YouTube Vital Signs
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
0:07
7 seconds
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
0:15
15 seconds
pulse ox a watch and some gloves along with a disinfectant wipe to clean the items that are not disposable then what
0:24
24 seconds
you want to do is you want to perform hand hygiene and Don the appropriate PPE if necessary like if your patience and
0:32
32 seconds
contact precautions you'll want to put on the correct PPE now what is collected during the bottle sign measurement well
0:40
40 seconds
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
0:48
48 seconds
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
57 seconds
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
1:04
1 minute, 4 seconds
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
1:12
1 minute, 12 seconds
their armband having them tell you their name and their date of birth then I like to start with the easiest thing which is
Chapter 2: Pain
1:20
1 minute, 20 seconds
pain and so I'm going to ask him his pain level now this is a very easy and important assessment tool because high
1:28
1 minute, 28 seconds
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
1:35
1 minute, 35 seconds
really important especially to ask a patient their pain level if they've just had surgery or some type of trauma so to
1:42
1 minute, 42 seconds
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
1 minute, 51 seconds
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
1:59
1 minute, 59 seconds
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
2:08
2 minutes, 8 seconds
pain located at and please can you describe it for me like burning as a radiating things like that
2:15
2 minutes, 15 seconds
and then you want to document that the numerical rating along with the words that the patient used to describe the
2:22
2 minutes, 22 seconds
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
Chapter 3: Oxygen
2:31
2 minutes, 31 seconds
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
2:38
2 minutes, 38 seconds
to obtain the reading so make sure that you pick some fingers that have good circulation they're nice and warm in
2:45
2 minutes, 45 seconds
pink so we'll turn on our device and we will place it on the finger and let it
2:53
2 minutes, 53 seconds
get a reading and here the patient's oxygen saturation is 97% a normal oxygen saturation is anywhere between 95 to a
3:02
3 minutes, 2 seconds
hundred percent and below you can also see the heart rate as well but here in a moment we will actually check the heart
3:09
3 minutes, 9 seconds
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
3:17
3 minutes, 17 seconds
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
Chapter 4: Body Temperature
3:26
3 minutes, 26 seconds
anywhere between 97 to 99 degrees Fahrenheit with the average being about 98.6 degrees Fahrenheit
3:35
3 minutes, 35 seconds
orally and an adult it's considered a temperature if the temperature is greater than a hundred point four degrees Fahrenheit now the temperature
3:43
3 minutes, 43 seconds
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
3:52
3 minutes, 52 seconds
tympanic lis which is via the ear rectally or axillary via the armpits and a rule of thumb to remember is that
4:00
4 minutes
rectal and tympanic temperatures will be one degree higher than the oral route and temperatures that are collected via
4:07
4 minutes, 7 seconds
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
4:16
4 minutes, 16 seconds
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
4:25
4 minutes, 25 seconds
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
4:33
4 minutes, 33 seconds
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
4:40
4 minutes, 40 seconds
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
4:49
4 minutes, 49 seconds
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
4:59
4 minutes, 59 seconds
you'll hear it beeping and scan it to the hairline and look at our temperature now if your patient was sweating on the
5:06
5 minutes, 6 seconds
forehead because a lot of times whenever patients have fevers they can sweat you would want to do it the same way probe
5:14
5 minutes, 14 seconds
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
5:23
5 minutes, 23 seconds
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
5:32
5 minutes, 32 seconds
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
5:39
5 minutes, 39 seconds
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
Chapter 5: Pulse
5:48
5 minutes, 48 seconds
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
5:55
5 minutes, 55 seconds
the pulses absent one plus week 2 plus normal and three plus bounding and the
6:02
6 minutes, 2 seconds
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
6:11
6 minutes, 11 seconds
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
6:19
6 minutes, 19 seconds
it in this wrist area along the radial bone hence why we call it the radial artery and whenever you're checking the
6:26
6 minutes, 26 seconds
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
6:35
6 minutes, 35 seconds
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
6 minutes, 41 seconds
three fingers and find it within that area I just told you and lightly just
6:47
6 minutes, 47 seconds
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
6:57
6 minutes, 57 seconds
thirty seconds if the pulse is regular and multiply that number by two if it's irregular count it for one full minute
7:05
7 minutes, 5 seconds
