Vital Signs Assessment Procedure

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I'm gonna assess the apical pulse. "Ma'am pwede ba nato madunggan ang pagtibok sa imong heart, okay lang po i lift nato gamay imong shirt ma'am kay kailangan po i apply sa skin mo ang stethoscope para madunggan po nato, okay lang po?" Sige okay po ma'am.

I'll warm the diaphragm with my hand to avoid startling the patient which can alter the heart rate.

I'll place it on the apex of the heart, locating the point of maximal impulse and put on the earpiece to get the loudest sound of the heart. I'm gonna count the pulsation for one minute for accurate findings and note for the rate and rhythm and intensity of the quality.

-- count. now that it's done, I'm gonna assist the patient to a comfortable manner." okay lang po ka ma'am?"

In no instance, the apical pulse count is greater than the radial pulse rate because it lies directly on the heart.

I'm gonna record it on the jot down notebook. "Ma'am bago ko nagsugod ganina naka ihi naka? ikapila po? nga pila man siya kabaso if I estimate nimo ma'am? okay po, nakalibang na ma'am?"

-- ma'am humana po ang vital signs assessment, mubalik lang ko diri unya maam para I monitor balik imong condition ma'am ha thank you for the cooperation. Kung kailangan mi nimo for assistance ma'am, punduta lang po ang signal cord diria. Thank again ma'am.

Now I'm going to arrange my equipment and leave the room. I'll go back to the nurses station and first report the findings to the clinical instructor. If there are any abnormalities, I will refer them immediately. "For patient Milan, the vital sign findings show no abnormalities and shows normal results."

After that, I will record the findings on the TPR sheet, vital signs master sheet, and graphic chart.

That's concludes my Vital Signs, Thank you ma'am.

While the thermometer was in place, I assessed the patient's pulse rate by using my index and middle fingers on the inner aspect of the wrist to locate the radial pulse, with my thumb providing support for moderate palpation to avoid detecting my own pulse. I counted for one full minute to determine the pulse rate, rhythm, and volume, and to note any abnormalities. I then measured the respiratory rate by observing the rise and fall of the patient's chest for one minute without informing them, to prevent conscious control of breathing.

Now I'm gonna get the blood pressure by first explaining the procedure and knowing what they did prior to the procedure.

Ma'am unsa po imong gibuhat mga thirty minutes ago? naa po ba kay gibuhat na makahapo, nanigarilyo, inom ug kape? wala po, okay, I raise sa nato imong sleeve balik ma'am ha kay kuhaon nato imong blood pressure, okay lang po? comfortable ka?

I'm gonna place the patient arm comfortably at the table with the palm facing upward to expose the brachial and radial artery, antecubital fossa.

I'm gonna position myself to see the calibration properly at eye level, making sure I'm not more than three feet away for direct vision.

I'm gonna cleanse the earpiece and diaphragm of the stethoscope to be used later.

I'm gonna locate both the brachial and radial artery and remember it.

What I'm going to do is place the cuff by first putting two fingers above the antecubital fossa to guide the proper positioning, making sure the cuff is centered over the anterior surface of the brachial artery so the pressure reading will be accurate. I'll wrap it properly without twisting it, and I'll make sure I can still insert two fingers to check that it isn't too tight.

I am going to use my fingertip to feel a strong pulsation, this is so that I know where I'll place my stethoscope.

I'm gonna place my fingers in the radial artery and inflate the cuff until I can no longer feel the pulse, now I'm gonna put on the stethoscope, put the diaphragm directly over the brachial artery for accurate findings and inflate the cuff by adding thirty millimeters of mercury.

After deflating and getting the results, I will now remove the cuff and make the patient comfortable. "Ma'am, one hundred ten over eighty po imong bp, normal lang po siya maam, thank you po for the cooperation."

I remembered the first loud sound which is the systolic pressure and the last loud sound which is the diastolic pressure. Now I'm gonna set aside the equipment and record the result on my jot down notebook.

I am going to perform the Vital Signs checking in order to know the physiological status of the patient as well as their ability to regulate temperature, maintain local and systemic blood flow, and oxygenated tissue.

I'll read the patient's chart first, specifically the doctor's order and health history to obtain necessary data.

I'm gonna wash my hands to deter the spread of microorganisms.

I'm gonna prepare my equipment. In this tray, I have a thermometer, stethoscope, sphygmomanometer, a jar with cotton and water, set of tissue paper, and a waste receptacle.

I'll put this on the bedside of the patient, start identifying myself, the patient, and explain the procedure to gain cooperation and so she'd know what is yet to be done.

Ma'am churva (verification ensures that I'm doing the procedure on the right patient).

I'm gonna rinse the thermometer using this cotton ball with water to approximate the surface through a firm twisting motion starting from the bulb to the stem to make sure to come in contact with the thermometer's entire surface.

now I will roll the sleeves of my patient.

I'll ask and assist the patient to pat her axilla dry with tissue paper to remove moisture that could alter the temperature and place it on the deepest area and in the center to provide accurate findings. Now I'm gonna assist the patient to lower down her arm to her body with the forearm on her chest.

I'll leave thermometer for about one to three minutes or until the beep is heard because sufficient time for the axillary tissue to be in contact with the bulb is good for accuracy.

now, I will assess the pulse and respiratory rate while the thermometer is ongoing.

count pulse and respiratory for one minute.

Now I'm gonna remove the thermometer and assist the patient in rolling down the sleeves. then "ma'am thirty-seven degrees Celsius po imong temperature and normal lang po siya maam".

I'll clean the thermometer from the stem to bulb with the cotton ball twice making sure that the dripping will go straight to the waste receptacle, I'll dispose of the cotton ball to prevent the spread of microorganisms and avoid contamination. I will then return the thermometer to the container.

I'm gonna record the temperature, pulse rate, and respiratory rate on the jot down notebook for the documentation.