Vital Signs-

antipyretic
(an-tih-pie-RET-ick)
an agent that reduces fever
apnea
(ap-nee-uh)
temporary or transient cessation of breathing
auscultatory gap
(aws-kul-tuh-torr-ee gap)
temporary disappearance of sounds usually heard over the brachial artery, occurr
ing when the cuff pressure is high and is gradually reduced, with the sounds aga
in heard at a lower level of pressure (usually occurring in patients who have hy
pertension)
axillary
(ak-suh-leh-ree)
pertaining to the axilla, the cavity beneath the junction of a forelimb and the
body; also called the armpit or the underarm
brachial pulse
(bray-kee-uhl puhls)
beating or throbbing felt over the brachial artery, usually palpated in the ant
ecubital space
bradycardia
(brad-ih-car-dee-uh, also bray-dih-car-dee-uh)
an abnormally slow pulse rate, usually fewer than 60 beats per minutes in an ad
ult
bradypnea
(brad-ip-nee-uh)
an abnormally slow respiratory rate, usually fewer than 12 breaths per minutes
in an adult
cardiac output
(car-dee-ack owt-put)
the amount of blood pumped into the arteries by the heart during one minute; th
e product of the heart rate and the stroke volume
Celsius
(sell-see-uhs)
relating to the international thermometric scale on which 0 is the freezing poin
t and 100 is the boiling point; centigrade
centigrade
(sen-tih-greyd, also sahn-tih-greyd)
relating to the international thermometric scale on which 0 is the freezing poin
t and 100 is the boiling point; Celsius
core temperature
(kor tem-per-uh-chur)
the amount of heat in the deep tissues and structures of the body, such as the
liver
diastolic pressure
(die-uh-stahl-ick preh-shur)
the force exerted when the heart is at rest in between each beat; the lowest pr
essure exerted against the arterial walls at all times
dyspnea
(disp-nee-uh, also dis-nee-uh)
difficult or labored breathing
eupnea
(yoop-nee-uh)
normal respiration
Fahrenheit
(fahr-unh-hite)
relating to the temperature scale on which 32 is the freezing point and 212 is th
e boiling point
febrile
(febb-rile)
feverish; pertaining to a fever
fever
(fee-vuhr)
an elevated body temperature
hypertension
(hye-pur-ten-shun)
a common cardiovascular disorder, often with no symptoms, in which the blood ex
erts an abnormal amount of force on the inside walls of the arteries persistentl
y and blood pressure readings are elevated
hypotension
(hye-poe-ten-shun)
a condition in which blood pressure falls below the normal range; not usually c
onsidered a problem unless it causes symptoms, such as dizziness or fainting
Korotkoff sounds
(kuh-rot-kof sownds)
a series of five sounds (four sounds followed by an absence of sound) heard duri
ng the auscultatory determination of blood pressure and produced by sudden diste
ntion of the artery because of the proximally placed pneumatic cuff
orthopnea
(or-thop-nee-uh)
ability to breathe without difficulty only when in an upright position (sitting
upright or standing)
orthostatic hypotension
(or-thuh-stat-ick hye-poe-ten-shun)
a sudden drop in blood pressure resulting from a change in position, usually wh
en standing up from a sitting or reclining position and often causing dizziness
oximetry
(ok-sim-uh-tree)
determination of the oxygen saturation of arterial blood using a photoelectric
device called an oximeter
oxygen saturation
(ok-sih-jun sah-chuh-ray-shun)
a clinical measurement of the percentage of hemoglobin that is bound with oxyge
n in the blood
palpation
(pal-pay-shun)
the application of the fingers with light pressure to the surface of the body t
o determine the condition of the underlying parts
pulse deficit
(puhls deh-fih-sit)
the difference between the apical and the radial pulse rates
pulse pressure
(puhls preh-shur)
the difference between the systolic and the diastolic blood pressure
radial pulse
(ray-dee-uhl puhls)
beating or throbbing felt over the radial artery, usually palpated over the gro
ove along the thumb side of the inner wrist
S1
(ess wun)
the first heart sound, heard when the atrioventricular (mitral and tricuspid) v
alves close
S2
(ess too)
the second heart sound, heard when the semilunar (aortic and pulmonic) valves c
lose
Sims' position
(sims poe-zih-shun)
a side-lying position with the lowermost arm behind the body and the uppermost
leg flexed
stethoscope
(steh-thuh skope)
a device used to convey sounds produced in the body to the listeners ears
stroke volume
(stroke vahl-yum)
the amount of blood entering the aorta with each ventricular contraction
systolic pressure
(sis-tahl-ick preh-shur)
the amount of force exerted within the arteries while the heart is actively pum
ping or contracting; the maximum pressure exerted against the arterial walls
tachycardia
(tack-ih-car-dee-uh)
an abnormally fast pulse rate, usually above 100 beats per minutes in an adult
tachypnea
(tuh-kip-nee-uh)
an abnormally fast respiratory rate, usually more than 20 breaths per minutes i
n an adult
tympanic
(tim-pah-nick)
pertaining to the ear canal or eardrum (tympanic membrane)
vital signs
(vie-tuhl sines)
measurements of physiological functioning, specifically temperature, pulse, resp
irations, and blood pressure, but may also include pain and pulse oximetry
Temperature
The goal of measuring a patients temperature is to determine the amount of heat i
n core body tissues. The mouth, the axilla or armpit, the rectum, the ear, and t
he forehead are all appropriate sites for temperature measurement; the best site
to use varies with the age of the patient, the situation, and agency policy. To
ensure an accurate temperature reading, you must use the thermometer properly a
nd document the site correctly. For repeated measurements or comparison of measu
rements over time, be sure to use the same site each time.
There is no single temperature reading that is normal for all patients, although m
any consider an oral temperature of 98.6 F (37 C) the norm. Age, exercise, hormone
s, stress, environmental temperature, time of day, body site, and medications ca
n all influence body temperature. In general, an oral body-temperature range of
96.4 F to 99.1 F (35.8 C to 37.3 C) is acceptable.
A rectal temperature is usually 0.9 F (0.5 C) higher than an oral temperature, and
axillary and tympanic temperatures are usually 0.9 F (0.5 C) lower than an oral t
emperature.
Agency policy usually specifies whether to document a temperature reading in deg
rees Fahrenheit or degrees Celsius. Many thermometers can convert a temperature
reading from one measurement scale to the other. If you use one that does not ha
ve this feature, convert degrees F to degrees C by subtracting 32 and then divid
ing by 1.8; convert degrees C to degrees F by multiplying by 1.8 and then adding
32
Several different types of thermometers are available for measuring temperature.
The most common types are electronic thermometers, tympanic thermometers, and t
emporal thermometers. The chemical-dot or strip thermometer is less commonly use
d than the others. Most healthcare facilities no longer use mercury thermometers
because of the environmental hazards that mercury-containing devices pose.
An electronic thermometer consists of a rechargeable, battery-powered display un
it, a thin wire cord, and two temperature probes. The blue-tipped probe measures
oral temperature; the red-tipped probe measures rectal temperature. A single-us
e, disposable plastic sheath covers the appropriate probe during use. An audible
signal indicates that the device has completed its measurement, after which the
temperature reading appears on the digital display. Placing the probe back in t
he display unit resets the device.
Measuring temperature orally is appropriate for most adults and for children who
are old enough to understand directions, usually by 3 or 4 years of age. When m
easuring oral temperature, wait 20 to 30 minutes if the patient has been eating,
drinking, smoking, or exercising, as these activities can alter the temperature
. Avoid this route for patients who have mouth sores or facial injuries or canno
t keep the mouth closed around the thermometer probe.
The rectum is probably the least preferred site for measuring temperature becaus
e of the discomfort for the patient and the invasive nature of the procedure. A
rectal temperature is sometimes appropriate, however, for very young infants and
for patients who are comatose, have facial injuries or deformities, or are crit
ically ill or injured. To measure rectal temperature, wear gloves, cover the red
-tipped probe with a disposable plastic sheath, and lubricate the probe cover be
fore inserting it into the patients rectum. For an adult, insert the probe approx
imately 1 to 1 inches (2.5 to 3.5 centimeters) into the rectum and in the directi
on of the umbilicus. If you feel resistance when inserting the probe, remove it
immediately. Do not force the probe into the rectum as this might injure the pat
ients rectal mucosa.
The axilla is appropriate for temperature measurement of most adults and childre
n, including infants. However, this site is not as accurate as the others and do
es not reflect core body temperature. If the axilla has open sores and rashes, u
se another site.
A tympanic thermometer consists of an otoscope-like tip with an infrared sensor
on the end that detects heat radiated from the ears tympanic membrane. When using
the thermometer, cover the tip with a single-use, disposable plastic sheath. Pl
ace the covered tip at the external opening of the ear canal, and wait 2 to 5 se
conds after you press the scan button for the temperature display. To obtain an
accurate reading from a tympanic thermometer, it is important to place the probe
at the proper angle for sealing the ear canal. Do not use the tympanic site if
the patient reports ear pain or has excessive earwax, drainage from the ear, or
sores or injuries in or around the ear.

