Brief Summary
This video by RegisteredNurseRN provides a step-by-step demonstration of how to accurately measure vital signs, including pain level, oxygen saturation, temperature, pulse, respirations, and blood pressure. It emphasizes the importance of proper technique, equipment, and patient communication to ensure accurate readings and patient safety.
- Proper technique and equipment are crucial for accurate vital sign measurement.
- Patient communication and comfort are essential throughout the process.
- Understanding normal ranges and potential variations is important for interpreting vital signs.
The video begins with an introduction to the process of taking vital signs. Essential supplies include a stethoscope, blood pressure cuff, thermometer, pulse oximeter, watch, gloves, and disinfectant wipes. The initial steps involve performing hand hygiene and donning appropriate personal protective equipment (PPE) based on the patient's condition, such as contact precautions.
The core components of vital sign measurement include blood pressure, heart rate, respirations, and temperature. Additionally, assessing the patient's pain level, often referred to as the fifth vital sign, and oxygen saturation are crucial. The nurse introduces herself to the patient, explains the procedure, and verifies patient identity using their armband and verbal confirmation of name and date of birth.
Pain assessment is a critical component of vital signs, as pain can influence other measurements like heart rate, blood pressure, and respirations. The video demonstrates the use of a 0-10 numerical pain scale, where 0 represents no pain and 10 represents the worst pain imaginable. If a patient reports pain, further assessment includes asking about the location and characteristics of the pain, such as whether it is burning or radiating, and documenting both the numerical rating and the patient's description.
To measure oxygen saturation, a pulse oximeter is used, either a portable device or one connected to a bedside monitor. The device is placed on a finger with good circulation, ensuring the nail bed is properly aligned with the probe. A normal oxygen saturation range is typically between 95% and 100%. The device also displays the heart rate. After use, the probe should be cleaned with a disinfectant wipe, and the findings documented.
Body temperature in adults can range from 97 to 99 degrees Fahrenheit, with an average of 98.6 degrees Fahrenheit orally. A temperature above 100.4 degrees Fahrenheit is considered a fever. Temperature can be measured via various routes, including orally, via the forehead using a temporal artery thermometer, tympanically (ear), rectally, or axillary (armpit). Rectal and tympanic temperatures are generally one degree higher than oral, while axillary and temporal temperatures are one degree lower. The video demonstrates using a temporal artery thermometer, emphasizing the importance of ensuring the probe makes direct contact with the skin and scanning across the forehead to the hairline. If the patient is sweating, scanning behind the ear can provide a more accurate reading. The device should be cleaned after use, and the route of administration documented.
When measuring the pulse, the rate, strength, and rhythm are assessed. The strength is graded on a scale of 0 to 3+, with 0 being absent, 1+ weak, 2+ normal, and 3+ bounding. In adults, the radial artery is commonly used due to its accessibility. The patient's arm should be supported and extended, and the first three fingers (not the thumb) are used to palpate the pulse. If the pulse is regular, count for 30 seconds and multiply by two; if irregular, count for a full minute. A normal adult heart rate is 60 to 100 beats per minute. The rate, rhythm, and strength should be documented.
Respirations are assessed for rate, depth, and rhythm. A normal adult respiratory rate is 12 to 20 breaths per minute. The depth should be noted as labored or unlabored, and the rhythm as regular or irregular. To avoid the patient consciously altering their breathing, respirations are often assessed while still palpating the radial pulse. Observing the rise and fall of the chest or gently placing a hand on the patient's back can aid in counting respirations. Count for 30 seconds if regular, and multiply by two; if irregular, count for a full minute, and document the findings.
For accurate blood pressure measurement, the patient should be seated with their arm at heart level and legs uncrossed. If the patient is lying down, ensure the arm is supported at heart level. The correct size cuff is essential to avoid inaccurate readings. Palpate the brachial artery in the bend of the arm to determine where to place the cuff. The cuff should be positioned about two inches above the brachial artery, aligning the arrow on the cuff with the artery. First, estimate the systolic pressure by palpating the brachial artery while inflating the cuff until the pulse is no longer felt, noting the pressure on the gauge. Deflate the cuff completely and wait 30-60 seconds. When taking the blood pressure, inflate the cuff 30 mmHg above the estimated systolic pressure to avoid missing the auscultatory gap, an abnormal silence that can occur in some patients with hypertension. Place the stethoscope over the brachial artery, inflate the cuff to the determined pressure, and release the pressure at a rate of about 2 mmHg per second, listening for the first sound (systolic) and the point at which the sound disappears (diastolic). Record the blood pressure, noting the arm used.
According to the 2017 American College of Cardiology guidelines, a normal blood pressure is less than 120/80 mmHg. Elevated blood pressure is 120-129/<80 mmHg. Hypertension Stage 1 is 130-139/80-89 mmHg, and Hypertension Stage 2 is greater than 140/90 mmHg.
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Transcript
Full transcript of “Vital Signs Nursing: Respiratory Rate, Pulse, Blood Pressure, Temperature, Pain, Oxygen”. Click a timestamp to open the video at that moment. Need another video? Use the YouTube transcript generator.
0:00 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
0:57 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
1:51 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
2:50 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
3:50 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
4:47 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
5:43 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
6:41 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
7:46 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
8:46 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
9:44 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
10:47 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
11:51 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
12:48 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
