Nursing Assessment: Evaluating Vital Signs and Response

QUESTION

during the vital assessment of client the PN count the left radial at 88 and pulse oxemiter clip to finger in left hand record a pulse rate of 68 with an oxygene saturate of 95% what should the pn do?

ANSWER

Nursing Assessment: Evaluating Vital Signs and Response

Introduction

The assessment of a client’s vital signs is a fundamental aspect of nursing care. Vital signs, including pulse rate, oxygen saturation, and blood pressure, provide crucial information about a patient’s overall health status. In this essay, we will discuss a hypothetical scenario in which a nurse (PN – Practical Nurse) assesses a client’s vital signs and provide guidance on what the PN should do based on the presented data.

Scenario

During a routine patient assessment, the PN counted the left radial pulse rate at 88 beats per minute and placed a pulse oximeter clip on the patient’s left hand, recording a pulse rate of 68 beats per minute with an oxygen saturation level of 95%. These findings raise important considerations for the PN to address promptly.

Interpreting the Findings

Radial Pulse Rate of 88 bpm:
A radial pulse rate of 88 beats per minute falls within the normal adult range, which typically ranges from 60 to 100 bpm.
It’s important to assess the regularity and quality of the pulse to rule out any arrhythmias or irregularities.

Pulse Oximeter Readings:
A pulse rate of 68 beats per minute recorded by the pulse oximeter is lower than the radial pulse rate.
A difference in pulse rates between peripheral pulse sites (e.g., radial) and the pulse oximeter can sometimes occur due to factors such as signal quality, vascular conditions, or motion artifacts.
The oxygen saturation level of 95% is within the normal range (typically 95-100%) and indicates adequate oxygenation.

Actions for the Practical Nurse (PN)

Based on the data provided, the PN should consider the following actions:

Reassess the Patient:
Confirm the accuracy of the pulse oximeter reading by checking for proper placement and signal quality. Ensure the patient’s hand is warm and well-perfused.
Recheck the radial pulse to assess its regularity and quality, as an irregular pulse could be a concern.

Assess for Symptoms
Evaluate the patient for any symptoms such as dizziness, shortness of breath, chest pain, or altered mental status, which could indicate a cardiovascular or respiratory issue.

Review Medical History:
Review the patient’s medical history for any pre-existing conditions or medications that could affect heart rate and oxygen saturation levels.

Consult with the Registered Nurse (RN) or Physician:
If there are discrepancies between the radial pulse rate and pulse oximeter reading or if the patient exhibits concerning symptoms, the PN should consult with the RN or physician for further evaluation and guidance.

Document Findings:
Accurate and timely documentation of vital sign assessments, including any discrepancies or interventions, is essential for the patient’s medical record.

Conclusion

In the scenario described, the PN has assessed the client’s vital signs, including the radial pulse rate and oxygen saturation level. While the findings fall within normal ranges, it is essential for the PN to critically assess and address any discrepancies, monitor the patient for symptoms, and consult with higher-level healthcare providers if necessary. Effective communication, documentation, and timely intervention are crucial in providing quality patient care and ensuring the best possible outcomes.