NCM 103L- FUNDAMENTALS OF NUSING (SKILLS LAB) BS NURSING (1ST YEAR – 2ND SEMESTER)

BATANGAS STATE UNIVERSITY – THE NATIONAL ENGINEERING UNIVERSITY

VITAL SIGNS TAKING

TEMPERATURE TAKING (AXILLA)
1. Introduce self and verify client’s identity. To alleviate fear and anxiety, thus promoting
cooperation.
To ensure that you are administering correct
procedure to right patient.

2. Explain the procedure to the client and discuss Explaining procedure reduces anxiety and fear thus
how results will be use. promoting cooperation from the patient.

3. Wash/sanitize hands Reduces transmission of microorganism.

4. Gather appropriate equipment. To facilitate systematic assessment and

measurement.

5. Provide privacy by drawing curtain around bed
and/or closing the door.
6. Assist patient to appropriate position (supine or
sitting position).
7. Move clothing or gown away from the shoulder
and arm.
8. Remove thermometer pack from package. Before
using, wipe the thermometer from the bulb down
to the stem.
To maintain client privacy and promote comfort.
To provide easy access to axilla.
To expose axilla for correct thermometer placement.
To remove chemical solutions, dust or dirt that may
irritate mucous membrane and to prevent spread of
microorganism.

9. Remove client’s arm and shoulder from sleeve of
gown. Avoid exposing chest. Make sure axillary
skin is dry; if necessary, pat dry with tissue.
10. Place the thermometer or probe into clear axilla.
Fold client’s arm across the chest.
To ensure an accurate reading since sweat or water
can alter the reading of temperature.
To maintain proper position of thermometer bulb
against blood vessel in axilla.

11. Leave digital thermometer in place until signal is To provide sufficient time for recording of the
heard. temperature.

12. Remove the thermometer and read the To ensure accurate reading.
temperature in eye level, discard the cover or To prevent cross contamination. Wipe from area with
cleanse with cotton balls with alcohol from the least contamination to area most contaminated.
stem to the bulb. Return thermometer in storage
position.
A. If gloves were applied, removed and discard
gloves. Perform hand hygiene.
13. Inform client of thermometer reading. To promote participation in care and understanding
of the status.

14. Assist client into comfortable position.

15. Wash/sanitize hands. To reduce transmission of microorganism.

16. Record the temperature to the graphing sheet. Serves as baseline data for health care providers.

PULSE RATE TAKING

1. Identify client and explain the procedure. To ensure right procedure to right patient.
To alleviate fear and anxiety, thus promoting
cooperation.

