Title

(Skill 29 – 1: Assessing Body Temperature)

Purpose:
 To establish baseline data for subsequent evaluation
 To identify whether the core temperature is within normal range
 To determine changes in the core temperature in response to specific therapies (e.g.,
antipyretic medication, immunosuppressive therapy, invasive procedure)
 To monitor clients at risk for imbalanced body temperature (e.g., clients at risk for infection or
diagnosis of infection; those who have been exposed to temperature extremes)
Assessment:
Assess
•Clinical signs of fever
• Clinical signs of hypothermia
• Site and method most appropriate for measurement
• Factors that may alter core body temperature
Planning: Routine measurement of the client’s temperature can be delegated to unlicensed assistive
personnel (UAP), or be performed by family members/caregivers in nonhospital settings. The nurse
must explain the appropriate type of thermometer and site to be used and ensure that the person
knows when to report an abnormal temperature and how to record the finding. The interpretation of an
abnormal temperature and determination of appropriate responses are done by the nurse.
Equipment
◦ Thermometer
◦ Thermometer sheath or cover
◦ Water-soluble lubricant for a rectal temperature
◦ Clean gloves for a rectal temperature
◦ Towel for axillary temperature
◦ Tissues/wipes

Delegation/Interpersonal Practice: Measuring the temperature may be within the scope of

practice for many health care providers. Although these other providers may verbally communicate
their findings and plan to the health care team members, the nurse must also know where to locate
their documentation in the client’s medical record.
Implementation Rationale Picture
1. Prior to performing the Provide patient’s safety
procedure, introduce self and and to provide comfort to
verify the client
the client’s identity using
agency protocol. Explain to the
client
what you are going to do, why
it is necessary, and how he or
she can participate. Discuss
how the results will be used in
planning further care or
treatments
2. Perform hand hygiene and To protect yourself from
observe appropriate infection any microorganisms and
prevention procedures. Apply to provide patient’s safety
gloves if performing a rectal
temperature.
3. Provide for client privacy. Privacy provides comfort
to the client

4. Position the client These positions allow the

appropriately (e.g., lateral or nurse to visualize the site
Sims’ position or side lying
position for inserting a rectal
thermometer).

5. Place the thermometer. Ensures the snug fit of the

• Apply a protective sheath or probe cover to prevent
probe cover if appropriate. the transmission of
• Lubricate a rectal microorganisms
thermometer.

6. Wait the appropriate amount of It indicates the final

time. Electronic and tympanic temperature reading
thermometers will indicate that
the reading is complete
through a light or tone. Check
package instructions for length
of time to wait prior to reading
chemical dot or tape
thermometers.
7. Remove the thermometer and To prevent transmission
discard the cover or wipe with of microorganisms and to
a tissue if necessary. If gloves maintain cleanliness
were applied, remove and
discard them.

8. Read the temperature and To ensure that the

record it on your worksheet. If reading is within normal
the temperature is obviously range without
too high, too low, or complications
inconsistent with the client’s
condition, recheck it with a
thermometer known to be
functioning properly
 9. Wash the thermometer if To change and ready for
necessary and return it to the use
storage location

10. Document the temperature in Used as a baseline and

the client record. ❶ A rectal for future references
temperature may be recorded
with an “R” next to the value or
with the mark on a graphic
sheet circled. An axillary
temperature may be recorded
with “AX” or marked on a
graphic sheet with an X.

Evaluation:
 Compare the temperature measurement to baseline data, normal range for age of client, and
client’s previous temperatures.
 Analyze considering time of day and any additional influencing factors and other vital signs.
 Conduct appropriate follow-up such as notifying the primary care provider if a temperature is
outside of a specific range or is not responding to interventions, giving a medication, or altering
the client’s environment. This includes teaching the client how to lower an elevated
temperature through actions such as increasing fluid intake, coughing and deep breathing, cool
compresses, or removing heavy coverings. Interventions for hypothermia include intake of
warm fluids and use of warm or electric blankets.

Health Teachings:
 Teach the client accurate use and reading of the type of thermometer to be used. Examine the
thermometer used by the client in the home for safety and proper functioning. Facilitate the
replacement of mercury thermometers with nonmercury ones. a broken mercury thermometer.
 Observe the client/caregiver taking and reading a temperature. Reinforce the importance of
reporting the site and type of thermometer used and the value of using the same site and
thermometer consistently.
 Discuss means of keeping the thermometer clean, such as warm water and soap, and avoiding
cross contamination.
 Ensure that the client has water-soluble lubricant if using a rectal thermometer.
 Instruct the client or family member to notify the health care provider if the temperature is
38.5°C (101.3°F) or higher.
 When making a home visit, take a thermometer with you in case the clients do not have a
functional thermometer of their own.
 Check that the client knows how to record the temperature. Provide a recording chart/table if
indicated.
 Discuss environmental control modifications that should be made during illness or extreme
climate conditions (e.g., heating, air conditioning, appropriate clothing and bedding).
 Title
(Skill 29 – 2: Assessing Peripheral Pulse)
Purpose:
 To establish baseline data for subsequent evaluation
 To identify whether the pulse rate is within normal range
 To determine the pulse volume and whether the pulse rhythm is regular
 To determine the equality of corresponding peripheral pulses on each side of the body.
 To monitor and assess changes in the client’s health status
 To monitor clients at risk for pulse alterations (e.g., those with a history of heart disease or
 experiencing cardiac arrhythmias, hemorrhage, acute pain, infusion of large volumes of fluids, or
fever)
 To evaluate blood perfusion to the extremities
Assessment:
Assess
◦ Clinical signs of cardiovascular alterations such as dyspnea (difficult respirations), fatigue, pallor,
cyanosis (bluish discoloration of skin and mucous membranes), palpitations, syncope (fainting), or
impaired peripheral tissue perfusion (as evidenced by skin discoloration and cool temperature).
◦ Factors that may alter pulse rate (e.g., emotional status and activity level).
◦ Which site is most appropriate for assessment based on the purpose.

