Written Report – 2nd Activity

Skill 29 - 1: Assessing Body Temperature

Purpose:
 To establish baseline data for subsequent evaluation
 To identify whether the core temperature is within normal range
 To determine changes in the core temperature in response to specific
therapies (e.g., antipyretic medication, immunosuppressive therapy,
invasive procedure)
 To monitor clients at risk for imbalanced body temperature (e.g.,
clients at risk for infection or diagnosis of infection; those who have
been exposed to temperature extremes)
Assessment:
 Clinical signs of fever
 Clinical signs of hypothermia
 Site and method most appropriate for measurement
 Factors that may alter core body temperature
Planning:
Equipment
• Thermometer
• Thermometer sheath or cover
• Water-soluble lubricant for a rectal temperature
• Clean gloves for a rectal temperature
• Towel for axillary temperature
• Tissues/wipes
Delegation/Interpersonal Practice:
DELEGATION
Routine measurement of the client’s temperature can be delegated to
unlicensed assistive personnel (UAP), or be performed by family
members/caregivers in nonhospital settings. The nurse must explain the
appropriate type of thermometer and site to be used and ensure that the
person knows when to report an abnormal temperature and how to record
the finding. The interpretation of an abnormal temperature and
determination of appropriate responses are done by the nurse.
INTERPROFESSIONAL PRACTICE
Measuring the temperature may be within the scope of practice for many
health care providers. Although these other providers may verbally
communicate their findings and plan to the health care team members, the
nurse must also know where to locate their documentation in the client’s
medical record.
Implementation Rationale Picture
Preparation Checking beforehand
Check that all will prevent non-
equipment is functioning of
functioning normally. equipment’s and to
avoid unnecessary
errors.
1. Prior to performing Identifying the patient
the procedure, ensures the right
introduce self and verify patient receives the
the client’s identity intervention and helps
using agency protocol. prevent errors.
Explain to the client Introducing self will
what you are going to facilitate cooperation
do, why it is necessary, and comfortability with
and how he or she can the nurse performing
participate. Discuss how the procedure.
the results will be used Explanation relieves
in planning further care anxiety and facilitates
or treatments. cooperation.
2. Perform hand This will prevent spread
hygiene and observe of microorganism.
appropriate infection Gloves prevent contact
prevention procedures. with contaminants and
Apply gloves if body fluids.
performing a rectal
temperature.
3. Provide for client This will provide comfort
privacy. and reduce anxiety
during assessment.
4. Position the client This will provide comfort
appropriately (e.g., and reduce anxiety
lateral or Sims’ position during the procedure.
for inserting a rectal The side-lying of Sim’s
thermometer). position allows the
nurse to visualize the
buttocks. Exposing only
the buttocks keeps the
patient warm and
maintains his or her
dignity.
5. Place the If the probe is not
thermometer. inserted correctly, the
• Apply a protective patient’s temperature
sheath or probe cover if may be noted as lower
appropriate. than normal.
• Lubricate a rectal Use of a disposable
thermometer. cover deters the spread
of microorganisms.
Lubrication reduces
friction and facilitates
insertion, minimizing
the risk of irritation or
injury to the rectal
mucous membranes.
6. Wait the appropriate Lubrication reduces
amount of time. friction and facilitates
Electronic and tympanic insertion, minimizing
thermometers will the risk of irritation or
indicate that the reading injury to the rectal
is complete through a mucous membranes.
light or tone. Check
package instructions for
length of time to wait
prior to reading
chemical dot or tape
thermometers.
7. Remove the Discarding the probe
thermometer and cover ensures that it
discard the cover or will not be reused
wipe with a tissue if accidentally on another
necessary. If gloves patient.
were applied, remove Wiping promotes
and discard them. cleanliness. Disposing of
• Perform hand hygiene. the toilet tissue avoids
transmission of
microorganisms.
Hand washing prevent
spread of
microorganisms.
8. Read the The electronic
temperature and record thermometer provides a
it on your worksheet. If digital display of the
the temperature ismeasured temperature.
obviously too high, too Record it for
low, or inconsistent with documentation.
the client’s condition, Rechecking it will
recheck it with aprovide proper
thermometer known to measurement of
be functioning properly. temperature.
9. Wash the This will prevent spread
thermometer if
of microorganism.
necessary and return it Proper storing for next
to the storage location. use.
10. Document the Documenting will
temperature in the provide data of the
client record. A rectal client and also for the
temperature may be primary care provider to
recorded with an “R” see. Also to note for any
next to the value or unusualities.
with the mark on a
graphic sheet circled.
An axillary temperature
may be recorded with
“AX” or marked on a
graphic sheet with an X.
Evaluation:
Compare the temperature measurement to baseline data, normal range for
age of client, and client’s previous temperatures. Analyze considering time of
day and any additional influencing factors and other vital signs.
Conduct appropriate follow-up such as notifying the primary care provider if
a temperature is outside of a specific range or is not responding to
interventions, giving a medication, or altering the client’s environment. This
includes teaching the client how to lower an elevated temperature through
actions such as increasing fluid intake, coughing and deep breathing, cool
compresses, or removing heavy coverings. Interventions for hypothermia
include intake of warm fluids and use of warm or electric blankets.
Health Education/Client Teachings:
Teach patients using electronic or digital thermometers to clean the probe
after use to prevent transmission of microorganisms between family
members. Clean according to manufacturer’s directions. • Teach patients
using non-mercury glass thermometers to clean the thermometer after use
in lukewarm soapy water and rinse in cool water. Store in an appropriate
place to prevent breakage and injury from the glass. • Pacifier
thermometers, which use the supra-lingual area, are available to screen for
fever. These thermometers give an approximation to rectal temperature
measurement in the home setting (Braun, 2006). This thermometer should
be left in place for 3 to 6 minutes, based on manufacturer’s
recommendations.

