Location via proxy:   [ UP ]  
[Report a bug]   [Manage cookies]                
Scribd Logo
Upload

Welcome to Scribd!

  • 109 views

    Vital Signs: Measuring Oral Temperature, Radial Pulse, Respiratory Rate, and Blood Pressure

    Uploaded by

    ellith
    This document provides instructions for assessing several common vital signs: oral temperature, radial pulse, blood pressure, and respiratory rate. It describes how to use various tools like digital thermometers, stethoscopes, and blood pressure cuffs to obtain accurate measurements for each vital sign. The procedures involve preparing equipment, positioning the patient correctly, taking accurate readings, and documenting the results.

    Copyright:

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

    Vital Signs: Measuring Oral Temperature, Radial Pulse, Respiratory Rate, and Blood Pressure

    Uploaded by

    ellith
    109 views4 pages
    This document provides instructions for assessing several common vital signs: oral temperature, radial pulse, blood pressure, and respiratory rate. It describes how to use various tools like digital thermometers, stethoscopes, and blood pressure cuffs to obtain accurate measurements for each vital sign. The procedures involve preparing equipment, positioning the patient correctly, taking accurate readings, and documenting the results.

    Original Description:

    Nc

    Original Title

    ncm103a-1st

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document provides instructions for assessing several common vital signs: oral temperature, radial pulse, blood pressure, and respiratory rate. It describes how to use various tools like digital thermometers, stethoscopes, and blood pressure cuffs to obtain accurate measurements for each vital sign. The procedures involve preparing equipment, positioning the patient correctly, taking accurate readings, and documenting the results.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    109 views4 pages

    Vital Signs: Measuring Oral Temperature, Radial Pulse, Respiratory Rate, and Blood Pressure

    Uploaded by

    ellith
    This document provides instructions for assessing several common vital signs: oral temperature, radial pulse, blood pressure, and respiratory rate. It describes how to use various tools like digital thermometers, stethoscopes, and blood pressure cuffs to obtain accurate measurements for each vital sign. The procedures involve preparing equipment, positioning the patient correctly, taking accurate readings, and documenting the results.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    You are on page 1of 4

    Vital Signs

    Measuring Oral Temperature, Radial Pulse, Respiratory Rate, and Blood


    Pressure

    Assessing Oral Temperature With an Electronic or Digital Thermometer


    1. Check physician's order or nursing care plan for frequency and route.
    2. Identify patient.
    3. Explain procedure to patient.
    4. Gather equipment.
    5. Perform hand hygiene and don gloves if appropriate or indicated.
    6. Make sure the electronic or digital thermometer is in operating condition.
    Release the electronic unit from the charging unit; remove the probe from within the
    7.
    recording unit.
    Cover thermometer probe with disposable probe cover and slide it into place until it
    8.
    snaps into place.
    Place probe beneath the patient's tongue in the posterior sublingual pocket. Ask the
    9.
    patient to close his or her lips around the probe.
    Continue to hold the probe until you hear a beep to let you know the reading is
    10.
    completed. Note the temperature reading.
    11. Remove the probe from the patient's mouth and dispose of the probe cover by holding
    the probe over an appropriate receptacle and pressing the probe release button.
    Return the thermometer probe to the storage place within the unit; return the electronic
    12.
    unit to the charging unit make sure it is fully charged.
    13. Perform hand hygiene. If wearing gloves, discard them in proper receptacle.
    Record temperature on paper, flow sheet, or computerized record. Report abnormal
    14.
    findings to the appropriate person. Identify assessment site if other than oral.

    Palpating the Radial Pulse


    1. Patient may either be supine with arm alongside body, wrist extended, and palms
    lateral or facing down or sitting with forearm at a 90-degree angle to body resting on a
    support with wrist extended and palm downward or facing laterally.
    2. Place your first, second, and third fingers along patient's radial artery and press gently
    against the radius. Rest your thumb on back of patient's wrist.
    3. Apply only enough pressure to distinctly feel the artery.
    4. Using a watch with a second hand, count the number of pulsations felt for 30 seconds.
    Multiply this number by 2 to have rate for 1 minute. If pulse's rate, rhythm, or amplitude
    are abnormal in any way, palpate for 1 minute longer.

