Fundamentals of Nursing PDF

# Fundamentals of Nursing ## Measuring a Pulse 11. Record temperature in vital signs flow sheet or record form. Report abnormal findings to nurse in charge or physician. **Pulse:** refers to the pressure wave that expands and recoils arteries when the left ventricle of the heart contracts. It is...

# Fundamentals of Nursing ## Measuring a Pulse 11. Record temperature in vital signs flow sheet or record form. Report abnormal findings to nurse in charge or physician. **Pulse:** refers to the pressure wave that expands and recoils arteries when the left ventricle of the heart contracts. It is palpated at many points throughout the body. **NB.** The pulse also means: - The beat of the heart felt at an artery as a wave of blood passes through the artery. - A pulse is felt every time the heart beats. - More easily felt in arteries that come close to the skin and can be gently pressed against a bone. - The pulse should be the same in all pulse sites on the body. - The pulse is an indication of how the cardiovascular system is meeting the body's needs. **Factors affecting the pulse rate:** 1. Age & Sex 2. Exercise & medications 3. Fear, anxiety and pain 4. Hemorrhage, fever and illness. **Pulse sites:** - **Apical pulse (central pulse):** It can be heard with a stethoscope at fifth intercostal space between fifth and six intercostals space at mid clavicular line slightly below the nipple. - **Peripheral pulse:** It can be palpated by middle three fingers at skin surface where artery located. ## Normal Heart Rate by Age: | Age Group | Heart Rate | |---|---| | Preterm | 120 - 180 B/M | | Newborn (0 to 1 month) | 100 - 160 B/M | | Infant (1 to 12 months) | 80 - 140 B/M | | Toddler (1 to 3 years) | 80 - 130 B/M | | Preschool (3 to 5 years) | 80 - 110 B/M | | School Age (6 to 12 years) | 70 - 100 B/M | | Adolescents (13 to 18 years) and Adults | 60 - 100 B/M | ## Characteristics of pulse: 1. **Rate:** The normal pulse for healthy adults ranges from 60 to 100 b/m 2. **Rhythm:** (regularity of pulse), can be reported as regular/irregular. - **Regular:** A regular interval of time occurs between each heartbeat and pulse felt. - **Irregular:** Interval interrupted by early, late, or missed beat. 3. **Volume:** (expansion or size of pulse) can be reported as full/ thread, feeble. 4. **Force:** (the strength of the pulse) can be reported as strong/ weak. ## (1) Taking radial pulse ### Equipment: - Watch with second graphic sheet - Pen - Nursing record ### Procedure: | Nursing action | Rationale | |---|---| | 1- Wash hands | To prevent cross of infection | | 2- Prepare equipment | To save time and effort | | 3- Check the patient's identification | To ensure the right care is given to right patient. | | 4- Explain procedure to patient. | To gain his cooperation | | 5- Assist the patient in assuming a supine or sitting position. | To provide easy access to pulse rate. | | 6- Place tip of your middle three fingers on radial artery on the inside of wrist on the thumb side. | | | 7- Apply enough pressure to radial artery. | It's better to feel pulse. <br>To facilitate palpation of pulse. | | 8- Using watch while feeling pulse and count it in one minute. | For more accurate reading and allow assessment of pulse strength and rhythm. | | 9- Observe rhythm and strength of pulse. | That reflect efficacy of heart. | | 10- Record the rate on patient sheet. | To provide ongoing data collection. | | 11- Wash your hands. | To prevent spread of infection. | | 12- Report to the senior staff if you find any abnormalities | To provide nursing care and medication properly and continuously. | ## (2) Taking apical pulse ### Purposes: * Assess heart rate when the peripheral pulse is weak or irregular. * Assess heart rate before administering medication such as digitalis. * Identify pulse deficit. ### Equipment: * Stethoscope * Watch with second * Alcohol swap * Nursing record ### Procedure: | Nursing action | Rationale | |---|---| | 1- Wash hands. | -To prevent cross of infection | | 2- Prepare equipment. | To save time and effort | | 3- Check the patient's identification. | To ensure