CARDIOVASCULAR SYSTEM

1. INSPECTION
 Inspect the chest. Note landmarks you can use to describe your findings as well the structures
underlying the chest wall.
 Look for pulsations, symmetry of movement, retractions
 Note the location of the apical impulse.(5th ICS or just medial to the left of the midclavicular line)

2. PALPATION
 To find the apical impulse, use the ball of your hand, then
fingertips to palpate over the precordium.
 Note for thrills (feels like a vibration or buzzing underneath your
hand) or heaves (feels like a "lifting feeling" under your hand.
;lifting of the cardiac area secondary to an increased workload
and force of left ventricular contraction).

3. PERCUSSION
 Percuss at the anterior axillary line and continue toward the
sternum along the 5th ICS.
 The sound changes from resonance to dullness over the left
border of the hearts, normally at the midclavicular line (MCL)

4. AUSCULTATION
 Begin auscultating over the aortic area, placing the stethoscope over the 2nd ICS, along the Right
sternal border.
 Then move to the pulmonic area, located at the 2nd ICS at the Left sternal border.
 Next, assess the tricuspid area which lies over the 4th & 5th ICS along the sternal border.
 Finally, listen over the mitral area, located at the 5th ICS, near the midclavicular line.

ASSESSING PERIPHERAL CIRCULATION

A. Capillary refill:
Ask the patient to hold his/her hands up and assess for the
following:
1. Press on the patient's thumbnail with your first finger
while holding the other side of the patient's finger with
your thumb.
2. The skin under the nail will blanch (turn a white color).
Measure the amount of time it takes to turn back to red.
This should be less than 2 sec, which indicates good
peripheral circulation.

B. Performing Allen Test

 To assess tissue perfusion
 To determine patency of radial and ulnar arteries.

Procedure:
(1) Compress both the radial and ulnar arteries.
(2) Firmly compress arteries and instruct client to open the
hand.
(3) Note color of palms.
(4) Release one artery and note the color of the palm
NEUROLOGIC SYSTEM
GLASGOW COMA SCALE (GCS) ASSESSMENT
 It is numerical rating system, originally used for measuring conscious state following traumatic brain
injury, which has become a widely used and recognised assessment tool for reporting any patient’s
conscious state.
 The GCS uses three categories that pertain to different areas of a person’s conscious state, they are;
eyes opening, vocal response and motor response.
 Each unit is given a range of numbers that correlate with definable levels in consciousness which are
then collated to give a GCS between 3 (deep unconscious) to 15 (normal conscious level). The best
response is recorded for each category.

Score: 14 - 15 = mild dysfunction

Score: 11- 13 = moderate to severe dysfunction
Score: 10 or less = severe dysfunction

ASSESS EYES OPENING Spontaneous (4): Observe the patient’s eyes. A patient that has eyes that are opening
spontaneously receives a 4.

Voice (3): Supply vocal stimulus by asking the patient loudly and clearly to open their
eyes. If the patient responds by opening their eyes they receive a 3.

Pain (2): Elicit a pain response by pushing down behind the ear anterior to the mastoid
process. You can also push down on the patient’s finger nail bed. If the patient then
opens their eyes they receive a score of 2.

ASSESS VERBAL RESPONSE
None (1): If there is not any response to pain the patient receives a score of 1.
Oriented (5): Ascertain whether the patient is orientated to time and place. Patients’
that respond appropriately receive a 5. Ask the patient questions which you know the
answer to, such as; ‘What day is it today’? and ‘Do you know where you are at the
moment?’.

Confused (4): If the patient appears slightly confused and/or disorientated during
conversation they receive a 4.

Inappropriate speech (3): If the patient has random or muddled speech without
exchange of information during conversation they receive a 3.

Incomprehensible (2): If the patient is making sounds but is unable to formulate words
they receive a 2.

