Clinical Skills - Vital Signs: Temperature, Pulse, Respirations & Blood Pressure

Hi. I'm Ellis with Level Up RN. In this video, I'll be demonstrating how to take vital signs. This is going to include respirations, pulse, and temperature. I'll be using the steps that we've included on our Clinical Nursing Skills cards. So if you've got the deck, grab the cards, and you can follow along with me. If you don't have the deck and you're interested in getting one, head on over to leveluprn.com.

Just a few notes before the demonstration starts, because there is an active part of the demonstration, and I want you to be ready for it. So you're going to need a watch with a second hand. When you're getting a watch with a second hand, I would recommend getting one that has a sweeping second hand instead of the ticking second hand because, when I'm following something like the ticking, it's really compelling to start counting the ticking, whereas the sweeping second hand, you don't really get that sensation that it's counting, and so you don't start changing your own counting. Furthermore, when you start your counting, wait until the second hand is at a comfortable number for you.

For example, when I'm working with my students and they start at the 7, they almost never get it right, especially when they're first learning, because now they also have to think about where it should end to make 30 seconds, and it's not a natural-feeling number, right, whereas if I started at the 12, then I know, without having to think about it, 30 seconds was 6. Or if I started at 6, 30 seconds was 12, right, and whereas if I start at 11, I have to actually think about, "Okay, where is 30 seconds?" And so a lot of times, they miscalculate that. And they'll go all the way to the 6, for example, or they'll stop at the 3 because it's just easy to stop at one of those four numbers. So just wait the extra couple seconds and allow yourself to start-- right? Set yourself up for success. Start at the 12. Or start at the 6.

And then one more thing, when it comes to the watch itself or looking at the watch, is actually don't look that much at the watch because, again, it starts being compelling to start counting what your watch is doing. So if I have my watch and I'm looking at it, then I'll wait till it gets to the 12, for example, and then I actually just look away. If I'm watching respirations, maybe I'll look at the patient. If I am palpating a radial pulse, maybe I'll just zone into the distance. And so I'll look at my watch, and then I'll just-- right? And just peek back and forth at it because, if I stare at my watch, it can get confusing about what it is I'm counting, and there's just too many different inputs from my brain.

One final thing that I would like to leave with you is that anytime I'm auscultating sounds on a patient, I cannot do it over clothing. That is all of your instructors' biggest pet peeve because it's not going to give you an accurate sound. You're going to get artifact from clothing rustling. You need your stethoscope to touch bare skin. So make sure that, if I'm listening to lung sounds or heart sounds or bowel sounds even, that I'm doing it with my stethoscope on my patient's skin, and I am not doing it over their clothing or gown. So good luck.

I'm going to demonstrate all the different ways that we can take a patient's temperature. So with this thermometer, I can take an oral temperature. I simply remove the probe from the device, click a probe cover on, insert it into my patient's mouth into the posterior sublingual pocket. If they weren't a mannequin, I would ask them to close their mouth, sealing their lips around the metal probe. If they're going to touch it, by the way, which a lot of them do instinctively, right - you reach up to grab it - make sure they're touching this plastic part here because, if they touch the metal part, they might alter the temperature that's being taken. Once I'm done, the monitor will beep, and I'll just eject the probe cover off by clicking the button on the back. And I would reset the monitor by inserting the probe.

This is also used to take axillary temperatures. So again, I remove my probe. I need to tell my monitor this time that I want to take an axillary temperature, which is one button on here. I'm going to insert to get my probe cover, and I'm going to put it into their axillary midline and ask them to kind of hold their arm against their body so we can create kind of a seal to get an appropriate temperature. And I would do that, of course, on the skin itself. The monitor would beep, and I would remove it, and, again, eject off my probe cover.

This device is to get a temporal temperature, and I sometimes will have caps for these as well. So I simply place the cap on. I'm going to place it against my patient's forehead, click the button, and drag it along the hairline towards the ear. His temperature is 75.2. And then again, I can remove my cap in between patients.

This thermometer is for your tympanic temperature. Oopsie. It has the probe covers on the inside as well. So I need to put on a probe cover. Because my patient is an adult, I'm going to grasp his pinna, which is this top part of his ear, and I'm going to pull it up and back slightly so that I can straighten out the ear canal. If he were a child under the age of three, I would actually pull his pinna down and back. So I'm going to pull his pinna up and back. And I'm going to insert the probe so that it is kind of pointing towards the jawline, which would be along that ear canal. And I'm going to click my button so that it would get his temperature. And once it beeps, I withdraw it. And just like my other ones, I do actually push this trigger button to remove the probe cover. So I'm just going to shoot it into my trash can. And now I'm going to actually reposition him to demonstrate a rectal temperature.

