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PULSE
RESPIRATIONS
BLOOD PRESSURE
INFANTS – PULL
THE EAR
STRAIGHT BACK
ADULTS AND
CHILDREN OVER
ONE YEAR –
PULL THE EAR UP
AND BACK
GLASS
THERMOMETER
o RINSE WITH COLD WATER
o CHECK THE THERMOMETER
FOR BREAKS AND CHIPS
o SHAKE DOWN THE
THERMOMETER SO THE
MERCURY IS BELOW THE LINES
AND NUMBERS
o PLACE A DISPOSABLE COVER
ON THE THERMOMETER
o PLACE THE THERMOMETER
UNDER THE PERSON’S TONGUE
o LEAVE THE THERMOMETER IN
PLACE FOR 2 – 3 MINUTES
o IF THE PERSON HAS BEEN
EATING, DRINKING, OR
SMOKING, WAIT 15 MINUTES
BEFORE TAKING TEMPERATURE
DO NOT TAKE AN ORAL TEMPERATURE ON:
o AN INFANT OR YOUNG CHILD ( UNDER AGE 6)
o AN UNCONSCIOUS PATIENT
o A PATIENT THAT HAS HAD ORAL SURGERY OR AN INJURY TO THE FACE,
NECK, NOSE, OR MOUTH
o A PERSON RECEIVING OXYGEN
o A PATIENT WITH A NASOGASTRIC TUBE IN PLACE
o A PATIENT WHO IS CONFUSED OR RESTLESS
o A PATIENT WHO IS PARALYZED ON ONE SIDE OF THE BODY
o HAS A HISTORY OF SEIZURES
o A PATIENT WHO BREATHES THROUGH THE MOUTH
o LUBRICATE THE THERMOMETER BEFORE INSERTING INTO THE RECTUM
o PLACE THE PERSON IN A SIDE-LYING POSITION
o INSERT THE THERMOMETER 1 INCH INTO THE RECTUM
o HOLD THE THERMOMETER IN PLACE FOR 2 MINUTES
o REMOVE THE DISPOSABLE COVER AND READ THE THERMOMETER
DO NOT TAKE A RECTAL TEMPERATURE ON:
o A PERSON WHO HAS HAD RECTAL SURGERY OR RECTAL INJURY
o IF THE PERSON HAS DIARRHEA
o IF THE PERSON IS CONFUSED OR AGITATED
o IF THE PERSON HAS HEART DISEASE ( STIMULATES THE VAGUS NERVE
WHICH SLOWS THE HEART RATE )
o TAKEN ONLY WHEN NO OTHER SITE CAN
BE USED
o MAKE SURE THE UNDERARM IS CLEAN
AND DRY
o THE ARM IS HELD CLOSE TO THE BODY
o YOU NEED TO HOLD THE THERMOMETER
IN PLACE WHILE THE TEMPERATURE IS
BEING TAKEN
o THE THERMOMETER IS LEFT IN PLACE
FOR 10 MINUTES
THE PULSE IS:
o THE BEAT OF THE HEART FELT AT AN ARTERY
AS A WAVE OF BLOOD PASSES THROUGH THE
ARTERY
o A PULSE IS FELT EVERY TIME THE HEART
BEATS
o MORE EASILY FELT IN ARTERIES THAT COME
CLOSE TO THE SKIN AND CAN BE GENTLY
PRESSED AGAINST A BONE
oTHE PULSE SHOULD BE THE SAME IN ALL PULSE
SITES ON THE BODY
o THE PULSE IS AN INDICATION OF HOW THE
CARDIOVASCULAR SYSTEM IS MEETING THE
BODY’S NEEDS
o THE PULSE RATE IS AFFECTED BY MANY
FACTORS – AGE, FEVER, EXERCISE, FEAR. ANGER,
ANXIETY, EXCITEMENT, HEAT, POSITION, AND PAIN.