A temporal thermometer is a hand-held device with a round, rubber-like probe on
the end that measures skin temperature over the temporal artery. While pressing
the scan button, hold the probe flat against the forehead while moving it gently
across the forehead over the temporal artery, and then touch the skin behind th
e earlobe. Release the scan button to display the temperature reading. Depending
on agency policy, either use disposable probe covers or clean the probe with a
disinfectant wipe between patients.
Chemical-dot, single-use thermometers are thin, disposable strips of plastic wit
h a temperature sensor at one end. The sensors consist of chemically treated dot
s that change color at different temperatures. The Celsius strip has 50 dots wit
h each representing temperature increments of 0.1 C over a range of 35.5 C to 40.4
C. The Fahrenheit strip has 45 dots with increments of 0.2 F and a range of 96.0 F
to 104.8 F. The chemical dots usually change color within 60 seconds. If you reu
se the temperature strip (for the same patient only), the chemical dots return t
o their original color within a few seconds. The advantages of chemical-dot ther
mometers are that they are inexpensive, unbreakable, and can be used in isolatio
n rooms.
Measuring temperature - Electronic, oral
1. Provide privacy and explain the procedure to the patient.
2. Place the covered temperature probe under the patient's tongue in the posteri
or sublingual pocket.
3. Instruct the patient to close the lips gently around the probe and to keep th
e mouth closed until the temperature has been measured. Remind the patient not t
o bite down on the temperature probe.
4. When the audible signal indicates that the temperature has been measured, rem
ove the probe and read the digital display.
5. Discard the disposable cover and document the results.
View poster preview
An electronic probe thermometer is recommended for measuring temperature orally
. The temperature is indicated on a digital display that is easy to read. Electr
onic probe thermometers can also be used for rectal and axillary readings.
Always use a protective cover over an oral electronic thermometer's probe. Place
the probe in the sublingual pocket and instruct the patient to close the mouth,
breathe through the nose, and hold the probe in place with the lips without bit
ing down. Wait for the device to beep before reading the temperature on the disp
lay.
Measuring temperature - Electronic, axillary
1. Provide privacy and explain the procedure to the patient.
2. Assist the patient to a sitting position and move the bed linens, gown, or ot
her clothing to expose the patient's axilla. Dry the axilla, if needed.
3. Place the covered temperature probe under the patient's arm in the center of
the axilla.
4. Leave the thermometer probe in place until the audible signal indicates that
the temperature has been measured.
The temperature reading appears on the digital display.
5. Discard the disposable cover and document the results.
View poster preview
Because the axilla is on the outside of the body, a temperature reading from th
e axillary site is generally 0.9 F (0.5 C) lower than that from the mouth or ear.
A normal reading for an axillary temperature is between 96.6 F (35.9 C) and 98 F (3
6.7 C). Factors that influence an axillary temperature are the time of day the te
mperature is measured and the patient's level of activity prior to temperature m
easurement.
Measuring temperature - Tympanic
1. Provide privacy and explain the procedure to the patient.
2. Gently push the disposable plastic cover over the tip of the electronic therm
ometer until the cover locks into place.
3. Gently pull the pinna, also called the auricle, back, up, and out, and insert
the tip of the covered thermometer probe into the patient's ear canal.
4. Leave the thermometer probe in place until the audible signal indicates that
the temperature has been measured.
The temperature reading appears on the digital display.
5. Discard the disposable cover and document the results.
View poster preview
The cone-shaped tip of the tympanic thermometer uses infrared technology to mea
sure body temperature from heat of the eardrum (tympanic membrane) and the surro
unding tissue. That heat is then converted to a digital reading. Most tympanic d
evices produce an easy-to-read digital display quickly. Many tympanic thermomete
rs provide Celsius and Fahrenheit conversions and reading equivalents for oral a
nd rectal temperatures.
Measuring temperature - Temporal
1. Provide privacy and explain the procedure to the patient.
2. Remove the protective cap and wipe the lens of the scanning device with an al
cohol swab to make sure it is clean.
3. Position the probe flat on the center of the patient's forehead at midpoint b
etween the hairline and the eyebrow.
4. Press the scan button and slowly slide the thermometer across the forehead.
Some arterial-scan thermometers recommend sliding the device from the forehead t
o just below the ear lobe.
5. Release the scan button and read the display.
View poster preview
The temporal artery is an excellent location for measuring temperature as it is
suitable for all ages and poses no risk of injury for the patient or for the cli
nician. The scan across the forehead is gentle, comfortable, and acceptable.
Arterial temperature is close to rectal temperature, but it is nearly 1 F (0.5 C)
higher than an oral temperature, and 2 F (1 C) higher than an axillary temperature
.
Assessing radial pulse rate
Assessing the rhythm, strength, and rate of a patients peripheral pulse provides
valuable information about the cardiovascular system. The rhythm of the pulse is
usually regular, reflecting the time interval between each heartbeat. The stren
gth of the pulse correlates with the volume of blood being ejected against the a
rterial walls with each contraction of the heart. Pulse strength is usually desc
ribed as absent, weak, diminished, strong, or bounding. If blood volume decrease
s, the pulse is often weak and difficult to palpate. If blood volume increases,
the pulse is often bounding and easy to palpate.
Although peripheral pulses are palpable at a variety of body sites, the radial
pulse is the easiest to access and is therefore the most frequently checked peri
pheral pulse. Assessment of other peripheral sites, such as the carotid or femor
al pulses, is not usually part of routine vital-sign measurement. Clinicians typ
ically access these sites when performing a complete physical examination. When
they cannot palpate peripheral pulses, they use a Doppler ultrasound stethoscope
to confirm the presence or absence of the pulse.
A normal adult pulse rate ranges from 60 to 100 beats per minute. It is usually
slightly faster in women and more rapid in infants and children. In addition to
gender and age, exercise, medications, decreased oxygen saturation, blood loss,
and body temperature can all influence a patients pulse rate. When assessing puls
e, it is important to find out what a normal rate is for that particular patient
.
A pulse rate slower than 60 beats per minute is called bradycardia. Conditions s
uch as decreased thyroid activity, hyperkalemia, an irregular cardiac rhythm, an
d increased intracranial pressure can all slow the heart rate. Many athletes who
do a lot of cardiovascular conditioning have pulse rates in the 50s and experie
nce no problems.
A pulse rate faster than 100 beats per minute is called tachycardia. Conditions
such as congestive heart failure (CHF), hemorrhage, shock, dehydration, and anem
ia can all speed up the heart rate. Patients who have tachycardia might experien
ce dyspnea, fatigue, chest pain, palpitations, and edema.
An abnormally irregular, weak, slow, or rapid pulse, especially if sustained, mi
ght mean that the heart cannot function properly and requires further evaluation
.
1. The radial pulse is easy to find and is the most frequently checked periphera
l pulse.
2. To check the radial pulse with the patient supine, position the patient's arm
along the side of the body or across the upper abdomen with the patient's wrist
relaxed.
3. Apply light pressure with the pads of the fingers in the groove along the rad
ial or thumb side of the patient's inner wrist.
Be careful not to apply too much pressure, as this can impair blood flow.
4. If the pulse is regular, count for 30 seconds, then multiply that number by 2
.
If the pulse is irregular, count for 1 full minute.
Palpate a patient's pulse to determine circulation distal to the pulse site and
for rhythm, quality, and strength. Is it normal, weak or thready, full or boundi
ng, or absent?
Perform hand hygiene before and after patient care and document your findings on
the appropriate flow sheet or record.
Assessing apical pulse rate
Evaluating the apical pulse is the most reliable noninvasive way to assess cardi
ac function. Each pulsation you hear is a combination of two sounds, S1 and S2.
S1 is the sound you hear when the tricuspid and mitral valves close at the end o
f ventricular filling and just before systolic contraction begins. S2 is the sou
nd you hear when the pulmonic and aortic valves close at the end of systolic con
traction.
When determining an apical pulse, it is important to use anatomical landmarks fo
