Practice Documenting: Vital Signs
You are working the day shift today. Your responsibilities include showering four clients: Martha, Amir, Isaiah, and Pat. One of your responsibilities on shower day is to complete a set of vital signs for each person. After the showers have been completed and documented you now visit each person in their room to take their vital signs. Typically, as you take the vital signs you write the information in your notebook so that you can go to the laptop at the nurses station to enter them all at the same time. First you visit Martha. They are having a good day today and after some chatting about the weather they sit quietly so that you can take their vital signs. In your notebook you write down the following: T = 98.1, P = 88, R = 14, BP = 118/74.
Next you go to Amir’s room. Amir is visiting with family, but they invite you in and chat a bit about Amir’s great-grandson that was just born. Amir shows you a picture of the great-grandson and is beaming with excitement because soon they will meet in person. You tell Amir you can come back later to take vital signs after the family is done visiting, but Amir says, “No worries, you can do that while they are here.” You take the vital signs and, in your notebook, write down the following: T = 97.9, P = 96, R = 18, BP = 116/78.
Then you go to Isaiah’s room. Isaiah is snuggling into bed for a post-lunch nap. You ask if it is okay that you take vital signs, and Isaiah says that is fine to do but to do so quickly. You are quiet and promptly take their vital signs. In your notebook you write the following: T = 97.0, P = 60, R = 12, BP = 110/70.
Finally, you get to Pat’s room right before the end of the shift. Pat is angry when you enter their room. You can tell because their face is red, and you just overheard Pat yelling at their roommate for being nosy. As you enter and introduce yourself, you ask to take a set of vital signs. Pat states, “If I had a nickel for every time I am interrupted at this place, I would be a millionaire!” You ask Pat if there is anything you can help them with to try to calm the situation. Pat responds with “No—just get your work done and then leave. I’m tired and want to take a nap.” You complete the vital signs and write the following in your notebook: T = 98.9, P = 110, R = 22, BP = 148/102.
How would you document the vital signs for these clients?