Planning: Measurement of the client’s radial or brachial pulse can be delegated to UAP, or be performed
by family members/caregivers in nonhospital settings. Reports of abnormal pulse rates or rhythms require
reassessment by the nurse, who also determines appropriate action if the abnormality is confirmed. UAP
are generally not delegated these techniques due to the skill required in locating and Interpreting peripheral
pulses other than the radial or brachial artery and in using Doppler ultrasound devices.
Equipment
◦ Clock or watch with a sweep second hand or digital seconds indicator
◦ Stethoscope
◦ Antiseptic wipes
◦ If using a DUS: the transducer probe, the stethoscope headset, transmission gel, and tissues/wipes

Delegation/Interpersonal Practice: Assessing a peripheral pulse may be within the scope of practice
for many health care providers. For example, in addition to nurses, both physical therapists and respiratory
therapists may check the client’s pulse before, during, and after treatment. Although these therapists may
verbally communicate their findings and plan to the health care team members, the nurse must also know
where to locate their documentation in the client’s medical record.

Implementation Rationale Picture

1. Prior to performing the procedure, Provide patient’s safety
introduce self and verify the and to provide comfort to
client’s identity using agency the client
protocol. Explain to the client
what you are going to do, why it is
necessary, and how he or she
can participate. Discuss how the
results will be used in planning
further care or treatments.

2. Perform hand hygiene and To protect yourself from

observe appropriate infection any microorganisms and
prevention procedures. to provide patient’s safety
3. Provide for client privacy. Privacy provides comfort
to the client

4. Select the pulse point. Normally, Ensures safety and

the radial pulse is taken, unless it accuracy of measure
cannot be exposed or circulation
to another body area is to be
assessed.

5. Assist the client to a comfortable For patient’s comfort and

resting position. When the radial to acquire accurate
pulse is assessed, with the palm measure
facing downward, the client’s arm
can rest alongside the body or the
forearm can rest at a 90-degree
angle across the chest. For the
client who can sit, the forearm
can rest across the thigh, with the
palm of the hand facing
downward or inward.
6. Palpate and count the pulse. Ensures accuracy of
Place two or three middle measurement
fingertips lightly and squarely over
the pulse point.

7. Assess the pulse rhythm and To avoid forgetting every

volume. little detail and avoid
◦ Assess the pulse rhythm by committing mistakes
noting the pattern of the
intervals between the beats.
A normal pulse has equal
time periods between beats. If
this is an initial assessment,
assess for 1 minute.
◦ 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. Record the
rhythm and volume on your
worksheet.
.
8. Document the pulse rate, To determine if the result
rhythm, and volume and your is within normal range
actions in the client record. and without
Also record in the nurse’s complications
notes pertinent related data
such as variation in pulse rate
compared to normal for the
client and abnormal skin color
and skin temperature.
Variation: Using a DUS • If
used, plug the stethoscope
headset into one of the two
output jacks located next to
the volume control. DUS units
may have two jacks so that a
second person can listen to
the signals.
◦ Apply transmission gel
either to the probe at the
narrow end of the plastic
case housing the
transducer, or to the
client’s skin. Rationale:
Ultrasound beams do not
travel well through air.
The gel makes an airtight
seal, which then
promotes optimal
ultrasound wave
transmission.
◦ Press the “on” button.
◦ Hold the probe against
Too much pressure can
the skin over the pulse stop the blood flow and
site. Use a light pressure,
obliterate the signal
and keep the probe in
contact with the skin.

Evaluation:
 Compare the pulse rate to baseline data or normal range for age of client.
 Relate pulse rate and volume to other vital signs; relate pulse rhythm and volume to baseline data
and health status.
 If assessing peripheral pulses, evaluate equality, rate, and volume in corresponding extremities.
 Conduct appropriate follow-up such as notifying the primary care provider or giving medication

Health Teachings:
 Explain the equipment and the procedure to the patient and family.
 Teach a patient who takes prescribed cardiotonic or antiarrhythmic medications to assess the
radial pulse to detect adverse effects.
 Teach a patient starting a prescribed exercise regimen how to monitor the periperal pulse to
determine his or her response to exercise.
  Encourage questions and answer them as they arise.

