ASSESSING

A
PERIPHERA
L PULSE
 PURPOSE
- TO DETERMINE THE CHARACTERISTICS
OF THE PULSE, TO ASCERTAIN THE
PRESENCE OF AN ARTERIAL BRUIT(S),
AND TO DETECT THE OCCURRENCE OF
VENOUS INFLAMMATION WITH POSSIBLE
SECONDARY THROMBOSIS OF THAT VEIN.
 ASSESS CLINICAL
SIGNS OF
CARDIOVASCULAR
ALTERATIONS.
 ASSESS FACTORS
THAT MIGHT ALTER
PULSE RATE
 INTRODUCE
YOURSELF AND
VERIFY THE
CLIENT’S IDENTITY.
 PERFORM
HAND HYGIENE
 PROVIDE FOR
CLIENT PRIVACY.
PUT ON CLEAN
GOVES
ASSIST THE CLIENT TO
A COMFORTABLE
RESTING POSITION
PALPATE AND
COUNT THE
PULSE
 SELECT THE PULSE POINT
- FEMORAL AREA
- POPLITEAL OR BACK OF THE
KNEE
- POSTERIOR TIBIALIS OR ANKLE
- DORSALIS PEDIS OR FOOT.
 ASSESS THE
PULSE RHYTHM
AND VOLUME
REMOVE AND
DISPOSE
GLOVES
DOCUMENT THE PULSE
RATE, RHYTHM, AND
VOLUME, AND YOUR
ACTIONS IN THE CLIENT
RECORD.
ASSESSING AN
APICAL–RADIAL
PULSE
 PURPOSE
- WHAT IS THE PURPOSE OF TAKING A RADIAL
PULSE?
ASSESSING AN APICAL–RADIAL PULSE
TAKING YOUR PULSE AND MEASURING HOW
MANY TIMES THE HEART BEATS IN A MINUTE.
IT HELPS MAKE YOU AWARE OF YOUR HEART
RHYTHM AND THE STRENGTH OF YOUR
HEARTBEAT.
 PERFORM
HAND HYGIENE
 PROVIDE FOR
CLIENT PRIVACY
PUT ON CLEAN
GLOVES
 POSITION THE
CLIENT
APPROPRIATELY.
 LOCATE THE
APICAL AND
RADIAL PULSE
SITES.
ASSESS THE APICAL
PULSE FOR 60
SECONDS.
USE A STETHOSCOPE
TO LISTEN FOR THE
S1 AND S2 HEART
SOUNDS
STRENGTH AND
VOLUME IS
NORMAL
ASSESS THE RADIAL
PULSE FOR 60
SECONDS.
TACHYCARDIA
BRADYCARDIA
REMOVE AND
DISCARD
GLOVES.
DOCUMENT THE APICAL AND
RADIAL (AR) PULSE RATES,
RHYTHM, VOLUME, AND ANY
PULSE DEFICIT IN THE CLIENT
RECORD. ALSO RECORD
RELATED DATA.
 ASSESSING
BODY
TEMPERATURE
 PURPOSE
- THE MEASUREMENT OF
BODY TEMPERATURE CAN
HELP DETECT ILLNESS. IT CAN
ALSO MONITOR WHETHER OR
NOT TREATMENT IS WORKING.
 ASSESS
CLINICAL SIGNS
OF FEVER.
ASSESS CLINICAL
SIGNS OF
HYPOTHERMIA.
PROVIDE FOR
CLIENT
PRIVACY.
PERFORM
HAND
HYGIENE
PLACE THE CLIENT
IN THE
APPROPRIATE
POSITION.
PUT ON
CLEAN
GLOVES
 PLACE THE
THERMOMETER.
 WAIT THE
APPROPRIATE
AMOUNT OF TIME.
 ELECTRONIC AND
TYMPANIC
THERMOMETERS WILL
INDICATE THAT THE
READING IS COMPLETE VIA
A LIGHT OR TONE
 REMOVE THE
THERMOMETER AND
DISCARD THE COVER, OR
WIPE WITH A TISSUE, IF
NECESSARY.
