ASSESSING BODY TEMPERATURE ●Check the package for the suggested time

between chemical dot or tape thermometer

The purpose of this is to:
readings.
 Establish baseline data for subsequent 7. Remove the thermometer and discard the
evaluation cover or wipe with a tissue if necessary.
 Identify whether the core temperature is ● If gloves were applied, remove, and discard
within normal range them. Then perform hand hygiene
 Determine changes in the core temperature 8. Read the temperature
 Monitor clients at risk for imbalanced body ● If the temperature is unexpectedly high or
temperature low, recheck it using a calibrated
thermometer.
Then, assess the: 9. Wash the thermometer if necessary and
● Clinical signs of fever and hypothermia return it to the storage location.
● Site and method most appropriate for 10. Document the temperature in the client
measurement record.
● Factors that may alter core body temperature ● Rectal temperatures are noted by a “R”
The equipment that we will be needing are: next to the figure or we could circle it.
Axillary temperatures are noted with a
1. Thermometer “AX” or an “X” on a graph.
2. Towel
For the evaluation:
3. Tissues or wipes
● Compare the measured temperature to
4. Thermometer sheath or cover
baseline, age, and previous temperatures.
5. Water-soluble lubricant
● Analyze time, other conditions, and vital
6. Clean gloves for a rectal temperature
signs.
Implementation ● Notify the primary care provider if a client's
temperature exceeds a range or doesn't
In preparation: We will check if the equipment is respond to treatment, medicine, or
functioning properly. environmental changes.
1. Next, we must introduce ourselves and
verify the client's identity. And We must ASSESSING THE PERIPHERAL PULSE
explain to the client what we are going to We will assess the client for the ff:
do? Why is it necessary? And how the
client can cooperate. ● Clinical signs of cardiovascular alterations
such as fatigue, pallor, and cyanosis.
2. Perform hand hygiene to reduce the spread ● Factors that may alter pulse rate.
of microorganisms ● Site is most appropriate for assessment.
3. Provide the client privacy so that the
patient will not be embarrassed and will be The equipment that we will be needing are:
comfortable. 1. Clock or watch with a sweep second hand
4. Position the client properly 2. If using a DUS: transducer probe,
● Either lateral or Sims’ position for inserting stethoscope headset, transmission gel, and
a rectal thermometer tissues or wipes
5. Place the thermometer
● Apply a protective sheath or probe cover if In the preparation, if using a DUS, we should
appropriate. check first if it is functioning properly.
● Lubricate a rectal thermometer 1. Next, we must introduce ourselves and
6. Wait the appropriate amount of time
verify the client's identity. Then, explain
● Electronic and tympanic thermometers
to the client what we are going to do? Why
light when done.
 is it necessary? And how the client can Rationale: Using a thumb is contraindicated. Our
cooperate. thumb has a pulse that may be mistaken for the
client's.
2. Perform hand hygiene to reduce the spread
of microorganisms. ● Count for 15 seconds and multiply by 4.
● On the worksheet, note the pulse in bpm.
3. Provide the client privacy so the patient
will not be embarrassed and will be ● Count for a full minute while taking a
comfortable  client's pulse for the first time, getting
baseline data, or if the pulse is irregular.
4. Select the pulse point ● If an irregular pulse is detected, obtain the
● Radial pulses are usually taken unless other apical pulse as well.
body areas need evaluation.
5. Assist the client to a comfortable resting 7. Assess the pulse rhythm and volume.
position ● Examine the pulse rhythm by counting
● Measure radial pulse with palm down. Arm beats. A normal pulse has even beat intervals.
may be parallel to the body or 90 degrees If it's the first assessment, take 1 minute.
across the chest. ● Examine the pulse volume. A normal pulse
● If the client can sit, the forearm can rest has equal pressure per beat. A strong pulse is
over the thigh, palm down or inward. full; a weak one is low. Record the rhythm
and volume.
6. Palpate and count the pulse. Place two or 8. Document the pulse rate, rhythm, and
three middle fingers lightly over the pulse volume and your actions in the client
point. record.
For the evaluation:
● Compare pulse rate to baseline or age-
appropriate range. Compare the results to a
physical therapist's assessment of the pulse.
Brachial ● Relate pulse rhythm and volume to baseline
Radial data and health status.
● Assess peripheral pulses for equality, rate,
and volume.
● Inform the PCP

ASSESSING THE APICAL PULSE:

Carotid Femoral
Assess the client for:
1. Clinical signs of cardiovascular alterations
such as fatigue, pallor, and cyanosis.
2. Factors that may alter pulse rate.
The equipment that we will be needing are:
Posterior tibial 1. Clock or watch with a sweep second hand
Popliteal
2. Stethoscope
3. Antiseptic wipes
4. If using a DUS: the transducer probe, the
stethoscope headset, transmission gel, and
tissues or wipes

Dorsalis Pedis IMPLEMENTATION

Preparation
If using a DUS, check that the equipment is
functioning normally.

