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Gibb's Reflection on Taking Vital Signs from a Patient

Reflect on the challenges in completing objective and accurate clinical assessment and its implications for a student on clinical placement next semester.

Added on   2023-06-11

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Analysis of Nursing Scenario through Gibbs Reflective Cycle lg ...

Reflection on obtaining vitals lg ..., clinical reflection lg ..., self-reflection on tpr assessment: a gibbs reflection model guide lg ..., integrating nursing practice lg ..., self reflection practice in nursing standards lg ....

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

OBSERVATIONS

Tem p erature, 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.

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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 ear and held it until l heard a beep sound. The beep sound is an indication that temperature would have been recorded. Normal body temperature should range between 36.5 & 37.7 Degrees Celsius (Weber and Kelly, 2003).

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.

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

Brown,S. (1990) Temperature taking-getting it right. Nurse Standard, 5 (12),4-5

Bogan, B., Kritzer, S. & Deane, D. (1993) Nursing Student Compliance to Standards for Blood Pressure Measurement.  J Nurse Educ, 32 (2), 90-2.

Campbell, N.R. et al. (1990) Accurate, reproducible measurement of blood pressure. Can Med Assoc J,  143 (1), 19-24.

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

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

Edwards, S. (1997) Measuring Temperature. Prof Nurse, 13 (2), 55-7.

Jarvis, C. (2004). Physical Examination & Health Assessment  (4th ed.). Missouri: Elsevier Science.

Knussman HK (2006).  Beyond the Basics: Interpreting Vital Signs.  Emergency Medical Service 35 (12).

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 (2 nd  ed)  Philadelphia: Lippincott Williams &Wilkins.

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Affiliation.

• 1 Queens University, Kingston, ON, Canada.
• PMID: 33001547
• DOI: 10.1111/nup.12326

Physiological observations or vital sign monitoring is a fundamental tenet of nursing care within an acute care setting. Surveillance of vital signs with algorithmic early warning frameworks aids the nurse in monitoring for early symptoms of clinical deterioration. The nurse must be cognizant of the factors that can influence the vital sign measurements because the framework score is only as reliable as the data inserted. Vital sign technology has made significant progress in its ability to objectify nursing subjective assessments. Early scientists have struggled with its relationship with subjectivity, claiming it has no relevance in true science. Quantitative measurements, regardless of how objectively they were created or obtained, need a subjective lens to interpret and act on the results. The skill of "making" the vital signs can be easily taught or done with technology, but it is the "taking" of the data for analysis of truth and action that requires a higher level of expertise. This paper will examine the truth of vital sign methodology and monitoring to explore the question, "Is true objectivity in the nursing practice of vital sign measurement possible?" The truth in vital sign recognition through a subjective lens will also be explored to challenge the philosophical scientific claims that objective data are the absolute truth.

© 2020 John Wiley & Sons Ltd.

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Free Vital Signs Essay Sample

Vital signs are measurements that measure the most basic functions of the body, which are undertaken by health care providers and medical professionals. These signs include blood pressure, pulse rate or heart rate, respiration rate, and body temperature. It should be noted that vital signs vary with several factors, e.g. age, health, sex, weight and health exercises. Medical equipments used to measure the vital signs include the thermometer, a watch, a sphygmomanometer and a stethoscope in cases. Normal and healthy adults should have their blood pressure at 90/60 mm/Hg for the low range to 120/80 mm/Hg for high the high range, at rest. The breathing should be between 12 to 18 breaths a minute; the pulse rate should be between 65 to 100 beats every minute, and their temperature should read at an average of 98.6 degrees Fahrenheit.

Body temperature can also vary depending on fluids and food taken, time of the day and the menstrual cycle in women. Body temperature is usually controlled by thermoregulation in the process of affecting the rate of chemical reactions in the body. Measurement of body temperature helps in assessing and finding out any signs of inflammation or systemic infection caused by a fever. Hyperthermia increases the temperature of a body and hypothermia decreases the body temperature. Measurement of body temperature can be done orally by placing a thermometer in the mouth, early by placing a thermometer in the ear to measure the eardrum’s temperature, by skin, rectally or auxiliary by placing a thermometer under the armpit. A thermometer is used to measure the temperature of the body.

The blood pressure can give systolic and diastolic pressure readings. Systolic pressure denotes a high pressure when the heart contracts at the maximum and diastolic pressure denotes a low blood pressure when the heart rests between the bets. Medical practitioners opt in measuring the blood pressure on the left arm if the arm is not damaged. Blood pressure is the difference between systolic and diastolic blood pressure. Blood pressure cuffs with an electronic or an aneroid sphygmomanometer may be used to measure blood pressures. Units used in measuring the blood pressure are mm/ Hg or millimeters of mercury. When the blood pressure is high, a patient suffers from hypertension, and suffers hypotension when the blood pressure is low. Hypertension leads to heart attack and stroke or brain attack.

Pulse rate is used to measure the rate, at which a heart beats in a minute. Besides measuring the heart beat, taking a pulse helps in showing the heart rhythm and the strength of the pulse. Pulse rate may vary according to exercises, emotions, injury and illnesses among others. Teenage and adult females have a faster pulse rate than males. A pulse can be found at the wrist in the radial artery, at the brachial artery on the inside part of the elbow; the carotid pulse on the neck, at popliteal artery, behind the knee, and at posterior tibial arteries in the foot. For anyone interested in monitoring his or her pulse rate, it is recommended that one should press firmly on the arteries until a pulse is felt, by using the tips of the first and second fingers.

Respiration rate is the number of breaths taken by a person in every minute. Respiration rate should be taken when one is at rest. For effective measurements, one should count the number of times a chest rises in every minute. Fever and difficult breathing problems like asthma can affect the respiration rate. Respiration helps in removal of carbon dioxide and aids in the entry of oxygen gas into the lungs for absorption into the blood stream.

Measurement of Vital signs helps the healthcare providers establish how sick a patient is, quickly and easily. Vital signs are basic elements of patient care, because they establish the protocols to be followed, provide life saving information and decisions, as well as an aid in the proper treatments to be conducted on a patient. 

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