ASSESS MOTOR RESPONSE
None (1): A patient that is unable to produce sounds receives a 1. This does not refer to
aphasia due to any cause, such as airway obstruction or laryngeal injury.
Obeys Commands (6): A patient who responds to you and does what you ask receives a
6. In order to assess this, shake the persons hand upon arrival or ask them ‘can I hold
your wrist to take your pulse’?
 Localizing to pain (5): Elicit a pain response through the techniques previously
mentioned. If the patient purposefully attempts to remove the stimulus they receive a
5. E.g. the patient pushes your hand away if you elicit nail bed pressure.

Withdraws to pain (4): Elicit a pain response through techniques previously mentioned.
If the patient pulls away from the stimulus they receive a 4.

Abnormal Flexion (Decorticate) (3): Elicit a pain response through techniques

previously mentioned. If the patient’s arms move toward their chest, their fingers and
wrists flex on their chest and they point their toes, then they are said to have
decorticate posturing and receive a 3. This posture is indicative of head injury and a
patient may present in this position prior to any painful stimuli.

Abnormal Extension (Decerebrate) (2): Elicit a pain response through techniques

previously mentioned. If the patient’s arms and legs extend, their wrists rotate away
from their body and they point their toes, then they are said to have decerebrate
posturing and receive a 2. This posture is also indicative of head injury and a patient
may present in this position prior to any painful stimuli.

No Response (1): A patient that does not have a motor response receives a 1.

THE CRANIAL NERVES

There are 12 pairs of cranial nerves that emerge from the lower surface of the brain and pass through the
foramina in the skull.
 3 are entirely sensory (I, II, VIII
 5 are motor (III, IV, VI, XI, and XII)
 4 are mixed (V, VII, IX, and X) as they have
 both sensory and motor functions
 CRANIAL NERVE MATERIALS/
NUMBER ASSESSMENT ABNORMAL FINDINGS
NAME PROCEDURE
I Olfactory Aromatic  With eyes closed, the Anosmia- the loss of the
substances patient identifies sense of smell, either total or
familiar odors (coffee, partial. It may be caused by
tobacco). head injury, infection, or
 Each nostril is tested blockage of the nose.
separately.
II Optic Snellen eye chart; Sensory stimuli to the retina Positive test for optic nerve
visual fields; 1. Shine a light in the lesion is loss of pupil
ophthalmoscopic patient’s eye (while constriction bilaterally
examination blocking the other eye)
and observe for pupil
constriction on same
side. Repeat the same
pupil for
accommodation reflex
(pupil constriction on
opposite side).

Assess visual acuity:

a. Position Snellen chart
20 feet in front of
client.
b. Remove corrective
lenses.
c. Instruct client to
cover one eye and
read lines, starting
with top of chart
from left to right;
note the line where
the client correctly
reads more than half
the letters.
d. Record results as a
fraction sc (without
correction),
20/distance number,
and the number of
letters missed for the
eye test.
e. Repeat steps a–d for
other eye. If
appropriate, repeat
steps a–e with client
wearing corrective
lenses, record result
cc (with correction).

Compare the number on that

line with the 20 feet where
they stand. “20/30” means
they stood twenty feet but
could only read a line that a
normal eye can read from 30
 feet.

