BASIC ASSESSMENT

AND BASIC CARE

PROCEDURES
A.HANDWASHING
B.TAKING VITAL
SIGNS OR
CARDINAL SIGNS
 TAKING VITAL SIGNS
VITAL SIGNS or CARDINAL SIGNS
The measurement of physiologic functioning,
specifically body temperature, blood pressure, pulse, and
respiration.

Purpose of taking vital signs:

1. Serves as guide in meeting the needs of the client
2. Aids in the planning of care for the client
3. Establish baseline values of the client’s cardio respiratory
integrity.
 1. TEMPERATURE TAKING

TEMPERATURE
Balance between heat production and heat loss
by the body.

Purpose of temperature taking:

1. To determine alterations in thermo- regulating
systems of the body.
2. To establish baseline data for subsequent
evaluation.
 NORMAL RANGES OF BODY
TEMPERATURE

ORAL : 36.4 to 37.2 degrees Celsius

RECTAL : 37 to 37.8 degrees Celsius
AXILLARY : 35.9 to 36.7 degrees
Celsius
EQUIPMENT:
Thermometer
Alcohol, cotton balls
Watch with second hand
Paper and pen
 TEMPERATURE TAKING
(AXILLARY METHOD)

PROCEDURE:
1. Identify and explain the procedure to the
patient.
2. Wash hands.
3. Gather equipment needed. Clean the probe
(pointed end) of the thermometer with
rubbing alcohol or soap and then rinse it in
cool water.
4. Draw curtain around bed and/ or close door.
5. Assist client in supine or sitting position.
6. Move clothing or gown away
from shoulder and arm.
7. Place the thermometer under
client’s armpit. ( You may have to
hold the thermometer specially if
your client is very sick and weak
that he/she cannot even hold the
thermometer with his/her armpit.)
8. Leave the thermometer in place until the
thermometer signals it is finished. When the
thermometer beeps, it means that it can be removed.

9. Remove the thermometer carefully and read the

temperature on the digital display. Clean the tip of
the thermometer with a cotton ball soaked in
alcohol. Put the thermometer’s tip cover. Place the
thermometer in its container.

10. Record the reading and wash your hands.

 2. PULSE TAKING
PULSE
-Expansion of the arterial walls occurring with
each ventricular contraction.

PURPOSE OF PULSE TAKING:

To provide clinical data regarding the heart’s
pumping action and the adequacy of peripheral
artery blood flow.

EQUIPMENT:
Watch with second hand
PULSE SITE
1. Temporal
2. Carotid
3. Apical
4. Brachial
5. Radial
6. Femoral
7. Popliteal
8. Posterior Tibial
9. Dorsalis pedis
 VARIATION IN PULSE RATE

AGE AVERAGE PULSE RATE RANGE

PER MINUTE

Newborn 130 80-180

to 1 month
1 year 120 80-140
2 years 110 80-130
6 years 100 75-120
10 years 70 50-90
Adult 80 60-100
 PULSE TAKING

PROCEDURE:

1. Wash hands.
2. Identify the client and explain the
procedure.
3. Have the patient rest his arm along
side of his body with the wrist
extended and the palm of the hand
downward.
4. 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.

5. Apply enough pressure so that you can

feel the pulse (not too hard not too tight)

6. Using a watch with second hand count

the number of pulsations felt on the
patient for one full minute.
7. If the pulse rate is abnormal, repeat
the counting in order to determine
accurately its rate, quality, and
rhythm.

8. Wash hands.

9. Record the number of pulse.

 3. RESPIRATION TAKING

RESPIRATION
-The act of breathing which includes intake of
oxygen and the output of carbon dioxide.

PURPOSE OF RESPIRATION TAKING:

To provide valuable information about a client’s
physical and emotional health.

EQUIPMENT:
Watch with second hand
 VARIATIONS IN RESPIRATORY RATE
AGE AVERAGE RANGE
RESPIRATORY
RATE PER
MINUTE
Newborn 35 30-80
1 year 30 20-40
2 years 25 20-30
8 years 20 15-25
16 years 18 15-20
Adult 16 12-20
 RESPIRATION TAKING
PROCEDURE:

1. Wash hands.

2. Identify and explain procedure to the

client.

3. Hold the client’s wrists just as if you

were taking his/her pulse.
4. Note the rise and fall of the client’s
chest with each respiration.

5. Using a watch with second hand,

count the number of respiration for
one full minute.

6. Record the number of respiration.

 4. BLOOD PRESSURE TAKING
BLOOD PRESSURE
Pressure exerted on the wall of the arteries when
the left ventricle of the heart pushes blood into the
aorta.

Purpose of blood pressure taking:

• To determine vascular resistance to blood flow
• To determine the effectiveness of cardiac
muscle in pumping blood to overcome the
vascular resistance.
EQUIPMENT:
1. BP APPARATUS
2. SPHYGMOMANOMETER
(ANEROID/DIGITAL)
3. STETHOSCOPE
4. COTTON BALLS WITH ALCOHOL
5. PAPER AND PEN
TWO BLOOD PRESSURE
MEASUREMENTS
1. Systolic pressure – is the maximum
pressure developed when heart
contracts as it pumps the blood into the
arteries.
2. Diastolic pressure – is the lowest
pressure as the heart relaxes between
each contraction.
VARIATION IN BP BY AGE
AGE Average BP (mmHg)
Newborn 73/55
1 year 90/55
6 years 95/57
10 years 102/62
14 years 120/80
Adult 120/80
Elderly(over 70 years) Diastolic pressure may
increase
BLOOD PRESSURE
TAKING
PROCEDURE:
1. Identify and explain the procedure
to the client.
2. Assess the client’s physical status.
3. Assemble the equipment.
4. Wash hands.
5. Place patient in a comfortable position (lying or
sitting) and position the arm at the level of the
heart with the palm of the hand facing up (
preferably use LEFT ARM because it is nearer the
heart)

6. Place the cuff so that the inflatable bag is

centered over the brachial artery, approximately
midway on the arm so that lower edge of the cuff
is about 2.5cm (1 to 2 inches) above the inner
aspect of the elbow. The tubing should leave the
edge on the cuff nearer the client’s elbow.
7. Wrap cuff around the arm smoothly and
snugly (not too loose, not too tight)

8. Feel the pulse beat over the brachial

artery t the inner aspect of the elbow with
the use of fingertips and don’t allow
diaphragm or bell of the stethoscope to
touch clothing of the cuff.

9. Place stethoscope earpiece in your ears

and close screw valve on the air pump.
10. Palpate brachial artery, turn valve
clockwise to close and compress bulb to
inflate cuff to 30mmHg above points where
palpated pulse disappears, then slowly
release valve (deflating cuff). Noting
reading when pulse is felt again.

11. Release the air in the cuff slowly so that

the pressure goes down at the rate of 2-3
mmHg per second and listen for the sound
(first distinctly loud muffling sound is
systolic pressure)
12. Continue to release the air evenly and slowly (
last soft muffling sound is diastolic pressure)

13. After the final sound has disappeared deflate

cuff rapidly and completely.

14. Roll the cuff and place it in the case. Wipe the
earpieces of the stethoscope with antiseptic swab
and put back in its proper place.

15. Wash hands and record the result.