so his heart rate is 82 its regular and it's two plus and a normal heart rate an
7:12
7 minutes, 12 seconds
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
7:20
7 minutes, 20 seconds
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
7:28
7 minutes, 28 seconds
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
Chapter 6: Respiratory Rate
7:36
7 minutes, 36 seconds
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
7:43
7 minutes, 43 seconds
the depth is it labored or unlaid and the rhythm are the breaths regular or irregular and I have found the easiest
7:51
7 minutes, 51 seconds
way to do this is really look at the patient from the side and watch their game their clothes are they rising and
7:59
7 minutes, 59 seconds
falling because one rise and one fall equals one respiration you could also sometimes just gently take your hand put
8:06
8 minutes, 6 seconds
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
8:13
8 minutes, 13 seconds
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
8:22
8 minutes, 22 seconds
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
Chapter 7: Blood Pressure
8:29
8 minutes, 29 seconds
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
8:37
8 minutes, 37 seconds
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
8 minutes, 46 seconds
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
8:54
8 minutes, 54 seconds
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
9:03
9 minutes, 3 seconds
systolic number which is that top number and this is the first sound we hear and then our diastolic number which is the
9:11
9 minutes, 11 seconds
bottom number and this is the point where we no longer hear the sound so whenever we're looking at the gauge of
9:17
9 minutes, 17 seconds
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
9:25
9 minutes, 25 seconds
we're going to do is we're going to put our cuff on our patient and we want to
9:33
9 minutes, 33 seconds
make sure we find the brachial artery this is the artery we palpate that we'll be using to determine our blood pressure
9:40
9 minutes, 40 seconds
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
9:49
9 minutes, 49 seconds
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
9:56
9 minutes, 56 seconds
direction of where that artery is so you're gonna put the cuff up about two inches above the bend of the arm first
10:05
10 minutes, 5 seconds
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
10:14
10 minutes, 14 seconds
artery and we're going to inflate the cuff until I no longer feel the brachial artery and at that point when I no
10:22
10 minutes, 22 seconds
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
10:30
10 minutes, 30 seconds
when I go to take the blood pressure I'm going to inflate the cuff 30 millimeters of mercury more than that estimated
10:37
10 minutes, 37 seconds
number now the whole reason for doing that is because we want to avoid missing the oscillatory gap that can occur in
10:44
10 minutes, 44 seconds
some patients all patients have it but some and it's usually patients with hypertension because the oscar tory gap
10:52
10 minutes, 52 seconds
is like this abnormal silence that occur and it will throw off whenever you actually hear that first sound which is
10:59
10 minutes, 59 seconds
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
11:06
11 minutes, 6 seconds
longer feel the artery which is about at the hundred then I'm going to deflate it
11:15
11 minutes, 15 seconds
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
11:24
11 minutes, 24 seconds
cuff to a hundred and thirty and that will avoid missing the oscillatory gap if one was present so I'm going to take
11:31
11 minutes, 31 seconds
my stethoscope put it in my ears you can use the bell or the diaphragm of your stethoscope I like to use the Bell
11:41
11 minutes, 41 seconds
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
11:49
11 minutes, 49 seconds
because you can include the artery then we're going to inflate our cuff to a hundred and thirty millimeters of
11:56
11 minutes, 56 seconds
mercury and we're going to let it fall about two millimeters of mercury per second and we're listening for that
12:05
12 minutes, 5 seconds
first sandwiches our systolic number okay is 104 and we're listening for that
12:14
12 minutes, 14 seconds
last sound and it was 78 so the blood pressure is 104 over 78 then once you
12:22
12 minutes, 22 seconds
have your reading make sure you fully deflate the cuff full of air and you're going to take the cuff off of your
12:29
12 minutes, 29 seconds
patient of course and clean it if it's not disposable and you will document the
12:36
12 minutes, 36 seconds
blood pressure and what arm you took it in now water normal blood pressure readings according to the American
12:43
12 minutes, 43 seconds
College of Cardiology 2017 updated guidelines a normal blood pressure is a systolic less than 120 and a diastolic
12:52
12 minutes, 52 seconds
less than 80 elevated blood pressure would be considered a systolic of 120 to 129 and
12:59
12 minutes, 59 seconds
a diastolic less than 80 hypertension stage 1 would be a systolic of
13:06
13 minutes, 6 seconds
thirty to 139 or a diastolic eighty to eighty nine and hypertension Stage two
13:13
13 minutes, 13 seconds
would be a systolic greater than 140 and a diastolic greater than ninety okay so that wraps up this demonstration on how
13:21
13 minutes, 21 seconds
to check vital signs thank you so much for watching and don't forget to subscribe to our channel for more videos