Vital Signs Assessment: Temperature Taking (Axilla) - Procedure & Rationale PDF

**VITAL SIGNS** **ASSESSING THE TEMPERATURE TAKING AXILLA METHOD** **DEFINITION** - Balance between heat production and heat loss by the body **PURPOSE** - To determine alteration in thermo regulating system of the body - To establish baseline data for subsequent evaluation **EQUIPMENT*...

**VITAL SIGNS** **ASSESSING THE TEMPERATURE TAKING AXILLA METHOD** **DEFINITION** - Balance between heat production and heat loss by the body **PURPOSE** - To determine alteration in thermo regulating system of the body - To establish baseline data for subsequent evaluation **EQUIPMENT** - **Axillary thermometer** - **Cotton balls and alcohol** - **Watch with a second hand** - **Paper and pen** +-----------------------+-----------------------+-----------------------+ | **NO** | **PROCEDURE** | **RATIONALE** | +-----------------------+-----------------------+-----------------------+ | 1. | Assess the client's | - To ensure correct | | | physical status | procedure to | | | | right patient | +-----------------------+-----------------------+-----------------------+ | 2. | Explain procedure | - Explaining | | | | procedures | | | | reduces anxiety | | | | and fear thus | | | | promoting | | | | cooperation from | | | | the client | +-----------------------+-----------------------+-----------------------+ | 3. | Draw curtain around | - To provide | | | bed and/or close door | privacy | +-----------------------+-----------------------+-----------------------+ | 4. | Assemble the | - To facilitate | | | equipment and | systematic | | | supplies and | assessment and | | | functionality of | measurement | | | instruments | | +-----------------------+-----------------------+-----------------------+ | 5. | Wash hands | - Reduces | | | | transmission of | | | | microorganisms | +-----------------------+-----------------------+-----------------------+ | 6. | Assess client's skin | - To provide | | | if warm to touch | correct procedure | +-----------------------+-----------------------+-----------------------+ | 7. | Assist client on | - To provide easy | | | supine or sitting | access to axilla | | | position | | +-----------------------+-----------------------+-----------------------+ | 8. | Clean the digital | - To remove | | | thermometer from bulb | chemical | | | to stem in rotating | solution, dust or | | | motion using soft | dirt that may | | | tissue or cotton | irritate mucous | | | balls with alcohol | membrane and to | | | | prevent spread of | | | | microorganism | +-----------------------+-----------------------+-----------------------+ | 9. | Remove clothing or | - To provide easy | | | gown away from | access | | | shoulder and arm | | +-----------------------+-----------------------+-----------------------+ | 10. | Raise clients' arm | - To maintain | | | away from torso, | proper position | | | insert into center of | of thermometer | | | axilla, lower arm | bulb against | | | over bulb and place | blood vessels in | | | arm across client's | axilla | | | chest | | +-----------------------+-----------------------+-----------------------+ | 11. | Leave thermometer in | - To provide | | | place for about 1-2 | sufficient time | | | minutes or until you | for recording of | | | hear a beep sounds | the temperature | | | for accurate reading | | | | then remove | | | | thermometer | | +-----------------------+-----------------------+-----------------------+ | 12. | Read the temperature | - To ensure | | | result | accurate reading | +-----------------------+-----------------------+-----------------------+ | 13. | Wipe thermometer from | - To prevent cross | | | stem to bulb with | contamination | | | firm rotating motion | | | | using soft tissue or | - Wipe from area | | | cotton balls with | with least | | | alcohol and return to | contamination to | | | its protective case | area most | | | | contaminated | +-----------------------+-----------------------+-----------------------+ | 14. | Assist the client in | - Restores of sense | | | replacing clothing or | of well being | | | gown | | +-----------------------+-----------------------+-----------------------+ | 15. | Wash hands | - To reduce | | | | transmission of | | | | microorganism | +-----------------------+-----------------------+-----------------------+ | 16. | Record and evaluate | - Serves as | | | the temperature | baseline data for | | | | health care | | | | providers | +-----------------------+-----------------------+-----------------------+ **ASSESSING PULSE RATE** **DEFINITION** - Expansion of the arterial walls occurring with each ventricular contraction **PURPOSE** - To provide clinical data regarding the heart's pumping action and the adequacy of peripheral artery blood flow **EQUIPMENT** - **Watch with a second