Pulse and Respiration Flashcards
List the steps for the Pulse and Respiration procedure
- Do initial steps procedure.
- Place the resident’s hand on a comfortable surface.
- Feel for the pulse above the wrist on thumb side with tips of your first three fingers.
- Count the beats for 60 seconds, noting rate, rhythm, and force.
- Continue position as if feeling for pulse. Count each rise and fall of chest as one respiration.
- Count respirations for 60 seconds noting rate, regularity, and sound.
- Record pulse and respiration rates.
- Report any unusual findings to the nurse.
- Do final steps procedure.
What is the rationale for step “3. Feel for the pulse above the wrist on thumb side with tips of your first three fingers.”?
Because of the artery in your thumb, pulse would not be accurate if you use your thumb.
What is the rationale for step “4. Count the beats for 60 seconds, noting rate, rhythm, and force.”?
Ensures accurate count. Rate is number of beats. Rhythm is regularity of beats. Force is strength of beats.
What is the rationale for step “5. Continue position as if feeling for pulse. Count each rise and fall of chest as one respiration.”?
Resident could alter breathing pattern if aware that respirations are being taken.
What is the rationale for step “6. Count respirations for 60 seconds noting rate, regularity, and sound.”?
Ensure accurate count. Rate is number of breaths. Regularity is pattern of breathing. Sound is type of auditory breaths heard.
What is the rationale for step “7. Record pulse and respiration rates.”?
Record pulse and respirations immediately so you won’t forget. Accuracy is necessary because decisions regarding the resident’s care may be based on your report. What you write is a legal record of what you did. If you don’t document it, legally, it didn’t happen.
What is the rationale for step “8. Report any unusual findings to the nurse.”?
Provides the nurse with information to assess the resident’s condition and needs.
