Recording should include measuring and documenting temperature, pulse, respirations, blood pressure, and pulse oximetry. Recording should follow guidance from the Virginia Board of Nursing.
Measure vital signs
- when ordered by HCP
- to determine baseline vital signs
- if required by facility policy and procedure on a routine basis
- when monitoring the client’s response to certain medications
- when the client shows signs of physical distress
Measuring and recording vital signs (ranges may vary per client) should include
- temperature
- Older adults often have diminished ability to regulate body temperature, putting them at higher risk for hypothermia.
- pulse
- respirations
- blood pressure
- causes of inaccurate blood pressure readings
- pulse oximetry
- Oximeter may be placed on a fingertip, toe, or ear lobe.
- Document vital sign measurements in the client’s record.
- Report abnormal findings per facility protocol.
Administer medications per facility protocol.
Process/Skill Questions:
- What are the definitions of blood pressure, systolic, diastolic, apical pulse, radial pulse, oral temperature, rectal temperature, axillary temperature, and tympanic temperature?
- When do vital signs need to be measured and recorded?
- What are the normal ranges for blood pressure, pulse, respiration, and temperature?
- What are the factors that influence blood pressure, pulse, and temperature?
- What are the proper techniques for taking blood pressure, pulse, respiration, and temperature?
- What factors help an MA determine the site of temperature measurement?
- What circumstances alert the need to immediately report vital signs?