Vital SignsPain Assessment

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Vital Signs/Pain Assessment

• Nursing Clinical Practice Laboratory

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Vital Signs Objective

• Accurately assess and document vital signs within
  specific parameters

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VITAL SIGNS/PAIN ASSESSMENT PREPARATION Read in
Read in Taylor et al. Chapter 24 - Vital Signs
(pages 555-595) and Chapter 41 Comfort (pages
1366-1393). Lecture hall/classroom or skills
lab View video BASIC CLINICAL SKILLS 1.
BLOOD PRESSURE 2. PAIN 3.
TEMPERATURE/PULSE/ RESPIRATION
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VITAL SIGNS/PAIN ASSESSMENT PREPARATION Complete
vital signs for ten (10) people and document on
the vital signs recording form. Turn
documentation in on day of check-off. 3.
Attend a PLA for the skill 4. After completion
of 1 - 3 above, Perform documented practice for
at least one hour. Fill in individual practice
record and have instructor sign. 5. Make
appointment for check-off by signing up on the
sheet in the designated area. 6. Complete 1-5
before being checked off 7. Allotted time 40
minutes, including documentation, per pair of
students (20 minutes for each individual).
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8. Critical Elements During this check-off each
student must be able to a. Obtain vital
signs accurately within the following range of
the instructor 4 pulse 4 for blood
pressure 2 for respirations accurately read
glass thermometer perform pain assessment b.
When taking pulse and respirations, begin
count simultaneously with instructor (verbally)
with 1, 2, 3 and continue to count in silence.
c. Document on the graphic sheet.
d. Report abnormal findings.
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ASSESSMENT OF VITAL SIGNS Objective Accurately
assess and document vitals signs within specified
parameters Pain Assessment
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Temperature Assessing oral temperature using a
glass thermometer
Temperature Assessing oral temperature using a
glass thermometer
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• Body Temperature
• Reflects the difference between heat
• lost and heat produced
• Factors affecting Body Temperature
• Age
• Circadian rhythms
• Exercise
• Hormones
• Stress
• Environment

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Rectal 3 minutes Oral 3 minutes Axillary
5 minutes
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• Factors affecting Pulses
• Age
• Gender
• Exercise
• Fever
• Medication
• Hypovolemia
• Stress
• Position changes
• Pathology

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All pulses will be taken for one full minute
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Radial Pulse
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Factors affecting respirations

• Exercise
• Increased environmental temperature
• Lowered oxygen concentration
• Certain medications
• Increased intracranial pressure

Respirations will be taken for one full minute
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Respirations
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Factors affecting Blood Pressure

• Age
• Exercise
• Stress
• Race
• Gender
• Medications
• Diurnal variations
• Disease process

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Blood Pressure
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Radial or Brachial Artery
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Apical Pulse

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Identify The Peripheral Pulses Listed
Bilaterally 1. POINT DO NOT PALPATE
2. PALPATE
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Assessing adequacy of blood flow to certain areas

• Peripheral pulse

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Locations of Peripheral Pulses

• Brachial, at the inner aspect of the biceps
  muscle of the are or medially in the antecubital
  space
• Femoral, where the femoral artery passes
  alongside the inguinal ligament
• Popliteal, where the popliteal artery passes
  behind the knee
• Posterior tibial, on the medial surface of the
  ankle where the posterior tibial artery passes
  behind the medial malleolus
• Pedal (dorsalis pedis), where the dorsalis pedis
  artery passes over the bones of the foot, on an
  imaginary line drawn from the middle of he ankle
  to the space between the big and second toes.

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Questions?

• wakita.bradford_at_gpc.edu