How to Check Vital Signs | Checking Vitals Nursing Assessment

Summary

In this educational video, Sarah from registernurseRN.com demonstrates how to check the six vital signs: pain, oxygen saturation, temperature, heart rate, respirations, and blood pressure. She emphasizes the importance of hand hygiene, patient privacy, and clear communication. Sarah explains the process of assessing pain, measuring temperature using an oral thermometer, checking oxygen saturation with a pulse oximeter, and counting heart rate and respirations together for accuracy. She also covers the proper technique for manually measuring blood pressure using a sphygmomanometer and stethoscope, ensuring the correct cuff size and placement. The video concludes with a reminder to inform patients of their vital signs and maintain hygiene.

Takeaways

• 🧼 Start with hand hygiene and ensure patient privacy.
• 🌡️ Pain assessment is the first vital sign to check, using a scale of 0-10.
• 🔍 Ask about the quality and location of pain if present.
• 🌡️ Temperature can be measured in various ways, with oral being common for adults.
• 🩺 Be aware of temperature variations depending on the measurement site.
• 🫁 Oxygen saturation is measured using a device on the fingernail bed, with normal levels being 95% to 100%.
• ❤️ Heart rate and respirations are typically counted together for accuracy.
• 🔊 Use the radial artery to count the pulse, and count for 30 seconds if regular, or 1 minute if irregular.
• 🩸 Blood pressure is measured using a cuff, with the correct size and placement being crucial.
• 📊 Listen for the first and last Korotkoff sounds to determine systolic and diastolic pressures.
• 🗣️ Inform the patient of their vital signs after measurement and maintain hygiene practices.

Q & A

What are the six vital signs that Sarah discusses in the video?

The six vital signs Sarah discusses are pain, oxygen saturation, temperature, heart rate, respirations, and blood pressure.

How does Sarah instruct to assess a patient's pain level?

Sarah instructs to ask the patient to rate their pain on a scale of zero to 10, with zero being no pain and 10 being the worst pain they've ever experienced. She also asks about the quality and location of the pain.

What is the normal temperature range for an adult according to the video?

The normal temperature range for an adult is about 97°F to 99°F.

What are the different methods Sarah mentions for taking a patient's temperature?

Sarah mentions several methods for taking a temperature: orally, axillary, temporally, in the ear (tympanic), and rectally.

How does Sarah demonstrate measuring oxygen saturation and what is the normal range?

Sarah demonstrates measuring oxygen saturation by placing a device on the nail bed of the finger. The normal oxygen saturation range is 95% to 100%.

What is the normal pulse rate for an adult as stated in the video?

The normal pulse rate for an adult is 60 to 100 beats per minute.

How does Sarah suggest counting the heart rate and respirations together?

Sarah suggests counting the heart rate for 30 seconds if it's regular, and then counting the respirations for the next 30 seconds by observing the rise and fall of the chest.

What is the correct placement for the blood pressure cuff according to the video?

The blood pressure cuff should be placed with the arrow about 1 to 2 inches above the brachial artery, which is located in the bend of the arm.

How does Sarah describe the process of manually obtaining blood pressure?

Sarah describes the process of manually obtaining blood pressure by palpating the brachial artery, inflating the cuff to 180 to 200 mmHg, and then slowly releasing the pressure while listening for the first and last sounds with a stethoscope.

What is the normal blood pressure reading Sarah gets for the patient in the video?

The normal blood pressure reading Sarah gets for the patient is 114 over 65.

What is the importance of hand hygiene and privacy as mentioned by Sarah before starting the vital signs check?

Sarah emphasizes the importance of hand hygiene to prevent infection and providing privacy to the patient to ensure their comfort and respect their personal space before starting the vital signs check.

Outlines

00:00

🩺 Introduction to Vital Signs Assessment

Sarah from registernurseRN.com introduces a video tutorial on how to check six vital signs: pain, oxygen saturation, temperature, heart rate, respirations, and blood pressure. She emphasizes the importance of hand hygiene, patient privacy, and communication before starting the assessment. Sarah demonstrates how to ask a patient about their pain level using a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. She also explains the process of taking a patient's temperature, mentioning various methods and the importance of following hospital protocols. Sarah uses a thermometer to check the patient's temperature, ensuring it is taken orally and cleaned properly afterward. The normal temperature range is discussed as 97°F to 99°F.

