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

RegisteredNurseRN
13 May 201913:28
EducationalLearning
32 Likes 10 Comments

TLDRIn this informative video, Sarah Thread Sterner demonstrates the proper technique for taking a patient's vital signs, including blood pressure, heart rate, respirations, temperature, and pain rating. She emphasizes the importance of hand hygiene, using appropriate PPE, and accurate patient identification. Sarah also explains how to assess pain levels, measure oxygen saturation, and correctly interpret temperature readings. The video provides a step-by-step guide on checking vital signs, ensuring accurate and reliable results for better patient care.

Takeaways
  • 🧼 Hand hygiene and appropriate PPE are essential before starting the procedure.
  • 📝 Gather necessary supplies including stethoscope, blood pressure cuff, thermometer, pulse oximeter, watch, gloves, and disinfectant wipes.
  • 👋 Introduce yourself to the patient and explain the procedure to ensure their comfort and cooperation.
  • 🌟 Assess the patient's pain level first using a 0 to 10 numerical scale and document the rating and description.
  • 📊 Check oxygen saturation using a pulse oximeter on the patient's finger, with normal levels between 95-100%.
  • 🌡️ Measure body temperature using various methods (oral, forehead, tympanic, rectal, axillary) and note the route for accurate records.
  • 💓 Evaluate the patient's pulse, grading its strength and rhythm, with a normal rate of 60-100 beats per minute.
  • 👃 Assess respirations without altering the patient's natural breathing pattern, observing rate, depth, and rhythm.
  • 🩸 Measure blood pressure correctly, ensuring the cuff is at heart level and using the correct size for the patient's arm.
  • 🏥 Document all findings accurately, including pain levels, oxygen saturation, temperature, pulse, respirations, and blood pressure.
  • 📈 Understand the classification of blood pressure according to the American College of Cardiology 2017 guidelines.
Q & A

  • What are the supplies typically needed to take vital signs?

    -The supplies needed include a stethoscope with a blood-pressure cuff, a thermometer, a pulse oximeter, a watch, gloves, and disinfectant wipes for non-disposable items.

  • What is the first step in the process of taking vital signs?

    -The first step is to perform hand hygiene and don the appropriate Personal Protective Equipment (PPE) if necessary.

  • How does one assess a patient's pain level?

    -A patient's pain level is assessed using a 0 to 10 numerical scale, with zero being no pain at all and ten being the worst pain the patient has ever experienced.

  • Why is it important to assess pain levels, especially in patients who have had surgery or trauma?

    -High pain ratings can alter vital signs, increasing heart rate, blood pressure, and respirations, which is why it's crucial to assess pain levels to obtain accurate vital sign measurements.

  • What is the normal range for oxygen saturation?

    -A normal oxygen saturation is anywhere between 95 to 100 percent.

  • How does one measure a patient's body temperature using the temporal artery?

    -A temporal artery thermometer is used by holding the probe flush against the skin at the center of the forehead, scanning it across to the hairline, and reading the temperature displayed.

  • What are the different sites to check a patient's pulse and why is the radial artery commonly used?

    -The pulse can be checked at various sites including the radial, carotid, or femoral arteries. The radial artery is commonly used because it is easily accessible and found below the thumb in the wrist area along the radial bone.

  • How is the respiratory rate assessed and what are the normal parameters?

    -The respiratory rate is assessed by observing the rise and fall of the chest or patient's clothes, which equates to one respiration. A normal breathing rate in an adult is 12 to 20 breaths per minute.

  • What is the correct procedure for measuring blood pressure and what are the normal readings according to the American College of Cardiology 2017 guidelines?

    -Blood pressure is measured with a stethoscope and cuff at heart level. The first sound heard indicates systolic pressure and the last sound indicates diastolic pressure. According to the ACC 2017 guidelines, a normal blood pressure is a systolic less than 120 and a diastolic less than 80.

