Measurement and Recording: Temperature, Pulse, Respiration, Blood Pressure
Measurement and Recording of Temperature
Every nurse should be able to take and record patients’ temperatures accurately. This measurement should be undertaken as a part of a clinical assessment in different situations. For example, a temperature should be recorded when a patient needs to undergo surgery or has complaints of feeling unwell. Moreover, it can also be measured routinely per the doctor’s instructions. Temperature can be taken orally, rectally, axillary, and using the ear (tympanic measurement).
Preparation of Client
I would notify the patient about the procedure to ensure that they understand it and consent. I would assess the patient regarding a preferable method for temperature recording: oral, rectal, axillar, or tympanic. If a patient is unconscious, confused, is receiving oxygen, has had a hot or cold drink or food, and is prone to seizures, the temperature cannot be measured orally. Rectal measurements should not be taken if a patient had diarrhea, rectal disorders, heart disease, or had undergone bowel surgery. If a client has had ear surgery or has an ear infection, I will not use the ear to take their temperature. I would also ensure that the client had not had a hot drink and had been in a quiet condition within the last ten minutes.
Organization of Material/Resources Required
Using a mercury thermometer, I would inspect the device, ensuring that it is clean and undamaged and is reading below 35°C. If needed, I would shake it down and apply the disposable cover. I would also use an alcohol swab to clean and disinfect the device without a disposable cover. Using an electronic thermometer or a tympanic thermometer, I would also ensure that it is clean and apply a disposable plastic cover for the probe.
Procedure and Rationale
Axillar measurement would be performed in the following way:
- I would ask the patient to loosen their clothes or remove long sleeves to access the armpit.
- I would place the prepared thermometer in the armpit, ensuring that the forearm is placed across the chest and the upper arm is resting against the client’s side.
- A thermometer should be left in the axilla for five minutes to provide an accurate measurement.
- Due to quick cooling, I would remove the device and read the temperature immediately to prevent incorrect recordings.
- The temperature should be recorded immediately in the patient’s notes or on the record chart.
- I would inform the patient about their temperature and tell them whether they need further investigations.
- If the temperature were high, I would also inform the healthcare provider to ensure that the client would receive appropriate care.
In case of an oral measurement, the procedure would be performed in the following way:
- I would ask the client to open their mouth and insert the prepared device under their tongue near the frenulum. Since the tongue frenulum is next to a large artery, the temperature will be similar to a core temperature.
- I would ask the client to close their lips but leave the teeth unclenched. Thus, cool air would not circulate in the mouth and affect the temperature.
- The thermometer should be left in the mouth for two-three minutes.
- I would remove the device without touching the part that was in contact with the patient’s mouth to prevent the spread of infection. A disposable cover should be removed at this stage.
- I would read and record the client’s temperature and report any abnormality to them and a clinical person in charge.
- Finally, I would make certain that the client feels relaxed after the procedure.
Safety & Infection Control
As mentioned above, I would disinfect the thermometer before measuring a client’s temperature. After the procedure, I would also disinfect the device with the help of an alcohol wipe or a swab soaked with the disinfectant. The thermometer should be dried with a dry tissue or a swab. To prevent cross-infection, I would use disposable covers when possible. In other cases, I would touch only that part of the thermometer that was not in contact with the patient’s mucous membranes. I would wear gloves if contact with blood, excretions, body fluid or secretions were unavoidable. I would adhere to the main principles of hand hygiene, according to which hands should be washed or disinfected before touching the patient, before medical procedures, after an operation, after touching a client, and after handling their surroundings. If a patient had signs of infectious disease, I would ensure that they and I wear safety masks or other personal protective equipment to avoid the spread of the disease.
Reflection on Learning
Having learned the temperature measurement and recording procedure, I can conclude that this process should be carried out accurately to ensure good patient care, safety, and comfort. The knowledge I gained would assist me in providing clients with proper care and help me go forward in my practice. I have learned that safety and infection control are crucial even if an axillary method is used to measure a temperature. Moreover, I realized that it was important to inform patients about every step of the procedure to ensure they feel comfortable with it and consent.
Measurement and Recording of Pulse
Nurses should also be able to measure and record the arterial pulse since it reflects the heart rate and helps identify whether a patient has any heart problems. The pulse can be measured at different body points: radial, temporal, carotid, brachial, femoral, popliteal, dorsalis pedis, and apical. The most widely used point is the radial point, i.e., the artery inside the wrist, and the pulse is measured with the base of the thumb. However, the choice of the site depends on various factors that may affect pulse, including age, illness, drugs, poison, sex, emotions, temperature, activity level, or physical training. The normal pulse rate is 60-100 beats per minute, and the beats should be regular and not weak.