the right care is given to right patient. | | 4- Explain procedure to patient. | To gain his cooperation | | 5- Assist the patient to comfortable position (supine position). | To provide easy access to pulse rate. | | 6- Clean the stethoscope, chest piece and earpieces with alcohol sponge before and after the procedure. | To decrease maximum amount of microorganisms. | | 7- Locate the patient apical pulse, for adult, above the apex of the heart between fifth and sixth ribs, fifth intercostals space at mid clavicular line, slightly below the nipple. | | | 8- Warm the end pieces (diaphragm) of the stethoscope by rubbing it in palm of your hands. | To prevent chills to patient. | | 9- Insert the ear pieces in your ears with the tips bent forward toward your nose. | According to anatomical position of external auditory ear canal. | | 10- Place the diaphragm over the apex of the heart and count for full one minute. | | | 11- Observe rhythm & volume and strength of pulse. | To hear pulse clearly. <br> That reflect efficacy of heart.- | | 12- Record the rate on patient sheet. | To provide ongoing data collection. | | 14- Wash your hands. | To prevent spread of infection. | | 15- Report to the senior staff if you find any abnormalities | To provide nursing care and medication properly and continuously. | ### Abnormalities of heart beat: * **Tachycardia:** heart rate over 100b/m. * **Bradycardia:** heart rate less 60b/m. * **Thread pulse:** heart rate rapid & weak in (shock & hemorrhage). ## C. Assessing the Apical-Radial Pulse **Definition of (pulse deficit):** is the difference between apical and peripheral pulse (normal range from 0-10 b/m). ### Procedure: | Nurse action | Rationale | |---|---| | 1. Palpate the radial pulse while listening for apical pulse. Using both senses, determine if the apical and radial pulses are synchronous. | Identifies differences between pulsations and heart sounds. | | 2. Explain to the client that one nurse is counting his or her heart beats while the second counts his or her radial pulse. | Informs the client's answers his or her questions because the unusual procedure may arouse his or her anxiety; simple straight forward explanations usually are helpful. Listen to the client's fears or anxiety with empathy. | | 3. Prepare to monitor the apical pulse. | | | 4. Direct the second nurse to locate and count the radial pulse. | | | 5. Look at the watch dial. Note the location of the second hand and signal the second nurse to begin counting at "one, two..." | Synchronizes the count, essential to determine if deficit is present. | | 6. Count the remaining 60 seconds silently as the second nurse counts the radial pulse silently. | Ensures accuracy. | | 7. Say "Stop" when exactly 60 seconds have passed. | Ensures accuracy. | | 8. Reposition the client comfortable. | | | 9. Record the apical and radial rates immediately. Note any deficits and report it. | Ensures prompt and accurate documentation. | ## Pulse oximetery ### Definitions: **Pulse oximetery:** is the noninvasive measurement of peripheral oxygen saturation (SpO2), which is expressed as the percentage of hemoglobin that is filled with oxygen (reading would be between 94% and 100%). **The pulse oximeter:** is a small, clip-like device. It attaches to a body part, most commonly to a finger, foot, ear lobe, nose & forehead. ### Indications: Medical professionals may use pulse oximeter to monitor the health of people with conditions that affect blood oxygen levels. These can include: * Chronic obstructive pulmonary disease (COPD). * Asthma. * Pneumonia. * Lung cancer. * Anemia. * Heart attack or heart failure. * Congenital heart disease. ### The purpose of pulse oximeter: * Assess how well a new lung medication is working. * Evaluate whether someone needs help breathing. * Monitor oxygen levels during or after surgical procedures that requires sedation. * Determine whether someone needs supplemental oxygen therapy. * Determine how effective supplemental oxygen therapy is, especially when treatment is new. * Assess someone's ability to tolerate increased physical activity. * Evaluate whether someone