  • Why is it important to estimate the systolic pressure before taking a blood pressure reading?

    -Estimating the systolic pressure helps avoid missing the oscillatory gap that can occur in some patients, particularly those with hypertension, ensuring accurate blood pressure readings.

  • What should be done after obtaining all vital signs?

    -After obtaining all vital signs, one should fully deflate the blood pressure cuff, remove it from the patient, clean it if it's not disposable, and document all findings.

Outlines
00:00
🩺 Introduction to Vital Signs Assessment

The video begins with Sarah Thread Sterner introducing herself and explaining the process of taking vital signs. She emphasizes the importance of gathering necessary supplies such as a stethoscope, blood-pressure cuff, thermometer, pulse oximeter, watch, gloves, and disinfectant wipes. Sarah also highlights the significance of hand hygiene and wearing appropriate Personal Protective Equipment (PPE). The first step in the assessment is to ask the patient about their pain level using a 0 to 10 numerical scale, which is crucial as pain can affect other vital signs. Sarah demonstrates how to document the patient's pain rating and describes the procedure for measuring oxygen saturation using a portable probe on the patient's finger.

05:02
🌡️ Measuring Body Temperature and Oxygen Saturation

In this section, Sarah explains the importance of measuring body temperature and provides a detailed explanation of the different routes for taking a temperature, including oral, forehead, temporal, tympanic, rectal, and axillary. She notes that the normal temperature range for an adult is between 97 to 99 degrees Fahrenheit orally, and a fever is considered if the temperature is above 100.4 degrees Fahrenheit. Sarah then demonstrates how to measure temperature using the temporal artery method, emphasizing the need for a clear forehead for accurate readings. She also discusses how to properly clean and document the findings. Following this, Sarah moves on to assess the patient's pulse, focusing on the rate, strength, and rhythm, and explains how to count the pulse for 30 seconds or a full minute depending on its regularity.

10:06
💓 Assessing Heart Rate and Respirations

Sarah continues the vital signs assessment by checking the patient's respirations. She advises on the best practices for observing the breathing rate, depth, and rhythm without causing the patient discomfort. Sarah explains that a normal adult respiratory rate is 12 to 20 breaths per minute. She then transitions to measuring blood pressure, stressing the importance of having the patient at heart level and using the correct size cuff. Sarah demonstrates how to estimate systolic pressure by palpating the brachial artery and inflating the cuff above the point where the pulse disappears. She provides a detailed walkthrough of taking blood pressure using a stethoscope and explains the significance of systolic and diastolic readings. Sarah concludes by discussing normal blood pressure guidelines according to the American College of Cardiology and how to document the findings properly.

