Ch29_Vital_Signs_Chapter_Notes_Fundamentals_
Nursing_Chamberlain_University
, lOMoARcPSD|52942330
Chapter 29: Vital Signs
Vital Signs: temp, pulse, BP, RR, SpO2, pain. Used to determine baseline.
Guidelines for Measuring Vital Signs
-They are nurse responsibility. Maybe delegated in select situations. Still must review, interpret, & think
critically about interventions
-Make sure equipment is in working order to provide accurate findings
-Choose equipment based on patient condition/characteristics (ex: no adult cuff on child)
-Know patient’s usual range of vitals; may differ from the acceptable range. Provide the baseline to
compare change over time.
-Know patient medical hx, therapies, meds. Illness/treatments/ can cause predictable changes.
-Minimize environmental factors that affect vitals.
-Use organized, systematic approach; each procedure requires step-by-step approach for accuracy.
-Based on patient, collaborate with healthcare providers to decide vitals assessment frequency; nurse
responsible for judging whether more frequent assessments are necessary.
-Use vitals to determine indications for administering meds (ex: fever gets antipyretics)
-Analyze the results of vital signs based on patient condition & past medical history
-Verify & communicate significant changes in vital signs; if abnormal, have another nurse or provider
repeat the measurement to verify reading. Inform charge-nurse or provider, document immediately.
-Instruct patient/family in vital sign assessment & their significance.
Acceptable Ranges for Adults
-Temperature: 96.8*-100.4* F (36*-38* C)
-Pulse: 60-100 beats/min, strong & regular
-Pulse Oximetry (SpO2): greater than 95%
-Respirations: 12-20 breaths/min, deep & regular
-Blood Pressure: <120 mmHg systolic, <80 mmHg diastolic, 30-50 mmHg pulse pressure
-Capnography (EtCO2): 35-45 mmHg
When to Measure Vital Signs
-On admission to health care facility
-When assessing during home care visits