SCORE SHEETNAME:DATE:CaregiverASSESSING PULSE RATE

ACTION530

1. RADIAL PULSEa. Inform client of the site(s) at which you will measure pulse.

b. Flex clients elbow and place lower part of arm across chest.

c. Support clients wrist by grasping outer aspect with thumb.

d. Place your index and middle finger on inner aspect of clients wrist over the radial artery and apply light but firm pressure until pulse is palpated.

e. Identify pulse rhythm.

f. Determine pulse volume.

g. Count pulse rate by using second hand on a watch: For an irregular rhythm, count number of beats for a full minute, noting number of irregular beats.

ASSESSING RESPIRATIONS

Action530

1. Continue to place your hand over clients wrist and observe one complete respiratory cycle.

3. Start to count with first inspiration while looking at second hand sweep of watch. Count a full minute.

4. Observe depth of respirations by degree of chest wall movement and rhythm of cycle (regular or interrupted).

5. Record rate and character of respirations.

ASSESSING BLOOD PRESSURE

ACTION530

1. Determine which extremity is most appropriate for reading. Do not take a pressure reading on an injured or painful extremity or one in which an intravenous line is running.

2. Select a cuff size that completely encircles upper arm without overlapping.

3. Move clothing away from upper aspect of arm.

4. Position arm at heart level, extend elbow with palm turned upward.

5. Make sure cuff is fully deflated and pump valve moves freely.

6. Locate brachial artery in the antecubital space.

7. Apply cuff snugly and smoothly over upper arm, 2.5 cm (1 in.) above antecubital space with center of cuff over brachial artery.

8. Insert earpiece of stethoscope in ears with a forward tilt, ensuring diaphragm hangs freely.

9. Relocate brachial pulse with your nondominant hand and place bell or diaphragm chestpiece directly over pulse. Chestpiece should be in direct contact with skin and not touch cuff.

10. With dominant hand, turn valve clockwise to close. Compress pump to inflate cuff.

11. Slowly turn valve counterclockwise so that mercury falls at a rate of 23 mm Hg per second.

14. Deflate cuff rapidly and completely.

15. Remove cuff or wait 2 minutes before taking a second reading.

16. Inform client of reading.

17. Record reading.

18. Lower bed, raise side rails, place call light in easy reach.

19. Put all equipment in proper place.

20. Wash hands.

21. Document measurements in clients medical record on appropriate form, usually vital signs flow sheet.

22. Compare data with clients baseline and normal range for age group.

23. If any measurements are abnormal, measure again and report abnormal findings to instructor or charge nurse.