r correct placement of the stethoscope over the apex of the heart so that you ca
n hear the heart sounds clearly. If the apical rate is regular, you can usually
determine an accurate rate in 30 seconds. When the apical pulse is irregular, it
is best to count for at least 1 minute to obtain an accurate rate.
1. Determining an apical pulse involves locating the point of maximal impulse (P
MI), placing the bell or diaphragm of your stethoscope at this site, and listeni
ng for 1 minute.
2. Expose the patient's sternum and the left side of the chest.
3. Locate the PMI. Slide your fingers down each side of the angle of Louis to th
e second intercostal space.
4. Move your fingers down the left side of the sternum to the fifth intercostal
space and laterally to the left midclavicular line and the PMI.
5. Place the diaphragm of your stethoscope over the PMI and auscultate for norma
l S1 and S2 heart sounds. You will usually hear them as "lub-dub." If the apical
pulse is regular, count for 30 seconds, then multiply that number by 2. If the
apical pulse is irregular or the patient is taking cardiovascular medications, c
ount for 1 full minute to ensure an accurate measurement.
Use the apical pulse when the patient has a history of heart-related health prob
lems or is taking cardiovascular medications. Count the apical pulse rate while
the patient is at rest. If the patient has been active, wait at least 5 to 10 mi
nutes before beginning.
Assessing pulse deficit
A pulse deficit occurs when the heart contracts inefficiently and does not trans
mit a pulse wave to a peripheral site. Pulse deficits are often associated with
irregular cardiac rhythms and can be a sign of alterations in cardiac output.
To assess for a pulse deficit, you will need another healthcare worker. One pers
on assesses the peripheral pulse rate while the other person assesses the apical
pulse rate. Compare the two rates; the difference between the two is the pulse
deficit, which reflects the number of ineffective cardiac contractions in 1 minu
te. If you find a pulse deficit, assess the patient for other signs and symptoms
of decreased cardiac output, such as dyspnea, fatigue, chest pain, and palpitat
ions.
1. To determine the pulse deficit, take the radial and the apical pulses simulta
neously.
2. Position the patient either in a supine or a sitting position and expose the
patient's sternum and the left side of the chest.
3. Using the appropriate anatomical landmarks, locate the radial and the apical
pulses.
4. Start counting on command and count the pulse rates simultaneously for 1 full
minute. Stop counting on command.
5. To calculate the pulse deficit, subtract the radial pulse rate from the apica
l pulse rate.
Count the apical pulse rate while the patient is at rest. If the patient has bee
n active, wait at least 5 to 10 minutes before beginning. To calculate the pulse
deficit, subtract the radial pulse rate from the apical pulse rate.
Respiration
Respiration involves exchanging oxygen and carbon dioxide between the atmosphere
and the cells of the body. This is accomplished through breathing, which is mad
e up of two phases: inspiration and expiration. Inspiration is an active process
that involves the diaphragm moving down, the external intercostal muscles contr
acting, and the chest cavity expanding to allow air to move into the lungs. Expi
ration is a passive process that involves the diaphragm moving up, the external
intercostal muscles relaxing, and the chest cavity returning to its normal resti
ng state. The respiratory center in the medulla of the brain and the level of ca
rbon dioxide in the blood help regulate breathing.
Accurate assessment of respiration is an important component of vital-signs skil
ls. It involves observing the rate, depth, and rhythm of chest-wall movement dur
ing inspiration and expiration. During normal breathing, the chest gently rises
and falls in a regular rhythm. For a healthy adult, a respiratory rate between 1
2 and 18 breaths per minute is considered normal.
Many factors can alter a patients respiratory rate. Exercise, anxiety, fever, and
a low hemoglobin level can all increase respiratory rate. A rate faster than 20
breaths per minute is called tachypnea. Neurological injuries and medications t
hat depress the respiratory system, such as opiates, can slow the respiratory ra
te. A rate slower than 12 breaths per minute is called bradypnea.
The rhythm of a patients respirations is usually regular, but certain conditions
and illnesses can make it irregular. Cheyne-Stokes respirations are breathing cy
cles that increase in rate and depth and then decrease and are followed by a per
iod of apnea. You might observe this pattern in patients who have heart failure
or increased intracranial pressure. It can also be a sign that death is approach
ing. Biots respirations involve a period of slow and deep or rapid and shallow br
eathing followed by apnea. This type of breathing pattern reflects central nervo
us system abnormalities. Kussmauls respirations involve deep and gasping respirat
ions, likely due to renal failure, septic shock, or diabetic ketoacidosis. Apnea
is the absence of breathing and is often associated with other abnormal respira
tory patterns.
The depth of a patients breathing, also called tidal volume, is the amount of air
that moves in and out of the lungs with each breath. To determine precise tidal
volume, you would need a spirometer, but you can estimate tidal volume by obser
ving the expansion and symmetry of chest-wall movement during inspiration and ex
piration. With normal respiration, the chest gently rises and falls. If a patien
t is in pain or has a chest or an abdominal injury, respiration often becomes sh
allow. After exercise or other physical exertion, respiration tends to deepen.
Measuring blood pressure
Blood pressure is the force that blood exerts against the vessel wall. During a
normal cardiac cycle, blood pressure reaches a high point and a low point. The h
igh point is referred to as systole and occurs when the ventricles of the heart
contract, forcing blood into the aorta. The low point is referred to as diastole
and occurs when the ventricles relax and minimal pressure is exerted against th
e vessel wall.
A normal blood pressure for a healthy adult ranges from 90 to 120 mm Hg systolic
and from 60 to 80 mm Hg diastolic. Under normal circumstances, blood volume rem
ains constant at 5,000 mL. Changes in this volume can affect blood pressure, as
can age, ethnicity, gender, position changes, exercise, weight, anxiety, medicat
ions, time of day, and smoking.
For hemodynamically unstable patients, blood pressure is often measured invasive
ly by inserting a small catheter into the brachial, radial, or femoral artery. F
or healthy patients, use either a sphygmomanometer and stethoscope or an electro
nic device. The sphygmomanometer consists of a pressure manometer, a cloth or vi
nyl cuff that covers an inflatable rubber bladder, and a pressure bulb. The mano
meter has metal parts that can expand and contract at certain temperatures and s
hould be calibrated at least every 6 to 12 months to ensure accurate blood-press
ure readings. Be sure to use the appropriate-size cuff to help ensure an accurat
e reading. The width of the cuff should be 40% of the circumference of the midpo
int of the limb on which you position the cuff, and the length of the bladder sh
ould be twice its width. The bladder should encircle at least 80% of the arm.
To measure blood pressure, listen for the five Korotkoff sounds. As you deflate
the blood-pressure cuff, youll hear a clear, rhythmic tapping sound that coincide
s with the patients systolic blood pressure. The second sound is a whooshing soun
d, the third is a knocking sound, and the fourth is a softer blowing sound that
fades. For most adult patients, youll document the fifth sound, which is actually
the disappearance of sound, as the diastolic blood pressure. However, with some
patients, there is no distinct fifth sound. Youll hear sounds all the way to 0 m
m Hg. For these patients, youll record the fourth Korotkoff sound as the diastoli
c blood pressure.
Blood pressure two-step
1. Provide privacy, explain the procedure, and perform hand hygiene.
2. With the arm at heart level and the palm turned up, palpate for the brachial
pulse. Center the blood-pressure cuff about an inch (about 2.5 centimeters) abov
e where you palpated the brachial pulse. Wrap the cuff evenly and snugly around
the patients upper arm.
3. Inflate the blood-pressure cuff with your dominant hand while you use the fin
gertips of your nondominant hand to palpate the brachial pulse. The point at whi
ch you no longer feel the pulse is the estimated systolic pressure.
Continue to inflate the blood-pressure cuff 30 mm Hg more.
4. Slowly deflate the blood-pressure cuff by turning the valve on the bulb count
erclockwise. Note the number at which the pulse reappears.
Wait 30 seconds.
5. Listening to the brachial pulse with your stethoscope, inflate the blood-pres
sure cuff to 30 mm Hg above the patients estimated systolic pressure.
6. Slowly deflate the blood-pressure cuff and note the number on the manometer w
hen you hear the first clear sound. This is the patients systolic blood pressure.

