Name: NCM 100.1 Score:

Clinical Instructor: Date:

ASSESSING A PULSE

Definition: Pulse is a throbbing sensation that can be palpated over a peripheral artery or auscultated over the apex of the heart. It results from a wave of blood being pumped into the arterial circulation by the contraction of the left ventricle.

Equipment: > Watch with second hand or digital readout >Stethoscope (for apical pulse)

>Alcohol swab (for stethoscope) >Pen and flow sheet

>Disposable gloves if needed

Assessment: CHOOSE A SITE TO ASSESS THE PULSE:

For an adult patient the most common site is the radial or apical pulse. For a child older than 2 years the radial pulse may be palpated. In infants and young children the brachial pulse may be palpated or the apical pulse may be auscultated.

PROCEDURE RATIONALE

1. Identify the patient. Identifying patient ensure patient safety

2. Explain procedure to the patient. Explanation reduces apprehension and encourages cooperation

3. Gather equipment. Having all the equipment on hand provides for an organized approach to the task.

4. Perform hand hygiene and don gloves as appropriate. Gloves and hygiene deters the spread of microorganisms.

5. Select the appropriate site. Different arteries may be used to assess the pulse.

6. The patient may either be supine by the arm alongside of the body, wrist extended and palms of the hand Lateral or facing down or sitting with the forearm at a 90 degree angle to the body resting on a support with the wrist extended and the palm downward or facing laterally.

These positions are comfortable for the patient and convenient for the nurse.

7. Place your first, second, and third finger along the patient’s radial artery, and press gently against the radius. Rest your thumb on the back of the patient’s wrist.

The sensitive fingertips can feel the pulsation of the artery.

8. Apply only enough pressure so that the artery can be felt distinctly. Moderate pressure facilitates palpations. Too much pressure obliterates the pulse with too little pressure the pulse is imperceptible.

9. Using a watch with a second hand count the number of pulsations felt for 30 seconds. Multiply this number by 2 to calculate the rate for 1 minute. If the rate rhythm or amplitude of the pulse is abnormal in any way, palpate and count the pulse for 1 minute or longer.

To have an accurate assessment and counting of the radial pulse.

10. Dispose gloves if used. Perform hand hygiene. Hand Hygiene deters the spread of microorganisms.

11. Record pulse rate and site on paper, flow sheet, or computerized record. Report abnormal findings to the appropriate person. These actions provide documentation and reporting.

Name: NCM 100.1 Score:

Clinical Instructor: Date:

ASSESSING BLOOD PRESSURE

Definition: Blood Pressure refers to the force of blood against the arterial wall. The standard unit for measuring blood pressure millimetres of mercury (mm Hg).

During normal cardiac cycle, BP reaches a peak that is followed by a trough.

The peak or maximum pressure occurs during SYSTOLE (systolic pressure) as the left ventricle pumps blood into the aorta.

The trough occurs during DIASTOLE (diastolic pressure) as the ventricles relax. Diastolic pressure is the minimal pressure exerted against the arterial walls at all times.

The difference between the systolic and diastolic pressure is the PULSE PRESSURE. Equipment: >Stethoscope >Sphygmomanometer >Blood pressure cuff of appropriate size

>Pen and flow sheet >Alcohol Swab

Assessment: . Palpate the brachial artery

. Assess for an intravenous infusion.

. Assess for breast or axilla surgery on the side.

. Assess for cast, arteriovenous shunt or injured or disease limb.

. Assess for size of the arm so that the appropriate-sized BP cuff can be used.

. Assess the patient pain. If the patient reports pain, give pain medication as ordered before assessing BP (blood pressure).

PROCEDURE RATIONALERATING

1 2 3

1. Identify the patient. Provides patient safety

2. Explain the procedure to the patient. Reduces apprehension and encourages cooperation

3. Gather equipment. Having all equipment on hand provides for an organized approach to the task.

4. Perform hand hygiene. Deters the spread of microorganisms.

5. Delay obtaining the BP if the patient is emotionally upset, is in pain or has just exercised (unless measurement is urgent) Factors such as emotional upset, exercise, and pain alters BP.

6. Select the appropriate arm for application of the cuff (no intravenous infusion, breast or axilla surgery on that side, cast arteriovenous shunt or injured or diseased limb).

Measurement of BP may temporarily impede circulation to the extremity.

