CONDUCT OF PHYSICAL EXAMINATION

REMINDERS
Before entering patient’s room and before any procedure:
1. Read, check, browse over patient’s chart
2. Know patient’s name, age, gender, room and bed number, admitting diagnosis and
attending physician
3. Make sure you have prepared and gathered all needed materials and tools which are to be
utilized during your patient assessment or visit
4. Knock at the door, greet your patient with a smile
5. If a sink is available in the patient’s room, you may perform medical handwashing
6. If none, you may proceed to handrubbing with the use of a hand alcohol sanitizer or gel
(Hand hygiene and the 5 moments of handwashing should always be observed)
7. Introduce yourself to the patient and the watcher to establish rapport
8. Request patient to state/give her full name, and discreetly confirm his/her identity by taking a
look at the wrist band as a valid identifier
9. Make patient feel comfortable and relaxed
10. Obtain a signed informed consent (if an invasive procedure is to be done)
11. If not, state and explain the purpose of what you are about to perform and ask permission
from the patient in a tactful manner
12. Be respectful, kind, patient and understanding at all times

I. GENERAL SURVEY
Observe for: - race, sex
- general physical development
- nutrition state
- mental state (oriented, disoriented, confused, responsive,
unresponsive, incoherent, somnolent, unconscious)
- evidence of pain, restlessness
- body position, stature, gait
- clothes, age, hygiene, grooming
- emotional status, including attitudes or mood
- apparent state of health, in acute distress or chronically ill
II. VITAL SIGNS AND CLINICAL MEASUREMENT
Include actual body weight, height, temperature, blood pressure (BP), pulse rate (PR),
respiratory rate (RR), and heart rate (HR)

III. SKIN
Observe for:

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 1. Color - cyanosis, pallor, jaundice, flushing, pigmentation
2. Lesions - macule, papule, etc. (distribution type, configuration, size)
3. Vascularity - evidence of bruising, bleeding, edema, vascular and purpuric lesions
(angioma, purpuras, petechiae)
4. Moisture - dryness, sweating, oiliness
5. Texture - rough, smooth, scaly
6. Temperature - warm, hot, cold
7. Mobility and turgor - firm, loose, wrinkles, edematous, turgid, skin rapidly resumes its
original shape; loss of turgor is indicated by the persistence of the skin fold for a time-
pinching.
8. Hair and nails - brittleness, presence or absence, quality, quantity, and distribution
IV. HEAD- normally the skull and face are symmetrical, with the distribution of hair varying from
person to person.

1. Hair - quantity and distribution,

2. Texture - dry, brittle, luster, color
2. Scalp - lice, dandruff, lesions, lacerations, tenderness, or swelling
3. Skull size, contour, configuration, depression
4. Face - portrays emotions, pain intelligence and understanding
Observe for:
a. expression- flat, expressionless, wide-eyed, confused or quizzical
expression, angry, excited
b. Symmetry
c. Edema
d. Masses
e. Involuntary movements - tics, spasmodic contractions
f. Shape - round, oval, triangular
g. Skin - color and pigmentation

5. Forehead-smooth, furrowed with wrinkles

6. Eyes - general expression, use of supportive aid such as contact lenses. eyeglasses.
a. Eyebrows - quality of hair, presence of flakes, scars, lesions, etc.
b. Eyelids - lid margins are normally clear, and the lacrimal duct opening (puncta) is
evident at the nasal side of the upper and lower lids.
Observe for:
- Height of palpebra! fissures (longitudinal openings between the
eyelids which appear equal in size when the eyes are open)
- Blinking reflex
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 - Presence of edema, hemorrhage, hematoma
- Color - redness, cyanosis
- Direction of lashes (outward, inward)
- Lid eversion or inversion

c. Bulbar and palpebral conjunctiva

- Color (pale, pink, red) - growths or lesions

d. Sclerae - clear color pigments

e. Cornea and lens - check transparency, opacities, ulcerations, scratches
f. Iris - color
g. Pupil - normally constricts with light and when looking at near objects and dilate in the
dark and when looking at far objects. They are round and can change in size from
very small (pinpoint) to large (occupying the entire space of the iris)
h. Eyeballs
- position and alignment
- the prominence of eyeballs
- sunken, bulging - eye movement
*extraocular movement - the movement of the eyes in conjugate fashion

