ASSESSING BODY TEMPERATURE

Definition: It is a procedure used to take patient’s body temperature using a thermometer. The normal
body temperature of a person varies depending on gender, recent activity, food and fluid consumption,
time of day, and, in women, the stage of the menstrual cycle. A person's body temperature can be taken in
any of the following ways: Orally. Rectally. Axillary. By ear. By skin.
Purposes:
• To monitor and evaluate the clients body temperature
• To establish baseline data for subsequent evaluation and to determine if the
client is medically stable or in chronic condition
Principles:
• Check the thermometer for cracks. (Recommended non-hazardous
thermometer for safety disposal)
Equipment:
 Thermometer
 Cloth or Tissue
Procedure:
1. Wash hands before starting the procedure. Don gloves if performing a rectal temperature. To
reduce number of microorganism present in the hands.
2. Provide for client privacy.
3. Place the client in the appropriate position. (Sitting or supine position for oral and axillary, Sim’s
or lateral position for inserting a rectal thermometer).
4. Place the thermometer. (I am going to use the axillary method)
 Axillary – pat the axilla with cloth or tissue to dry if it’s moist. The bulb is placed in the center of
the axilla.
5. Wait for the appropriate amount of time.
6. Remove the thermometer and discard the cover or wipe with a tissue if necessary. To prevent
contamination.
7. Read the temperature and record it on your worksheet.
8. Wash the thermometer if necessary and return it to the proper place.
ASSESSING PERIPHERAL PULSE
Definition:
This procedure is used to measure the wave of blood created by the contraction of the ventricle using
pulse located away from the heart.
Locations of Pulses:
1. Peripheral Pulse: Pulse located away from the heart
2. Apical Pulse: Central pulse located at the apex of the heart
Purpose:
• To establish baseline data for subsequent evaluation
• To identify whether the pulse is within normal range.
• To compare the equality of corresponding peripheral pulses on each side of the body
• To monitor and assess changes in the client's health status
Principle:
• Palpate the radial pulse and count for at least 30 seconds. If pulse is irregular, count for full minute and
note the number of irregular beats per minute
Note: Whether the beat of the pulse against your finger is strong or weak, bounding, or thready.
Equipment:
• Watch with second hand
Procedure:
1. Wash hands. To reduce number of microorganism present in the hands.
2. Provide for client privacy.
3. Select the pulse point.
4. Assist the client to a comfortable resting position. For the clients who can sit, the forearm can rest
across the thigh, with the palm of the hand facing downward or inward.
5. Palpate and count the pulse. Place two or three middle fingertips lightly and squarely over the
pulse point.
6. Assess the pulse rhythm and volume.
7. Assess the pulse rhythm by noting the pattern of the intervals between the beats.
8. Assess the pulse volume. Record the rhythm and volume on your worksheet.
9. Make the patient comfortable and wash your hands. To reduce the number of microorganisms.
10. Document the pulse rate, rhythm, and volume in the client record.
ASSESSING RESPIRATIONS
Definition:
This procedure is used to determine any abnormalities of the lungs during breathing. It must be
performed when the patient is relaxed because exercise affects respiration, increasing rate and depth.
The normal respiration is 16-20cpm.
Purpose:
• To acquire baseline data against which future measurements can be composed
• To monitor abnormal respiration and respiratory patterns and identify changes
• To monitor clients at risk for respiratory attention
Principle:
• Make sure your patient is at rest
Equipment:
• Watch with second hand
Procedure:
1. Wash hands before starting the procedure. To reduce number of microorganism present in the
hands.
2. Provide for client privacy.
3. Observe or palpate and count the respiratory rate.
 The client’s awareness that the nurse is counting the respiratory rate could cause the client to
alter the respiratory pattern.
 Count the respiratory rate for one full minute. An inhalation and an exhalation count as one
respiration.
4. Observe the depth, rhythm, and character of respirations.
 Observe the respirations for depth by watching the movement of the chest.
 Observe the respirations for regular or irregular rhythm.
 Observe the character of respirations – the sound they produce and the effort they require.
5. Make the patient feel comfortable and wash your hands. To reduce the number of
microorganisms.
6. Document the respiratory rate on the client’s record.
ASSESSING BLOOD PRESSURE
Definition:
This procedure is done to measure the pressure against arteries of the client. Measured in millimeters of
Mercury (mmHg) Systolic pressure is written over the diastolic pressure Average adult BP: 120/80 mm
Hg.
Purposes:
 To obtain a baseline measure of arterial BP for subsequent evaluation
 To determine the client's hemodynamic status
 To identify and monitor changes in BP
Principles:
• The procedure must be done first in the morning before eating or taking any medication
Equipments:
• BP cuff
• Sphygmomanometer
• Stethoscope
Procedure:
1. Wash hands. To reduce number of microorganism present in the hands.
2. Provide for client privacy.
3. Position the client appropriately.
 The adult client should be sitting unless otherwise specified. Both feet 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 heart level.
4. Wrap the deflated cuff evenly around the upper arm. Locate the brachial artery. Apply the center
of the bladder directly over the artery.
5. If this is the client’s initial examination, perform a preliminary determination of systolic pressure.
 Palpate the brachial artery with the fingertips.
 Close the valve on the bulb.
 Pump up the cuff until you no longer feel the brachial pulse.
 Release the pressure completely in the cuff, and wait 1 to 2 minutes before making further
measurements.
6. Position the stethoscope appropriately.
 Cleanse the earpieces with antiseptic wipe.
 Insert the ear attachments of the stethoscope in your ears so that they tilt slightly forward.
 Ensure that the stethoscope hangs freely from the ears to the diaphragm.
 Place the bell side of the amplifier of the stethoscope over the brachial pulse site.
 Place the stethoscope on the skin, not on clothing over the site.
 Hold the diaphragm with the thumb and index finger.
7. Auscultate the client’s blood pressure.
 Pump up the cuff
 Release the valve on the cuff carefully
 As the pressure falls, identify the manometer reading at Korotkoff phases.
8. Deflate the cuff rapidly and completely.
 Wait 1 to 2 minutes before making further determinations.
 Repeat the above steps to confirm the accuracy of the reading.
9. If this is the client’s initial examination repeat the procedure on the client’s other arm.
10. Make the patient feel comfortable.
11. Clean the earpieces of the stethoscope. To prevent contamination.
12. Do the aftercare of the equipment and wash your hands. To reduce number of microorganism
present in the hands and transfer of microorganisms.
13. Document the BP reading on the client’s record