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    Assessing Pulse Rate-Rle

    Uploaded by

    Jan Jamison Zulueta
    This document provides a score sheet for assessing a client's vital signs, including pulse rate, respirations, and blood pressure. It lists the steps to take for each assessment, such as placing fingers over the radial artery to count pulse rate for one minute, observing a full respiratory cycle and counting respirations for one minute, and using a blood pressure cuff to measure systolic and diastolic pressure by listening with a stethoscope. The scorer rates the caregiver's performance of each step as 5 (performed correctly), 3 (performed acceptably with minor errors), or 0 (performed incorrectly or not at all).

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Assessing Pulse Rate-Rle

    Uploaded by

    Jan Jamison Zulueta
    159 views2 pages
    This document provides a score sheet for assessing a client's vital signs, including pulse rate, respirations, and blood pressure. It lists the steps to take for each assessment, such as placing fingers over the radial artery to count pulse rate for one minute, observing a full respiratory cycle and counting respirations for one minute, and using a blood pressure cuff to measure systolic and diastolic pressure by listening with a stethoscope. The scorer rates the caregiver's performance of each step as 5 (performed correctly), 3 (performed acceptably with minor errors), or 0 (performed incorrectly or not at all).

    Original Description:

    ASSESSING PULSE RATE

    Original Title

    Assessing Pulse Rate-rle

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    © © All Rights Reserved

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    This document provides a score sheet for assessing a client's vital signs, including pulse rate, respirations, and blood pressure. It lists the steps to take for each assessment, such as placing fingers over the radial artery to count pulse rate for one minute, observing a full respiratory cycle and counting respirations for one minute, and using a blood pressure cuff to measure systolic and diastolic pressure by listening with a stethoscope. The scorer rates the caregiver's performance of each step as 5 (performed correctly), 3 (performed acceptably with minor errors), or 0 (performed incorrectly or not at all).

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    159 views2 pages

    Assessing Pulse Rate-Rle

    Uploaded by

    Jan Jamison Zulueta
    This document provides a score sheet for assessing a client's vital signs, including pulse rate, respirations, and blood pressure. It lists the steps to take for each assessment, such as placing fingers over the radial artery to count pulse rate for one minute, observing a full respiratory cycle and counting respirations for one minute, and using a blood pressure cuff to measure systolic and diastolic pressure by listening with a stethoscope. The scorer rates the caregiver's performance of each step as 5 (performed correctly), 3 (performed acceptably with minor errors), or 0 (performed incorrectly or not at all).

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    SCORE SHEET

    NAME:
    Caregiver

    DATE:
    ASSESSING PULSE RATE
    ACTION

    1. RADIAL PULSE
    a. Inform client of the site(s) at which you will measure pulse.
    b. Flex clients elbow and place lower part of arm across chest.
    c. Support clients wrist by grasping outer aspect with thumb.
    d. Place your index and middle finger on inner aspect of clients
    wrist over the radial artery and apply light but firm pressure
    until pulse is palpated.
    e. Identify pulse rhythm.
    f. Determine pulse volume.
    g. Count pulse rate by using second hand on a watch:
    For an irregular rhythm, count number of beats for a full
    minute, noting number of irregular beats.
    ASSESSING RESPIRATIONS
    Action
    1. Continue to place your hand over clients wrist and observe
    one complete respiratory cycle.
    3. Start to count with first inspiration while looking at second
    hand sweep of watch. Count a full minute.
    4. Observe depth of respirations by degree of chest wall
    movement and rhythm of cycle (regular or interrupted).
    5. Record rate and character of respirations.
    ASSESSING BLOOD PRESSURE
    ACTION
    1. Determine which extremity is most appropriate for reading.
    Do not take a pressure reading on an injured or painful
    extremity or one in which an intravenous line is running.
    2. Select a cuff size that completely encircles upper arm without
    overlapping.
    3. Move clothing away from upper aspect of arm.
    4. Position arm at heart level, extend elbow with palm turned
    upward.
    5. Make sure cuff is fully deflated and pump valve moves freely.
    6. Locate brachial artery in the antecubital space.
    7. Apply cuff snugly and smoothly over upper arm, 2.5 cm (1
    in.) above antecubital space with center of cuff over brachial

    artery.
    8. Insert earpiece of stethoscope in ears with a forward tilt,
    ensuring diaphragm hangs freely.
    9. Relocate brachial pulse with your nondominant hand and
    place bell or diaphragm chestpiece directly over pulse.
    Chestpiece should be in direct contact with skin and not touch
    cuff.
    10. With dominant hand, turn valve clockwise to close.
    Compress pump to inflate cuff.
    11. Slowly turn valve counterclockwise so that mercury falls at a
    rate of 23 mm Hg per second.
    14. Deflate cuff rapidly and completely.
    15. Remove cuff or wait 2 minutes before taking a second
    reading.
    16. Inform client of reading.
    17. Record reading.
    18. Lower bed, raise side rails, place call light in easy reach.
    19. Put all equipment in proper place.
    20. Wash hands.
    21. Document measurements in clients medical record on
    appropriate form, usually vital signs flow sheet.
    22. Compare data with clients baseline and normal range for
    age group.
    23. If any measurements are abnormal, measure again and
    report abnormal findings to instructor or charge nurse.

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