Continue to deflate the blood-pressure cuff slowly, noting the number at which t
he sound disappears. This number is the patients diastolic blood pressure.
7. Remove the blood-pressure cuff, perform hand hygiene, and document your findi
ngs. Be sure to indicate the site and whether you measured the blood pressure on
the right or the left side of the patients body.
View poster preview
Palpate a patient's pulse to determine circulation distal to the pulse site and
for rhythm, quality, and strength. Is it normal, weak or thready, full or boundi
ng, or absent?
Perform hand hygiene before and after patient care and document your findings on
the appropriate flow sheet or record.
Blood pressure one-step
1. Provide privacy, explain the procedure, and perform hand hygiene.
2. With the arm at heart level and the palm turned up, palpate for the brachial
pulse. Center the blood-pressure cuff about an inch (about 2.5 centimeters) abov
e where you palpated the brachial pulse. Wrap the cuff evenly and snugly around
the patients upper arm.
3. Place the bell or the diaphragm of your stethoscope over the pulse.
Quickly inflate the blood-pressure cuff to 30 mm Hg above the patients usual syst
olic blood pressure.
Slowly release the valve on the bulb and allow the manometer needle to drop at
a rate of 2 to 3 mm Hg per second.
4. Note the number on the manometer when you hear the first clear sound.
This is the patients systolic blood pressure.
Continue to deflate the blood-pressure cuff slowly, noting the number at which t
he sound disappears.
This is the patients diastolic blood pressure.
5. Remove the blood-pressure cuff, perform hand hygiene, and document your findi
ngs. Be sure to indicate the site and whether you measured the blood pressure on
the right or the left side of the patients body.
Perform hand hygiene before and after patient care and document your findings on
the appropriate flow sheet or record.
When documenting blood pressure, record the systolic number first, followed by a
slash and the diastolic number, as in 120/80. The difference between the systol
ic and diastolic values is called the pulse pressure. This number is usually bet
ween 30 and 50 mm Hg and provides information about a patients cardiac function a
nd blood volume.
How often you measure blood pressure varies from patient to patient. For critica
lly ill patients, it might be every 5 to 15 minutes around the clock. For stable
patients, you might only measure blood pressure every 4 or 8 hours or even less
often.
When a patient's blood pressure is outside the normal range, further evaluation
is often necessary. A blood pressure with a systolic of 140 mm Hg or higher or a
diastolic pressure of 90 mm Hg or higher is considered high, although for patie
nts with certain chronic conditions, like coronary artery disease, the guideline
s vary. In any case, a single high reading does not automatically mean that a pa
tient has hypertension. Hypertension is commonly diagnosed after a patient has h
ad two or more high readings at two or more visits after the initial blood-press
ure measurement. Some patients can control hypertension with diet and exercise a
lone, but many must take antihypertensive medication.
A blood pressure with a systolic reading below 90 mm Hg or a diastolic reading b
elow 60 mm Hg is usually considered hypotension. Some patients with low blood pr
essure experience no problems. Others report feeling dizzy or lightheaded with p
osition changes. Orthostatic hypotension is a term used when systolic pressure d
rops more than 20 mm Hg or the pulse increases by 20 beats per minute or more wh
en the patient moves from a recumbent to a standing position. Orthostatic hypote
nsion is often related to a decrease in blood volume, prolonged bed rest, older
age, and medications.
Lower-extremities blood pressure
If you cannot measure a patients blood pressure on the upper extremities, use the
lower extremities. You might also measure blood pressure on a lower extremity i
f an arm pressure in an adolescent or young adult seems unusually high. If the p
atient has coarctation of the aorta, a congenital heart defect, the arm blood pr
essure will be higher than the leg pressure.
Two areas on the leg where you can measure blood pressure are the thigh just abo
ve the knee, using the popliteal pulse, and the calf just above the ankle, using
the posterior tibial pulse. The systolic reading in the thigh is usually 10 to
40 mm Hg higher than in the arm, and the diastolic number usually remains the sa
me.
Remove the patients clothing to expose the leg, and be sure to use the appropriat
e-size blood-pressure cuff to ensure an accurate reading. Wrap the cuff evenly a
nd snugly around the leg about 1 inch, or 2.5 centimeters, above the knee or ank
le. Place the bell or diaphragm of your stethoscope over the pulse and inflate t
he cuff quickly to 30 mm Hg above the patients usual systolic blood pressure. The
n slowly deflate the cuff at a rate of 2 to 3 mm Hg per second. The first sound
you hear is the systolic pressure and silence denotes the diastolic pressure.
Document the blood-pressure reading on the appropriate flow sheet and indicate t
he site of the measurement. Also note the size of the cuff if it is different fr
om the standard adult cuff.
Pain assessment
Pain is often considered a fifth vital sign, assessed along with temperature, pu
lse, respiration, and blood pressure. Because pain can affect patients physical,
emotional, and mental well-being, it must be managed immediately and effectively
so that they can perform daily activities.
Pain can be acute pain or chronic. Acute pain is often severe with a rapid onset
and a short duration. It generally resolves with healing. Chronic pain continue
s beyond the point of healing, often for more than 6 months. Cancer pain is in a
category of its own. It can be acute, chronic, or intermittent and is caused by
tumor growth and tissue necrosis.
Various tools are available for assessing pain. Which tool to use depends on the
patients age and cognitive abilities. The CRIES pain assessment tool is used for
assessing postoperative pain in preterm and term neonates. Behavioral and physi
ologic indicators are measured on a 3-point scale. The FACES pain scale or the O
UCHER pain scale is commonly used with pediatric patients. Both assessment tools
require patients to point to the face that best matches how they feel about the
ir pain. A numeric rating scale is the most common pain assessment tool used for
