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    Finals - Rle Osce

    Uploaded by

    Jhaztene Mae Baniqued
    This document provides instructions for properly taking blood pressure. It outlines 29 steps, including preparing the client, appropriately positioning the arm and stethoscope, inflating and deflating the cuff, and listening for Korotkoff sounds to determine systolic and diastolic pressure. The nurse explains each step, ensures client comfort, and documents the results for reporting.

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

    Finals - Rle Osce

    Uploaded by

    Jhaztene Mae Baniqued
    19 views4 pages
    This document provides instructions for properly taking blood pressure. It outlines 29 steps, including preparing the client, appropriately positioning the arm and stethoscope, inflating and deflating the cuff, and listening for Korotkoff sounds to determine systolic and diastolic pressure. The nurse explains each step, ensures client comfort, and documents the results for reporting.

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    Original Title

    FINALS- RLE OSCE

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    This document provides instructions for properly taking blood pressure. It outlines 29 steps, including preparing the client, appropriately positioning the arm and stethoscope, inflating and deflating the cuff, and listening for Korotkoff sounds to determine systolic and diastolic pressure. The nurse explains each step, ensures client comfort, and documents the results for reporting.

    Copyright:

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

    Finals - Rle Osce

    Uploaded by

    Jhaztene Mae Baniqued
    This document provides instructions for properly taking blood pressure. It outlines 29 steps, including preparing the client, appropriately positioning the arm and stethoscope, inflating and deflating the cuff, and listening for Korotkoff sounds to determine systolic and diastolic pressure. The nurse explains each step, ensures client comfort, and documents the results for reporting.

    Copyright:

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

    HAND WASHING

    1. Removes Jewelry.
    2. Assesses hand for hangnails
    3. Turns on water.
    4. Adjusts flow.
    5. Wets hand and lower forearms
    6. Keeps hands and forearms in down position with elbows straight.
    7. Avoids splashing water and touching sides of the sink.
    8. Applies about 5 mL (1 tsp) of liquid soap.
    9. Lathers thoroughly by:
     Palm to palm
     Right over left dorsum with interlaced fingers and vice versa
     palm to palm with fingers interlaced
     back of fingers to opposing palms with fingers interlaced.
    9.3. Rotational rubbing of left thumb clasped in right palm and vice
    versa.
    9.4. Rotational rubbing backwards and forwards with clasped fingers of
    right in left palm and vice versa.
    10. Rubs hands vigorously together for 15 seconds.
    11. Rinses hands with elbows straight, in direction of forearm to wrist
    and fingers.
    12. Dry from fingers to wrist and forearms --- tissue
    14. Turns off the water with used tissue
    15. Trash the tissue
    BLOOD PRESSURE ASSESSMENT
    1. Introduce self, and verify the client's
    For your last assessment sir, I need you to let me know if you smoke po
    ba sir, because if you do, we’ll have to wait pa po sir for 15 minutes if
    you recently smoked.
    (ASK IF OKAY LANG BA ANG PATIENT)
    2. Explains why the BP is taken and why
    BP IS TAKEN TO MEASURE THE PRESSURE IN YOUR ARTERIES AS YOUR
    HEART PUMPS. IT IS USED TO TRACK YOUR HEALTH AND IT IS
    IMPORTANT TO IDENFTIFY IF YOU ARE AT RISK FOR HEART DISEASE OR
    STROKE.
    3. Performs hand hygiene.
    4. Provides client privacy.
    CLOSE THE DOOR/ WINDOW
    5. Places the client in sitting position unless otherwise specified.
    NURSE: Sir I’m going to have to position you in a proper sitting position
    6. Moves client's clothing away from upper aspect of arm.
    NURSE: Okay, next sir, I’m going to move your clothing
    around your arm, I’m going to fold it nicely would that
    be okay po?
    PATIENT: YES
    (ITAAS YUNG DAMIT SA ARM NG IBBP)
    7. Positions client's arm at heart level, extending elbow with palm
    turned upward
    8. Wraps the deflated cuff evenly around the upper arm.
    9. Applies the center of the bladder directly over the artery.
    10. Places the lower border of the cuff approximately 2.5 cm (1 inch)
    above the antecubital space.

    11. NEXT IM GOING TO LOCATE THE BRACHIAL ARTERY WITH MY


    FINGERTIPS AND I WILL PALPATE IT AS WELL. (Locates the brachial
    artery in the antecubital space with the fingertips.)
    12. Palpate the brachial artery with the fingertips.
    13. Closes the valve on the bulb.
    14. Pumps up the cuff until you no longer feel the brachial pulse.
    15. Note the pressure on the sphygmomanometer at which the pulse is
    no longer felt.
    16. Releases the pressure completely in the cuff AFTER THAT, WE WILL
    JUST WAIT FOR 1-2 MINUTES BEFORE TAKING FURTHER
    MEASUREMENTS.
    17. Positions the stethoscope appropriately.
    18. Place the bell side of the amplifier of the stethoscope over the
    brachial pulse.
    19. Place the stethoscope directly on skin
    20. NEXT I’M GOING TO HOLD THE DIAPGRAHM WITH MY THUMB AND
    INDEX FINGER.
    22. NEXT IM GOING TO PUMP UP THE CUFF UNTIL THE
    SPYGMAMOMETER IS 30 MILLIMEERS OF MERCURY above the point
    where the brachial pulse disappears.
    23. AFTER THAT I’M GONNA RELEASE THE VALVE SO THAT THE
    PRESSURE WILL DECREASE
    24. Identifies the manometer reading at korotkoff phases I, IV and V as
    the pressure fails. AND I WILL NOW IDENTIFY THE MANOMETER
    READING (120/80 NORMAL)
    25. Deflates the cuff rapidly and completely.
    28. Removes the cuff.
    29. DOCUMENT AND REPORT AND REPORT THE PERTINENT
    ASSESSMENT DATA OF MY CLIENT. (Documents and report pertinent
    assessment data.)

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