*Normal vision, based on the

Snellen chart, is 20/20 (at a
distance of 20 fee the normal
eye can read the chart).
III Oculomotor Important: III, IV Assess 6 ocular movements & Oculomotor ( III ) nerve
IV Trochlear and VI pupil reaction. Ask the damage:
V Abducens These three (3) patient to open his or her - Lid ptosis, withinability
nerves operate as eyes. Instruct him or her to to completely open eye
a unit and should focus on a point directly in - eyeball deviated
be tested and front of him/her. Observe her outward and slightly
evaluated ability to focus on one point downward
together effectively. - pupil dilated and
unreactive to light
Assess extraocular muscle - nystagmus (involuntary,
function: rhythmical oscillation of
the eyes, and
1. CARDINAL FIELDS GAZE accommodation power
lost.
TEST:
a. Instruct client to follow Trochlear ( IV ) nerve
your finger held 6 to 12 damage:
inches in front of eyes. - Inability to turn eye
Move your finger downward or outward.
through the eight
vision fields of gaze
b. Observe for parallel Abducens ( VI ) nerve
eye movement. damage:
c. Pause during upward - Eyeball deviated
and lateral gaze fields inward, diplopia (double
to detect involuntary vision) paralysis of
movement of the eyes. lateral gaze.
d. Note position of the
upper eyelid in relation
to the iris and eyelid
lag as the client’s eyes
move from up to down.
e. Record results.
*Eye movements should be
symmetrical as both eyes
follow the direction of the
gaze. The upper eyelids cover
only the uppermost part of
the iris and are free from
VI Trigeminal Sterile Assessment: (Sensory) Inability to distinguish
gauze/cotton, 1. While client looks or feel is positive for CN
safety pin upward , lightly touch V lesion.
the lateral sclera of the
eye with sterile gauze
to elicit blink reflex.
2. To test light sensation,
have client close eyes
wipe wisp of cotton
over client’s forehead
and paranasal sinuses.
3. To test deep sensation,
 use alternating blunt
and sharp ends of
safety pin over the
same areas. Unequal tension
Motor: bilaterally in muscles is
1. Put fingers on bilateral positive for CN V lesion.
masseters and
temporalis muscles and
ask patient to bite
down.
VII Facial Sugar, salt, lemon Sensory Inability or
juice Ask client to identify asymmetrical facial
various tastes placed on tip expression is positive
& sides of the tongue. for CN VII lesion
Identify areas of taste

Motor BELL’S PALSY – is a condition

Ask patient to frown, smile, that causes a temporary
and wrinkle brow. weakness or paralysis of the
muscles in the face. It can
occur when the nerve that
controls your facial muscles
becomes inflamed, swollen,
or compressed.
VIII Vestibulocochlear/ For EQUILIBRIUM- For Vestibular branch Abnormal Finding:
Acoustic Romberg Test (EQUILIBRIUM/ POSITIVE ROMBERG- cannot
BALANCE)- Romberg Test: maintain stance, moves the
For Hearing: feet apart to maintain
Weber test and 1. Ask the client to stand stance.
Rinner test, with feet together and
Tuning arms resting at the Ataxia is a neurological sign
Fork sides, first with eyes consisting of lack of
open, then closed for 30 voluntary coordination of
sec muscle movements that
2. Stand close during this includes gait abnormality.
test to prevent the
client from falling.

* Normal Finding:
NEGATIVE ROMBERG- may
sway slightly but is able to
maintain upright posture and
foot stance.

For Cochlear branch

(HEARING)-:
a. Weber Test- Assesses
bone conduction by
examining lateralization
(sideward transmission
of sounds)

Procedure:
1. Hold the tuning fork
at its base. Activate it
by tapping the fork
gently against the
 back of your hand
near the knuckles or
by stroking the fork
between your thumb
& index fingers.
2. Place the base of the
vibrating fork on top
of the client’s head
and ask where the
client hears the
noise.

Normal Finding: WEBER Abnormal Finding:

NEGATIVE- Sound is heard in WEBER POSITIVE sound is
both ears or is localized at heard better in impaired ear,
the center of the head. indicating a bone- conductive
hearing loss or Weber
a. Rinne Test- Compares Positive that is the sound is
air conduction and heard better in ear without a
bone conduction. problem indicating
sensorineural disturbance.
Procedure:
1. Hold the handle of the
activated tuning fork
on the mastoid process
of one ear until the
vibration can no longer
be heard
2. Immediately hold the
still vibrating fork
prongs in front of the
client’s ear canal. Ask
the client whether the
client now hears the
sound.

