Observation and reflection. Measuring vital signs - Temperature, Pulse, Respiration and Blood Pressure.

University Degree Subjects allied to Medicine

OBSERVATIONS

Temperature, Pulse, Respiration and Blood Pressure

Temperature, pulse, respirations and blood pressure are the vital signs which indicate the body’s ability to regulate body temperature, maintain blood flow, and oxygenate body tissues. Vital signs indicate patients’ responses to the physical, environmental, and psychological stressors. Vital signs may also reveal sudden changes in a patient’s condition (NICE 2007). A change in one vital sign can directly lead to a detection of a change in another vital sign.

As a first year student l was allocated a new post-operative patient from the theatres to the orthopaedic ward by my mentor and to record patients’ observations. The British journal of Nursing (2006) states that patient’s vital signs need to be measured and recorded upon arrival to a health care facility as well as on admission to the ward. I also had the opportunity to do baseline observations. According to the Emergency Medical Service, 2006, p194, the baseline observation is used to ….”identify the patient’s condition, such as the improvement, stability or deterioration.” Prior to going over to the patient, l made sure that my equipment was clean and functioning well. l also had to have the MEWS Chart where l would record the vital signs data. MEWS is acronym for the ‘Modified Early Warning System’.

In the Nursing and Midwifery Council (NMC 2008) Code of Professional Conduct, a range of professional and ethical issues are addressed including the need for practitioners to respect the patient as an individual, to obtain consent before the implementation of any assessment/treatment or care, to cooperate with others in the team, to protect confidential information, and to act to indentify and minimise risk to patients.

I thoroughly washed my hands with soap and water and dried them before going to the patient’s bed so as to minimise the risk of cross infection from one patient to the other(DH 2005: C). When I got to the bed I introduced myself and asked for consent from the patient (NMC 2008) to take his observations and he duly obliged. All this was done in the presence of my mentor. The patient appeared to know what l meant by observations and how l was going to do it because it was not his first time to be in the hospital. The “hands on” physical assessment begins by taking vital signs according to Weber and Kelly (2003,p84). My assessment began as soon as l laid my eyes on the patient, l was looking for signs of anxiousness, pain or upset. I made sure the patient was positioned correctly and comfortable enough so as to obtain accurate results.

Maze et al (1993) states that “In the postoperative period the patient’s temperature should be observed preoperatively for hypothermia or hyperthermia as a reaction to surgical procedures. I started to measure the temperature followed by pulse, respiration and blood pressure to ease the patient’s anxiety and lower their activity which greatly increased the accuracy of the data taken (Bartlett 1996). Temperature was also measured using a tympanic thermometer. There are few places where temperature can be obtained and these include the mouth (oral), under the arm and in the ear (tympanic). I placed the covered probe (thermometer) in the patient’s ...

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After the temperature l had to measure pulse. For adults the radial pulse is the site for assessment while for infants & young children the brachial pulse is used (Elkin, Perry & Potter, 2004). I placed my index and middle fingers on the patient radial arterial and counted the number of times the heart beats in one minute. Adult resting heart rate should be between 60 & 90 beats / minute (JBS 2005).

Respiration was measured while the patient was unaware of the assessment so that the rate and rhythm would not be affected by voluntary control of their respiration. I measured respiration by watching the chest movement for a minute and also looked for signs of regular rhythm and effortless breathing. High respiration can show if the patient is in pain or can be a sign of low blood oxygen. The adult respiration rate varies between 12 & 20 (Marieb & Hoehn 2007).