Title
(Skill 29 – 3: Assessing Apical Pulse)
Purpose:
 To obtain the heart rate of an adult with an irregular peripheral pulse
 To establish baseline data for subsequent evaluation
 To determine whether the cardiac rate is within normal range and the rhythm is regular
 To monitor clients with cardiac, pulmonary, or renal disease and those receiving medications to
improve heart action
Assessment:
Assess
◦ Clinical signs of cardiovascular alterations such as dyspnea (difficult respirations),
fatigue/weakness, pallor, cyanosis (bluish discoloration of skin and mucous membranes),
palpitations, syncope (fainting), or impaired peripheral tissue perfusion as evidenced by skin
discoloration and cool temperature
 ◦ Factors that may alter pulse rate (e.g., emotional status, activity level, and medications that affect
heart rate such as digoxin, beta-blockers, or calcium channel blockers)
Planning: Due to the degree of skill and knowledge required, UAP are generally not responsible for
assessing apical pulses.
Delegation/Interpersonal Practice: Assessing an apical pulse may be within the scope of practice for
many health care providers. For example, in addition to nurses, respiratory therapists may check the
client’s apical pulse before, during, and after treatment, and physicians often check the apical pulse when
assessing the chest during examinations. Although these providers may verbally communicate their
findings and plan to other health care team members, the nurse must also know where to locate their
documentation in the client’s medical record.

Implementation Rationale Picture

1. Prior to performing the Provide patient’s safety
procedure, introduce self and and to provide comfort to
verify the client’s identity using the client
agency protocol. Explain to the
client what you are going to do,
why it is necessary, and how he
or she can participate. Discuss
how the results will be used in
planning further care or
treatments.

2. Perform hand hygiene and To protect yourself from

observe appropriate infection any microorganisms and
prevention procedures. to provide patient’s
safety

3. Provide for client privacy. Privacy provides comfort

to the client

4. Position the client appropriately This position allows easy

in a comfortable supine position access for selection of
or in a sitting position. Expose site.
the area of the chest over the
apex of the heart.
5. Locate the apical impulse. This Usually, the heart beat is
is the point over the apex of the found at the fifth
heart where the apical pulse can intercostal space, near
be most clearly heard. the midclavicular line
◦ Palpate the angle of Louis
(the angle between the
manubrium, the top of the
sternum, and the body of the
sternum). It is palpated just
below the suprasternal notch
and is felt as a prominence.
◦ Slide your index finger just to
the left of the sternum, and
palpate the second
intercostal space.
◦ Place your middle or next
finger in the third intercostal
space, and continue
palpating downward until
you locate the fifth
intercostal space.
◦ ❷ • Move your index finger
laterally along the fifth intercostal
space toward the MCL.
◦ ❸ Normally, the apical impulse
is palpable at or just medial to
the MCL
.

6. Auscultate and count heartbeats. The diaphragm needs to

◦ Use antiseptic wipes to clean the be cleaned and
earpieces and diaphragm of the disinfected if soiled with
stethoscope. body substances. Both
earpieces and
diaphragms have been
shown to harbor
pathogenic bacteria.

The metal of the

◦ Warm the diaphragm of the diaphragm is usually
stethoscope by holding it in the cold and can startle the
palm of the hand for a moment. client when placed
immediately on the
chest.
◦ Insert the earpieces of the
stethoscope into your ears in the This is to be sure it is the
direction of the ear canals, or active side of the head. If
slightly forward. Rationale: This necessary, rotate the
position facilitates hearing. head to select the
◦ Tap your finger lightly on the diaphragm side.
diaphragm.
◦ Place the diaphragm of the
stethoscope over the apical
impulse and listen for the normal
S1 and S2 heart sounds, which
are heard as “lub-dub.”
◦ If you have difficulty hearing the
apical pulse, ask the supine
client to roll onto his or her left
side or the sitting client to lean
slightly forward.
◦ If the rhythm is regular, count
the heartbeats for 30 seconds
and multiply by 2. If the rhythm is
irregular or for giving certain
medications such as digoxin,
count the beats for 60 seconds
The heartbeat is
normally loudest over
the apex of the heart.
Each lub-dub is counted
as one heartbeat.
Rationale: The two heart
sounds are produced by
closure of the heart
valves. The S1 heart
sound (lub) occurs when
the atrioventricular
valves close after the
ventricles have been
sufficiently filled. The S2
heart sound (dub) occurs
when the semilunar
valves close after the
ventricles empty.
This positioning moves
the apex of the heart
closer to the chest wall.
A 60-second count
provides a more acc
urate assessment of an
irregular pulse than a 30-
second count.
 7. Assess the rhythm and the To determine any
strength of the heartbeat. abnormalities and to
◦ Assess the rhythm of the intervene properly
heartbeat by noting the pattern
of intervals between the beats.
A normal pulse has equal time
periods between beats.
◦ Assess the strength (volume) of
the heartbeat. Normally, the
heartbeats are equal in strength
and can be described as strong
or weak.

8. Document the pulse rate and Documentation is

rhythm, and nursing actions in established with the
the client record. Also record personal record of the
pertinent related data such as patient, which
variation in pulse rate compared constitutes a base of
to normal for the client and information on the
abnormal skin color and skin situation of his health.
temperature. The importance of
nursing documentation is
neuralgic, provided that
without it, there cannot
be a complete qualitative
nursing intervention and
not even an effective
care for the patient. In
the purposes of nursing
documentation are
included the research on
a more effective care of
the already detected
problems
Evaluation:
◦ Relate the pulse rate to other vital signs. Relate the pulse rhythm to baseline data and health
status.
◦ Report to the primary care provider any abnormal findings such as irregular rhythm, reduced ability
to hear the heartbeat, pallor, cyanosis, dyspnea, tachycardia, or bradycardia.
◦ Conduct appropriate follow-up such as administering medication ordered based on apical heart
rate.