o MEDICATIONS CAN BE TAKEN THAT EITHER
INCREASE OR DECREASE A PERSON’S PULSE RATE.
o MOST COMMON SITE USED FOR
TAKING A PULSE
o CAN BE TAKEN WITHOUT
DISTURBING OR EXPOSING THE
PERSON
o PLACE THE FIRST TWO OR THREE
FINGERS OF ONE HAND AGAINST THE
RADIAL ARTERY
o THE RADIAL ARTERY IS ON THE
THUMB SIDE OF THE WRIST
o DO NOT USE YOUR THUMB TO TAKE
A PERSON’S PULSE
o USE GENTLE PRESSURE
o COUNT THE PULSE FOR 30 SECONDS
AND MULTIPLY BY TWO
ALWAYS CLEAN THE
EARPIECES OF THE
STETHOSCOPE WITH
ALCOHOL BEFORE AND AFTER
USE
WARM THE DIAPHRAGM IN
YOUR HAND BEFORE PLACING
IT ON THE PERSON
HOLD THE DIAPHRAGM IN
PLACE OVER THE ARTERY
DO NOT LET THE TUBING
STRIKE AGAINST ANYTHING
WHILE THE STETHOSCOPE IS
BEING USED
o TAKEN WITH A STETHOSCOPE
o COUNTED BY PLACING THE STETHOSCOPE
OVER THE HEART
o COUNTED FOR ONE FULL MINUTE
o THE HEART BEAT NORMALLY SOUNDS LIKE A
LUB-DUB. EACH LUB-DUB IS COUNTED AS ONE
HEARTBEAT.
o DO NOT COUNT THE LUB AS ONE
HEARTBEAT AND THE DUB AS ANOTHER.
o THE APICAL PULSE IS TAKEN ON PATIENTS
WHO HAVE HEART DISEASE , AN IRREGULAR
PULSE RATE, OR TAKE MEDICATIONS THAT CAN
AFFECT THE HEART.
THE APICAL AND RADIAL PULSE RATES SHOULD BE EQUAL
SOMETIMES THE HEART BEAT IS NOT STRONG ENOUGH TO CREATE A PULSE IN
THE RADIAL ARTERY
THIS WOULD CAUSE THE RADIAL PULSE TO BE LESS THAN THE APICAL PULSE
ONE PERSON COUNTS THE APICAL WHILE THE OTHER PERSON COUNTS THE
RADIAL
THE DIFFERENCE IN PULSES IS CALLED THE PULSE DEFICIT
NORMAL ADULT PULSE RATE IS – 60 TO 100 BEATS PER MIN.
TACHYCARDIA – HEART RATE OVER 100
BRADYCARDIA – HEART RATE BELOW 60
ONE RESPIRATION CONSISTS OF ONE INSPIRATION AND
ONE EXPIRATION
o THE CHEST RISES DURING INSPIRATION (BREATHING
IN) AND FALLS DURING EXPIRATION (BREATHING OUT)
o COUNT EACH TIME THE CHEST RISES
o COUNT FOR 30 SECONDS AND MULTIPLY X 2
o DO NOT LET THE PERSON KNOW YOU ARE COUNTING
THEIR RESPIRATIONS
o COUNT AFTER TAKING THE PULSE – KEEP YOUR
FINGERS ON THE PULSE SITE
o NORMAL RESPIRATORY RATE FOR ADULT IS 12 – 20
BREATHS PER MIN.