teens and adults. This type of pain scale requires patients to rate their pain
on a scale of 0 to 10, with 0 reflecting no pain and 10 indicating the worst pos
sible pain. For older adults, a descriptor scale is often used. This type of sca
le lists words that describe different levels of pain intensity. For patients wh
ose cognitive abilities are impaired or for those who cannot respond verbally, i
t is essential to assess nonverbal cues such as facial expressions, behavior, vo
cal sounds (moaning), and unusual movements. For whichever pain-assessment tool
you use, teach the patient how to use the scale and make sure the same one is us
ed each time the patients pain is assessed.
Managing pain involves implementing both pharmacological and nonpharmacological
interventions. To provide the most effective pain relief when using pharmacologi
cal agents, the medication should be prescribed and administered on a regular sc
hedule rather than on an as-needed basis. Because each patient experiences pain
differently, it is important to manage it on an individual basis. For more infor
mation about pain management, both pharmacological and non-pharmacological, see
the pain-management skills module.
Oxygen saturation
Pulse oximetry is a quick and noninvasive way to measure a patients oxygen satura
tion. The pulse oximeter works by reading the light reflected from hemoglobin mo
lecules. It consists of a sensor with a light-emitting diode (LED) that is conne
cted to the oximeter by a cable.
Normal oxygen saturation for a healthy adult is above 90%. To obtain the best re
ading, place the oximeter sensor on a vascular area of the body. The fingers, to
es, earlobes, and bridge of the nose are the most common sites. If you use a pat
ients finger, make sure nail polish and artificial nails are removed because they
can interfere with obtaining an accurate reading. Patient movement, hypothermia
, medications that cause vasoconstriction, peripheral edema, hypotension, and an
abnormal hemoglobin level can also affect pulse-oximetry readings.
Pulse oximetry is rarely part of a general examination. It is most often indicat
ed for patients whose oxygen status is unstable and for those who are at risk fo
r respiratory problems that reduce oxygen saturation.
Documentation is an essential component of patient care. Not only does it provid
e information about the care you give and the status of your patient, but it als
o communicates information to other healthcare workers to help assure both quali
ty and continuity. The format used for documentation varies from agency to agenc
y, so be sure to familiarize yourself with your agencys format and follow it. Use
only approved abbreviations and make sure all documentation is clear, concise,
and legible. Maintain privacy and confidentiality of patient information at all
times.
Mandatory compliance with the privacy rule of the Health Insurance Portability a
nd Accountability Act of 1996 (HIPAA) was introduced in 2003 to help ensure that
patient information is kept confidential and to give patients more control over
their personal healthcare information and who has access to it. HIPAA originall
y required written consent for disclosure of all patient information. Because th
is sometimes delayed the process of giving patients timely care, the act was rev
ised. Now healthcare providers are only required to notify patients of their pri
vacy policy and to make a reasonable effort to obtain written acknowledgment of
this notification.
All healthcare providers, including students, have a legal and ethical obligatio
n to follow HIPAA regulations. In clinical settings, students should only gather
the information from the patients medical record that they need to provide safe
and efficient care. Any written material students prepare and share, submit, or
distribute must exclude the patients name, room number, date of birth, medical re
cord number, and any other identifiable demographic information.
Types of documentation
Documentation of vital signs includes the following plus any other pertinent inf
ormation about your assessment procedure:
Temperature
the temperature reading
the route you used to measure the temperature
any signs or symptoms of temperature alterations
your nursing interventions (antipyretic given)
the patients response to care
Pulse
the rate, rhythm, and strength of the pulse
the site you used to palpate the pulse
any signs or symptoms of pulse alterations
the pulse deficit (if applicable)
your nursing interventions
the patients response to care
Respiration
the rate, rhythm, and depth of respirations
any signs or symptoms of respiratory alterations
abnormal respiratory sounds
the type of oxygen therapy (nasal cannula, mask) and flow rate
respiratory status after a specific treatment (nebulizer therapy)
any specimens and cultures obtained and sent to the lab
your nursing interventions
the patients response to care
Blood pressure
the blood pressure reading
the site where you measured the blood pressure
any signs or symptoms of blood-pressure alterations
your nursing interventions
the patients response to care
Pain
the location, intensity, quality, duration, and pattern of the pain
any signs or symptoms of pain
the patients vital signs
your nursing interventions
the patients response to care
Oxygen saturation
the patients oxygen saturation
the site where you measured oxygen saturation
any signs or symptoms of abnormal oxygen saturation
type of oxygen therapy (nasal cannula, mask) and flow rate
oxygen saturation after a specific treatment (nebulizer therapy)
your nursing interventions
the patients response to care
FAQ -
What are my responsibilities related to vital-sign assessment?
An integral component of nursing care, vital-sign assessment requires knowledge
of normal vital-sign variations at various ages, as well as the ability to incor
porate factors affecting vital signs into a patients individual plan of care. You
may delegate vital-sign assessment to other healthcare personnel, but you are r
esponsible for ensuring the accuracy of the data collected and for reporting and
documenting abnormal findings. When a patient experiences problematic symptoms
or unexpected changes in vital signs, double-check your findings and reassess th
e patient continually, evaluating the patients condition along with the vital sig
ns. Reassessment validates the data you collected about the patients condition, t
hus ensuring accuracy when reporting your findings to the provider.Close answer