*nystagmus - rapid, lateral horizontal or rotary movement of the eye;

maybe normal as a result of fatigue

*strabismus - deviation of one eye so that the visual axis is no longer

parallel to that of the other eye

i. Convergence - the ability of the eye to turn in and focus on a very close object

7. Ears – symmetry
a. Pinna - observe for size, shape, color, lesions, masses, swelling - discharge -
whether serous, purulent, sanguineous; observe odor, tenderness and
consistency of the cartilage
b. External canal - normally clear with perhaps minimal cerumen - examine for
discharge; impacted cerumen; inflammation; masses, foreign bodies, etc.
c. Tympanic membrane - examine for color, luster, shape, position, transparency,
integrity, and scarring
d. Auditory acuity - distance within which one can hear spoken words or a watch
tick (occlude one ear at a time when testing). A person with normal hearing can
hear whispered words from approximately 4.5 meters (15 feet and a watch tick
from 30 cm (1 foot)
e. Response to mechanical tests.

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 - Weber test - test for lateralization of vibration
- Rinne's test - compares air and bone conduction
8. Nose - inspect the external surface of the nose for symmetry color, shape, size
9. Mouth
a. lips - color, moisture; masses; ulceration; fissures; lesions; edema; congenital
defect
b. teeth - number (23 adult); arrangement; general condition; carries;
discoloration; fillings; absence of one tooth or more; abnormal dental shape and
use of artificial teeth
c. gum - color; texture; swelling; retraction; bleeding; lesions
d. buccal mucosa - normally the mucosa should be pink, smooth and fine lesions
f. hard palate and soft palate; uvula - observe for ulcerations congenital defects
and symmetry when the patient says "ah"
g. tonsils-size, ulcerations, exudates; inflammation
h. odor or breath - ability to masticate and swallow. Odor - use of tobacco or
alcohol, poor dental hygiene; gingivitis, acetone breath - for a diabetic coma,
musty odor for severe liver disease; urinary odor - for uremic status.
10. Pharynx - for inflammation; exudates and masse.
11. Larynx - voice (hoarseness) and disorder of speech.
V. NECK
a. Inspect all the areas of the neck anteriorly and posteriorly for muscular symmetry,
masses, unusual swelling or pulsations and range of motion - which includes right and
left lateral, right and left rotation, reflexion, extension, and hyperextension. The neck
should move easily without any discomfort.
b. Thyroid - inspect enlargement; which may not be visible, especially in extremely thin
persons. If palpable, it is not normal smooth, without nodules, masses or irregularities or
bruits (gushing sound) produced by blood moving through a narrow vessel.

c. Trachea - palpate for deviation

d. Lymph nodes and salivary glands - cervical nodes - not normally palpable unless the
patient is very thin.
e. Carotid arteries lying at 30 to 40 degrees angle; neck should not be flexed.
f. Observe for any limitation of movements (e.g. torticollis)
VI. BREAST
a. nipples and areolae - position, pigmentation, inversion, discharge, crusting and
masses.

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 b. breast tissue - size, shape, color, symmetry, surface, contour, skin, characteristics,
level of breast; note for any retraction or dimpling.
c. axilla - rashes, infection, lymph nodes
VII. CHEST AND LUNGS
A. Inspection
Observe for:
- Symmetry of the posterior chest and the posture and mobility of the thorax upon
respiration, retraction of intercostals in bring spaces.
- Note the anteroposterior diameter in relation to the Internal diameter in relation to the
lateral diameter of the Chest.
Normal findings
- Thorax is symmetrical, it moves easily and without impairment upon registration. There
are bulges in retracted intercostal spaces.
- The AP diameter of the thorax in relation to the lateral diameter is approximately 1:2.
- Examine for skin lesions, masses, cyanosis.
- Respiratory rate and rhythm - regular, irregular, noisy, deep, fast, slow.
- Presence of:
Dyspnea - exertional, paroxysmal, nocturnal, orthopnea
Cough- single or paroxysmal
Cough- single or paroxysmal
• Unproductive cough short, sharp, no production of sputum
• Productive cough - sputum is raised with rattle and distinctive sound brassy
when it is unproductive and has strident quality
- whooping - characterized by long strident,
• Hemoptysis - spitting or coughing up blood
• Describe sputum - color, amount, odor, time of day
• Hiccup or hiccough - sudden involuntary diaphragmatic contraction producing
an inspiration interrupted by glottial closure with a characteristic sound
- rib cage – shape, e.g. funnel, barre!
- presence of tubes and drainage
- spinal deformities:
• Scoliosis - abnormal lateral curvature of the spine
• Lordosis - the normal anterior lumbar curvature is exaggerated

