Transcription
hello everyone. I am Shekinah Aquino Maranga from the SN111A, and today I am going to perform obtaining of vital signs. Accurate measurement of vital signs is critical because it reflects the body's basic functioning. It serves as a baseline data which allows us to track changes in patient's condition, recognize early patient deterioration, and prevent harm or errors that may occur. Vital signs include temperature, pulse rate, respiration rate, and blood pressure. Paraphernalia needed are: digital axillary thermometer for patients body temperature; stethoscope and sphygmomanometer to measure patient's blood pressure; and a watch with a sweep secondhand to measure patients pulse rate and respiration rate; and of course, alcohol for disinfection and to avoid contamination.
So now I'm going to start by taking my patient's body temperature. The temperature is very important because it reflects the balance between the heat produced and heat loss of the body, and there are a few sites in which we could obtain its measurements from. It could be through oral, temporal, rectal, axillary, or through the tympanic membrane. But for today, I am going to take my patient's body temperature through her oral and axillary sites.
So prior to the conduct of the procedure, I am going to close the door to ensure my patient's privacy. I am going to adjust the light and adjust the room temperature for patient's comfort and of course perform hand hygiene to disinfect and avoid contamination. Okay, so now I am going to introduce myself to my patient and verify her identity and of course explain to her the procedure that I'm about to do. "Good morning, Ma'am. I'm Shekinah Aquino Miranda, your student nurse for today, and may I see your response, Ma? Please take your complete name." "Sure." "Okay, and your birthday, please?" "You're probably sick." "Okay, thank you very much, Ma'am. So today I am going to um take your body temperature. Okay, I'm gonna have to put um a digital thermometer in your mouth so I'll be able to have your body temperature. Is it okay with you?" "No, it's okay."
So to take from a patient's body temperature, I am going to use a digital thermometer and disinfect it first. Okay, and I'm gonna have to place it on the um posterior sublingual pockets of my patient's mouth. "Okay, Ma'am, please come open your mouth and touch the roof of your mouth. Okay, close now." Okay, so now we'll just have to wait until um the temperature uh or the thermometer beeps. Okay, so now we'll just have to wait until the thermometer beeps, which indicates that it has already obtained my patient's body temperature. Of course, after that, I'm gonna have to inform the patient of the results of her temperature and disinfect the thermometer and of course document the data that I have gathered. "So, Ma'am, your body temperature is 37.5 degrees Celsius, which is within the normal range." Okay, so now I'll have to disinfect the thermometer that I have used and place it back. So after the procedure, I am going to perform another hand hygiene and document the data that I have gathered and plot it on the patient's TPR sheet.
Okay, so now I'm going to uh take for my patient's body temperature through her axillary site. But prior to the conduct of the procedure, I still need to do the first three introductory steps, which are to ensure my patient's privacy, provide comfort, do the hand hygiene, and of course introduce myself to my patient and explain what procedure I'm about to do. "So, good morning, Ma'am. I'm Shekinah Miranda, and today I'll be um taking your body temperature through your axillary site or through under your armpits. Okay, so I see your hand, Mom, and please take your complete name." "I'm sure you know." "And your birthday, please?" "Very sick." "Okay, thank you very much. So, Ma'am, I'm gonna have to um pull up your sleeves so I can put your I can put the thermometer." Okay, so I'm going to be using another digital thermometer for my patient's body temperature through her axillary site, and before I'm going to place it on the area, I'm going to have I'm going to need to first take a look at it and see if there are any scars or lesions and pat dry if the area is wet or moist. "Okay, Ma'am, can you please raise your hand for me?" Okay, so now we're just gonna have to wait for a minute or up until the thermometer beeps, which indicates that it has already obtained the body temperature of the patient. So now we just have to wait for uh thermometer to be. "Okay, all right." So after um this happens, I'm gonna need to inform the patient of the result of her temperature and of course disinfect the thermometer and perform hand hygiene and document the data that I have gathered. "Thank you so much. Your temperature is at 36.5 degrees Celsius, which is within the normal range." Okay, so I'm gonna have to disinfect the thermometer that I have just used, okay, back and then perform hand hygiene. It is important that we know that the axillary temperature is one degree lower than the oral temperature, and of course after that I'm gonna have to document the data that I have gathered in the patient's PPR sheet.
Okay, now I'm going to proceed to taking my patient's pulse rate. The pulse is a wave of blood created by the contraction of the left ventricles of the heart, and in order for me to measure it, I'm going to need to do palpation on the both sides of the patients, which could be through her temporal, carotid, ethical, brachial, radial, femoral, umplitiol, tibial, and her versailles pedis. But today I am going to be palpating for her radial pulse because it is the easiest and the most accessible pulse site. So prior to the conduct of the procedure, I'm gonna need to do the first four pre-introductory steps, which are to close the door to secure patient's privacy; I'm gonna need to provide an adequate lighting and adjust room temperature for patient's comfort; and of course perform hand hygiene. "So, good morning, Ma'am. I'm Shekinah Aquino Maranga, your student nurse, and today I'm going to need to um measure your pulse rate. Is that okay with you?" "No, so much." "Let me see your hand, Mom. Please take your complete name and your birthday, please." "Okay, thank you very much." So now I'm gonna assess for your um pulse rate. "Can you give me your hand?" Okay, so now um to locate the radial artery or for the radial pulse, I'm gonna need to use these two fingers of my hands, and I won't be using my thumb because the thumb actually has a pulse in it, and so I'll just have to trace her thumb and place my fingers in this area of her wrist and feel for the balls. And it is important to know that aside from the number of beats per minute to count, I also need to check for the strength of her pulse, which is um bracketed on a 0 to 3 plus scale: 0 being the pulse is absent; one plus if it is weak; two plus for normal; and three plus if it is bounding; and of course I'm also I also need to check for its rhythm if it is regular or irregular. "Okay, Ma'am, so now that I have um found her um radial pulse, I'm going to start counting um the beats per minute." "Okay." Okay, so now I have obtained my patient's pulse rate. "Ma'am, your pulse rate is uh at 75 beats per minute. It is graded two plus, which means it is normal and it has a regular rhythm." "Okay." Okay, so after doing the procedure or after taking my patient's pulse rate, I can just simply proceed to taking her respiration rate too without removing my fingers on her radial artery and simply just look at the rise and fall of her chest so as not to make the patient um conscious and uneasy, which can actually alter her breathing. Okay, and um of course this gives a much more accurate result for her respiration rate. Okay, so after doing the procedure, I'm gonna have to do a hand hygiene and of course document the data that I have gathered in her TPR sheet.
