Vital Signs Nursing: Respiratory Rate, Pulse, Blood Pressure, Temperature, Pain, Oxygen

Summary

In 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.