Self-Learning Workbook

Related Learning Experience

RLE FOCUS: Develop the student’s basic skills in the care of individual and families.
COURSE CODE: CP 100
COURSE NAME/ TITLE: Clinical Practicum 100
COURSE DESCRIPTION:
This course develops the student’s basic skills in the care of individual and families.
PROGRAM OUTCOMES:
The graduates of the program can:
a. give the necessary supervision, care, and advice to women during pregnancy, labor, and
postpartum period.
b. manage normal deliveries on her own responsibility and care for the child.
c. perform primary health care services within the community ( promotive & preventive care)
d. counsel and educate women, family and community regarding family planning including
preparation for parenthood/parenting.
e. detect abnormal conditions in the mother and infant
f. obtain specialized assistance as necessary (consultation or referral)

LEVEL, OFFERING, ACADEMIC YEAR & SEMESTER:

LEVEL I-AY 2022-2023: First Semester
CLINICAL AREA OF ASSIGNMENT:
SKILLS LABORATORY
DATE OF CLINICAL EXPOSURE:
AUGUST- DECEMBER 2022
NUMBER OF HOURS:
3 Units /153 HOURS
MODULE OVERVIEW:

Midwife is a profession that requires intensive training on both theories and clinical perspective.
The course subject deals with the basic skills in the care of individual and families. It develops the
necessary competencies in instituting nursing measures to the clients and student will learn to apply
these procedures and techniques in the Midwifery Care. A total of 153 hours related learning
experience, students will be catered to a flexible clinical learning experience through this self-
instructional module. Remember, this might not be a substitute for the actual clinical experience but
this can help you navigate through your patient care experiences in this alternatives learning platform.
LEARNING MAP: At the end of the semester, the students will have:
Develop the necessary competencies in instituting nursing measures including drug administration.

Course Content:
LESSON I: DATA COLLECTION
A. History Taking
B. Physical assessment
C. Vital Signs
LESSON II: NURSING MEASURES:
A. PREVENTIVE:
1. Aseptic technique
1.1. Hand washing
1.2. Donning and removing on facemask, Gown and gloves
1.3. Opening sterile packs
2. Body mechanics
2.1. Positions
LESSON III. COMFORT MEASURES:
1. Bed making
2. Hygiene
2.1. Oral Care
2.2. Cleansing bed bath
2.3. Perineal flushing
2.4. Partial bath
2.5. Tub bath
3. Correct Massage technique
4. Heat and cold application
5. Rest and sleep
6. Nutrition
7. Elimination
7.1. Inducing urination
7.2. Catheterization
LESSON IV: COMMON EMERGENCY MEASURES:
1. First Aide for:
● Burns

● Poisoning

● Fracture
 ● Bleeding

● Shock

● Unconsciousness
2. Basic life support
● CPR

LESSON V: DRUG ADMINISTRATION:

1. Classification of drugs
a. types of medication
2. Routes
3. Administration
4. Drugs and solution
 Module 1
Data Collection
History Taking , Physical Assessment and Vital Signs
This module presents the process of Data collection through History Taking, Physical assessment with
Vital Signs taking.

Objective
[Link] skills in collecting patients data.
[Link] and apply the components of the head- to- toe assessment.
3. Incorporate the four assessment techniques within the head- to- toe assessment.
[Link] the head-to-toe assessment in clinical situation.

How are to going to learn?

1. Read and understand carefully the module objectives
2. Answer the quiz or exercises in the module.
3. Accomplish all the exercises in the module. Interpretation of the exercises shall be submitted to
the faculty concerned for assessment
4. Expect that there will be quizzes to be posted to the Google classroom
5. Read through the requirement and try to perform the required tasks. Fill up the template for the
data required from you

PHYSICAL ASSESSMENT
Definition - is a complete health assessment maybe conducted starting at the head and
proceeding in a systematic manner downward head to toe assessment?

THERE ARE SOME PURPOSES OF THE PHYSICAL EXAMINATION:

- To obtain baseline data about the client functional abilities.

- To supplement, confirm or refute data obtained in the nursing history.
- To obtain data that will help establish nursing diagnosis and plans of care.
- To evaluate the physiologic outcomes of health care and thus the progress of a client health
problem.
- To make clinical judgement about a client health status.
- To identify areas for health promotion and disease prevention.

METHODS OF EXAMINING:
 A. INSPECTION:
- the visual examination, that is assessing by using the sense of sight.

The Midwife inspect with the naked eye and with a lighted instrument such as an otoscope (use to view
the ear). In addition to visual observations, olfactory (smell) and auditory (hearing) cues are noted.
Midwife frequently use visual inspection to assess moisture, color, and symmetry of the body. Lighting
must be sufficient for the midwife to see clearly.; either natural or artificial light can be used. When using
the auditory senses, it is important to have a quiet environment for accurate hearing. Observation can be
combined with the other assessment techniques.
B. PALPATION:
- the examination of the body using the sense of touch.

The pads of the fingers are used because their concentration of nerves ending makes them highly sensitive
to tactile discrimination. Palpation is use to determine (a) texture, example: hair (b) temperature, example:
skin area, (C) Vibration, example: of a joint, (d) position, size, consistency and mobility of organs or
masses, (e) distention, example: of the urinary bladder, (f) pulsation and (g) the presence of pain upon
pressure.

TWO TYPES OF PALPATION:

LIGTH (SUPERFICIAL) PALPATION:
- should always precede deep palpation because heavy pressure on the fingertips can dull the sense of
touch. For light palpation, the midwife extends the dominant hands fingers parallel to the skin surface and
presses gently while moving the hand in a circle. With light palpation, the skin is slightly depressed. If it
is the necessary to determine the details of a mass, the midwife presses lightly several times rather than
holding the pressure.
DEEP PALPATION:
- using the lower hand to support the body while the upper hand palpates the organ
- done with two hands (bimanually) or one hand. In deep bimanual palpation, the midwife extends the
dominant hand as for light palpation., then places the finger pads of the non dominant hand on the dorsal
surface of the distal interphalangeal joint of the middle three fingers of the dominant hand. The top hands
apply pressure while the lower hands remain relax to perceive the tactile sensations. For deep palpation
using one hand, the fingers pad of the dominant hand press over the area to be palpated often the other
hand is used to support a mass an organ from below.
Deep palpation is usually not done during a routine examination and requires significant
practitioner skill. It is performed with extreme caution because pressure can damage internal organ. It is
usually not indicated in clients who have acute abdominal pain that is not yet diagnosed.
The effectiveness of palpation depends largely on the client relaxation. Midwife can assist a client to relax
by gowning or draping a client appropriately. (B) positioning the client comfortably, and (c) ensuring that
their hands are warm before beginning. During palpation the midwife should be sensitive to the client
verbal and facial expression indicating discomfort.
Characteristics of Masses:
Location – site on the body, dorsal/ventral surface
Size – length and width in centimeters
Shape – oval, round, elongated, irregular
Consistency – soft, firm, hard
Surface – smooth, nodular
Mobility – fixed, mobile
Plasticity – present or absent
Tenderness – degree of tenderness to palpitation
C. PERCUSSION:
- the act of striking a body surface to elicit sounds that can be heard or vibration that can be felt.

