Vital signs with rationale PDF

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Summary

Axilla Method Definition Balance between heat production and heat loss by the body. Purpose To serve as baseline data for health care provider. Equipment  Axillary thermometer  Cotton Balls and Alcohol  Watch with a second hand  Paper and penProcedure Rationale 1. Identify and explain procedure ...

Description

Axilla Method Definition Balance between heat production and heat loss by the body. Purpose To serve as baseline data for health care provider. Equipment  Axillary thermometer  Cotton Balls and Alcohol  Watch with a second hand  Paper and pen Procedure Rationale 1. Identify and explain procedure to  To ensure correct procedure to right patient patient.  Explaining procedure reduces anxiety and fear thus promoting cooperation from the client . 2. Wash Hands  Reduces transmission of microorganism. 3. Gather equipment needed.  To facilitate systematic assessment and measurement. 4. Draw Curtain around and/or close  To maintain client privacy and promote door. comfort. 5. Assist client in supine or sitting  To provide easy access to axilla. position. 6. Move clothing or gown away from  To expose axilla for correct shoulder and arm. thermometer placement. 7. Wipe thermometer from bulb to  To remove chemical solutions, dust or dirt that may irritate mucous stem with firm rotating motion membrane and to prevent spread of using soft tissue or cotton balls. microorganism. 8. Grasp thermometer firmly with thumb  To ensure accurate reading. and forefinger and sharply flick wrist downward. Continue shaking until mercury line reaches lowest markings 9. Raise client's arm away from torso,  To maintain proper position of insert bulb into center of axilla, lower arm thermometer bulb against blood vessel over bulb and place arm across client's in axilla. chess. 10. Leave thermometer in place for 5-10  To provide sufficient time for recording of the temperature. minutes for more accurate reading. 11. Remove thermometer and wipe off any  To prevent cross contamination. from area with least remaining secretions with clean tissue.  Wipe contamination to area most Wipe with rotating motion from stem contaminated. toward the bulb. 12. Read thermometer at eye level.  To ensure accurate reading. 13. Inform client of thermometer reading.  To promote participation in care and understanding of the status. 14. Store thermometer in appropriate  Protective storage prevent breakage. protective storage.

15. Assist client in replacing clothing or gown. 16. Wash hands. 17. Record result.

 Restores sense of well being.  Reduces transmission of microorganism.  Serves as baseline data for health care providers.

Pulse taking Definition - Expansion of the arterial walls occurring with each ventricular contraction. Purpose - To provide clinical data regarding the heart’s pumping action and the adequacy of peripheral artery blood flow. Equipment - Watch with second hand

Procedure 1. Wash Hands

Rationale  Reduces transmission of microorganism 2. Identify and explain procedure to  To ensure correct procedure to right patient patient.  Explaining procedure reduces anxiety and fear thus promoting cooperation from the client . 3. Have the patient rest his arm along side  This position places the radial artery on of his body with the wrist extended and the the inner aspect of the patient's wrist. palm of the hand downward.  Sufficient time is necessary to detect irregularities and abnormalities. 4. Place the tips of your middle three  Finger tips are sensitive to touch and will feel the pulsation of the patient's fingers on the palm side of the patient's artery. wrist. Rest thumb on the back of the  Thumb should not be used because it patient wrist. has pulse to avoid confusion. 5. Apply enough pressure so that you can  Pressing too hard may stop the flow of feel the pulse (not too hard not too light). the blood and you will not be able to feel the pulse.  Too little pressure will be imperceptible. 6. Using a watch with second hand count  Sufficient time is necessary to detect the number of pulsations felt on the irregularities and abnormalities. patient for one full minute. 7. If the pulse rate is abnormal, repeat the  Repeating the count is necessary for accuracy. counting in order to determine accurately its rate, quality and rhythm. 8. Wash hands.  For infection control measures 9. Record the pulse rate, rhythm and force  To serve as baseline data for health immediately in the graphing sheet. care provider.

Respiration Taking Definition - The act of breathing which includes intake of oxygen and the output of carbon dioxide. Purpose - To provide valuable information about a client’s physical and emotional health. Equipment - Watch with second hand PROCEDURE 1. Wash hands 2. Identify and explain procedure to the client

RATIONALE  To reduce transfer of microorganisms  To ensure right procedure to right patient  To alleviate fear and anxiety and promote cooperation

3. Hold the client's wrists just as if you were taking his/her pulse.

 This way client is not conscious breathing is being watched.  Awareness of respiratory rate assessment will cause the client voluntarily to alter the respiratory pattern.

4. Note the rise and fall of the client's chest with each respiration.

 Complete cycle of inspiration and expiration constitutes one act of respiration.  Sufficient time to observe depth and the other characteristics is necessary.

5. Using a watch with a second hand, count the number of respiration for one full minute. 6. Record the number of respiration.

 Serves as a baseline data.

