How to take an apical pulse rate

Taking an apical pulse rate

Nursing procedure: taking vital sign (taking an apical pulse)

Equipment

• Watch with second hand
• Stethoscope
• Alcohol swab
• Gloves

 

HOW TO TAKE A RADIAL (WRIST) PULSE RATE

TAKING A RADIAL (WRIST) PULSE RATE

Nursing procedure: taking a radial pulse rate

EQUIPMENT

• Watch with a second hand
• Gloves

NURSING ACTION

HOW TO TAKE A RADIAL (WRIST) PULSE RATE

• Wash hands/hand hygiene. Rationale: Reduces transmission of microorganisms.

• Inform client of the site(s) where pulse will be measured. Rationale: Encourages participation and allays anxiety.

TAKING BODY TEMPERATURE USING DISPOSABLE CHEMICAL STRIP THERMOMETER

HOW TO TAKE BODY TEMPERATURE USING DISPOSABLE CHEMICAL STRIP THERMOMETER

Nursing procedure: taking body temperature with chemical strip thermometer

EQUIPMENT

• Thermometer: Disposable, single-use chemical strip thermometer
• Two pairs of nonsterile gloves
• Tissues

NURSING ACTION:

MEASURING DISPOSABLE (CHEMICAL STRIP) THERMOMETER

• Review medical record for baseline data factors that influence vital signs. Rationale: Establishes parameters for client’s normal measurements, provides direction in device selection, and helps determine site to use for measurement. Vital signs are measured in the order of temperature, pulse, and respiration (TPR) and blood pressure (BP), usually without interruptions, to provide the nurse with an objective clinical database to direct decision making.

TAKING AXILLARY TEMPERATURE

HOW TO TAKE AXILLARY TEMPERATURE

Nursing procedure: taking body temperature (axillary temperature)

EQUIPMENT

• Thermometer
• Two pairs of nonsterile gloves
• Tissues

NURSING ACTION:

TAKING AXILLARY TEMPERATURE

• Review medical record for baseline data factors that influence vital signs. Rationale: Establishes parameters for client’s normal measurements, provides direction in device selection, and helps determine site to use for measurement. Vital signs are measured in the order of temperature, pulse, and respiration (TPR) and blood pressure (BP), usually without interruptions, to provide the nurse with an objective clinical database to direct decision making.

TAKING RECTAL TEMPERATURE USING ELECTRONIC THERMOMETER

HOW TO TAKE RECTAL TEMPERATURE USING ELECTRONIC THERMOMETER

Nursing procedure: taking body temperature (rectal).

EQUIPMENT

• Thermometer: Rectal Electronic Thermometer
• Lubricant
• Two pairs of nonsterile gloves
• Tissues

NURSING ACTION:

TAKING RECTAL TEMPERATURE—ELECTRONIC THERMOMETER

• Review medical record for baseline data factors that influence vital signs. Rationale: Establishes parameters for client’s normal measurements, provides direction in device selection, and helps determine site to use for measurement. Vital signs are measured in the order of temperature, pulse, and respiration (TPR) and blood pressure (BP), usually without interruptions, to provide the nurse with an objective clinical database to direct decision making.

MEASURING ORAL TEMPERATURE USING GLASS THERMOMETER

HOW TO MEASURE ORAL TEMPERATURE USING GLASS THERMOMETER

Nursing procedure: measuring oral temperature

EQUIPMENT

• Thermometer
• Two pairs of nonsterile gloves
• Tissues

NURSING ACTION

MEASURING ORAL TEMPERATURE USING GLASS THERMOMETER

• Review medical record for baseline data factors that influence vital signs. Rationale: Establishes parameters for client’s normal measurements, provides direction in device selection, and helps determine site to use for measurement. Vital signs are measured in the order of temperature, pulse, and respiration (TPR) and blood pressure (BP), usually without interruptions, to provide the nurse with an objective clinical database to direct decision making.

TAKING TYMPANIC (EAR) TEMPERATURE: INFRARED THERMOMETER

HOW TO TAKE TYMPANIC (EAR) TEMPERATURE USING INFRARED THERMOMETER

Nursing procedures: taking tympanic ear temperature.

EQUIPMENT

·         Thermometer: Tympanic membrane thermometer with probe cover.
·         Two pairs of nonsterile gloves
·         Tissues

NURSING ACTION:

TAKING TYMPANIC (EAR) TEMPERATURE: INFRARED THERMOMETER

• Review medical record for baseline data factors that influence vital signs. Rationale: Establishes parameters for client’s normal measurements, provides direction in device selection, and helps determine site to use for measurement. Vital signs are measured in the order of temperature, pulse, and respiration (TPR) and blood pressure (BP), usually without interruptions, to provide the nurse with an objective clinical database to direct decision making.

TAKING/MEASURING ORAL TEMPERATURE (ELECTRONIC THERMOMETER)

HOW TO TAKE ORAL TEMPERATURE USING ELECTRONIC THERMOMETER

This is a sample of nursing procedure how to take oral temperature.

EQUIPMENT

• ·         Thermometer: Electronic thermometer with disposable protective sheathing
•        Two pairs of nonsterile gloves and 
•         Tissues

Oral (Electronic) Thermometer

NURSING ACTION:

TAKING/MEASURING ORAL TEMPERATURE (ELECTRONIC THERMOMETER)

1.     Review medical record for baseline data factors that influence vital signs. Rationale: Establishes parameters for client’s normal measurements, provides direction in device selection, and helps determine site to use for measurement. Vital signs are measured in the order of temperature, pulse, and respiration (TPR) and blood pressure (BP), usually without interruptions, to provide the nurse with an objective clinical database to direct decision making.

2.     Explain to the client that vital signs will be assessed. Encourage the client to remain still; refrain from drinking, eating, and smoking; and avoid mouth breathing, if possible. Rationale: Encourages participation, allays anxiety, and ensures accurate measurements. Cold or hot liquids and smoking alter circulation and body temperature. Mouth breathing can alter temperature.

3.     Assess client’s toileting needs, and proceed as appropriate. Rationale: Prevents interruptions during measurements, communicates caring, and promotes client’s comfort.

4.     Gather equipment. Rationale: Facilitates organized assessment and measurement.

5.     Provide for privacy. Rationale: Decreases embarrassment.

6.     Perform hand hygiene/wash hands, and apply gloves when appropriate. Rationale: Reduces transmission of microorganisms. Hands are washed before and after every contact with a client. Gloves are worn to avoid contact with bodily secretions and to reduce transmission of microorganisms.