Nursing & Health Survival Guide: Essential Clinical Skills

Susan Carlisle

• Publisher: Routledge
• Year: 2014
• Print ISBN:
  9780273768814
• eBook ISBN:
  9781317905561
• Topic: Medicina
• Subtopic: Atención sanitaria

Whether you're a student nurse on clinical placement or a healthcare worker on a busy ward, you need practical guidance at your fingertips, fast! This pocket-sized guide will help you to provide safe, effective, everyday patient care.

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Observation of vital signs

Temperature

Measurement of body temperature is carried out:

1. To determine a baseline
2. To monitor fluctuations in temperature

Key fact: Body temperature is usually maintained between 36°C and 37.5°C.

Digital thermometer technique

• Introduce yourself and explain to the patient the purpose of recording temperature in order to gain consent and cooperation.
• Ensure patient is in a comfortable position.
• Collect equipment and wash your hands.
• Remove protective cap from thermometer and check the symbol on the display.
• Apply new probe cover.
• Lift the pinna of the ear (flap of skin and cartilage that projects from the head) and gently insert the probe into the auditory canal.
• Keep the thermometer in position until an audible tone signals the correct temperature has been reached.
• Read the display.
• Discard the probe cover into a yellow clinical waste bag.
• Replace the protective cap on the probe.
• Wash your hands.
• Record/report the temperature.

Single-use clinical thermometer technique

Oral use:

• Place under the tongue as far back as possible.
• Have the patient press the tongue down on the thermometer and keep the mouth closed for 60 seconds.
• Remove the thermometer. Some blue dots may disappear as the device locks in for accuracy.
• Read the last blue dot; ignore any skipped dot.
• Discard thermometer.
• Wash your hands.
• Record temperature.

Axillary use:

• Position thermometer high in the armpit, vertical to the body, with the dots against the torso.
• Lower the patient’s arm to hold the thermometer in place.
• Remove the thermometer after 3 minutes.
• Discard thermometer.
• Wash your hands.
• Record temperature.

Pulse

Pulse is taken to gather information on the heart rate, rhythm (pattern of beats) and strength of pulse. Measurement is carried out:

1. To determine the individual’s pulse as a baseline
2. To monitor changes

Key fact: The normal pulse rate per minute for an adult ranges from 55 to 90 beats per minute.

Figure 3 Locations of pulse in the body

Technique

• Introduce yourself and explain to the patient the purpose of measuring and recording the pulse in order to gain consent and cooperation.
• Ensure the patient’s arm is in a comfortable resting position.
• Locate the radial artery at the base of the thumb.
• Place the first, second or third fingers of the dominant hand along the artery and press gently.
• Count the number of beats for 60 seconds. Note: rate, rhythm, character, volume.
• Wash your hands.
• Record pulse and report any abnormality.

Respiration

Respiration is measured:

1. To determine a baseline respiratory rate
2. To monitor changes in respiration
3. To evaluate the patient’s response to medications or treatments that affect the respiratory system

Key fact: The average rate for an adult is 15–20 breaths per minute.

Technique

• Continue to hold the patient’s wrist for a further 60 seconds while counting the respirations.
• Count every rise and fall of the chest as one respiration.
• Leave the patient comfortable.
• Wash your hands.
• Record/report the respiration rate, reporting any abnormality. Note the rhythm or depth as appropriate.

Blood Pressure

Blood pressure is monitored:

1. To determine a baseline
2. To monitor fluctuations

Key fact: Blood pressure in an adult generally ranges from 100/60 to 140/90 mmHg. However, this can fluctuate within a wide range and still be considered normal.

Manual blood pressure technique

• Introduce yourself and explain the procedure in order to gain the consent and cooperation of the patient.
• Wash your hands.
• Ensure the patient has been resting for 5 minutes and has not eaten for 30 minutes.
• Assist the patient into a comfortable position; ensure the arm is at heart level, resting on a suitable firm surface.
• Ensure the arm is free from restrictive clothing.
• Palpate the brachial/radial artery.
• Apply the cuff around the arm smoothly and firmly with the bladder centred over the brachial artery 2.5 centimetres above the ante-cubital fossa (the depression at the front of the elbow).
• Position the sphygmomanometer at heart level, ensuring that the mercury level is at zero and can be easily read.
• Connect the cuff tubing and close the valve to create a sealed unit within the equipment.
• Remind the patient of the feeling of tightness in the arm as the cuff is inflated, emphasising that this is temporary.
• Palpate the radial artery and inflate the cuff until th...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Introduction
• Communication
• Infection Control
• Moving and Handling
• Assisting the Patient
• Observation of Vital Signs
• Eye Care
• Mouth Care
• Wound Care (Simple Dressing)
• Catheter Care
• Specimen Collection
• Urinalysis
• Peak Flow
• Oxygen Administration
• Medicine Administration
• Action in the Event of a Needlestick Injury
• Basic Life Support