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• Kyphosis - exaggerated of the normal thoracic convexity

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 B. Palpation
1. Palpate the ribs and costal margins for symmetry, mobility and tenderness and
the spine for tenderness and vertebral position.
2. Areas of tenderness, masses, inflammation.
3. Fremitus - sensation felt by the hand when place on the part.
- ask patient to say '99' posteriorly, it is generally equal throughout the lung
fields. It may be decreased or absent anteriorly, when posture is not erect, or
when excessive tissue or underlying structures are present.
4. Crepitation - fine cracking feeling due to air in the soft tissue, as in subcutaneous
emphysema.
5. Pleural friction rub - it is leathery or grating feeling resulting from rubbing one
pleural surface against another and is due to the presence of inflammation or
absence of adequate lubricating fluid.
C. Percussion
- detect changes from normal density of the organ
- resonance: dull, flat tympanitic
D. Auscultation - must be done systematically and symmetrically in a top to bottom
direction.
- quality of breath sound; clear, coarse, diminished, absent
- rales - sound in the lung from the movement of fluid or exudates in the
airway or passage of air through constricted tube
a. coarse rales or rhochi or gurgling of fluid or exudates in the airway or
passage of air through constricted tube
b. moist, medium, crepitant rales - arises from relatively thin fluid moving
in bronchi or bronchioles
VIII. HEART
A. Inspection
- Inspect for bulging, heavy or thrusting in the pericardium
- Note of pulsation
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 - Pericardial bulge - protrusion of bony thorax once right ventricle hypertrophies
due to enlargement from CHF

B. Palpation
- location of apical beat - note also rate, rhythm, duration
- presence of:
• Thrills - palpable murmur - fine buzzing sensation similar to that felt while a
purring cat
• Note size and force of PMI (point of maximal impulse)
C. Percussion
- define cardiac borders or area of cardiac dullness
D. Auscultation
- count cardiac rate, note cardiac rhythm - regular, irregular, rapid, slow
(tachycardia, bradycardia)
- abnormal beats-bigeminal, trigeminal, premature, missed - palpitations -
pounding, fluttering, missing, stopping
- murmurs - turbulent blood flow, note pitch, quality, grade loudness radiation

IX. ABDOMEN
A. Inspection
- be sure patient has an empty bladder, lying comfortably and abdomen fully exposed.
1. Observe the general contour of the abdomen - flat, protuberant, scaphoid,
concave, local bulges, symmetry, visible peristalsis aortic pulsations.
2. Umbilicus - contour, hernia
3. Skin - scars, rashes, lesions, pigmentation, etc.
B. Auscultation
- abdomen has the familiar "growling" sound, it has 5-35 bowel sounds per minute.
There should be no rubs or bruits.
1. bowel sound - pitch, duration, absence, increase, gurgling
2. bruit - aorta and renal arteries-abnormal blood flow
C. Percussion
- note tympani and dullness (tympani normally predominates)

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 - masses; fluids levels
D. Palpation (light)
- determine muscle tension and resistance, tenderness and superficial masses or organ
enlargement
- skin fold test for dehydration

E. Palpation (deep)
- Masses - size, shape, consistency, mobility, location
- Abnormal distention - 6 fs - fluids, fat, flatus, fetus, feces, fetal growths.
- Area of tenderness, deep and rebound tenderness
- Palpable organs: liver, kidney, cecum, and abdominal aorta
- Lymph nodes - inguinal and femoral areas
Note: Palpation is not done in the abdomen if contraindicated (e.g. aortic
aneurysm)

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X. GENITO – URINARY
- Observe the distribution of pubic hair, size, shape, color lesion, edema nodules
- Penis size, location, and placement of urethral meatus, discharge, lesions
- Scrotum - size, contour, skin color, lesions, symmetry, shape, tenderness
- Inspect mons pubis, labia majora, perineum, distribution of public hair, inflammation,
swelling, lesions, and growths.

