Name: Score: Clinical Instructor:

NCM 100.1 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 >Alcohol swab (for stethoscope) >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. >Stethoscope (for apical pulse) >Pen and flow sheet

PROCEDURE 1. 2. Identify the patient. Explain procedure to the patient.

RATIONALE Identifying patient ensure patient safety Explanation reduces apprehension and encourages cooperation Having all the equipment on hand provides for an organized approach to the task. Gloves and hygiene deters the spread of microorganisms. Different arteries may be used to assess the pulse.

3. Gather equipment. 4. Perform hand hygiene and don gloves as appropriate.

5. Select the appropriate site.

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 These positions are comfortable for the patient and forearm at a 90 degree angle to the body resting convenient for the nurse. on a support with the wrist extended and the palm downward or facing laterally. 7. Place your first, second, and third finger along the patients radial artery, and press gently against The sensitive fingertips can feel the pulsation of the artery. the radius. Rest your thumb on the back of the patients wrist. 8. Moderate pressure facilitates palpations. Too much pressure Apply only enough pressure so that the artery can obliterates the pulse with too little pressure the pulse is be felt distinctly. imperceptible. 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 To have an accurate assessment and counting of the radial minute. If the rate rhythm or amplitude of the pulse. pulse is abnormal in any way, palpate and count the pulse for 1 minute or longer. Hand Hygiene deters the spread of microorganisms.

9.

10.Dispose gloves if used. Perform hand hygiene.

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

Name: Clinical Instructor:

NCM 100.1 Score: 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 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. (blood . Assess the patient pain. If the patient reports pain, give pain medication as ordered before assessing BP pressure). >Alcohol Swab

PROCEDURE 1. Identify the patient.

RATIONALE Provides patient safety Reduces apprehension and encourages cooperation Having all equipment on hand provides for an organized approach to the task. Deters the spread of microorganisms.

RATING 1 2 3

2. Explain the procedure to the patient. 3. Gather equipment. 4. Perform hand hygiene.

5. Delay obtaining the BP if the patient is Factors such as emotional upset, exercise, and pain emotionally upset, is in pain or has just exercised alters BP. (unless measurement is urgent) 6. Select the appropriate arm for application of the cuff (no intravenous infusion, breast or axilla Measurement of BP may temporarily impede surgery on that side, cast arteriovenous shunt or circulation to the extremity. injured or diseased limb). 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.

Clothing over the artery interferes with the ability to 8. Expose the brachial artery by removing hear sounds and may cause inaccurate BP readings. garments, or move a sleeve, if it is not too tight, A tight sleeve would cause congestion of blood and above the area where the cuff would be placed. 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 patients 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. 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.

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. 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 Palpation allows for measurement of the artery by pressing gently with the fingertips. approximate systolic reading. 13.Tighten the screw valve on the air pump. The bladder within the cup will not inflate with the valve open

The point where the pulse disappears provides an 14.Inflate the cuff while continuing to palpate the estimate of the systolic pressure. To identify the artery. Note the point on the gauge where the first Korotkoff sound accurately, the cuff must be pulse disappears. 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. 16.Assume a position that is no more than 3 feet away from the gauge. Allowing a brief pause before continuing permits the blood to refill and circulate through the arm. 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. Proper placement blocks extraneous noise and Direct the earpieces forward into the canal and allows sound to travel more quickly. not against the ear itself.

Having the bell or diaphragm directly over the artery allows more accurate readings. Heavy 18.Place the bell or diaphragm of the stethoscope pressure on the brachial artery distorts the shape of firmly but with as little pressure as possible over the artery and the sound. Placing away the bell or the brachial artery. Do not allow stethoscope to diaphragm away from the clothing and the cuff touch clothing or 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). 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. 21.Read the pressure the closest even number. 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. 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. It is common practice to read BP to the closest even number. 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.

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

23.Note the pressure at which the sound first The point at which the sound changes corresponds becomes muffled. Also observe the points at to phase IV Korotkoff sounds and is considered the which the sound completely disappears. These first diastolic pressure. may occur separately or at the same point. 24.Allow the remaining air to escape quickly. False readings are likely to occur if there is Repeat any suspicious reading, but wait 30-60 congestion of blood in the limb while obtaining seconds between readings to allow normal repeated readings.

circulation to return in the limb. Deflate the cuff completely between attempts to check the BP. 25.Remove the cuff, and clean and store the equipment. 26.Perform hand hygiene. If gloves were worn, discard them in proper receptacle. Equipment should be left ready for use.

