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Assess: A.) Temperature - Clinical signs of fever - Clinical signs of hypothermia - Client’s readiness for the procedure - Site most appropriate for measurement - Factors that may alter core body temperature B.) Pulse - Clinical signs of cardiovascular alteration, other than pulse rate, rhythm, or volume - Factor that may alter pulse rate C.) Respiration - Skin and mucus membrane color - Position assumed for breathing - Signs of cerebral anoxia - Chest movement - Activity tolerance - Chest pain - Dyspnea Medications affecting respiratory rate. D.) Blood Pressure - Signs and symptoms of hypertension - Signs and symptoms of hypotension - Factors affecting blood pressure. 2. Assemble equipment and Supply: · - Thermometer · - Cotton balls with alcohol or alcohol wipes · - Tissue /wipes · - Watch with a second hand or indicator. · - Stethoscope · - Blood pressure cuff of the appropriate size · - Sphygmomanometer Procedure 1. Identify the client properly and explain what you are going to do, why it is necessary, and how he can cooperate. 2. Wash hand and observe other appropriate infection control procedure 3. Provide for client privacy. 4. Place the client in the appropriate position ASSESSING BODY TEMPERATURE (AXILLARY TEMPERATURE) 1. Wipe the armpit with tissue paper or ask the client to do it if able 2. Wipe the thermometer from bulb to stem with alcoholized cotton ball. 3. Place the thermometer on the client’s opposite side. 4. Wait for appropriate amount of time. (While waiting for the time, the nurse can now assess the other vital signs.) 5. Remove the thermometer and wipe with the tissue if necessary. 6. Read the temperature. 7. Wipe the thermometer with alcoholised cotton ball from stem to bulb. Return to container. ASSESSING A PERIPHERAL PULSE (RADIAL PULSE) 1. Palpate and count the pulse. Place two or three middle fingers lightly and squarely over the
pulse point. 2. Count for one full minute and note the pulse rhythm and volume. ASSESSING RESPIRATION 1. Place the client’s arm across the chest and observe the chest movements while supposedly taking radial pulse. 2. Count the respiratory rate for 1 full minute. An inhalation and an exhalation is counted as one respiration. Observe the depth, rhythm, and character or respiration. ASSESSING BLOOD PRESSURE 1. The elbow should be slightly fixed with the palm of the hand facing up and the forearm supported at heart level. 2. Expose the upper arm 3. Wrap the deflated cuff evenly around the upper arm. Locate the brachial artery. Apply the center of the bladder directly over the artery. 4. For an adult, place the lower border of the cuff appropriately 2.5 cm (1 inch) above the antecubital space. 5. If this is the client’s initial examination, perform a preliminary palpatory determination of systolic pressure. 6. Palpate the brachial artery with fingertips. 7. Close the valve on the pump by turning the knob clockwise. 8. Pump the cuff until you no longer feel the brachial pulse. At that pressure, the blood cannot flow through the artery. Note the pressure on the sphygmomanometer at which pulse is no longer felt. 9. Release the pressure completely in the cuff, and wait for one to two minutes before making further measurements. 10. Position the stethoscope appropriately 11. Clean the earpieces of the stethoscope with alcohol. 12. Warm the amplifier by rubbing it with the palm of your hand. 13. Insert the ear attachments of the stethoscope in your ears so that they tilt slightly forward. 14. Ensure that the stethoscope hands freely from the ears to the diaphragm. 15. Place the bell of the amplifier of the stethoscope over the brachial pulse. Hold the diaphragm with thumb and index finger. 16. Auscultate the client’s blood pressure. 17. Pump the cuff until the sphygmomanometer reads 30 mm Hg above the point where the brachial pulse disappeared. 18. Release the valve of the cuff carefully so that the pressure decreases at the rate of 2-3 mm Hg per second. 19. As the pressure falls, identify the mamometer reading at each of five phases, if possible. 20. Deflate the cuff rapidly. 21. Wait one or two minutes before making further determinations. 22. Repeat the above steps once or twice as necessary to confirm the accuracy of the reading. 23. If this is the client initially examination, repeat the procedure on the client’s other arm.
24. Remove the cuff. 25. Wipe the cuff with an approved disinfectant. 26. Document in the client’s record (TPR Sheet): A.) The temperature in the client record. B.) The pulse rate and rhythm C.) The respiratory rate, depth, and rhythm Report pertinent assessment date according to agency policy.
*Only the correctly done procedures are counted. Not done or incorrectly done procedures are not counted but remarks must be written to provide feedback on student’ performance. Formula Procedure Checklist Raw Score -------------- X 50 + 50 X 60 Total Score Evaluation Tool Raw Score -------------- X 100 X 40 25 Over-all RD Grade Clinical Instructor:__________________________________ Computation Rating