TWO TYPES OF PERCUSSION:

1. DIRECT PERCUSSION
- Using one hand to strike the surface of the body
- The midwife strikes the area to be percussed directly with the pads of two three
or four fingers or with the pad of the middle finger. The strikes are rapid, and the
movement is from the wrist. This technique is not generally use to percuss the thorax
but is useful in percussing in adult sinuses.
2. INDIRECT PERCUSSION:
- Using the finger of one hand to tap the finger of the other hand
- the striking of an object held against the body area to be examined. In this technique,
the middle finger of the non dominant hand, referred to as the perimeter, is placed
firmly on the client’s skin. Only the distal phalanx and joint of this finger should be
in contact with the skin. Using the tip of the flexed middle finger of the other hand,
called the plexor, the nurse strikes the perimeter, usually at the distal interphalangeal
joint.
Flatness – is an extremely dull sound produced by very dense tissue, such as muscle or bone.
Dullness – is a thud like sound produced by dense tissue such as liver, spleen, or heart.
Resonance – is a hollow sound such as that produced by lungs filled with air.
Hyper resonance – is not produced in the normal body. It is described as booming and can be heard over
an emphysematous lung.
Tympany – is a musical or drum like sound produced from an air-filled stomach.
On a continuum, flatness reflects the densest tissue (the least amount of air) and tympany the least dense
tissue (the greatest amount of air). A percussion sound is described according to its intensity, pitch,
duration, and quality.
D. AUSCULTATION
- the process of listening to sounds produced within the body. Auscultation may be
direct or indirect.
 a. Direct Auscultation – the use of unaided ear, for example, to listen to respiratory wheeze or the
grating of a moving joint
b. Indirect Auscultation – the use of a stethoscope, which transmits the sound to the nurse’s ears.
Stethoscope is used primarily to listen to sounds from within the body, such as bowel sounds or
valve sounds of the heart and blood pressure.

Auscultated sounds are described according to their pitch, intensity, duration and quality.

Pitch – the frequency of the vibrations (the number of vibrations per second). Low pitched
sounds, such as some heart sounds, have fewer vibration per second than high pitched sounds
such as bronchial sounds.
Intensity- (Amplitude) refers to the loudness or softness of a sound. Some body sounds are loud,
for example normal breath sounds heard in the lungs.
Duration- a sound is its length (long or short)
Quality- sound is a subjective description of a sound for example, whistling, gurgling, or
snapping.

GENERAL SURVEY:

Health assessment- begins with general survey that involves observation of the client’s general
appearance and mental status, and measurement of vital signs, height, and weight. Many
components of the general survey are assessed while taking the clients health history, such as the
clients body build, posture, hygiene, and mental status.

-A comprehensive health assessment encompasses the physical, psychological, social and

spiritual dimensions of a person. Physical health includes basic function such as breathing eating
and walking. Psychological health includes intellect, self -concept emotion and behaviors, Social
dimensions of health involve relationship interactions among family members, friends, and co-
worker.

Appearance and Mental status:

The general appearance and behavior of an individual must be assessed in relationship
to culture, educational level, socio economic status, and current circumstances. For example, an
individual who has recently experienced a personal loss may appropriately appear depressed (sad
expression, slumped posture. The client age, sex, and race are also useful factors in interpreting
findings that suggest increased risk for known condition.

Data Collection
[Link] Data
[Link] Complain
[Link] of Present Illness
[Link] Health History
 [Link] History of Illness
[Link] data
7..Review of System

PHYSICAL ASSESSMENT

● Prepare the client

[Link] the procedure and to lessen the anxiety while doing the procedures or assessment
 [Link] client used empty the bladder before examination
[Link] sequence of assessment differs with children and adults; children always proceed with the least
invasive or uncomfortable aspect of the exam
● Prepare the Environment
[Link] environment needs to be well lighted and the equipment should be organized for efficient use
[Link] privacy

Methods of Examination

A. Inspection
● Performed first because it is the least invasive physical
assessment technique.
● Use of the naked eye to visually observe and examine the
patient.
● Also involves using the sense of smell.
B. Auscultation
● Performed after inspection because it is more invasive than
inspection and before percussion and palpation because these
steps can alter the results of auscultation.
● Use of the ears to listen for sounds produced by the body.
C. Percussion
● Performed after auscultation because it is more

● invasive than auscultation and before palpation because

palpation can alter the results of percussion. Use of fingers to
strike a patient’s body part directly to elicit a sound or
vibration.
[Link]
● Performed last after percussion.

● Use of the fingers or hands to apply pressure to the external

surface of the body to feel for deviations in the skin or
determine underlying structures below the skin.
● Palpate tender or painful areas last; observe for grimacing,
response to initiation or release of pressure, and reports of
discomfort or pain.

The position of the hand

for light Palpation
 The position of the hands
for deep bimanual
palpation
Palpation

Deep Palpation using the

lower hand to support
the body while upper
hand palpates the organ

Direct percussion. Using

one hand to strike the
surface of the body

Percussion

Indirect Percussion, Use

finger of one hand to tap
the finger of the other
hand.

PERCUSSION SOUND AND TONE

Sound Intensity Pitch Duration Quality Location

Flatness Soft High Short Extremely Muscle, Bone

Dull
 Dullness Medium Medium Moderate Thudlike Liver, Heart

Resonance Loud Low Long Hollow Normal Lung

Hyperesonance Very Loud Very Low Very Long Blooming Emphysematous

lung

Tympany Loud High Moderate Musical Stomach filled

with gas

PHYSICAL ASSESSMENT

● General Survey
Assess for the Body frame / Built ,Posture, Gait ,Grooming Physical Deformities and Vital Signs
● SKIN

Assess for the skin color, texture, lesions its location and size.
● HAIR
Lifespan Consideration

Infants It is normal for infant to have either very little or a great deal of body and
scalp hair

Children As puberty approaches, axillary and pubic hair will appear

Older Adults Older adults may experience a loss of scalp public and axillary hair
Hairs of the eyebrows, ears and nostrils became bristle like and coarse

● NAILS

Blanch Test
- Can be carried out and test the capillary refill, that is peripheral circulation,
-Normal bed capillaries blanch when pressed , but quickly turned pink or their usual color
when pressure is released
-a slow rate of capillary refill may indicate respiratory problem
 Normal Nail Showing convex shape and
the nail plate angle of about
160 degrees

Spoon – shape nails Which may be seen in

client with iron deficiency
anemia

Early clubbing

Late clubbing May caused by long term

oxygen deficit

Beau’s line on the nail May result form sever

injury or illness

● Eyes and Vision

 Testing distance vision

Assessing the client’s left peripheral visual fields

Visual fields the area an individual can see when looking straight
Visual aquity the degree of detail the eye can discern in an image

