Vital Signs: Monitoring A Patient's Health Indicators

Nurses are responsible for providing patient-centred care and are often the first to notice changes in a patient's health. The nursing process is a critical thinking model that guides nurses in their practice and is based on the Standards of Professional Nursing Practice established by the American Nurses Association (ANA). This process involves six steps: assessment, diagnosis, outcomes identification, planning, implementation, and evaluation.

Assessment is the first step, where nurses collect subjective and objective data from the patient and their family, through interviews, physical examinations, and review of laboratory results. This information is then analysed to identify relevant cues and patterns that can indicate potential problems. The next step is diagnosis, where nurses use critical thinking and clinical judgment to analyse assessment data and identify actual or potential nursing diagnoses, problems, and issues. This is followed by outcomes identification, where expected outcomes are set in collaboration with the patient and the healthcare team, and are tailored to the patient's needs, values, and cultural beliefs.

Planning involves developing a collaborative plan to achieve the expected outcomes, which includes selecting evidence-based nursing interventions. These interventions can be independent, dependent, or collaborative and should be individualised to the patient. Implementation is the fifth step, where nurses prioritise and carry out the planned interventions while ensuring patient safety. This step also involves delegation of tasks to unlicensed assistive personnel or licensed practical nurses, and documentation of interventions. Finally, evaluation involves assessing the patient's progress and determining if the expected outcomes have been met. If not, the nursing care plan is revised accordingly.

Monitor for signs of infection

Infection is the invasion and growth of a microorganism within the body. Infection can lead to disease that causes signs and symptoms resulting in a deviation from the normal structure or functioning of the host. When an infection occurs, early recognition is important to prevent it from spreading within the individual, as well as to others. Protecting people from developing an infection, as well as preventing the spread of infection, is a major concern for nurses.

Preventing infection

Infection control practices are integral to health care workers and the patients and families that they serve. Proper infection control techniques enhance patient safety and are foundational to quality patient care. Partnering to Heal is a computer-based, video-simulation training program on infection control practices for clinicians, health professional students, and patient advocates. Visit these web simulations to review infection control scenarios and the implications of various care decisions.

Interested in testing your knowledge regarding the chain of infection? Visit WISC-Online "Chain of Infection" for a fun interactive quiz.

Putting it all together

Mrs. Charles is a 74-year-old woman admitted to the medical surgical floor with pneumonia. She has a history of right-sided hemiplegia (paralysis on one side of the body) and dysphagia (difficulty swallowing) as a result of a cerebral vascular accident three years ago. Upon assessment, the patient has a RR of 22, and rhonchi in her upper lobes. Her oxygenation saturation is 89% on room air, and she is utilising accessory muscles during respiration.

Applying the Nursing Process

Assessment: The nurse notes that the patient demonstrates tachypnea, hypoxemia, and abnormal breath sounds. She has a history of hemiplegia and dysphagia.

Based on the assessment information that has been gathered, the following nursing care plan is created for Mrs. Charles.

Nursing Diagnosis: Ineffective Airway Clearance related to excessive mucus as evidenced by adventitious breath sounds and alteration in respiratory rate.

Overall Goal: The patient will maintain patent airway at all times.

SMART Expected Outcome: Mrs. Charles will effectively clear secretions throughout the hospitalization.

Planning and Implementing Nursing Interventions:

The nurse will assess the patient’s respiratory rate, rhythm, and depth of respiration. The nurse will assess and instruct the patient on the methods of appropriate cough and deep breathing. The nurse will auscultate lung fields to identify areas of worsening airflow. The nurse will elevate the patient’s head of bed and encourage hydration to thin secretions. The nurse will instruct the patient regarding proper deep breathing exercises and encourage assisted ambulation to mobilize secretions.

