Checking-The-Vital-Signs For Return Demo
Checking-The-Vital-Signs For Return Demo
Checking-The-Vital-Signs For Return Demo
Equipment:
1. Tray containing:
a. Thermomete
b. jar of CB in water
c. jar with cut tissue paper d. waste receptacle
Procedure
4. Bring the tray to the bedside and When the patient knows what is to
explain the procedure to the patient. be done, he will cooperate better.
8. Pat the patient’s axilla dry with a Moisture in the axilla may alter the
wash cloth or tissue. Place the probe result of the temperature. The
of the thermometer into the center of deepest area of the axilla provides
the axilla. Bring the patient’s arm the most accurate temperature
down close to his body and place his measurement.
forearm over his chest.
14. Dispose the used CB and tissue Confining contaminated articles help
paper in the waste receptacle. to reduce the spread of pathogens.
Purpose: To obtain an estimate of the quality of the heart’s action per minute.
Procedure
Action Rationale
2. Have the patient rest his arm This position places the radial artery
along side of his body with the wrist on the inner aspect of the patient’s
extended and the palm of the hand wrist. The nurse’s fingers rest
downward, or place arm on top of conveniently on the artery with
the patient’s upper abdomen with the thumb in a position to the outer
palm downward position. aspect of the patient’s wrist.
3. Place your first, second and third The fingertips which are sensitive to
fingers along the radial artery and touch will feel the pulsation of the
press gently against the radius; rest patient’s radial artery. If the thumb is
the thumb on the back of the used to palpate the patient’s pulse,
patient’s wrist. the nurse may feel her own pulse.
4. Apply enough pressure so that the Moderate pressure allows the nurse
patient’s pulsating artery can be felt to feel the superficial artery expand
distinctly. and contract with each heart beat.
Procedure
Action Rationale
6. Place the diaphragm of the This gives the loudest and most
stethoscope over the apex of the distinctive sound of the heart.
heart, located at the fifth intercostal
space, left midclavicular line 5th ICS,
LMCL). Then, insert the earpieces in
your ears.
A full minute count is important for
7. Move the diaphragm to the site of an accurate assessment. A longer
the loudest beats. Count the beats duration helps determine pulse
for 60 seconds and note their rhythm rhythm and quality. In no instance, is
and volume. Also evaluate the the radial pulse count greater than
intensity (loudness) of heart sounds. the apical pulse count.
8. Remove the stethoscope and
make the client comfortable.
Purpose: To obtain the respiratory rate per minute and an estimate of the
patient’s respiratory status.
Procedure
Action Rationale
Purposes:
1. To aid in diagnosis
2. To observe changes in a patient’s condition
Equipment:
1. Stethoscope
2. Sphygmomanometer with appropriate size of cuff
3. Jotdown notebook and pen
4. Alcohol swab
Normal Ranges:
4. Place the cuff so that the inflatable Pressure applied directly to the
bag is centered and lies midway artery will yield most accurate
over the anterior surface of the readings.
brachial artery, (the surface of the
brachial artery should be at the
center of the 2 tubings of the cuff) so
that the lower edge of cuff is 2.5 – 5
cm. above antecubital fossa.
5. Wrap the cuff smoothly and A twisted cuff and wrapping could
snugly around the arm with the end produce inaccurate reading.
of the cuff secure
7. Inflate the cuff to 30 mmHg where This will prevent you from missing
the pulsation disappears. Place the the first tap sound as a result of the
diaphragm of the stethoscope auscultatory gap (period where no
directly over the pulse. sound is heard)
.
8. Gradually deflate cuff all the way First sound is the systolic BP and
to zero taking note of the first and last sound is diastolic BP.
the last clear, loud sound.
* Pulse pressure – the difference between systolic and diastolic pressures. e.g.
120/ 80 BP Pulse pressure is 40 – may be ordered in patients with Dengue
Hemorrhagic Fever.