    Taking Blood Pressure Using a Blood Pressure Cuff and Stethoscope


    Delay obtaining the blood pressure if the patient is emotionally upset, is in pain, or has
    1.
    just exercised (unless measurement is urgent).
    Select the appropriate arm for application of cuff (no intravenous infusion, breast or
    2.
    axilla surgery on that side, cast, arteriovenous shunt, or injured or diseased limb).
    Have the patient assume a comfortable lying or sitting position with the forearm
    3.
    supported at the level of the heart and the palm of the hand upward.
    Expose the brachial artery by removing garments, or move a sleeve, if it is not too tight,
    4.
    above the area where the cuff will be placed.
    5. Center the bladder of the cuff over the brachial artery, about midway on the arm, so
    that the lower edge of the cuff is about 2.5 to 5 cm (1" to 2") above the inner aspect of
    the elbow. The tubing should extend from the edge of the cuff nearer the patient's
    elbow.
    Wrap the cuff around the arm smoothly and snugly, and fasten it securely or tuck the
    end of the cuff well under the preceding wrapping. Do not allow any clothing to interfere
    6. with the proper placement of the cuff.
    7. Check that the needle on the aneroid gauge is within the zero mark. If using a mercury
    manometer, check to see that the manometer is in the vertical position and that the
    mercury is within the zero level with the gauge at eye level.
    8. Palpate the pulse at the brachial or radial artery by pressing gently with the fingertips.
    9. Tighten the screw valve on the air pump.
    Inflate the cuff while continuing to palpate the artery. Note the point on the gauge where
    10.
    the pulse disappears.
    11. Deflate the cuff and wait 15 seconds.
    12. Assume a position that is no more than 3 feet away from the gauge.
    Place the stethoscope earpieces in your ears. Direct the earpieces forward into the
    13.
    canal and not against the ear itself.
    Place the bell or diaphragm of the stethoscope firmly but with as little pressure as
    14. possible over the brachial artery. Do not allow the stethoscope to touch clothing or the
    cuff.
    15. Pump the pressure 30 mm Hg above the point at which the systolic pressure was
    palpated and estimated. Open the valve on the manometer and allow air to escape
    slowly (allowing the gauge to drop 2 to 3 mm per heartbeat).
    Note the point on the gauge at which the first faint, but clear, sound appears that slowly
    16.
    increases in intensity. Note this number as the systolic pressure.

    17. Read the pressure to the closest even number.


    Do not inflate the cuff once the air is being released to recheck the systolic pressure
    18.
    reading.
    Note the pressure at which the sound first becomes muffled. Also observe the point at
    19. which the sound completely disappears. These may occur separately or at the same
    point.
    20. Allow the remaining air to escape quickly. Repeat any suspicious reading, but wait 30
    to 60 seconds between readings to allow normal circulation to return in the limb. Deflate
    the cuff completely between attempts to check blood pressure.
    21. Remove the cuff, and clean and store the equipment.
    22. Perform hand hygiene.
    Record the findings on paper, flow sheet, or computerized record. Record abnormal
    23. findings to the appropriate person. Identify arm used and site of assessment if other
    than brachial.

    Assessing Blood Pressure With An Electronic Device


    Turn the machine on. If the machine has different settings for infants, children, and
    1. adults, select the appropriate setting. Push the start button. Instruct the patient to hold
    the arm still.
    2. Perform hand hygiene. If gloves are worn, discard them in the proper receptacle.
    Record the findings on paper, flow sheet, or computerized record. Report abnormal
    3. findings to the appropriate person. Identify arm used and site of assessment if other
    than brachial.