Skill 29-2: Assessing Peripheral Pulse

Purpose:
• To establish baseline data for subsequent evaluation
• To identify whether the pulse rate is within normal range
• To determine the pulse volume and whether the pulse rhythm is
regular
• To determine the equality of corresponding peripheral pulses on each
side of the body
• To monitor and assess changes in the client’s health status
• To monitor clients at risk for pulse alterations (e.g., those with a
history of heart disease or experiencing cardiac arrhythmias,
hemorrhage, acute pain, infusion of large volumes of fluids, or fever)
• To evaluate blood perfusion to the extremities
Assessment:
• Clinical signs of cardiovascular alterations such as dyspnea
(difficult respirations), fatigue, pallor, cyanosis (bluish discoloration of
skin and mucous membranes), palpitations, syncope (fainting), or
impaired peripheral tissue perfusion (as evidenced by skin
discoloration and cool temperature)
• Factors that may alter pulse rate (e.g., emotional status and activity
level)
• Which site is most appropriate for assessment based on the purpose
Planning:
Equipment
• Clock or watch with a sweep second hand or digital seconds indicator
• If using a DUS: transducer probe, stethoscope headset (some
models), transmission gel, and tissues/wipes
Delegation/Interpersonal Practice:
DELEGATION
Measurement of the client’s radial or brachial pulse can be delegated to UAP,
or be performed by family members/caregivers in nonhospital settings.
Reports of abnormal pulse rates or rhythms require reassessment by the
nurse, who also determines appropriate action if the abnormality is
confirmed. UAP are generally not delegated these techniques due to the skill
required in locating and interpreting peripheral pulses other than the radial
or brachial artery and in using Doppler ultrasound devices.
INTERPROFESSIONAL PRACTICE
Assessing a peripheral pulse may be within the scope of practice for many
health care providers. For example, in addition to nurses, both physical
therapists and respiratory therapists may check the client’s pulse before,
during, and after treatment. Although these therapists may verbally
communicate their findings and plan to the health care team members, the
nurse must also know where to locate their documentation in the client’s
medical record.
Implementation Rationale Picture
Preparation Improper functioning
If using a DUS, check may not give an
that the equipment is accurate reading.
functioning normally.
1. Prior to performing Identifying the patient
the procedure, ensures the right
introduce self and verify patient receives the
the client’s identity intervention and helps
using agency protocol. prevent errors.
Explain to the client Introducing self will
what you are going to provide client comfort
do, why it is necessary, and facilitates
and how he or she can cooperation.
participate. Discuss how Explanation relieves
the results will be used anxiety and facilitates
in planning further care cooperation.
or treatments.
2. Perform hand Hand hygiene prevent
hygiene and observe the spread of
appropriate infection microorganisms.
prevention procedures.
3. Provide for client This will provide comfort
privacy. and relieve anxiety.
4. Select the pulse Ensures safety and
point. Normally, the accuracy of
radial pulse is taken, measurement.
unless it cannot be
exposed or circulation
to another body area is
to be assessed.
5. Assist the client to a This will provide comfort
comfortable resting and reduce anxiety
position. When the during the procedure.
radial pulse is assessed, Proper positioning will
with the palm facing give the nurse to
downward, the client’s visualize the site
arm can rest alongside properly.
the body or the forearm
can rest at a 90-degree
angle across the chest.
For the client who can
sit, the forearm can rest
across the thigh, with
the palm of the hand
facing downward or
inward.
6. Palpate and count the Using the thumb is
pulse. Place two or contraindicated because
three middle the nurse’s thumb has a
Fingertips lightly and pulse that could be
squarely over the pulse mistaken for the
point. client’s pulse.
• Count for 15 seconds The sensitive fingertips
and multiply by 4. can feel the pulsation of
Record the pulse in the artery.
beats per minute on Ensures accuracy of
your worksheet. If measurement and
taking a client’s pulse assessment.
for the first time, when
obtaining baseline data,
or if the pulse is
irregular, count for a full
minute. If an irregular
pulse is found, also take
the apical pulse.
7. Assess the pulse Provides additional
rhythm and volume. assessment data
• Assess the pulse regarding the patient’s
rhythm by noting the cardiovascular status.
pattern of the intervals
between the beats. A
normal pulse has equal
time periods between
beats. If this is an initial
assessment, assess for
1 minute.
• Assess the pulse
volume. A normal pulse
can be felt with
moderate pressure, and
the pressure is equal
with each beat. A
forceful pulse volume is
full; an easily
obliterated pulse is
weak. Record the
rhythm and volume on
your worksheet.
8. Document the pulse Documenting will
rate, rhythm, and provide data of the
volume and your actions client and also for the
in the client record. Also primary care provider to
record in the nurse’s see. Also to note for any
notes pertinent related unusualities.
data such as variation in
pulse rate compared to
normal for the client
and abnormal skin color
and skin temperature.
Variation: Using a Ultrasound beams do
DUS not travel well through
• If used, plug the air. The gel makes an
stethoscope headset airtight seal, which then
into one of the two promotes optimal
 output jacks located ultrasound wave
next to the volume transmission.
control. DUS units may Too much pressure can
have two jacks so that a stop the blood flow and
second person can obliterate the signal.
listen to the signals. Alcohol or other
• Apply transmission gel disinfectants may
either to the probe at damage the face of the
the narrow end of the transducer.
plastic case housing the
transducer, or to the
client’s skin.
• Press the “on” button.
• Hold the probe against
the skin over the pulse
site. Use a light
pressure, and keep the
probe in contact with
the skin.
• Adjust the volume if
necessary. Distinguish
artery sounds from vein
sounds. The artery
sound (signal) is
distinctively pulsating
and has a pumping
quality. The venous
sound is intermittent
and varies with
respirations. Both artery
and vein sounds are
heard simultaneously
through the DUS
because major arteries
and veins are situated
close together
throughout the body. If
arterial sounds cannot
be easily heard,
reposition the probe. If
you cannot hear any
pulse, move the probe
to several different
locations in the same
area before determining
that no pulse is present.
• After assessing the
pulse, remove all gel
from the probe to
prevent damage to the
surface. Clean the
transducer with water-
based solution.
• Remove all gel from
the client.
Evaluation:
• Compare the pulse rate to baseline data or normal range for age of
client.
• Relate pulse rate and volume to other vital signs; relate pulse rhythm
and volume to baseline data and health status.
• If assessing peripheral pulses, evaluate equality, rate, and volume in
corresponding extremities.
• Conduct appropriate follow-up such as notifying the primary care
provider or giving medication.
Health Education/Client Teachings:
• Teach the patient and family members how to take the patient’s pulse, if
appropriate.
• Inform the patient and family about digital pulse monitoring devices.
• Teach family members how to locate and monitor peripheral pulse sites, if
appropriate.