- Separate labia and inspect vestibule - note inflammation, swelling, lesions,

discharges, atrophy, abnormal odor, clitoris, urethral opening, vaginal introitus

- Groin - note any scars, lesions, enlarge lymph nodes, hernia, bulging
-Rectum-perineal region - any discoloration, inflammation, skin lesions, scars,
tissues, fistula, hemorrhoids

XI. EXTREMITIES
Upper limb
• Shoulder and arms - inspect for swelling, deformity, atrophy, or symmetry palpate
sternoclavicular joint at the sternum, grooves, and head of the humerus for
tenderness, nodules, and fluid (note: range of motion).
• Elbows - note for swelling, nodules, and deformities, observe a range of motion.
• Forearms flex, extended, supinate, pronate - note range of motion; pain
• Hand and Wrist -inspect missing deformed fingers, contractures, swelling redness,
pallor, bone enlargements, nodules, atrophy, and tremors.
- Condition of hand - callused, strained, scarred, soft, well-manicured.
- Palpate all bones of the wrist, hands, and fingers for tenderness or nodules
• Nails - color, shape, deformities, lesions
Lower Limb
• Hip joint and thigh - range of motion, any pain tenderness; is one leg longer than the
other, any deformities, scars, amputation.
• Leg and knees - range of motion, deformities, edema, inflammation
• Foot - deformities (clubfoot, Flatfoot), alignment, tenderness, range of motion of ankle
joint
• Nails - color, deformities, lesions

VITAL SIGNS OR CARDINAL SYMPTOMS

TEMPERATURE

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Definition
It is the degree of heat of the body measured according to some chosen scale. It is the balance
between heat produced heat lost by the body.

Three Common Methods:

1. Oral
2. Rectal
3. Axillary

Rarely Used Methods:

1. Vaginal
2. Groin

Normal Body Temperature:

1. Oral 37°C (98.6°F)
2. Rectal 37.5°C (99.5°F)
3. Axillary 36.7°C (98°F)
4. Esophageal 37.3°C

Formula In Converting °F To °C And °C To °F

1. °C = 5/9 (°F – 32)
2. °F = (9/5 x °C) +32

NOTE:
Variations occur in each individual and a range of 0.3° to 0.6°C (0.5°F to 1.0°F) from the
average normal temperature is considered to be within normal limits. Newborns and young
children normally have a high body temperature than adults.

PARTS OF THE THERMOMETER:

Digital Clinical Thermometer

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Precautions:
1. Stand in a good light to read a thermometer most accurately.
2. Pick up the thermometer at the stem of shaft, never on the bulb, since this is the part
that goes in to the patient’s mouth; hold the thermometer between thumb and index of
forefinger on the level of your eyes.
When using a glass thermometer
1. Notice the lines and figures on the glass tubing or (stem calibration).
2. Turn the ridge edge toward you; look for the column of mercury between the lines of
the figures.
3. Read the scale to include the degree (long bold line) and the nearest 2/10 (0.2) of a
degree (short line) you may need to roll the thermometer slowly back and forth to find
the mercury.
NOTE:

12
Do not be discouraged if you cannot read the thermometer quickly. Skill in reading at a glance is
developed after a long practice.
A. ORAL METHOD
Contraindications:
1. Unconsciousness, irrational or confused patients
2. Mentally ill or depressed patients
3. Small children and infants
4. For patients who breathe through their mouth
5. Those patients who cough frequently
6. Those with diseases of the oral cavity and surgery of the nose or mouth
7. Those who are too weak or ill to hold the thermometer in the mouth
8. Those who have dentures
9. Those who have taken cold or warm foods or fluids (less than 30 minutes before
temperature is to be taken)
Equipment:
Articles required depend on the practices in the work situations. In some agencies, the patient is
issued his own thermometer on admission. This is stored in the patients’ room in individual
holder with antiseptic solution.
If thermometers are requisitioned (one for each patient) from central services or kept in the
utility room of the nurse’s station.
Equipment:
1. Tray containing:
a. 2 containers for thermometers
(1 container with antiseptic solution, 1 labeled “SOILED ORAL”)
b. Thermometer
c. Paper wipes (2)
d. Waste receptacles for used wipes
e. Record form (TPR sheet or pocket notebook)
f. A watch with second hand
g. Pen

