Basic Nursing Skills

Vital signs (VS)

  • Indicators of basic bodily functions

  • Reflections of what the body automatically regulates

    • How fast the heart beats

    • The internal temperature of the body

    • The rate at which a person breathes

Key vital signs:

  • Temperature

  • Pulse

  • Respirations

  • Blood pressure

  • Pulse oximetry

The fifth/sixth vital sign in pain

VS are measured and compared to normal values. Also, against those considered normal for the individual.

  • As needed:

    • Before and after medication

    • Pre/post-op

    • Emergancy

    • After a fall/accident or other incident

Temperature

  • Measurement of body heat

    • Consistent if healthy

    • Core temperature is higher than peripheral and surface

    • “normal” is individualized

  • Febrile vs afebrile

    • 0.5-1.0 degree higher/lower is considered normal

  • Hypothermia is temp below 97 degrees F

Temperature methods:

  • Oral

  • Ear/Tympanic

  • Rectal (core measure)

  • Temporal (core measure)

  • Axillary

Measuring Temperature

  • Oral: Under the tongue

  • Rectal: Lubricated probe, inserted 1 inch

  • Axillary: Under the armpit

  • Tympanic: In the ear canal

  • Temporal: Across the forehead

Important Considerations When Checking Patient Temperature:

Contraindications to the Oral Route:

  • Recent oral surgery

  • Ongoing oxygen therapy

  • Seizure disorders

  • Recent drinking or smoking

Contraindications to the Rectal Route:

  • Hemorrhoids

  • Rectal bleeding

Pulse

  • Heartbeats per minute

  • Measurement Site:

    • Radial - palpate

    • Apical - auscultation

Measuring Pulse

Peripheral Pulse:

  1. Within 2nd and 3rd fingers locate the peripheral pulse (radial most common)

  2. Count the number of beats for 30 seconds, multiply x2 = beats per minute

  3. Irregular pulse - always count x60 seconds

Apical Pulse:

  1. Place stethoscope on chest wall over apex of heart

  2. Count the beats

  3. ALWAYS count an apical pulse x60 seconds

  4. Pulse rate should be the same no matter where on the body it’s taken

Abnormal Pulse

Tachycardia: rapid HR greater than 100 bpm

Bradycardia: Slow HR less than 60 bpm

TELL THE NURSE!!

  • The person’s pulse rate is higher than normal

  • The person’s pulse rate is lower than normal

  • The person’s pulse rhythm is irregular

  • The perosn’s pulse is weak or “thready”

  • You have difficulty rtakinf the person’s pulse

Respiratory Rate

  • Breaths per minute

  • Indicated respiratory function

  • What affects rate?

    • Pain

    • Anxiety

    • Fear

Measuring respiration:

  • Observe chest rise and fall

  • Count for 60 seconds or for 30 seconds and multiply by 2

Abnormal resperation;

  • Tachypnea:

    • Rapid breathing rate greater than 24 (adult)

  • Bradypnea:

    • Slow breathing rate less than 10 (adult)

  • Dyspnea:

    • Labored or difficult

  • Hyperventilation:

    • Increased rate/depth

  • Hypoventilation:

    • Decreased rate/depth

TELL THE NURSE!!

  • The person’s respiratory rate is greater than 24 breaths per minute

  • The person’s respiratory rate is less than 10 breaths per minute

  • The person’s respiratory rhythm is irregular