Good day everyone! I am Yvan Karla E.

Lacandola from BSN 1-Y2-

Dash 3.
Today, I will be performing a return demonstration on how to take our
client’s vital signs.
One of the very first practical skills that we should learn as nursing
students is how to take vital signs. The importance of measuring vital
signs cannot be overstated because it serves as a fundamental indicator
of an individual's health status.
Healthcare professionals usually collect four vital signs, and today I will
demonstrate how to obtain the following readings: namely, body
temperature, heart rate, respiration rate, and blood pressure.
These can be taken with nothing more than a few basic pieces of
equipment. The paraphernalia needed are
Digital Axillary Thermometer for client’s temperature
Cotton balls with and without alcohol for disinfection and to avoid
contamination
Wrist watch with a sweep second hand to measure client’s pulse rate and
respiration rate
and Stethoscope and Sphygmomanometer for client’s blood pressure
Before starting the procedure, let us wash our hands first using the
World Health Organization technique for handwashing and we are good
to go.
Good morning ma’am, I am Yvan Karla E. Lacandola, your student
nurse for today.
Can I take a look at your ID band ma’am?
So ma’am may I ask what is your name? Alright.
What is your birthday ma’am? Okay.
So ma’am for today I will be checking your vital signs. This includes
your body temperature, pulse rate, respiration rate and blood pressure.
These are important because it provides critical information about our
bodies and it assesses our wellbeing. Is it okay for you if I take your
vital signs ma’am?
PRIVACY.
So first ma’am, I’ll be getting your body temperature on your axillary
site. I will be using a digital thermometer and put it on your armpit. This
is important for us to detect illness because there are certain diseases that
are characterized by a change in body temperature. It is also an easy way
for us to see if a fever is present. Can I proceed ma’am?
I’ll be pulling up your sleeves for me to be able to put the thermometer
ma’am. Okay.
Are you comfortable with your position ma’am?
Alright ma’am.
Voiceover:
- To start off, obtain the thermometer from the container. Wipe it using a
cotton ball with alcohol from the bulb to the stem. After that, dry it using
a dry cotton ball in the same manner.
- Check if the thermometer or the battery is functioning well.
- To obtain our client’s axillary temperature press the button to set the
thermometer. Then, you have to put the end of the thermometer securely
on your client’s armpit.
Please hold your arm down tightly at your side ma’am and we’ll have to
wait for several minutes until the thermometer beeps which indicates
that the reading is complete.
While we are waiting ma’am, I will begin to assess your pulse rate or the
number of times your heart beats in one minute. We do this to see how
well your heart is working. I will be palpating for your radial pulse
which can be found in your wrist because it is the easiest and the most
accessible pulse site.
Can I have your arm ma’am. Okay just relax ma’am.
- Position your client and begin to assess the radial pulse rate
- Support your client’s wrist by grasping outer aspect of the thumb.
Place your index and middle finger over your client’s artery and palpate
for the pulse. Do not use your thumb because it has its own pulse that
you may feel.
- Apply just enough pressure so you can feel each beat. Do not push too
hard or you will obstruct the blood flow.
- Count the pulse to one full minute. Take a look of the second hand on
your watch as you count how many times you feel the pulse of your
client.
- Assess the rhythm and volume of the pulse as well
- When counting, do not watch the clock continuously, but concentrate
on the beats of the pulse.
Right after you obtain your client’s pulse rate, do not remove your
fingers from her wrist. Observe the chest movement while supposedly
taking the radial pulse. It may be useful to assess the respiratory rate at
the same time as pulse rate because this will give a more accurate rate
and minimize any subconscious influence, as patients may alter their
breathing if they know they are being observed.
- Using again your watch, count breaths for one full minute. An
inhalation and exhalation is counted as one respiration. This is observed
with the rise and fall of the chest wall.
- Respiratory rate is a clinical sign that represents ventilation or the
movement of air in and out of our lungs.
- Don’t forget to observe the depth, rhythm, and the character of
respiration.
- Once done, remove the thermometer from the client’s axilla and read
the result at eye level.
- Right after, disinfect the thermometer used. Wipe it again with cotton
balls from stem to bulb and return it into its proper container.
- Document the reading of the body temperature, pulse and respiration
including the date, time and method used, noting any observations.
For the last one ma’am, I would be taking your blood pressure.
- Assess the factors that may affect the blood pressure of your client. It
may include age, exercise, stress, race, obesity, sex, medication, and
diurnal variation.
May I know your age again ma’am?
Have you done some sort of exercise before this procedure?
Are you experiencing stress right now?
Are taking up some medications ma’am?
Alright ma’am, thank you.
We are supposed to wash our hands prior to taking our client’s blood
pressure, but because I have already done so, I will instead do a hand rub
with the use of alcohol to disinfect. I would still be using the World
Health Organization technique for this one. After that, we have to
determine our client’s baseline blood pressure as well as the extremity
that is most appropriate for reading.
Ma’am may I know what do you usually get when you take your blood
pressure?
Alright. Let me just check where I can take your blood pressure
accurately ma’am.
Then, prepare the paraphernalia needed.
Once done, identify your client and explain the procedure.
Can I take a look at your ID band again ma’am?
May I ask again what is your name? Alright.
What is your birthday ma’am? Okay.
Again ma’am I will be taking your blood pressure. This is vital in the
prevention and treatment of blood-pressure–related diseases. This test is
simple, quick and usually painless. However, the blood pressure cuff
squeezes your arm while it inflates. Some people find this slightly
uncomfortable but this feeling lasts for only a few seconds. Can I
proceed ma’am?
Place your client in an appropriate position and move your client’s
clothing away from the upper aspect of their arm.
Are you comfortable with that position ma’am?
Let me just pull up your sleeves prior to the procedure ma’am.
- Position client’s arm at heart level, extending elbow with palm turned
upward. Have client relax arm and not overly tighten elbow.
- Wrap deflated cuff evenly around the upper arm. For an adult, place
lower border of the cuff approximately 2.5cm (1inch) above the
antecubital space. You have to apply cuff snugly smoothly over upper
arm
- Next, insert earpieces of stethoscope into ears with a forward tilt.
- After that, relocate brachial pulse and place the bell or diaphragm
directly over brachial pulse. You must hold the diaphragm with your
thumb and index finger.
- Then, close the valve of the pump by turning the knob clockwise.
- Now, inflate the cuff to 30mmHg above the normal systolic reading of
your client. In the case of my client, her normal systolic reading is 110
as I’ve asked beforehand.
- Release the valve of the cuff carefully so that the pressure decreases at
the rate of 2-3mmHg per second. As the pressure falls, identify the
manometer reading by listening for the korotkoff’s sounds
- Mark the first audible sound as the systolic pressure reading and the
last audible sound as the diastolic pressure reading.
- After final sound has disappeared, deflate cuff rapidly and completely.
- You may now remove the cuff or wait for 2 minutes if you want to take
a second reading. Then, inform your client of the reading and position
her comfortably.
Alright ma’am your blood pressure is
- Once done, put all the equipment used into their proper place.
- Now, you have to disinfect your hands again and document pertinent
data that you have obtained from your client.
Alright ma’am, let me state your overall vital signs.
For your body temperature, as I’ve mentioned earlier it is _
For the heart rate, it’s bpm.
For yor respiratory rate, it is breaths per minute
And lastly, for your blood pressure it is
Based on the results that we have obtained, all vital signs are normal so
there is nothing to worry about.
Thank you so much ma’am and have a good day ahead!