Preparation of Client
The first step of patient preparation is to inform them about the procedure and gain their consent and co-operation. I would ensure that the client is resting, either sitting or lying down. Moreover, the patient should rest for a while before the procedure. I would ask whether the client had smoked or had been physically active or upset before the measurement. If they had not, I would start the measurement. However, if they smoked or were physically active, I would ask them to rest for twenty minutes and start measurement afterward. Finally, I would perform hand hygiene to prevent cross-infection.
Organization of Material/Resources Required
To measure a client’s pulse, I would need a watch with a second hand or an electronic stopwatch timer and a chart to record the pulse.
Procedure and Rationale
First, I would ensure that a client feels comfortable and relaxed. I would choose a point of the body to record the pulse. In most cases, it would be a radial point. I would place the tips of my first and second fingers on the inside of the client’s wrist and press gently against the artery. If the pulse is irregular, I will count the number of beats per minute. However, if it is regular, I will measure the pulse for 30 seconds and double the number after that to receive the number of beats per minute.
I also need to note the pulse’s rhythm (regular or irregular) and strength/volume (strong, weak, faint, or bounding). I would compare the records with the Tableland record to see whether the pulse is normal. I would report any abnormalities to the healthcare provider in charge. For example, an irregular rhythm may indicate that a patient has some problems with the heart. I would also examine the patient’s skin and mucous membranes’ color to detect anemia, lack of oxygen, or other issues. At the end of the procedure, I would record the results, discuss them with the client and tell them whether any further investigations are needed.
If I had to measure a carotid pulse, I would act the following way. The first steps would be the same as in the previous procedure. When the patient is ready, I would find their pulse on the right or left side of the neck with the help of my index and middle fingers. I would choose the side where the pulse is more palpable. After that, I would count the pulse beats for one minute. I would also pay attention to its strength and rhythm while measuring. I would record the results and the date and time taken and inform the patient about the results.
Safety & Infection Control
To prevent cross-infection, I would ensure proper hand hygiene before, during, and after the procedure. If a client had signs of infectious disease, I would ask them to wear a protective mask and use personal protective equipment.
Reflection on Learning
I have learned that pulse measurement is an important medical procedure that helps detect different heart problems. I discovered that a nurse should be able to measure pulse and note its strength and rhythm simultaneously. If the pulse rhythm is irregular or weak, a patient should be assigned to further investigations to reveal the health issue. Moreover, pulse measurement helps assess a patient’s cardiovascular status, essential for determining the care plan treatment regime. I will use the knowledge gained to improve my nursing practice skills and provide patients with proper care.
Measurement and Recording of Respiration
The process of respiration involves taking in oxygen and exhaling carbon dioxide from the lungs and breathing passages. The respiratory rate is the number of breaths per minute. Different factors affect the respiratory rate: age, physical activity, drugs, body position, and others. The normal rate is about twelve to twenty breaths per minute. Higher or lower respiration rate may indicate changes in physiological conditions due to physical exercises, strong emotions, or usage of drugs, alcohol, and other substances. The depth of breathing is also important since it may denote various pathological conditions, anxiety states, lung infections, heart problems, or other health issues.
Preparation of Client
The client should not be informed about the respiration test. It should happen immediately after pulse measurement so that the preparation process will be the same. Before measuring and recording the patient’s pulse, I would introduce myself, explain what I would do next, and ask permission to touch them. The client should be relaxed and should not have been physically active before the procedure. I would ask the patient to sit up in a chair or bed before taking their pulse so that they would stay there during the respiration measurement.
I would also ensure a constant temperature in the room so that the client does not feel cold or hot. It is essential for the client to feel comfortable because shivering may negatively influence the respiratory rate. If the patient has bulky clothing or a bed cover on their chest, it should be removed so that I can observe depth, symmetry, and pattern of breathing. If the client is sitting, their feet must be on the floor, and they should not be suspended because it may lead to an increased heart rate and respiratory rate. The client should also be alert and orientated to place and time. When the patient is ready, I will begin the procedure.
Organization of Material/Resources Required
I would need a patient chart to record the respiration measurement and a watch with a second hand or an electronic timer to note the time.
Procedure and Rationale
I would start counting the number of breaths after taking the client’s pulse. While holding the patient’s wrist, I would begin to observe their breathing. I would pay attention to the chest and abdomen movements and see whether they are heavy or normal. If respirations are quiet, effortless, and regular, they will be considered normal. After that, I would count breaths for fifteen seconds and multiply the number by four to understand how many breaths the client makes per minute. I would record the number, indicating depth and rhythm of breathing.