● EARS
Inspect Auricle , Ear Canal

Assess auditory acuity to spoken or whispered voice

If hearing is diminished use a tuning fork
Test Lateralization ( Weber Test ) or Compare air an bone conduction (Rinne test )
● NOSE
Inspect External Nose , Nasal Mucosa and Position of Nasal Septum
● MOUTH and PHARYNX
Assess for the lips, oral mucosa, gums, teeth, roof of the mouth, tongue
 For Pharynx assess for the color, presence or size of tonsils and symmetry of the soft palate.
● NECK
Inspect the neck
Palpate superficial and deep anterior, posterior cervical and super clavicular lymph nodes
Inspect and palpate position of the trachea
Inspect thyroid gland at rest and as the patient swallows.
● BREAST AND AXILLA

Assess for the size, symmetry, contour, appearance of the skin

Inspect Nipples , compare sizes , shape , note rashes or lesions

Palpate breast for tenderness and nodules

Vertical strip
Pie Wedge

Concentric circles

A. Nonpreganant
B. Preganant
C. during laction
 Clinical Breast Examination

● Done by the healthcare professional

● Every 3 years from age 20-40 an yearly after the age of 40 and up

● CHEST AND LUNGS

Rate and Rhythm of Breathing

Assess for the symmetry
Palpate for tenderness or visible deformities
Percuss each chest

● HEART

Cardiac Auscultation Sites

Heart Sound Location Physiology Description

S1 Mitral and triscupid Beginning of systole Lub; Dull, low pitched

Area while sitting sound

S2 Aortic and pulmonic Closure of valves between Dub ; Hinger in pitch an

areas while sitting the ventricles and the dshorter in length tha S1
arteries exiting the heart

S3 Apical site and patient Early in diastole ee:Gallop tempo when

in left lateral-position combined S1 and S2; lub-
Immediately after S2
dub-ee
Produced by rapid
ventricular filling

S4 Apical site with patient Late in diastole Presystolic gallop that has
I left- lateral position a rhythm like the FLOrida
Immediately before S1
Heart in some athletes and
Produced by rapid
older adults
ventricular filing
Associated with
hypertension , coronary
artery disease and
 pulmonic stenosis

● ABDOMEN

Inspect for the symmetry , scars and lesions.

Auscultate the four quadrants
Palpate light and deep palpation, Asses for lumps and bumps
Abdomen

Right Upper Quadrant Left Upper Quadrant

Liver, Gall bladder, Head of Pancreas,Right Stomach, Spleen, Body of Pancreas, Left Kidney,
Kidney , Large Intestine, Small Intestine Large Intestine, Small Intestine

Right Lower Quadrant Left Upper Quadrant

Appendix, Right Ovary , Large Intestine, Small Left Ovary , Large Intestine, Small Intestine
Intestine

Stria Stretch Marks

Hernias A protrusion of abdominal organs

Distenstion Swelling by intestinal gas , tumor or fluid in the abdominal cavity

Peristalsis Movement of contents through the intestine , which is normal function

of small and large intestine

Boborygami Growling sound which are hyperactive bowel sounds

Rebound Tenderness The pain may experience when the nurse quickly lifts his or her hand
away after pressing it deeply into the involved area

Aneurysm Is a localized dilation of vessel wall

● Musculoskeletal Sytstem

Goniometer – an instrument that measures the precise degree of motion in a particular joint
Assess for the patients posture

Description
Kyphosis Hunchback, an exaggeration of
the posterior curvature of the
thoracic spine

Lordosis A swayback, an increase lumbar

curvature

Scoliosis Lateral spinal curvature

Osteoporosis Metabolic bone disease that

causes decrease in quality and
quantity of bone

UPPER EXTREMITIES
Arms
Inspect for size, symmetry and swelling
Palpate radial and brachial pulse
LOWER EXTREMITIES
Legs
Inspect for size, symmetry and swelling
Venus Pattern
Color and texture of skin
Palpate and Grade pulses
Palpate edema

GENITALIA
Assess for Sexual Health
A. Female Genitalia
Ask the following if applicable.
Menarche, Menstruation, Menopause, Bleeding and Pregnancy
B. Male Genitalia
Assess Penile Discharge, Lesion or pains, Hernias
Male/ Female Homologues

Male Female

Penis Clitoris

Testes Ovaries

Scrotum Labia Majora

Prostate gland Skene’s gland

Cowper’s gland Bartholin’s gland

Rectum and Anus

- Inspect the anus and surrounding tissue for the color,integrity and skin lesions

Infants L:ightly touching the anus result in a brief and contraction

(‘wink” relax)

Children Erythema and scratch makes around the anus indicate a

pinworm parasites

Older Adults Chronic constipation and straining at stool cause an

increase in the frequency of hemorrhoids and metal
prolapse

Vital signs, also called the Cardinal signs are the blood pressure, pulse rate, respiratory rate, and the
temperature. Pain is considered as the fifth vital sign. Vital signs serve as important indicator of the client’s condition.

TIMES TO ASSESS VITAL SIGNS

1. Upon admission to the health care agency to obtain baseline data.
2. When a client has a change in health status or reports symptoms such as chest pain, or feeling hot or faint.
3. Before and after surgery or an invasive procedure.
4. Before and after the administration of medication that could affect the respiratory or cardiovascular systems.
5. Before and after any nursing interventions that could affect the vital signs
A. BODY TEMPERATURE

Body temperature reflects the balance between the heat produced and the heat lost from the body,
measured in heat units called degrees.

TWO KINDS OF BODY TEMPERATURE

1. CORE TEMPERATURE – Is the temperature of the deep tissues of the body, the abdominal cavity and
pelvic cavity.
2. SURFACE TEMPERATURE – Is the temperature of the skin, the subcutaneous tissue and fat. It, by
contrast, rises and falls in response to environment.

HEAT BALANCE – When the amount of heat produced by the body equals the amount of heat loss.

FACTORS AFFECTING THE BODY’S HEAT PRODUCTION

1. BASAL METABOLIC RATE (BMR) – is the rate of energy utilization in the body required to maintain
essential activities such as breathing, metabolic rates decrease with age. In general, the younger the
person, the higher the BMR.
2. MUSCLE ACTIVITY – muscle activity, including shivering, increases the metabolic rate.
3. THYROXINE OUTPUT – increased thyroxine output increases the rate of cellular metabolism throughout
the body. This effect is called “Chemical Thermogenesis”, the stimulation of heat production in the body
through increased cellular metabolism.
4. EPINEPHRINE, NOREPINEPHRINE, AND SYMPATHETIC STIMULATION – these hormones immediately
increase the rate of cellular metabolism in many body tissues. Epinephrine and norepinephrine directly
affect liver and muscle cells, thereby increasing cellular metabolism.
5. FEVER – it increases the cellular metabolic rate and thus increases the body’s temperature further.

MECHANISMS OF HEAT IS LOST FROM THE BODY

1. RADIATION – is the transfer of heat from the surface of one object to the surface of another without contact
between the two objects, mostly in the form of infrared rays.
2. CONDUCTION – is the transfer of heat from one molecule to a molecule of lower temperature.
3. CONVECTION – is the dispersion of heat by air currents.
4. VAPORIZATION – is the continuous evaporation of moisture from the respiratory and from the skin.
a. INSENSIBLE WATER LOSS – is the continuous and unnoticed water loss.
b. INSENSIBLE HEAT LOSS – the accompanying heat loss.

