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BLOOD PRESSURE MONITORING: Blood pressure is the measurement of the pressure exerted by the blood within the blood

vessel walls .usually refers to the pressure within the arteries which may be measured in MM- Hg using a sphygmomanometer. -The arterial blood pressure fluctuates with each heart beat, having a maximum valve (the systolic pressure which is related to the e!ection of blood from the heart into the arteries and a minimum value ("iastolic pressure when the aortic and pulmonary vines are closed and the heart is relaxed. PURPOSE: - To establish a baseline blood pressure. - To monitor fluctuation in the blood pressure. - To monitor response to treatment. POLICY #. $atient should be at rest before his % her blood pressure is ta&en. '. $atient should not be allowed to see the mercury while the blood pressure is being ta&en to avoid anxiety which could lead to a false increase in B$. (. B$ should not be ta&en on an arm where arterial blood supply to the limbs is compromised. ). *f there is any significant change or a doubt about the B$ a second opinion should be sort before informing the doctor. EQUIPMENTS: #. +phygmomanometer '. +tethoscope. PROCEDURE: #. ,xplain procedure to the patient. '. Have patient laying comfortably in bed or sitting down. (. -sing correct si.e cuff , apply the cuff to the patient /s upper arm !ust above the elbow. ). *dentify and mar& the position of the brachial pulse. 0. 1ocate patient2s radial pulse and place the first three fingers of the non-dominant hand on it. 3. *nflate the cuff until the radial pulse is no longer felt, then further inflate for additional #0-'4 mm-Hg. 5. 6ffix earphones of the stethoscope to your ears and the bell to the patient2s brachial pulse. 7. "eflate the cuff slowly. 8. 9atch the gradual fall of the level of the mercury in the manometer and at the same time: listen for the &orot &offs sounds. #4. ;ote the level at which you heard the first distinct &orot&off sound. This is the systolic presser. ##. 6s the cuff is deflated further, the sounds become louder, then muffled, the last distinct sound is the diastolic pressure. #'. "eflate the cuff completely. #(. <emove stethoscope from your ears and cuff from patient2s arm. #). Ma&e patient comfortable. #0. =lear e>uipment. #3. <ecord both systolic and diastolic pressure.

MONITORING PULSE RATE Measurement of the local rhythmic expansion of an artery corresponding to each contraction of the left ventricle of the heart. EQUIPMENTS: #. 9atch with second hand. '. T$< sheet. (. $en. PROCEDURE: #. ,xplain procedure to the patient. '. 6llow the patient/s arm to rest in a comfortable and relaxed position either across the chest or next to the body.

(. $lace three middle finger tips on the radial artery. ). $ress fingers firmly enough to feel the radial pulse. 0. 9hen the pulse is felt count pulse for one full minute or for (4 seconds and multiply by tow if the pulse is regular. *f pulse not regular it must be counted for full minute. 3. ?bserve rate, rhythm, and volume. 5. <ecord date, time, rate, and any abnormality in rhythm or volume. MONITORING RESPIRATORY RATE PURPOSE: To detect any respiratory abnormalities. EQUIPMENTS: #. 9atch with second hand. '. T.$.< sheet. (. $en. PROCEDURE: #. 6fter counting patient2s pulse , &eep fingers still on the patient2s wrist. '. ?bserve the rise and fall of the chest as the patient breathes in and out. (. =ount respiratory for one full minute or for (4 seconds and multiply by tow if it is regular. ). ?bserve respiratory rate , depth and rhythm. 0. <ecord date, time and any abnormality. MONITORING BODY TEMPRATURE Measurement of blood temperature orally, rectally or axillary using a clinical thermometer. PURPOSE: -To record accurate patient2s body temperature. - To detect any abnormality. POLICY: -patients with ever or hypothermia should have their temperature ta&en more often. - Temperature should not be ta&en orally for patients with the fallowing conditions@ a. =hildren below 3 years old. b. "elirious patients. c. *f patient is liable to having fits. d. $atient with nasal pac&. e. *f there is any disease or operation in the mouth. f. -nconscious or mentally unbalanced patient. *f temperature is to be ta&en in the axilla, the area should be dried before placing the thermometer. Aor rectal temperature the thermometer should be lubricated before inserting it into the rectum. EQUIPMENTS: #. 6rac& with individual thermometer in a test tube ( *f patients do not have individual thermometer at the bedside . '. =otton swabs soa&ed in alcohol or a pac&et of meddab. (. Bidney dish for used swabs. ). 9atch with second hand. 0. Celly for rectal thermometer. 3. ,xtra sheets of T$< chart. 5. $en. PROCEDURE: A. ORAL -Ta&e trolley to patients2 bed side. - ,xplain procedure to patient. - <emove thermometer from the test, wipe with alcohol swab or meddab and allow time to dry. - ,xamine thermometer to see there are no crac&s and that the mercury level is below (0D c. (80 D A . - +ha&e thermometer with a sharp wrist movement if mercury is above this level ma&ing sure that it dose not come in contact with any ob!ect. - *nstruct patient to open his % her mouth.

- $lace thermometer under patient2s tongue. - *nstruct patient to close his % her mouth without biting the thermometer. - 1eave thermometer in place for #- ' times. - <emove thermometer and read the mercury level. - 9ipe thermometer with meddab or alcohol swab starting from top to bottom. - +ha&e down the mercury and return thermometer to its container. B. AXILLA - ,xplain procedure to patient. - ,xpose patient2s axilla. - 9ipe axilla with flannel and paper towel. - =hec& and place thermometer in patient2s axilla. - 6ssist patient to place arm across the chest to aold thermometer in place. - 1eave thermometer in place for ' minutes. - <emove thermometer and read level of mercury. - 9ipe thermometer with alcohol swab , sha&e down mercury and return to its container. C. RECTAL - ,xplain procedure to patient. - +creen patient . -6ssist patient to assume a lateral position ( anew born may be placed in lateral or prone position . -9ipe thermometer with alcohol swab . - +ha&e down mercury. - 1ubricate bulb end of thermometer. - *nsert lubricated end of thermometer into the rectum for about ' to '.0 cm. - Hold thermometer in place for #-' minutes. - <emove thermometer and read the mercury level. - 9ipe thermometer with alcohol swab , sha&e down mercury and return to its container.