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).
- 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.