Skills: Vital Signs Flashcards
Introduction
- Introduce yourself
- Check ID (2 identifiers; DOB & name)
- Explain procedure
- Provide privacy
- Check physician orders
Reduces microorganisms
Wash hands and don gloves
Promotes efficiency and time management
Gather appropriate equipment
Demonstrate knowledge of appropriate time intervals for data accuracy
Verbalize knowledge of frequency of vitals
Once the PT is admitted, per the health care providers notes, and per the nurses judgement if the PT’s condition worsens
Reduces transmission of microorganisms
Sanitize, Sanitize, Sanitize
Oral Temperature
Ensure accuracy
Question: has the client eaten, drank fluids or smoked within 20-30 min.?
Ensure accurate reading
Oral
Effectively applies probe and places thermometer into posterior sublingual pocket and removes after audible signal
Reduces spread of microorganisms
Oral
Remove probe from PT’s mouth and toss in trash
Rectal
Ensures accurate thermometer placement
Assist PT into Sim’s position (lies on their left side, with right hip and knees bent).
Move bed linens and expose only rectal area
Ensure safety, of yourself and the PT
Rectal
Don gloves, remove therm. from charging unit, use red probe
Prevents possible rectal perforation
Rectal
Lube probe prior, insert 1.5in into rectum.
Hold therm. until signal
- DO NOT FORCE THERM. -
Provide comfort and hygiene
Rectal
Carefully remove probe and toss cover into trash
- Clean area of lube and possible feces
Reduces spread of microorganisms
Rectal
Remove and dispose of gloves, wash hands
Axillary
Ensure correct therm. placement for accuracy
Assist PT into supine position
Maintains proper positioning of temperature probe
Axillary
Place probe in center of axilla, lowers arm over therm., places arm across PT’s chest
Reduces spread of microorganisms
Axillary
Remove from axilla, places probe in trash
Tympanic
Ensures comfort and exposes auditory canal for accurate reading
Assist PT to a comfortable position with head turned away from nurse
Preps unit to measure temp. and reduces spread of microorganisms
(Tympanic)
Slides disposable plastic cover over otoscope until click
Ensures correct placement
Tympanic
Gently tugs ear pinna upward and back for adults; down and back for child
Ensures correct placement and accurate reading
Tympanic
Fits probe into ear canal snugly. Clicks button and waits for signal when complete
Reduces spread of microorganisms
Tympanic
Carefully remove from ear, press eject button to remove speculum into trash
Brachial Pulse
Ensure accuracy and prevent nurse from feeling own pulse
Locates groove between biceps and triceps muscle above elbow at antecubital fossa. Place index and middle fingers in groove to locate pulsation
Ensures accurate pulse rate
Brachial Pulse
Counts pulse for 15sec x 4, 30sec x 2, or 60sec, using timer. Adjusts technique according to regularity/irregularity of pulse.
Ensure accuracy of info/data
Brachial Pulse
Records pulse rate, rhythm and volume/strength.
Apical Pulse
Ensure correct placement for accurate auscultation
Locates pulse by placing stethoscope on chest at PMI
Provides accurate rate and identifies abnormalities
Apical Pulse
Counts pulse for 1 full min. and evaluates rhythm
Radial Pulse
Ensures nurse is feeling PT’s pulse and not their on
Locates radial pulse by placing tips of index and middle fingers over radial artery, and applies light but firm pressure until palpated
Ensures accurate pulse rate data
Radial Pulse
Counts pulse for 15sec x 4, 30sec x 2, or 60sec, using timer. Adjusts technique according to regularity/irregularity of pulse.
Ensure accuracy of info/data
Radial Pulse
Records pulse rate, rhythm and volume/strength.
Blood Pressure
Facilitates locating the brachial artery and ensures accuracy
Removes clothing of upper arm, positions arm at heart level extended with palm supine
Places cuff at best position for occluding blood flow through the brachial artery
(Blood Pressure)
Places cuff around upper arm so that inflatable bag is centered over the brachial artery. The lower edge of the cuff should be 1-2in above antecubital
Provides approx. systolic assessment
Blood Pressure
Palpates radial artery and inflates cuff. Notes the point on gauge at which the radial pulse is obliterated
Avoids auscultatory gap that may provide an incorrect reading
(Blood Pressure)
Palpates the brachial artery and places the stethoscope bell over it. Re-inflates cuff to 30 mm Hg above where the radial pulse was obliterated
Determines diastolic pressure
Blood Pressure
Slowly releases air, so that mercury falls at a rate of 2-3 mm Hg per sec. Notes when a distinct soft muffling sound is heard or no sound is heard
Ensures accurate data
Blood Pressure
Records systolic and diastolic BP.
Respirations
Client will be unaware of being watched and will discourage control of breathing during assessment
While fingertips are in place after counting pulse rate, observes clients respirations
Determines respiratory rate per min
Respirations
Notes each rise and fall of clients chest as breathing occurs
Ensures accuracy of data
Respirations
Counts pulse for 15sec x 4, 30sec x 2, or 60sec, using timer. Adjusts time according to normal or abnormal breathing patterns
