Assessment...vitals

  1. Checking off on vitals Thursday AM....here's my assessement/procedure...


    walk in/introduce self, wash hands, check patient id (to confirm patient and their readings from checking chart prior to entering room).

    Assess for:
    • activity level ( has patient ambulated within last thirty mins, if so how strenous?)
    • caffeine (had any withing past 15-30 mins, causes increased pulse and BP readings)
    • is patient on heart meds (hypo, hyper) and if so have they taken them recently?
    • is patient stressed? can cause increased HR
    • is patient febrile? can increase pulse
    • is smoking a factor, have they smoked recently
    First (this is the order im going to go in, doesn't matter which order according to instructor) CHECK BP (is it best to do in sitting/lying position we've been practicing in lying position), first assess if cuff is appropriate size (too small causes high readings, too big causes low readings) palpate brachial pulse, inflate cuff to 30mmHG above normal BP or until brachial pulse can no longer be heard..... deflate no more than 5mmHG at a time....record results

    CHECK PULSE....30 secs x 2, then last 30 secs check respirations x 2 ....record results (my partner has steady normal pulse...is that what I would document?) For respirations you document the number and maybe if client has DOE?

    CHECK PERIPHERAL PULSE (we exempt temporal) provide client privacy. Start with carotid, brachial, radial, femoral, popliteal, dorals, pedal and apical we do when we listen for heart sounds.

    CHECK HEART SOUNDS: aortic which is 2nd R intercostal space (loudest @ S2 (semilunar valves)) ...2nd L pulmonic, 3 L ERBS point (listening for S1 and S2 together) ....4th space tricuspid.....5th midclavical line apical....count apical for 60secs difference btw apical and radial=pulse deficit (would you chart this if there was a deficit)

    CHECK LUNG SOUNDS : FRONT....SIDE...SIDE....BACK ....my partner has asthma and is moderately overweight and me nor my instructor could hear, if we did it was diminished lung sounds posteriorly. How do you chart this?

    Sorry I have so many charting questions, we don't go over documentation until 3 more weeks

    Am I leaving anything out? We have to complete this assessment within 15 mins :uhoh21: Any input would be appreciated.
    Last edit by srg4784 on Oct 3, '06
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    About srg4784

    Joined: Jun '06; Posts: 123; Likes: 4

    5 Comments

  3. by   lilypad2424
    what about AAX3 and checking ID bracelet and asking their name. I know every school does it differently, just a thought.
  4. by   Achoo!
    Don't forget to provide privacy
  5. by   rtaz315
    For vital sign check off's the only questions we had to ask before taking the blood pressure were -- "Do you have a preference as to which arm I take your blood pressure in" and "Have you had any procedures or injuries that may interfere with blood pressure readings in this arm?" And if we could not establish baseline from the client chart (provided by the instructor as a scenerio for your lab partner) "Do you know what your BP normally is?" The things you have listed we only inquired about if the blood pressure was out of range (hypo or hyper) to assess what the cause may be.
    You mentioned assessment -- are you only doing vital sign checkoff's or a complete patient assessment?
  6. by   Icess64
    I know that our instructors are always reminding us to explain to our patients what we are about to do. Probably a minor detail, but just thought I'd throw it in...also, you might want to do the BP lying down since that will more than likely be the position that the clients are in. If you are going to ambulate them you would take it lying down, sitting up, then standing to make sure they don't have orthostatic hypotension, and pass out on you!

    Oh, and I just noticed you didn't mention counting their respirations. I know we always do this with vitals, usually right after taking pulse. We're supposed to pretend like we're still counting their pulse so they don't realize we are counting their breaths and change their breathing. good luck!
  7. by   srg4784
    we're just doing vital signs, but he makes us consider the "whole" picture so your really doing a whole head to toe assessment as your checking vital signs. THanks for all your help, we gotta be "perfect'' and complete it in 15 mins is going to be hard

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