Pulse taking Definition - Expansion of the arterial walls occurring with each ventricular contraction. Purpose - To provide clinical data regarding the heart’s pumping action and the adequacy of peripheral artery blood flow. Equipment - Watch with second hand

Procedure 3. Wash Hands 4. Identify and explain procedure to patient

Rationale  Reduces transmission of microorganism  To ensure correct procedure to right patient.  Explaining procedure reduces anxiety

3. Have the patient rest his arm along side  of his body with the wrist extended and the palm of the hand downward.  4. Place the tips of your middle three  fingers on the palm side of the patient's wrist. Rest thumb on the back of the patient wrist.  5. Apply enough pressure so that you can feel the pulse (not too hard not too light).

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 6. Using a watch with second hand count the number of pulsations felt on the patient for one full minute. 7. If the pulse rate is abnormal, repeat the counting in order to determine accurately its rate, quality and rhythm. 8. Wash hands. 9. Record the pulse rate, rhythm and force immediately in the graphing sheet.

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and fear thus promoting cooperation from the client . This position places the radial artery on the inner aspect of the patient's wrist. Sufficient time is necessary to detect irregularities and abnormalities. Finger tips are sensitive to touch and will feel the pulsation of the patient's artery. Thumb should not be used because it has pulse to avoid confusion. Pressing too hard may stop the flow of the blood and you will not be able to feel the pulse. Too little pressure will be imperceptible. Sufficient time is necessary to detect irregularities and abnormalities.

 Repeating the count is necessary for accuracy.  For infection control measures  To serve as baseline data for health care provider.

BLOOD PRESSURE TAKING DEFINITION Pressure exerted on the wall of the arteries when the left ventricle of the heart pushes blood into the aorta. PURPOSE To determine vascular resistance to blood flow. To determine the effectiveness of cardiac muscle in pumping blood to overcome the vascular resistance. EQUIPMENT  Blood Pressure Apparatus  Sphygmomanometer  Stethoscope  Paper and pen PROCEDURE 1. Identify and explain procedure to the client. 2. Assess the client's physical status.

RATIONAL  To ensure the right procedure is done to client and gain the client's cooperation.  To ensure that the client is rested and to identify the affected side of the client.

3. Assemble the equipment 4. Wash hands 5. Place client in a comfortable position (lying or sitting) and position the arm at the level of the heart with the palm of the hand facing up (preferably use Left arm because it is nearer the heart) 6. Place the cuff so that the inflatable bag is centered over the brachial artery. approximately midway on the arm so that lower edge of the cuff is about 2.5 cm (1 to 2 inches) above the inner aspect of the elbow. The tubing should leave the edge on the cuff nearer the client's elbow. 7. Wrap cuff around arm smoothly and snugly (not to loose, not too tight).

8. Feel the pulse beat over the brachial artery at the inner aspect of the elbow with the use of fingertips and don't allow diaphragm or bell of the stethoscope to touch clothing of cuff. 9. Place stethoscope earpiece in your ears and close screw valve on the air pump.

 To promote the efficiency of the health care provider.  To decrease the transfer of microorganisms.  This position places the brachial artery on the inner aspect of the elbow that a stethoscope disc can rest on it conveniently. Having the arm above the level of the heart causes a decrease in BP.  Pressure in the cuff applied directly to the artery will give the most accurate readings. If the cuff get in the way of the stethoscope disc on the anterior elbow, readings are likely to be inaccurate. A cuff placed upside down with the tubing toward the patients head will give a false reading.  A smooth cuff and wrapping produce equal pressure and give accurate reading. A cuff too loosely wrapped will give inaccurate reading.  Having the stethoscope disc directly over the artery makes more accurate reading, and having the stethoscope disc firmly placed on the skin away from clothing and the cuff prevents missing sounds.  Sounds are heard more clearly when the earpiece follow the direction of the ear canal.  Lack of blood in patient's arm may cause a temporary tingling and numbing sensation.

10. Palpate brachial artery, turn valve clockwise to close and compress bulb to inflate cuff to 30mm Hg above points where palpated pulse disappears, then slowly release valve (deflating cuff). Noting reading when pulse is felt again. 11. Release the air in the cuff slowly so that  If the air is released too slowly from the pressure goes down at the rate of 2 3 the cuff, there will be congestion in the mm Hg/second and listen for the sound extremity causing false reading and if it (first distinctly loud muffling sound is is released too rapidly sounds may not systolic pressure) be heard at accurate levels. 12. Continue to release the air evenly and  Diastolic is when the blood flows easily slowly (last soft muffling sound is diastolic in the brachial artery and it is pressure). approximately equivalent to the amount of pressure normally present on the walls of the arteries when the heart is at rest. 13. After the final sound has disappeared  To release the remaining air from the deflate cuff rapidly and completely. cuff and prevent congestion in extremity.

14. Roll the cuff and place it in the case.  This method of removing dirt prevents Wipe the earpieces of the stethoscope with possible cross infection of the ears. antiseptic swab and put back in its proper place. 15. Wash hands.  To prevent the transmission of microorganisms. 16. Record result..  To serve as baseline data for health care provider....