Mindmap
Keywords
💡Vital Signs
Vital signs are the essential indicators of a person's physical state, which include measurements like blood pressure, heart rate, respiratory rate, temperature, and pain level. In the video, the nurse demonstrates how to assess these signs systematically to evaluate a patient's health condition. This is crucial as changes in vital signs can signal various health issues or responses to medical treatments.
💡Stethoscope
A stethoscope is a medical instrument used for listening to the internal sounds of a patient's body, such as their heartbeat and breathing. It is an essential tool for medical professionals when assessing vital signs. In the video, the nurse uses a stethoscope to listen to the patient's heart and lungs, which helps in determining the heart rate and respiratory rate.
💡Blood-Pressure Cuff
A blood-pressure cuff is a device used in conjunction with a stethoscope to measure blood pressure. It operates by inflating around the upper arm and listening for the sounds of blood flow through the brachial artery. The nurse in the video demonstrates the correct placement of the cuff and the technique for finding the brachial artery to accurately measure blood pressure.
💡Thermometer
A thermometer is an instrument used to measure body temperature. It is vital in assessing a patient's overall health, as fever can indicate the presence of an infection or other medical conditions. The video mentions the use of a thermometer to collect the patient's body temperature data.
💡Pulse Oximeter
A pulse oximeter is a non-invasive device that measures the oxygen saturation level in a patient's blood. It is clipped onto the finger and provides a reading of the oxygen level, which is crucial for assessing a patient's respiratory function. In the video, the nurse uses a pulse oximeter to check the patient's oxygenation status.
💡Hand Hygiene
Hand hygiene refers to the practice of cleaning hands to remove dirt, bacteria, or viruses and prevent the spread of infections. In the healthcare setting, it is a critical step before any patient contact to maintain a sterile environment and protect both the healthcare provider and the patient. The video emphasizes the importance of performing hand hygiene before beginning the assessment of vital signs.
💡PPE (Personal Protective Equipment)
Personal Protective Equipment (PPE) includes garments and equipment used to protect the wearer from health or safety hazards, such as infectious diseases. In the context of the video, PPE like gloves and other disposable items are used when necessary to prevent cross-contamination and protect both the patient and the healthcare provider.
💡Pain Rating
Pain rating is a subjective measure of the intensity of pain felt by a patient, often assessed using a numerical scale from 0 to 10. This rating is important as it provides healthcare providers with information about the patient's pain experience, which can influence vital signs and overall well-being. In the video, the nurse asks the patient to rate their pain level to better understand their current condition.
💡Oxygen Saturation
Oxygen saturation refers to the percentage of hemoglobin in the blood that is bound to oxygen. It is an important indicator of a person's respiratory function and overall health. A normal oxygen saturation level is between 95 to 100%. In the video, the nurse measures the patient's oxygen saturation using a pulse oximeter to ensure that the patient's oxygen levels are within a healthy range.
💡Respirations
Respirations refer to the act of breathing, specifically the rate at which a person inhales and exhales. In adults, a normal respiratory rate is between 12 to 20 breaths per minute. Monitoring respirations is a key part of assessing a patient's vital signs and can indicate potential respiratory issues or the patient's response to medical conditions. The video demonstrates how to assess the patient's respirations without causing the patient to alter their natural breathing pattern.
💡Blood Pressure Reading
A blood pressure reading is a numerical representation of the force exerted by the blood against the walls of the blood vessels. It is typically expressed as two numbers: systolic and diastolic, written as 'systolic/diastolic'. The systolic number indicates the pressure when the heart beats and pushes blood through the circulatory system, while the diastolic number represents the pressure when the heart is at rest. In the video, the nurse explains the process of obtaining an accurate blood pressure reading and the significance of the readings in relation to the patient's health.
Highlights

Introduction to the process of taking vital signs using a stethoscope, blood-pressure cuff, thermometer, pulse oximeter, and other necessary equipment.

The importance of hand hygiene and the use of Personal Protective Equipment (PPE) when taking vital signs.

The need to verify patient identifiers such as name and date of birth to ensure accurate data collection.

Assessing a patient's pain level using a numerical scale and documenting the pain's description and location.

Measuring a patient's oxygen saturation and the significance of a normal oxygen saturation range.

The various methods for measuring body temperature and the impact of the route on the reading.

Utilizing a temporal artery thermometer for a non-invasive body temperature measurement.

The process of checking a patient's pulse, including rate, strength, and rhythm, and the optimal site for pulse checking.

Assessing a patient's respirations by observing the rate, depth, and rhythm without altering the patient's natural breathing pattern.

The correct procedure for measuring blood pressure, including the proper placement of the cuff and the importance of the brachial artery.

Estimating systolic pressure by palpating the brachial artery and inflating the cuff accordingly.

The significance of avoiding the oscillatory gap when measuring blood pressure, especially in hypertensive patients.

The use of a stethoscope's bell for detecting low-pitched noises during blood pressure measurement.

The American College of Cardiology's 2017 updated guidelines for classifying blood pressure readings.

The necessity of documenting all findings and the method used for temperature measurement.

The conclusion of the demonstration and a call to action for viewers to subscribe for more informative content.

Transcripts

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