Vital Signs Nursing: Respiratory Rate, Pulse, Blood Pressure, Temperature, Pain, Oxygen
Summary
TLDRIn this video, Sarah demonstrates how to take vital signs, including blood pressure, heart rate, respirations, temperature, pain assessment, and oxygen saturation. She explains the necessary equipment, such as a stethoscope, thermometer, and pulse oximeter, and outlines each step of the process, from gathering supplies to cleaning equipment and documenting findings. Sarah also provides details on how to assess pain levels and explains the importance of accurate measurements. She concludes by covering normal ranges for vital signs and proper techniques for taking blood pressure readings.
Takeaways
- 🩺 Gather supplies for taking vital signs, including a stethoscope, blood pressure cuff, thermometer, pulse oximeter, watch, gloves, and disinfectant wipes.
- 🧼 Perform hand hygiene and don appropriate PPE, especially when the patient is under contact precautions.
- 💬 Ask the patient for their pain rating, often referred to as the fifth vital sign. Pain can affect heart rate, blood pressure, and respiration.
- 📊 Measure the patient's oxygen saturation using a pulse oximeter, ensuring to use fingers with good circulation.
- 🌡️ Check body temperature using various methods (oral, temporal, tympanic, rectal, or axillary), remembering the specific temperature ranges for each route.
- 💓 Measure the patient's pulse at the radial artery, noting the rate, strength, and rhythm. A normal heart rate for adults is 60-100 beats per minute.
- 💨 Check the patient's respirations without alerting them, counting the rate, depth, and rhythm.
- 🩸 Take the patient's blood pressure using the correct size cuff, and ensure the patient's arm is at heart level. Record both systolic and diastolic numbers.
- 🎯 Estimate the systolic pressure first to avoid missing the auscultatory gap, especially in patients with hypertension.
- 📑 Document all findings accurately, including pain rating, oxygen saturation, temperature route, pulse characteristics, respiration rate, and blood pressure readings.
Q & A
What supplies are typically needed to take vital signs?
-You need a stethoscope, a blood pressure cuff, a thermometer, a pulse oximeter, a watch, gloves, and disinfectant wipes.
Why is it important to assess a patient's pain level before measuring vital signs?
-Pain can alter vital signs by increasing heart rate, blood pressure, and respiration, so assessing pain first helps ensure accurate measurements.
How is oxygen saturation measured and what is a normal range?
-Oxygen saturation is measured using a pulse oximeter placed on the nail bed. A normal range is 95-100%.
What is the normal body temperature range for adults, and when is a temperature considered a fever?
-The normal body temperature range for adults is between 97°F and 99°F, with 98.6°F being average. A temperature above 100.4°F is considered a fever.
What are the different ways to measure body temperature, and how do they differ in accuracy?
-Temperature can be measured orally, rectally, via the forehead (temporal artery), tympanically (ear), or axillary (armpit). Rectal and tympanic temperatures are typically 1°F higher than oral, while axillary and temporal readings are about 1°F lower.
How is pulse assessed and what factors are observed in addition to the pulse rate?
-Pulse is typically assessed at the radial artery. In addition to the rate, the strength (graded from 0 to 3+) and rhythm (regular or irregular) of the pulse are observed.
What are the normal heart rate ranges for adults, and how is the pulse counted?
-The normal heart rate range for adults is 60-100 beats per minute. The pulse is counted for 30 seconds if regular and multiplied by two, or for a full minute if irregular.
What is the best way to observe a patient's respiratory rate without influencing their breathing?
-You can continue holding the patient's wrist after checking their pulse, then observe the rise and fall of their chest for 30 seconds (or a full minute if irregular).
What is the procedure for taking blood pressure manually with a stethoscope and cuff?
-First, estimate the systolic pressure by palpating the brachial artery and inflating the cuff until the pulse disappears. Inflate the cuff 30 mmHg above that estimate, listen for the first sound (systolic pressure), and note when the sound disappears (diastolic pressure).
What are the updated 2017 guidelines for normal and elevated blood pressure ranges?
-A normal blood pressure is a systolic of less than 120 and a diastolic of less than 80. Elevated blood pressure is a systolic of 120-129 and a diastolic of less than 80. Stage 1 hypertension is systolic of 130-139 or diastolic of 80-89. Stage 2 hypertension is systolic above 140 or diastolic above 90.
Outlines
🩺 Introduction to Vital Signs Measurement
Sarah Thread Sterner introduces a tutorial on how to measure vital signs. She emphasizes the importance of gathering necessary supplies such as a stethoscope, blood pressure cuff, thermometer, pulse oximeter, gloves, and disinfectant wipes. Sarah also highlights the need for hand hygiene and appropriate PPE. The tutorial covers checking blood pressure, heart rate, respirations, temperature, pain rating, and oxygen saturation. Sarah demonstrates how to introduce oneself to the patient, perform patient identifiers, and assess pain levels using a numerical scale. She also explains how to measure oxygen saturation using a pulse oximeter and the importance of documenting findings.
🌡️ Measuring Body Temperature
Sarah explains how to measure a patient's body temperature, noting that it can vary and the average is 98.6 degrees Fahrenheit. She discusses different methods of temperature measurement, including oral, temporal artery, tympanic, rectal, and axillary, and their respective normal ranges. Sarah demonstrates using a temporal artery thermometer, emphasizing the importance of a clear forehead for accurate readings. She also advises on how to handle a sweating patient and the need to clean the device and document the temperature route used.
💓 Assessing Pulse and Respirations
Sarah demonstrates how to check a patient's pulse, focusing on rate, strength, and rhythm. She explains the grading system for pulse strength and the importance of using the radial artery for accessibility. Sarah also discusses how to assess respirations, including rate, depth, and rhythm, and shares a technique for counting breaths by observing the patient's chest movement. She emphasizes the importance of documenting these findings.