Normal Finding: POSITIVE Abnormal Finding:

RINNE- Sound conducted by
the air is heard more readily
than sound conducted by
bone. The tuning fork
vibrations conducted by air
are normally heard longer.
NEGATIVE RINNE – bone
conduction time is equal to
or longer than the air
conduction time BC> AC

*Air conducted (AC) hearing

is greater than bone-
conducted hearing. AC >BC

Terms:

Air conduction- uses the
apparatus of the middle

ear (pinna, eardrum a
nd ossicles) to amplify
and direct the sound to
the cochlea

Bone conduction-
bypasses some or all
 apparatus of the middle
ear (pinna, eardrum a
nd ossicles) and allows
the sound to be
transmitted directly to
the inner ear even if at a
reduced volume, or via
the bones of the skull to
the opposite ear.

TYPES OF HEARING LOSS:


Conductive Hearing
Loss- Any problem in the
outer or middle ear that
prevents sound from
being conducted
properly
 Sensorineural Hearing
Loss- loss results from
missing or damaged
sensory cells (hair cells)
in the cochlea and is
usually permanent. Also
known as “nerve
deafness”, g conducted
properly is known as a
conductive hearing loss
IV Glossopharyngeal tongue depressor, Assessment : Motor portion of Gag reflex:
sugar, salt, lemon 1. Apply tastes on Touch the back of Patient’s
juice posterior tongue for throat with tongue
identification depressor. Not gagging is
2. Ask client to move positive for CN IX lesion
tongue from side to sit
and up and down
3. Motor portion of Gag
reflex: Touch the back
of patient’s throat with
tongue depressor.
X Vagus Penlight Observe for hoarseness of Uvula will deviate away from
voice. Shine light in patients’ the side of a CN X lesion.
mouth, ask patient to say
“Ahhhh”. Check to see if
uvula is deviating to one side.
XI Spinal Accessory Ask the client to shrug the Weakness is positive for
shoulders against resistance ipsilateral CN XI lesion.
from your hands and turn
head to side against
resistance from your hand
XII Hypoglossal Observe patient for slurred Tongue will deviate toward
speech. Ask patient to stick the side of a CN XII lesion
tongue straight out.
Lesson 4

VITAL SIGNS
 Refers to taking a client’s temperature, pulse, respiration and blood pressure.
 Objective measurement of one’s overall health status.

General Guidelines:
1. The Health Care Provider (HCP) should know the normal values of vital signs.
2. The HCP in charge of the client is responsible for assessing vital signs.
3. Equipment for vital signs taking should be functioning and appropriate for client’s age, size and condition.
4. The HCP should be aware of the client’s condition, therapies and medication.
5. The HCP should minimize environmental factors that can alter vital signs results.
6. The HCP uses a calm and caring approach towards the client when performing vital signs.
7. The HCP is systematic and organized when measuring vital signs to ensure accuracy.

WHEN TO ASSESS VITAL SIGNS:

1. Upon admission and before discharge of the client.
2. At the start of every shift.
3. Before, during and after an invasive procedure
4. Before and after an intervention, therapy or treatment.
5. Before and after medication administration
6. Whenever a client’s condition changes

TEMPERATURE - the result of the amount of heat produced and the amount of heat lost by the body.
1. To obtain baseline information
2. To assess the progression of an illness
3. To monitor a response to therapy

Types of Body Temperature:

1. Core temperature
2. Surface temperature
Sites: skin, and axillae

HYPOTHALAMUS AS TEMPERATURE CONTROL CENTER

a. Anterior hypothalamus- controls heat loss; nerve sensors send out signals that initiate sweating, peripheral
vasodilation and inhibition of heat production.
b. Posterior hypothalamus- controls heat production; nerve sensors send out signals that initiate shivering,
vasoconstriction and release of epinephrine.