So now I'm going to be measuring my patient's respiration rate. So the respiration rate is simply the number of breathing a person takes in a minute, and it is usually done um when the person is at rest and by just simply counting the number of rising of the chest of the patient. So prior to the conduct of the procedure, I am going to do the four pre-introductory steps, which is to ensure patient security and privacy and provide comfort and perform hand hygiene, of course, introduce myself to the patient, verify her identity, and um tell her what the procedure will be all about. "Good morning, Mom. I'm Shekinah Maranga, your student nurse, and may I see your wristband, please?" "Take your complete name." "Okay, okay, thank you, Mom. So today I'm gonna be um counting your um respiration rate. Okay, I just need you to be at ease and be relaxed." Okay, so for counting the respiration rate, I'm not only simply counting for the number of breaths she takes but also for the depth of her breathing if it is labored or unlabored and for the rhythm if it is regular or irregular and for the character of course, and it is important to know that one rise and one fall of the chest would be equivalent to one respiration rate. "Okay, here. Okay, and just relax." "Okay." Okay, so "Ma'am, your respiration rate is at 16 breaths per minute, which is um within the normal range and it is it has a regular rhythm and a labor." Okay, so after doing the procedure, I then need to uh do the hand hygiene and of course um document the pulse rate at the respiratory rate um in her TPR sheet.
Okay, so now I'm going to be uh measuring for her fourth vital sign, which is the blood pressure. So the blood pressure is the pressure of the circulating blood against the walls of the arteries, and it could be obtained with the use of stethoscope and a sphygmomanometer. Okay, prior to the procedure, I have to do the pre-introductory steps, which are to ensure my patient's privacy, to provide comfort, um do the hand hygiene, and introduce myself to my patient and tell her what the procedure will be all about. "So, good morning, Ma, I'm Shekinah Maranga, and I'll be taking your blood pressure today. Okay, may I see your hand, please?" "Take your complete name and your birthday, please." "Okay." So prior to the conduct of the procedure, I have already um checked for my equipment if they are clean and that they are well functioning. I also have the correct size of the cuff that I'm gonna need for my patient's arm, and of course inspected my patient if she has any um injuries, casts, bandages, uh intravenous infusions, uh blood transfusions, or any arterial venous um fistula which could um hinder me from taking um her blood pressure in a particular limb. "Okay, Ma'am, can you move?" Since the patient is sitting, I'm gonna need to make sure that both of her feet are on the ground because um the blood pressure increases if um the legs are crossed. Okay, and I'm gonna have to place her arm at a heart level because if the arm is at a lower level then it would give us a higher blood pressure reading, and if the arm is at a higher level than the heart then it would give us a low blood pressure reading. Okay, so since this is the initial um examination of my patient, I'm gonna have to do a preliminary palpatory determination of her systolic pressure to avoid um having a lower systolic um reading by oscillatory method um if there is an oscillatory gap, and to do that I'm first gonna need to place the top around her arm just about one to two centimeters above the anticubicle space. Okay, and palpate for her um brachial artery through the use of my two fingers. Once I have found the brachial artery, I'm gonna start inflating the cuff and until I no longer feel the pulse of her brachial artery. So I'm gonna deflate the cuff, and I have already taken her um estimated systolic pressure, which is at 110 millimeters of mercury. So for the actual um taking of her blood pressure, I'm gonna need to inflate the cuff at about 30 millimeters of mercury um higher than the estimated systolic pressure. This is to ensure or to avoid uh missing the oscultory gap, which is the um which is the temporary disappearance of the Korotkoff sound while uh deflating the cuff. Okay, so for the actual procedure, I'm now gonna need to use my stethoscope, but first I'm gonna need to disinfect the ear pieces and the diaphragm and the bell of my stethoscope. Okay, for this time, gonna have to use the bell part of my stethoscope because the bell is best used for hearing low pitched sounds. So once I have found the brachial artery, I'm gonna need to inflate the cuff up until 140 millimeter millimeter of mercury. Okay, so now I'm gonna fully inflate the cuff, and the first sound that I have heard would be her systolic pressure, and for the diastolic number it would be the period of silence after the last sound that I have heard. And so since this is my patient's initial examination, I'm gonna need to do the procedure again on her other arm here again. Okay, so now I have your you got your um blood pressure, and it is 115 over 75 millimeters of mercury. Okay, it is within the normal range. "Thank you very much for your cooperation." And so I already have her um blood pressure, and after doing the that procedure I'm gonna need to fully deflate the cuff and wipe the cuff with disinfectant so as to reduce the risk of um cross contamination, and of course I'm gonna need to do a hand hygiene and plug the data that I have gathered in my patient's TPR sheets, and that would be all for my return demonstration of obtaining vital signs. Thank you very much.