Name : F. X.

Risal Maru

NIM : 2021013

Taking and recording a full set of vital signs which includes temperatur pulse respirations and
blood pressure.

Nurse : Knock knock hello mrs. Smith

Mrs. Smith : Hello
Nurse : my name is Lisa and i’m going to be your CNA today and iam came to take a
set of vital signs okay
Mrs. Smith : okay
Nurse : i’m going to go wash my hands before get started and provide privacy and i
will be right with you so i’m going to wash my hands i’m going to provide
privacy and for my supplies i’ve got a thermometer i’ve got a blood presure
cuff and a stethoscope and i have a watch with a second hand okay i think
that’s it so i’m going to go ahead and position, mrs. Smith here she’s laying in
the bed she’s semi soup semi fowler’s position that’s fine are you comfortable
okay.
Mrs Smith : yes
Nurse : so let me start with go ahead i’m going to take your temperature first okay.
Mrs. Smith : Okay
Nurse : so with the digital thermometer i’m going to remove the probe until it wait
for it to beep i’m going to place the probe cover on to push down kind of hard
to get it to to snap on okay and then go under your tongue okay until the
thermometer beeps very good 97.9 i’m going to degrees fahrenheit i’m going
to go ahead and get rid of my probe in the trash can right over here just just
push the button and it pops off okay i’m going to place that back in the holder
and i’m going to document her temperature ninety seven point nine and i also
want to document the site that was an oral temperature someone write oral
next to that okay now i’m going to do your pulse and respiration okay mrs.
Smith
Mrs. Smith : Okay
Nurse : allright so i’m going to go ahead and find her radial pulse it’s on the anterior
side of the the thumb side of the anterior wrist and i’m going to fill it with two
to three fingers you never want to feel the pulse with your thumb so i’m going
to use my fingertips here and i’m also going to go ahead and turn your palm
prone you can do it with the palm up or down just whatever you prefer
whatever is most comfortable is this okay for and scream okay.
Mrs. Smith : okay
Nurse : Thank you
Nurse : allright i’m going to count her radial pulse of one full minute i’m going to
use this clock over here so when i i’m pulse for one full minitu i’m going to
use this clock over here so when i i’m going to start when it gets to the 12 and
then when it comes back around to the 12 after one full minute i’m going to
count her respirations so one inhale wonderful inhale and exhale is one so i’m
going to count pulse for one minute respiratons for one minute you just relax
thank you mrs. Smith. Okay thank you mrs. Smith accountant her pulse rate at
63 beatsper minute and your respiratory rate is 15 now when i record those i
don’t have to write 63 beats per minute i just write 63 and it’s understood that
that’s for one full minute and what i’m feeling for with the radial pulse is
every time i feel the pulse hit my fingertips that’s one beat okay so between 60
and 100 is normal average for an adult so that looks that’s good um respiratory
rate i counted 15 a full inhale and a full exhale as one i counted 15 anywhere
between 12 and 20 would be normal for an adult so if it was anything less than
12 or greater than than 20 i would go ahead and report that to the nurse okay
the last thing we’re going to do is takeyour blood pressure okay.
Mrs. Smith : Okay
Nurse : allright so to do blood presure the first thing i want to do is um you have my
equipment ready and i’m going to go ahead and clean my stethoscope to be put
together, okay so i’m going to clean the earpieces some alcohol and i’m also
going to clean the diaphragm of tge stethoscope the diaphragm is the larger
side and the bell side is this other side here okay so that in the trashcan.
Allright so this is ready got my blood pressure cuff here i’m going togo ahead
and find your brachial pulse okay the brachial pulse i always start right in the
center of the antecubital space again don’t use your thumb use your fingertips
and i’m going to start in the center here and then a bit like the inside of the
elbow and then i’m going to work my may inside and it is a deeper artery so
i’m going to have to push push down a little harder to to feel that to palpate it
okay i’m feel that to palpte it okay i’m going to line up on my blood pressure
cuff the artery marker here this is mrs. Smith’s left arm so i’m going to line up
the artery marker with where i felt that brachial pulse okay very good thak you
just straight your arm there for me and i’m going to place this cuff around it i
want it to be snug and i want it to be pretty straight okay very good allright and
i want the bottom of the cuff here to be about and inch above the bend in the
honor the antecubital space, okay ready ?
Mrs. Smith : ready
Nurse : okay and i make sure you can see everything here and i’m actually going
reposition myself just a little bit now when you put this stethoscope in your
ears you do want to make sure that the earpieces are angled forward or toward
your patient and i’m going to give this a little tap to make sure it is on the
loudest side because it will you can turn it and click it and turn it off on this
side where it’s on the belt side but we’re going to use the diaphragm with a
larger side and that sounds good okay i’m going to place this antecubital space
and if you’ll make sure your tubing isn’t going to rub or touch that will really
decrease on the extra sounds now i’m going to pump this up i don’t know what
mrs. Smith’s blood pressure normally runs so i’m going to go ahead and pump
up the blood pressure cuff or the sphygmomanometer to about 180 millimeters
 of mercury and then i’m going to slowly with my valve here i’m going to start
with it turned off just until it stops pump it up to 180 slowly release the air and
i want my needle to drop slow and steady about five to ten millimeters of
mercury per secoond okay so it’s pretty slow – you have to fairly slow to be
accurate but we do want to steady drop of the needle, okay are you ready mrs.
Smith?
Mrs. Smith : Ready
Nurse : this is going to squeeze you arm just a bit but it’s only going to last a few
seconds okay
Nurse : okay 120 over 82 allright go ahead remove this blood pressure cuff thank you
i’m going to record the result as a fraction 120 over 82 and also want to date
tie this and i’m going to record that in mrs. Smith’s chart, allright i’m going to
go ahead and clean this stethoscope pne more time after using it to make sure
that it’s clean for the next person if they do in case they do forget to clean it
before they use itis there anything else that do you need anything right now
mrs. Smith ?
Mrs. Smith : No
Nurse : are you comfortable ?
Mrs. Smith : yeah
Nurse : okay well thanks for letting me take your vital signs
Mrs. Smith : thank you
Nurse : and i’m going to go ahead and store these sipplies and i’m to wash my hands
before i leave the room and i’m going to unprovided privacy open the cutain
back up and i’m going to go document in her record her vital signs and if
there was anything abnormal outside of the normal range i’d report that to the
nurse immediately okay thank you
Mrs. Smith : thank you