FUNDAMENTAL OF NURSING PROCEDURE MANUAL for PCL ...

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d. Measuring Blood Pressure 46 Fundamental of Nursing Procedure Manual Definition: Monitoring blood pressure using palpation and/or sphygmomanometer Purpose: 1. To obtain baseline data for diagnosis and treatment 2. To compare with subsequent changes that may occur during care of patient 3. To assist in evaluating status of patient’s blood volume, cardiac output and vascular system 4. To evaluate patient’s response to changes in physical condition as a result of treatment with fluids or medications Procedure: by palpation and aneroid manometer Care Action Rationale 1. Wash your hands. Handwashing prevents the spread of infection 2. Gather all equipments. Cleanse the stethoscope 's ear pieces and diaphragm with a spirit swab wipe. 3. Check the client’s identification. Explain the purpose and procedure to the client. 4. Have the client rest at least 5 minutes before measurement. 5. Determine the previous baseline blood pressure , if available, from the client’s record. 6. Identify factors likely to interfere which accuracy of blood pressure measurement : exercise, coffee and smoking 7. Setting the position: 1) Assist the client to a comfortable position. Be sure room is warm, quiet and relaxing. 2) Support the selected arm. Turn the palm upward. (Fig. 32 ) 3) Remove any constrictive clothing. Organization facilitates performance of the skill. Cleansing the stethoscope prevents spread of infection. Providing information fosters the client’s cooperation and understanding. Allow the client to relax and helps to avoid falsely elevate readings. To avoid misreading of the client’s blood pressure and find any changes his/her blood pressure from the usual Exercise and smoking can cause false elevations in blood pressure. The client's perceptions that the physical or interpersonal environment is stressful affect the blood pressure measurement. Ideally, the arm is at heart level for accurate measurement. Rotate the arm so the brachial pulse is easily accessible. Not constricted by clothing is allowed to access the brachial pulse easily and measure accurately. Do not use an arm where circulation is compromised in any way. Fig. 32 Care Action 7. 2) Placing the selected arm on the bed and turn the palm upward
47 Fundamental of Nursing Procedure Manual Care Action Rationale 8. Checking brachial artery and wrapping the cuff: 1) Palpate brachial artery. 2) Center the cuff’s bladder approximately 2.5 cm (1 inch) above the site where you palpated the brachial pulse 3) Wrap the cuff snugly around the client’s arm and secure the end approximately(Fig. 33) 4) Check the manometer whether if it is at level with the client’s heart (Fig. 34 ). Fig. 33 Care Action 8. 3) Wrapping the cuff with appropriate way Center the bladder to ensure even cuff inflation over the brachial artery Loose-fitting cuff causes false high readings. Appropriate way to wrap is that you can put only 2 fingers between the arm and cuff. (Fig. 33) Improper height can alter perception of reading. Fig. 34 Care Action 8. 4) Placing manometer at the level of heart Care Action Rationale 9.Meausre blood pressure by two step method: (A) Palpatory method 1) Palpate brachial pulse distal to the cuff with fingertips of nondominant hand. 2) Close the screw clamp on the bulb. 3) Inflate the cuff while still checking the pulse with other hand. (Fig. 35 ) 4) Observe the point where pulse is not longer palpable. 5) Inflate cuff to pressure 20-30 mmHg above point at which pulse disappears. 6) Open the screw clamp, deflate the cuff fully and wait 30 seconds. (B) Auscultation 1) Position the stethoscope’s earpieces comfortably in your ears( turn tips slightly forward). Be sure sounds are clear, not muffled. 2) Place the diaphragm over the client’s brachial artery. Do not allow chestpiece to touch cuff or clothing. (Fig. 36 ) Palpation identifies the approximate systolic reading. Estimating prevents false low readings, which may result in the presence of an auscultory gap. Maximal inflation point for accurate reading can be determined by palpation. Short interval eases any venous congestion that may have occurred. Each earpiece should follow angle of ear canal to facilitate hearing. Proper stethoscope placement ensures optimal sound reception. Stethoscope improperly positioned sounds that often result in false low systolic and high diastolic readings.
Page 1 and 2: FUNDAMENTAL OF NURSING PROCEDURE MA
Page 3 and 4: 3 Fundamental of Nursing Procedure
Page 5 and 6: III. Specimen collection 1.Collecti
Page 9 and 10: Bed making a. Making an Un-occupied
Page 11 and 12: Fig.3 Tuck the bottom sheet under t
Page 13 and 14: Bed making b. Changing an Occupied
Page 19 and 20: Performing Oral Care Definition: Mo
Page 21 and 22: a. Assisting the client with Oral c
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Page 29 and 30: Care Action Action 18.Back and butt
Page 31 and 32: 2) Turn the client to her/ his side
Page 35 and 36: Caring for fingernails and toenails
Page 37 and 38: Performing Perineal Care 37 Fundame
Page 39 and 40: Taking Vital Signs: 39 Fundamental
Page 43 and 44: . Measuring a Radial Pulse Definiti
Page 45: c. Counting Respiration 45 Fundamen
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Procedure: Care Action Rationale 1.
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Procedure: b. Removal a Nasal-Gastr
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Procedure: 103 Fundamental of Nursi
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Supplying Oxygen Inhalation 109 Fun
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Administering Oral Medications Defi
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Removing Medications from an Ampoul
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Prevention of the Needle-Stick Inju
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❖Nursing Alert❖ Selection of ap
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Starting an Intra-Venous Infusion 1
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Performing Nebulizer Therapy 147 Fu
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Equipments required: 1. Dr.’s ord
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III. Specimen Collection 151 Fundam
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Definition: Collecting Blood Specim
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Collecting Urine Specimen 159 Funda
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. Collecting a 24-hour Urine Specim
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. Collecting a sputum culture 169 F
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Appendix 1 Checklist for Taking Vit
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Appendix 2 Checklist for Bedmaking:
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Appendix 3 Checklist for Changing o
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General Comments: 179 Fundamental o
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References: 181 Fundamental of Nurs
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