ASSESSING PULSE RATEEQUIPMENTS:

Watch with a second hand Stethoscope

Action Rationale1. RADIAL PULSEa. Inform client of the site(s) at which you will measure pulse.

b. Flex client’s elbow and place lower part of arm across chest.

c. Support client’s wrist by grasping outer aspect with thumb.

d. Place your index and middle finger on inner aspect of client’s 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.

a. Encourages participation and allays anxiety.

b. Maintains wrist in full extension and exposes artery for palpation. Placing client’s hand over chest will facilitate later respiratory assessment without undue attention to your action.

c. Stabilizes wrist and allows for pressure to be exerted.

d. Fingertips are sensitive, facilitating palpation of pulsating pulse. The CG may feel own pulse if palpating with thumb. Applying light pressure prevents occlusion of blood flow and pulsation.

e. Palpate pulse until rhythm is determined.Describe as regular or irregular.

f. Quality of pulse strength is an indication of stroke volume. Describe as normal, weak, strong, or bounding.

g. An irregular rhythm requires a full minute of assessment to identify the number of inefficient cardiac contractions that fail to transmit a pulsation, referred to as a “skipped” or irregular beat.

2. APICAL PULSEa. Raise client’s gown to expose sternum and left side of chest.

b. Cleanse earpiece and diaphragm of stethoscope with an alcohol swab.

c. Put stethoscope around your neck.

d. Apex of heart:• With client lying on left side, locate suprasternal notch.

• Palpate second intercostal space to left of sternum.

• Place index finger in intercostal space, counting downward until fifth intercostal space is located.

• Move index finger along fourth intercostals space left of the sternal border and to the fifth intercostal space, left of the midclavicular line to palpate the point of maximal impulse (PMI)

a. Allows access to client’s chest for proper placement of stethoscope.

b. Decreases transmission of microorganisms from one practitioner to another (earpiece) and from one client to another (diaphragm).

• Identification of landmarks facilitates correct placement of the stethoscope at the fifth intercostal space in order to hear point of maximal impulse.

• Ensures correct placement of stethoscope.

• Keep index finger of nondominant hand on the PMI.

e. Inform client that you are going to listen to his heart. Instruct client to remain silent.

f. With dominant hand, put earpiece of the stethoscope in your ears and grasp diaphragm of the stethoscope in palm of your hand for 5 to 10 seconds.

g. Place diaphragm of stethoscope over the PMI and auscultate for sounds S1 and S2 to hear lub-dub sound.

h. Note regularity of rhythm.

i. Start to count while looking at second hand of watch. Count lub-dub sound as one beat:• For a regular rhythm, count rate for60 seconds.

• For an irregular rhythm, count rate for a full minute, noting number of irregular beats.

j. Share your findings with client.

k. Record by site the rate, rhythm, and, if applicable, number of irregular beats.

e. Elicits client support. Stethoscope amplifies noise.

f. Dominant hand facilitates psychomotor dexterity for placement of earpiece with one hand. Heat warms metal or plastic diaphragm and prevents startling client.

h. Establishment of a rhythm pattern determines length of time to count the heartbeats to ensure accurate measurement.

i. Ensures sufficient time to count irregular beats.

j. Supports client participation in care.

k. Record rate and characteristics at bedside to ensure accurate documentation.

ASSESSING RESPIRATIONSEquipment

Watch with a second handAction Rationale

1. Before replacing client’s gown from auscultating heart sounds, assess respirations.

1. Facilitates observation of chest wall and abdominal movements.

2. Place your hand over client’s wrist and observe one complete respiratory cycle.

2. Hand rises and falls with inspiration and expiration.

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

3. Respiratory rate is one complete cycle (inspiration and expiration).

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

4. Reveals volume of air movement into and out of the lungs. Describe as shallow, normal, or deep.

5. Replace client’s gown. 5. Prevents embarrassment and chilling.6. Record rate and character of respirations. 6. Record rate and characteristics at bedside to

ensure accurate documentation

ASSESSING BLOOD PRESSUREEQUIPMENT

Alcohol swabs Sphygmomanometer with proper size cuff Stethoscope

ACTION RATIONALE1. 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.

1. Cuff inflation can temporarily interrupt blood flow and compromise circulation in an extremity already impaired or a vein receiving intravenous fluids.

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

2. Provides equalization of pressure on the artery to ensure accurate measurement.

3. Move clothing away from upper aspect of arm. 3. Ensures accurate measurement.4. Position arm at heart level, extend elbow with palm turned upward.

4. Blood pressure increases when arm is below level of heart and decreases when arm is above level of heart.

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

5. Equipment must function properly to obtain an accurate reading.

6. Locate brachial artery in the antecubital space. 6. Designates placement of stethoscope.7. Apply cuff snugly and smoothly over upper arm, 2.5 cm (1 in.) above antecubital space with center of cuff over brachial artery.

7. Ensures even pressure distribution over brachial artery. Prevents tubing from being constricted and allows visualization of aneroid manometer dial.

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

8. Enhances sound transmission from chestpiece to ears.

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.

9. Sound heard best directly over artery; decreases muffled sounds that cause inaccurate reading. Bell chestpiece is more sensitive to low-frequency sound that occurs with pressure release.

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

10. Prevents air leak during inflation.

11. Slowly turn valve counterclockwise so that mercury falls at a rate of 2–3 mm Hg per second.Listen for five phases of Korotkoff’s sounds whilenoting manometer reading:

• A faint, clear tapping sound appears and increases in intensity (phase I).

• Swishing sound (phase II).• Intense sound (phase III).• Abrupt, distinctive muffled sounds (phase IV).

• Sound disappears (phase V).

11. Maintains constant release of pressure to ensure hearing first systolic sound. Identify manometer readings for each of the five phases.

• Identify two consecutive tapping sounds to confirm systolic reading.

• Phase IV is the best indicator of diastolic pressure in children.• Phase V is the best index of diastolic blood pressure in clients over age 13.

14. Deflate cuff rapidly and completely. 14. Prevents arterial occlusion and client discomfort of numbness or tingling.

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

15. Releases trapped blood in the vessels.

16. Inform client of reading. 16. Promotes client participation in care.17. Record reading. 17. Ensures accuracy.18. Lower bed, raise side rails, place call light in easy reach.

18. Promotes client safety.

19. Put all equipment in proper place. 19. Fosters maintenance of equipment.20. Wash hands. 20. Prevents transmission of microorganisms.21. Document measurements in client’s medical record on appropriate form, usually vital signs flow sheet.

21. Vital sign measurements are usually charted on the graphic section of the vital signs form.

22. Compare data with client’s baseline and normal range for age group.

22. Provides for comparative data analysis.

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

23. Reporting abnormal measurements alerts staff to possible problems requiring intervention.