7. Have the patient assume a comfortable lying or sitting position. This position places the brachial artery on the inner aspect of the elbow so that the bell or diaphragm of the stethoscope can rest on it easily.

8. Expose the brachial artery by removing garments, or move a sleeve, if it is not too tight, above the area where the cuff would be placed.

Clothing over the artery interferes with the ability to hear sounds and may cause inaccurate BP readings. A tight sleeve would cause congestion of blood and possibly inaccurate readings.

9. 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.

Pressure in the cuff applied directly to the artery provides the most accurate reading. If the cuff gets in the way of the stethoscope, readings are likely to be inaccurate. A cuff placed upside-down with the tubing towards the patients head may give a false reading.

10. 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 with the proper placement of the cuff.

A smooth cuff and snug wrapping produce equal pressure and help promote an accurate measurement. A cuff too loosely wrapped results in an accurate reading.

11. Check that the needle on the aneroid gauge is within the mark. If using a mercury manometer, check to see that the manometer is in vertical position and that the mercury is within the zero level with the gauge at eye level.

If the needle is not in the zero area, the BP may not be accurate. Tilting a mercury manometer, in accurate calibration, or improper height for reading the gauge can lead to error in determining the pressure measurements.

12. Palpate the pulse at the brachial or radial artery by pressing gently with the fingertips. Palpation allows for measurement of the approximate systolic reading.

13. Tighten the screw valve on the air pump. The bladder within the cup will not inflate with the valve open

14. Inflate the cuff while continuing to palpate the artery. Note the point on the gauge where the pulse disappears.

The point where the pulse disappears provides an estimate of the systolic pressure. To identify the first Korotkoff sound accurately, the cuff must be inflated to a pressure above the point at which the pulse can no longer be felt.

15. Deflate the cuff and wait for 15 seconds. Allowing a brief pause before continuing permits the blood to refill and circulate through the arm.

16. Assume a position that is no more than 3 feet away from the gauge. A distance of more than about 3 feet can interfere with accurate readings of the number on the gauge.

17. Place stethoscope earpieces in your ears. Direct the earpieces forward into the canal and not against the ear itself.

Proper placement blocks extraneous noise and allows sound to travel more quickly.

18. Place the bell or diaphragm of the stethoscope firmly but with as little pressure as possible over the brachial artery. Do not allow stethoscope to touch clothing or the cuff.

Having the bell or diaphragm directly over the artery allows more accurate readings. Heavy pressure on the brachial artery distorts the shape of the artery and the sound. Placing away the bell or diaphragm away from the clothing and the cuff prevents noise, which would distract from the sounds made by blood flowing through the artery.

19. 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 2-3 mm per heartbeat).

Increasing the pressure above the point where the pulse disappeared ensures a period before hearing the first sound that corresponds with systolic pressure. It prevents misinterpreting phase II sounds as phase I.

20. Note the point on the gauge at which the first faint, but clear sound appears that slowly increases in intensity. Note this number as the systolic pressure.

Systolic pressure is the point at which the blood in the artery is first able to force its way through the vessel at a similar pressure exerted by the air bladder in the cuff. The first sound is phase I of Korotkoff sound.

21. Read the pressure the closest even number. It is common practice to read BP to the closest even number.

22. Do not reinflate the cuff once the air is being released to recheck the systolic pressure reading.

Reinflating the cuff while obtaining the BP is uncomfortable for the patient and may cause an inaccurate reading. Reinflating the cuff causes congestion of blood in the lower arm, which lessens the loudness of Korotkoff sound.

23. Note the pressure at which the sound first becomes muffled. Also observe the points at which the sound completely disappears. These may occur separately or at the same point.

The point at which the sound changes corresponds to phase IV Korotkoff sounds and is considered the first diastolic pressure.

24. Allow the remaining air to escape quickly. Repeat any suspicious reading, but wait 30-60 seconds between readings to allow normal circulation to return in the limb. Deflate the cuff completely between attempts to check the BP.

False readings are likely to occur if there is congestion of blood in the limb while obtaining repeated readings.

25. Remove the cuff, and clean and store the equipment. Equipment should be left ready for use.

26. Perform hand hygiene. If gloves were worn, discard them in proper receptacle. Hand hygiene deters the spread of microorganisms.

27. Record the findings on paper, flow sheet or computerized record. Report abnormal findings to the appropriate person. Identify arm used and site of assessment if other than brachial.