Now that I've positioned my patient in a modified left lateral recumbent position, which you might know as Sims' position, I can take their rectal temperature. So you'll notice that these thermometers are exactly the same. The blue is usually indicated for oral or axillary temperatures, and the red is usually indicated for rectal temperatures. So make sure you don't get these mixed up, because one will go in their mouth and one will go in their rectum. So I'm going to set this one aside, and I'm going to use the red one for their rectal temperature.

So I'm going to go ahead and expose their anus. I've prepared a packet of lubricant to facilitate the insertion. And this works almost identically. Only step I've added is the lubricant. So I'll remove the probe. I'll insert it into the probe cover. I'll get lubricant on it. I'll insert it into the rectum approximately one inch, and I want it pointed towards the umbilicus or the belly button. I'll wait for it to beep, and then once it beeps, I simply remove it, and I can eject this using this button over my trash can. And then I would simply clean up their rectum and return them to a comfortable position. And that's how you get a rectal temperature.

I'm going to start by taking my patient's pulse radially. So I'm going to find his radial pulse on his wrist right here. It's going to be proximal to the thumb, so you can sometimes just follow the thumb down, and there's usually that bone that you can find as well. So I'm going to place two or three of my finger pads onto his radial pulse. I need to press firmly enough that I can feel the bounce, but if I press too hard, I'm actually going to occlude it. So this can take some getting used to, and you definitely want to try on different types of people so that you can feel different types of pulses.

So as I'm pressing down, I'm assessing a couple of different things. I need to know the rate. So how fast is it going? I need to know the strength, so +1 to +4 of the force that it's showing. I need to know whether or not it's equal. So is this radial pulse in his right arm the same as this radial pulse in his left arm? So I do want to quickly just touch them both at the same time, but I don't need to actually count his pulse on both at the same time. But when I'm ready, I'm going to go ahead and place my two fingers on his radial pulse. Three fingers is also fine. I just prefer two. I'm going to use my watch, and I'm going to count for 30 seconds. So let's do that together.

[silence]

All right. So I got 32, which means, when I multiply that by 2 to get the 60 seconds or 1 minute's worth, I have 64. So my patient's pulse is 64 beats per minute. I can only do that if the pulse is regular, meaning the beat is consistent and it always comes at the same time. If their pulse is really irregular, I can't take it for 30 seconds and multiply it by 2. I would need to really listen or feel for that full minute.

So let's listen to his apical pulse. So I'm going to pull your gown down, sir. And I'm going to place my stethoscope over his apical pulse, which is that fifth intercostal space in the left midclavicular line. And we're going to listen to his apical pulse together for 30 seconds and see what we think. And begin.

[silence]

All right. So that time, I actually got 46, and so I would multiply that again by 2, and I would know that that is their beats per minute. We're going to do this twice more, just so that you can get the practice and the feel of listening to a beat. I find that some students have to kind of move with it to really get it. I think, especially when we're listening to an apical pulse, it can be very distracting, right? It's moving. He's potentially moving. I'm also maybe hearing his respiratory sounds. Things around me can be distracting. So if you're really starting to learn this, I would recommend maybe closing your eyes even. And bounce your head a little bit, not your body, because that might help you stay on track, because it's so easy to just let it slip away from you, and then you panic and you don't remember what number you're on. So let's try two more times. So I'm going to count for 30 seconds again, and then we'll do one more time after that. And begin.

[silence]

All right. So that time, I got 52. So that's 104. So he was going a little bit faster that time. This time, let's do an irregular heartbeat. So I'm going to have an irregular heartbeat play. That means we're going to have to count for the full minute because it's not that consistent pattern. So we're going to listen for a full minute and see if we can't keep up with it. And begin.

[silence]

All right. I wonder how you felt about that. That can be really tricky to stay on track with those ones, especially because one minute feels like such a long time when you're actually tracking for one minute, right? But that was also a little bit fast. I got 136. So I hope you got something similar. Thanks.

