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Checklist For The VS Measurement (TPR and BP) A. Temperature A.1. Axillary Temperature (Digital Thermometer) Done Needs Practice

This document provides a checklist for measuring vital signs including temperature, pulse, respiration, and blood pressure. It lists the steps to take for each measurement, including preparing the patient, using the appropriate equipment correctly, taking the measurement, and documenting the results. The temperature should be taken axillary with a digital thermometer. Pulse is measured at the radial artery by feeling for 30 seconds and multiplying by 2. Respiration is counted by watching chest rise and fall for 30 seconds and multiplying by 2. Blood pressure is measured using a sphygmomanometer and stethoscope by inflating the cuff until the pulse disappears then slowly deflating to note sounds.

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192 views

Checklist For The VS Measurement (TPR and BP) A. Temperature A.1. Axillary Temperature (Digital Thermometer) Done Needs Practice

This document provides a checklist for measuring vital signs including temperature, pulse, respiration, and blood pressure. It lists the steps to take for each measurement, including preparing the patient, using the appropriate equipment correctly, taking the measurement, and documenting the results. The temperature should be taken axillary with a digital thermometer. Pulse is measured at the radial artery by feeling for 30 seconds and multiplying by 2. Respiration is counted by watching chest rise and fall for 30 seconds and multiplying by 2. Blood pressure is measured using a sphygmomanometer and stethoscope by inflating the cuff until the pulse disappears then slowly deflating to note sounds.

Uploaded by

Cyrill
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Checklist for the VS measurement (TPR and BP)

A. Temperature
A.1. Axillary Temperature (Digital Thermometer) Done Needs
Practice
1. Wash your hands
2. Inform the client what you will do and elicit his cooperation
3. Determine the time the client last took hot or cold food, fluids
or smoked.
4. Check for proper lighting
5. Expose client’s axilla; if wet, dry with a towel, using a patting
motion
6. Press the on button of the digital thermometer and place the
digital thermometer in the client’s dry axilla. Assist him to place
the arm lightly across the chest to keep the thermometer in
place.
7. Leave the thermometer in place for about 1 minute, until a
“beep” is heard.
8. Remove and wipe the thermometer with a tissue toward the
bulb. Discard tissue in an appropriate receptacle.
8. Record finding on slip of paper
9. Wipe down the thermometer with a cotton pad with alcohol.
10. Wash your hands
11. Transfer temperature reading to TPR sheet in the patient’s
chart

PULSE
B.1 Radial Pulse
1. Wear watch with second hand.
2. Inform client of procedure and elicit his cooperation.
3. Assist him to comfortable resting position. His arm can rest
alongside the body, the palm facing downward or the forearm
can rest at a 90-degree angle across the chest with the palm
downward. For the client who can sit, the forearm can rest
across the thigh, with the palm of the hands facing downward or
inward. Position a child comfortably in the parent’s arm, or
have the parent remain close by.
4. Place 2 or 3 middle fingertips lightly over radial artery.
5. With gentle pressure, feel for pulsation.
6. If pulse is regular, count for 30 seconds and multiply by 2. If
irregular, count the pulse for 1 full minute. When obtaining
baseline data, count the pulse for a full minute.
7. Assess pulse rhythm by noting the pattern of the intervals
between the beats. A normal pulse has equal periods between
beats.
8. Assess the pulse volume. A normal pulse can be felt with
moderate pressure, and the pressure is equal with each beat. A
forceful pulse volume is full; an easily obliterated pulse is weak.
9. Record pulse rate, rhythm, and volume.
10. Record. Note unusual rate of quality.

RESPIRATION
1. With fingers still in place after taking pulse rate, note rise and
fall of patient’s chest with respiration. You may place client’s
arm across the chest and observe the chest movements.
2. Count for 30 seconds if respirations are regular and multiply
by 2. Count for 1 full minute if they are regular.
3. Observe the respirations for regular or irregular rhythm.
Observe respirations for depth by watching the movements of
the chest. Normally, respirations are evenly spaced.
4. Observe the character of respirations- the sound they
produce and the effort they require. Normally, respirations are
silent and effortless.
5. Document the respiratory rate, depth, rhythm, and
character.

BLOOD PRESSURE
1. Wash your hands.2
2. Gather sphygmomanometer and stethoscope.
3. Inform client of procedure to elicit his cooperation.
4. Diminish room noise.
5. Position patient comfortably lying or sitting down.
6. Wrap the deflated cuff snugly on upper arm, the center of the
bladder directly the medial aspect, at least 2-3 fingers above
elbow, tubings alongside brachial artery.
7. Palpate the brachial artery with your fingertips. It is normally
found medially in the antecubital space.
8. Close the valve on hand pump by turning the knob clockwise
9. Insert the ear attachments of the stethoscope in your ears so
that they tilt slightly forward.
10. Ensure that the stethoscope hangs freely from the ears to
the diaphragm
11. Place diaphragm of stethoscope over brachial pulse. Hold
the diaphragm with thumb and index finger.
12. Pump up the cuff until the sphygmomanometer registers
about 30 mmHg above the point where the brachial pulse
disappeared.
13. Release the valve on the cuff carefully so that the pressure
decreases at the rate of 2-3 mmHg per second.
14. As the pressure falls, note the first sound, muffling and last
sound heard.
15. Deflate the cuff rapidly and completely after noting the last
sound.
16. Wait 1-2 minutes before making further determinations.
17. Remove cuff from patient’s arms and earpieces of the
stethoscope from your ears.
18. Wash your hands.
19. Record appropriately, including narrative PRN

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