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Purpose: To measure body temperature
Procedure:
Important Steps Key Points-Rationale
Wash your hands. Handwashing deters the spread of
microorganisms.
Bring the tray to the bedside and explain When the patient knows what is to be
the procedure to the patient. done, his cooperation will be gained
easily.
Since the thermometer has been stored in Wiping from an area where there are few
a chemical solution; wipe it by using CB organisms may be present minimizes the
with water in a firm twisting motion from spread of organisms to the cleaner area.
the bulb to the shaft and dry using same
motion.
Grasp the thermometer firmly with thumb A construction in the mercury line near
and forefinger. (For glass thermometer, the bulb of the thermometer prevents the
with strong wrist movement shake the mercury from dripping below the last
thermometer until the mercury line temperature reading unless it is shaken
reaches lowest marking (35°C or 94°F)) down forcefully.
Read the thermometer by folding it Holding the thermometer at eye level
horizontally at eye level, and rotate it facilitates reading. Rotating the
between the fingers until the mercury line thermometer will aid in placing the
can be seen clearly. (when using glass mercury line in a position where it can be
thermometer) read best.
Place the bulb of the thermometer under Where the bulb rest against the
the patient’s tongue and instruct him to superficial blood vessels under his tongue
close his lips tightly. and the mouth is closed, a measurement
of the body temperature can be obtained
more accurately since it prevents to the
cool outside air from influencing the
temperature reading.
Leaving the thermometer for 3 minutes or Allowing sufficient time for oral tissues to
until the beep signal is heard. reach their maximum temperature results
in a more clearly accurate measurement
of body temperature.
Remove the thermometer and wife it at Cleansing from the least contaminated
once by dry CB from the stem to the bulb area to the more contaminated area
using a firm twisting motion. prevents the spread of microorganisms to
clean area. Friction helps to loosen matter
from a surface.
Dispose paper wipes in waste receptacle. Confining contaminated articles helps to
reduce the spread of pathogens.
Read the thermometer (shake the glass Recording temperature reading at once
thermometer until the mercury line after taking does not give room for
reaches the lowest marking). Place the confusion and forgetting.
thermometer in a container labeled Example:
“SOILED” and record reading on pocket T - 37.6°C
notebook and TPR sheet. P - 84
R - 20

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B. AXILLARY METHOD
Used only when both oral and rectal methods are contraindicated.
This is less reliable, so extra care must be used.
Equipment:
Same as oral with the addition of towel
Important Steps
Bring the preparation to the bedside and
explain the procedure to the patient.
Do step 2 to 5 of oral method.
Pat axilla with patient’s towel so that it will
be free from moisture. Place the
thermometer well into the axilla with bulb
directed to towards the patient’s head.
Bring the patient’s arm close to the body
for forearm over his chest.
Leave the thermometer in place for 9
minutes. Or until the beep signal is heard.
Key-Points Rationale
Cooperation is gained easily when the
patient understands what is to be done to
him.
Oral solution will irritate the skin and the
presence of solution may alter the skin
temperature. All other information same
for steps mentioned.
When the bulb rests against the
superficial blood vessels in the axilla and
the skin surfaces are brought together to
reduce the amount of sir surrounding the
bulb and reasonably reliable
measurement of the body temperature
can be obtained.
Allowing sufficient time for the axilla
tissues to reach its maximum temperature
accurate measurement of body
temperature.

C. RECTAL
Temperature taken in this method is the most accurate. This method is used in infants, children,
and weak, irrational unconscious or patients falling under the category of oral method
contraindications.
Contraindicated For:
1. Patient’s having rectal surgery.
2. Patient’s having diarrhea.
3. Patient’s having diseases of the rectum.

Precautions:
1. Plan your temperature taking assignment in such a way that all temperature by mouth will
be taken before you start taking those by rectum for aesthetic and aseptic reason.
2. Never dip the thermometer into a jar of lubricant because you will contaminate (infect with
pathogenic organisms or other impurities) the content of the jar making it unfit for use with other
patients. Use spatula to take jelly and transfer it to paper wipes or tissues.