Skill 29-3: Assessing Apical Pulse

Purpose:
• To obtain the heart rate of an adult with an irregular peripheral pulse
• To establish baseline data for subsequent evaluation
• To determine whether the cardiac rate is within normal range and the
rhythm is regular
• To monitor clients with cardiac, pulmonary, or renal disease and those
receiving medications to improve heart action
Assessment:
• Clinical signs of cardiovascular alterations such as dyspnea (difficult
respirations), fatigue/weakness, pallor, cyanosis (bluish discoloration
of skin and mucous membranes), palpitations, syncope (fainting), or
impaired peripheral tissue perfusion as
evidenced by skin discoloration and cool temperature
• Factors that may alter pulse rate (e.g., emotional status, activity
level, and medications that affect heart rate such as digoxin, beta-
blockers, or calcium channel blockers)
Planning:
Equipment
• Clock or watch with a sweep second hand or digital seconds indicator
• Stethoscope
• Antiseptic wipes
• If using a DUS: the transducer probe, the stethoscope headset,
transmission gel, and tissues/wipes
Delegation/Interpersonal Practice:
DELEGATION
Due to the degree of skill and knowledge required, UAP are generally not
responsible for assessing apical pulses.
INTERPROFESSIONAL PRACTICE
Assessing an apical pulse may be within the scope of practice for many
health care providers. For example, in addition to nurses, respiratory
therapists may check the client’s apical pulse before, during, and after
treatment, and physicians often check the apical pulse when assessing the
chest during examinations. Although these providers may verbally
communicate their findings and plan to other health care team members,
the nurse must also know where to locate their documentation in the client’s
medical record.
Implementation Rationale Picture
Preparation Improper functioning
If using a DUS, check may not give an
that the equipment is accurate reading.
functioning normally.
1. Prior to performing Identifying the patient
the procedure, ensures the right
introduce self and verify patient receives the
the client’s identity intervention and helps
using agency protocol. prevent errors.
Explain to the client Introducing self will
what you are going to provide patient comfort
do, why it is necessary, towards the nurse.
and how he or she can Explanation relieves
participate. Discuss how anxiety and facilitates
the results will be used cooperation.
in planning further care
or treatments.
2. Perform hand Hand hygiene prevents
hygiene and observe the spread of
appropriate infection microorganisms.
prevention procedures.
3. Provide for client Provides comfort and
privacy. relieves anxiety.
4. Position the client This position facilitates
appropriately in a identification of the site
comfortable supine for stethoscope
position or in a sitting placement.
position. Expose the This position facilitates
area of the chest over identification of the site
the apex of the heart. for stethoscope
placement.
5. Locate the apical Palpating will help
impulse. This is the locate the apical pulse
point over the apex of of the heart. And also
the heart where the will facilitate on where
apical pulse can be to place the stethoscope
most clearly heard. to assess for the pulse.
• Palpate the angle of
Louis (the angle
between the
manubrium, the top of
the sternum, and the
body of the sternum). It
is palpated just below
the suprasternal notch
and is felt as a
prominence.
• Slide your index finger
just to the left of the
sternum, and palpate
the second intercostal
space.
• Place your middle or
next finger in the third
intercostal space, and
continue palpating
downward until you
locate the fifth
intercostal space.
• Move your index
finger laterally along the
fifth intercostal space
toward the MCL.
Normally, the apical
impulse is palpable at or
just medial to the MCL.
6. Auscultate and count Position the stethoscope
heartbeats. over the apex of the
• Use antiseptic wipes heart, where the
to clean the earpieces heartbeat is best heard.
and diaphragm of the Counting for a full
stethoscope. minute increases the
• Warm the diaphragm accuracy of assessment.
of the stethoscope by The diaphragm needs to
holding it in the palm of be cleaned and
the hand for a moment. disinfected if soiled with
• Insert the earpieces of body substances. Both
the stethoscope into earpieces and
your ears in the diaphragms have been
direction of the ear shown to harbor
canals, or slightly pathogenic bacteria.
forward. Warming the diaphragm
• Tap your finger lightly promotes patient
on the diaphragm. comfort.
• Place the diaphragm Proper positioning of
of the stethoscope over earpieces facilitates
the apical impulse and hearing.
listen for the normal S1 This is to be sure it is
and S2 heart sounds, the active side of the
which are heard as “lub- head. If necessary,
dub.” rotate the head to select
• If you have difficulty the diaphragm side.
hearing the apical pulse, The heartbeat is
ask the supine client to normally loudest over
roll onto his or her left the apex of the heart.
side or the sitting client The two heart sounds
to lean slightly forward. are produced by closure
• If the rhythm is of the heart valves. The
regular, count the S1 heart sound (lub)
heartbeats for 30 occurs when the
seconds and multiply by atrioventricular valves
2. If the rhythm is close after the ventricles
irregular or for giving have been sufficiently
certain medications filled. The S2 heart
such as digoxin, count sound (dub) occurs
the beats for 60 when the semilunar
seconds. valves close after the
ventricles empty.
Side-lying towards the
left moves the apex of
the heart closer to the
chest wall.
A 60-second count
provides a more
accurate assessment of
an irregular pulse than
a 30-second count.
7. Assess the rhythm Provides additional
and the strength of the assessment data
heartbeat. regarding the patient’s
• Assess the rhythm of cardiovascular status.
the heartbeat by noting
the pattern of intervals
between the beats. A
normal pulse has equal
time periods between
beats.
• Assess the strength
(volume) of the
heartbeat. Normally,
the heartbeats are
equal in strength and
can be described as
strong or weak.
8. Document the pulse Documenting will
rate and rhythm, and provide data of the
nursing actions in the client and also for the
client record. Also primary care provider to
record pertinent related see. Also to note for any
data such as variation in unusualities.
pulse rate compared to
normal for the client
and abnormal skin color
and skin temperature.
Evaluation:
• Relate the pulse rate to other vital signs. Relate the pulse rhythm to
baseline data and health status.
• Report to the primary care provider any abnormal findings such as
irregular rhythm, reduced ability to hear the heartbeat, pallor,
cyanosis, dyspnea, tachycardia, or bradycardia.
• Conduct appropriate follow-up such as administering medication
ordered based on apical heart rate.
Health Education/Client Teachings:
• Teach the patient and family members how to take the patient’s pulse, if
appropriate.
• Inform the patient and family about digital pulse monitoring devices.
• Teach family members how to locate and monitor apical pulse sites, if
appropriate.
 Skill 29-4: Assessing Apical-Radial Pulse
Purpose:
• To determine adequacy of peripheral circulation or presence of pulse
deficit
Assessment:
• Clinical signs of hypovolemic shock (hypotension, pallor, cyanosis, and
cold, clammy skin)
Planning:
Equipment
• Clock or watch with a sweep second hand or digital seconds indicator
• Stethoscope
• Antiseptic wipes
Delegation/Interpersonal Practice:
DELEGATION
UAP are generally not responsible for assessing apical-radial pulses using the
one-nurse technique. UAP may perform the radial pulse count for the two-
nurse technique.
INTERPROFESSIONAL PRACTICE
Assessing an apical-radial pulse may be within the scope of practice for
many health care providers. Any provider who assesses a pulse can serve as
the second person in the two-person technique.
Implementation Rationale Picture
Preparation For the proper
If using the two-nurse procedure technique to
technique, ensure that take place,
the other nurse is appropriately.
available at this time.
1. Prior to performing Identifying the patient
the procedure, ensures the right
introduce self and verify patient receives the
the client’s identity intervention and helps
using agency protocol. prevent errors.
Explain to the client Introducing self will give
what you are going to patient comfort towards
do, why it is necessary, the nurse.
and how he or she can Explanation relieves
participate. Discuss how anxiety and facilitates
the results will be used cooperation.
in planning further care
or treatments.
2. Perform hand Hand hygiene prevents
hygiene and observe the spread of
appropriate infection microorganisms.
prevention procedures.
3. Provide for client To help relieve anxiety
privacy. and provide comfort.
4. Position the client This ensures an
appropriately. Assist the accurate comparative
client to a comfortable measurement.
supine or sitting
position. Expose the
area of the chest over
the apex of the heart. If
previous measurements
were taken, determine
what position the client
assumed, and use the
same position.
5. Locate the apical and This facilitates
radial pulse sites. In the collaboration between
two-nurse technique, the two nurses and also
one nurse locates the will provide an accurate
apical impulse by comparative
palpation or with the measurements.
stethoscope while the
other nurse palpates the
radial pulse site
6. Count the apical and This ensures that
radial pulse rates. simultaneous counts are
Two-Nurse Technique taken.
• Place the clock or A full 60-second count
watch where both is necessary for
nurses can see it. The accurate assessment of
nurse who is taking the any discrepancies
radial pulse may hold between the two pulse
the watch. sites.
• Decide on a time to
begin counting. A time
when the second hand
is on 12, 3, 6, or 9 or
an even number on
digital clocks is usually
selected. The nurse
taking the radial pulse
says “Start.”
• Each nurse counts the
pulse rate for 60
seconds. Both nurses
end the count when the
nurse taking the radial
pulse says, “Stop.”
• The nurse who
assesses the apical rate
also assesses the apical
pulse rhythm and
volume (i.e., whether
the heartbeat is strong
or weak). If the pulse is
irregular, note whether
the irregular beats come
at random or at
predictable times.
• The nurse assessing
the radial pulse rate
also assesses the radial
pulse rhythm and
volume.
One-Nurse Technique
Within a few minutes:
• Assess the apical
pulse for 60 seconds,
and
• Assess the radial pulse
for 60 seconds.
7. Document the apical Documenting will
and radial (AR) pulse provide data of the
rates, rhythm, volume, client and also for the
and any pulse deficit in primary care provider to
the client record. Also see. Also to note for any
record related data such unusualities.
as variation in pulse
rate compared to
normal for the client
and other pertinent
observations, such as
pallor, cyanosis, or
dyspnea.
Evaluation:
• Relate pulse rate and rhythm to other vital signs, to baseline data, and
to general health status.
• Report to the primary care provider any changes from previous
measurements or any discrepancy between the two pulse rates.
Health Education/Client Teachings:
• Teach the patient and family members how to take the patient’s pulse, if
appropriate.
• Inform the patient and family about digital pulse monitoring devices.
• Teach family members how to locate and monitor apical pulse sites, if
appropriate.