When the number of breaths is smaller than twelve beats per minute, a patient has bradypnea. When the number of breaths is bigger than twenty beats per minute, a client can be diagnosed with tachypnoea. Both bradypnea and tachypnoea should alert the healthcare provider to examine the reasons for such an abnormality of respiratory rate. Thus, when the patient is breathing too fast, they may have asthma, pneumonia, shock, heart failure, neuromuscular disorders, pulmonary disease, pain, emotional distress, and many other problems. In comparison, bradypnea may result from depression of the respiratory center, drug overdose, diabetic coma, sleep apnea, and some other issues. Therefore, it is vital to measure the respiratory rate accurately and pay attention to every detail.
Safety & Infection Control
First, I would wash my hands with soap and water to avoid cross-infection. I would also wear a protective mask to reduce the infection risk during the pandemic. If a client were prescribed oxygen, I would ensure that their oxygen mask is properly positioned. I would also record the information about the oxygen mask on the patient chart before recording the respiration rate. After the procedure, I would wash and dry my hands again.
Reflection on Learning
Respiratory rate measurement and recording are crucial since they help detect a respiratory failure and other changes in patients’ health. I have learned that any abnormality or changes in respiratory rate may indicate health deterioration and lead to poor results for the client. As a nurse practitioner, I will use this knowledge in my practice to detect and prevent respiratory failure at an early stage. Measuring respiratory rate is a core nursing skill, and it should be prioritized in daily routine because it is easier to prevent a disease than to treat it. However, it is important to perform this procedure discreetly so that the patients do not know about it. If a person knows that they are observed, they will change their breathing style, and the observation results will be wrong. To conclude, respiratory measurement is a part of a holistic assessment of a patient, and it should never be ignored since it could save a client’s life.
Measurement and Recording of Blood Pressure
Blood pressure is the force of blood against the artery walls. The systolic pressure is the first reading recorded, and it occurs when the heart is beating. The diastolic reading is the second reading recorded, which occurs when the heart relaxes. Normal blood pressure is vital for a patient’s health, and nurses should be able to measure and record it properly. Normal systolic blood pressure is 90 to 140 millimeters of mercury, while normal diastolic blood pressure is from 60 to 90 millimeters of mercury. When blood pressure is higher than 140/90, it is considered hypertension. When it is lower than 90/60, it is considered hypotension. Various factors affect blood pressure, including weight, age, sleep, emotions, illness, heredity, and blood viscosity.
Preparation of Client
I would ask whether the client feels comfortable or needs the toilet. I would also ask whether they have had a meal, caffeine, or alcohol or have exercised or smoked within the last thirty minutes. If the client confirms that they have performed one of the actions mentioned above, I would ask them to take a rest for half an hour. If the client were not physically active and had no meal, alcohol, or caffeine, I would ask them to sit down and rest for several minutes before starting the measurement. I would wash my hands with soap and water and dry them. Then, I would inform the client about the procedure and gain their consent. Finally, I would explain the process of the cuff tightening on the client’s arm and assure them that it is safe.
Organization of Material/Resources Required
I need a sphygmomanometer and three different cuffs: small, medium, and large. I could also use an electronic blood pressure machine if it were available. Other important equipment includes a stethoscope, alcohol wipe, patient’s observation chart, and a chair.
Procedure and Rationale
I would ask the client to loosen tight clothing or take a long sleeve from the upper arm. If the client has some problems with the arm, I will use another arm when possible. I would place a cuff of an appropriate size around the arm and tighten it accordingly. I would ensure that the cuff’s bladder is centered over the brachial artery and about 2 cm above the antecubital fold. The cuff tubing should be connected to the sphygmomanometer tubing. I would place the patient’s arm on the table or other surface at the same level as their arm. After that, I would palpate the radial pulse and pump up the cuff until the pulse disappears. I would also use a stethoscope, placing it over the brachial artery to listen to the pulse better.
When the pulse disappears, I would stop inflating the cuff and start to deflate it slowly. I would observe the mercury level in the sphygmomanometer and listen to the pulse. When the pulse reappears, I would note the systolic pressure. I would continue to lower the pressure slowly until the heartbeat sounds disappear and record the diastolic pressure. Finally, I would record both measurements (for example, 90/60 mmHg) in the patient’s observation chart. I would replace the patient’s clothing, ensure that they feel comfortable, and inform them about the measurement results. If I noticed any fluctuations from normal blood pressure readings, I would tell the healthcare provider in charge of the client’s care.
Safety & Infection Control
After the procedure, I would disinfect the stethoscope drum and earpieces with an alcohol wipe. I would ensure that the sphygmomanometer is left safe and undamaged aside so that the mercury does not spill. Finally, I would wash and dry my hands to prevent cross-infection.