Sample Documentation:

Mrs. Charles has ineffective airway clearance as a result of aspiration pneumonia secondary to dysphagia. The patient has rhonchi in bilateral upper lobes, decreased oxygenation, and tachypnea. In order to enhance airway clearance and mobilize secretions, the patient has received instruction to maintain fluid intake, increase ambulation, and cough and deep breathe. The patient will maintain an elevated head of bed to encourage ease of respiration and will be assessed frequently for worsening respiratory status.

During the patient’s hospitalization, she maintains a patent airway and effectively clears secretions resulting in improved respiratory effort and overall function. The SMART outcome was “met.”

Check for allergies

Allergies can range from mild to severe, and some can be life-threatening, so it is important for nurses to be vigilant in checking for allergies and taking appropriate action. When admitting a patient, the nurse should always ask about any known allergies and document them clearly in the patient's record. This includes drug allergies, food allergies, and any environmental allergies, such as pollen or pet allergies.

For patients with known allergies, the nurse should ensure that the patient's medication regimen does not include any allergens. This may involve checking the ingredients of medications, especially if they are derived from common allergens such as penicillin or peanuts. Nurses should also be aware of cross-reactivity, where a patient may react to a substance that is similar in structure to their known allergen.

In addition to medication, nurses should also consider potential allergens in other aspects of patient care. For instance, latex gloves are a common source of allergic reactions, so vinyl or nitrile gloves may be preferable. Patients with skin allergies may require specialized dressings or skin care products to prevent triggering a reaction.

Nurses should also closely monitor patients for signs and symptoms of an allergic reaction, particularly when introducing new medications or treatments. These symptoms can vary but may include skin rashes, hives, itching, swelling of the lips or tongue, nasal congestion, wheezing, or anaphylaxis in severe cases. If a patient exhibits any of these symptoms, the nurse should take prompt action to manage the reaction and notify the treating physician.

In summary, checking for allergies is a critical aspect of nursing care. By diligently identifying allergies, avoiding allergens, and recognizing and responding to allergic reactions, nurses can help ensure patient safety and provide effective, tailored care.

Evaluate nutritional status

Nutritional assessment is a critical process that involves evaluating an individual's nutritional intake and status to identify any imbalances or deficiencies. This process is particularly important for individuals with underlying conditions or those at risk of developing pathological conditions due to nutritional imbalances. Here is an overview of the key components of nutritional assessment:

Clinical History

The clinical history aims to identify indications of malnutrition and underlying factors that may lead to or increase the risk of malnutrition. It involves collecting information about the patient's constitutional symptoms, weight changes, dietary habits, and factors affecting food intake. Additionally, it includes inquiring about current and past illnesses, medications, and lifestyle habits such as physical activity and social habits.

Dietary Assessment

Dietary assessment is crucial to ensure adequate nutrition and hydration intake. It involves collecting information about dietary habits, frequency of meals, serving sizes, food preferences, and restrictive diets or allergies. This information can be obtained through various methods, such as 24-hour recall, food frequency questionnaires, diet charts, observation, or wearable monitoring devices.

Physical Examination

The physical examination aims to identify signs of malnutrition and factors affecting nutritional status. It includes observing the patient's general condition, vital signs, height, weight, and specific assessments of the eyes, oral cavity, skin, hair, nails, and extremities.

Anthropometric Measurements

Anthropometric measurements include height, weight, and body mass index (BMI) calculations. Other measurements such as circumference measurements and skinfold thickness can also be used to evaluate nutritional status.

Diagnostic Tests

Diagnostic tests are performed to validate the results of the clinical presentation. They include routine clinical tests such as serum electrolytes, blood glucose levels, lipid profile, and complete blood count. Additionally, micronutrient levels may be measured if specific deficiencies are suspected.

Body Composition Studies

Body composition studies, such as bioelectrical impedance analysis (BIA) and dual-energy X-ray absorptiometry (DEXA), provide a more detailed evaluation of the body's composition in terms of water, muscle, bone, and fat mass.