Skill 29-5: Assessing Respirations

Purpose:
• To acquire baseline data against which future measurements can be
compared
• To monitor abnormal respirations and respiratory patterns and identify
changes
• To monitor respirations before or after the administration of a general
anesthetic or any medication that influences respirations
• To monitor clients at risk for respiratory alterations (e.g., those with
fever, pain, acute anxiety, chronic obstructive pulmonary disease,
asthma, respiratory infection, pulmonary edema or emboli, chest
trauma or constriction, brainstem injury)
Assessment:
• Skin and mucous membrane color (e.g., cyanosis or pallor)
• Position assumed for breathing (e.g., use of orthopneic position)
• Signs of lack of oxygen to the brain (e.g., irritability, restlessness,
drowsiness, or loss of consciousness)
• Chest movements (e.g., retractions between the ribs or above or
below the sternum)
 • Activity tolerance
• Chest pain
• Dyspnea
• Medications affecting respiratory rate
Planning:
Equipment
• Clock or watch with a sweep second hand or digital seconds indicator
Delegation/Interpersonal Practice:
DELEGATION
Counting and observing respirations may be delegated to UAP. The follow-up
assessment, interpretation of abnormal respirations, and determination of
appropriate responses are done by the nurse.
INTERPROFESSIONAL PRACTICE
Assessing respirations may be within the scope of practice for many health
care providers. For example, in addition to nurses, respiratory therapists will
check the client’s breathing before, during, and after treatment. Although
these therapists may verbally communicate their findings and plan to the
health care team members, the nurse must also know where to locate their
documentation in the client’s medical record.
Implementation Rationale Picture
Preparation To avoid inaccurate
For a routine result when assessing
assessment of respiration.
respirations, determine
the client’s activity
schedule and choose a
suitable time to monitor
the respirations. A client
who has been exercising
will need to rest for a
few minutes to permit
the accelerated
respiratory rate to
return to normal.
1. Prior to performing Identifying the patient
the procedure, ensures the right
introduce self and verify patient receives the
the client’s identity intervention and helps
using agency protocol. prevent errors.
Explain to the client Introducing self will
what you are going to provide patient comfort
do, why it is necessary, towards the nurse.
and how he or she can Explanation relieves
participate. Discuss how anxiety and facilitates
the results will be used cooperation.
in planning further care
or treatments.
2. Perform hand Hand hygiene prevent
hygiene and observe the spread of
appropriate infection microorganisms.
prevention procedures.
3. Provide for client To provide comfort and
privacy. relieve anxiety.
4. Observe or palpate While your fingers are
and count the still in place for the
respiratory rate. pulse measurement,
• The client’s awareness after counting the pulse
that the nurse is rate, observe the
counting the respiratory patient’s respirations to
rate could cause the prevent the patient in
client to purposefully being conscious.
alter the respiratory Sufficient time is
pattern. If you necessary to observe
anticipate this, place a the rate, depth, and
hand against the client’s other characteristics.
chest to feel the chest A complete cycle of an
movements with inspiration and an
breathing, or place the expiration composes
client’s arm across the one respiration.
chest and observe the
chest movements while
supposedly taking the
radial pulse.
• Count the respiratory
rate for 30 seconds if
the respirations are
regular. Count for 60
seconds if they are
irregular. An inhalation
and an exhalation count
as one respiration.
5. Observe the depth, During deep
rhythm, and character respirations, a large
of respirations. volume of air is
• Observe the exchanged; during
respirations for depth shallow respirations, a
by watching the small volume is
movement of the chest. exchanged.
• Observe the Normally, respirations
respirations for regular are evenly spaced.
or irregular rhythm. Normally, respirations
• Observe the character are silent and effortless.
of respirations—the
sound they produce and
the effort they require.
6. Document the Documenting will
respiratory rate, depth, provide data of the
rhythm, and character client and also for the
on the appropriate primary care provider to
record. see. Also to note for any
unusualities.
Evaluation:
• Relate respiratory rate to other vital signs, in particular pulse rate;
relate respiratory rhythm and depth to baseline data and health
status.
• Report to the primary care provider a respiratory rate significantly
above or below the normal range and any notable change in
 respirations from previous assessments; irregular respiratory rhythm;
inadequate respiratory depth; abnormal character of breathing—
orthopnea, wheezing, stridor, or bubbling; and any complaints of
dyspnea.
Health Education/Client Teachings:

Skill 29-6: Assessing Blood Pressure

Purpose:
• To obtain a baseline measurement of arterial blood pressure for
subsequent evaluation
• To determine the client’s hemodynamic status (e.g., cardiac
output: stroke volume of the heart and blood vessel resistance)
• To identify and monitor changes in blood pressure resulting from a
disease process or medical therapy (e.g., presence or history of
cardiovascular disease, renal disease, circulatory shock, or acute pain;
rapid infusion of fluids or blood products)
Assessment:
• Signs and symptoms of hypertension (e.g., headache, ringing in the
ears, flushing of face, nosebleeds, fatigue)
• Signs and symptoms of hypotension (e.g., tachycardia, dizziness,
mental confusion, restlessness, cool and clammy skin, pale or cyanotic
skin)
• Factors affecting blood pressure (e.g., activity, emotional stress, pain,
and time the client last smoked or ingested caffeine)
• Some blood pressure cuffs contain latex. Assess the client for latex
allergy and obtain a latex-free cuff if indicated.
Planning:
Equipment
• Stethoscope or DUS
• Blood pressure cuff of the appropriate size
• Sphygmomanometer
Delegation/Interpersonal Practice:
DELEGATION
Blood pressure measurement may be delegated to UAP. The interpretation of
abnormal blood pressure readings and determination of appropriate
responses are done by the nurse.
INTERPROFESSIONAL PRACTICE
Measurement of blood pressure is within the scope of practice for many
health care providers. For example, in addition to nurses, therapists may
check the client’s blood pressure before, during, and after treatment.
Although these therapists may verbally communicate their findings and plan
to the health care team members, the nurse must also know where to locate
their documentation in the client’s medical record.
Implementation Rationale Picture
1. Ensure that the Improper functioning or
equipment is intact and broken equipment
functioning properly. might not give an
Check for leaks in the accurate result.
tubing between the cuff
and the
sphygmomanometer.
2. Make sure that the Smoking constricts
client has not smoked blood vessels, and
or ingested caffeine caffeine increases the
within 30 minutes prior pulse rate. Both of
to measurement. these cause a
temporary increase in
blood pressure.
3. Prior to performing Identifying the patient
the procedure, ensures the right
introduce self and verify patient receives the
the client’s identity intervention and helps
using agency protocol. prevent errors.
Explain to the client Introducing self
what you are going to provides patient comfort
do, why it is necessary, towards the nurse.
and how he or she can Identifying the patient
participate. Discuss how ensures the right
the results will be used patient receives the
in planning further care intervention and helps
or treatments. prevent errors.
4. Perform hand Hand washing prevents
hygiene and observe spread of
appropriate infection microorganism.
prevention procedures.
5. Provide for client To provide comfort and
privacy. relieve anxiety.
6. Position the client Legs crossed at the
appropriately. knee results in elevated
• The adult client should systolic and diastolic
be sitting unless blood pressures.
otherwise specified. The blood pressure
Both feet should be flat increases when the arm
on the floor. is below the heart level
• The elbow should be and decreases when the
slightly flexed with the arm is above heart
palm of the hand facing level.
up and the arm
supported at heart
level. Readings in any
other position should be
specified. The blood
pressure is normally
similar in sitting,
standing, and lying
positions, but it can
vary significantly by
position in certain
persons.
• Expose the upper
arm.
7. Wrap the deflated The bladder inside the
cuff evenly around the cuff must be directly
upper arm. Locate the over the artery to be
brachial artery. Apply compressed if the
the center of the reading is to be
bladder directly over the accurate.
artery.
• For an adult, place the
lower border of the cuff
approximately 2.5 cm
(1 in.) above the
antecubital space.
8. If this is the client’s The initial estimate tells
initial examination, the nurse the maximal
perform a preliminary pressure to which the
palpatory determination sphygmomanometer
of systolic pressure. needs to be elevated in
• Palpate the brachial subsequent
artery with the determinations. It also
fingertips. prevents
• Close the valve on the underestimation of the
bulb. systolic pressure or
• Pump up the cuff until overestimation of the
you no longer feel the diastolic pressure
brachial pulse. At that should an auscultatory
pressure the blood gap occur.
cannot flow through the This gives an estimate
artery. Note the of the systolic pressure.
pressure on the A waiting period gives
sphygmomanometer at the blood trapped in the
which pulse is no longer veins time to be
felt. released. Otherwise,
• Release the pressure false high systolic
completely in the cuff, readings will occur.
and wait 1 to 2 minutes
before making further
measurements.
9. Position the Deters the spread of
stethoscope microorganisms.
appropriately. Sounds are heard more
• Cleanse the earpieces clearly when the ear
with antiseptic wipe. attachments follow the
• Insert the ear direction of the ear
attachments of the canal.
stethoscope in your ears If the stethoscope
so that they tilt slightly tubing rubs against an
forward. object, the noise can
• Ensure that the block the sounds of the
stethoscope hangs blood within the artery.
freely from the ears to Because the blood
the diaphragm. pressure is a low-
• Place the bell side of frequency sound, it is
the amplifier of the best heard with the bell-
stethoscope over the shaped diaphragm.
brachial pulse site. This is to avoid noise
• Place the stethoscope made from rubbing the
directly on the skin, not amplifier against cloth.
on clothing over the
site.
• Hold the diaphragm
with the thumb and
index finger.
10. Auscultate the If the rate is faster or
client’s blood pressure. slower, an error in
• Pump up the cuff until measurement may
the sphygmomanometer occur.
reads 30 mmHg above There is no clinical
the point where the significance to phases 2
brachial pulse and 3.
disappeared. This permits blood
• Release the valve on trapped in the veins to
the cuff carefully so that be released.
the pressure decreases
at the rate of 2 to 3
mmHg per second.
• As the pressure falls,
identify the manometer
reading at Korotkoff
phases 1, 4, and 5.
• Deflate the cuff
rapidly and completely.
• Wait 1 to 2 minutes
before making further
determinations.
• Repeat the above
steps to confirm the
accuracy of the reading
—especially if it falls
outside the normal
range (although this
may not be routine
procedure for
hospitalized or well
clients). If there is
greater than 5 mmHg
difference between the
two readings, additional
measurements may be
taken and the results
averaged.
11. If this is the client’s False readings are likely
initial examination, to occur if there is
repeat the procedure on congestion of blood in
the client’s other arm. the limb while obtaining
There should be a repeated readings.
difference of no more
than 10 mmHg between
the arms. The arm
found to have the
higher pressure should
be used for subsequent
examinations.
12. Remove the cuff For patient to be
from the client’s arm. comfortable after the
procedure.
13. Wipe the cuff with Cuffs can become
an approved significantly
disinfectant. contaminated. Many
The client uses it for the institutions use
length of stay and then disposable blood
it is discarded. pressure cuffs.
This decreases the risk
of spreading infection
by sharing cuffs.
14. Document and Documenting will
report pertinent provide data of the
assessment data client and also for the
according to agency primary care provider to
policy. Record two see. Also to note for any
pressures in the form unusualities.
“130/80” where “130” is
the systolic (phase 1)
and “80” is the diastolic
(phase 5) pressure.
Record three pressures
in the form “130/90/0,”
where “130” is the
systolic, “90” is the first
diastolic (phase 4), and
sounds are audible even
after the cuff is
completely deflated.
Use the abbreviations
RA or RL for right arm
or right leg and LA or LL
for left arm or left leg.
Evaluation:
• Relate blood pressure to other vital signs, to baseline data, and to
health status. If the findings are significantly different from previous
values without obvious reasons, consider possible causes.
• Report any significant change in the client’s blood pressure. Also report
these findings:
• Systolic blood pressure (of an adult) above 140 mmHg
• Diastolic blood pressure (of an adult) above 90 mmHg
• Systolic blood pressure (of an adult) below 100 mmHg.
Health Education/Client Teachings:
• Automated blood pressure devices in public areas are generally inaccurate
and inconsistent. In addition, the cuffs on these devices are inadequate for
persons with large arms.
• Use a cuff size appropriate for limb circumference. Inform the patient that
cuff sizes range from a pediatric cuff to a large thigh cuff and that a poorly
fitting cuff can result in an inaccurate measurement.
• Inform patient about digital blood pressure monitoring equipment.
Although more costly than manual cuffs, most provide an easy-to-read
recording of systolic and diastolic measurements.
• Home monitoring devices should be checked for accuracy every 1 to 2
years.