Health Teachings:
 Explain the equipment and the procedure to the patient and family.
 Teach a patient who takes prescribed cardiotonic or antiarrhythmic medications to assess the
radial pulse to detect adverse effects.
 Teach a patient starting a prescribed exercise regimen how to monitor the apical pulse to
determine his or her response to exercise.
 Encourage questions and answer them as they arise.

Title
(Skill 29 – 4: Assessing Apical Radial Impulse)
Purpose:
 To determine adequacy of peripheral circulation or presence of pulse deficit.
Assessment:
Assess
◦ Clinical signs of hypovolemic shock (hypotension, pallor, cyanosis, and cold, clammy skin)

Planning: UAP are generally not responsible for assessing apical-radial pulses using the one-nurse
technique. UAP may perform the radial pulse count for the two-nurse technique.
Equipment
◦ Clock or watch with a sweep second hand or digital seconds indicator
◦ Stethoscope
◦ Antiseptic wipes
Delegation/Interpersonal Practice: Assessing an apical-radial pulse may be within the scope of
practice for many health care providers. Any provider who assesses a pulse can serve as the second
person in the two-person technique.

Implementation Rationale Picture

1. Prior to performing the Provide patient’s safety
procedure, introduce self and and to provide comfort to
verify the client’s identity using the client
agency protocol. Explain to the
client what you are going to do,
why it is necessary, and how he
or she can participate. Discuss
how the results will be used in
planning further care or
treatments.

2. Perform hand hygiene and To protect yourself from

observe appropriate infection any microorganisms and
prevention procedures. to provide patient’s
safety

3. Provide for client privacy. Privacy provides comfort

to the client

4. Position the client appropriately. This ensures an

Assist the client to a comfortable accurate comparative
supine or sitting position. Expose measurement.
the area of the chest over the
apex of the heart. If previous
measurements were taken,
determine what position the
client assumed, and use the
same position.
 5. Locate the apical and radial
pulse sites. In the two-nurse
technique, one nurse locates the
apical impulse by palpation or
with the stethoscope while the
other nurse palpates the radial
pulse site
6. Count the apical and radial pulse
rates. Two-Nurse Technique
◦ Place the clock or watch where
both nurses can see it. The
nurse who is taking the radial
pulse may hold the watch.
◦ Decide on a time to begin
counting. A time when the
second hand is on 12, 3, 6, or 9
or an even number on digital
clocks is usually selected. The
nurse taking the radial pulse
says “Start.”
◦ Each nurse counts the pulse rate
for 60 seconds. Both nurses end
the count when the nurse taking
the radial pulse says, “Stop.”
The pulse at your wrist is
called the radial pulse.
The pedal pulse is on
the foot, and the brachial
pulse is under the elbow.
The apical pulse is
the pulse over the top of
the heart, as typically
heard through a
stethoscope with the
patient lying on his or
her left side
This ensures that
simultaneous counts are
taken.
A full 60-second count is
necessary for accurate
assessment of any
discrepancies between
the two pulse sites.

◦ The nurse who assesses the

apical rate also assesses the
apical pulse rhythm and volume
(i.e., whether the heartbeat is
strong or weak). If the pulse is
irregular, note whether the
irregular beats come at random
or at predictable times.
◦ The nurse assessing the radial
pulse rate also assesses the
radial pulse rhythm and volume.

One-Nurse Technique Within a few

minutes:
◦ Assess the apical pulse for 60
seconds, and
◦ Assess the radial pulse for 60
seconds. 7. Document the apical
and radial (AR) pulse rates,
rhythm, volume, and any pulse
deficit in the client record. Also
record related data such as
variation in pulse rate compared
to normal for the client and other
 pertinent observations, such as
pallor, cyanosis, or dyspnea.

7. Assess the rhythm and the To determine any

strength of the heartbeat. abnormalities and to
◦ Assess the rhythm of the intervene properly
heartbeat by noting the pattern
of intervals between the beats.
A normal pulse has equal time
periods between beats.
◦ Assess the strength (volume) of
the heartbeat. Normally, the
heartbeats are equal in strength
and can be described as strong
or weak.

8. Document the pulse rate and Documentation is

rhythm, and nursing actions in established with the
the client record. Also record personal record of the
pertinent related data such as patient, which
variation in pulse rate compared constitutes a base of
to normal for the client and information on the
abnormal skin color and skin situation of his health.
temperature. The importance of
nursing documentation
is neuralgic, provided
that without it, there
cannot be a complete
qualitative nursing
intervention and not
even an effective care
for the patient. In the
purposes of nursing
documentation are
included the research on
a more effective care of
the already detected
problems
Evaluation:
◦ Relate pulse rate and rhythm to other vital signs, to baseline data, and to general health status.
◦ Report to the primary care provider any changes from previous measurements or any discrepancy
between the two pulse rates.