Reporting and recording ensure accurate documentation and communication.

.

Name: NCM 100.1 Score:

Clinical Instructor: Date:

ASSESSING RESPIRATION

Definition: Respiration involves two distinctly processes: external respiration, or the movement of air between the environment and the lungs; and internal respiration, or the movement of oxygen between hemoglobin and single cells. NOTE: The nurse can directly assess only the process of external respiration, specifically by assessing ventilation.

Equipment: >Watch with second hand or digital readout >Pen and flow sheet Assessment: >Assess the patient for any signs of respiratory distress, which include retractions, nasal flaring, grunting, orthopnea, or tacypnea.

PROCEDURE RATIONALE RATING1. While your finger is still in place after counting the

pulse rate, observe the patients respirations.The patient may alter the rate of respirations if he or she is aware if they are being counted.

2. Note the rise and fall of the patient’s chest. Complete cycle of an inspiration and expiration composes one respiration

3. Using a watch with a second hand, count the number of respirations for about 30 seconds. Multiply the number by 2 to calculate the respiratory rate per minute.

Sufficient time is necessary to observe the rate, depth, and other characteristics.

4. If respirations are abnormal in any way count the respirations for at least 1 full minute. Increased time allows the detection of unequal timing between respirations

5. Perform hand hygiene. Hand hygiene deters the spread of microorganisms

6. Document respiratory rate on paper, flow sheet, or computerized record. Report any abnormal findings to the appropriate persons. These actions provide for accurate documentation and reporting.

Name: NCM 100.1 Score:

Clinical Instructor: Date:

ASSESSING BODY TEMPERATURE

Definition: Axilla is the safest site foe temperature measurement, especially with newborn. However, the time required for measurement with a thermometer and the difficulty with thermometer placement makes the axilliary area less convenient and accurate.

Equipment: > Digital, Electronic or glass thermometer > Container with thermometer > Alcohol Swab

>Probe covers for electronic thermometer > Container with tissue/dry cotton balls

>Disposable gloves > Pen and flow sheet

PROCEDURE RATIONALERATING

1 2 3

1. Check physician’s order or NCP for frequency and route. This provides for patient safety.

2. Identify the patient. This provides for patient safety.

3. Explain procedure to the patient. Explaining reduces apprehension and encourages cooperation.

4. Assemble the equipments. Preparation promotes efficient time management and organized approach to the task.

5. Ensure that the thermometer is in working condition especially if it is electronic or digital thermometer.

An improperly functioning thermometer may not give an accurate reading.

6. Perform hand hygiene and don gloves if appropriate or indicated. Hand hygiene deters the spread of microorganism.

7. Draw curtain around bed or close the door of the patient’s room. Provides privacy and minimizes embarrassment.

8. Position client in supine or sitting position. Provides easy access to the axilla.

9. Move clothing or gown away from shoulder and arm. Provides optimal exposure of axilla.

10. If thermometer is stored in a chemical solution, wipe the thermometer dry with a soft tissue, using a firm twisting motion. Wipe

Reduces contamination of the bulb end.

from bulb toward the finger.

11. Grasp the thermometer firmly with the thumb and the forefinger and using strong wrist movement, shake it until the thermometer line reaches at least 36 degree Celsius.

Brisk shaking lowers mercury level in glass tube.

12. Read the thermometer by holding it horizontally at eye level and rotate it between your forefingers until you can see mercury level. This position makes it easier to see the mercury level.

13. Insert thermometer into center of axilla, lower arm over thermometer and place arm across client’s chest.

Maintains proper position of the thermometer against blood vessels in axilla.

14. Hold thermometer in place for 5-10 minutes or according to agency policy.

Time needed for the mercury in the thermometer to expand and accurately measure temperature. Recommended time varies among institution.

15. Remove thermometer and wipe off any moisture with the tissue. Wipe in rotating fashion from fingers toward bulb. Dispose of tissue.

Wiping the thermometer minimizes the spread of organisms from an area of least contamination to area of most contamination.

16. Read thermometer at eye level. Ensure accurate reading.

17. Inform client of temperature reading. Promotes participation in care and understanding of health status.

18. Wash thermometer in lukewarm soapy water, rinse in cool water, dry and replace in storage container.

Mechanically removes organic material that can harbour microorganisms and hinder action of disinfectant. Storage container prevents breakage.