05:27

🌡️ Measuring Oxygen Saturation and Heart Rate

Sarah proceeds to measure the patient's oxygen saturation using a portable device clipped onto the fingernail bed. The normal range for oxygen saturation in a hospital setting is 95% to 100%. She notes the patient's oxygen saturation is 98% and simultaneously observes the heart rate, which is 64 beats per minute. Sarah then explains the process of counting the heart rate and respirations together for accuracy, using the radial artery for pulse measurement. She emphasizes the importance of counting for 30 seconds if the heart rate is regular and for a full minute if it's irregular, with a normal adult pulse rate being 60 to 100 beats per minute. The patient's heart rate is confirmed as 60 beats per minute, and respirations are counted as 16 breaths per minute.

🩂 Blood Pressure Measurement Technique

Sarah demonstrates how to measure blood pressure, starting with the selection of the correct cuff size. She explains the importance of palpating the brachial artery and positioning the cuff correctly, with the arrow on the cuff placed one to two inches above the artery. She advises checking with the patient which arm can be used for the measurement, considering any medical conditions that might affect blood flow. Sarah then shows how to inflate the cuff to 180 to 200 mmHg and uses a stethoscope to listen for the Korotkoff sounds, which indicate the systolic and diastolic blood pressure readings. The patient's blood pressure is measured as 114/65 mmHg. Sarah concludes by reminding viewers to inform the patient of their vital signs, practice hand hygiene, and clean equipment after each assessment.

Keywords

💡Vital Signs

Vital signs are a group of four specific, fundamental measurements taken regularly to determine a patient's state of health. In the video, Sarah, the nurse, explains that the six vital signs include pain, oxygen saturation, temperature, heart rate, respirations, and blood pressure. These are essential for assessing a patient's condition and are used to monitor their health status over time.

💡Pain

Pain is a subjective experience that can be assessed using a numerical rating scale. In the video, Sarah asks the patient to rate their pain on a scale of zero to ten, with zero being no pain and ten being the worst pain they've ever experienced. This helps in understanding the patient's current discomfort level and is an essential part of the patient's overall assessment.

💡Oxygen Saturation

Oxygen saturation, also known as SpO2, is a measure of the amount of oxygen in the blood. Sarah uses a portable device to measure the patient's oxygen saturation by placing it on the nail bed of the finger. A normal oxygen saturation level in a hospital setting is 95% to 100%, indicating adequate oxygenation.

💡Temperature

Temperature is a measure of the body's heat and can be taken in various ways, such as orally, axillary, temporally, or rectally. In the video, Sarah opts for an oral temperature measurement, which is a common method for adults. A normal oral temperature is about 97°F to 99°F, and the script provides an example of the patient's temperature being 98.2°F.

💡Heart Rate

Heart rate refers to the number of times the heart beats per minute. Sarah demonstrates how to measure heart rate by feeling for the pulse at the radial artery. A normal pulse rate for an adult is 60 to 100 beats per minute. The video script includes an example where the patient's heart rate is found to be 60 beats per minute.

💡Respirations

Respirations are the act of breathing, and in medical terms, it refers to the rate of breathing. Sarah explains that respirations are counted by observing the rise and fall of the chest, which equals one breath. A normal respiratory rate is typically 12 to 20 breaths per minute, and the script shows the patient's respiration rate as 16 breaths per minute.

💡Blood Pressure

Blood pressure is the force exerted by circulating blood on the walls of blood vessels. Sarah demonstrates how to measure blood pressure manually using a sphygmomanometer and a stethoscope. The blood pressure is recorded as two numbers, systolic (higher number) and diastolic (lower number), and the script provides an example of the patient's blood pressure being 114 over 65.

💡Hand Hygiene

Hand hygiene is the practice of cleaning one's hands to remove dirt, soil, and microorganisms. In the video, Sarah emphasizes the importance of performing hand hygiene before and after checking vital signs to prevent the spread of infections, which is a critical aspect of patient care and safety.