hand** +-----------------------+-----------------------+-----------------------+ | 17. | Assess client's | - To ensure right | | | condition and check | procedure to | | | nature of pulse | right patient | +-----------------------+-----------------------+-----------------------+ | 18. | Assist client to a | - To provide easy | | | comfortable resting | access to pulse | | | position | | +-----------------------+-----------------------+-----------------------+ | 19. | Have the patient rest | - This position | | | his arm alongside of | places radial | | | his body with the | artery on the | | | wrist extended and | inner aspects of | | | palm of the hands | the patient's | | | downward or the | wrist | | | forearm can rest at a | | | | 90-degree angle | | | | across the chest | | +-----------------------+-----------------------+-----------------------+ | 20. | Place the tips of | - Finger tips are | | | your middle three | sensitive to | | | fingers on the palm | touch and will | | | side of the client's | feel the | | | wrist where radial | pulsation of the | | | pulse is located | patient's artery | | | | | | | | - Thumb should not | | | | be used because | | | | it has pulse to | | | | avoid confusion | +-----------------------+-----------------------+-----------------------+ | 21. | Apply enough pressure | - Pressing to hard | | | that you can feel the | may stop the flow | | | pulse (not too hard | of the blood and | | | not too light) | you will not be | | | | able to feel the | | | | pulse | | | | | | | | - Too little | | | | pressure will be | | | | imperceptible | +-----------------------+-----------------------+-----------------------+ | 22. | Using a watch with a | - Sufficient time | | | second hand count the | is necessary to | | | number of pulsations | detect | | | felt on the client | irregularities | | | for one full minute | and abnormalities | +-----------------------+-----------------------+-----------------------+ | 23. | Assess the pulse | - Serves as | | | rhythm, if the pulse | baseline data for | | | is abnormal repeat | health care | | | the counting to | providers | | | determine accurately | | | | and document the | | | | pulse rate | | +-----------------------+-----------------------+-----------------------+ **ASSESSING RESPIRATORY RATE** **DEFINITION** - The act of breathing which includes intake of oxygen and the output of carbon dioxide **PURPOSE** - To provide valuable information about a client's physical and emotional health **EQUIPMENT** - **Watch with a second hand** +-----------------------+-----------------------+-----------------------+ | 24. | Hold client's wrist | - This way client | | | as if you are taking | is not conscious | | | his/her pulse, if you | breathing is | | | anticipate this, | being watch | | | place a hand against | | | | the client's chest to | - Awareness of | | | feel the chest | respiratory rate | | | movements with | assessment will | | | breathing | cause the client | | | | voluntarily to | | | | alter the | | | | respiratory | | | | pattern | +-----------------------+-----------------------+-----------------------+ | 25. | Note rise and fall of | - Complete cycle of | | | the client's chest | inspiration and | | | with each respiration | expiration | | | | constitute one | | | | act of | | | | respiration | +-----------------------+-----------------------+-----------------------+ | 26. | Using a watch with | - Sufficient time | | | second hand, count | is necessary to | | | the number of | detect | | | respiration for one | irregularities | | | full minute | and abnormalities | +-----------------------+-----------------------+-----------------------+ | 27. | Record and evaluate | - Serves as | | | respiratory rate | baseline data for | | | | health care | | | | providers | +-----------------------+-----------------------+-----------------------+ **ASSESSING THE BLOOD PRESSURE** **DEFINITION** - Pressure exerted on the wall of the arteries when the left ventricle of the heart pushes blood into the aorta **PURPOSE** - To determine vascular resistance to blood flow - To determine the effectiveness of cardiac muscle in pumping blood to overcome the vascular resistance **EQUIPMENT** - **Blood pressure apparatus** - **Sphygmomanometer** - **Stethoscope** - **Paper and pen** +-----------------------+-----------------------+-----------------------+ | 28. | Explain the next | - To ensure correct | | | procedure and ask | procedure to | | | permission if you can | right patient and | | | proceed | gain client's | | | | cooperation | +-----------------------+-----------------------+-----------------------+ | 29. | Place the patient in | - This position | | | a comfortable | places the | | | position (lying or | brachial artery | | | sitting) and position | on the inner | | | the arm at the