General Points to Consider in Vital Sign Measurement

Therapeutic Environment and Informed Consent

 It is important to seek informed consent while creating a therapeutic and safe environment during all encounters with clients. You will usually begin by introducing yourself by name and designation, so the client knows who you are. Next, explain what you are going to do and always ask permission to touch before beginning vital sign measurement. For example, an appropriate introduction is:

 “Hello, I am XXX (state first name). I am a XXX (state designation, e.g., I am a Health Care Assistant). Today, I am here to take your vital signs. It will involve me touching your arm, are you okay with that?”

It is also important to ensure the client’s privacy by closing the curtains or the door to the room.

Infection Prevention and Control

Clean hands and clean equipment are essential to infection prevention and control when measuring vital signs. Ensuring cleanliness helps reduce communicable and infectious diseases, particularly health care-associated infections, which are infectious organisms acquired by a client while in hospital. Common infections include clostridium difficile (C. diff), vancomycin-resistant enterococcus (VRE), and methicillin-resistant staphylococcus aureus (MRSA). Ensuring your hands are clean is the best way to prevent and control infection. Please see Unit 2 Infection control for review of hand hygiene.

Equipment

Healthcare providers always inspect equipment before use to ensure it is in good working condition. Equipment (e.g., stethoscopes, pulse oximeters) can be cleaned with alcohol-based solutions to disinfect the surfaces. Automated devices should be regularly serviced to ensure accuracy. Biomedical technicians/experts are responsible for preventative maintenance and calibration to optimize functioning.

Order of Vital Sign Measurement

The order of vital sign measurement is influenced by the client situation. Healthcare providers often place the pulse oximeter probe on a client while proceeding to take pulse, respiration, blood pressure, and temperature. However, in some situations this order is modified, and the healthcare provider needs to critically assess the situation to prioritize the vital sign measurement order. For example, with clients with cognitive impairment, it is best to proceed from least invasive to most invasive, so it is best to begin with respiration, pulse, oxygen saturation, temperature and if required, blood pressure. In an emergency situation or if a person loses consciousness, it is best to begin with pulse and blood pressure. Generally, it is important to conduct a complete set of vital signs unless otherwise indicated.

Significance of Measurements

Determining the significance of vital sign measurements involves a process of diagnostic reasoning.   The role of the Health Care Assistant is to measure and report vital signs, but your are not trained to interpret.  However, knowledge of normal ranges is important as prompt reporting will be necessary. Additionally, the HCA should consider the client’s baseline vital signs and immediately report any significant changes to the LPN/RN.

Documentation

Timely documentation of vital sign measurements is imperative as a form of communication, to observe trends in vital sign measurements, and to ensure effective intervention when needed. Documentation occurs on paper-based vital sign records or electronic systems depending on the agency. Healthcare providers follow the agency’s documentation policy and the professional standards of practice. If using a vital sign record, healthcare providers use the symbols noted on the legend of the record.