    Measuring Tympanic Temparature

    1. Check physician's order or nursing care plan for frequency and route.
    2. Identify patient.
    3. Explain procedure to patient.
    4. Gather equipment.
    5. Make sure the tympanic thermometer is in operating condition.
    6. Perform hand hygiene and don gloves if appropriate or indicated.
    7. If necessary, push the "On" button and wait for the "Ready" signal on unit.
    8. Attach tympanic probe cover.
    Using gentle but firm pressure, insert probe snugly into external ear, angling
    9. thermometer toward patient's jaw line. Pull pinna up and back to straighten the ear
    canal in an adult.
    Activate unit by pushing trigger button. The reading is immediate, usually within 2
    10.
    seconds. Note temperature reading.
    Discard probe cover in appropriate receptacle by pushing the probe release button and
    11.
    replace thermometer in its charger or holder.

    Measuring a Rectal Temparature

    1. Check physician's order or nursing care plan for frequency and route.
    2. Identify patient.
    3. Explain procedure to patient.
    4. Gather equipment.
    5. Put on gloves.
    6. Provide privacy for the patient by closing door or curtain.
    Place the bed at an appropriate working height to reduce back strain during the
    7.
    procedure.
    Assist the patient into side-lying position. Pull back covers enough to expose only the
    8.
    buttocks.
    Remove the probe from within the recording unit of the electronic thermometer. Cover
    9.
    the probe with a disposable probe cover and slide it until it snaps into place.
    10. Lubricate about 1 inch of the probe with water-soluble lubricant.
    11. Reassure patient. Separate the buttocks until anal sphincter is clearly visible.
    12. Insert thermometer probe into the anus about 1 ½ inch in an adult or 1 inch in a child.
    Hold the probe in place until you hear a beep, then carefully remove the probe. Note
    13.
    the temperature reading on the display.
    Dispose of the probe cover by holding the probe over an appropriate waste receptacle
    14.
    and pressing the release button.
    Using toilet tissue, wipe the anus of any feces or excess lubricant. Dispose of the toilet
    15.
    tissue.
    16. Remove gloves and discard them. Perform hand hygiene.
    Cover the patient and help him or her to a position of comfort. Place the bed in the
    17.
    lowest position; elevate rails as needed.
    18. Return the thermometer to the charging unit.

    Measuring an Axillary Temperature

    1. Check physician's order or nursing care plan for frequency and route.
    2. Identify patient.
    3. Explain procedure to patient.
    4. Gather equipment.
    5. Ensure privacy by closing door or curtains.
    6. Place bed at an appropriate working height to reduce back strain during skill.
    7. Move patient's clothing to expose axilla.
    Remove probe from recording unit of the electronic thermometer. Slide on a disposable
    8.
    probe cover and snap it securely into place.
    9. Place the end of the probe in the center of the axilla. Have patient bring his or her arm
    down and close to the body.
    Hold the probe in place until you hear a beep, and then carefully remove probe. Note
    10.
    the temperature reading.
    Dispose of the probe cover by holding probe over appropriate waste receptacle and
    11.
    pushing release button.
    Place the bed in the lowest position and elevate rails as needed. Leave the patient
    12.
    clean and comfortable.
    13. Return the electronic thermometer to the charging unit.

    Measuring an Apical Pulse

    1. Check physician's order or nursing care plan for frequency and route.
    2. Identify patient.
    3. Explain procedure to patient.
    4. Gather equipment.
    5. Use alcohol swab to clean stethoscope ear pieces and diaphragm.
    6. Assist patient to sit in chair or sit up in bed and then expose chest area.
    7. Hold stethoscope diaphragm against the palm of your hand for a few seconds.
    Palpate the fifth intercostal space and move to left midclavicular line. Place diaphragm
    8.
    over apex of the heart.
    9. Listen for heart sounds, identified as a "lub-dub" sound.
    10. Using watch with a second hand, count heartbeat for 1 minute.

    You might also like