Why is it so important for me to establish my patients baseline vital-sign measur
ements?
On initial contact with a patient, you obtain a baseline assessment of vital sig
ns temperature, pulse, respiration, blood pressure, pain, and pulse oximetry to
help evaluate the patients circulatory, pulmonary, endocrine, and neurological fu
nctioning. These baseline measurements become a basis for comparison with subseq
uent measurements to detect changes and abnormal findings. Any significant chang
e warrants repeating the measurement to verify accuracy, possibly by a second he
althcare provider if you have any reason to doubt your findings.Close answer

When and how often should I assess vital signs?
How often you routinely assess vital signs and how you collect them varies with
institutional and agency policies, as well as in certain situations where you mu
st establish a baseline or evaluate changes in patients condition. Typically, you
would assess vital signs on a patients admission to your facility or agency, thr
oughout the process of reassessing and evaluating changes in the patients conditi
on, and in emergency or critical-care situations. Assess vital signs any time a
patient loses consciousness, before and after any surgical or invasive diagnosti
c procedure, before and after any activity that can alter a patients condition, a
nd before and after administering medications that affect a patients cardiovascul
ar and respiratory function.Close answer

What measures must I take when assessing the vital signs of a patient requiring
more than standard infection-control precautions?
Do not share the equipment you use on a patient requiring more than standard inf
ection-control precautions with other patients. Disposable single-use thermomete
rs are ideal for these patients because they eliminate the danger of cross-infec
tion. Clean any stethoscopes and blood-pressure equipment after use according to
institutional policy and the manufacturers instructions.Close answer

What do the terms core body temperature and surface body temperature mean?
Body temperature, measured in degrees, signifies the difference between heat pro
duction and heat loss. Metabolic processes in the core tissues of the body gener
ate heat, which circulating blood transfers to the surface of the skin where it
is then dispersed to the environment. Core body temperature is maintained within
a range of 97 F (36 C) to 99.5 F (37.5 C) with variations among individuals and wit
h times of the day. A healthy person maintains core body temperature at a fairly
constant range via the thermoregulatory center located in the hypothalamus. Col
d and warm thermal receptors located throughout the body send messages to the th
ermoregulatory center to initiate responses to either produce or conserve body h
eat or to promote heat loss. Core body temperature is higher than surface body t
emperature and is measured at tympanic and rectal sites as well in the esophagus
, the pulmonary artery, or the bladder by invasive monitoring devices. Surface b
ody temperature reflects the temperature on the skin and is measured at oral (su
blingual) and axillary sites.Close answer

Is it acceptable practice to use a glass thermometer?
Traditionally, mercury-in-glass thermometers were the method of choice for measu
ring body temperature. Currently, many healthcare organizations are phasing out
or have eliminated equipment containing mercury, based on federal safety recomme
ndations identifying mercury as a toxic and hazardous material. Non-mercury glas
s thermometers (filled with alcohol or a petroleum-based liquid) might be used i
n critical care units or as single-patient use items for patients on isolation p
recautions. Any glass thermometers used for patients with hepatitis or acquired
immune deficiency syndrome should be discarded when the patient is discharged. M
ercury-filled glass thermometers may still be used by patients at home, so home
health nurses must incorporate mercury precautions and disinfection instructions
into their patient-education strategies.Close answer

When I have a choice, which temperature-measuring device should I use?
Temperature-measuring devices include mercury-in-glass thermometers, electronic
thermometers, and chemical thermometers all available as single-use or reusable
items. Mercury-in-glass thermometers, once considered the gold standard for temp
erature measurement, might be cost-effective and versatile, but many organizatio
ns are phasing them out due to the risk of breakage and potential for mercury ex
posure, plus it takes 3 minutes to get an acceptable reading. Electronic thermom
eters are widely available and display temperature readings within a few seconds
. Separate probes are available for oral and rectal use, with disposable plastic
probe sheaths to make them safe for multiple-patient use. Another type of elect
ronic thermometer is the tympanic thermometer, with an infrared sensor tip that
detects heat radiated from the ears tympanic membrane. This method provides rapid
and accurate readings of core temperature from a site that is easily accessible
. This type of thermometer is especially useful with comatose patients and when
it is best to avoid repositioning or otherwise disturbing patients. Chemical the
rmometers, available as a single-use chemical dot or reusable form (single-patie
nt use only), consist of chemical indicators that change colors at different tem
peratures. They are disposable, unbreakable, and easy to use and are particularl
y useful for patients who require isolation. But when a temperature is registere
d in a color outside the color indicator or a patient becomes unstable, you must
recheck the patients temperature using another more reliable method.Close answer

How do I decide which site to use for measuring my patients temperature?
Your objective is to obtain a reading that reflects the average temperature of
core or deep body tissues. The temperature-measurement sites that best approxima
te core temperature are the rectum, esophagus, tympanic membrane, urinary bladde
r, and pulmonary artery, as opposed to those reflecting surface temperature, suc
h as the mouth, skin, and axilla. Use the site that is most accurate but also sa
fe for the patient and use the same site for repeated temperature readings and c
omparisons. Close answer