 READ THE
TEMPERATURE.
NO NEED TO
RECHECK
 WASH THE
THERMOMETER, IF
NECESSARY, AND RETURN
IT TO THE STORAGE
LOCATION.
REMOVE AND
DISCARD
GLOVES
DOCUMENT THE
TEMPERATURE IN
THE
CLIENT RECORD.
 ASSESSING
RESPIRATIONS
 PURPOSE
- THE PURPOSE OF RESPIRATORY
ASSESSMENT IS TO ASCERTAIN THE
RESPIRATORY STATUS OF THE PATIENT
AND TO PROVIDE INFORMATION
RELATED TO OTHER SYSTEMS SUCH AS
THE CARDIOVASCULAR AND
NEUROLOGICAL SYSTEMS.
ASSESS SKIN AND
MUCOUS
MEMBRANE
COLOR.
ASSESS POSITION
ASSUMED FOR
BREATHING.
ASSESS CHEST
MOVEMENTS.
ASSESS CHEST
PAIN.
 PROVIDE FOR
CLIENT PRIVACY.
PERFORM HAND
HYGIENE
PUT ON
GLOVES
OBSERVE OR PALPATE
AND COUNT THE
RESPIRATORY RATE.
(15 BREATHS)
PLACE A HAND AGAINST
THE CLIENT’S CHEST TO
FEEL THE CHEST
MOVEMENTS WITH
BREATHING
 OBSERVE THE CHEST
MOVEMENTS WHILE
SUPPOSEDLY TAKING THE
RADIAL PULSE.
 OBSERVE THE
RESPIRATIONS FOR
DEPTH BY WATCHING
THE MOVEMENT OF THE
CHEST.
 OBSERVE THE
RESPIRATIONS FOR
REGULAR OR IRREGULAR
RHYTHM OF THE CHEST
 OBSERVE THE CHARACTER
OF RESPIRATIONS—THE
SOUND THEY PRODUCE AND
THE EFFORT THEY REQUIRE.
(bronchial and vesicular)
REMOVE AND
DISCARD
GLOVES
 DOCUMENT THE
RESPIRATORY RATE,
DEPTH, RHYTHM, AND
CHARACTER ON THE
APPROPRIATE RECORD.
ASSESSING BLOOD
PRESSURE
 PURPOSE
- MEASURING YOUR BLOOD
PRESSURE IS THE ONLY WAY TO
KNOW WHETHER YOU HAVE
HIGH BLOOD PRESSURE.
 PROVIDE FOR
CLIENT PRIVACY.
PERFORM HAND
HYGIENE
PUT ON
GLOVES
 POSITION THE
CLIENT
APPROPRIATELY.
 THE PATIENT SHOULD
SIT AND BOTH FEET ON
THE FLOOR
 THE ELBOW SHOULD BE
SLIGHTLY FLEXED, WITH THE
PALM OF THE HAND FACING
UP AND THE FOREARM
SUPPORTED AT HEART LEVEL.
EXPOSE THE UPPER
ARM.
 WRAP THE DEFLATED CUFF
EVENLY AROUND THE UPPER
ARM. LOCATE THE BRACHIAL
ARTERY. APPLY THE CENTER OF
THE BLADDER DIRECTLY OVER
THE ARTERY.
PUMP UP THE CUFF UNTIL YOU
NO LONGER FEEL THE
BRACHIAL PULSE. NOTE THE
PRESSURE ON THE
SPHYGMOMANOMETER AT
WHICH PULSE IS NO LONGER
FELT.
 RELEASE THE PRESSURE
COMPLETELY IN THE CUFF
AND WAIT 1–2 MINUTES
BEFORE TAKING FURTHER
MEASUREMENTS
REPEAT THE STEPS DONE
IF WE WANT TO CHECK IF
THE READING IS
CORRECT.
CLEAN THE EARPIECE
 REMOVE AND
DISCARD GLOVES.
 DOCUMENT AND
REPORT PERTINENT
ASSESSMENT DATA
ACCORDING TO AGENCY
POLICY.