vital signs Flashcards
TAKING THE AXILLARY TEMPERATURE
Wash hands. Explain the procedure to be performed to the client.
Position the client in a comfortable position and provide for privacy Put on gloves if contact with blood, body fluids,
secretions is likely.
Expose and pat the axilla dry of perspiration. Check if the digital thermometer is functional by pressing the button.
Place the thermometer in the client’s axilla and lower the arm down across the abdomen.
Leave the digital thermometer in place. Remain with the client and hold the thermometer in piece if the client is irrational or very young,
PALPATING THE RADIAL PULSE
When the radial pulse is assessed, the arms can rest alongside the client with the palm facing downward across the abdomen.
Place two or three middle fingertips lightly and squarely over the pulse point. Use the pads of the fingers in palpating.
Count the pulse for 1 full minute while observing for character, regularity and rhythm.
COUNTING RESPIRATION
Maintaining the sane position, start counting with first inspiration while looking at the second hand of a watch.
Count for 1 full minute.
Observe the respiration for depth by watching the movement of the chest.
Observe the respiration for regular or irregular rhythm. Observe the character of respiration, the sounds they produce and the effort they require.
Remove the thermometer from the axilla and read the digital display that registers the client’s body
temperature.
Wipe the thermometer equipment with on alcohol swab from the stem to the bulb. Wash hands and note down the results.
MEASURING BLOOD PRESSURE
Position the client appropriately. The adult client should be sitting unless otherwise specified. Both feet 11 should be flat on the floor. The elbow should be slightly flexed with the palm of the hand facing up and the forearm supported at level. Expose the upper ann.
Wrap the deflated cuff evenly around the upper arm. \
Locate the brachial artery and apply the center of the bladder directly over the artery. For an adult, place the lower border of the cuff approximately 2.5 cm
above the antecubital space.
if this is the client’s initial examination, perform a preliminary palpatory determination of systolic 1 pressure.
Palpate the brachial artery with fingertips. Close The valve on the pump by turning the knob clockwise.
Pump up the cuff until you no longer feel the brachial pulse. Note the pressure on the sphygmomanometer at which the pulse is no longer felt Release the pressure completely in the cuff and wait for 1 to 2 minutes before making further measurements.
Cleanse the earpieces with alcohol or recommended disinfectant Insert the car attachments of the stethoscope 15 in your ears so that they tit slightly forward. Ensure that the stethoscope hangs freely from the ears to the
diaphragm.
16 Place the diaphragm of the stethoscope over the brachial pulse.
Pump up the cuff until the sphygmomanometer is 30 mmHg above the point where the brachial pulse disappeared.
Release the value on the cuff carefully so that the pressure decreases ad the rate of 2 to 3 mmg/second. As 18 the pressure tails, identify the manometer reading where the first tapping sound is heard and when the sounds become inaudible. 19 Deflate the cuff rapidly and completely.
Remove the cuff from the client’s arm and wipe it with an approved disinfectant. Return all equipment property.
Wash your hands and document the findings using the graphic sheet.
