Makalah Vital Sign : Measuring a Radial Pulse,Counting

Respiration, And Taking axillary temperature by glass thermometer

Group 3

Disusun Oleh :
Prischeilla Inkiriwang Marizkah Batasina

Melinda wenas Elisabet Yogobi

Yefta Mongdong Pretty Wendersteyt

Dian Legi Militia Aring

Mata Kuliah :

Bahasa inggris

Dosen Mata Kuliah :

Ns.Autry Mandagi,S.Kep.,MSN

Universitas Sariputra Indonesia Tomohon

Yayasan Dharma Bhakti Indonesia Tomohon
Fakultas Keperawatan
Tahun 2021
 MEASURING A RADIAL PULSE

A. Definition

Checking presence, rate, rhythm and volume of throbbing of artery.

B. Purpose

1. To determine number of heart beats occurring per minute (rate)

2. To gather information about heart rhythm and pattern of beats

3. To evaluate strength of pulse

4. To assess heart's ability to deliver blood to distant areas of the blood

viz.fingers and lower extremities

5. To assess response of heart to cardiac medications, activity, blood volume

and gas exchange

6. To assess vascular status of limbs

C. Equipment

 Book

 Watches

 Pen

D. Procedure

Care Action Rationale

1. Wash hands Hand washing prevents the spread of
infection
2. Prepare all equipments required Organization facilitates accurate skill
on tray. problema

3. Check the client’s identification To confirm the necessity

4. Explain the procedure and Providing information fosters cooperation
purpose to the client. and understanding

5. Assist the client in assuming a  To provide easy access to pulse sites

supine or sitting position.  Relaxed position of forearm and slight
 If supine, place client’s flexion of wrist promotes exposure of
forearm straight along side artery to palpation withoutrestriction
body with extended straight
or upper abdomen with
extended straight
 If sitting, bend client’s elbow
90 degrees and support
 lower arm on chair or on
nurse’s arm slightly flex the
wrist
6. Count and examine the pulse
 Place the tips of your first,
index, and third finger over the
client's radial artery on the
inside of the wrist on the thumb
side.
 Apply only enough pressure to
radial pulse
 Using watch, count the pulse
beats for a full minute.
 Examine the rhythm and the
strength of the pulse.
7. Record the rate on the client’s
chart. Sign on the chart.
8. Wash your hands
9. Report to the senior staff if you To provide nursing care and medication
find any abnormalities.
 The fingertips are sensitive and better
able to feel thepulse.Do not use your
thumb because it has a strong pulse of
its own.
 Moderate pressure facilitates palpation
of the pulsations. Too much pressure
obliterates the pulse, where as the pulse
is imperceptible with too little pressure
 Counting a full minute permits a more
accurate reading and allows assessment
of pulse strength and rhytem
 Strength reflects volume of blood
ejected against arterial wall with each
heart contraction.
 Documentation provides ongoig data
collection
 To maintain professional accountability
Hand washing prevents the spread of
infection
properly and continuously
 COUNTING RESPIRATION

A.Definition

Monitoring the involuntary process of inspiration and expiration in a patient

B. Purpose

1. To determine number of respiration occurring per minute

2. To gather information about rhythm and depth

3. To assess response of patient to any related therapy or medication

C. Equipment

• Book

• Pen

• Watches

D. Procedure

Care action Rationale

1. Close the door and or use To maintain privacy
screen.

2. Make the client's position To ensure clear view of chest wall and
comfortable, preferably sitting or abdominal movements. If necessary,
lying with the head of the move the bed linen.
elevated 45to 60 degrees.

3. Prepare count respirations by A client who knows are counting

keeping your fingertips on the respirations may not breathe naturally.
client’s pulse

4. Counting respiration:  One full cycle consists of an

 Observe the rise and fall of the
client’s (one inspiration and one
expiration).
 Count respirations for one full
minute.
 Examine the depth, rhythm, facial
expression, cyanosis, cough and
movement accessory.
inspiration and an expiration.
 Allow sufficient time to assess
respirations, especially when the rate
is with an irregular
 Children normally have an
irregular,more rapid rate. Adults with
an irregular rate require more careful
assessment including depth and
rhythm of respirations.

5. Replace bed linens if necessary.  Documentation provides ongoing

Record the rate on the client’s datacollection.
chart. Sign the chart  Giving signature maintains
 professional accountability
6. Perform hand hygiene To prevent the spread of infection
7. Report any irregular findings to To provide continuity of care
the senior staff
 TAKING AXILLARY TEMPERATURE BY GLASS THERMOMETER

A. Definition

Measuring or monitoring patient’s body temperature using clinical thermometer

B. Purpose

1. To determine body temperature

2. To assist in diagnosis

3. To evaluate patient’s recovery fromillness

4. To determine if immediate measures should be implemented to reduce

dangerously elevated body temperature or converse body heat when body
temperature is dangerous low

5. To evaluate patient’s response once heat conserving or heal reducing

measures have been implemented

C. Equipment

• Book

• Watches

• Pen

• Glass thermometer

D. Procedure

Care Action Rationale

Wash your hands.
Prepare all required equipments
Check the client’s identification.
Hand washing prevents the spread of
infection
Organization facilitates accurate skill
performance.
To confirm the necessity

Explain the purpose and the procedure to Providing information fasters cooperation
the client. and understanding

Close door’s and or use a screen. Maintains client’s privacy and minimize
embarrassment
Take the thermometer and wipe it with Wipe from the area where few organisms
cotton swab from bulb towards the tube are present to the area where more
organisms are present to limit spread of
infection
Shake the thermometer with strong wrist Lower the mercury level within the stem
movements until the mercury line falls to so that it is less than the client’s potential
at least 95 ℉ (35 ℃). body temperature

Assist the client to a supine or sitting To provide easy access to axilla.

position.
Move clothing away from shoulder and To expose axilla for correct
arm thermometer bulb placement

Be sure the client’s axilla is dry.If it is Moisture will alter the reading. Under
moist, pat it dry gently before inserting the condition moistening, temperature is
the thermometer. generally measured lower than the real.

Place the bulb of thermometer in hollow To maintain proper position of bulb

of axilla atanterior inferior with 45 degree
or horizontally.
Keep the arm flexed across the chest,
close to the sideof the body
Hold the glass thermometer in place for 3
minutes
Remove and read the level of mercury of To ensure an accurate reading
thermometer at eye level.
against blood vessels in axilla
Close contact of the bulb of the
thermometer with the superficial blood
vessels in the axilla ensures a more
accurate temperature registration.
To ensure an accurate reading

Shake mercury down carefully and wipe To prevent the spread of infection
the thermometer from the stem to bulb
with spirit swab.

Explain the result and instruct him or her To share his/her data and provide care
if he or she has fever or hypothermia needed immediately

Dispose of the equipment properly. Wash To prevent the apread of infection

your hands.

Replace all equipments in proper place. To prepare for the next procedure

Record in the client’s chart and give  Axillary temperature readings usually
signature on the chart. are lower than oral readings.
 Giving signature maintains
professional accountability
Report an abnormal reading to the senior Documentation provides ongoing data
staff. collection