What factors affect selecting the oral route for temperature assessment?
The patient must be able to close his or her mouth around the thermometer or pro
be. It is best to wait 15 to 30 minutes after a patient has consumed hot or cold
food or fluids or has been chewing gum or smoking to assess temperature by this
route. Waiting 15 to 30 minutes allows time for the oral tissues to return to n
ormal temperature. Assessing an oral temperature using a glass thermometer is co
ntraindicated for unconscious, irrational, or seizure-prone patients and for inf
ants and children. Using the oral route for temperature assessment is contraindi
cated for patients who have diseases of the oral cavity, those who have had surg
ery of the mouth or nose, or those receiving oxygen by mask (as there is a poten
tial for a significant drop in the patients blood-oxygen level).Close answer

What physical effects do patients experience with a fever?
Patients experiencing an increased body temperature, also referred to as pyrexia
or fever, may manifest a multitude of signs and symptoms including hot, dry ski
n; loss of appetite; headache; general malaise; and thirst, as well as periods o
f delirium or seizures. Because of immature temperature-control mechanisms, infa
nts younger than 3 months may display only a mild elevation in temperature despi
te serious infection. Older patients often have a lower baseline body temperatur
e with fever manifesting as a later sign of illness despite extensive pathologic
processes. Your assessment must include observing for other potentially dangero
us signs and symptoms of fever, including but not limited to dehydration, rapid
heart rate, and decreased urinary output.Close answer

What can I do to reduce fever?
Try controlling the patients environmental temperature by cooling the room. Remov
e any unnecessary clothing or blankets, keep the patients clothing and bed linens
dry, limit physical activity, and administer any prescribed antipyretic agents,
such as acetaminophen, to help reduce fever.Close answer

Which clinical conditions require frequent temperature checks?
Temperature monitoring becomes especially crucial for patients with an infection
, open wounds or burns, or a white blood cell count below 5,000/mcL or above 12,
000/mcL, and those who are postoperative or are receiving an infusion of blood p
roducts. Other situations that warrant frequent temperature checks are the use o
f suppressive drug therapy, injury to the hypothalamus, exposure to temperature
extremes, and the use of hypothermia or hyperthermia therapy.Close answer

What are the signs and symptoms of fever, hyperthermia, hypothermia, and heatstr
oke?
Fever is a temperature elevation. Sources vary in their interpretation, but gene
rally, a temperature elevation of 100 F (37.8 C) or above is considered fever. The
patients skin might be warm or hot, pale or flushed, and dry or diaphoretic, usu
ally with mucous membranes notably dry. Fever associated with chills or shiverin
g often triggers piloerection (goose bumps). Patients with fever might also have t
achycardia, muscle or joint pain, nausea, vomiting, diarrhea, and restlessness a
nd might feel hot or cold. Hyperthermia is also an elevation of core body temper
ature, but it differs from fever in an important way: Fever is an upward shift i
n the bodys temperature set point, while hyperthermia results in an overload of the
bodys thermoregulatory mechanisms. Hyperthermia causes tachycardia, decreased sk
in turgor, hypotension, concentrated urine, and decreased venous filling. Patien
ts with heatstroke, a dangerous condition resulting from prolonged exposure to h
eat, have dry skin that is hot to the touch, tachycardia, hypotension, excessive
thirst, muscle cramps, confusion, hallucinations, and visual disturbances. Pati
ents with hypothermia, a drop in core body temperature to 96.8 F (36 C) or below,
typically have pale skin that is cool or cold, with uncontrolled shivering, a re
duced level of consciousness, shallow respirations, bradycardia, and dysrhythmia
s.Close answer

What is a pulse deficit?
A pulse deficit is the difference between a patients apical and radial pulse rate
s as counted simultaneously by two healthcare providers. A difference of more th
an 2 beats per minute indicates possible alterations in cardiac output. A pulse
deficit results when the heart contracts inefficiently and fails to transmit a p
ulse wave to peripheral pulse sites. In other words, all of the hearts pulsations
are not reaching the peripheral arteries or the pulses are too weak to be palpa
ted.Close answer

When should I count my patients pulse for a full 60 seconds?
When a pulse is regular, whether rapid or slow, count it for 30 seconds and mult
iply that result by 2 to reflect pulsations per minute. When a pulse is irregula
r, count it for 60 seconds to ensure accuracy. Be sure to evaluate an irregular
pulse for the frequency and pattern of irregularity, strength, and for any pulse
deficit. Also, compare irregular peripheral pulses bilaterally.Close answer

Why must I palpate each carotid artery separately?
Palpate the carotid arteries separately to prevent any decrease in cerebrovascul
ar circulation. If you palpate both arteries simultaneously, the patient could l
ose consciousness as a result of reduced circulation to the brain.Close answer

What are the S1 and the S2 sounds?
Every apical pulse is a combination two sounds, defined as S1 and S2. The S1 is
the low-pitched, dull sound (lub) heard when the tricuspid and mitral valves close
as ventricular filling ends. The S2 is the higher pitched, shorter sound (dub) he
ard when the pulmonic and aortic valves close at the end of ventricular ejection
.Close answer

When should I expect alterations in apical pulse?
Typically, apical pulses are altered in patients who have heart disease, cardiac
dysrhythmias, or a sudden onset of chest pain or a sudden onset of pain from an
y site or are bleeding internal or externally. Surgery or invasive cardiovascula
r diagnostic tests, the sudden infusion of a large volume of intravenous (IV) fl
uid, and the administration of medications that affect heart function can also r
esult in alterations in apical pulse.Close answer

How do ventilation, diffusion, and perfusion differ?
Respiration encompasses ventilation, a mechanical process involving the movement
of gases into and out of the lungs; diffusion, the movement of oxygen and carbo
n dioxide between the alveoli and the red blood cells; and perfusion, the proces
s of blood distribution (pulmonary circulation) to and from the blood-gas barrie
r in the pulmonary capillaries where gas exchange occurs.Close answer

Why should I assess respiration after I count my patients pulse?
Assessing respiration immediately after you count a patients pulse allows you to
evaluate breathing inconspicuously. This keeps the patient from consciously or u
nintentionally altering the depth and rate of respirations.Close answer

How should I position my patient when assessing dyspnea?
Make sure the patient is in a comfortable position, preferably sitting or lying
with the head of the bed elevated 45 to 60, to promote full ventilatory movement.
It is best to assess patients prone to dyspnea (difficulty breathing), those who
have congestive heart failure or abdominal ascites, and those in the late stage
s of pregnancy in a position of greatest comfort. Placing them in a position tha
t deters maximum ventilatory movement may make them breathe more rapidly than us
ual, thus altering the accuracy of your assessment.Close answer

What is orthostatic hypotension?
Orthostatic hypotension, also known as postural hypotension, is a drop in blood
pressure of 15 mm Hg or more when a patient rises from a sitting to a standing p
osition. A patient whose blood pressure is otherwise normal but has orthostatic
hypotension might also experience lightheadedness or dizziness or even a loss of
consciousness with position changes. These orthostatic changes are often reliab
le indicators of blood-volume depletion. Generally, when a healthy adult rises f
rom a sitting to a standing position, the peripheral blood vessels in the legs c
onstrict, the heart rate and the hearts contractility increase, and the blood pre
ssure remains constant, thus providing adequate blood perfusion to the heart and
the brain.Close answer