Skill 29-7: Measuring Oxygen Saturation

Purpose:
• To estimate the arterial blood oxygen saturation
• To detect the presence of hypoxemia before visible signs develop
Assessment:
• The best location for a pulse oximeter sensor based on the
client’s age and physical condition. Unless contraindicated, the finger is
usually selected for adults.
• The client’s overall condition including risk factors for
development of hypoxemia (e.g., respiratory or cardiac disease) and
hemoglobin level
• Vital signs, skin color and temperature, nail bed color, and
tissue perfusion of extremities as baseline data
• Adhesive allergy
Planning:
Equipment
• Nail polish remover as needed
• Alcohol wipe
• Sheet or towel
• Pulse oximeter
Delegation/Interpersonal Practice:
DELEGATION
Application of the pulse oximeter sensor and recording of the SpO2 value
may be delegated to UAP. The interpretation of the oxygen saturation value
and determination of appropriate responses are done by the nurse.
INTERPROFESSIONAL PRACTICE
Measuring oxygen saturation may be within the scope of practice for many
health care providers. For example, in addition to nurses, respiratory
therapists may check the client’s oxygen saturation before, during, and after
treatment. Although these therapists may verbally communicate their
findings and plan to the health care team members, the nurse must also
know where to locate their documentation in the client’s medical record.
Implementation Rationale Picture
Preparation Improper functioning of
Check that the oximeter equipment might give
equipment is an inaccurate result.
functioning normally.
1. Prior to performing Identifying the patient
the procedure, ensures the right
introduce self and verify patient receives the
the client’s identity intervention and helps
using agency protocol. prevent errors.
Explain to the client Introducing self
what you are going to provides patient comfort
do, why it is necessary, towards the nurse.
and how he or she can Identifying the patient
participate. Discuss how ensures the right
the results will be used patient receives the
in planning further care intervention and helps
or treatments. prevent errors.
2. Perform hand Hand washing prevents
hygiene and observe spread of
appropriate infection microorganism.
prevention procedures.
3. Provide for client To provide comfort and
privacy. relieve anxiety.
4. Choose a sensor
appropriate for the
client’s weight, size, and
desired location.
Because weight limits of
sensors overlap, a
pediatric sensor could
be used for a small
adult.
• If the client is allergic
to adhesive, use a clip
or sensor without
adhesive.
• If using an extremity,
apply the sensor only if
the proximal pulse and
capillary refill at the
point closest to the site
are present. If the client
has low tissue perfusion
due to peripheral
vascular disease or
therapy using
vasoconstrictive
medications, use a
nasal sensor or a
reflectance sensor on
the forehead. Avoid
using lower extremities
that have a
compromised circulation
and extremities that are
used for infusions or
other invasive
monitoring.
5. Prepare the site. Nail polish may interfere
• Clean the site with an with accurate
alcohol wipe before measurements although
applying the sensor. the data about this are
• It may be necessary inconsistent.
to remove a female
client’s dark nail polish.
• Alternatively, position
the sensor on the side
of the finger rather than
perpendicular to the nail
bed.
6. Apply the sensor, and
connect it to the pulse
oximeter.
• Make sure the LED
and photodetector are
accurately aligned, that
is, opposite each other
on either side of the
finger, toe, nose, or
earlobe. Many sensors
have markings to
facilitate correct
alignment of the LEDs
and photodetector.
• Attach the sensor
cable to the connection
outlet on the oximeter.
Turn on the machine
according to the
manufacturer’s
directions. Appropriate
connection will be
confirmed by an audible
beep indicating each
arterial pulsation. Some
devices have a wheel
that can be turned
clockwise to increase
the pulse volume and
counterclockwise to
decrease it.
• Ensure that the bar of
light or waveform on
the face of the oximeter
fluctuates with each
pulsation.
7. Set and turn on the
alarm when using
continuous monitoring.
• Check the preset
alarm limits for high and
low oxygen saturation
and high and low pulse
rates. Change these
alarm limits according
to the manufacturer’s
directions as indicated.
Ensure that the audio
and visual alarms are
on before you leave the
client. A tone will be
heard and a number will
blink on the faceplate.
8. Ensure client safety.
• Inspect and/or move
or change the location
of an adhesive toe or
finger sensor every 4
hours and a spring-
tension sensor every 2
hours.
• Inspect the sensor site
tissues for irritation
from adhesive sensors.
9. Ensure the accuracy Movement of the client’s
of measurement. finger or toe may be
• Minimize motion misinterpreted by the
artifacts by using an oximeter as arterial
adhesive sensor, or pulsations.
immobilize the client’s Bright room light may
monitoring site. be sensed by the
• If indicated, cover the photodetector and alter
sensor with a sheet or the SpO2 value.
towel to block large A large discrepancy
amounts of light from between the two values
external sources (e.g., may indicate oximeter
sunlight, procedure malfunction.
lamps, or bilirubin lights
in the nursery).
• Compare the pulse
rate indicated by the
oximeter to the radial
pulse periodically.
10. Document the Documenting will
oxygen saturation on provide data of the
the appropriate record client and also for the
at designated intervals. primary care provider to
see. Also to note for any
unusualities.
Evaluation:
• Compare the oxygen saturation to the client’s previous oxygen
saturation level. Relate to pulse rate and other vital signs.
• Conduct appropriate follow-up such as notifying the primary care
provider, adjusting oxygen therapy, or providing breathing treatments.
Health Education/Client Teachings:
 Skill 30 - 1: Assessing Appearance and Mental Status
Purpose:
 This is to observe the client’s posture, movements, and overall
appearance.
Assessment:
 Develop an overall impression of the patient, focusing on overall
appearance and behavior, vital signs, height, and weight.
Planning:
Equipment
• None
Delegation/Interpersonal Practice:
DELEGATION
Due to the substantial knowledge and skill required, assessment of general
appearance and mental status is not delegated to unlicensed assistive
personnel (UAP). However, many aspects are observed during usual care
and may be recorded by individuals other than the nurse. Abnormal findings
must be validated and interpreted by the nurse.
INTERPROFESSIONAL PRACTICE
Assessing appearance and mental status is within the scope of practice of
many health care providers other than nurses before, during, and after their
treatments. Although these providers may verbally communicate their
findings and plan to other health care team members, the nurse must also
know where to locate their documentation in the client’s medical record.
Implementation Rationale Picture
1. Prior to performing Identifying the patient
the procedure, ensures the right
introduce self and verify patient receives the
the client’s identity intervention and helps
using agency protocol. prevent errors.
Explain to the client Introducing self will
what you are going to provide patient comfort
do, why it is necessary, towards the nurse.
and how he or she can Explanation relieves
participate. Discuss how anxiety and facilitates
the results will be used cooperation.
in planning further care
or treatments.
2. Perform hand Hand hygiene prevent
hygiene and observe the spread of
other appropriate microorganisms.
infection prevention
procedures.
3. Provide for client To provide for comfort
privacy. and relieve anxiety.
4. Observe for signs of Appearance provides
distress in posture or information about
facial expression. various aspects of the
patient’s health.
Changes in cognitive
processes, asymmetry,
and signs of distress
can be indicators of
health abnormalities.
5. Observe body build, Height that is
height, and weight in excessively short or tall,