FACTORS AFFECTING BODY TEMPERATURE

1. AGE. Children’s temperature continues to be more available than those of adults until puberty. Older people
(75 y/o) are at risk of Hypothermia (temperature less than 36 oC or 96.8oF) because of inadequate diet, loss
of subcutaneous fat, lack of activity, and reduced thermoregulatory efficiency. Older people are also
particularly sensitive to extremes in the environmental temperature due to decreased thermoregulatory
controls.
2. DIURNAL VARIATIONS (CARDIAN RHYTHMS). Body temperature change throughout the day, varying as
much as 1.0oC (1.8oF) between the early morning and the late afternoon. Point of highest body temperature
is usually reached between 8pm and midnight, and the lowest point is reached during sleep between 4AM
and 6AM.
3. EXERCISE. Hard work or strenuous exercise can increase body temperature as high as 38.3 to 40oC (101 –
104oF) rectally.
4. HORMONES. Women’s temperature increases because of progesterone secretion at the time of ovulation
for about 0.3 to 0.6oC ( 0.5 to 1o F ).
 5. STRESS. Stimulation of the sympathetic nervous system can increase the production of “epinephrine and
nor epinephrine”, thereby increasing metabolic activity and heat production.
6. ENVIRONMENT. Increase environmental temperature, increases body temperature, or vice versa.
7. FOOD INTAKE. A high caloric, energy giving food increased temperature. Fasting or starvation decreases
temperature due or minimal metabolism or less energy and heat production.

ALTERATIONS IN BODY TEMPERATURE

1. PYREXIA – a body temperature or above usual range (also called HYPERTHERMIA ) or in lay terms
FEVER.
HYPERPYREXIA – is a very high fever such as 41oC (105.8oF), client who has fever is referred to
as “FEBFRILE”; thereof who has not is “AFEBRILE”.
HYPOTHERMIA – is a core body temperature below the lower limit of normal.

PHYSIOLOGIC MECHANISMS OF HYPOTHERMIA

1. Excessive heat
2. Inadequate heat production to counteract heat loss
3. Impaired hypothalamic thermoregulation.

COMMON TYPES OF FEVER

1. INTERMITTENT FEVER – alternate regulating between period of pyrexia; the body temperature alternates
at regular intervals between periods of fever and periods of normal or subnormal.
2. CONSTANT FEVER – the body temperature fluctuates minimally but always remains above normal;
Temperature remains constantly high during the day and night and varies slightly but does not fall below the
moderately high fever.
3. RELAPSING FEVER – short febrile periods of a few days interspersed with periods of 1 or 2 normal
temperature ( elevated for several days )
4. REMITTENT – a wide range of temperature fluctuations (more than 2 oC/3.6oF) occurs over the 24 hour
period, all of with are above normal ( fluctuates for several degrees )

FEVER SPIKE – a temperature that rises to fever level rapidly following a normal temperature then returns to
normal within a few hours.

OTHER KINDS OF THERMOMETER

1.) ELECTRONIC THERMOMETER – can provide a reading in 2 to 60 seconds depending on the model. It
consists of a battery operated portable electronic unit.
2.) CHEMICAL DISPOSSABLE THERMOMETERS – using liquid crystal dots or bars or heat sensitive tapes,
or patches applied to the forehead change color to indicate temperature.
3.) TEMPERATURE SENSITIVE TAPE – contains liquid crystal that change color according to temperature.
When applied to the skin, usually of the forehead.
4.) INFRARED THERMOMETER – sense body heat in the form of infrared energy given off by a heat source,
which the ear canal is primarily the tympanic membrane.

ADVANTAGES AND DISADVANTAGES OF THE FOUR SITE OF BODY TEMPERATURE

SITES ADVANTAGES DISADVANTAGES
ORAL Accessible and convenient Inaccurate if client just ingested hot or cold food,
liquid, or smoked

Could injure the mouth following oral surgery

RECTAL Reliable measurement Inconvenient and more unpleasant for clients
 Difficult for client who cannot turn to the side

Could injure the rectum after rectal surgery

A rectal glass thermometer does not respond to

changes in arterial temperature as quickly as an
oral thermometer, a fact that maybe potentially
dangerous for febrile clients because misleading
information may be acquired.

Presence of stool may interfere the thermometer

placement. Is the stool is soft, the thermometer
may be embedded in stool rather than against the
rectum’s wall.

AXILLARY Safe and non-invasive The thermometer must be left in place a long
time to obtain an accurate measurement

TYMPANIC Readily accessible Can be uncomfortable and involve risk of

MEMBRANE Reflects the core temperature injuring the membrane if the probe is inserted too
Very fast far

Repeated measurements may vary. Right and left

measurement can differ.

Presence of cerumen can affect the reading

CONVERSION

Fahrenheit to Centigrade Centigrade to Fahrenheit

Formula: oC = (oF – 32) x 5/9 Formula: oF = (oC x 9/5) + 32

B. PULSE

PULSE – is a wave of blood created by the contraction of the left ventricle of the heart.
CARDIAC OUTPUT – is the volume of blood pumped into the arteries by the heart and equals the
stroke volume (SV) times the heart rate (HR) per minute.
PERIPHERAL PULSE – is a pulse located away from the heart.
APICAL PULSE – in contrast, is a central pulse; that is located at the apex of the heart.

FACTORS AFFECTING PULSE

1. AGE. As the age increases, the pulse gradually decreases.
2. GENDER. After puberty, the average male’s pulse rate is slightly lower than the female.
3. EXERCISE. The pulse rate normally increases with activity.
 4. FEVER. The pulse rate increases in response to the lowered blood pressure that results from
peripheral vasodilation associated with elevated body temperature and because of increase
metabolic rate.
5. MEDICATIONS. Some medications decrease the pulse rate and others increase.
6. HEMORRHAGE. Loss of blood from the vascular system normally increases pulse rate.
7. STRESS. In response to stress, sympathetic nervous stimulation increases the overall activity of
the heart. Stress increases the rate as well as the force of the heartbeat.
8. POSITION CHANGES. When a person assumes a sitting or standing position, blood usually
pulls in dependent vessels of the venous system.

PARAMETERS IN ASSESSING PULSE

1. PULSE RATE – expressed in beats per minute.
TACHYCARDIA – excessively fast heart rate
BRADYCARDIA – slow or low heart rate
2. PULSE RHYTHM - pattern of the beats and the intervals between beats.
DYSRRHYTHMIA – pulse with irregular rhythm
ARRHYTHMIA – pulse with no rhythm
REGULAR - evenly spaced beats
REGULARLY IRREGULAR – regular pattern overall w/ “skipped” beats
IRREGULARLY IRREGULAR – chaotic w/ no discernable pattern.
3. PULSE VOLUME – also called Pulse Strength or Amplitude, refers to the force of the blood
with each beat.

