Nursing Procedure Count the Respiratory Rate

The respiratory rate is a count of one full inspiration/expiration cycle for 1 full minute. Assessing respirations includes checking rate, rhythm, and depth. It includes assessing inspiration (taking oxygen into the lungs) and expiration (removing carbon dioxide from the lungs). The normal respiratory rate varies with age. The newborn’s respiratory rate is quite rapid, averaging about 40 breaths per minute. The respiratory rate gradually decreases with age until it reaches the adult rate of 12 to 20 breaths per minute. Respiratory rates that are within normal range are termed eupnea, those above normal range are termed Tachypnea; and those below normal range are called bradypnea. Absent breathing is apnea, and difficult breathing is Dyspnea. Respirations are diaphragmatic on children younger than 7 years of age observe or place hand on abdomen. Respirations are thoracic in children older than 7 years of age observe or place hand on chest. 

Client education Count the respiratory rate: 

• Instruct the client about the reason for assessing respiration. 
• Teach the caregiver to count respiration while the client is not aware. 
• Instruct the caregiver to contact the nurse if there is an alteration in the client’s respiration’s. 
• Clients should be taught to notify their caregiver or nurse when they feel a change in their respiration’s. 
• Clients who have decreased ventilation may benefit from being taught deep-breathing and coughing techniques. 

Equipment Needed for Count the respiratory rate 

• Stethoscope 
• Watch with a second hand 

General Guidelines for Vital Signs Count the Respiratory Rate 

1. Check record for baseline and factors (age, illness, medications, etc.) influencing vital signs. 
2. Gather equipment, including paper and pen, for recording vital signs. 
3. Wash hands. 
4. Prepare child and family in a quiet and nonthreatening manner. 

Nursing Procedure Count the respiratory rate: 

1. General Guidelines 1-4. 
2. Be sure chest movement is visible. Client may need to remove heavy clothing. 
3. Observe one complete respiratory cycle. If it is easier, place the client’s hand across his abdomen and your hand over the client’s wrist. 
4. Start counting with first inspiration while looking at the second hand of a watch. Infants and children: Count Respiration’s for one full minute for infants and younger children because respiration’s are normally irregular Adults: count for 30 seconds and multiply by 2 to obtain the rate per minute, if an irregular rate or rhythm is present, count for one full minute. 
5. Observe character of respiration’s; Depth of respiration’s by degree of chest wall movement (shallow, normal, or deep) Rhythm of cycle (regular or interrupted) 
6. Observe movement of chest and abdomen; Assess chest movements for symmetry, in infants observe movement of abdomen. Paradoxical abdominal movement, abdomen rises on inspiration as chest retracts (see or saw movement), is abnormal except in premature infants. 
7. Auscultate for normal, abnormal, and diminished and/or absent breath sounds on both back and chest; use a regular pattern; compare breath sounds side-to-side. 
8. Replace client’s gown if needed. 
9. Record rate and character of respiration’s. 
10. Wash hands.

Continue

Nursing Procedure Measuring Blood Pressure

Nursing Procedure Measuring Blood Pressure. Blood pressure (BP) is a measurement of the pressure within the vascular system as the heart contracts (systole) and relaxes (diastole). BP indirectly reflects your patient’s overall cardiovascular functioning. It is equal to CO time’s peripheral vascular resistance (BP CO PVR). Normal BP varies with age. Other factors that can affect BP include stress, genetics, medications, heavy meals, diurnal variations, exercise, and weight. Normal BP for an adult ranges from 100 to less than 120 mmHg (systolic) and from 60 to less than 80 mm Hg (diastolic). Normal BP for children and infants are much lower. A systolic reading 120 to 139 mmHg and a diastolic reading 80 to 89 mmHg is considered prehypertension; a systolic 140 to 159 mm Hg with a diastolic 90 to 99 mmHg, stage 1 hypertension; a systolic 160 mm Hg or higher with a diastolic 100 mm Hg or higher, stage 2 hypertension; and a systolic reading lower than 90 mm Hg and a diastolic reading lower than 60 mm Hg is considered hypotensive. Do not take a blood pressure (BP) on an injured or painful extremity or one where there is an intravenous line (IV). Cuff inflation can temporarily interrupt blood flow and compromise circulation in an extremity already impaired or a vein receiving IV fluids. 