Health Teachings:
◦ Assist in obtaining and using an electronic pulse-measuring device if indicated.
◦ Teach the client to monitor the pulse prior to taking medications that affect the heart rate. Tell the client to
report any notable changes in heart rate or rhythm (regularity) to the health care provider.
◦ Inform the client/family of activities known to significantly affect pulse rate such as emotional stress, exercise,
ingesting caffeine, and sleep. Clients sensitive to pulse rate changes should consider whether any of these
activities should be modified in order to stabilize the pulse.
◦ Some clients require lengthy monitoring of the pulse and cardiac pattern (electrocardiogram). A special
device, often referred to as a Holter monitor, is used for this type of monitoring. It is usually applied in an office
or clinic setting, and the client wears the portable recorder for 24 hours. Other portable devices used for
recording episodic arrhythmias include cardiac event monitors. The client activates the device during times
when symptoms appear and then the recorded data can be
 transmitted to a central location through a telephone.
Title
(Skill 29 – 5: Assessing Respirations)
Purpose:
 To acquire baseline data against which future measurements can be compared
 To monitor abnormal respirations and respiratory patterns and identify changes
 To monitor respirations before or after the administration of a general anesthetic or any medication that
influences respirations
 To monitor clients at risk for respiratory alterations (e.g., those with fever, pain, acute anxiety, chronic
obstructive pulmonary disease, asthma, respiratory infection, pulmonary edema or emboli, chest trauma or
constriction, brainstem injury)
Assessment:
Assess
◦ Skin and mucous membrane color (e.g., cyanosis or pallor)
◦ Position assumed for breathing (e.g., use of orthopneic position)
◦ Signs of lack of oxygen to the brain (e.g., irritability, restlessness, drowsiness, or loss of consciousness)
◦ Chest movements (e.g., retractions between the ribs or above or below the sternum)
◦ Activity tolerance
◦ Chest pain
◦ Dyspnea
◦ Medications affecting respiratory rate
Planning: Counting and observing respirations may be delegated to UAP. The follow-up assessment,
interpretation of abnormal respirations, and determination of appropriate responses are done by the nurse.
Equipment
• Clock or watch with a sweep second hand or digital seconds indicator
Delegation/Interpersonal Practice: Assessing respirations may be within the scope of practice for many
health care providers. For example, in addition to nurses, respiratory therapists will check the client’s breathing
before, during, and after treatment. Although these therapists may verbally communicate their findings and plan to
the health care team members, the nurse must also know where to locate their documentation in the client’s
medical record.

Implementation Rationale Picture

1. Prior to performing the procedure, Provide patient’s safety
introduce self and verify the client’s and to provide comfort to
identity using agency protocol. Explain the client
to the client what you are going to do,
why it is necessary, and how he or she
can participate. Discuss how the results
will be used in planning further care or
treatments.

2. Perform hand hygiene and observe To protect yourself from

appropriate infection prevention any microorganisms and
procedures. to provide patient’s safety
3. Provide for client privacy. Privacy provides comfort
to the client

4. Observe or palpate and count the To acquire accurate

respiratory rate. measure
◦ The client’s awareness that the nurse is
counting the respiratory rate could
cause the client to purposefully alter the
respiratory pattern. If you anticipate this,
place a hand against the client’s chest to
feel the chest movements with
breathing, or place the client’s arm
across the chest and observe the chest
movements while supposedly taking the
radial pulse.
◦ Count the respiratory rate for 30
seconds if the respirations are regular.
Count for 60 seconds if they are
irregular. An inhalation and an
exhalation count as one respiration.

5. Observe the depth, rhythm, and During deep respirations,

character of respirations. a large volume of air is
◦ Observe the respirations for depth by exchanged; during
watching the movement of the chest. shallow respirations, a
small volume is
exchanged.

◦ Observe the respirations for regular or Normally, respirations are

irregular rhythm. evenly spaced.
◦ Observe the character of respirations—
the sound they produce and the effort
they require. Rationale: Normally,
respirations are silent and effortless.
6. Document the respiratory rate, depth, Documentation is
rhythm, and character on the established with the
appropriate record. personal record of the
patient, which constitutes
a base of information on
the situation of his health.
The importance of
nursing documentation is
neuralgic, provided that
without it, there cannot
be a complete qualitative
nursing intervention and
not even an effective
 care for the patient. In the
purposes of nursing
documentation are
included the research on
a more effective care of
the already detected
problems
Evaluation:
◦ Relate respiratory rate to other vital signs, in particular pulse rate; relate respiratory rhythm and depth to
baseline data and health status.
◦ Report to the primary care provider a respiratory rate significantly above or below the normal range and
any notable change in respirations from previous assessments; irregular respiratory rhythm; inadequate
respiratory depth; abnormal character of breathing—orthopnea, wheezing, stridor, or bubbling; and any
complaints of dyspnea.

Health Teachings: At the heart of good patient care is teaching respiratory patients’ educational protocols to
improve their respiratory health. For example, incentive spirometry is an exercise designed to help patients take
long, deep breaths using an incentive spirometer to gauge how well the lungs expand. Because it requires deep
breaths, it may improve a patient’s ability to clear mucus from the lungs. It may also increase the amount of oxygen
that gets deeper into the lungs. Teaching patients the risk factors associated with their specific respiratory condition
is also essential to good patient care.

