2) Guidelines For Measuring Vital Signs Flashcards
When are vital signs measured?
- During complete physical assessments
- As needed to assess patient’s condition
- During routine exams to establish baseline
What determines when, where, how and by whom vital signs are measured?
- The patient’s needs and condition
What must the nurse do regarding vital sign measurement?
- Measure vital signs correctly
- Delegate measurement appropriately
What is crucial for correct interpretation of vital signs?
- Understanding vital sign values
- Knowledge of patient’s developmental stage and life stage
What should be done after measuring vital signs?
- Communicate findings appropriately
- Begin interventions as needed
How can prioritization of interventions be determined?
- In part by vital signs
- Using ABC acronym (airway, breathing, circulation)
Who can measure vital signs?
- Unregulated care providers can measure selected vital signs in stable patients
- The nurse responsible interprets and acts on these measurements
How should equipment be selected for vital sign measurement?
- Use functional and appropriately sized equipment for the patient’s age
- Select based on the patient’s condition and characteristics
How can environmental factors affect vital signs?
- Minimize factors like room temperature that may yield inaccurate readings
- Assess in an environment that won’t skew the patient’s true condition
What approach should be used when measuring vital
- Use an organized, step-by-step approach to ensure accuracy
- Approach calmly and proficiently to avoid altering vital signs
How should vital sign frequency be determined?
- Follow guidelines to decide frequency of assessment
- Increase frequency if the patient’s condition warrants more checks
- Ordered frequency is the minimum to be checked
When should vital signs be measured?
- Upon admission to a healthcare facility
- During community care visits
- Per provider’s order or facility standards
When should vital signs be measured related to procedures?
- Before, during, and after surgical/invasive procedures
- Before, during, and after blood product administration
When should vital signs be measured related to medications?
- Before, during, and after medications affecting cardiovascular, respiratory, temperature functions
- To determine if vital signs are in range for certain medication administration
When should vital signs be measured based on patient condition?
- When general physical condition changes (e.g. unconsciousness, increased pain)
- Before/after interventions affecting vital signs (e.g. ambulation, exercises)
- When patient reports nonspecific distress