19. Assist client in replacing clothing or gown. Restores sense of well-being.

20. Dispose gloves if used. Wash hands. Reduces transmission of microorganisms.

Name: NCM 100.1 Score:

Clinical Instructor: Date:

ASSESSING BODY TEMPERATURE

Definition: Body Temperature is the heat of the body measured in degrees. Body temperature indicates the differences between production of heat and loss of heat. Heat is generated by metabolic process in the core tissues of the, transferred to the skin surface by the circulating blood and then dissipated to the environment. Core body temperature is normally maintained with the range of 36oC-37.5oC (97oF-99.5oF).

Equipment: > Digital, electronic or glass thermometer > Container with thermometer > Alcohol Swab

> Probe covers for electronic thermometer > Container with tissue/dry cotton balls > lubricant

> Disposable gloves > Pen and flow sheet

Assessment: (Rectal route)

Review client’s platelet level (if ordered). Do not insert a rectal thermometer into a patient who has a low platelet count. The rectum is very vascular and the thermometer could cause rectal bleeding. With a low platelet count, the patient could lose a large amount of blood.

Taking a rectal temperature is contraindicated in a patient who is immunosupressed because of the risk of rectal Abscess.

Many institutions will not allow a rectal temperature to be taken on patients with heart disease or those who have recently undergone thoracic surgery due to chance of stimulating the vagus nerve and causing bradycardia.

Do not take rectal temperature if the patient has had rectal or perineal surgery.

If a patient complains of diarrhea or has been placed under coronary precautions.

PROCEDURE RATIONALE RATING

1 2 3

1. Check physician’s order or NCP for frequency and route. This provide for patients safety.

2. Identify the patient. This provide for patients safety.

3. Explain procedure to the patient. Explaining reduces apprehension and encourages cooperation.

4. Assemble the equipment. Preparation promotes efficient time management and organized approach to the task.

5. Ensure that the thermometer is in working condition especially if it is electronic or digital thermometer. An improperly functioning may not give an accurate reading.

6. Perform hand wash and don gloves. Hand hygiene deters the spread of microorganisms.

7. Draw curtain around bed and/or close the door of the patients room. Keep clients upper body and lower extremities covered with shift blanket.

Maintains privacy, minimizes embarrassment, promotes comfort.

8. Assist client in assuming side-lying or Sims position. Move a side bed linen to expose only anal area. Exposes anal area for correct thermometer placement.

9. If thermometer is stored in a chemical solution, wipe the thermometer dry with a soft tissue using a firm twisting motion. Wipe from the bulb toward fingers.

Twisting helps cover the entire surface. Wiping area of few or no organisms to an area where organisms might be present minimizes spread to a cleaner area.

10. Grasp the thermometer firmly with the thumb and the forefinger and using strong wrist movements. Shake it until the mercury level reaches at least 36oC.

Thermometer reading must below body temperature before use. Brisk shaking lowers the mercury level in glass tube.

11. Read the thermometer by holding it horizontally at eye level and rotate it between your fingers until you can see the mercury level. This position makes it easier to see the mercury level.

12. Squeeze liberal portion off lubricant onto tissue .Dip thermometer’s blunt end onto lubricant, covering 2.5 to 3.5 cm (1 to 11/2 in) for adult or 1.2 to 2.5 cm (1/2 to 1 in) for infant.

Lubrication minimizes trauma to rectal mucosa during insertion.

13. With non-dominant hand, separate buttocks to expose anus. Fully exposes anus for thermometer insertion.

14. Ask client to breathe slowly and relax. Relaxes anal sphincter for easier thermometer insertion.

15. Gently insert thermometer into anus in direction of umbilicus. Insert 1.2 cm (1/2 in) for infant and 3.5 cm (1 ½ in) for adult. Do not force thermometer.

Ensures adequate exposure against blood vessels in rectal wall.

16. If resistance is felt during insertion, withdraw thermometer immediately. Never force it. Prevents trauma to mucosa. Glass thermometer can break.

17. Hold thermometer in place for 2 to 3 minutes or according to agency protocol. Prevents injury to client. Recommended times vary among institution.

18. Carefully remove thermometer and wipe off secretions with tissue. Wipe in rotating fashion from fingers toward bulb. Dispose of tissue. Avoids contact with microorganisms. Wipe from area of least

contamination to area of most contamination.

