7/5/20

Measuring Vital Signs

What are the vital signs?

• Temperature
• Blood Pressure
• Pulse (Heart rate)
• Rate of breathing (Respiratory rate) & Oxygen saturation
• Pain*
* Many believe nurses neglect pain assessment
and traditionally measurement of pain is not
regarded as a vital sign.

Why do we measure vital signs?

• Historical
• Indicate function of heart, lungs and metabolism
• Changes provide evidence of stress or current physiology
• The most frequent measurements of a patient’s health and
physiology

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Guidelines & Reasons

• Know medical history, treatment, medications
– These will provide context for vital signs
• Need to know why you are taking vital signs at a particular
time
• If you are responsible for the patient you are responsible for
measuring their vital signs although you may
delegate, you must always interpret
• Your equipment must work and you must
know how to use it

Guidelines & Reasons

• Typically, you will work with a doctor to establish frequency
of assessment
• Approach the patient in a calm, caring and confident manner
respecting their privacy and dignity.
• Make sure you introduce yourself
• Be organised and systematic
• Analyse and Interpret what you find
• Communicate and document your findings

Adult values
• Temperature: 36 – 37.5 oC
– Average oral 37 oC
– Average rectal 37.5 oC
– Average axilla 36.5 oC
• Pulse: 60 – 100 beats per minute
• Respirations: 12 – 20 breaths per minute
• Blood Pressure: 120/80 mmHg
– Means 120 mmHg systolic over 80 mmHg diastolic
– With a pule pressure of 30 – 50 mmHg
= Systolic minus diastolic
• Pain: none

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Paediatric Values
Heart Rate Resp Rate BP
Newborn 120 - 160 30 - 60 85/54
Toddlers 90 – 140 25 - 40 95/65
Preschoolers 80 – 110 20 - 35 100/65
Primary School 70 – 100 20 - 30 105/65
Adolescent 60 – 90 16 - 19 120/75
Adult 60 - 100 12 - 20 120/80

§ Heart rate and Respiratory rate decrease with age

§ Blood Pressure increases with age
§ Temperature decreases slightly with age

When should you measure vital signs?

• On admission
• Routinely as ordered
• When needing to frequently check a patient
• Before and after a procedure or medication that might affect any vital
sign
– Surgery, diagnostic procedure, medication
• When you notice a change in their condition such as a change in their
level of consciousness or increased pain
• When the patient ‘feels funny’
• Before and after nursing interventions such
as increasing their mobility
• Health Promotion

How often should you measure vital signs?

• Continually in ICU, ED, Operating theatres, Coronary Care
• 5 minutely for some medications and procedures (IV Fentanyl)
• 15 minutely immediately after regaining consciousness
• Half hourly Unwell patient on a general ward
• Hourly Potentially unwell patient
• Every 2 hours When patient has been unwell or after surgery
• Every 4 Hours Routine ward observations
• Every 8 Hours Routine ward observations on a low acuity ward
• Once a day Routine observations on a rehabilitation ward
• Once a week Some Psychiatric inpatients
• Once a month Antenatal check up
• 4 times a year GP visits for BP