Vital Signs: Introduction (Nursing)

by Samantha Rhea, MSN, RN

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    00:00 Hello. Welcome to the series on vital signs. This is a really important fundamental topic for us as nursing students and nurses. This helps give us a really great baseline idea of our patient's condition, so let's take a further look. So when we talk about vital signs, we're going to look at these 5 main areas. Number 1 being our temperature. Just know, depending on the area of the body that you take the temperature, it's going to vary slightly. And we'll discuss this later. And number 2 is our pulse otherwise known as our heart rate. Number 3 is our respiratory rate and how fast we breathe. Four will be our blood pressure. And 5 is our oxygen saturation. So these big 5 components is what we call a full set of vital signs. As you can see, these are hitting many different areas of the body and our body systems, so it's going to give us a really great indication of how well your patient's doing. Now, let's take a look at one more vital sign. We call this the 6th vital sign, otherwise known as pain.

    01:08 Now, realistically, this is not a vital sign. However, this is really important information to collect on your patient because if a patient's actually in pretty severe pain, it can indeed affect some of these other vital signs such as how fast you breathe, your pulse, or even your blood pressure for example. So this is also a great baseline condition to make sure you assess on your patient. So why do we even take vital signs? Again, it's a great determination of a patient's baseline health status. Now, with these vital signs, we can identify some potential problems that may arise and hopefully implement interventions early. Then we can evaluate those interventions and see if they were effective for our patients. And again, this is going to give us a more accurate understanding of our patient's baseline health. So one thing to know is many times as a nurse when you go in and assess the patient visually, we may see some indicators with the patient that, you know, they may not quite seem right but maybe nothing too alarming. Well, vital signs are a good tip off that there could be some changes with your patient's hemodynamic status or their baseline health. So again, another great assessment piece when you're taking care of your client.

    02:24 Let's discuss guidelines for measuring vital signs for our client. There's a lot of important points to consider but we'll talk through each one. So first and foremost, making sure your equipment is functional is very important. And we also need to consider it's appropriate for the size and the age of the client. An example of this is there's pediatric cuff when we're obtaining blood pressure for our client, for a pediatric patient. Also know that the size of the cuff matters in regards to the accuracy of the reading. So if I have a really small cuff for a patient's arm, this can give us an abnormally and false high reading. The same is true if the cuff is far too large, we can have a false low reading. So this is important in regards to the size of our equipment and considering the age of the client. And don't forget about delegation. Vital signs is something we can typically delegate to a licensed personnel, but it's also important to note that there are occasions where it's not appropriate, so as a nurse we need to use our judgment. We also want to be able to understand and interpret those values we obtained. If we have a set of vital signs, we need to know what they mean.

    03:43 Right? Otherwise, we're just looking at numbers. The same is true as knowing the client's usual range of vital signs. This becomes important because some patient's blood pressure, what we called trend, and normally runs lower than maybe the 120/80 that's a normal blood pressure range. The same can be true as well when we're talking about heart rate. Some patient's heart rate may run a little bit lower and that's normal for them. We also want to determine the client's medical history, the therapies they are getting, and the prescribed medications can all affect their vital signs. We also want to control or minimize environmental factors that affect vital signs. Here is a great example of that. In healthcare, you may hear something called white coat syndrome or you may have this yourself. All we really mean by that is, I will tell you when I used to work in a cardiology clinic, patients would come in to the office and their blood pressure and heart rate would be really high. It really just had to do with the doctor made them nervous so their blood pressure and their heart rate were elevated everytime they came in. But they would give us readings of blood pressures at home and they were much lower and much better results. Keep this in mind that there are different factors that can affect patient's vital signs. We also want to consider using an organized, systematic approach when we take their vital signs. When we get a set of vitals, we want to take a full set of those meaning all the temperature, the respiratory rate, the blood pressure, the pulse. All of those pieces matter, so we want to do it in organized and systematic way, that way we make sure we're accurate and we obtain all the results we need. You want to consider as a nurse the acceptable ranges for medication administration. Many times we have to use vital sign measurements to determine indications for meds. Sometimes we got to give medications to lower that blood pressure for example or even to increase a blood pressure. Whatever findings that you get for vital signs, we need to be sure to communicate those which may mean that we are accurate in our documentation. There are occasional instances where we've got to communicate abnormal findings to a healthcare provider because they could mean a decline in a patient's status. And of course, always analyze those results of vital sign measurement because analyzing this is going to matter in regards to the patient's condition and their treatment.

