First is you have to read the patients chart

- This is to obtain data and to know the status of the PT

Was your hands
- This s to avoid the spread of microorganism
Then prepare for the equipments that I will be needing.
- This will help you save time and for the procedure to go smoothly
Identify the PT and explain the procedure
- This is to make sure that you are in the right PT and also to gain cooperation from the client
and to inform them
Wipe the thermometer from the bulb towards the stem with cotton ball
- This is to clean the thermometer since it was used by many PT
Pat dry the axilla.
- Pat dry the axilla to avoid sweat that may alter the results
Turn on the thermometer and place it in the deepest part of the axilla in an upward position
in the PT arm across the chest.
- So that it will provide the accurate answer. Make sure that the bulb is not expose so that
there are no descripancy
Leave the thermometer in place for 2 to 60 seconds or until a sound is heard
- It will longer contact between the axilla and the thermometer resulting in an accurate
answer
Remove the thermometer dry using tissue paper. And record the temperature
-
Then wipe the thermometer twice using a cotton ball with alcohol from the stem to the buld
in a twisting motion
- Cleaning it from the contaminated and less contaminate will help deter the spread of
microorganism. And return it in the case
I will locate for the radial pulse by using my fingers and put it in the chest of the PT
- Using my fingers will be able to feel the pulse easily
With a watch with a swift second hand count the pulse rate in a full time
- Sufficient time will detect irregularities.
With my fingers still in place I will note of the PT’s chest upon respiration
- Counting the respiration while presumably still counting the pulse keeps the PT from
becoming conscious
Record the pulse rate and the respiration rate in the jot down notebook for you to not forget
about it.
Put the BP cuff without contraptions and feel the pulsation on the brachial artery with use of
2 - 3 finger pads
- Contraptions may produce inaccurate reading
Position the diaphragm directly over the pulse.
- Since accurate blood reading is obtained when the stethoscope is directly over the artery
Pumps the bulb to 20mmhg where the pulsation disappears.
- This will prevent you from missing the first tap sound.
Gradually deflate cuff all the way to zero
- First sound is the systolic BP and last sound is diastolic BP
Remove the cuff and makes PT comfortable, and record the result in the jot down notebook.
So that you will not forget the measurement
Warms the diaphragm of the stethoscope with the palm.
- If the diaphragm is cold it may startle the pt and may alter the heart rate.
With the PT in a supine position, locates the apical pulse on the left side and drape for
privacy
- So that the PT will not feel conscious
Places the diaphragm of the stethoscope over the PMI
- It will the loudest and distinct sound
Count the beat for a full minute
- Long assessment is needed for accuracy
Record it the the jot down notebook
Ask for the PT stool and urine output within the shift.
-
Report to the CI for any unusualties in the VS
- Referral for any unsualties enable the professional nurse to respond immediately to the
needs.
Record the result in the master list
- This will serve as for a further bases.