Title
(Skill 29 – 6: Assessing Blood Pressure)
Purpose:
 To obtain a baseline measurement of arterial blood pressure for subsequent evaluation
 To determine the client’s hemodynamic status (e.g., cardiac output: stroke volume of the heart and
blood vessel resistance)
 To identify and monitor changes in blood pressure resulting from a disease process or medical
therapy (e.g., presence or history of cardiovascular disease, renal disease, circulatory shock, or
acute pain; rapid infusion of fluids or blood products)
Assessment:
Assess
◦ Signs and symptoms of hypertension (e.g., headache, ringing in the ears, flushing of face,
nosebleeds, fatigue)
◦ Signs and symptoms of hypotension (e.g., tachycardia, dizziness, mental confusion, restlessness,
cool and clammy skin, pale or cyanotic skin)
◦ Factors affecting blood pressure (e.g., activity, emotional stress, pain, and time the client last
smoked or ingested caffeine)
◦ Some blood pressure cuffs contain latex. Assess the client for latex allergy and obtain a latex-free
cuff if indicated.
Planning: Blood pressure measurement may be delegated to UAP. The interpretation of abnormal blood
pressure
Equipment
◦ Stethoscope or DUS
◦ Blood pressure cuff of the appropriate size
◦ Sphygmomanometer and determination of appropriate responses are done by the nurse.
Delegation/Interpersonal Practice: Measurement of blood pressure is within the scope of practice for
many health care providers. For example, in addition to nurses, therapists may check the client’s blood
pressure before, during, and after treatment. Although these therapists may verbally communicate their
findings and plan to the health care team members, the nurse must also know where to locate their
documentation in the client’s medical record.
Implementation Rationale Picture
1. Prior to performing Provide patient’s safety and
the procedure, to provide comfort to the
introduce self and client
verify the client’s
identity using agency
protocol. Explain to
the client what you
are going to do, why it
is necessary, and how
he or she can
participate. Discuss
how the results will be
used in planning
further care or
treatments.

2. Perform hand hygiene To protect yourself from any

and observe microorganisms and to
appropriate infection provide patient’s safety
prevention
procedures.

3. Provide for client Privacy provides comfort to

privacy. the client

4. Position the client Legs crossed at the knee

appropriately. results in elevated systolic
◦ The adult client and diastolic blood
should be sitting pressures.
unless otherwise
specified. Both feet The blood pressure
should be flat on the increases when the arm is
floor. below heart level and
decreases when the arm is
◦ The elbow should be above heart level.
slightly flexed with the
palm of the hand
facing up and the arm
supported at heart
 level. Readings in any
other position should
be specified. The
blood pressure is
normally similar in
sitting, standing, and
lying positions, but it
can vary significantly
by position in certain
persons.

◦ Expose the upper arm

5. Wrap the deflated cuff Smooth cuff and shrug
evenly around the wrapping produce equal
upper arm. Locate the pressure and help promote
brachial artery. accurate measurement
◦ Apply the center of
the bladder directly
over the artery.
Rationale: The
bladder inside the cuff
must be directly over
the artery to be
compressed if the
reading is to be
accurate.
◦ For an adult, place
the lower border of
the cuff approximately
2.5 cm (1 in.) above
the antecubital space.
6. If this is the client’s The initial estimate tells the
initial examination, nurse the maximal pressure
perform a preliminary to which the
palpatory sphygmomanometer needs
determination of to be elevated in
systolic pressure. subsequent determinations.
It also prevents
underestimation of the
systolic pressure or
overestimation of the
diastolic pressure should an
◦ Palpate the brachial auscultatory gap occur.
artery with the
fingertips.
◦ Close the valve on the
bulb.
◦ Pump up the cuff until
you no longer feel the
brachial pulse. At that
pressure the blood
cannot flow through
the artery. Note the
pressure on the
sphygmomanometer
at which pulse is no
longer felt.
7. Position the If the stethoscope tubing
stethoscope rubs against an object, the
appropriately. noise can block the sounds
◦ Cleanse the earpieces of the blood within the
with antiseptic wipe. artery.
◦ Insert the ear
attachments of the
stethoscope in your
ears so that they tilt
slightly forward.
Rationale: Sounds are
heard more clearly
when the ear
attachments follow the
direction of the ear
canal.
◦ Ensure that the
stethoscope hangs
freely from the ears to
the diaphragm.
◦ Place the bell side of Because the blood pressure
the amplifier of the is a low-frequency sound, it
stethoscope over the is best heard with the bell-
brachial pulse site. shaped diaphragm.
◦ Place the stethoscope This is to avoid noise made
directly on the skin, from rubbing the amplifier
not on clothing over against cloth.
the site.
◦ Hold the diaphragm
with the thumb and
 index finger.

8. Auscultate the client’s Proper placement of

blood pressure. stethoscope blocks extra
◦ Pump up the cuff until flows and allow sound to
the travel more clearly
sphygmomanometer
reads 30 mmHg Increasing the pressure
above the point where above the point where the
the brachial pulse pulse disappeared ensures
disappeared. a period before hearing the
◦ Release the valve on first sound that corresponds
the cuff carefully so systolic pressure
that the pressure
decreases at the rate If the rate is faster or slower,
of 2 to 3 mmHg per an error in measurement
second. may occur.
◦ As the pressure falls,
identify the There is no clinical
manometer reading at significance to phases 2 and
Korotkoff phases 1, 4, 3.
and 5.
◦ Deflate the cuff rapidly This permits blood trapped
and completely. in the veins to be released.
◦ Wait 1 to 2 minutes
before making further
determinations.
Repeat the above
steps to confirm the
accuracy of the
reading—especially if
it falls outside the
normal range
(although this may not
be routine procedure
for hospitalized or well
clients). If there is
greater than 5 mmHg
difference between
the two readings,
additional
measurements may
be taken and the
results averaged.
 9. If this is the client’s
initial examination,
repeat the procedure
on the client’s other
arm. There should be
a difference of no
more than 10 mmHg
between the arms.
The arm found to
have the higher
pressure should be
used for subsequent
examinations.