SCALE FOR MEASURING PULSE VOLUME

SCALE DESCRIPTION OF PULSE
0 Absent, not discernible
1 Thready or weak, difficult to feel
2 Normal, detected readily, obliterated by strong pressure
3 Bounding, difficult to obliterate

4. ELASTICITY OF ARTERIAL WALL – its expansibility or deformities (straight, smooth, soft

& pliable)

PULSE SITES
 PULSE SITE LOCATION IN THE BODY REASONS FOR USE
TEMPORAL PULSE Superior and lateral to the eye Used when radial pulse is
inaccessible
CAROTID PULSE At the side of the neck, below the Used in cases of cardiac arrest
lobe of the ear
Used to determine the circulation
of the brain.
BRACHIAL PULSE Inner aspect or medial to the Used to measure blood pressure
antecubital space
Used in cases of cardiac arrest
for infants
RADIAL PULSE On the thumb side of the inner Readily accessible and routinely
aspect of the wrist used
FEMORAL PULSE Along the inguinal area Used in cases of cardiac arrest

Used for infants and children

Used to determine circulation to

the leg
POPLITEAL PULSE Behind the knee Used to determine blood pressure

Used to determine circulation to

the lower leg.
POSTERIOR TIBIAL PULSE Medial surface of the ankle Used to determine circulation to
the foot
DORSALIS PEDIS/PEDAL Found at the dorsum of the foot Used to determine circulation to
PULSE the foot
APICAL PULSE Located at the apex of the heart Routinely used for infants and
children up to 3 years of age
ADULT – left side of the chest
about 3 inches to the left of the Used in conjunction with some
sternum and at the 4th, 5th, or 6th medications
in intercostal space midclavicular
line. Used to determine the
discrepancies with radial pulse
BEFORE 4 YEARS OLD –
midclavicular line NOTE: Monitored by
Auscultation ( using
CHILDREN 7 TO 9 YEARS stethoscope )
OLD – 4th or 5th intercostal space

C. RESPIRATORY RATE

RESPIRATIONS – is the act of breathing.

TYPES OF RESPIRATIONS
1. EXTERNAL RESPIRATION – refers to the interchange of oxygen and carbon dioxide between the
alveoli of the lungs and pulmonary blood.
PHASES OF RESPIRATION
a. INHALATION OR INSPIRATION – refers to the intake of air into the lungs
b. EXHALATION OR EXPIRATION – refers to breathing out or the movement of gasses
from the lungs to the atmosphere.
2. INTERNAL RESPIRATION – by contrast takes place throughout the body; it is the interchange of
these same gasses between the circulating blood and the cells of the body tissue.

VENTILATION – refers to the movement of air in and out of the lungs.

HYPERVENTILATION – over expansion of the lungs.
HYPOVENTILATION – under expansion of the lungs.
TWO TYPES OF BREATHING
1. COSTAL BREATHING (THORACIC BREATHING) – involves the internal intercostal muscles and
other accessory muscles, such as the strenocleidomastoid muscles. It can be observed by the
movement of the chest upward and outward.
2. DIAPHRAGMATIC BREATHING (ABDOMINAL BREATHING) – involves the contraction and
relaxation of the diaphragm, and it is observed by the movement of the abdomen, which occurs as
a result of the diaphragm’s contraction and downward motion.

FACTORS AFFECTING RESPIRATION

1. AGE. As the age increases, the respiratory rate decreases. But in elderly, the respiratory rate
increases owing to decreased elasticity of the lungs and decreased efficiency of gas exchange.
2. BODY SIZE. Men have a larger vital capacity than women.
3. EXERCISE. Respiratory rate and depth will increase as a result of increased oxygen consumption
and carbon dioxide production.
4. MEDICATIONS. Some medications alter the respiration.
5. BODY POSITION. The supine position can significantly affect respiration due to compression of
the chest against the supporting surface and increased volume of intrathoracic blood.

PARAMETERS OF RESPIRATION
1. RESPIRATORY RATE – expressed in breaths per minute or cycles per minute.
● EUPNEA – breathing that is normal in rate and depth

● TACHYPNEA ( POLYPNEA ) – abnormally fast respiration

● BRADYPNEA – abnormally slow respiration

● APNEA – absence of breathing

2. RESPIRATORY VOLUME/DEPTH – amount of air with each breathe
● DEEP RESPIRATIONS – are those in which large volume of air is inhaled/exhaled, inflating
most of the lungs.
 ● SHALLOW RESPIRATION – involve the exchange of a small volume of air and often the
minimal use of lung tissue.
● HYPERVENTILATION – over expansion of the lungs; characterized by rapid and deep breaths

● HYPOVENTILATION – under expansion of the lungs; characterized by shallow respirations.

3. RESPIRATORY RHYTHM – regularity of the expirations and the inspirations. These can be
described as regular or irregular. Note that infant’s respiratory rhythm may be less regular than an
adult.
● CHEYNE STOKE BREATHING – rhythmic waxing and waning of respirations, from very deep
shallow breathing and temporary apnea. Often associated with cardiac failure, increased
intracranial pressure or brain damage.
4. RESPIRATORY QUALITY/CHARACTER – aspects of breathing that is different from normal,
effortless breathing. These are the sound of breathing and the amount of effort a client must exert
to breathe.
● DYSPNEA – difficult and labored breathing during which the individual has a persistent,
unsatisfied need for air and feels distressed.
● ORTHOPNEA – ability to breath only in upright sitting or standing position.

BREATH SOUNDS/ABNORMAL SOUNDS

Audible without amplification:
● STRIDOR – a shrill, harsh sound heard during inspiration with laryngeal obstruction.

● STERTOR – snoring or sonorous respiration

● WHEEZE – continuous, high pitched musical squeak or whistling sound occurring on expiration
and sometimes on inspiration when air moves through a narrowed or partially obstructed airway.
● BUBBLING – gurgling sounds heard as air passes through moist secretions in the respiratory tract.

Audible with amplification:

● CRACKLES (RALES) – dry or wet crackling sounds simulated by rolling a lock of hair near the ear.

● GURGLES (RHONCHI) – coarse, dry, wheezy or whistling sound more audible during expiration
as the air moves through tenacious mucus or narrowed bronchi.
● PLEURAL FRICTION RUB – coarse, leathery or grating sound produced by the rubbing together
of inflamed pleura.

D. BLOOD PRESSURE
 It is the measure of the pressure exerted by the blood as it flows through the arteries.

SYSTOLIC PRESSURE – pressure of the blood as a result of contraction of the ventricles (90 – 140
mmHg).
DIASTOLIC PRESSURE – pressure when the ventricles are at rest (60 – 90 mmHg).
PULSE PRESSURE – difference between the diastolic and systolic pressure. It is measured in millimeters
of mercury (mmHg) and recorded as a fraction.