1. Next, we must introduce ourselves and

verify the client's identity. And We must
explain to the client what we are going to Fifth intercostal space, MCL
do? Why is it necessary? And how the 6. Auscultate and count heartbeats
client can cooperate. ● Use antiseptic wipes to clean the stethoscope
o Rationale: Regularly clean and
2. Perform hand hygiene  to reduce the spread disinfect the stethoscope.
of microorganisms.  Warm the diaphragm of the stethoscope by
3. Provide the client privacy so that the holding it in your palm.
patient will not be embarrassed and will be o Rationale: When placed against the
comfortable  chest, the diaphragm's metal can be
surprisingly cold.
4. Position the client appropriately in a
 Insert stethoscope earpieces slightly forward.
comfortable supine position or in a sitting
o Rationale: This position will facilitate
position.
hearing
● Then expose the area of the chest over the
apex of the heart.  Tap your finger lightly on the diaphragm
o Rationale: This assures that it is the
5. Locate the apical impulse. This is the point
over the apex of the heart where the apical head's active side.
pulse can be most clearly heard.  Place the stethoscope diaphragm above the
apical impulse and listen for S1 and S2 heart
● Palpate the angle of Louis. It can be palpated sounds.
right below the suprasternal notch as a o Rationale: The heartbeat is normally
prominence. loudest over the apex of the heart.
● Slide out index finger to the left of the  If we are having difficulty hearing the apical
sternum and palpate the second intercostal pulse, we could ask the supine client to roll
space. onto their side or the sitting client to lean
slightly forward.
o Rationale: This position moves the
apex of the heart closer to the chest
wall.
 If the rhythm is regular, count the heartbeats
for 30 seconds and multiply by 2. Count beats
Second intercostal space
for 60 seconds if the rhythm is irregular or
● Then place middle finger in the third before giving digoxin.
intercostal space, and continue palpating ○ Rationale: A 60-second pulse count is
downward until we locate the fifth intercostal more accurate than a 30-second
space. count.
7. Assess the rhythm and the strength of the
heartbeat.
● Note the intervals between heartbeats to
determine the rhythm. A normal pulse has
even beat intervals.
● Assess heartbeat volume. Normal heartbeats
Third intercostal space can be defined as strong or weak.
8. Record the client's pulse and nursing
● Move the index finger laterally along the fifth
actions. Note any changes in pulse rate,
intercostal space toward the MCL.
skin color, or skin temperature.
For the evaluation: ● The client may alter his or her breathing if
they know the nurse is counting so place a
 Relate pulse rate to other vital signs. hand on the client's chest to feel chest
 Relate the pulse rhythm to the health movements with breathing.
status. ● Regularly count 30 seconds of respiration.
 Report any abnormal findings to the PCP. Imagine they're abnormal. Single breath and
exhale count as one respiration.
ASSESSING RESPIRATIONS 5. Observe the depth, rhythm, and character
The purpose of this is to: of respirations.
 Acquire baseline data.  Observe the respirations for depth by
 Monitor abnormal respirations and watching the movement of the chest.
respiratory patterns and identify changes. ○ Rationale: Deep breathing exchanges
 Monitor respirations before/after the more air than shallow breathing.
administration medication.  Observe the respirations for regular or
 Monitor clients at risk for respiratory irregular rhythm.
alterations. ○ Rationale: Normally, respirations are
evenly spaced.
Then assess the client for the :  Observe respiration sound and exertion.
1. Skin and mucous membrane color like ○ Rationale: Normally, respirations are
cyanosis or pallor silent and effortless.
2. Activity tolerance 6. Document respiratory rate, depth, and
3. Chest pain rhythm.
4. Dyspnea
5. Position assumed for breathing For the evaluation:
6. Signs of lack of oxygen to the brain like ● Relate respiratory rhythm and depth to
irritability, restlessness, and drowsiness baseline data and health status.
7. Chest movements ● Report to the PCP.
8. Medications affecting respiratory rate ● Collaborate with the respiratory therapist to
9. History of pulmonary conditions, smoking, develop a respiratory care plan.
exposure to toxic fumes, and living with
smokers.
The equipment that we will be needing are:
1. Clock or watch with a sweep second hand

For the preparation:

Determine the client's activity schedule and assess
respiration then. After exercise, the client should
relax to regulate their breathing.

1. Next, we must introduce ourselves and

verify the client's identity. And We must
explain to the client what we are going to
do? Why is it necessary? And how the
client can cooperate.

2. Perform hand hygiene 

3. Provide the client privacy. 

4. Observe or palpate and count the

respiratory rate