FACTORS THAT PROMOTE HEAT PRODUCTION

1. Basal metabolic rate
2. Muscle activity
3. Thyroxine production

FACTORS THAT PROMOTE HEAT LOSS

1. Conduction
2. Radiation
3. Convection
4. Vaporization (evaporation)

FACTORS AFFECTING TEMPERATURE

1. Age
2. Diurnal variations
3. Environment
4. Exercise
5. Hormones
6. Stress
ROUTES OF TEMPERATURE ASSESSMENT
1. Oral route
Advantage:
 most accessible and convenient
 reflects rapid change in core temperature
Disadvantages:
 contraindicated in children below 3 y/o
 Seizure-prone client
 Confused, irrational and unconscious clients
 clients who experience nausea and vomiting
 contraindicated after oral and nasal surgery.

Client care considerations:

1. Ensure that the client has not smoke or ingested hot or cold foods or liquids for 9 minutes before
measurement and capable of sealing the lips around the thermometer.
2. Insert the thermometer under the tongue in the posterior sublingual pocket.
3. Hold the thermometer in place until temperature is obtained.; 3-5 minutes for a glass or plastic
thermometer.
4. Wash the thermometer a. Bulb to stem (before use) b. Stem to bulb (after use)

2. Rectal route
Advantage:
 most accurate and reliable measurement of temperature
Disadvantages:
 inconvenient and difficult to clients who are unable to turn to sides presence of stool may interfere with
thermometer placement
 may cause ulcerations and rectal perforations in children and infants
 contraindicated to client with diarrhea, after rectal and/or prostatic surgery or injury, recent myocardial
infarction and post head injury
 may embarrass the client; requires privacy
 contraindicated for newborns; clients with hemorrhoids, or a fragile rectal mucosa and those underwent
colon and rectal surgery, clients with heart conditions

Client care considerations:

1. Draw the curtain and position the client properly.
2. Wash hands and don gloves.
3. Lubricate the tip of the thermometer.
4. Raise the upper buttock with one hand, instruct the client to take a deep breath while inserting the
thermometer into the anus.
 1 – 1.5 inches = adult
 0.5- 0.9 inches = child
 0.5 inches = infant
2. Hold the thermometer in place until it is time of removal; 2 minutes (adult) & 5 minutes (infants).
5. Remove, clean and read the thermometer.
6. Remove any gel from perianal area after the removal.
7. Remove and discard your gloves in an appropriate receptacle; wash your hands.

3. Axillary route
Advantage:
 safest and non-invasive; accessible
 can be used for newborns and uncooperative clients Disadvantages:
 thermometer must remain in place for long periods; approx. 8 minutes.
 not as accurate as rectal route

1. Pat dry the axilla if moist.

2. Place the thermometer in the middle of the axilla and instruct to position the arms across the chest.
 3. Leave the thermometer for 8-10 minutes.
4. Remove the thermometer and wipe with rotating motion from stem to bulb.
5. Hold the thermometer at eye level.
6. Read the temperature.
7. Clean the thermometer with soap and water (if mercurial glass).
8. Use same thermometer for repeat temperature taking to ensure accuracy.

4. Tympanic route
Advantages:
 easily accessible
 reflects results within seconds
 unaltered by eating, smoking, drinking, and oxygen administration
 can be used for infants, unconscious and dyspneic clients.
Disadvantages:
 equipment is expensive
 can be uncomfortable
 contraindicated for clients with ear infection and those who underwent ear surgery
 earwax may result to inaccurately low result

Client care considerations:

1. Clean the lens under the probe before use.
2. Straighten the ear canal.
- Pull the pinna UP and BACK (adult).
- Pull the pinna DOWN and BACK (children 3 years and younger).
3. Insert the probe into the ear canal firmly but gently towards tympanic membrane.
4. Push the button to take the temperature.
5. Remove the device when it beeps.
6. Eject the probe cover into an appropriate trash receptacle.
7. Repeat procedure for the other ear using a new probe cover.