DETERMINANTS OF BLOOD PRESSURE

1. PUMPING ACTION OF THE BLOOD. When pumping action of the heart is weak, less blood is
pumped into arteries (low Cardiac Output), blood pressure decreases. But when pumping action of
the heart is strong, the volume of the blood pumped into the circulation increases (high Cardiac
Output), blood pressure increases.
2. PERIPHERAL VASCULAR RESISTANCE. The smaller the space within a vessel
(vasoconstriction) the greater the resistance (increase BP).
3. BLOOD VOLUME. When the blood volume decreases (hypovolemia) the BP decreases.
Conversely, when the volume increases (hypervolemia) the BP increases.
4. BLOOD VISCOSITY. Increased blood viscosity, increases the BP. ( Viscosity increases when
hematocrit is more than 60 – 65 % )

FACTORS AFECTING BLOOD PRESSURE

1. AGE. Older people have higher BP due to decrease elasticity of the arteries.
2. EXERCISE. Physical activity increases cardiac output therefore increases BP.
● Allow 30 minutes for the client to rest before assessing BP.
3. STRESS. Stimulation of sympathetic nervous system increases cardiac output and
vasoconstriction, thus increases BP.
4. RACE. Black person have higher BP than white person.
5. GENDER. After puberty and before age 65 years, males have higher BP but after age 65 years,
females have higher BP due to hormonal variations in menopause.
6. MEDICATIONS. Some medications may increase or decrease BP.
7. OBESITY. Childhood and adult obesity predispose to hypertension.
8. DIURNAL VARIATIONS. BP is lowest in the morning when the metabolic rate is lower, and highest
in the late afternoon or early evening.
9. DISEASE PROCESS. Any condition affecting the cardiac output, blood volume, blood viscosity has
a direct effect on the BP.

BLOOD PRESSURE SITES

Is usually assessed in the client’s arm using the brachial artery and a standard stethoscope.

Assessing blood pressure on a client’s thigh is usually indicated in these situations:

1. The blood pressure cannot be measured on either arm (eg. Because of burns on the arm )
2. Blood pressure on one thigh is to be compared on the blood pressure on the other thigh.

Blood pressure is not measured on a client’s arm or thigh in the following situations:
1. The shoulder, arm or hand (or the hip, knee, or ankle ) is injured or diseased.
 2. A cast or bulky bandage is on any part of the limb
3. The client has had removal or axilla (or hip ) lymph nodes on that side.
4. The client has an IV infusion on that limb.
5. The client has an arteriovenous fistula ( eg. For renal dialysis ) in the limb

EQUIPMENT USED IN TAKING BLOOD PRESSURE

Blood pressure cuff, sphygmomanometer, and stethoscope are used to measure the blood pressure.
● BLADDER/CUFF - rubber bag that can be inflated with air. It is covered with cloth and has 2
tubes attached to it.
● VALVE – releases the air in the bladder if turned counterclockwise. If turned clockwise, valve
is tightened and air pumped into the bladder remains there.
● SPHYGMOMANOMETER – indicates the pressure of the air within the bladder.

TWO TYPES OF SPHYGMOMANOMETER

1. ANEROID SPHYGMOMANOMETER – is calibrated dial with a needle that points to the
calibrations.
2. MERCURY SPHYGMOMANOMETER – is a calibrated cylinder filled with mercury. The pressure is
indicated at the point to which the rounded curve of the meniscus rises.

HYPERTENSION – BP that is persistently above normal.

Primary Hypertension – elevated BP of unknown cause.
Secondary Hypertension – elevated BP of known cause.
HYPOTENSION – BP that is below normal.
Orthostatic Hypotension – BP that falls when the client sits or stands.
KOROTKOFF’S SOUND – series of sounds heard when taking BP

METHODS IN ASSESSING BLOOD PRESSURE

1. DIRECT MEASUREMENT (INVASIVE MONITORING) – involves the insertion of catheter into the
brachial, radial or femoral artery. This pressure reading is highly accurate.
2. INDIRECT METHODS (NON INVASIVE)
● Auscultatory Method – requires sphygmomanometer, a cuff and a stethoscope. When carried
out correctly, this method is relatively accurate.
● Palpatory Method – using a light to moderate pressure, palpates the pulsations of the artery as
the pressure in the cuff is released. Sometimes used when Korotkoff’s sounds cannot be heard
and electronic equipment to amplify the sound is not available.

COMMON ERRORS IN ASSESSING BLOOD PRESSURE

ERROR EFFECT
Bladder cuff too narrow False high
Bladder cuff too wide False low
Deflating cuff too slowly False high
Deflating cuff too quickly False low
 Cuff wrapped too loosely False high
Arm above the level of the heart False low

VITAL SIGNS

DEFINITION: Bodily functions that are indicator of a person’s health condition

PURPOSES:
1. To determine the course of illness, which serves as a guide in meeting the needs of the patient.
2. To give an opportunity to observe the general condition of the patient.
3. To aid the physician in making his diagnosis and planning patient’s care.

GENERAL CONSIDERATIONS:
1. Before vital signs are taken, be sure that the patient has rested.
2. Remember the frequency of taking the TPR/BP depends upon the condition of the patient and the
doctor’s order.
3. Explain the procedure to the patient so that he will feel at ease.

TEMPERATURE

DEFINITION: The balance between heat produced and heat loss.

SPECIAL CONSIDERATIONS:
1. Remember that the temperature is usually taken by mouth unless ordered or contraindicated.
2. Stay with the patient while thermometer is in place.
3. Provide individual Thermometer for each patient.
4. Use only oral Thermometer, for taking oral temperature and rectal thermometer for rectal
temperature.
5. When patient has diarrhea do not take temperature by rectum.
6. Using axillary method, see to it that the axilla is dry and the bulb of the thermometer is within the
hollow of the axilla.
7. Remember that the rectal temperature is taken on the following conditions only:
● When there is respiratory obstruction which prevents closure of the mouth

● When the mouth is dry and inflamed

● When there is oral or nasal surgery or disease

● When a patient is mouth breather

ARTICLES: Thermometer
Cotton balls
 Alcohol

Normal Body Temperature

Normal Range 36-37 C
Pyrexia 38-40 C
Hyperpyrexia 40.1 C and above
Heat Stroke Usually occurs around 41-41
Death 43 C and above
Hypothermia 35 c and below

Method of Temperature Taking Range

Oral 36.5 – 37.5 (97.6 – 99.6 C)
Axillary 35.8 – 37.0 (96.6-98.6 C)
Rectal 37.0 – 38.1 C (98.6 – 100.6 C
Tympanic 36.8 - 37.9 C (98.2 – 100.2 F)

ASSESSING BODY TEMPERATURE (AXILLA)

PREPARATION RATIONALE
1. Gather the equipment needed To save time and effort.
2. Check that all equipment is functioning normally. Ensure the accuracy of the data that
will be gathered.
PROCEDURE
3. Introduce yourself, and verify the client’s identity. To gain client’s cooperation.
Explain to the client what you are going to do, why it is
necessary, and how he or she can cooperate.
4. Wash hands and observe appropriate infection control To prevent cross contamination
procedures.
5. Provide for client privacy. Privacy keeps the patient from being
anxious to other patient
6. Place the client in the appropriate position. Move the
gown to expose the axilla.
7. Clean the thermometer using cotton ball with alcohol To prevent spread of microorganisms
starting from bulb to stem, using firm twisting motion.
8. Dry the thermometer using dry cotton ball starting from
bulb to stem, using firm twisting motion.
9. Wipe the axilla of the patient using paper towel in order Frictions may produce heat thereby
to dry it without using friction. resulting to inaccuracy.
10. Press the button.
11. Place the bulb of the thermometer into the center of the
axilla. Bring the patient’s arm down close to his body
and place his forearm over his chest.
12. Remove the thermometer when you heard a beeping
 sound. It means that the final reading is done.
13. Remove the thermometer. Clean the thermometer with To prevent spread of microorganisms
dry cotton ball from stem to bulb with one stroke only.
14. Read the thermometer. Press the button.
15. Clean the thermometer using cotton ball will alcohol To prevent spread of microorganisms
starting from the stem to bulb, using firm twisting
motion. Discard the cotton balls.
16. Wash hands. To prevent spread of microorganisms
17. Document the temperature in the client record.