Variation: Obtaining a Blood

Pressure by the Palpation
Method If it is not possible to
use a stethoscope to obtain
the blood pressure or if the
Korotkoff sounds cannot be
heard, palpate the radial or
brachial pulse site as the cuff
pressure is released. The
manometer reading at the
point where the pulse
reappears is an estimate of
systolic value.

Variation: Taking a Thigh

Blood Pressure
◦ Help the client to
assume a prone
position. If the client
cannot assume this
position, measure the
blood pressure while
the client is in a
supine position with
the knee slightly
flexed. Slight flexing
of the knee will
facilitate placing the
stethoscope on the
popliteal space.
◦ Expose the thigh,
taking care not to
expose the client
unduly.
◦ Locate the popliteal
artery
◦
Variation: Using an
Electronic Indirect Blood
Pressure Monitoring Device
◦ Place the blood
pressure cuff on the
 extremity according to
the manufacturer’s
guidelines.
◦ Turn on the blood
pressure switch.
◦ If appropriate, set the
device for the desired
number of minutes
between blood
pressure
determinations.
◦ When the device has
determined the blood
pressure reading,
note the digital
results.

10. Remove the cuff from This decreases the risk of

the client’s arm. spreading infection by
SAFETY ALERT! sharing cuffs.
Electronic/automatic
blood pressure cuffs
can be left in place for
many hours. Remove
the cuff and check
skin condition
periodically. The client
uses it for the length
of stay and then it is
discarded.
11. Wipe the cuff with an Cuffs can become
approved disinfectant. significantly contaminated.
Many institutions use
disposable blood pressure
cuffs.

◦ The client uses it for This decreases the risk of

the length of stay and spreading infection by
then it is discarded. sharing cuffs.

12. Document and report Documentation is

pertinent assessment established with the
data according to personal record of the
agency policy. Record patient, which constitutes a
two pressures in the base of information on the
form “130/80” where situation of his health. The
“130” is the systolic importance of nursing
(phase 1) and “80” is documentation is neuralgic,
the diastolic (phase 5) provided that without it,
pressure. Record there cannot be a complete
three pressures in the qualitative nursing
form “130/90/0,” intervention and not even an
where “130” is the effective care for the patient.
systolic, “90” is the In the purposes of nursing
first diastolic (phase documentation are included
 4), and sounds are the research on a more
audible even after the effective care of the already
cuff is completely detected problems
deflated. Use the
abbreviations RA or
RL for right arm or
right leg and LA or LL
for left arm or left leg.
Evaluation:
◦ Relate blood pressure to other vital signs, to baseline data, and to health status. If the findings are
significantly different from previous values without obvious reasons, consider possible causes
◦ Report any significant change in the client’s blood pressure. Also report these findings:
◦ Systolic blood pressure (of an adult) above 140 mmHg
◦ Diastolic blood pressure (of an adult) above 90 mmHg
◦ Systolic blood pressure (of an adult) below 100 mmHg
Health Teachings:
◦ If the client takes blood pressure readings at home, the nurse should use the same equipment or
calibrate it against a system known to be accurate.
◦ Observe the client or family member taking the blood pressure and provide feedback if further
◦ instruction is needed.
◦ Home blood pressure measurement done by the client or family can confirm pressures identified
when the client is seen in a clinic or office setting. This may be significant because so-called
“white coat” hypertension can occur, which is an elevation in blood pressure due to mild anxiety
associated with the health care provider’s presence—who historically wore a white laboratory coat.
An elevated blood pressure may be dismissed as the white coat phenomenon when, in fact, the
blood pressure is truly elevated.
◦ If the client is in a chair or low bed, position yourself so that you
maintain the client’s arm at heart level and you can read the
sphygmomanometer at eye level.
 Title
(Skill 29 – 7: Measuring Oxygen Saturation)
Purpose:
 To estimate the arterial blood oxygen saturation
 To detect the presence of hypoxemia before visible signs develop
Assessment:
Assess
◦ The best location for a pulse oximeter sensor based on the client’s age and physical condition.
Unless contraindicated, the finger is usually selected for adults.
◦ The client’s overall condition including risk factors for development of hypoxemia (e.g.,
respiratory or cardiac disease) and hemoglobin level
◦ Vital signs, skin color and temperature, nail bed color, and tissue perfusion of extremities as
baseline data
◦ Adhesive allergy

Planning: Many hospitals and clinics have pulse oximeters readily available for use with other vital
signs equipment (or even as an integrated part of the electronic blood pressure device). Other facilities
may have a limited supply of oximeters, and the nurse may need to request it from the central supply
department.
Equipment
◦ Nail polish remover as needed
◦ Alcohol wipe
◦ Sheet or towel
◦ Pulse oximeter
Delegation/Interpersonal Practice: Application of the pulse oximeter sensor and recording of the
SpO2 value may be delegated to UAP. The interpretation of the oxygen saturation value and
determination of appropriate responses are done by the nurse. Measuring oxygen saturation may be
within the scope of practice for many health care providers. For example, in addition to nurses,
respiratory therapists may check the client’s oxygen saturation before, during, and after treatment.
Although these therapists may verbally communicate their findings and plan to the health care team
members, the nurse must also know where to locate their documentation in the client’s medical record.