🩸 Blood Pressure Measurement Technique
Sarah provides a detailed explanation of how to measure blood pressure correctly. She discusses the importance of patient positioning, cuff size, and palpating the brachial artery. Sarah demonstrates the process of estimating systolic pressure and avoiding the oscillatory gap, especially in hypertensive patients. She shows how to use a stethoscope to listen for systolic and diastolic sounds and records a blood pressure of 104 over 78. Sarah concludes by discussing normal blood pressure readings according to the American College of Cardiology guidelines and the importance of documenting the blood pressure and the arm used for measurement.
Mindmap
Keywords
💡Vital Signs
💡Blood Pressure
💡Heart Rate
💡Respirations
💡Oxygen Saturation
💡Pain Scale
💡Thermometer
💡Pulse Oximeter
💡Personal Protective Equipment (PPE)
💡Systolic and Diastolic Pressure
Highlights
Introduction to taking vital signs, including the necessary supplies: stethoscope, blood-pressure cuff, thermometer, pulse oximeter, watch, gloves, and disinfectant wipe.
Perform hand hygiene and don appropriate PPE when necessary, such as in cases of patient contact precautions.
Blood pressure, heart rate, respirations, temperature, pain rating, and oxygen saturation are the vital signs to be measured.
Pain is often referred to as the fifth vital sign, and it's important to ask the patient for their pain rating using a 0-10 scale.
Proper pain assessment involves asking follow-up questions if the patient reports pain, such as its location, description, and intensity.
When measuring oxygen saturation, use a portable or bedside monitor and place the device on a well-circulated finger, aiming for normal readings of 95-100%.
Temperature readings can vary based on the method used, and normal adult body temperatures range between 97 and 99 degrees Fahrenheit.
Different temperature measurement routes include oral, rectal, tympanic, axillary, and temporal artery, with each method having specific advantages and limitations.
Proper technique for measuring pulse: use the radial artery, support the arm, and use three fingers to feel the pulse without using the thumb.
Respiration measurement should be discreet to avoid the patient altering their breathing, and the normal rate in adults is 12-20 breaths per minute.
Blood pressure measurement requires proper cuff sizing, positioning, and listening for systolic and diastolic sounds using a stethoscope.
The correct procedure for estimating systolic blood pressure is to palpate the brachial artery while inflating the cuff until the pulse disappears.
To avoid missing the oscillatory gap in hypertensive patients, inflate the cuff 30mmHg above the estimated systolic pressure before taking the reading.
Blood pressure guidelines by the American College of Cardiology (2017): normal, elevated, stage 1 hypertension, and stage 2 hypertension thresholds.
Document findings for each vital sign and clean all non-disposable equipment after use to maintain infection control.
Transcripts
hey everyone it's sarah thread sterner
sorry and calm and today I want to
demonstrate how to take bottle 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 patience and
contact precautions you'll want to put
on the correct PPE now what is collected
during the bottle 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
bottle son along with the 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 skills most commonly we use the
0 to 10 numerical scale so can you tell
me your pain with zero being no pain at
all to 10 being the worst pain you've
ever had what what's your 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 8 well
you would want to ask some more
questions you and I say where's your
pain located at and please can you
describe it for me like
burning as a 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 in 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 they're nice and warm in
pink so we'll turn on our device and we
will place it on the finger and let it
get a reading and here the patient's
oxygen saturation is 97% a normal oxygen
saturation is anywhere between 95 to a
hundred percent 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 an adult it's considered a
temperature if the temperature is
greater than a hundred point four
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
tympanic lis 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 gonna 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 her
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 our 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
gonna 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 gonna 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 gonna
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 skill with zero being
the pulses absent one plus week 2 plus
normal and three 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 set and
bad they can lie down and you'll want to
support their arm extended out in some
horde 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
thirty seconds if the pulse is regular
and multiply that number by two if it's
irregular count it for one full minute
so his heart rate is 82 its regular and
it's two plus and a normal heart rate 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 going to 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 unlaid 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
game their clothes are they rising and
falling because one rise and one fall
equals one respiration you could also
sometimes just gently take your hand put
it on their back and fill 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 a patient is sitting down with
their arm at heart level and their legs
are uncross 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
our blood pressure cuff and you want to
make sure you get the right size cuff
for your patients arm because if you use
too big of a cuff or too small of a cup
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
Kufner 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 gonna put the cuff 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 now the whole reason for doing
that is because we want to avoid missing
the oscillatory gap that can occur in
some patients all patients have it but
some and it's usually patients with
hypertension because the oscar tory gap
is like this abnormal silence that
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 thirty to
sixty seconds and then we'll take the
blood pressure
so we're 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 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-pitched noises so we're going to
place that over the brachial artery do
it lightly don't fully compress it
because you can include the artery then
we're going to inflate our cuff to a
hundred and thirty millimeters of
mercury and we're going to let it fall
about two millimeters of mercury per
second and we're listening for that
first sandwiches our systolic number
okay is 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
not disposable and you will document the
blood pressure and what arm you took it
in now water normal blood pressure
readings according to the American
College of Cardiology 2017 updated
guidelines a normal blood pressure is a
systolic less than 120 and a diastolic
less than 80
elevated blood pressure would be
considered a systolic of 120 to 129 and
a diastolic less than 80 hypertension
stage 1 would be a systolic of
thirty to 139 or a diastolic eighty to
eighty nine and hypertension Stage two
would be a systolic greater than 140 and
a diastolic greater than ninety okay so
that wraps up this demonstration on how
to check vital signs thank you so much
for watching and don't forget to
subscribe to our channel for more videos
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