💡Privacy

Privacy is the right of an individual to be free from unwarranted intrusion or disturbance. Sarah mentions the importance of providing privacy to the patient before starting the procedure, which is a fundamental aspect of respecting the patient's dignity and ensuring a comfortable environment for the examination.

💡Pain Quality

Pain quality refers to the nature or type of pain a patient is experiencing. In the video, Sarah asks the patient to describe the quality of their pain, such as whether it is sharp, dull, or throbbing. This information helps in understanding the patient's experience and can guide further assessment and treatment.

💡Cuff

A cuff, in the context of the video, refers to the blood pressure cuff used to measure blood pressure. Sarah explains the importance of using the correct size cuff and placing it properly above the brachial artery. The script includes a detailed demonstration of how to apply the cuff and take a blood pressure reading, highlighting the accuracy needed for this procedure.

Highlights

Introduction to checking six vital signs: pain, oxygen saturation, temperature, heart rate, respirations, and blood pressure.

Importance of hand hygiene and patient privacy before starting the procedure.

Explanation of pain assessment using a scale of zero to ten.

Inquiry about the quality and location of the patient's pain.

Demonstration of introducing oneself and explaining the procedure to the patient.

Techniques for measuring temperature using different methods.

Instructions on how to use a thermometer for oral temperature measurement.

Normal temperature range and how to clean the thermometer post-measurement.

Procedure for measuring oxygen saturation using a pulse oximeter.

Normal oxygen saturation range and how to interpret the reading.

Method for counting heart rate and respirations simultaneously for accuracy.

Technique for locating and using the radial artery to measure heart rate.

Normal heart rate range for adults and how to count irregular heart rates.

Process for measuring blood pressure manually using a sphygmomanometer.

Importance of using the correct blood pressure cuff size and placement.

Step-by-step guide on how to manually inflate the cuff and locate the systolic and diastolic pressures.

Final vital signs reading and the importance of informing the patient and maintaining hygiene.

Encouragement to explore more nursing skills videos for further learning.