Hand hygiene deters the spread of microorganisms.

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

Name: Score: Clinical Instructor:

NCM 100.1 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 1. While your finger is still in place after counting the pulse rate, observe the patients respirations. 2. Note the rise and fall of the patients chest. 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. 4. If respirations are abnormal in any way count the respirations for at least 1 full minute. 5. Perform hand hygiene. 6. Document respiratory rate on paper, flow sheet, or computerized record. Report any abnormal findings to the appropriate persons.

RATIONALE The patient may alter the rate of respirations if he or she is aware if they are being counted. Complete cycle of an inspiration and expiration composes one respiration Sufficient time is necessary to observe the rate, depth, and other characteristics.

RATING

Increased time allows the detection of unequal timing between respirations Hand hygiene deters the spread of microorganisms These actions provide for accurate documentation and reporting.

Name: Score: Clinical Instructor:

NCM 100.1 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 Alcohol Swab >Probe covers for electronic thermometer >Disposable gloves PROCEDURE

> Container with thermometer > Container with tissue/dry cotton balls > Pen and flow sheet RATIONALE

>

RATING 1 2 3

1. Check physicians order or NCP for frequency and This provides for patient safety. route. 2. Identify the patient. This provides for patient safety. 3. Explain procedure to the patient. 4. Assemble the equipments. Explaining reduces apprehension and encourages cooperation. Preparation promotes efficient time management and organized approach to the task.

5. Ensure that the thermometer is in working An improperly functioning thermometer may not condition especially if it is electronic or digital give an accurate reading. thermometer. 6. Perform hand hygiene and don gloves if appropriate or indicated. 7. Draw curtain around bed or close the door of the patients room. 8. Position client in supine or sitting position. 9. Move clothing or gown away from shoulder and arm. 10. 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 Hand hygiene deters the spread of microorganism. Provides privacy and minimizes embarrassment. Provides easy access to the axilla. Provides optimal exposure of axilla. Reduces contamination of the bulb end.

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 This position makes it easier to see the mercury at eye level and rotate it between your forefingers level. until you can see mercury level. 13. Insert thermometer into center of axilla, lower arm over thermometer and place arm across clients 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.

Wiping the thermometer minimizes the spread of 15. Remove thermometer and wipe off any organisms from an area of least contamination to moisture with the tissue. Wipe in rotating fashion area of most contamination. from fingers toward bulb. Dispose of tissue. 16. Read thermometer at eye level. 17. Inform client of temperature reading. 18. Wash thermometer in lukewarm soapy water, rinse in cool water, dry and replace in storage container. Ensure accurate reading. Promotes participation in care and understanding of health status. 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. 20. Dispose gloves if used. Wash hands.

Restores sense of well-being. Reduces transmission of microorganisms.

Name: Clinical Instructor:

NCM 100.1 Score: 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 Alcohol Swab > Probe covers for electronic thermometer lubricant > Disposable gloves Assessment: (Rectal route) Review clients 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. > Pen and flow sheet > Container with thermometer > Container with tissue/dry cotton balls > >

PROCEDURE 1. Check physicians order or NCP for frequency and route. 2. Identify the patient. 3. Explain procedure to the patient. 4. Assemble the equipment. 5. Ensure that the thermometer is in working condition especially if it is electronic or digital thermometer. 6. Perform hand wash and don gloves.

RATIONALE This provide for patients safety. This provide for patients safety. Explaining reduces apprehension and encourages cooperation. Preparation promotes efficient time management and organized approach to the task. An improperly functioning may not give an accurate reading. Hand hygiene deters the spread of microorganisms.

RATING 1 2 3

7. Draw curtain around bed and/or close the door of Maintains privacy, minimizes embarrassment, the patients room. Keep clients upper body and promotes comfort. lower extremities covered with shift blanket. 8. Assist client in assuming side-lying or Sims Exposes anal area for correct thermometer position. Move a side bed linen to expose only anal placement. area. 9. If thermometer is stored in a chemical solution, Twisting helps cover the entire surface. Wiping area wipe the thermometer dry with a soft tissue using a of few or no organisms to an area where organisms firm twisting motion. Wipe from the bulb toward

fingers.

might be present minimizes spread to a cleaner area.