Implementation Rationale Picture

1. Prior to performing the Provide patient’s safety
procedure, introduce self and to provide comfort
and verify to the client
the client’s identity using
agency protocol. Explain to
the client
what you are going to do,
why it is necessary, and how
he or
she can participate. Discuss
how the results will be used
in
planning further care or
treatments
2. Perform hand hygiene and To protect yourself from
observe appropriate infection any microorganisms and
prevention procedures. to provide patient’s
Apply gloves if performing a safety
rectal
temperature.

3. Provide for client privacy. Privacy provides comfort

to the client

4. Choose a sensor appropriate Avoid using thumb, it

for the client’s weight, size, has its own pulse, know
and desired location. the exact site where you
Because weight limits of can put the oximeter
sensors overlap, a pediatric
sensor could be used for a
small adult.
◦ If the client is allergic to
adhesive, use a clip or
sensor without adhesive.
◦ If using an extremity, apply
the sensor only if the
proximal pulse and capillary
refill at the point closest to
the site are present. If the
client has low tissue
perfusion due to peripheral
vascular disease or therapy
using vasoconstrictive
medications, use a nasal
sensor or a reflectance
sensor on the forehead.
Avoid using lower
extremities that have a
compromised circulation and
extremities that are used for
infusions or other invasive
monitoring.
5. Prepare the site. Nail polish may interfere
◦ Clean the site with an with accurate
alcohol wipe before applying measurements although
the sensor. the data about this are
◦ It may be necessary to inconsistent.
remove a female client’s
dark nail polish.
◦ Alternatively, position the
sensor on the side of the
finger rather than
perpendicular to the nail bed.
6. Apply the sensor, and To avoid any harmful
connect it to the pulse effects to the patient
oximeter.
◦ Make sure the LED and Making sure that the
photodetector are accurately
equipment is
aligned, that is, opposite
each other on either side of
functioning and will
the finger, toe, nose, or give the accurate
earlobe. Many sensors have measurement
markings to facilitate correct
alignment of the LEDs and
photodetector.
◦ Attach the sensor cable to
the connection outlet on the
oximeter. Turn on the
machine according to the
manufacturer’s directions.
Appropriate connection will
be confirmed by an audible
beep indicating each arterial
pulsation. Some devices
have a wheel that can be
turned clockwise to increase
the pulse volume and
counterclockwise to
decrease it.
◦ Ensure that the bar of light
or waveform on the face of
the oximeter fluctuates with
each pulsation.
7. Set and turn on the alarm Check the manufacturer
when using continuous directions as indicated.
monitoring. Ensure that it is
◦ Check the preset alarm limits functioning properly
for high and low oxygen
saturation and high and low
pulse rates. Change these
alarm limits according to the
manufacturer’s directions as
indicated. Ensure that the
audio and visual alarms are
on before you leave the
client. A tone will be heard
and a number will blink on
 the faceplate.
8. Ensure client safety. This is to ensure patient
◦ Inspect and/or move or safety
change the location of an
adhesive toe or finger sensor
every 4 hours and a spring-
tension sensor every 2
hours.
◦ Inspect the sensor site
tissues for irritation from
adhesive sensors.
9. Ensure the accuracy of A large discrepancy
measurement. between the two values
◦ Minimize motion artifacts by may indicate oximeter
using an adhesive sensor, or malfunction.
immobilize the client’s
monitoring site. Rationale:
Movement of the client’s
finger or toe may be
misinterpreted by the
oximeter as arterial
pulsations.
◦ If indicated, cover the sensor
with a sheet or towel to block
large amounts of light from
external sources (e.g.,
sunlight, procedure lamps, or
bilirubin lights in the
nursery). Rationale: Bright
room light may be sensed by
the photodetector and alter
the SpO2 value.
◦ Compare the pulse rate
indicated by the oximeter to
the radial pulse periodically.
10. Document the oxygen Documentation is
saturation on the appropriate established with the
record at designated personal record of the
intervals. patient, which
constitutes a base of
information on the
situation of his health.
The importance of
nursing documentation
is neuralgic, provided
that without it, there
cannot be a complete
qualitative nursing
intervention and not
even an effective care
for the patient. In the
purposes of nursing
documentation are
included the research on
a more effective care of
the already detected
 problems
Evaluation:
 Compare the oxygen saturation to the client’s previous oxygen saturation level. Relate to pulse
rate and other vital signs.
 Conduct appropriate follow-up such as notifying the primary care provider, adjusting oxygen
therapy, or providing breathing treatments

Health Teachings:
◦ Pulse oximetry is a quick, inexpensive, noninvasive method of assessing oxygenation. Like an
automatic blood pressure cuff, it also provides a pulse rate reading. Use in the ambulatory or
home setting whenever indicated.
◦ If the client requires frequent or continuous home monitoring, teach the client and family how to
apply and maintain the equipment. Remind them to rotate the site periodically and assess for
skin trauma.