15
Equipment:
Same as the oral method with the addition of:
1. Jar of Vaseline.
2. Rectal thermometer instead of oral thermometer.
Procedure:
Important Steps
Wash your hands.
Wipe, read, and shake thermometer as
suggested procedure for obtaining an oral
or axillary temperature.
Lubricate the bulb of the thermometer an
area approximately 1 inch above the bulb,
using a small lubricating jelly (K-Y),
mineral oil or Vaseline on the tissue wipe.
Put it on the tray.
Screen the patient, position him in Sim’s
lateral position. Drape upper bed cover
and separate buttocks, exposing only the
rectal area. Let someone help you if
patient is restless, unconscious and
weak.
With the hand gently lift the upper
buttocks to exposure anal opening
clearly. Ask patient to take a deep breath,
with the other hand holding the
thermometer, insert lubricated bulb about
1 ½ inch very carefully for 2 minutes.
Lubricate the bulb of thermometer an
area approximately 1 inch above the bulb,
using a small lubricating jelly (K-Y)
mineral oil or Vaseline on the tissue wipe.
Put it in the tray.
Remove the thermometer, wipe it with
tissue paper from the stem, to bulb in
twisting motion, then read, and keep
reading in mind.
Shake, discard wipes in waste receptacle
and place thermometer to SOILED
container.
Wash hands and dry, then record reading
on pocket notebook or TPR sheet.
Do your after care of used articles.
Key Points- Rationale
Cooperation is gained easily where the
patient understands what is to be done to
him.
Lubrication reduces friction, and thereby
facilitates insertion of the thermometer
and minimizes irritation of the mucous
membrane of the rectal canal.
Avoid unnecessary exposure; the other
patients are not used to this procedure.
This will make the anal opening clearly
visible for ease in insertion.
If not placed into the anal opening the
bulb of the thermometer may injure the
sphincter or hemorrhoid if present.
Lubrication reduces friction and thereby
facilitates insertion of the thermometer
and minimizes irritation of the mucous
membrane of the anal canal.
Cleansing from an area of lesser to
greater contamination minimizes the
spread of organisms.
Confining contaminated articles helps
reduce the spread of pathogens.
Washing after handling rectal
thermometer maintains asepsis.
Spread of pathogens is minimized if
immediate cleaning and disinfecting of
used articles is always done immediately.
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PULSE
Definition
It is a regular beating or throbbing caused in the arteries by each ventricular contraction.

Equipment:
a. Watch with second hand
b. Paper and pencil

Common Sites for Taking the Pulse:

a. radial artery e. femoral artery
b. facial artery f. popliteal artery
c. temporal artery g. carotid artery
d. dorsalis pedis h. posterior tibials

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 PULSE SITES

What to note while taking the pulse:

a. rate c. tension or compressibility
b. rhythm or regularity d. volume

Normal pulse rate per minute:

Newborn – 130-140 Adult Male: 70-80 beats/minute
First year – 115-130 Female: 80-90 beats/minute
Second year – 100-115
Seventh year – 85-90

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Purpose: To count the number of times the heart beats per minute and to obtain an estimate of
the quality of heart’s action.

Procedure:
Suggested Actions
Have the patient rest his arm alongside of
his body with the wrist extended and the
palm of the hand downward, or place arm
on top of the patient’s upper abdomen,
Place the first, the second and the third
fingers along the radial artery and press
gently against the radius rest the thumb
on the back of the patient wrists.
Apply enough pressure so that the
patient’s pulsating artery can be felt
distinctly.
Using a watch with second hand, count
the number of pulsation felt for one full
minute.
If the pulse rate is abnormal in any way,
repeat the counting to determine
accurately, the rate, the quality and the
volume.
Record pulse rate on pocket notebook.
Principles
This position places the radial artery on
the inner aspect of the patient’s wrist. The
nurse finger rest conveniently on the
artery with thumb in opposition on the
outer aspect of the patient’s wrists.
The fingertips which are sensitive to touch
will free the pulsation of the patient’s
radial artery. If the thumb is used to
palpating the patient’s pulse the nurses
may feel her won pulse.
Moderate pressure allows the nurse to
feel the superficial artery expand and
contract with each heartbeat.
Sufficient time is necessary to detect
irregularities or other defects.