Indirect Blood Pressure Measurement 

• Bladder width should equal 40% and length should be at least 60% of the circumference of the extremity. 
• Auscultatory pressure is the traditional method using a sphygmomanometer cuff. It correlates poorly with directly measured values at the extremes of pressure. 
• Palpatory systolic pressure is defined as the pressure when a pulse is detected in the radial artery as the cuff is deflated. 
• Automated indirect devices measure without manual inflation and deflation. 
• Oscillometric methods correlate well with group average values, but they correlate poorly with intra-arterial pressures in individual patients. 
• Doppler sensing devices are slightly better but still vary quite a bit. 
• Volume clamp devices respond rapidly to changes in blood pressure and may be appropriate for use in critical care in the future. 
• Automated noninvasive monitors have a role in following trends of pressure change but are of little value in situations in which blood pressure fluctuates rapidly. Critical management decisions should not be made based on their results unless use of a direct method is impossible. 

Direct Invasive Blood Pressure Measurement 

Advantages of arterial catheters: 

• measure the end-on pressure propagated by the arterial pulse 
• detect pressures at which Korotkoff sounds are either absent or inaccurate 
• provide beat-to-beat changes in blood pressure 
• eliminate the need for multiple punctures when frequent blood draws needed 

Disadvantages of arterial catheters: 

• Require invasive procedure with complications including arterial injury, ischemia, thrombus formation, infection, and blood loss, among others. 

Equipment Needed Measuring Blood Pressure: 

• Stethoscope 
• Mercury sphygmomanometer with bladder and cuff 
• Alcohol wipe 
• Gloves if required 

Client education needed Measuring Blood Pressure: 

Teach the client to refrain from eating, drinking, or smoking 30 minutes before the procedure. Ask the client to sit or lie down in a warm, quiet room. Ask the client to rest for 5 minutes before taking the measurement. Explain the procedure. Advise the client regarding the correct size blood pressure cuff to use at home for his individual anatomy. Advise the client to take his blood pressure at the same site using the same cuff for consistency. Teach the client that the “top number” in a blood pressure reading is always higher than the “bottom number.” 

ACTION: 

General Guidelines for Measuring Blood Pressure 

1. Check record for baseline and factors (age, illness, medications, etc.) influencing vital signs. Provides parameters and helps in device and site selection. 
2. Gather equipment, including paper and pen, for recording vital signs. Promotes organization and efficiency. 
3. Wash hands. Reduces transmission of microorganisms. 
4. Prepare child and family in a quiet and nonthreatening manner. Enhances cooperation and participation; reduces anxiety and fear, which can affect readings. 