What is hypertension?
Hypertension criteria change as the evidence base changes, but generally, a syst
olic blood pressure of 140 mm Hg or higher and/or a diastolic blood pressure of
90 mm Hg or higher is considered hypertension. Hypertension is not diagnosed unt
il the average of two or more readings performed at two or more clinical assessm
ents after an initial screening reflects hypertension.Close answer

How should I apply a blood-pressure cuff?
If the blood-pressure cuff you use is the wrong size for the extremity you measu
re or you apply it inappropriately, your reading will be inaccurate. The cuff sh
ould be 40% of the circumference (or 20% wider than the diameter) of the midpoin
t of the limb and the bladder should encircle at least 80% of the adult extremit
y and a childs entire limb. The outcomes of cuff errors are as follows:
Bladder or cuff too wide: falsely low reading
Bladder or cuff too narrow: falsely high reading
Cuff wrapped unevenly or too loosely: falsely high reading
Cuff deflation too slow: falsely high diastolic reading
Cuff deflation too rapid: falsely low systolic and falsely high diastolic readi
ng
Cuff inflation too slow: falsely high diastolic reading
Inaccurate inflation level: inaccurate analysis of systolic and diastolic readi
ng Close answer

Why is pain referred to as the fifth vital sign?
Organizations such as the Joint Commission have developed accreditation standard
s that focus on pain assessment as a priority during vital sign assessment, thus
setting the standard toward routine assessment of the physiologic, psychologica
l, emotional, and sociocultural facets of pain. Incorporating pain assessment du
ring routine vital-sign assessment highlights ongoing assessment while focusing
on an individualized pain plan for the patient. Appropriate pain management is a
ssociated with quicker clinical recovery, fewer hospital admissions, shorter hos
pital stays, and improved quality of life. Monitoring pain with the same vigilan
ce as temperature, pulse, respiration, and blood pressure emphasizes the shift o
f the focus of pain management from traditional control practices (patient-docto
r) to a more systematic approach involving multidisciplinary team members.Close
answer

Do artificial nails and nail polish interfere with pulse-oximetry readings?
A patients artificial nails or fingernail polish can interfere with the passage o
f light waves from the light-emitting sensor to the light-receiving sensor, thus
interfering with satisfactory operation of the pulse-oximetry equipment and acc
urate readings of the oxygen saturation of arterial blood (SpO2). Manufacturers i
nstructions as well as institutional policy provide guidelines for this procedur
e; you might have to remove the nail enhancements or select another appropriate
site for monitoring pulse oximetry.Close answer

Can a patient with a low hemoglobin appear to have a normal SpO2?
Pulse-oximetry measures only the percentage of oxygen carried by the available h
emoglobin, with a range of 95% to 100% considered normal. However, a patient wit
h a low hemoglobin could appear to have a normal SpO2 because most of the hemogl
obin is saturated, yet in actuality might not have enough oxygen to meet the bod
ys needs.Close answer
Here are several studies, reviews, and guidelines that address current research
about best practice for vital signs. We suggest that healthcare providers access
the entire research study and assess the studys quality and generalizability bef
ore applying the findings to their own clinical practice.
Evidence-based practice guidelines for vital signs
American Society of Anesthesiologists Task Force on Postanesthetic Care. (2002).
Practice guidelines for postanesthetic care 2002. Anesthesiology, 96(3), 742-75
2.
American Academy of Pediatrics. (2004). The fourth report on the diagnosis, eval
uation, and treatment of high blood pressure in children and adolescents. Pediat
rics, 114(2). 555-576.
American Heart Association Nutrition Committee. Diet and lifestyle recommendatio
ns revision 2006: A scientific statement from the American Heart Association Nut
rition Committee. Circulation, 224(1), 82-96.
American Heart Association. (2006). AHA scientific statement: Dietary approache
s to prevent and treat hypertension. Hypertension, 47, 296. Retrieved March 18,
2007, from http://hyper.ahajournals.org/cgi/content/full/47/2/296
American Pain Society Quality of Care Task Force. (2005). American Pain Society
recommendations for improving the quality of acute and cancer pain management.
Archives of Internal Medicine, 165(14), 1574-1580.
American Society of Anesthesiologists Task Force on Acute Pain Management. (2004
). Practice guidelines for acute pain management in the perioperative setting: A
n updated report by the American Society of Anesthesiologists Task Force on Acut
e Pain Management. Anesthesiology, 100(6), 1573-1581.
American Society of Interventional Pain Physicians Medical Specialty Society. (2
003, revised 2005). Interventional techniques in the management of chronic spina
l pain: Evidence-based practice guidelines NGC: 004173. Retrieved March 20, 2007
, from http://www.guideline.gov
Association of periOperative Registered Nurses. (2005). AORN guidance statement:
Postoperative patient care in the ambulatory surgery setting. Retrieved April 2
, 2007, from http://www.aorn.org/About/positions/pdf/SECTI-2e-postopcare.pdf
Association of periOperative Registered Nurses. (2003). Recommended practices fo
r selection and use of surgical gowns and drapes. AORN Journal, 77(1), 206-213.
National Heart Lung and Blood Institute. (2003). Seventh report of the Joint Nat
ional Committee on Prevention, Detection, Evaluation and Treatment of High Blood
Pressure (JNC 7) 2003. Retrieved March 23, 2007, from www.nhlbi.nih.gov/guideli
nes
Oncology Nursing Society. Cancer pain management: Oncology Nursing Society posit
ion statement on cancer pain management. Retrieved March 20, 2007, from http://w
ww.ons.org/publications/positions/CancerPainManagement.shtml
Pain practice guidelines from the National Guideline Clearinghouse. Retrieved Ma
rch 20, 2007, from www.guideline.gov
Pickering, T. G., Hall, J. E., Appel, L. J., Falkner, B. E., Graves, J., Hall, M
. N., Jones, D. W., Kurtz, T., Sheps, S. G., & Roccella, E. J. (2005). Recommend
ations for blood-pressure measurement in humans and experimental animals: Part 1
: Blood-pressure measurement in humans: A statement for professionals from the S
ubcommittee of Professional and Public Education of the American Heart Associati
on Council on High Blood Pressure Advisory Committee. Circulation, 111(5), 697-7
16.
Registered Nurse Association of Ontario. (2005). Nursing care of dyspnea: The 6t
h vital sign in individuals with chronic obstructive pulmonary disease (COPD). R
etrieved April 3, 2007, from www.ngc.gov.
Veterans Administration, Department of Defense. (2004). VA/DOD clinical practice
guideline for the diagnosis and management of hypertension in the primary care
setting. Retrieved April 2, 2007, from http://www1.vagov/health/hypertension/HTN
.doc