Mastering Vital Signs: A Comprehensive Guide for Nurses

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