10. Grasp the thermometer firmly with the thumb Thermometer reading must below body temperature and the forefinger and using strong wrist before use. Brisk shaking lowers the mercury level in movements. Shake it until the mercury level glass tube. reaches at least 36oC. 11. Read the thermometer by holding it horizontally This position makes it easier to see the mercury at eye level and rotate it between your fingers until level. you can see the mercury level. 12. Squeeze liberal portion off lubricant onto tissue .Dip thermometers blunt end onto lubricant, Lubrication minimizes trauma to rectal mucosa covering 2.5 to 3.5 cm (1 to 11/2 in) for adult or 1.2 during insertion. to 2.5 cm (1/2 to 1 in) for infant. 13. With non-dominant hand, separate buttocks to expose anus. 14. Ask client to breathe slowly and relax. Fully exposes anus for thermometer insertion. 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 Ensures adequate exposure against blood vessels in infant and 3.5 cm (1 in) for adult. Do not force rectal wall. thermometer. 16. If resistance is felt during insertion, withdraw thermometer immediately. Never force it. 17. Hold thermometer in place for 2 to 3 minutes or according to agency protocol. Prevents trauma to mucosa. Glass thermometer can break. Prevents injury to client. Recommended times vary among institution.

18. Carefully remove thermometer and wipe off Avoids contact with microorganisms. Wipe from area secretions with tissue. Wipe in rotating fashion from of least contamination to area of most contamination. fingers toward bulb. Dispose of tissue. Ensures accurate reading. 19. Read thermometer at eye level.

20. Inform client of temperature reading. 21. Wipe anal area to remove lubricant or feces. 22. Help client return to comfortable position. 23. Wash thermometer in lukewarm soapy water, rinse in cool water dry and replace in storage container. 24. Dispose of gloves. Wash hands.

Promotes participation in care and understanding of status. Promotes comfort Restores comfort. Mechanically removes organic material that can harbour microorganisms and hinder action of disinfectant. Storage container prevents breakage. Deters the spread of microorganisms.

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

Name: Score: Clinical Instructor: Date:

NCM 100.1

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

> Disposable gloves Assessment: (Oral Route)

> Pen and flow sheet

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 1530 MINUTES before taking an oral temperature because of the possible direct influence on the patients temperature. PROCEDURE 1. Check physicians order or NCP for frequency and route. 2. Identify the patient. 3. Explain procedure to the patient. 4. Assemble the equipment. 5. Ensure that the thermometer is in working condition especially if it is electronic or digital thermometer. 6. Perform hand wash and don gloves. 7. Assist client in assuming comfortable position that provides easy access to mouth. 8. If thermometer is stored in a chemical solution, wipe the thermometer dry with a soft tissue, RATIONALE This provide for patients safety. This provide for patients safety. Explaining reduces apprehension and encourages cooperation. Preparation promotes efficient time management and organized approach to the task. An improperly functioning may not give an accurate reading. Hand hygiene deters the spread of microorganisms. Ensures comfort and accuracy of temperature reading. Reduces contamination of the bulb end. RATING 1 2 3

using a firm twisting motion. Wipe from bulb toward the finger. 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. 10. Read the thermometer by holding it horizontally at eye level and rotate it between your forefingers until you can see 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. 12. Ask client to close his/her lips. Caution against bitting down 13. Leave thermometer in place for 3 minutes or according to agency protocol. 14. Carefully remove the thermometer and read at eye level. 15. Inform client of temperature. 16. Wipe secretions from the thermometer. Wipe it from the fingers down to the bulb, using a firm, twisting motion. 17. Wash thermometer in lukewarm soapy water, rinse in cool water dry and replace in storage container. Brisk shaking lowers mercury level in glass tube.

This position makes it easier to see the mercury level.

Heat from the superficial blood vessels in sublingual pocket produces temperature reading. Maintains proper position of thermometer recording. Breakage of thermometer may injure mucosa and cause mercury poisoning. Time is needed for the mercury in the thermometer to expand and accurately measure temperature. Ensures accurate reading. Promotes participation in care and understanding of health status. 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. Washing removes organic material and organisms. Storage container prevents breakage.

18. Remove and dispose of gloves if used. Wash hands 19. Report temperature reading in a flow sheet or any computerized record. Report any abnormal findings to the appropriate persons.

Deters the spread of microorganisms. Recording and reporting ensure accurate documentation and communication.