RESPIRATION
Definition
It is the continual process of drawing in and spelling air from the lungs.

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Equipment:
a. Watch with second hand
b. Paper and pencil
Normal rates of respiration:
1. Infants: 30 – 40/minute
2. Children: 20 – 25/minute
3. Adult: 16 – 20/minute
Purpose: To obtain the respiratory rate per minute and estimate the patient’s respiratory
status.
Procedure:
Important Steps Key Points-Rationale
While the fingertips are still in place after Counting the respiration while presumably
counting the pulse rate, observe the still counting the pulse keep the patients
patient’s respiration. from becoming conscious of his breathing
and possibly altering his unusual rate.
Note the rise and fall of the patient’s chest A complete cycle of inspiration and
with each inspiration and expiration. This expiration constitutes one act of
observation can be made without respiration.
disturbing the patient’s bedclothes.
Using a watch with second hand, count A complete cycle of inspiration and
the number of respiration for one whole expiration constitutes one act of
minute. respiration.
If respirations are abnormal anyway,
repeat to determine accurately the rate,
the characteristics of the breathing.
Record respiration on pocket notebook
and TPR.

BLOOD PRESSURE
Definition
Blood pressure is the force exerted by the blood against the walls of the vessels during
ventricular contraction.

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Purpose:
1. As an aid in diagnosis
2. As a means of observing changes in a patient’s condition

Sites for taking Blood Pressure:

1. Either arm on the antecubital space.
2. Either leg on the popliteal space.

Equipment:
1. Stethoscope
2. Sphygmomanometer
a. Mercurial/Baumanometer
b. Aneroid

Normal Blood Pressure:

1. Adults 110 – 149 mm Hg Systolic 60 – 90 mm Hg Diastolic
2. Children 60 – 90 mm Hg Systolic 40 – 60 mm Hg Diastolic
3. Infants 50 – 80 mm Hg Systolic 40 – 58 mm Hg Diastolic

Procedure:
Important Steps
Place the patient in a comfortable position
with the forearm supported and the palm
upward.
Place yourself so that the meniscus of the
Key Points-Rationale
This position places the brachial artery so
that a stethoscope can rest on it
conveniently in the antecubital area.
An accurate reading is obtained when the
21
mercury can be read at eye level and no
more than 3 feet away.
Place the cuff so that the inflatable bag is
centered over the brachial artery, (it lies
midway between the anterior and of the
arm) so that medical aspects lower edge
of cuff is 2cm above antecubital fossa.
Wrap the cuff smoothly the arm and tuck
end cuff securely under preceding
wrapping.
Use the fingertips to feel a strong
pulsation on the antecubital space
Place the stethoscope on the brachial
artery of the antecubital space where the
pulse was noted.
Pump the bulb of the manometer until the
mercury rises to approximately 20mm.
above the point where it is anticipated
that systolic pressure should be.
Using the valve of the bulb, release air
gradually and note on the manometer the
point at which the first sound is heard,
record this figure as the systolic pressure.
Continue to release air gradually from the
cuff. Not the reading of the manometer
when the last distinct loud sound is heard
with stethoscope. Record this figure as
the diastolic pressure.
head of the mercury column is in direct
vision. If the eye is above or below the
meniscus, it will give inaccurate reading.
A distance of more than 3ft. will result in
inaccurate reading. Pressure applied
directly to the artery will yield most
accurate readings.
A twisted cuff and wrapping could
produce unequal pressure and thus an
inaccurate reading.
Accurate blood pressure reading is
possible when the stethoscope is directly
over the artery.
Direct placement of stethoscope over
artery will produce best possible sound
transmission.
Pressure in the cuff prevents blood from
flowing through the brachial artery. (Lack
of blood causes a numb sensation in
patient’s lower arm).
Systolic pressure is that point at which the
blood in the brachial artery is first able to
force its way through against the pressure
exerted on the vessel by the cuff of the
manometer. This is the maximum
pressure exerted on the wall of the
arteries when the left ventricle of the heart
pushes blood into the aorta.
Diastolic pressure is that point which
blood flows freely in the brachial artery
and is equivalent to the amount of
pressure normally exerted on the walls of
the arteries when the heart is at rest, or
the minimum pressure which is constantly
present on the arterial walls.
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