To take a patient's respirations, you have to be a little bit sneaky because the problem is, if you were to tell someone, "I'm going to watch you breathe now," they're going to suddenly become very conscious of what is usually an unconscious effect. And so they're like, "Am I breathing right? Do I breathe this fast? Should I breathe harder? Am I breathing too slow?" And it will change their pattern and depth and rate. And so instead of doing that, you have to be a little bit sneaky about it and take their respirations without them knowing you're taking their respirations.

So how we usually do this is, when I'm taking a pulse, I've got my fingers on their radial pulse, and after I finish completing taking their pulse, I'll go ahead and also take their respirations. The only tricky part here is that now I have to remember their pulse and count and remember their respirations. But it gets easier the more you practice doing that. When somebody doesn't have a really noticeable respiration pattern, sometimes you have to be a little more covert in touching them. For someone who doesn't have a deep inhale, it can be hard to see that or even hear that, and so I may need to gently rest my hand on their shoulder. Or even if while I'm taking their pulse-- unfortunately his elbow doesn't bend very well. While I'm taking their pulse, I might just kind of gently put their hand up and allow it to rest on their chest so that I can feel when they're breathing because their arm would then be moving.

And when I'm doing this, I, of course, need to count the rate. So how many times per minute are they taking a breath? The pattern. Is it regular or irregular? And the depth. So is it shallow or is it labored, perhaps? And I would need to document all of those things. Just like a pulse, if it's a regular pattern, I could count for 30 seconds and multiply it by 2 to get their rates per minute, their breaths per minute. If it's irregular pattern, I, of course, would need to count and watch their respirations for that full minute to get an accurate number. And that's how I take my patient's respirations.

To take my patient's blood pressure, I want them to be relaxed, have their arms supported with their legs uncrossed. And this is important more when I'm doing it in a clinic setting or if they're sitting up in a chair, right? I don't want them to just hold their arm out for me like this while I'm taking their blood pressure because then they're kind of straining and tensing these muscles, and that's going to change my results. So I want their arm relaxed and supported. I'm going to apply the cuff one inch above the brachial artery, pretty snugly. And I need it on an arm that doesn't have a current IV running, that doesn't have something like a PICC line or an AV fistula, or that's on the same side of a mastectomy. Sometimes both arms have something going on, and you need to use clinical judgment to decide which arm is appropriate, but you need to just be cognizant when you're choosing the arm to use.

The method I'm going to demonstrate and that we've included on our cards is kind of a combination of a step one and two. So I'm going to inflate the cuff while palpating the radial artery. Once the radial artery disappears, I'm going to continue to inflate the cuff 30 mmHg, and that's where I'll start my countdown when I'm doing my blood pressure. So let's do that together real quick. So I'm going to put my stethoscope in my ears. I'm going to palpate my radial artery. I'm going to hold the bulb in my dominant hand, then I'm going to put the bulb in my hands like this, and I'm going to control the dial with these two fingers. So I'm going to lock it and pump it up until I can no longer feel the radial artery. All right. So I lose it at about 140. So I need to go 50, 60, 70, and at that point, I can release the dial after I place my stethoscope.

[silence]

And what we're listening is for the first sound, which is our systolic blood pressure - and I heard that at 130 - and for our diastolic sound, our diastolic blood pressure, which is the absence of sound. So at about 80, I no longer heard sound. So those are the two numbers I would document. So she would be or he would be 130/80.

So I'm going to do that again, and I'm going to do it twice more so that we can listen and watch the dial together. And make sure when you're using your stethoscope that you're holding it fairly snugly against the brachial artery. I like to put my fingers into the stethoscope itself and wrap my thumb around their forearm - and I can do that from any position, right - because it's allowing this to kind of adhere to their skin. And it helps me because if I hold it without wrapping my thumb, sometimes they wiggle a little bit, and then I'm hearing artifact. I'm hearing kind of like a crunching or crinkling noise on my stethoscope itself, and then it's really hard to differentiate, like, "Was that their blood pressure? Was that just me moving? Was that something else?" And so I want to fairly snugly push that against their arm. So I'm going to go ahead and take a couple more blood pressures, and this time, we'll just use the one-step approach. Well, I'll pump it up, and then we'll listen for blood pressure. It's just so we can practice noting when that first sound happens and that absence of sound occurs.

[silence]

All right. So that one, I got 162/110. So he's got a little bit of hypertension going on. And then we'll do one more.

[silence]

All right. 118/66. And that's how you take a blood pressure.