19. Read thermometer at eye level. Ensures accurate reading.

20. Inform client of temperature reading. Promotes participation in care and understanding of status.

21. Wipe anal area to remove lubricant or feces. Promotes comfort

22. Help client return to comfortable position. Restores comfort.

23. Wash thermometer in lukewarm soapy water, rinse in cool water dry and replace in storage container.

Mechanically removes organic material that can harbour microorganisms and hinder action of disinfectant. Storage container prevents breakage.

24. Dispose of gloves. Wash hands. Deters the spread of microorganisms.

25. Record temperature reading in a flow sheet or any computerized record. Report any abnormal findings to the appropriate persons. Provides accurate documentation and reporting.

Name: NCM 100.1 Score:

Clinical Instructor: Date:

ASSESSING BODY TEMPERATURE

Definition: Body Temperature is the heat of the body measured in degrees. Body temperature indicates the differences between production of heat and loss of heat. Heat is generated by metabolic process in the core tissues of the, transferred to the skin surface by the circulating blood and then dissipated to the environment. Core body temperature is normally maintained with the range of 36oC-37.5oC (97oF-99.5oF).

Equipment: > Digital, electronic or glass thermometer > Container with thermometer > Alcohol Swab

> Probe covers for electronic thermometer > Container with tissue/dry cotton balls

> Disposable gloves > Pen and flow sheet

Assessment: (Oral Route)

Assess whether the client can close his /her lips around thermometer.

Assess oral cavity for any stores, disease of the oral cavity or previews surgery of nose or mouth.

Ask the patient if he/she has recently smoked, has been chewing gum, or was eating and drinking immediately before assessing temperature. If the patient has done any of these things. WAIT FOR 15-30 MINUTES before taking an oral temperature because of the possible direct influence on the patient’s temperature.

PROCEDURE RATIONALERATING

1 2 3

1. Check physician’s order or NCP for frequency and route. This provide for patients safety.

2. Identify the patient. This provide for patients safety.

3. Explain procedure to the patient. Explaining reduces apprehension and encourages cooperation.

4. Assemble the equipment. Preparation promotes efficient time management and organized approach to the task.

5. Ensure that the thermometer is in working condition especially if it is electronic or digital thermometer. An improperly functioning may not give an accurate reading.

6. Perform hand wash and don gloves. Hand hygiene deters the spread of microorganisms.

7. Assist client in assuming comfortable position that provides easy access to mouth. Ensures comfort and accuracy of temperature reading.

8. If thermometer is stored in a chemical solution, wipe the thermometer dry with a soft tissue, using a firm twisting motion. Wipe from bulb toward the finger.

Reduces contamination of the bulb end.

9. Grasp the thermometer firmly with the thumb and the forefinger and using strong wrist movement, shake it until the thermometer line reaches at least 36 degree Celsius.

Brisk shaking lowers mercury level in glass tube.

10. Read the thermometer by holding it horizontally at eye level and rotate it between your forefingers until you can see mercury level. This position makes it easier to see the mercury level.

11. Ask the client to open his/her mouth gently place thermometer under tongue in posterior sublingual pocket lateral to center of lower jaw.

Heat from the superficial blood vessels in sublingual pocket produces temperature reading.

12. Ask client to close his/her lips. Caution against bitting down Maintains proper position of thermometer recording. Breakage of thermometer may injure mucosa and cause mercury poisoning.

13. Leave thermometer in place for 3 minutes or according to agency protocol.

Time is needed for the mercury in the thermometer to expand and accurately measure temperature.

14. Carefully remove the thermometer and read at eye level. Ensures accurate reading.

15. Inform client of temperature. Promotes participation in care and understanding of health status.

16. Wipe secretions from the thermometer. Wipe it from the fingers down to the bulb, using a firm, twisting motion.

Wiping the thermometer minimizes the spread of organisms from an area of higher concentration to a cleaner area, friction helps loosen material from the thermometer surface.

17. Wash thermometer in lukewarm soapy water, rinse in cool water dry and replace in storage container.

Washing removes organic material and organisms. Storage container prevents breakage.

18. Remove and dispose of gloves if used. Wash hands Deters the spread of microorganisms.

19. Report temperature reading in a flow sheet or any computerized record. Report any abnormal findings to the appropriate persons.

Recording and reporting ensure accurate documentation and communication.