ASSESSING BODY TEMPERATURE (RECTAL)

PREPARATION RATIONALE
1. Gather the equipment needed To save time and effort.
2. Check that all equipment is functioning normally. Ensure the accuracy of the data that
will be gathered.
PROCEDURE
3. Introduce yourself, and verify the client’s identity. To gain client’s cooperation.
Explain to the client what you are going to do, why it is
necessary, and how he or she can cooperate.
4. Wash hands and observe appropriate infection control To prevent cross contamination
procedures. Don gloves.
5. Provide for client privacy. Privacy keeps the patient from being
anxious to other patient
6. Place the client in Lateral or Sim’s position, and then
expose the buttocks of the patient.
7. Clean the thermometer using cotton ball with alcohol To prevent spread of microorganisms.
starting from bulb to stem, and then rinse it with water.
8. Dry the thermometer using dry cotton ball starting from
bulb to stem, using firm twisting motion.
9. Lubricate the rectal thermometer 1 to 2inches from the To facilitate easy insertion of the
bulb. thermometer.
10. Press the button.
11. Insert the thermometer (1 to 1½ inches for adult; ½ to 1 Taking a deep breath while inserting
inch for children). Instruct the patient to take a deep help the anal sphincter to relax and to
breath while inserting the thermometer. facilitate easy insertion of the
thermometer.
12. Remain with the client and leave the thermometer in
place until it beeps.
13. Remove the thermometer. Clean the thermometer with To prevent spread of microorganisms.
dry cotton ball from stem to bulb with one stroke only.
14. Read the thermometer and then press the button.
15. Clean the thermometer using cotton ball will alcohol To prevent spread of microorganisms.
starting from the stem to bulb, using firm twisting
motion. Discard the cotton balls.
 16. Remove gloves and wash hands. To prevent spread of microorganisms.
17. Document the temperature in the client record.

ASSESSING BODY TEMPERATURE (ORAL)

PREPARATION RATIONALE
1. Gather the equipment needed To save time and effort.
2. Check that all equipment is functioning normally. Ensure the accuracy of the data that
will be gathered.
PROCEDURE
3. Introduce yourself, and verify the client’s identity. To gain client’s cooperation.
Explain to the client what you are going to do, why it is
necessary, and how he or she can cooperate.
4. Wash hands and observe appropriate infection control To prevent cross contamination
procedures.
5. Provide for client privacy. Privacy keeps the patient from being
anxious to other patient
6. Place the client in the appropriate position.
7. Rinse the thermometer. Clean it using cotton ball with To prevent spread of microorganisms.
alcohol, and then rinse with water to remove the
alcohol.
8. Dry the thermometer using dry cotton ball starting from
bulb to stem, using firm twisting motion.
9. Press the button.
10. Place the bulb of the thermometer under the tongue.
11. Remove the thermometer when you heard a beeping
sound. It means that the final reading is done.
12. Remove the thermometer. Clean the thermometer
witdry cotton ball from stem to bulb with one stroke
only.
13. Read the thermometer. Press the button.
14. Rinse the thermometer. Clean it with cotton ball with To prevent spread of microorganisms.
alcohol, and rinse again. Dry using a cotton ball from
stem to bulb using firm twisting motion.
15. Wash hands. To prevent spread of microorganisms.
16. Document the temperature.

PULSE RATE

DEFINITION: The expansion of the arterial walls occurring with each ventricular contraction.
PURPOSE:
1. To count the number of times that the heart beats per minute.
2. To obtain information regarding condition of the heart action and patient’s general condition.
SPECIAL CONSIDERATIONS:
1. One complete rise and fall of the arterial wall is considered as one beat or one count
2. Take the pulse at a convenient site for the patient and the nurse.
3. When taking the pulse, note the rate, rhythm, volume and quality of the arterial wall.
4. Do not take the pulse when the patient is restless or when a child is crying.
5. If peripheral pulse is difficult to obtain, take the apical or cardiac rate.

ARTICLES: Watch with second hand

Paper and Pen

Age / Age Group Normal Values

Newborn 120-160 beats per minute
Toddler 90- 140 beats per minute
School Age 75-100 beats per minute
Adolescent 60- 90 beats per minute
Adult 60-100 beats per minute

ASSESSING RADIAL PULSE

PREPARATION RATIONALE
1. Gather the equipment needed To save time and effort.
2. Check that all equipment is functioning normally. To ensure accuracy of data that will
be gathered.
PROCEDURE
3. Introduce yourself, and verify the client’s identity. Gain client’s cooperation
Explain to the client what you are going to do, why it is
necessary, and how he or she can cooperate.
4. Provide for client privacy.
5. Position the client appropriately. Have the client lie
This position places the radial
down and rest his arm along the side of the body with
artery on the inner aspect of the
the wrist extended and the palm of the hand downward.
patient’s wrist. The nurse fingers
Or the client can sit with his or her forearm at a 90˚
rest conveniently on the artery with
angle to the body resting on a support and with the
the thumb in a position on the outer
wrist extended and the palm of the hand downward.
aspect of the patient’s wrist
6. Place the first, second, and third finger pads along the
The pads of the fingers are used
client’s radial artery, and press gently against the
because it is the most sensitive
radius; rest your thumb in position to fingers on the
area in detecting pulse. Thumb is
back of the client’s wrist. not used in palpating pulse
because it has an own pulse.
7. Apply one enough pressure so that the client’s If too much pressure is applied, the
pulsating artery can be felt distinctly. pulse might be obliterated. If the
pressure is too light, the pulse
 might not be detected.
8. Using a watch with second hand, count the number of Sufficient time is necessary for
pulsations for one full minute. accurate measurement.
9. Assess the rhythm while counting.
10. Record the pulse rate. Report any findings.