    06:20 And don't forget to instruct the client or their family or the caregiver in vital sign assessment. This is really important because if they're monitoring these at home, they need to know "Is this a significant finding? Do I need to call my doctor or not?" We talked about many guidelines for measuring vital signs. This helps emphasize health promotion and activity that helps support our health. So again, you may need to teach a client and their families to assess and record their vital signs. Also stress that these vital signs need to be taken at the same time everyday. There are different times throughout the day that our vital signs are naturally going to change. So stress when you're doing education with your family members or your patient that they take them at the exact same time everyday, if at all possible. In regards to recording vital signs, let's talk about 4 points to keep in mind. We want to make sure we record the values on either electronic health record or the paper graphic, whatever your facility is using at the time. We also want to record in our nurse's notes if there are any accompanying or precipitating symptoms of a patient's vital signs.

    07:35 This could be key information for the healthcare provider later. And of course, there are times when interventions are needed for abnormal vital signs. It's important that we document those interventions and to follow up. And if a vital sign is outside anticipated ranges, this is a point where we may need to consider contacting the healthcare provider.

    07:58 So let's take a look at some guidelines when we're talking about safety and performing vital signs. It's really important to communicate clearly with members of the healthcare team.

    08:08 This could mean that we had to discuss precipitating symptoms of an abnormal vital sign or maybe clear and accurate documentation in the record. Also of course, make sure you assess and incorporate the client's priorities of their care and their preferences, and always use best evidence when making decision about your client's care. Let's talk about a few more safety guidelines when we're measuring vital signs for our patient to ensure safe individual clients and their care. Now a really important point is to clean your devices between client uses. This is going to help decrease the risk of infection. So here's another really important point to know. Many times your patient's going to be in special precautions that are ordered by the physician such as contact precautions, airborne precautions for example. Now, there's certain agency protocols on how we clean that equipment so make sure you check your agency's policy. Also make sure you rotate your sites when you're doing repeated measurements of vital signs like blood pressure or pulse ox, for example.

    09:16 This can decrease the risk of our skin breakdown. Also, it can actually give us an inaccurate measurement. Here's what I mean by that. If I take a blood pressure on my arm, I take one really quickly and pump up a cuff and then maybe wait 30 seconds to do it again and to do it another 30 seconds. That could give us an inaccurate reading. So make sure you rotate sites if you have to repeat measurements. And of course, make sure you analyze those trends for vital signs and report any abnormal findings. Just keep in mind that each patient has a little bit different baseline on their blood pressure, for example, or their heart rate.

    09:55 If there's something abnormal here, make sure you report this to the healthcare provider.

    10:00 And of course, determine the appropriate frequency of measuring those vital signs based on the client's condition. Here's a great example of that. If a patient is in the intensive care unit, for example, many times a patient's pretty ill so we may have to do these vital signs very frequently, for example, much more frequently than maybe a patient on a medical surgical unit. However, many times you're going to have a physician order for that that's appropriate for your patient. Thanks for watching.

    About the Lecture

    The lecture Vital Signs: Introduction (Nursing) by Samantha Rhea, MSN, RN is from the course Vital Signs (Nursing).

    Included Quiz Questions

    1. Respiratory rate
    2. Oxygen saturation
    3. Temperature
    4. Weight
    5. Urine output
    1. Blood pressure cuffs come in different sizes.
    2. Being in a hospital setting can increase a client’s blood pressure.
    3. Some clients will naturally have a lower than average blood pressure.
    4. A cuff that is too large for the client can cause a false high reading.
    1. “Make sure to take your vitals in the morning on Monday, Wednesday, and Friday, and in the evening on Tuesday, Thursday, Saturday, and Sunday.”
    2. “Try and rotate which arm you take your blood pressure on to avoid skin breakdown.”
    3. “Can you show me the blood pressure machine you purchased so I can make sure the cuff fits you?”
    4. “Your vital signs may be different at home than they were when you were in hospital.”
    1. The student nurse takes a client’s blood pressure three times on the same arm to confirm an abnormal result
    2. The student nurse cleans the vitals machine between each client
    3. The student nurse alerts the physician of an abnormal heart rate
    4. The student nurse documents each client’s vitals as per institution policy before going to the next client
    1. Pain
    2. Pulse
    3. Last bowel movement
    4. Mood
    5. Temperature

    Author of lecture Vital Signs: Introduction (Nursing)

     Samantha Rhea, MSN, RN

    Samantha Rhea, MSN, RN

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