The commonly measured vital signs include body temperature; blood pressure; heart rate, also called pulse; and respiratory rate. Pain is often considered a vital sign and is measured along with the others.
Measuring vital signs is a crucial component in taking care of a client’s health. Vital signs help assess the general physical health of a person, provide clues to possible diseases, and help monitor the progress of the client’s health status. As a nurse, you will measure and interpret vital signs.
Figure 1: Commonly measured vital signs.
WHEN TO MEASURE VITAL SIGNS
Vital signs are typically measured at certain times. Vital signs are measured when you encounter the client for the first time during the admission process or during the initial home care visits (Fig. 2a). This will provide the client’s baseline and can be used to compare with future measurements.
Usually, vital signs are measured every shift. Clients who are ill, like those in hospitals, need their vital signs measured every few hours. You will even find some severely ill clients attached to machines that monitor their vital signs continuously. On the other hand, clients such as those in long-term care facilities may have their vital signs measured only a couple of days each week. Check the client’s plan of care to learn how often the client’s vital signs need to be taken (Fig. 2b).
Next, vital signs are often measured when the client is receiving medications (Fig. 2c); during nursing interventions (Fig. 2d); and before, during, and after medical procedures, such as surgical operation (Fig. 2e). This is because such procedures may cause significant stress to the client that may result in a significant change in the vital signs. So, it is important to take measurements, document them, and report any unusual findings to the healthcare provider.
You should also measure vital signs after an incident, like a fall (Fig. 2f); when you notice changes in the client’s status like a decreased level of consciousness; or when the client reports any specific symptoms of physical distress, like dizziness or feeling cold (Fig. 2g).
Figure 2: Vital signs are typically measured A. when encountering the client for the first time, B. according to their plan of care, C. when receiving medication, D. during nursing interventions, E. before, during, and after medical procedures, F. after an incident, and G. when you notice changes in the client's status.
MEASURING VITAL SIGNS ACCURATELY
Vital signs can vary within a normal range throughout the day and can be influenced by a number of things, such as the client's activity or if they are experiencing pain or anxiety.
To get the most accurate measurements:
- As much as possible, make sure the client is relaxed and comfortable.
- Take the measurements in a quiet and well-lit room.
- The client should be seated with their back supported and feet on the floor.
- Some clients might not be able to get out of bed, and you will need to measure their vital signs in bed. Before starting, raise the bed to your comfortable height and make sure the client is as relaxed as possible.
- The client should not have consumed alcohol, tobacco, or caffeine or exercised for 30 minutes prior to the measurement because this can temporarily alter some of the client’s vital signs, such as the pulse and blood pressure.
Figure 3: To get the most accurate measurements, ensure that the client is relaxed and comfortable.
After taking a set of vital signs, be sure to report any critical values to the healthcare provider.
- your measurements
- any observations