ASSESSING APICAL PULSE

PREPARATION RATIONALE
1. Gather the equipment needed To save time and effort.
2. Check that all equipment is functioning normally. To ensure accuracy of data that will
be gathered.
PROCEDURE
3. Introduce yourself, and verify the client’s identity. Gain client’s cooperation
Explain to the client what you are going to do, why it is
necessary, and how he or she can cooperate.
4. Wash hands
5. Provide client privacy.
6. Position the client appropriately in a comfortable Apical pulse is located at the apex
supine position. Expose the area of the chest over the of the heart.
apex of the heart.
7. Locate the apical impulse. This is the point over the
apex of the heart where the apical pulse can be most
clearly heard.
8. Palpate the fifth intercostal scape (for adults) and the To locate apical pulse correctly.
fourth intercostal space (for children) and move to the
left mid-clavicular line.
9. Clean the earpiece and diaphragm of the stethoscope
using cotton balls with alcohol.
10. Warm the diaphragm of the stethoscope by holding it
against your palm.
11. Insert the earpiece of the stethoscope into your ears in
the direction of the ear canals, or slightly forward.
12. Tap your finger lightly on the diaphragm. If necessary,
rotate the head to select the diaphragm.
13. Place the diaphragm of the stethoscope over the apical
impulse and listen to the normal S1, and S2 heart
sounds, which are heard as “lub-dub”. Each lub-dub is
counted as one heartbeat.
14. Assess the rhythm and strength of the heartbeat.
15. Document the pulse rate, rhythm, and volume.

RESPIRATORY RATE
DEFINITION: The process by which oxygen and carbon dioxide are interchanged.

PURPOSE:
1. To obtain the respiratory rate per minute.
2. To obtain an information of the patient’s respiratory status and general condition.

SPECIAL CONSIDERATION:
1. Note the rate, depth, and the character of respiration.
2. Note the color of the patient and his act of breathing while taking his respiration.

ARTICLES: Watch with second hand

Paper and pen

PREPARATION RATIONALE
1. Gather equipment and check if functioning well. To save time and effort
PROCEDURE
2. Introduce yourself, and verify the client’s identity. Promote client cooperation And
Explain to the client what you are going to do, why it obtain informed consent , through this
is necessary, and how he or she can cooperate. step is often omitted where there is a
danger that the person may
voluntarily control their breathing and
thus after the rate.
3. Wash hands. To prevent transfer of
microorganisms
4. Provide for client privacy.
5. If you anticipate the client’s awareness of respiratory Counting the respirations while
assessment, place the client’s arm across his/her presumably still counting the pulse
chest. Observe the patient’s respiration. keeps the patient from becoming
conscious of his breathing and
possibly altering the result.
6. Note the rise and the fall of the patient’s chest with One inspiration and expiration
each inspiration and expiration. constitutes one respiration.
7. Count for the required one full minute. Sufficient time is necessary for
accurate measurement and to
observe the depth and the
characteristics of respiration.
8. Observe the depth, rhythm, and character of
respirations.
9. Document the breathing characteristics, rate and
rhythm.

Respiration

Age Group Normal Values

New-born 30-80 rpm
Early childhood 20-40 rpm
Late Childhood 15-25 rpm
Adult male 14-18 rpm
Adult female 16-20 rpm

BLOOD PRESSURE

DEFINITION: The pressure that is exerted on the wall of the arteries when the left ventricle of the heart
pushes blood into the aorta.

PURPOSES:
1. To measure the systolic, diastolic, and the pulse pressure.
2. To determine certain physiologic changes that may occur.
3. To determine the pumping action of the heart.
4. To aid in diagnosis.
5. To evaluate the general condition of the patient.

SPECIAL CONSIDERATION:
1. Keep patient physically, and emotionally rested before taking the blood pressure.
2. For repeated reading, take the blood pressure in the same arm, in the same position, and time.
3. Take the blood pressure reading as quickly as possible to prevent venous congestion.
4. Allow for 20-30 seconds for venous circulation to normal if repeated reading as necessary.
5. Report promptly to the physician or to the head nurse any significant change in the blood pressure
reading.
6. Size of cuff should be appropriate to the size of the patient’s arm.

ARTICLES: Sphygmomanometer, Stethoscope, Paper and pen

Age Group Normal Values

New-born 80-40 mmHg
1-7 years old 100/65 mmHg
8-12 years 100/70 mmHg
Adult 120/80 mmHg
Elderly Systolic 100+ age in the elderly the
diastolic may raise also

PREPARATION RATIONALE
1. Gather equipment needed To save time and effort
2. Select a blood pressure cuff of an appropriate size Inappropriate Blood pressure cuff size
for the client. affects BP reading.
PROCEDURE
3. Introduce yourself, and verify the client’s identity.
Explain to the client what you are going to do, why
it is necessary, and how he or she can cooperate.
4. Perform hand hygiene To prevent transfer of microorganisms.
5. Provide for client privacy
6. Have the client assume a comfortable lying or This position places the brachial artery
sitting position with the forearm supported at a so that the stethoscope can rest on it
level of the heart and the palm of the hand upward. conveniently in the antecubital area.
7. Select appropriate arm for the application of cuff
( no intravenous infusion, breast or axilla surgery
on that side, cast, arteriovenous, shunt, or injured
or diseased limb).
8. Expose the area of brachial artery by removing Locating the artery allows you to place
garments, or move the sleeve up. the stethoscope for maximum
auscultation.
9. Place the lower edge of the bladder cuff 1 inch .
(2.5cm) above the antecubital space.
10. Wrap the cuff around the client’s arm properly. A twisted cuff and wrapping could
Check the gauge. It must be within the zero area. produce unequal pressure and thus
inaccurate reading.

Proper placement of the cuff and

pressure applied directly over the artery
will yield most accurate reading.
11. Palpate the brachial or the radial pulse by pressing
gently with the fingertips.
12. Tighten the screw valve on the bulb. Rubbing the stethoscope against an
object can obliterate the sounds of the
blood within an artery.
13. Inflate the bladder cuff while palpating the artery. This gives an estimate to the maximum
Note the point on the gauge where the pulse pressure required to measure the
disappears. systolic pressure
14. Deflate the cuff and wait for 1 to 2 minutes. A waiting period gives the blood trapped
in the veins time to be released.
Otherwise, false high systolic readings
will occur.
15. Clean the earpiece and the bell using cotton ball Sounds are heard more clearly when the
with alcohol. Place the stethoscope earpiece at the ear attachment follow the direction of the
ear properly. ear canal.
16. Place the bell of the stethoscope over the brachial
artery. Hold the diaphragm with the thumb and
index finger.
17. Inflate the cuff 30mmHg above the point at which If the rate is faster or slower an error in
 the pulse disappeared. Release the valve and measurement may occur.
allow the gauge to drop 2 to 3 mmHg per second.
18. Listen for the Korotkoff sounds while releasing the Be sure to read the pressure on the
valve. Note the first faint but clear sound (systolic), lower meniscus to prevent false low
and the point at which the sound disappears reading of the systolic pressure.
(diastolic). Read the pressure closest to the
number.
19. Allow the remaining air to escape quickly and To prevent erroneous blood pressure
completely. Wait for 2 minutes if you want to reading.
recheck the BP reading.
20. Remove the cuff. Clean and store the equipment. To prevent transfer of microorganism.
Wash your hands.
21. Record blood pressure.