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.
Introduction and Preparation
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.
Components of Vital Sign Measurement
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
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.
Oxygen Saturation Measurement
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.
Temperature Measurement
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.
Pulse Measurement
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.
Respiration Measurement
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.
Blood Pressure Measurement
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.
Understanding Blood Pressure Readings
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.