level | aspect of the | | | of the heart with the | elbow that a | | | palm of the hand | stethoscope can | | | facing up ( | rest on it | | | preferably use left | conveniently. | | | arm because it is | Having the arm | | | nearer the heart) | above the level | | | | of the heart | | | | causes a decrease | | | | in BP | +-----------------------+-----------------------+-----------------------+ | 30. | Place the cuff so | - Pressure in the | | | that the inflatable | cuff applied | | | bag is centered over | directly to the | | | the brachial artery, | artery will give | | | approximately midway | the most accurate | | | on the arm so that | reading. If the | | | the lower edge of the | cuff gets in the | | | cuff is about 2.5cm | way of the | | | (1 to 2 inches) above | stethoscope on | | | the inner aspect of | the anterior | | | the elbow | elbow, reading is | | | | likely to be an | | | | inaccurate. A | | | | cuff placed | | | | upside down with | | | | the tubing toward | | | | the patient's | | | | head will give a | | | | false reading. | +-----------------------+-----------------------+-----------------------+ | 31. | Wrap the cuff around | - A smooth cuff and | | | the arm smoothly and | wrapping produce | | | snugly (not too | equal pressure | | | loose, not too tight) | and give accurate | | | | reading. A cuff | | | | too loosely | | | | wrapped will give | | | | inaccurate | | | | reading | +-----------------------+-----------------------+-----------------------+ | 32. | Feel the pulse beat | - Having the | | | over the brachial | stethoscope | | | artery at the inner | directly over the | | | aspect of the elbow | artery makes more | | | with the use of | accurate reading | | | finger tips. | and having the | | | | stethoscope | | | | firmly placed on | | | | the skin away | | | | from clothing and | | | | the cuff prevent | | | | missing sounds | +-----------------------+-----------------------+-----------------------+ | 33. | Turn valve clockwise | - Lack of blood | | | to close and compress | patient's arm may | | | bulb until pulsation | cause a | | | disappears, then | temporarily | | | slowly release valve | tingling and | | | (deflating cuff). | numbing sensation | | | Note reading where | | | | pulse disappear | | +-----------------------+-----------------------+-----------------------+ | 34. | Place stethoscope | - Sounds are heard | | | earpiece in your | more clearly when | | | ears. Place the | the earpiece | | | diaphragm of your | follow the | | | stethoscope over the | direction of the | | | brachial pulse. Don't | ear canal | | | allow the head of the | | | | stethoscope to touch | | | | clothing of cuff | | +-----------------------+-----------------------+-----------------------+ | 35. | Turn the valve | - Lack of blood | | | clockwise to close | patient's arm may | | | and compress bulb, | cause a | | | add 30mmhg above | temporarily | | | points where palpated | tingling and | | | pulse disappear | numbing sensation | +-----------------------+-----------------------+-----------------------+ | 36. | Release the air in | - If the air is | | | the cuff slowly so | released too | | | that the pressure | slowly from the | | | goes down at the rate | cuff, there will | | | of 2-3mmhg/second and | be congestion in | | | listen for the sound | the extremity | | | (first distinctly | causing false | | | loud muffling sound | reading and if it | | | is systolic pressure) | is released too | | | | rapidly sounds | | | | may not be heard | | | | at accurate | | | | levels | +-----------------------+-----------------------+-----------------------+ | 37. | Continue to release | - Diastolic is when | | | the air evenly and | the blood flows | | | slowly (last soft | easily in the | | | muffling sound is the | brachial artery | | | diastolic pressure) | and it is | | | | approximately | | | | equivalent to the | | | | amount of | | | | pressure normally | | | | present on the | | | | walls of the | | | | arteries when the | | | | heart is at rest | +-----------------------+-----------------------+-----------------------+ | 38. | After the final sound | - To release the | | | has disappeared | remaining the air | | | deflate cuff rapidly | from the cuff and | | | and completely | prevent | | | | congestion in | | | | extremity | +-----------------------+-----------------------+-----------------------+ | 39. | Roll the cuff and | - This method of | | | place in the case. | removing dirt | | | Wipe the earpiece of | prevents possible | | | the stethoscope with | cross infection | | | antiseptic swab and | of the ears | | | put back in its | | | | proper place | | +-----------------------+-----------------------+-----------------------+ | 40. | Document and report | - Serves as | | | pertinent date | baseline data for | | | | health care | | | | providers | +-----------------------+-----------------------+-----------------------+ | 41. | Wash hands | - Reduces | | | | transmission of | | | | microorganisms | +-----------------------+-----------------------+-----------------------+ **CHECKLIST IN ASSESSING VITAL SIGNS** **NAME: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ DATE: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** **COURSE / YEAR/ SECTION: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ SCORE: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** ---------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------- --------------------------------- --------------------------- **NO** **PROCEDURE** **ABLE TO PERFORM (3)** **PERFORM WITH ASSISTANCE (2)** **UNABLE TO PERFORM (1)** **PREPARATION** 1. Assess the client's physical status 2. Explain procedure 3. Draw curtain around bed and/or close door 4. Assemble the equipment and supplies and functionality of instruments 5. Wash hands **ASSESSING THE TEMPERATURE TAKING AXILLA METHOD** 6. Assess client's skin if warm to touch 7. Assist client on supine or sitting position 8. Clean the digital thermometer from bulb to stem in rotating motion using soft tissue or cotton balls with alcohol 9. Remove clothing or gown away from shoulder and arm 10. Raise clients' arm away from torso, insert into center of axilla, lower arm over bulb and place arm across client's chest 11. Leave thermometer in place for about 1-2 minutes or until you hear a beep sounds for accurate reading then remove thermometer 12. Read the temperature result 13. Wipe thermometer from stem to bulb with firm rotating motion using soft tissue or cotton balls with alcohol and return to its protective case 14. Assist the client in replacing clothing or gown 15. Wash hands 16. Record and evaluate the temperature **ASSESSING PULSE RATE** 17. Assess client's condition and check nature of pulse 18. Assist client to a comfortable resting position 19. Have the patient rest his arm alongside of his body with the wrist extended and palm of the hands downward or the forearm can rest at a 90-degree angle across the chest 20. Place the tips of your middle three fingers on the palm side of the client's wrist where radial pulse is located 21. Apply enough pressure that you can feel the pulse (not too hard not too light) 22. Using a watch with a second hand count the number of pulsations felt on the client for one full minute 23. Assess the pulse rhythm, if the pulse is abnormal repeat the counting to determine accurately and document the pulse rate **ASSESSING RESPIRATORY RATE** 24. Hold client's wrist as if you are taking his/her pulse, if you anticipate this, place a hand against the client's chest to feel the chest movements with breathing 25. Note rise and fall of the client's chest with each respiration 26. Using a watch with second hand, count the number of respiration for one full minute 27. Record and evaluate respiratory rate **ASSESSING THE BLOOD PRESSURE** 28. Explain the next procedure and ask permission if you can proceed 29. Place the 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) 30. Place the cuff so that the inflatable bag is centered over the brachial artery, approximately midway on the arm so that the lower edge of the cuff is about 2.5cm (1 to 2 inches) above the inner aspect of the elbow 31. Wrap the cuff around the arm smoothly and snugly (not too loose, not too tight) 32. Feel the pulse beat over the brachial artery at the inner aspect of the elbow with the use of finger tips. 33. Turn valve clockwise to close and compress bulb until pulsation disappears, then slowly release valve (deflating cuff). Note reading where pulse disappear 34. Place stethoscope earpiece in your ears. Place the diaphragm of your stethoscope over the brachial pulse. Don't allow the head of the stethoscope to touch clothing of cuff 35. Turn the valve clockwise to close and compress bulb, add 30mmhg above points where palpated pulse disappear 36. Release the air in the cuff slowly so that the pressure goes down at the rate of 2-3mmhg/second and listen for the sound (first distinctly loud muffling sound is systolic pressure) 37. Continue to release the air evenly and slowly (last soft muffling sound is the diastolic pressure) 38. After the final sound has disappeared deflate cuff rapidly and completely 39. Roll the cuff and place in the case. Wipe the earpiece of the stethoscope with antiseptic swab and put back in its proper place 40. Document and report pertinent date 41. Wash hands **TOTAL: 123** ---------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------- --------------------------------- --------------------------- **Remarks:**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **Clinical Instructor's Name & Signature Student' Name & Signature**