Checking vitals is an essential skill nurses learn in nursing school. The vital signs assessment is performed routinely in all health care settings by both nurses and nursing assistants.
Vital signs allow the nurse to know how well the patient is doing or responding to treatment.
In this article, I will demonstrate how to check vitals as a nurse. You will learn the following:
- How to assess a patient’s pain rating
- How to take a temperature
- How to assess oxygen saturation
- How to count a heart rate
- How to count respirations
- How to take a manual blood pressure
Video Demonstration on Checking Vital Signs
Assessing Pain Rating
This is best done at the beginning of your vital signs check. Ask the patient to rate their patient rating on a scale 0 to 10 (with 0 being NO pain and 10 being the absolute worst pain they have ever experienced). If they are having pain, ask them to tell you the location and quality of the pain.
Taking a Temperature
This can be done in various locations, such as:
- Mouth (oral)
- Armpit (axillary)
- Forehead (temporal)
- Rectum (rectal)
- Ear (tympanic)
Remember that temperatures taken axillary and temporally will read 1 degree LOWER than an oral temperature, and temperatures taken in the rectum and ear will reading 1 degree HIGHER than an oral temperature.
A normal temperature in adults is: 97’F to 99’F (36.1 ‘C to 37.2 ‘C)
Assessing Oxygen Saturation (O2 Sat)
This is performed with an oxygen saturation monitor. This device is placed on the nail bed of a finger. A normal oxygen saturation is 95% to 100%.
How to Count a Heart Rate
You can count a heart rate in various locations, such as:
- Radial (the most commonly used)
Count the heart rate (if regular) for 30 seconds and multiply by 2. If the heart rate is irregular count for 1 full minute.
Normal heart rate in an adult is 60-100 beats per minute.
How to Count Respirations
It is best to count respirations after counting the heart rate and to let the patient know you counted their respirations afterwards. This is because if you tell a patient you are counting their respirations they will change their rate of breathing.
Count the respirations for 30 seconds if regular and multiply by 2, and if the respirations are irregular count for 1 minute. Remember one breath in and one breath out equals 1 respiration.
Normal respiratory rate in an adult is 12-20 breaths per minute.
How to take a Manual Blood Pressure
Below are steps on how to take a manual blood pressure using the one step method. Here is a tutorial on how to take a manual blood pressure using the two-step method (use which ever method your nursing program instructs you)
- Ask the patients to sit up straight with their arms stretched forward. The patient’s palms should face up, and the arm in which their blood pressure will be taken should be slightly bent. The upper arm should be level with the heart, and the feet should remain flat on the floor during the process. Some patients may wish to rest their arm on a table or armrest for added support while having their blood pressure taken.
- Make sure that the patient is relaxed and calm before proceeding.
- Turn the sphygmomanometer’s air release valve clockwise to close. Ask the patient to roll up his or her sleeve before slipping on the blood pressure cuff. Make sure that the cuff is snug around the patient’s upper arm. The bottom 1-2 inches of the cuff should rest directly above the patient’s elbow. Straighten the rubber tubing connected to the cuff before moving proceeding.
- Find the patient’s pulse by using the middle and index finger to press against the inside crease of the elbow of the patient’s arm. Place the stethoscope’s earpieces in the ears and the diaphragm on the skin directly below the blood pressure cuff. Place the chest piece over the brachial artery in order to get a strong pulse reading.
- Pump the rubber bulb until no sounds continue to come through the stethoscope. Continue to inflate the cuff by squeezing and releasing the bulb in a rapid motion. Blood flow in the arteries will stop when the cuff is inflated accurately. Inflate the cuff until it reaches 180 millimeter when the patient’s normal blood pressure is unknown but make sure that the cuff is not inflated more than needed. The reading for patients with known previous readings should be 30 to 40 millimeters above the reading of their normal systolic pressure.
- Release the air valve by turning it counterclockwise. The pressure in the cuff will release at a rate of 2 to 3 millimeters per second.
- The patient’s systolic and diastolic pressure will be taken. The sounds heard through the earpieces will resemble a slight tapping sound. Monitor the reading on the gauge for the patient’s systolic pressure. This is the first number needed for a blood pressure reading. Next, wait until the faint sound in the earpiece stops. Check the gauge to get the patients diastolic blood pressure reading.
- Take the patient’s blood pressure once or twice again for accuracy. It is necessary to wait at least 5 minutes between readings so that the flow of blood is restored in the arm.
- Release the remaining air from the blood pressure cuff when finished.
An ideal blood pressure reading is 120/80.