After finishing the respiratory reading l took the manual blood pressure using the sphygmomanometer (inflatable bladder and cuff) and stethoscope. I checked if the cuff was the right size for the patient to ensure that an accurate reading was taken (BHS 2006). I placed a pillow under the patient’s arm to ensure that the upper arm was at heart level, for accurate measurement the arm should be supported at the level of the heart. If the arm is unsupported the muscles may contract leading to a rise in diastolic blood pressure. Raising the arm above heart level can lead to underestimation of blood pressure (Medicines and Healthcare products Regulatory Agency (MHRA) 2006).I wrapped the upper arm with the cuff, positioned the stethoscope over the brachial artery with one hand, inflated the cuff and listened through the earpiece until l could not hear any sound (Hill &Grim 1991). I then opened the valve on the pump slowly and the first tapping sound l heard was that of the systolic pressure. The sound became faint as the pressure in the cuff decreased until l could not hear any sound (diastolic pressure). Normal blood pressure ranges from 100/60 to 140/90 (Marieb & Hoehn 2007).

Errors in blood pressure measurement are often the result of poor technique or faulty equipment. It is therefore important for all staff performing blood pressure measurements to be adequately trained and for equipment to be checked and calibrated on a regular basis. Errors occur for a variety of reasons including: The use of faulty equipment, use of an incorrectly sized cuff, Inadequate support of the arm, poor observer technique, deflating the cuff too quickly, rounding up readings to the nearest 5 or 10mmHg. Practical advice for accurate blood pressure measurement has been published by

the BHS (2007b, 2007c) and MHRA (2006).

I immediately documented the observations on the vital signs chart (MEWS) so as not to forget and to reduce the risk of errors (Williams et al, 2004: C). My patient’s pulse was high and blood pressure low so I reported this abnormal reading to my mentor. She checked the knee where the patient had been operated on and noticed that the patient was bleeding profusely, leading to appropriate measures being taken to stop the bleeding.

When observations are carried out it is always important to minimize the risk of cross- infections by washing and drying hands (DH 2005: C), the person carrying out the observations must have enough knowledge on how the equipment works, how to use the equipment and also be able to record the accurate readings. Inaccurate reading may cause a lot of harm to the patient. It is important that a health care professional be aware that there is a wide range of normal values that can apply to persons of different ages.

It is standard practice for vital sign measurements to be taken upon admission of a new patient into a medical facility (British Journal of Nursing 2006). Each area of the hospital has guidelines which outline the intervals and the way in which the measurements should be taken. Sometimes it is up to the nurse which technique to use, depending on their experience and training. Assessment also depends on the patient’s age and gender. Nurses will face moments when they will be unable to perform the assessment. These circumstances may include aggressive behaviour of the patient or permission being declined by the patient. Some cultural / religious barriers might prevent the nurse going ahead with the assessment. The equipment available may also limit the ways in which the assessments can be done.

The nurse will need to think critically when making the decision to perform or not to perform certain assessments, depending on the characteristics of the presented patient i.e. patient’s age, gender, cultural/religious background, health status and cognitive ability. Some of the procedures can be invasive e.g. a rectal temperature measurement, therefore privacy and the level of comfort of the patient will need to be considered before performing certain assessments.

Vital signs measurement is an essential clinical skill and nursing staff must be competent in undertaking the procedures. Accuracy is essential and nurses should be appropriately trained in the various methods of vital signs measurement and the correct use of equipment.

Reference

British Journal of Nursing (2000). The Importance of Measuring and Recording Vital Signs Correctly. 15(5)

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DH (2005) Saving Lives: a Delivery Programme to Reduce Healthcare Associated Infection Including MRSA: Skills for Implementation. Department of Health, London.

Elkin, M.K., Perry, A.G., & Potter, P.A. (2004). Nursing Interventions & Clinical Skills (3rd ed.). Missouri: Mosby.

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Marieb, E.M. & Hoehn, K. (2007) Human Anatomy and Physiology. Pearson Benjamin Cummings, San Francisco.

Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics of Nursing and Midwifery .Nursing and Midwifery Council, London

Nursing and Midwifery Council (2007) NMC. Record and Keeping Guidance.

Place, B. (2000) Pulse oximetry: benefits and limitations. Nursing Times, 96 (26), 42.

Weber, J., & Kelly, J., (2003). Health Assessment in Nursing (2nd ed) Philadelphia: Lippincott Williams &Wilkins.