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.

Outlines

00:00

🩺 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.

05:02

🌡️ 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.

10:06

💓 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.

Keywords

💡Vital Signs

Vital signs are the measurements of the body's basic functions, including blood pressure, heart rate, respirations, and temperature. In the video, the speaker describes how to collect these measurements as part of routine patient assessments, demonstrating their importance in monitoring a patient's health status.

💡Blood Pressure

Blood pressure measures the force of blood pushing against the walls of arteries. The video explains how to measure it using a stethoscope and a blood pressure cuff, highlighting the importance of correct cuff size and technique. The speaker also covers normal ranges and stages of hypertension as per updated guidelines.

💡Heart Rate

Heart rate refers to the number of heartbeats per minute. In the video, the speaker checks the pulse at the radial artery using fingers and explains how to assess whether the pulse is regular or irregular. Heart rate is a key indicator of cardiovascular health, with a normal range of 60-100 beats per minute in adults.

💡Respirations

Respirations refer to the number of breaths a person takes per minute. The speaker explains how to assess breathing by observing the rise and fall of the chest and discusses the importance of not alerting the patient to avoid altered breathing patterns. A normal respiratory rate for adults is 12-20 breaths per minute.

💡Oxygen Saturation

Oxygen saturation measures the percentage of oxygen-carrying hemoglobin in the blood. The video demonstrates the use of a pulse oximeter to check oxygen levels, typically between 95-100%. This is crucial for assessing a patient's respiratory function, particularly in conditions like COPD or during post-surgical recovery.

💡Pain Scale

The pain scale is a tool used to measure the intensity of a patient’s pain, typically on a scale from 0 (no pain) to 10 (worst pain). The video refers to pain as the 'fifth vital sign' and emphasizes how pain can influence other vital signs like blood pressure and heart rate, making it essential to assess regularly.

💡Thermometer

A thermometer is a device used to measure body temperature. The speaker explains different methods to take temperature, including oral, rectal, tympanic, and temporal. The video highlights the importance of knowing which method to use as different routes can yield slightly different temperature readings.

💡Pulse Oximeter

A pulse oximeter is a medical device that measures oxygen saturation by attaching to a patient’s finger. The video demonstrates how to use this device and how to ensure an accurate reading by choosing fingers with good circulation. It plays a crucial role in monitoring oxygen levels in patients.

💡Personal Protective Equipment (PPE)

PPE refers to protective gear such as gloves and masks used to protect healthcare workers from contamination. The video stresses the importance of wearing appropriate PPE, especially when patients are in contact precautions, to prevent the spread of infection during vital sign collection.

💡Systolic and Diastolic Pressure

Systolic and diastolic pressures are the two components of blood pressure. Systolic is the top number, indicating the pressure when the heart beats, and diastolic is the bottom number, showing the pressure when the heart is at rest. The speaker describes how to identify these readings while taking blood pressure, explaining their relevance in diagnosing conditions like hypertension.

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