Factors Affecting Nutritional Status

Physiological, pathological, and psychosocial factors can influence an individual's nutritional status. Physiological factors include age, sex, growth, pregnancy, and lactation. Pathological factors encompass infections, medical and surgical illnesses, trauma, malignancies, and medications. Psychosocial factors include socioeconomic conditions, cultural norms, religious beliefs, eating disorders, mental illnesses, and substance use.

Assess for risk of falling

Falls are a significant concern for patients, particularly in hospital or healthcare settings, and can lead to serious injuries and complications. Nurses play a vital role in assessing and mitigating the risk of falls, and this process should begin with a comprehensive patient assessment.

A thorough fall risk assessment should consider a patient's medical history, current medications, and any underlying conditions that may impact their balance, mobility, or cognitive function. For example, patients with a history of stroke, Parkinson's disease, or multiple sclerosis may have an increased risk of falling due to impaired gait or balance. Additionally, certain medications can cause dizziness or drowsiness, increasing the likelihood of a fall.

The nurse should also evaluate the patient's current level of mobility and functional ability. This includes observing their gait and balance, assessing muscle strength and coordination, and understanding any limitations they may have in activities of daily living. For instance, patients who require assistance with walking or transferring may be at a higher risk of falling.

The environment is also crucial when it comes to fall prevention. Nurses should ensure that the patient's surroundings are safe and free of hazards, such as loose rugs, cluttered floors, or poor lighting. Providing appropriate assistive devices, like canes, walkers, or grab bars, can also help reduce the risk of falling.

Finally, patient education and engagement are essential to preventing falls. Nurses should involve patients in the fall risk assessment process, providing information and instructions tailored to their specific needs. Encouraging patients to take an active role in their safety—such as wearing non-slip footwear or using a call bell when assistance is needed—can help reduce the likelihood of falls.

Monitor for adverse medication effects

Monitoring for adverse medication effects is a critical aspect of patient care, especially in older adults, as it can help identify and mitigate complications that may arise during drug therapy. Here are some strategies and considerations for nurses to effectively monitor and manage adverse medication effects:

Health Information Technology and Systems Redesign:

• Utilize health information technology to link pharmacy and laboratory data, enabling the tracking of overdue laboratory tests and generating alerts for non-completion.
• Implement laboratory tracking systems within individual physician offices to improve test result management.
• Integrate laboratory and pharmacy data to provide real-time computerized decision support and safety checks during the prescribing process.
• Utilize electronic reminders and decision support systems to improve monitoring and reduce adverse events.

Risk-Assessment Tools:

• Develop risk-assessment tools to individualize monitoring frequency and intensity based on a patient's predicted risk of adverse events.
• Focus on adverse events that are amenable to amelioration (slow in onset and reversible with drug withdrawal) and adjust monitoring regimens accordingly.

Patient Outreach and Activation:

• Implement patient outreach programs using team-based approaches, such as pharmacist-based outreach or automated reminder calls, to improve laboratory monitoring and patient engagement.
• Educate patients about the purpose of their medications, potential side effects, and the importance of reporting symptoms.
• Provide concise, easy-to-understand information sheets about drugs, side effects, and actions to take if side effects occur.
• Encourage patients to learn about their medications from reliable sources and actively report symptoms or concerns.

Medical Education and Heuristics of Prescribing:

• Integrate principles and practices of drug monitoring into medical and nursing school curricula, especially in pharmacology courses.
• Emphasize the dynamic nature of prescribing, where benefits and harms of drugs are actively monitored, managed, and reassessed over time.
• Role-model and teach monitoring practices during interdisciplinary training to foster a team-based approach to patient care.

Clinical Significance:

• Prioritize the identification and management of life- or limb-threatening conditions during the initial nursing assessment to ensure better patient outcomes.
• Utilize critical thinking skills and therapeutic communication techniques, such as the SBAR model, to effectively communicate assessment findings and collaborate with the healthcare team.
• Stay vigilant for physiological abnormalities, such as changes in vital signs and level of consciousness, which may indicate deteriorating patient conditions and require prompt intervention.

Frequently asked questions