Hey everyone, it's Sarah with RegisteredNurseRN.com and today I want to demonstrate how to take vital signs. First what you want to do is you want to gather your supplies. Typically what you're going to need is a stethoscope with a blood pressure cuff along with a thermometer of some type, a pulse ox, a watch, and some gloves along with a disinfectant wipe to clean the items that are not disposable.
Then what you want to do is you want to perform hand hygiene. and don the appropriate PPE if necessary. Like if your patient's in contact precautions, you'll want to put on the correct PPE. Now, what is collected during the vital sign measurement?
Well, you'll be checking the patient's blood pressure, heart rate, respirations, and temperature. In addition, you'll be asking the patient their pain rating, which is sometimes referred to as the fifth vital sign, along with collecting their oxygen saturation. So I've arrived to the patient's exam room and I've- performed hand hygiene.
Now what I want to do is I want to introduce myself to the patient and tell them what we're going to be doing. So hello, my name is Sarah. I'm a nurse here and I want to be taking your vital signs. Is that okay with you? Yes.
Okay, then you want to do your patient identifiers by looking at their armband, having them tell you their name and their date of birth. Then I like to start with the easiest thing, which is pain. And so I'm going to ask him his pain level.
Now this is a very easy and important assessment tool. because high pain ratings, if the patient is in pain, it can alter their vital signs. It can increase their heart rate, their blood pressure, and respirations.
And it's really important, especially to ask a patient their pain level if they've just had surgery or some type of trauma. So to assess pain levels, you can do that with various scales. Most commonly, we use the 0 to 10 numerical scale. So can you tell me your pain was 0 being no pain at all to 10 being the worst pain you've ever had? What's your pain?
pain rating? Zero. Okay. He says he's having no pain.
That's easy. But let's say that they, he said that his pain rating was an eight. Well, you would want to ask some more questions.
You want to say, where's your pain located at? And please, can you describe it for me? Like, is it burning?
Is it radiating? Things like that. And then you want to document that, the numerical rating, along with the words that the patient used to describe the pain and its location. Next, we're going to measure the patient's oxygenation status. And to do that you can use a portable probe like this one or one that connects to a bedside monitor And to do that you're going to place the device on the nail bed because that's where it's going to obtain the reading So make sure that you pick some fingers that have good circulation and they're nice and warm and pink so we'll turn on our device and We will place it on The finger and let it get a reading and here are the patient's oxygen saturation is 97%.
A normal oxygen saturation is anywhere between 95 to 100%. And below you can also see the heart rate as well, but here in a moment we will actually check the heart rate. And then you'll just want to remove the device and if it's like a portable one like this you'll want to clean it with a disinfectant wipe and then document your findings.
Now we're going to collect the patient's body temperature and some things you want to remember about body temperature is that in an adult it can vary. It can be anywhere between 97 to 99 degrees Fahrenheit, with the average being about 98.6 degrees Fahrenheit orally. And in an adult, it's considered a temperature if the temperature is greater than 100.4 degrees Fahrenheit. Now, the temperature reading will depend on the route that you use, and you can take a patient's temperature various ways, like orally, the forehead via the temporal artery, tympanically, which is via the ear, rectally, or axillary via the armpits.
And a rule of thumb to remember is that rectal and tympanic temperatures will be one degree higher than the oral route and temperatures that are collected via the axillary or the temporal route will be one degree lower than oral temperatures. So we're going to take the patient's temperature using the temporal artery and we're going to use this device. So what you want to do first is you want to use a probe cover if your device has one that just protects it from becoming contaminated and what we're going to do is we're going to hold the probe flush up against the skin at the center of the forehead we're going to take it and scan it across the forehead to the hairline and look at our reading and before we do that you want to make sure that the forehead is clear of any type of hair or anything because this probe needs to be making contact with the skin if anything comes into contact with it can throw off the reading so we're going to put it flush against the skin and hold the button in on the device and you'll hear it beeping.
and scan it to the hairline and look at her temperature. Now if your patient was sweating on the forehead because a lot of times whenever patients have fevers they can sweat, you would want to do it the same way. Probe up against the forehead in the middle, hold the button down, scan across the forehead to the hairline, but you're also going to go behind the ear because sweating will decrease the temperature and it's very vascular back here behind the ear and that will just help us obtain a proper reading.
Then what you're going to do is you're going to clean your device and document your finding. And if you didn't take it orally, you want to make sure you document the route that you actually took the temperature. Next, we're going to check the patient's pulse.
And as we feel the pulse, we're going to be looking at several things. Of course, we're going to be counting the rate, but we're also going to be feeling the strength of the pulse. And we will be grading it on a zero to three plus scale with zero being the pulse is absent, one plus, weak, 2 plus normal and 3 plus bounding. And the rhythm.
Is the pulse regular or is it irregular? Now in adults, the most common site to use to check the pulse is the radial artery because it's really easy to access. So it's found, what you want to do is find the thumb and it's found below it in this wrist area along the radial bone, hence why we call it the radial artery. And whenever you're checking the pulse, have the patient... they can sit in bed, they can lie down, and you'll want to support their arm, extend it out and support it.