2. Perform hand hygiene. To reduce transfer of microorganisms.

3. Provide privacy if necessary.

4. Have the patient rest in his arms alongside of his
body with the wrist extended and the palm of the
hand downward.
5. Place the tips of your middle three fingers on the
palm side of the patient’s wrist. Rest thumb on
the back of the patient’s wrist
6. Apply enough pressure so that you can feel the
pulse (not too hard not too light).
7. Using a watch with a second hand count the
number of pulsations felt in the client’s pulse for
one full minute.
8. If the pulse rate is abnormal repeat the counting
in order to determine accurately its rate, quality
and rhythm.
9. Wash/sanitize hands.
10. Evaluate nature of pulse.
11. Record result rhythm and force in graphing sheet. To serve as baseline data for health care provider.
RESPIRATORY RATE TAKING
1. Assess client’s condition.
2. Check nature of respiration.
3. Wash/sanitize hands.
4. Identify client and explain the procedure.
5. Hold the client’s wrists just as if you were taking
his/her pulse.
6. Note the rise and fall of the client’s chest.
7. Using a watch with a second hand, count the
number of respiration for one full minute.
8. Wash/sanitize hands.
9. Evaluate the character of respiration.
10. Record the character and the depth of the
respiration.
BLOOD PRESSURE TAKING
1. Identify and explain procedure to the client.
2. Assess the client’s physical condition.
This position places the radial artery on the inner
aspect of the patient’s wrist.
Fingertips are sensitive to touch and will feel the
pulsation of the patient’s artery.
Thumb should not be used because it has pulse to
avoid confusion.
Pressing too hard may stop the flow of the blood and
you will not be able to feel the pulse.
Too little pressure will be imperceptible.
Sufficient time is necessary to detect irregularities
and abnormalities.
Repeating the count is necessary for accuracy.
For infection control measures.
To determine the appropriate position to be
performed on client.
To reduce transfer of microorganisms.
To ensure right procedure to right patient.
To alleviate fear and anxiety and promote
cooperation.
This way client is not conscious breathing is being
watched.
Awareness of respiratory rate assessment will cause
the client voluntarily to alter the respiratory pattern.
Complete cycle of inspiration and expiration
constitute one act of respiration.
Sufficient time to observe depth and the other
characteristics is necessary.
To reduce transfer of microorganisms.
So it will serves as a baseline data
To ensure the right procedure is done to client and
gain the client’s cooperation.
To ensure that the client is rested and to identify the
affected side of the client.
3. Assess for the factors that affect blood pressure.
4. Determine the client’s baseline blood pressure.
5. Wash hands.
6. Gather the equipment.
7. Place the client in a comfortable position (lying
or sitting) and position the arm at the level of the
heart.
8. Place the cuff at the center observing at least 1-2
inches above the inner aspect of the brachial
artery.
9. Wrap the cuff around the arm smoothly and
snugly.
10. Feel the pulse beat over the inner aspect of the
elbow with the use of finger tips.
11. Place the stethoscope earpiece and close screw
valve on the air pump.
12. Palpate brachial artery, turn valve clockwise to
close and compress bulb to inflate cuff to 30
mmHg above points where palpated pulse
disappears, then slowly release valve (deflating
cuff). Noting reading when pulse is felt again.
13. Release the valve (deflating) on the cuff slowly
so that the pressure goes down at the rate of 2-3
mmhg/sec. Listen to the sound (first distinct loud
muffling sound is systolic).
14. Continue to release the air evenly and slowly
(last soft muffling sound is diastolic pressure).
15. Deflate cuff rapidly and completely after the
final sound has disappeared.
16. Clean and store the equipment.
17. Wash/sanitize hands.
18. Evaluate the nature of the blood pressure.
19. Evaluate the client’s condition.
20. Record the results taken.
To decrease the transfer of microorganisms.
To promote the efficiency of the health care giver.
This position places the brachial artery on the inner
aspect of the elbow that a stethoscope disc can rest
on it conveniently. Having the arm above the level of
the heart causes a decrease in BP.
Pressure in the cuff apply directly to the artery will
give the most accurate readings. If the cuff get in the
way of the stethoscope disc on the anterior elbow,
readings are likely to be inaccurate. A cuff placed
upside down with the tubing toward the patients head
will give a false reading.
A smooth cuff and wrapping produce equal pressure
and give accurate reading. A cuff too loosely
wrapped will give inaccurate reading.
Having the stethoscope disc directly over the artery
makes more accurate reading, and having the
stethoscope disc firmly placed on the skin away from
clothing and the cuff prevents missing sounds.
Sounds are heard more clearly when the earpiece
follow the direction of the ear canal.
Lack of blood in patient’s arm may cause a
temporary tingling and numbing sensation
If the air is released too slowly from the cuff, there
will be congestion in the extremity causing false
reading and if it is released too rapidly sounds may
not be heard at accurate levels.
Diastolic is when the blood flows easily in the
brachial artery and it is approximately equivalent to
the amount of pressure normally present on the walls
of the arteries when the heart is at rest.
To release the remaining air from the cuff and
prevent congestion in extremity.
This method of removing dirt prevents possible cross
infection of the ears.
To prevent the transmission of microorganisms.
To serve as baseline data for health care provider.