momentarily stops breathing while. sleeping, like in cases of sleep apnea & during a sleep study. ### Equipment: 1. Pulse oximeter 2. Alcohol wipe 3. Clean gauze 4. Pen 5. Record vital signs ### Procedure: | Nurse action | Rationale | |---|---| | 1. Wash hands. | Reduces transfer of microorganisms. | | 2. Gather Equipment. | Needed to perform testing. | | 6. Explain procedure to individual & Nail polish removed, if indicated. | Decreases anxiety and facilitates cooperation. | | 3. Prepare site | Ensures that area is clean & dry | | 4. Use alcohol wipe to gently cleanse site | | | 5. Remove nail polish from finger, if needed | Colored nail polish may interfere with pulse oximeter reading | | 6. Apply sensor unit. | Sensors that are not properly aligned will not yield an accurate reading. | | 7. Place LED/photo detector unit onto chosen site. | The emitting sensors will transmit red and infrared light through the tissue. | | 8. Ensure proper alignment. The LED/sensors should be directly opposite each other. | Turn the pulse oximeter to the ON position. | | 9. Listen for beep and note bar of light on front of pulse oximeter. | Each beep indicates a pulse detected by the pulse oximeter. | | 10. Note reading on the display area. | A desired reading would be between 94% and 100%. | | 12. Report reading to nurse as per established parameters. | | | 13. Wash hands. | To prevent spread of infection | | 14. Clean Equipment: <br> a). Utilize alcohol wipe or saturate clean gauze with alcohol. <br> b). Wipe all surfaces of sensor and cable. <br> c). Dry all surfaces with clean gauze. | Reduces the transfer of microorganisms | | 15. Documentation: <br> 1. Date and time. <br> 2. Location of sensor. <br> 3. Percentage of oxygen saturation. <br> 4. Percentage of oxygen (or room air) client is receiving. <br> 5. Any reporting/interventions. | No task is completed until documentation & reporting occurs. | ## Measuring Respirations **Respiration:** is the process that occurs when oxygen is inhaled into the lungs, converted into energy via a chemical reaction and expelled as carbon dioxide and water vapor. **❖ Respiration** consists of one inspiration and one expiration and measured by cycle/min. **Characteristics of respiration:** 1- Rate: (16-24) cycle/min 2- Rhythm: regular or irregular. 3- Depth: shallow/deep. **Abnormality of respiration:** * **Bradypnea:** respiratory rate less than 16 c/m(abnormal) * **Tachypnea:** respiratory rate more than 24 c/m(abnormal) * **Dyspnea:** shortness of breath - difficulty in breathing. * **Apnea:** no breathing. * **Hyperventilation:** fast and shallow respirations. * **Hypoventilation:** slow and deep respirations. ## Normal Respiratory Rate by Age: | Age | Normal Range | |---|---| | Newborn to one month | 30 - 60C/M | | One month to one year | 26 - 60C/M | | 1-10 years of age | 14 - 50C/M | | 11-18 years of age | 12 - 22C/M | | Adult (ages 18 and older) | 16 - 24C/M | ### Procedure: | Nursing action | Rationale | |---|---| | 1- Wash hands | To prevent cross of infection | | 2- Prepare equipment | To save time and effort | | 3- prepare environment and use curtain | To maintain patient privacy | | 4- Check the patient's identification | To ensure the right care is given to right patient. | | 5- Don't Explain procedure to patient and take it after radial pulse. | To avoid voluntary control on respiration. | | 6- Assist the patient to comfortable position (preferably sitting or lying with the head of the bed elevated 45 to 60 degree). | To ensure clear view of chest wall and abdominal movements. | | 7- Put your finger tips on radial pulse while you observe movement of his chest. | | | 8- Count respiration for full one minute (observe the rise and fall of the patient's chest called one cycle). | | | 9- Examine the depth, rhythm, facial expression, cyanosis, cough and movement accessory. | | | 10- Record the rate on patient sheet. | To provide ongoing data collection. | | 12- Perform hand washing. | To prevent spread of infection. | | 13- Report to the senior staff if you find any abnormalities | To provide nursing care and medication properly and continuously. |