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
Supplies Needed to Check Vital Signs:
- Blood pressure cuff with sphygmometer
- Pulse oximetry
- Disinfectant wipes and gloves
Before you Collect Vital Signs:
Perform hand hygiene, don PPE (if needed…example: patient is in some type of isolation precaution), perform patient identification checks, and explain to the patient about the procedure for collecting vitals.
Assess Pain Rating
This is best done at the beginning of your vital signs check. Ask the patient to rate their pain by rating it 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.
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) and a temperature greater than 100.4’F is considered a fever.
- Apply the probe cover to the unit if it has one.
- Free the forehead of any hair or materials (if you don’t this, it will alter the temperature because the probe has to maintain contact with the skin of the forehead to get a proper reading).
- Touch the probe to the center of forehead and swipe the probe across the forehead to the hairline and always maintain contact with the skin.
****If the patient is sweating, then touch the probe to the back of the neck under the ear. The reason for this is because sweating will decrease the temperature if present on the forehead and the vascular area below the ear will help make sure it receives a proper reading.
- Dispose of probe and clean device per facility’s protocol.
- Document the temperature and the route taken if not orally.
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 in the adult)
- Use the first three fingers of your hand and find the radial artery.
- It is located in the wrist, right below the thumb along the radial bone.
- Note the rate, strength, and rhythm.
- Grade the strength of the pulse with the following scale:
- 0: absent
- 1+: weak
- 2+: normal
- 3+: bounding
- Grade the strength of the pulse with the following scale:
- 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
Count the respiratory rate right after counting the heart rate. To do this, keep you fingers on the radial site and look at the rate of breathing, depth, and rhythm. The patient should be UNAWARE you are counting the respiratory rate so they don’t 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
- 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 (not crossed) 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.
- First estimate the systolic blood pressure measurement: The reason for doing this is so you will avoid missing the auscultatory gap (if present). This is an abnormal silence that can occur in some patients, and it may cause you to miscalculate the systolic number, which is the first sound heard.
- Palpate the brachial artery with your first three fingers: It’s found in the bend of the arm, closest to the patient.
- Secure the cuff about 2 inches above the bend of the arm on the patient and line up the arrow of the cuff with the brachial artery.
- Palpate the brachial artery again and inflate the cuff until you NO longer feel the artery.
- The point where you no longer feel the artery on the gauge is the estimated systolic blood pressure measurement. Remember this number because when you take the blood pressure you will inflate the cuff 30 mmHg ABOVE this number.
- Deflate the cuff and wait 30-60 seconds before you take the blood pressure.
- After waiting about 30-60 seconds, palpate the brachial artery again and secure your stethoscope in your ears and place the bell or diaphragm of the stethoscope over the location of the brachial artery. You can use either the bell or diaphragm of the stethoscope. However, the bell is best for assessing low-pitched sounds.
- Inflate the cuff 30 mmHg above the estimated systolic blood pressure you obtained earlier. Example: If you estimated 100 as the systolic, inflate the cuff to 130.
- Then let the needle of the gauge fall about 2 mmHg per second.
- The first sound you hear if the systolic number.
- The last sound you hear if the diastolic number.
- Once you note the diastolic number, deflate the cuff and remove it from the patient.
- Document your findings and what arm you measured the blood pressure in.
American College of Cardiology 2017 Updated Guidelines for High Blood Pressure:
- Normal BP- SBP: <120 DBP: <80 mm Hg
- Elevated BP- SBP: 120-129 DBP: <80 mm Hg
- Hypertension Stage 1- SBP: 130-139 or DBP: 80-89 mm Hg
- Hypertension Stage 2- SBP: ≥140 or DBP: ≥90 mm Hg