5. Temporal artery
 head covering, hair or temporal area against a pillow or mattress can cause inaccurately high results.
 influenced by perspiration

1. Determine that the site is not influenced by hair, a hat or lying on a pillow or mattress.
2. Dry the site if there is perspiration.
3. Ensure the device is charged.
4. Remove the protective cap & clean the probe following the manufacturer’s instructions.
5. Place probe with gentle pressure on the center of the forehead, halfway between the hairline and
eyebrows.
6. Depress and hold the start button while dragging the probe laterally across the forehead to the
opposite hairline.
7. Continue to depress the start button and touch the probe behind the ear lobe on the soft area
below the mastoid process.
8. Release the button and read the result.
9. Clean the probe.

ALTERATIONS IN BODY TEMPERATURE

A. Decreased body temperature

1. Hypothermia- body temperature < 36°C.
2. Severe hypothermia- body temperature < 28°C.
Clinical indicators:
 shivering initially
 decreased, irregular pulse
 decreased respirations
  hypotension
 pale, cool skin
 oliguria
 reduced muscle coordination
 disorientation
 decreased level of consciousness
 WOF: Coma

B. Increased body temperature

1. Hyperthermia- temperature > 40.5°C.
a. Heat exhaustion- caused by excessive environmental heat and dehydration
Clinical indicators: weakness, muscle aches, headache, syncope, N/V, pallor, dizziness, diaphoresis.
b. Heat stroke- caused by exercise in hot weather
Clinical indicators: flushed, hot & dry skin; throbbing headache; rapid, strong pulse;
WOF: impaired judgment, delirium, unconsciousness & seizure
2. Fever (pyrexia, febrile)- temperature 37.8°C (orally) or 38.3°C (rectally).
- NOTE: Fever up to 38.9°C enhances immune response, promote phagocytosis, hinder reproduction of
pathogens.
a. Hyperpyrexia- temperature of 41°C or more.
Clinical indicators: agitation, confusion, stupor and may progress to coma.

PULSE
- wave of blood created by contraction of the left ventricles of the heart.
- regulated by autonomic nervous system

Related terms:
STROKE VOLUME- amount of blood that enters the aorta with each ventricular contraction.
CARDIAC OUTPUT- amount of blood pumped by the heart in one full minute

FACTORS AFFECTING PULSE RATE

1. Age 5. Medications
2. Sex 6. Stress and hormones
3. Exercise 7. Blood volume
4. Fever 8. Position

PULSE SITES
Techniques in Pulse Assessment
1. By palpation
- Select the pulse site.
- Place the client in a comfortable resting position.
- Place two or three fingertips and apply moderate pressure. Do not use thumb to palpate arterial pulsation.
- Count for 1 full minute to obtain accurate picture of rate and irregularities.

2. By auscultation
- Use the diaphragm of the stethoscope to count the apical pulse at Left 5th ICS MCL for adult and Left 4th ICS
MCL for children.
- Make sure the tubing extends straight as kinks cn distort sound transmission.
- movement of gases into and out of the lungs, promoting an exchange of gases between the atmosphere
and the capillary beds in the alveoli.
- involves inhalation and exhalation.

TYPES OF BREATHING:
1. Coastal breathing - external intercostal muscles and other accessory muscles, such as the sternocleidomastoid
muscles
2. Diaphragmatic breathing - the contraction and relaxation of the diaphragm, and it is observed by the
movement of the abdomen
 FACTORS AFFECTING RESPIRATION:
1. Increases Respiratory rate
• exercise (increases metabolism)
• stress (readies the body for “fight or flight”),
• increased environmental temperature, and
• lowered oxygen concentration at increased altitudes
2. Decreases Respiratory rate
• Decreased environmental temperature,
• certain medications (e.g., narcotics), and
• increased intracranial pressure.

ASSESSING RESPIRATIONS
a. Count respiration with client in comfortable position. Place client’s arm in relaxed position across abdomen
or lower chest.
b. Discreetly observe the rise and fall of the chest.
c. Observe the character of respirations.

a. Eupnea – normal
b. Tachypnea – fast
c. Bradypnea – slow
d. Apnea – absence of breathing
e. Hyperpnea – labored respiration normally occurring during exercise

EFFORT
a. Dyspnea – difficulty in breathing
b. b. Orthopnea – ability to breathe only in upright, sitting or standing position.