TACHYPNEA – RESPIRATORY RATE OVER 20
BRADYPNEA – RESPIRATORY RATE BELOW 12
DYSPNEA – SHORTNESS OF BREATH – DIFFICULTY IN
BREATHING
APNEA – NO BREATHING
HYPERVENTILATION – FAST AND DEEP RESPIRATIONS
HYPOVENTILATION – SLOW AND SHALLOW
RESPIRATIONS
THE MEASUREMENT OF THE AMOUNT OF FORCE THE
BLOOD EXERTS AGAINST THE ARTERY WALLS
o SYSTOLIC PRESSURE – PRESSURE EXERTED WHEN THE
HEART MUSCLE IS CONTRACTING
o DIASTOLIC PRESSURE – PRESSURE EXERTED WHEN THE
HEART MUSCLE IS RELAXING BETWEEN BEATS
BLOOD PRESSURE IS RECORDED AS A FRACTION WITH THE
SYSTOLIC PRESSURE ON TOP AND THE DIASTOLIC PRESSURE
ON THE BOTTOM
SYSTOLIC SYSTOLIC /DIASTOLIC
DIASTOLIC 120/80
BP IS MEASURED IN MM (MILLIMETERS) OF HG (MERCURY)
AVERAGE ADULT SYSTOLIC RANGE – 100 TO 140
AVERAGE ADULT DIASTOLIC RANGE – 60 TO 90
MERCURY ANEROID
o DO NOT TAKE A BLOOD PRESSURE ON AN ARM WITH AN IV, A CAST, OR
A DIALYSIS SHUNT.
o DO NOT TAKE A BLOOD PRESSURE ON THE SIDE THAT A PERSON HAS
HAD BREAST SURGERY ON.
o MEASURE BLOOD PRESSURE WITH THE PERSON SITTING OR LYING.
o APPLY THE CUFF TO THE BARE UPPER ARM. DO NOT APPLY THE CUFF
OVER CLOTHING.
o MAKE SURE THE CUFF IS SNUG.
o USE A LARGE CUFF IF NECESSARY.
o MAKE SURE THE ROOM IS QUIET.
o IF YOU DO NOT HEAR THE BLOOD PRESSURE, WAIT 30 TO 60 SECONDS
AND TRY AGAIN. IF YOU STILL CAN NOT HEAR IT OR ARE UNSURE OF
YOUR READINGS, HAVE THE NURSE CHECK YOUR MEASUREMENTS.
1. CLEAN THE STETHOSCOPE EARPIECES AND DIAPHRAGM WITH ALCOHOL.
2. LOCATE THE BRACHIAL PULSE. THIS IS WHERE THE STETOSCOPE WILL BE PLACED.
3. WRAP THE CUFF ABOVE THE ELBOW WITH THE ARROW POINTING TO THE BRACHIAL
ARTERY. FASTEN THE CUFF SO IT FITS SNUGLY.
4. PLACE THE DIAPHRAGM OF THE STETHOSCOPE FLAT ON THE PULSE SITE, HOLDING IT
IN PLACE WITH THE INDEX AND MIDDLE FINGERS OF ONE HAND.
5. LOCATE THE RADIAL PULSE.
6. CLOSE THE VALVE ON THE BP CUFF BY TURNING IT TO THE RIGHT (CLOCKWISE).
7. INFLATE THE CUFF UNTIL YOU CAN NO LONGER FEEL THE RADIAL PULSE. ,THEN
INFLATE THE CUFF 30 MM HG BEYOND THIS POINT.
8. DEFLATE THE CUFF SLOWLY BY OPENING THE VALVE SLIGHTLY AND TURNING IT
COUNTERCLOCKWISE (TO THE LEFT) WITH YOUR THUMB AND INDEX FINGER. ALLOW
THE AIR TO ESCAPE SLOWLY WHILE LISTENING FOR A PULSE SOUND.
9. NOTE THE READING AT WHICH YOU HEAR THE FIRST CLEAR, REGULAR PULSE SOUND.
THIS NUMBER IS THE SYSTOLIC PRESSURE.
10. CONTINUE LISTENING UNTIL THE SOUND DISAPPEARS. THIS IS THE DIASTOLIC
PRESSURE. NOTE THIS READING.
11. OPEN THE VALVE COMPLETELY TO DEFLATE THE CUFF. REMOVE THE CUFF FROM THE
PATIENT.
MEASURING WEIGHT AND HEIGHT