relation to the client’s asymmetry, one-sided
age, lifestyle, and atrophy or hypertrophy,
health. abnormal posture, and
abnormal body
proportion can be
indicators of health
problems.
6. Observe client’s Abnormalities in gait
posture and gait, and ROM can indicate
standing, sitting, and health concerns.
walking.
7. Observe client’s Deficits in hygiene and
overall hygiene and grooming may indicate
grooming. alterations in health.
8. Note body and Unusual body odor may
breathe odor. indicate alterations in
health.
9. Note obvious signs of That may indicate
health or illness (e.g., in client’s health concerns.
skin color or breathing).
10. Assess the client’s Facial expressions,
attitude (frame of speech, eye contact,
mind). and other behaviors
provide clues to mood
and mental health.
11. Note the client’s To assess any change of
affect/mood; assess the mood that may indicate
appropriateness of the mental health.
client’s responses.
12. Listen for quantity Abnormality when
of speech (amount and speaking may indicate
pace), quality speech defect.
(loudness, clarity,
inflection).
13. Listen for relevance Illogical thinking may
and organization of indicate mental health.
thoughts.
14. Document findings Documenting will
in the client record provide data of the
using printed or client and also for the
electronic forms and primary care provider to
checklists supplemented see. Also to note for any
by narrative notes when unusualities.
appropriate.
Evaluation:
 Perform a detailed follow-up examination of specific systems based on
findings that deviated from expected or normal for the client. Relate
findings to previous assessment data if available.
 Report significant deviations from expected or normal findings to the
primary care provider.
Health Education/Client Teachings:
 Skill 30 - 2: Assessing the Skin
Purpose:
 Provides data that may reveal local or systemic problems or alterations
in a client’s self-care activities. It will also provide the nurse with data
related to health maintenance and self-care activities such as hygiene,
exercise, and nutrition.
Assessment:
Complete a health history, focusing on the integumentary system. Identify
risk factors by asking about the following:
• History of rashes, lesions, change in color, or itching
• History of bruising or bleeding in the skin
• History of allergies to medications, plants, foods, or other substances
• History of bathing routines and products
• Exposure to the sun and sunburn history
• Presence of lesions (wounds, bruises, abrasions, or burns)
• Change in the color, size, or shape of a mole
• Recent chemotherapy or radiation therapy
• Exposure to chemicals that may be harmful to the skin, hair, or nails
• Degree of mobility
• Types of food eaten and liquids consumed each day
• Recent falls or injury
• Lifestyle choices: tattoos, body piercing
• Cultural practices related to skin
Planning:
 Review characteristics of primary and secondary skin lesions if
necessary.
 Ensure that adequate lighting is available.
Equipment
 Millimeter ruler
 Clean gloves
 Magnifying glass
Delegation/Interpersonal Practice:
DELEGATION
Due to the substantial knowledge and skill required, assessment of the skin
is not delegated to UAP. However, the skin is observed during usual care and
UAPs should record their findings. Abnormal findings must be validated and
interpreted by the nurse.
INTERPROFESSIONAL PRACTICE
Assessing the skin may be within the scope of practice of many health care
providers other than nurses. For example, physical therapists and
occupational therapists may notice edema or skin lesions during treatment.
Although these other providers may verbally communicate their findings and
plan to health care team members, the nurse must also know where to
locate their documentation in the client’s medical record.
Implementation Rationale Picture
1. Prior to performing Identifying the patient
the procedure, ensures the right
introduce self and verify patient receives the
the client’s identity intervention and helps
using agency protocol. prevent errors.
Explain to the client Introducing self will
what you are going to provide patient comfort
do, why it is necessary, towards the nurse.
and how he or she can Explanation relieves
participate. Discuss how anxiety and facilitates
the results will be used cooperation.
in planning further care
or treatments.
2. Perform hand Hand hygiene prevents
hygiene and observe the spread of
other appropriate microorganisms.
infection prevention
procedures.
3. Provide for client To provide comfort and
privacy. relieve anxiety.
4. Inquire if the client Obtaining client’s
has any history of the history before
following: pain or performing procedure
itching; presence and will provide baseline
spread of lesions, data that will help the
bruises, abrasions, nurse to know if there is
pigmented spots; any complications that
previous experience the nurse needed to
with skin problems; know beforehand.
associated clinical signs;
family history; presence
of problems in other
family members;
related systemic
conditions; use of
medications,
lotions, home remedies;
excessively dry or moist
feel to the skin;
tendency to bruise
easily; association of
the problem to season
of year, stress,
occupation,
medications, recent
travel, housing, and so
on; recent contact with
allergens (e.g., metal
paint).
5. Inspect skin color Skin color varies among
(best assessed under races and individuals;
natural light and on individual skin color
areas not exposed to should be relatively
the sun). consistent across the
body. Abnormal findings
include cyanosis, pallor,
jaundice, and erythema.
6. Inspect uniformity of Overall coloration is a
skin color. good indication of
health status.
7. Assess edema, if Edema may be the
present (i.e., location, result of over hydration,
color, temperature, heart failure, kidney
shape, and the dysfunction, or
degree to which the peripheral vascular
skin remains indented disease.
or pitted when pressed
by a finger). Measuring
the circumference of the
extremity with a
millimeter tape may be
useful for future
comparison.
8. Inspect, palpate, and Lesions can be normal
describe skin lesions. variations, such as a
Apply gloves if lesions macule or freckle, or an
are open or draining. abnormal lesion, such
Palpate lesions to as a melanoma.
determine shape and Palpation of lesions may
texture. Describe result in drainage,
lesions according to which provides clues to
location, distribution, the type or cause of the
color, configuration, lesion.
size, shape, type, or Gloves prevent contact
structure. Use the with blood and body
millimeter ruler to fluids.
measure lesions. If To prevent spread of
gloves were applied, microorganism.
remove and discard
gloves. Perform hand
hygiene.
9. Observe and palpate In a dehydrated patient,
skin moisture. skin is dry, loose, and
wrinkled. Elevated body
temperature may result
in increased
perspiration.
10. Palpate skin The back of the hand is
temperature. Compare more sensitive to
the two feet and the temperature. Increase
two hands, using the in skin temperature
backs of your fingers. may indicate elevated
body temperature.
11. Note skin turgor This technique provides
(fullness or elasticity) information about the
by lifting and pinching patient’s hydration
the skin on an extremity status as well as
or on the sternum. mobility and elasticity of
the skin. Decreased
elasticity may be
present in dehydrated
patients.
12. Remove and discard Removing PPE properly
gloves. reduces the risk for
• Perform hand hygiene. infection transmission
and contamination of
other items. Hand
hygiene prevents the
spread of
microorganisms.
13. Document findings Documenting will
in the client record provide data of the
using printed or client and also for the
electronic forms or primary care provider to
checklists supplemented see. Also to note for any
by narrative notes when unusualities.
appropriate.
Evaluation:
 Compare findings to previous skin assessment data if available to
determine if lesions or abnormalities are changing.
 Report significant deviations from expected or normal findings to the
primary care provider.
Health Education/Client Teachings:

Skill 30 - 3: Assessing the Hair

Purpose:

Assessment:

Planning:
Equipment
• Clean gloves
Delegation/Interpersonal Practice:
DELEGATION
Due to the substantial knowledge and skill required, assessment of the hair
is not delegated to UAP. However, many aspects are observed during usual
care and may be recorded by individuals other than the nurse. Abnormal
findings must be validated and interpreted by the nurse.
INTERPROFESSIONAL PRACTICE
Assessing the hair is within the scope of practice for many health care
providers other than nurses. Although these providers may verbally
communicate their findings and plan to other health care team members,
the nurse must also know where to locate their documentation in the client’s
medical record.
Implementation Rationale Picture
1. Prior to performing
the procedure,
introduce self and verify
the client’s identity
using agency protocol.
Explain to the client
what you are going to
do, why it is necessary,
and how he or she can
participate. Discuss how
the results will be used
in planning further care
or treatments.
2. Perform hand
hygiene, apply gloves,
and observe other
appropriate infection
prevention procedures.
3. Provide for client
privacy.
4. Inquire if the client
has any history of the
following: recent use of
hair dyes, rinses, or
curling or straightening
preparations; recent
chemotherapy (if
alopecia is present);
presence of
disease, such as
hypothyroidism, which
can be associated with
dry, brittle hair.
5. Inspect the evenness
of growth over the
scalp.
6. Inspect hair thickness
or thinness.
7. Inspect hair texture
and oiliness.
8. Note presence of
infections or infestations
by parting the hair in
several areas, checking
behind the ears and
along the hairline at the
neck.
9. Inspect amount of
body hair.
10. Remove and discard
gloves.
• Perform hand hygiene.
11. Document findings
in the client record
using printed or
electronic forms or
checklists supplemented
by narrative notes when
appropriate.
Evaluation:
 Perform a detailed follow-up examination based on findings that
 deviated from expected or normal for the client. Relate findings to
previous assessment data if available.
 Report significant deviations from expected or normal findings to the
primary care provider.
Health Education/Client Teachings:

Skill 29 - 1: Assessing Body Temperature

Purpose:

Assessment:

Planning:
Equipment
 None
Delegation/Interpersonal Practice:
DELEGATION
Due to the substantial knowledge and skill required, assessment of the nails
is not delegated to UAP. However, many aspects are observed during usual
care and may be recorded by individuals other than the nurse. Abnormal
findings must be validated and interpreted by the nurse.
INTERPROFESSIONAL PRACTICE
Assessing the nails is within the scope of practice for many health care
providers other than nurses. Although these providers may verbally
communicate their findings and plan to other health care team members,
the nurse must also know where to locate their documentation in the client’s
medical record.
Implementation Rationale Picture
1. Prior to performing
the procedure,
introduce self and verify
the client’s identity
using agency protocol.
Explain to the client
what you are going to
do, why it is necessary,
and how he or she can
participate. Discuss how
the results will be used
in planning further care
or treatments. In most
situations, clients with
artificial nails or polish
on fingernails or
toenails are not
required to remove
these for assessment;
however, if the
assessment cannot
be conducted due to the
presence of polish or
artificial nails, document
this in the record.
2. Perform hand
hygiene and observe
other appropriate
infection prevention
procedures.
3. Provide for client
privacy.
4. Inquire if the client
has any history of the
following: presence of
diabetes mellitus,
peripheral circulatory
disease, previous injury,
or severe illness.
5. Inspect fingernail
plate shape to
determine its curvature
and angle.
6. Inspect fingernail and
toenail texture.
7. Inspect fingernail and
toenail bed color.
8. Inspect tissues
surrounding nails.
9. Perform blanch test
of capillary refill. Press
the nails between your
thumb and index finger;
look for blanching and
return of pink color to
nail bed. Perform on at
least one nail on each
hand and foot.
10. Document findings
in the client record
using printed or
electronic forms or
checklists supplemented
by narrative notes when
appropriate.
Evaluation:
 Perform a detailed follow-up examination of other systems based on
findings that deviated from expected or normal for the client. Relate
findings to previous assessment data if available.
 Report significant deviations from expected or normal to the primary
care provider.
Health Education/Client Teachings:
Skill 30 - 5: Assessing the Skull and Face
Purpose:

Assessment:

Planning:
Equipment
• None
Delegation/Interpersonal Practice:
DELEGATION
Due to the substantial knowledge and skill required, assessment of the skull
and face is not delegated to UAP. However, many aspects are observed
during usual care and may be recorded by individuals other than the nurse.
Abnormal findings must be validated and interpreted by the nurse.
INTERPROFESSIONAL PRACTICE
Assessing the skull and face is within the scope of practice of many health
care providers other than nurses. Although these other providers may
verbally communicate their findings and plan to health care team members,
the nurse must also know where to locate their documentation in the client’s
medical record.
Implementation Rationale Picture
1. Prior to performing
the procedure,
introduce self and verify
the client’s identity
using agency protocol.
Explain to the client
what you are going to
do, why it is necessary,
and how he or she can
participate. Discuss how
the results will be used
in planning further care
or treatments.
2. Perform hand
hygiene and observe
other appropriate
infection prevention
procedures.
3. Provide for client
privacy.
4. Inquire if the client
has any history of the
following: past
problems with lumps or
bumps, itching, scaling,
or dandruff; history of
loss of consciousness,
dizziness, seizures,
headache, facial pain, or
injury; when and how
any lumps occurred;
length of time any other
problem existed; any
known cause of
problem; associated
symptoms, treatment,
and recurrences.
5. Inspect the skull for
size, shape, and
symmetry.
6. Inspect the facial
features (e.g.,
symmetry of structures
and of the distribution
of hair).
7. Inspect the eyes for
edema or hollowness.
8. Note symmetry of
facial movements. Ask
the client to elevate the
eyebrows, frown, or
lower the eyebrows,
close the eyes tightly,
puff the cheeks, and
smile and show the
teeth.
9. Document findings in
the client record using
printed or electronic
forms or checklists
supplemented by
narrative notes when
appropriate.
Evaluation:
 Perform a detailed follow-up examination of other systems based on
findings that deviated from expected or normal for the client. Relate
findings to previous assessment data if available.
 Report deviations from expected or normal findings to the primary
care provider.
Health Education/Client Teachings:

