what vital signs do I need to perform?

[Eohippus]

Hello;

I have a scenario that I'd like to have some comments on;

Patient has an NG tube, and needs staples removed from knee incision. Do I just need to check temperature? I'm trying to be as efficient & practical as possible.

Sorry, I don't have much info to supply here. Any thoughts or comments are appreciated.

Best

Eohippus

[xtxrn, ASN, RN]

Hello to all & thank you for your time in replying;

It was good to hear all the opinions. The scenario I posted is a practical test I have to perform. I have a 20 min time limit. That's why I was trying to ascertain whether I have to perform all VS. Just trying to find ways to beat the clock.

Best

Eohippus

Yep. Do them all; you can't go wrong, and it may be that the instructor gives you a reading ONLY if you go about doing the motions on a dummy. Be sure to check NG placement, and assess the wound around the staples. Again- the instructor may give verbal results to use :)

Good luck

[chocolatechip]

I would assess pain and do a focused physical, if this is your "first time in pt's room."

[joanna73, BSN, RN]

Why are some people saying its ok to leave BP out? Logically, and legally, you're obligated to check all vitals and do a pain assessment. If you need to call the Dr for an order, he or she will want to know anyway. Temp, pulse, respirations, O2 sat, BP, pain.

[nurseprnRN, BSN, RN]

you're checking temp because the patient evidently had an incision which could mean a potential infection, or maybe a postop pneumonia or urinary tract infection. you're checking bp because the ng might be draining a lot and making him hypovolemic, or he could be bleeding internally from that surgery, or because he hd something else go wrong that would drop his bp. pulse and bp go together and tell you about fluid volume status, cardiac capability, and maybe other things. pulse ox can tell you about serious problems with peripheral circulation and oxygenation. pain is perhaps more important to the patient than to you, but you'd be wrong if you thought so. ask him if his doctor explained what would be happening next; if he says "not really," then tell him.

never, never, never skip any vital sign. don't forget to check the suture line, u/o, ng output, and skin over pressure points.

[chevyv, BSN, RN]

Yep, I too would do all VS. There is a lot you can do in 20 minutes. Asses the area where the staples are to be removed before and after. Watch and feel for redness, swelling, warmth. Remember pain as the 5th vital sign and asses accordingly both before and after, providing prn if ordered and indicated. :)