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    Body Temperature: Assessment

    Uploaded by

    Chezka Mendoza
    This document provides guidelines for assessing and measuring body temperature, peripheral pulse, and respiration. It describes preparing the necessary equipment, positioning the client appropriately, taking accurate measurements over a full minute, documenting the findings, and ensuring proper infection control procedures are followed. Factors that could impact the vital signs are also assessed to help interpret the results.

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

    Body Temperature: Assessment

    Uploaded by

    Chezka Mendoza
    29 views3 pages
    This document provides guidelines for assessing and measuring body temperature, peripheral pulse, and respiration. It describes preparing the necessary equipment, positioning the client appropriately, taking accurate measurements over a full minute, documenting the findings, and ensuring proper infection control procedures are followed. Factors that could impact the vital signs are also assessed to help interpret the results.

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    Original Title

    Vital Sign

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    This document provides guidelines for assessing and measuring body temperature, peripheral pulse, and respiration. It describes preparing the necessary equipment, positioning the client appropriately, taking accurate measurements over a full minute, documenting the findings, and ensuring proper infection control procedures are followed. Factors that could impact the vital signs are also assessed to help interpret the results.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    29 views3 pages

    Body Temperature: Assessment

    Uploaded by

    Chezka Mendoza
    This document provides guidelines for assessing and measuring body temperature, peripheral pulse, and respiration. It describes preparing the necessary equipment, positioning the client appropriately, taking accurate measurements over a full minute, documenting the findings, and ensuring proper infection control procedures are followed. Factors that could impact the vital signs are also assessed to help interpret the results.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    BODY TEMPERATURE

    PREPARATION
    Assessment
     Assess for clinical signs of fever
     Clinical signs of hypothermia
     Site of most appropriate measurement
     Factors that may alter core body temperature
    Assemble equipment and supplies
     Digital thermometer
     Lubricant for rectal temperature
     Disposable gloves
     Tissue wipes and/or towel for axillary temperature
    Procedure
    1. Explain to the client about the procedure to be done and how he/she can
    cooperate
    2. Wash hands and observe other appropriate infection control procedure
    3. Provide the client privacy
    4. Place the client in appropriate position, sitting or lying with head elevated
    unless taking a rectal or tympanic temperature
    5. Expose the client’s arm and shoulder from sleeves of gown and make
    sure axillary skin is dry, if necessary, pat dry
    6. Prepare and set the digital thermometer
    7. Place the thermometer appropriately, apply a protective sheath if
    necessary, and apply lubricant if rectal thermometer is to be done.
    8. Leave the digital thermometer until the signal is heard and/or check
    package instructions for length of time to wait prior to reading
    thermometer.
    9. Remove and read thermometer, if the reading is too high or too low or
    inconsistent with the client’s condition, recheck using a well-functioning
    one.
    10. Inform client of temperature reading.
    11. Wash or cleanse the thermometer and return it to the proper storage.
    12. Document temperature in the client record and the site taken
    13. Wash hands
    PERIPHERAL PULSE

    Preparation
    Assessment
     Assess for signs for cardiovascular alterations, other than pulse rate,,
    rhythm, or volume.
     Factors that may affect the character of the pulse rate.
     Assess for appropriate site for obtaining pulse.
    Assemble equipment and supplies
     Watch with second hand or indicator
     If using Doppler ultrasound stethoscope, obtain the transducer probe,
    handset, transmission gel, and tissue/wipes
    Procedure
    1. Explain to the client about the procedure to be done and how he/she can
    cooperate
    2. Wash hands and observe other appropriate infection control procedure
    3. Provide the client privacy
    4. Select the pulse point at which you will measure the pulse rate
    5. Assist the client in a comfortable resting position, flex client’s elbow and
    place lower part of arm across chest.
    6. Place your index and middle finger over the radial artery, palpate and
    count the pulse and record the beats in full minute. Recheck if the pulse is
    irregular and count for a full minute.
    7. Assess the rhythm and volume.
    8. Inform the findings with the client
    9. Document the pulse rate, rhythm, and volume and your action in the client
    record.
    10. Wash hands.
    RESPIRATION

    Preparation
    Assessment
     Skin and mucous membrane color
     Position assumed for breathing
     Signs for cerebral anoxia
     Chest movement
     Activity tolerance
     Chest pain
     Dyspnea
     Medications affecting respiratory rate
    Assemble equipment and supplies
     Watch with second hand or indicator
    Procedure
    1. Explain to the client about the procedure to be done and how he/she can
    cooperate
    2. Wash hands and observe other appropriate infection control procedure
    3. Provide the client privacy
    4. Observe or palpate and count the respiratory rate
     If you anticipate the client’s awareness of respiratory awareness, place a
    hand against the chest movements with breathing, or place the client’s
    arm across the chest and observe the chest movements while supposedly
    taking the radial pulse
     An inhalation and an exhalation count as one respiration. Count the
    respiratory rate in a full minute.
    5. Observe the depth, rhythm, and character of respiration.
     Observe the respiration for depth by watching the movement of chest.
     Observe the respiration for regular or irregular rhythm
     Observe the character of the respiration, the sound they produce and the
    effort they require
    6. Inform the findings with the client
    7. Document the respiratory rate, depth, rhythm, and character on the
    appropriate client record.
    8. Wash hands.

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