Auscultation Method Using Brachial Artery 

1. General Guidelines for Measuring Blood Pressure 1- 4. 
2. Cleanse ear pieces and bell/diaphragm of stethoscope with an alcohol wipe 
3. Determine which extremity is most appropriate for reading. Do not take a pressure reading on an injured or painful extremity or one in which an intravenous line is running. 
4. Select a cuff size that completely encircles upper arm without overlapping 
5. Remove clothing as necessary to expose extremity. Move clothing away from upper aspect of arm. 
6. Position arm at heart level, extend elbow with palm turned upward. 
7. Make sure bladder cuff is fully deflated and pump valve moves freely. 
8. Locate the artery by palpation. Allows for proper placement of stethoscope to hear BP. Locate brachial artery in the antecubital space. 
9. Apply cuff snugly and smoothly over upper arm, 2.5 cm (1 inch) above antecubital space with center of cuff over brachial artery. 
10. Connect bladder tubing to manometer tubing. If using a portable mercury-filled manometer, position vertically at eye level. 
11. Palpate brachial artery, turn valve clockwise to close and compress bulb to inflate cuff to 30 mm Hg above point where palpated pulse disappears, then slowly release valve (deflating cuff ), noting reading when pulse is felt again. 
12. Insert earpieces of stethoscope into ears with a forward tilt, ensuring diaphragm hangs freely. 
13. Relocate brachial pulse with your nondominant hand and place bell or diaphragm chestpiece directly over pulse. Chestpiece should be in direct contact with skin and not touch cuff. Place stethoscope gently over artery. Too firm a pressure will occlude blood vessel. 
14. With dominant hand, turn valve clockwise to close. Compress pump to inflate cuff until manometer registers 30 mm Hg above diminished pulse point identified. 
15. Slowly turn valve counterclockwise so that mercury falls at a rate of 2–3 mm Hg per second. Listen for five phases of Korotkoff sounds while noting manometer reading. (A faint, clear tapping sound appears and increases in intensity. Swishing sound. Intense sound. Abrupt, distinctive muffled sounds. Sound disappears). 
16. Obtain a blood pressure reading. Systolic pressure: The pressure at which you first hear sounds. . Diastolic pressure: The American Heart Association recommends the onset of muffling as the diastolic pressure in children up to 13 years of age; the pressure when sounds become inaudible is the diastolic pressure in children > 13 years of age. 
17. Deflate cuff rapidly and completely. 
18. Remove cuff or wait 2 minutes before taking a second reading. 
19. Inform client of reading. 
20. Record reading. 
21. If appropriate, lower bed, raise side rails, place call light in easy reach. 
22. Put all equipment in proper place. 
23. Wash hands. 

Measuring Blood Pressure Using Palpation Method on Brachial or Radial Artery 

1. Palpate brachial or radial artery with fingertips of one hand. Inflate cuff to 30 mm Hg above point at which pulse disappears. 
2. Palpation: Continue to slowly release pressure until a pulse is felt. This is the systolic pressure. The diastolic pressure is recorded as P, e.g., 100/P. The systolic pressure obtained by palpation is 5–10 mm Hg lower than that obtained by auscultation. 
3. Deflate cuff slowly as you note on the manometer when the pulse is again palpable. 
4. Deflate cuff rapidly and completely. 
5. Remove cuff or wait 2 minutes before taking a second reading. 
6. Inform client of reading. 
7. Record reading. 
8. Wash hands.

Continue

Nursing Procedure Taking Temperatures

What is Body temperature? Body temperature is the difference between heat produced and heat lost. The hypothalamus acts as the body’s thermostat to maintain a constant body temperature. The balance is maintained between the body’s heat producing functions (metabolism, shivering, muscle contraction, exercise, and thyroid activity) and the heat-losing functions (radiation, convection, conduction, and evaporation). When one temperature becomes greater than the other, temperature changes are seen greater heat-producing functions result in temperature elevations (fever/hyperthermia), and greater heat losing functions result in temperature decreases (hypothermia). 

Sites of measurement of Body temperature: 

• Core temperature true body temperature. Rectal, bladder, and tympanic temperatures are in general the most reliable sites for maesuring body temperature. 
• Sublingual convenient site to measuring body temperature. Tachypnea and consumption of hot or cold substances affect result. Best for intermittent measurement. 
• Axillary temperatures average 1.5° to 1.9°C lower than tympanic. The accuracy of axillary temperatures is affected by inability to maintain probe position. 
• Tympanic measured with specifically designed thermometer. In theory, correlates well with core temperature. In practice, correlates poorly because of difficulty performing the technique and technical malfunctions, with a high degree of user dissatisfaction. 
• Skin poor correlation with core temperature. 

