Step-by-Step Guide to Taking Vital Signs

Running head: VITAL SIGNS ASSESSMENT
Vital Signs Assessment
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VITAL SIGNS ASSESSMENT1
Introduction
A critical aspect of clinical practice by the advanced practice nurse is to integrate
evidence-based patient assessment. Evidence-based practices are considered to be an
important force in the healthcare sector and healthcare professionals integrate such practices
during the initial assessment to determine the interventions required to treat the patient
(Mackey & Bassendowski 2017). The primary assessment of the vital signs of the patient
gives an overall view of the health status of the patient. However, to provide patient-centered
care, the specific framework of assessment is required to determine specific interventions
(Watkins, Whisman, & Booker 2016). The following sections of the paper will analyse a case
study and determine the current state of the patient and required intervention to recover the
health of the patient.
Patient Assessment
The patient, Mr. John, 68 years old, is admitted to the emergency department after a
car accident. The vital signs show the temperature of 36.5°C, pulse rate of 96 beats per
minute, respiratory rate of 28 breaths per minute, blood pressure of 160/95, oxygen
saturation of 92% and pain score of 9 out of 10. According to Qadir and Maqsood, the body
temperature of the patient is normal and considering the accident of the patient, the elevated
pulsation is justified. The blood pressure of the patient is highly elevated with readings of
160/95, higher than normal levels of 120/80, concluding high blood pressure. The pulse
oximeter readings of 92% indicate a normal oxygen saturation level. However, the pain score
of 9 out of 10 reveals that the patient is suffering from extreme or severe pain and requires
the immediate attention of healthcare professionals (Kannampallil et al. 2016). The normal
respiratory rate of a person at rest is between 15-20 breaths per minute. The patient has a
respiratory rate of 28 breaths per minute, which is abnormally elevated than normal levels,
indicating severe injuries to the lungs occurred due to the accident (Mastan et al. 2017).

VITAL SIGNS ASSESSMENT2
Glasgow Coma Scale (GCS) is used to measure prognosis and severity of brain injury
if any. The scaling measures of the Glasgow Coma Scale are measured on the basis of
patient’s verbal, motor and eye-opening response. The scaling of GCS is limited to 3-15, on
which, a patient with a score of 3 (minimum) has the worst prognosis & is potentially fatal,
with a highly reduced chance of recovery and the score of 15 (maximum) has the best
prognosis. As per the evaluation of the case study, the patient has a GCS score of 15,
indicating that the patient is in good condition and has the best prognosis with higher chances
of recovery (Jain et al. 2019). Moreover, the case study analysis reveals that the patient has
reported no Loss of Consciousness (LOC), which is a good indicator, increasing the chances
of a patient’s recovery.
Another concern found during the patient’s assessment is the weight of the patient.
The patient weighs 130 kilograms, which can be easily determined to be overweight. Upon
calculation of the BMI (Body Mass Index) with average height range, the result comes out to
be above 40 kg/m2, which is high above the normal level of 27.7 as determined by the World
Health Organization. Additional information suggests that Mr. John face difficulties in
performing daily activities due to his overweight status. This issue should be addressed in the
post-operative care plan of the patient.
To conduct further assessment of the patient’s current health status, a respiratory
system framework will be implemented. This is due to the fact that post the car accident, the
patient has suffered severe injuries to the lungs. This is evident with the elevated levels of
blood pressure and respiratory rate, which are abnormally higher than the normal levels of
respective vital signs. Respiratory assessment of the patient will include inspection of
breathing, face, neck, chest percussion and chest auscultation. Experienced nurses can carry
out a full respiratory assessment and document it and this is an essential skill of this
profession. The elements of this type of assessment framework include history taking, initial