And you're going to use your first three fingers to feel the pulse. Don't use your thumb. Your thumb actually has a pulse in it. So use your first three fingers and find it within that area I just told you and lightly just touch it.
Don't press too hard and feel the bounding of the pulse. And what you want to do is you want to count it for 30 seconds if the pulse is regular and multiply that number by 2. If it's irregular, count it for one full minute. So his heart rate is 82. It's regular and it's 2+.
And a normal heart rate in an adult is 60 to 100 beats per minute. Now what we're going to do is we're going to keep our fingers here. Because what we want to do next is check the patient's respirations and if you tell a patient that you're checking the respirations They're gonna alter the way that they're breathing.
So we're gonna stay in this same position and assess Respirations and when we're assessing Respirations we're looking at a couple things. First of all the rate a normal breathing rate in an adult is 12 to 20 breaths per minute We're also looking at the depth. Is it labored or unlabored and the rhythm?
Are the breaths regular or irregular? And I have found the easiest way to do this is really look at the patient from the side and watch their gown, their clothes. Are they rising and falling?
Because one rise and one fall equals one respiration. You can also sometimes just gently take your hand, put it on their back, and feel the rise and the fall of the chest. And so you will count that for 30 seconds if their breathing rate is regular and then multiply that by two. but if it was irregular you would need to count for one full minute and then document your findings and lastly what we're going to do is we're going to measure the blood pressure and to do that we want to make sure our patient is sitting down with their arm at heart level and their legs are uncrossed now they're lying in bed you would want to make sure that this arm is at heart level then what we're going to do is we are going to get our stethoscope and our blood pressure cuff And you want to make sure you get the right size cuff for your patient's arm because if you use too big of a cuff or too small of a cuff it can throw off the reading.
And what we're going to do is we're going to palpate the brachial artery because this is the artery we're going to be listening to to get our blood pressure because we're going to be getting our systolic number which is that top number and this is the first sound we hear and then our diastolic number which is the bottom number and this is the point where we no longer hear the sound. So whenever we're looking at the gauge of our blood pressure cuff, we want to make sure we're really noting those points because it's going to tell us our systolic and diastolic number. So what we're going to do is we're going to put our cuff on our patient and we want to make sure we find the brachial artery.
This is the artery we palpate that we'll be using to determine our blood pressure and it's found in the bend of the arm so we're going to find it and it is located here and we're going to look on our cuff and our cuff has these arrows and because this is the left arm we're going to make sure that this arrow is pointing in that direction of where that artery is so you're going to put the up about two inches above the bend of the arm. First what we want to do is we want to estimate the systolic pressure so we want to find that number. To do that we're going to palpate the brachial artery and we're going to inflate the cuff until I no longer feel the brachial artery and at that point when I no longer feel it I need to make sure I'm looking at this gauge to know that number because that number is our estimated systolic pressure number then when I go to take the blood pressure, I'm going to inflate the cuff 30 millimeters of mercury more than that estimated number. The whole reason for doing that is because we want to avoid missing the osculatory gap that can occur in some patients.
All patients have it, but some. It's usually patients with hypertension because the osculatory gap is like this abnormal silence that can occur and it will throw off whenever you actually hear that first sound, which is your systolic. number.
So I'm inflating the cuff by filling on the artery and I'm going to note the point where I no longer feel the artery which is about at the hundred. Then I'm going to deflate it completely and wait about 30 to 60 seconds and then we'll take the blood pressure. So our estimated systolic number is a hundred. Now I'm going to inflate the cuff to a hundred and thirty and that will avoid missing the oscillatory gap if one was pressed.
present. So I'm going to take my stethoscope, put it in my ears. You can use the bell or the diaphragm of your stethoscope.
I like to use the bell because it's best at picking up low pitch noises. So we're going to place that over the brachial artery. Do it lightly. Don't fully compress it because you can occlude the artery.
Then we're going to inflate our cuff to 130 millimeters of mercury. Then we're going to let it. fall about 2 millimeters of mercury per second and we're listening for that first sound which is our systolic number. Okay, it's 104 and we're listening for that last sound.
and it was 78. So the blood pressure is 104 over 78. Then once you have your reading, make sure you fully deflate the cuff full of air, and you're going to take the cuff off of your patient, of course, and clean it if it's a not disposable and you will document the blood pressure and what arm you took it in. Now what are normal blood pressure readings? According to the American College of Cardiology 2017 updated guidelines a normal blood pressure pressure is a systolic less than 120 and a diastolic less than 80. Elevated blood pressure would be considered a systolic of 120-129 and a diastolic less than 80. Hypertension stage 1 would be a systolic of 130-139 or a diastolic 80-89 and hypertension stage 2 would be a systolic greater than 140 and a diastolic greater than 80. Okay, so that wraps up this demonstration on how to check vital signs.
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