ROUTE	ADVANTAGES	DISADVANTAGES
·         Oral (Normal: 98.6_F; 37_C)       ·         Rectal (Normal: 99.5_F; 37.5_C)       ·         Tympanic (Normal: 99.5_F; 37.5_C)       ·         Axillary (Normal: 97.6_F; 36.5_C)       ·         Forehead (Normal: 94_F; 34.4_C)       ·         Temporal arterial (Normal: Close to rectal temperature, 1_F or 0.5_C higher than an oral temperature, and 2_F or 1_C higher than an axillary temperature)	Easy, fast, accurate More reflective of core Temperature Fast More reflective of core temperature Safe, good for children Safe, good for children and newborns Safe and easy	Cannot be used for clients who are unconscious, confused, prone to seizures, recovering from oral surgery, or under age 6. Need to wait 15–20 minutes after eating. Cannot be used for clients who have rectal bleeding, hemorrhoids, or diarrhea or who are recovering from rectal surgery. Contraindicated for cardiac clients because it may stimulate the vagus nerve and decrease heart rate. Not recommended for newborns because of risk of perforating anus. Reports of accuracy are conflicting. Measures skin surface, which can be variable. Measures skin surface temperature. Least accurate method.

Equipment Needed: 

• Thermometer: Glass, oral, or rectal, at client’s bedside. Or Electronic thermometer with disposable protective 
• Sheath Tympanic membrane thermometer with probe 
• Cover Disposable, single-use chemical strip thermometer 
• Lubricant for rectal and glass thermometer 
• Two pairs of nonsterile gloves 
• Tissues 

Purpose of Nursing Procedure Taking Temperatures: 

The thermometer measures body temperature. Measurements may be oral, rectal, temporal artery, tympanic, axillary, or skin. A rectal measurement is most reflective of core temperature, whereas skin or surface measurements are the least reflective. Thermometers measure temperature in either degrees Fahrenheit (F) or centigrade/Celsius (C). 

Types of thermometers include: 

• Glass mercury thermometer: Used for oral, rectal, or axillary temperature measurements. 
• Electronic digital thermometer: Used for oral, rectal, or axillary temperature measurements. 
• Tympanic thermometer: Uses infrared sensors to sense temperature measurements of the tympanic membrane. 
• Temporal artery thermometer: Measures arterial temperature through infrared scanning of the temporal artery. 
• Disposable paper strips with temperature sensitive dots: Used for oral or skin/surface temperature measurements. 

Client education needed when measuring Body temperature: 

Explain to client why an accurate body temperature is needed. Describe the equipment to the client and explain what to expect during the procedure. Answer any questions regarding the procedure and fears the client may have. 

General Guidelines for Nursing Procedure Taking Temperatures: 

• Review medical record for baseline data and factors that influence vital signs. 
• Explain to the client that vital signs will be assessed. 
• Encourage client to remain still and refrain from drinking, eating, and smoking. 
• Assess client’s toileting needs and proceed as appropriate. 
• Gather equipment. 
• Provide for privacy. 
• Wash hands and apply gloves. 
• Adjust Position the client in a sitting or lying position with the head of the bed elevated 45° to 60° for measurement of all vital signs except those designated otherwise. 
• Remove gloves and wash hands. 

Oral Temperature: Glass Thermometer 

1. Select correct color tip of thermometer from client’s bedside container 
2. Remove thermometer from storage container and cleanse under cool water. 
3. Use a tissue to dry thermometer from bulb’s end toward fingertips. 
4. Read thermometer by locating mercury level. It should read 35.5°C (96°F). 
5. If thermometer is not below normal body temperature reading, grasp thermometer with thumb and forefinger and shake vigorously by snapping the wrist in a downward motion to move mercury to a level below normal. 
6. Place thermometer in client’s mouth under the tongue and along the gum line to the posterior sublingual pocket. Instruct client to hold lips closed. 
7. Leave in place as specified by agency policy, usually 3–5 minutes. 
8. Remove thermometer and wipe with a tissue away from fingers toward the bulb’s end. 
9. Read at eye level and rotate slowly until mercury level is visualized. 
10. Shake thermometer down, and cleanse glass thermometer with soapy water, rinse under cold water, and return to storage container. 
11. Remove and dispose of gloves in receptacle. 
12. Wash hands. 
13. Record reading and indicate site as “OT.” 
14. Wash hands. 