BLOOD PRESSURE - pressure exerted by blood against the walls of the arteries.
Systolic pressure- ventricular contraction
Diastolic pressure- ventricular relaxation
Pulse pressure- difference between systolic and diastolic pressure.

Physiological Determinants of Blood Pressure

1. Cardiac output
- volume of blood that is pumped from the heart in 1 full minute. (about 5.6L).
- results from an increase in HR, increase in heart contractility, and increase in circulating blood volume.
2. Blood volume
- amount of blood within the intravascular compartment
- blood volume is directly proportional to BP.
3. Peripheral vascular resistance
- amount of friction between blood flow and vessel walls
- influenced by elasticity of arterial walls, width of arterial lumens & blood viscosity.

Personal Determinants of Blood Pressure

• Age. Older people have higher blood pressure due to decreased elasticity of blood vessel
• Exercise. Physical activity increases the cardiac output and hence the blood pressure.
• Stress. Stimulation of the sympathetic nervous system increases the blood pressure reading;
• Race. African Americans over 35 years tend to have higher blood pressures than European Americans of the same
age
• Sex. After puberty, females usually have lower blood pressures than males of the same age; this difference is
thought to be due to hormonal variations. After menopause, women generally have higher blood pressures than
before.
• Medications. Many medications, including caffeine, may increase or decrease the blood pressure.
• Obesity. Both childhood and adult obesity predispose to hypertension.
• Diurnal variations. Pressure is usually lowest early in the morning, when the metabolic rate is lowest, then rises
throughout the day and peaks in the late afternoon or early evening.
• Medical conditions. Any condition affecting the cardiac output, blood volume, blood viscosity, and/or compliance
of the arteries has a direct effect on the blood pressure.

CLIENT CARE CONSIDERATIONS:

1. Ensure that the client is rested
2. Allow 30 minutes to pass if the client had engaged in exercise or had smoked or ingested caffeine before
taking the BP.
3. Use appropriate size of the BP cuff. Too narrow cuff causes false high reading. Too wide cuff causes false low
reading.
4. Position the client in sitting or supine position
5. Position the arm at the level of the heart, with the palm of the hand facing up. The left arm is preferably used
because it is nearer the heart.
6. Apply BP cuff snugly, 1 inches above the antecubital space.
7. Use the bell of the stethoscope since the BP is a low-frequency sound.
8. Inflate and deflate BP cuff slowly, 2-3 mmHg at a time.

ASSESSING BLOOD PRESSURE

- The blood pressure is usually assessed in the client’s upper arm using the brachial artery and a standard
stethoscope.

Assessing the blood pressure on a client’s thigh is indicated in these situations:

- The blood pressure cannot be measured on either arm (e.g., because of burns or other trauma).
- The blood pressure in one thigh is to be compared with the blood pressure in the other thigh.

Blood pressure is not measured on a particular client’s limb in the following situations:
- The shoulder, arm, or hand (or the hip, knee, or ankle) is injured or diseased.
- A cast or bulky bandage is on any part of the limb.
- The client has had surgical removal of breast or axillary (or inguinal) lymph nodes on that side.
- The client has an intravenous infusion or blood transfusion in that limb.
- The client has an arteriovenous fistula (e.g., for renal dialysis) in that limb.

OTHER VITAL SIGNS

- Pain assessment
- Oxygen Saturation

PAIN
- an unpleasant and highly personal experience that maybe imperceptible to others, while consuming all parts
of the person’s life.
- subjective data; “what & where the client says it is.”
- Pain Assessment Scale: 0-10
Zero-No pain
10-Worst Possible scale

OXYGEN SATURATION
- A pulse oximeter is a noninvasive device that estimates a client’s arterial blood oxygen saturation (SaO2) by
means of a sensor attached to the client’s finger
- The oxygen saturation value is the percent of all hemoglobin binding sites that are occupied by oxygen.