Transcripts

hey everyone it's Sarah with register

nurse rn.com and in this video I'm going

to be going over how to check Vital

Signs what we're going to be doing is

checking the six Vital Signs which are

pain oxygen saturation temperature heart

rate respirations and blood pressure and

before you start what you want to do is

you want to perform hand hygiene and you

want to provide privacy to the patient

and tell them what you're going to be

doing because you're going to have to

touch them in order to do this so let's

get started the very first thing we want

to do is we want to ask them if they are

in pain so um whenever you do that

you're going to have them rated on a

scale of zero to 10 with zero being no

pain at all and 10 being the worst pain

they've ever had and if they do have

pain ask them the quality what does it

feel like and where it is at so hi Ben

my name is Sarah and I am your nurse and

I'm going to be getting your Vital Signs

and I performed hand hygiene and very

first thing I want to do is I want to

ask you what your pain rating is are you

having any pain rate on a scale of0 to

10 yes pain in my shoulder and it's a

three okay and what is it feel like it's

just a sharp pain when I raise my arm

okay so you're having a pain of three

and it's in your left arm and it's sharp

yes okay now I'm going to get your

temperature there's several ways you can

take a temperature every facility has a

different system set up so use what they

have but you can take it orally you can

take it axillary you can take it tanic

in the ear or you can take it temporally

or rect um rect is the preferred route

usually on your pediatric patients but

in adult patients normally we do it

orally some things to keep in mind

though axillary and temporally the

readings are going to run about one

degree lower than oral and for tanic and

rectal temperatures it's going to

usually run about one degree higher than

your oral reading so we are going to

check this

orally and what we're going to do turn

your thumb Omer on make sure you're

using the proper um sleeves if you have

any sleeves for it clean it everything

like that follow your hospital protocols

and have the patient lift up their

tongue and put the probe underneath the

tongue and have them close the mouth

with the tongue over the

probe and hold it there until it beeps a

normal temperature is about 97° fit to

99°

F okay and take the thermometer out and

read it and his temperature is

98.2 and then clean it properly per

Hospital protocol now I'm going to take

his oxygen saturation every system has

different ways of how they measure it um

different devices this is a little

portable device and what you do is you

put this on the nail bed of the finger

it has some red lights in there and

those red lights read through the nail

bed the oxygen saturation a normal

oxygen saturation O2 sat as you may hear

and the hospital setting is 95% to 100%

so let's see what his is um put this on

the index finger of the nail bed and

then just look for the

reading okay here you can see that his

oxygen saturation is 98% that is the

reading on the top it's read as spo2 and

then on the bottom you will see his

heart rate which is 64 but here in a

second I'm going to show you how to

actually count the heart rate using the

radial artery okay now we are going to

count the heart rate and respirations

generally I like to do this together um

while I'm counting the heart rate I

count that for 30 seconds if it's

regular and then the next 30 seconds I

count the respirations which I look at

the rise and the fall of the chest and

that equals one breath um generally if

you tell a patient you're going to count

their respirations they change the rate

of breathing so it's good to

conglomerate those two together so you

can get a more accurate reading so what

we're going to do is we're going to

first count the heart rate and to do

that you can use several different sites

typically people use the radial which is

right here right below the where the

radius bone is and the groove right

there or you can use the brachial artery

which is in the bend of the arm where

the anticubital fosset area is or you

can use the cored but here we're going

to use the radial so what I'm going to

do is I'm going to use my two I'm going

to use my index finger and my middle

finger don't use your thumb because you

can feel a pulse in your thumb so use

those two fingers and just put it over

in the groove of where the styloid

processes and the radial artery and feel

that and count for 30 seconds if it's

regular if it's irregular count for 1

minute and a normal pulse rate in an

adult is 60 to 100 beats per minute

okay the heart rate I got 60 and his

respiration were 16 now we are going to

get his blood pressure now whenever

you're getting blood pressure you want

to make sure that you get the right size

cuff in most settings they have the

automatic blood pressure cuffs where you

don't have to blow it up yourself so

you're really blessed with that but a

lot of times you may have to learn how

to do a manual one now my previous video

and a card should be popping up I go

over the two-step method if that's how

you're being instructed but in this

video we're going to go over the one

step blood pressure of how to obtain it

manually so what we're going to do we

are going to palpate the brachial artery

this is in the bend of the arm and make

sure you ask the patient which arm you

can take their blood pressure in because

you don't want to take it in uh arms

with if they've had blood clots or they

have a shunts things like that so you

want to make sure you have the right arm

and what you're going to do is you're

just going to have them extend the arm

out and you're going to palpate the

brachial artery this is found in the

anticubital faucet area and the bend of

the arm towards this area and um

extending the arm out helps that pulse

really pop out at you and just f that

and we feel about right here because

what you're going to do on your blood

pressure cuff you have these little

arrows and it says left arm right arm

and this is his left arm so we're going

to make sure that we put this Arrow

about 1 to two inches above that artery

so let's slide it up and then make sure

our cff it

properly so we're putting that Arrow

about one to two inches above where I

felt the brachial artery and going to

just put this on here

snugly and to make sure you have the

right blood pressure cuff take about two

fingers and slide it underneath the cuff

and make sure it fits snugly not too

tight not too loose because if you don't

fit it correctly you could get in

inaccurate blood pressures okay so we

have that there and put your little

spigon monometer somewhere where you can

see it because that is where you're

going to be finding your blood pressure

so put our stethoscope in her ears and

you're going to use the diaphragm of

your stethoscope and you're just going

to place it over where you have heard

that brachial

artery

and then you're going to blow the cuff

up to about 180 to 200 mm of mercury or

until you don't hear that braak your

artery

anymore okay we're blowing it up to

about 200 mm of mercury okay we're there

and now we're going to let the needle

drop about 2 to 3 mm of mercury slowly

not too fast not too slow and we're

listening for that first sound and that

first s sound will be our top number of

our blood pressure which is our

systolic so I haven't heard it yet and

I'll let you know whenever I hear

it okay I heard it at about the 114

Mark now we're listening for whenever it

stops and whenever it stops that's our

diastolic

okay it stopped right at 65 so his blood

pressure is 114 over

65 so that is how you check bottle signs

now whenever you're done remember to let

the patient know what their bottle signs

were and um do hand hygiene and clean

your equipment before you go to the next

patient so be sure to check out all my

other videos on nursing skills and thank

you so much for watching