Oral Temperature Electronic Thermometer 

1. Repeat Procedure 1–8 of General Guidelines 
2. Place disposable protective sheath over probe 
3. Grasp top of the probe’s stem. Avoid placing pressure on the ejection button. 
4. Place tip of thermometer under the client’s tongue and along the gumline to the posterior sublingual pocket lateral to center of lower jaw. 
5. Instruct client to keep mouth closed around thermometer. 
6. Thermometer will signal (beep) when a constant temperature registers. 
7. Read measurement on digital display of electronic thermometer. Push ejection button to discard disposable sheath into receptacle and return probe to storage well. 
8. Inform client of temperature reading. 
9. Remove gloves and wash hands. 
10. Record reading and indicate site “OT.” 
11. Return electronic thermometer unit to charging base. 
12. Wash hands. 

Rectal Temperature 

1. Repeat Procedure 1–8 of General Guidelines. 
2. Place client in the Sims’ position with upper knee flexed. Adjust sheet to expose only anal area. 
3. Place tissues in easy reach. Apply gloves. 
4. Prepare the thermometer. 
5. Lubricate tip of rectal thermometer or probe (usually a rectal thermometer has a red cap). 
6. With dominant hand, grasp thermometer. With other hand, separate buttocks to expose anus. 
7. After Instruct client to take a deep breath. Insert thermometer or probe gently into anus: infant, 1.2 cm (0.5 inches); adult, 3.5 cm (1.5 inches). If resistance is felt, do not force insertion. 
8. Hold thermometer in place for about 2 minutes. 
9. Wipe secretions off glass thermometer with a tissue. Dispose of tissue in a receptacle. 
10. Read measurement and inform client of temperature reading. 
11. While holding glass thermometer in one hand, use other hand to wipe anal area with tissue to remove lubricant or feces. Dispose of soiled tissue. Cover client. 
12. Cleanse thermometer. 
13. Remove and dispose of gloves in receptacle. Wash hands. 
14. Record reading and indicate site Rectal Temperature RT 

Axillary Temperature 

1. Repeat Procedure 1–8 of General Guidelines. 
2. Remove client’s arm and shoulder from one sleeve of gown. Avoid exposing chest. 
3. Make sure axillaries skin is dry; if necessary, pat dry. 
4. Prepare thermometer. 
5. Place thermometer or probe into center of axilla. Fold client’s upper arm straight down and place arm across client’s chest. 
6. Leave glass thermometer in place as specified by agency policy (usually 6–8 minutes). Leave an electronic thermometer in place until signal is heard. 
7. Remove and read thermometer. 
8. Inform client of temperature reading. 
9. Cleanse glass thermometer. Shake thermometer down, and cleanse glass thermometer with soapy water, rinse under cold water, and return to storage container. 
10. Assist client with replacing gown. 
11. Record reading and indicate site Axillary Temperature 
12. Wash hands. 

Disposable (Chemical Strip) Thermometer 

1. Repeat Procedure 1–8 of General Guidelines. 
2. Apply tape to appropriate skin area, usually forehead. 
3. Observe tape for color changes. 
4. Record reading and indicate method. 
5. Wash hands. 

Tympanic Temperature: Infrared Thermometer 

1. Repeat Procedure 1–8 of General Guidelines. 
2. Position client in Sims’ position. 
3. Remove probe from container and attach probe cover to tympanic thermometer unit. 
4. Turn client’s head to one side. For an adult, pull pinna upward and back; for a child, pull down and back. Gently insert probe with firm pressure into ear canal. 
5. Remove probe after the reading is displayed on digital unit (usually 2 seconds). 
6. Remove probe cover and replace in storage container. 
7. Return tympanic thermometer to storage unit. 
8. Record reading and indicate site 
9. Wash hands.

Continue