Vital Signs and How to Check Them
Measuring Vital Signs
Welcome to this video tutorial.
In this video we are going to look at the six most important vital signs we assess when caring for patients.
We will discuss the purpose of each measurement and how to perform each one.
This video will address the vital sign norms, variations and how often you should perform each one.
Assessing a temperature:
A person’s body temperature can signal warning signs.
If a patient’s body temperature is too low it may indicate neurovascular problems. If a patient’s body temperature is too high it usually indicates signs of infection.
This vital sign can be assessed in different locations using a thermometer. There are different types of thermometers depending on the facility you work in.
Therefore make sure you are trained on how to use your facilities equipment.
Orally means taking the temperature by mouth placing the thermometer underneath the tongue.
Axillary means placing the thermometer underneath the patient’s armpit. This method is widely used in the hospital because it is the most convenient and will work well with adults and pediatric patients.
Temporal is a method often seen in critical care units. This method requires a special thermometer, which is placed on the forehead.
Taking a temperature rectally requires careful consideration and is not used in the hospital too often. However, It is said to be one of the more accurate measurements of the body’s true temperature.
A tympanic temperature measures the body’s temperature by placing a specially made thermometer inside the patient’s ear canal near the tympanic membrane. The normal temperature for adults is 97 degrees Fahrenheit to 99 degrees Fahrenheit (36.1 to 37.2 degrees Celsius).
Remember: When checking a patient’s temperature, make sure you use the correct site with the correct equipment. Also, temperatures taken axillary and temporally typically tend to be one degree lower and rectal and tympanic temperatures tend to read one degree higher than the oral temperature.
Assessing the Pulse or Heart rate.
Assessing a patient’s heart rate is a vital component of checking on the patient’s overall health.
If a patient’s heart rate is too low this may indicate signs of poor cardiac perfusion. This condition is called Bradycardia and may lead to fainting or syncope and if prolonged may lead to cardiac arrest.
If a patient’s heart rate is too high this may indicate that the heart is beating too fast and therefore the blood is not being pumped effectively. This may deprive your organs and tissues of their required blood volume. This condition is called Tachycardia and if prolonged may cause stroke, sudden cardiac arrest, and death.
There are several sites we can use to assess the patient’s heart rate:
The radial (which is most commonly used) and is located on the wrist just beneath the thumb.
The brachial pulse, which is felt over the brachial artery at the inner aspect of the elbow, is usually palpated just before taking a blood pressure.
A pedal pulse is palpated on top of the foot and is usually used to determine the health of the peripheral vascular system.
Then there is the femoral artery used to determine the health of the heart and often used as a site for a cardiac catheterization.
The apical pulse, which is most accurate, can be assessed by placing your stethoscope at the 5th clavicular space just below the left breast.
Normal heart rate in an adult is 60-100 beats per minute.
Remember: Count the heart rate for a full minute. Make sure you note the rhythm and rate in your documentation.
How to measure a patient’s respirations:
The best way to count a patient’s respirations is to begin immediately following the apical heart rate. This method allows you to listen to the respiratory sounds and count at the same time.
Do not tell the patient that you are counting respirations because patients tend to change their breathing. The purpose of this vital sign is to give us a small picture of how well the respiratory system is functioning.
While the stethoscope is positioned on the patient’s chest count each breath. Normal respiratory rate in an adult is 12-20 breaths per minute.
Remember: Count the respiratory rate for one full minute. Make sure you note the rate, rhythm, and sounds.
How to measure Blood Pressure:
The patient’s blood pressure gives us an indication of how well the heart is performing.
If the pressure is too high a patient could suffer a stroke.
If the pressure is too low a patient is not perfusing well and could go into cardiac arrest.
It is important to assess the blood pressure of our patients to get a baseline.
- Always ask the patient which arm they prefer you use. Make sure you ask the patient if they’ve had any surgeries on either arm.
- Ask the patient to sit completely upright with their palms facing up. Make sure they do not cross their legs and feet remain flat on the floor. The arm you’ve chosen should be palms up and slightly bent.
- To palpate the brachial artery, draw an imaginary line from the patient’s pinky finger up toward the inner elbow. This is where you will place your stethoscope.
- Now place the blood pressure cuff (sphygmomanometer) about an inch above this location with the arrow on the cuff located directly above your target area.
- Make sure you use the proper cuff size. A blood pressure cuff too big or too small may cause an incorrect reading.
- Once the cuff is in place turn the air release valve clockwise to close. With your stethoscope and the blood pressure cuff in place, pump the rubber bulb until you can hear no sounds.
- Once you’ve reached your target number, which should be about 30 millimeters above the patient’s normal reading, begin to slowly release the air valve by turning it counterclockwise.
The cuff should release at a rate of two to three millimeters per second. Make sure you are in a quiet place and you pay attention to each sound. The first sound heard will be your systolic (the number that goes on top). The last sound heard will be your diastolic (the number that goes on the bottom). Normal blood pressure for an adult should be below 120/80.
Remember: It is vital that you find out your patients normal pressure. If unknown by the patient, use other assessment questions, such as history, to establish parameters.
How to assess the Pulse Oximetry:
The pulse oximetry measures the amount of oxygen in a patient’s blood.
The ideal pulse oximetry rate is 96-100%. Different facilities use different machines and techniques to monitor pulse oximetry.
This vital sign is especially important for someone who has respiratory or cardiac issues.
The method used may vary. However, usually the finger, toes, foot, or earlobe are used to gain this reading.
The method depends on the facility, condition, and age of the patient.
Remember: Make sure you are familiar with your facilities policies and use of equipment.
Pain is considered the “sixth vital sign.” Pain can be a contributing factor to a patient’s overall wellness. This measurement is best done at the beginning of your assessment.
Ask the patient to rate their pain on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain they have ever experienced. If they have a rating of 1 or above you must ask the patient to tell you the location and quality of their pain.
Remember: Pain is subjective. Each patient experiences pain in his or her own unique way. It is important to assess and reassess patients for pain with each encounter.
Now let’s take a look at some questions for review…
A nurse is assessing the patient’s blood pressure and notices it is extremely high for this patient. The nurse documents the blood pressure of 160/100. What would be an appropriate intervention for the nurse to do first?
- Begin CPR because this patient is at risk for a heart attack.
- Call the physician to get orders for hypertensive medications.
- Document the findings and tell the patient to take deep breaths.
- Wait 15-minutes and check the blood pressure again to verify the reading.
If you chose 4 “wait 15-minutes check the blood pressure again to verify the reading” you are correct. If the patient tells you that is not their normal pressure you want to be sure to verify your findings prior to notifying the physician. You may report both reading to the physician after taking it a second time.
Let’s try another one…..
Which of the following would most likely be an indication of an infection?
- An apical heart rate of 80
- A blood pressure of 110/80
- A pain rating of 6 on a scale of 0 to 10.
- An oral temperature of 101.9 degrees Fahrenheit.
If you chose 4, an oral temperature of 101.9 degrees Fahrenheit, you are correct. A higher than normal temperature is most likely the body’s way to heating up to fight off bacteria which causes an infection. The other options are normal and may not be an indication of an infection.
Thank you for watching! Hope it was helpful and I’ll see you next time!