fit perfectly, not too tight and not too loose. To check, insert a two finger inside the cuff. Wear your stethoscope and insert in the inner arm where you can feel the pulse. Inflate the bulb mostly up to 200 to 230mmhg then release slowly. First loud sound or s1 is the systolic and the s5 is the diastolic.

Pulse rate- to check the pulse rate manually, have your wrist watch and count the beats in one whole minute. Some pulse oximeter also check the pulse rate so you don't need to count them.

Temperature- in checking temperature orally, make sure the patient did not eat hot or cold food 2 hours prior the measurement. To measure temperature via tympanic or ear make sure you change the plastic cover of the thermometer each temperature check.

Respiratory rate- To measure respiratory rate manually, count the breath in and out of the patient it is visible every rise and fall of the chest. 1 rise and fall of the chest is equivalent to one breath. Do this in one whole minute.

Oxygen Saturation- You can check the oxygen saturation using the Pulse oximeter. Some pulse oximeter check the Respiratory rate and pulse rate as well.

2.Always consider in checking Blood Pressure makes sure there are no arm precaution. For example, if there is a recent mastectomy or there is an AV fistula in the arm. For temperature check you must also consider if the patient ate or drunk hot or cold foods prior to check if doing the oral route.

3.Blood pressure-mmhg

Pulse rate-beats per minute(bpm)

Respiratory rate-breaths per minute(bpm)

Temperature-degree celsius or degree fahrenheit

Oxygen Saturation- percentage(%)

4.Document the patients vital signs in the assigned form in the chart and refer any abnormal vital signs to your supervisor and to the physician.

5.The patients blood pressure is considered high or hypertensive. A BP of more than 140/90mmhg is considered hypertensive. Pulse rate is 87 which the normal range is 60-100bpm. RR-23 above normal(hypercapnea) since the normal range is 12-18bpm. Temp is 35 deg. celsius is below normal (hypothermia)since the normal range is 36.1 to 37.2 deg. celsius. Lastly, oxygen saturation is normal since normal range is 95% to 100%.