Reflection on Learning
Having learned the technique of measuring and recording blood pressure, I tried to perform this procedure. Another student nurse and I agreed to assist each other and practice blood pressure measurement. I undertook the process, following the instructions mentioned above. I palpated the radial artery because it was difficult to palpate the brachial artery. After estimating the systolic pressure, I utilized the stethoscope and began the procedure. I conducted the measurement properly and recorded the results from the first.
I believe that taking blood pressure manually is a vital nursing skill because it helps determine the patient’s health condition and understand whether they have any hidden heart problems. I realized that the client’s condition and the environment are highly important because the temperature, physical activity, emotional variation, and other factors can affect the blood pressure readings. The role of a nurse is to create a comfortable atmosphere and ensure that a client is relaxed and ready to open up. A client should be approached with the right posture and greeted with a smile to establish a positive atmosphere and make them feel welcome.
Measurement and Recording of Fluid Balance
Fluid balance measurement is important to help assess a client’s health condition, suggest diagnoses, and address fluid and electrolyte imbalance. Adults should take from 1,5 to 2 liters of fluid daily. If this minimum balance is not maintained, it will lead to dehydration and various health problems. In addition, such factors as fever, vomiting, diarrhea, hemorrhage, active physical exercises, drugs, severe burns, and others may cause dehydration. Consequently, a client may suffer from headaches, constipation, lethargy, loss of skin elasticity, kidney failure, kidney stones, mental confusion, and other problems. Moreover, dehydration may lead to death if it is not addressed promptly.
Preparation of Client
First, it is essential to understand whether the client needs to assess their fluid intake. When the patient demonstrates any signs of fluid imbalance, their fluid intake should be measured. These signs are thirst, dry skin, edema, hypo- or hypertension, tachycardia, changes in respiration and pulse, too high or too low urine output, diarrhea or vomiting, and other health issues. Before starting the measurement and fluid intake recording, I would inform the patient about the procedure. If the patient is compliant and can self-document the recordings, I would tell them how to perform the recordings. I would also ensure that the client is aware of any restrictions to intake and can use the equipment independently. If the client cannot perform the measurement and recording, I would tell them about the plan and measure all volumes myself.
Organization of Material/Resources Required
I would require an intake and output charge (I/O Chart) to record all daily input and output. I also need a jug marked in milliliters and gloves to handle excretions. If the patient is drinking from a cup or a glass, I would need to pre-measure the volume of these vessels. A separate container for fluid output would also be needed.
Procedure and Rationale
Fluid intake refers to all liquid food and drinks a person takes daily. I would measure all liquids a patient takes and note the time and date of the intake. If the client received food and drink through a nasogastric tube, I would measure the number of feeds before the feeding and subtract the amount left after the feeding. Similarly, I would count all intravenous drips. To calculate fluid output, I would use a separate container labeled ‘FOR OUTPUT ONLY.’ I would always wear gloves when handling the excretions (vomitus and urine) and other body fluids. If a patient passed urine while in the toilet, I would also document this fact to ensure that the chart was accurate. If a person had vomiting or diarrhea, I would record the time and the number of times it was passed. If needed, the volume of these liquids would be measured too. If the patient were sweating, I would also document it in the chart. The amount of drainage would also be measured if the client had drainage. Finally, if a patient received irrigation, it should also be noted in the I/O Chart.
Safety & Infection Control
I would wash and dry my hands before and after the procedure. I would always wear protective gloves when measuring excretions and body fluids. I would ensure that separate containers are used for output and input measurements. Both containers should be kept clean and disinfected.
Reflection on Learning
Measurement and recording fluid balance is crucial to patient care. Every nurse should be able to conduct this measurement accurately and effectively. Dehydration may lead to serious health outcomes, including reduced physical activity, impaired cognitive function, weakness, headaches, hypotension, cold hands and feet, kidney failure, and death. Fluid overload may also harm human health, resulting in heart failure, edema, dyspnea, and fatigue. Therefore, it is vital to assess fluid intake to prevent negative health outcomes.
I discovered that injuries and illnesses could also affect fluid balance. Measuring this balance could help monitor acute conditions and detect further deterioration, thus preventing negative health outcomes. Moreover, I found out that not only water and other drinks, but also liquid foods, such as yogurt, ice cream, ice, jelly, and others, affected fluid balance, so they had to be recorded in the patient’s chart. An accurate fluid balance chart should contain a detailed description of oral, intravenous, and cumulative input, and urine, bowels, and vomit output, and all these data should be calculated and cumulated at the end of each day. Suppose a nurse can conduct all the recordings properly and report any changes or abnormalities in time. In that case, a healthcare practitioner will use this information to correct a treatment plan or prescribe medications accordingly.