Skill 30 - 6: Assessing the Eye Structures and Visual Acuity

Purpose:
 It is to identify any changes in vision or signs of eye disorders in an
effort to initiate early treatment or corrective procedures.
Assessment:
 Before performing eye examination, review and recognize structures
 and functions of the eyes.
 Administer vision tests competently and record the results.
 Use the ophthalmoscope correctly and confidently.
 Recognize and distinguish normal variations from abnormal findings.
 Test distant visual acuity, near visual acuity, and visual fields for gross
peripheral vision.
 Inspect the eyelids and eyelashes; bulbar conjunctiva and sclera;
lacrimal apparatus; and iris and pupil.
 Observe the position and alignment of the eyeball in the eye socket.
 Assess pupillary reaction to light.
Planning:
Place the client in an appropriate room for assessing the eyes and vision.
The nurse must be able to control natural and overhead lighting during some
portions of the examination.
Equipment
 Millimeter ruler
 Penlight
 Snellen or E chart
 Opaque card
 Ophthalmoscope
 Clean Gloves
Delegation/Interpersonal Practice:
DELEGATION
Due to the substantial knowledge and skill required, assessment of the eyes
and vision is not delegated to UAP. However, many aspects are observed
during usual care and may be recorded by individuals other than the nurse.
Abnormal findings must be validated and interpreted by the nurse.
INTERPROFESSIONAL PRACTICE
Assessing the eyes and vision may be within the scope of practice of other
health care providers. Although these providers may verbally communicate
their findings and plan to other health care team members, the nurse must
also know where to locate their documentation in the client’s medical record.
Implementation Rationale Picture
EXTERNAL EYE
STRUCTURES
1. Prior to performing Introducing self to the
the procedure, client will help build
introduce self and verify trust to the nurse.
the client’s identity Identifying client’s
using agency protocol. identity will prevent
Explain to the client error (on who to
what you are going to perform the procedure).
do, why it is necessary, Explaining the
and how he or she can procedure will help
participate. Discuss how relieve client’s anxiety
the results will be used and will also provide
in planning further care comfort during the
or treatments. procedure.
2. Perform hand This will help prevent
hygiene, apply gloves, the spread of
and observe other microorganism.
appropriate infection
prevention procedures.
3. Provide for client This will provide comfort
privacy. to the client.
4. Inquire if the client Obtaining client’s
has any history of the history before
following: family history performing procedure
of diabetes, will provide baseline
hypertension, blood data that will help the
dyscrasia, or eye nurse to know if there is
disease, injury, or any complications that
surgery; client’s last the nurse needed to
visit to a provider who know beforehand.
specifically assessed the
eyes (e.g.,
ophthalmologist or
optometrist); current
use of eye medications;
use of contact lenses or
eyeglasses; hygienic
practices for corrective
lenses; current
symptoms of eye
problems (e.g., changes
in visual acuity, blurring
of vision, tearing, spots,
photophobia, itching, or
pain).
5. Inspect the eyebrows To assess if hair is
for hair distribution and evenly distributed and it
alignment and skin is symmetrically
quality and movement aligned. Also to assess
(ask client to raise and for equal movement and
lower the eyebrows). if the skin is intact.
6. Inspect the eyelashes
for evenness of
distribution and
direction of curl.
7. Inspect the eyelids
for surface
characteristics (e.g.,
skin quality and
texture), position in
relation to the cornea,
ability to blink, and
frequency of blinking.
Inspect the lower
eyelids while the
client’s eyes are closed.
8. Remove and discard
gloves.
• Perform hand hygiene.
INTERNAL EYE
STRUCTURES
9. Inspect the bulbar
conjunctiva (that lying
over the sclera) for
color, texture, and the
presence of lesions.
10. Inspect the cornea
for clarity and texture.
Ask the client to look
straight ahead. Hold a
penlight at an oblique
angle to the eye, and
move the light slowly
across the corneal
surface.
11. Inspect the pupils
for color, shape, and
symmetry of size. Pupil
charts are available in
some agencies. See for
variations in pupil
diameters.
12. Assess each pupil’s
direct and consensual
reaction to light to
determine the function
of the third
(oculomotor) and fourth
(trochlear) cranial
nerves.
• Partially darken the
room.
• Ask the client to look
straight ahead.
• Using a penlight and
approaching from the
side, shine a light on
the pupil.
• Observe the response
of the illuminated pupil.
It should constrict
(direct response).
• Shine the light on the
pupil again, and observe
the response of the
other pupil. It should
also constrict
(consensual response).
13. Assess each pupil’s
reaction to
accommodation.
• Hold an object (a
penlight or pencil) about
10 cm (4 in.) from the
bridge of the client’s
nose.
• Ask the client to look
first at the top of the
object and then at a
distant object (e.g., the
far wall) behind the
penlight. Alternate the
gaze from the near to
the far object. Observe
the pupil response.
• Next, ask the client to
look at the near object
and then move the
penlight or pencil
toward the client’s nose.
VISUAL FIELDS
14. Assess peripheral
visual fields to
determine function of
the retina and neuronal
visual pathways to the
brain and second (optic)
cranial nerve.
• Have the client sit
directly facing you at a
distance of 60 to 90 cm
(2 to 3 ft).
• Ask the client to cover
the right eye with a
card and look directly at
your nose.
• Cover or close your
eye directly
opposite the client’s
covered eye (i.e., your
left eye), and look
directly at the client’s
nose.
• Hold an object (e.g., a
penlight or pencil) in
your fingers, extend
your arm, and move the
object into the visual
field from various points
in the periphery. The
object should be at an
equal distance from the
client and yourself. Ask
the client to tell you
when the moving object
is first spotted.
a. To test the temporal
field of the left eye,
extend and move your
right arm in from the
client’s right periphery.
b. To test the upward
field of the left eye,
extend and move the
right arm down from
the upward periphery.
c. To test the downward
field of the left eye,
extend and move the
right arm up from the
lower periphery.
d. To test the nasal field
of the left eye, extend
and move your left arm
in from the periphery.
• Repeat the above
steps for the right eye,
reversing the process.
EXTRAOCULAR
MUSCLE TESTS
15. Assess six ocular
movements to
determine eye
alignment and
coordination.
• Stand directly in front
of the client and hold
the penlight at a
comfortable distance,
such as 30 cm (1 ft) in
front of the client’s
eyes.
• Ask the client to hold
the head in a fixed
position facing you and
to follow the
movements of the
penlight with the eyes
only.
Move the penlight in a
slow, orderly manner
through the six cardinal
fields of gaze, that is,
from the center of the
eye along the lines of
the arrows in and back
to the center.
• Stop the movement of
the penlight periodically
so that nystagmus can
be detected.
16. Assess for location
of light reflex by shining
penlight on the corneal
surface (Hirschberg
test).
17. Have client fixate on
a near or far object.
Cover one eye and
observe for movement
in the uncovered eye
(cover test).
VISUAL ACUITY
18. If the client can
read, assess near vision
by providing adequate
lighting and asking the
client to read from a
magazine or newspaper
held at a distance of 36
cm (14 in.). If the client
normally wears
corrective lenses, the
glasses or lenses should
be worn during the test.
The document must be
in a language the client
can read.
19. Assess distance
vision by asking the
client to wear corrective
lenses, unless they are
used for reading only
(i.e., for distances of
only 36 cm [14 in.]).
• Ask the client to stand
or sit 6 m (20 ft) from a
Snellen or character
chart, cover the eye not
being tested, and
identify the letters or
characters on the chart.
• Take three readings:
right eye, left eye, both
eyes.
• Record the readings of
each eye and both eyes
(i.e., the smallest line
from which the person
is able to read one-half
or more of the letters).
At the end of each line
of the chart are
standardized numbers
(fractions). The top line
is 20/200. The
numerator (top
number) is always 20,
the distance the person
stands from the chart.
The denominator
(bottom number) is the
distance from which the
normal eye can read the
chart. Therefore, a
person who has 20/40
vision can see at 20 feet
from the chart what a
normal-sighted person
can see at 40 feet from
the chart. Visual acuity
is recorded as “s ––c”
(without correction), or
“c ––c” (with
correction). You can
also indicate how many
letters were misread in
the line, e.g., “visual
acuity 20/40 – 2 c ––c”
indicates that two
letters were misread in
the 20/40 line by a
client wearing corrective
lenses.
20. If the client is
unable to see even the
top line (20/200) of the
Snellen-type chart,
perform selected vision
tests.
21. Document findings
in the client record
using printed or
electronic forms or
checklists supplemented
by narrative notes when
appropriate.
Evaluation:
 Perform a detailed follow-up examination of other systems based on
findings that deviated from expected or normal for the client. Relate
findings to previous assessment data if available.
 Report deviations from expected or normal findings to the primary
care provider. Individuals with denominators of 40 or more on the
Snellen or character chart, with or without corrective lenses, may need
to be referred to an optometrist or ophthalmologist.
Health Education/Client Teachings:

Skill 30 - 7: Assessing the Ears and Hearing

Purpose:
 It is to evaluate the condition of the external ear, the condition and
patency of the ear canal, the status of the tympanic membrane, bone
 and air conduction of sound vibrations, hearing acuity and equilibrium.
Assessment:
 Recognize the role of hearing in communication and adaptation to the
environment, particularly in regard to aging.
 Know how to use the otoscope effectively when performing the ear
examination
 Understand the usefulness and significance of basic hearing tests.
Planning:
It is important to conduct the ear and hearing examination in an area that is
quiet. In addition, the location should allow the client to be positioned sitting
or standing at the same level as the nurse.
Equipment
 Otoscope with several sizes of ear specula
 Tuning fork
Delegation/Interpersonal Practice:
DELEGATION
Due to the substantial knowledge and skill required, assessment of the ears
and hearing is not delegated to UAP. However, many aspects are observed
during usual care and may be recorded by individuals other than the nurse.
Abnormal findings must be validated and interpreted by the nurse.
INTERPROFESSIONAL PRACTICE
Assessing the ears and hearing are within the scope of practice for many
health care providers other than nurses. For example, audiologists and
physician assistants may check the client’s hearing. Although these
providers may verbally communicate their findings and plan to other health
care team members, the nurse must also know where to locate their
documentation in the client’s medical record.
Implementation Rationale Picture
1. Prior to Introducing
performing the self to the
procedure, client will help
introduce self and build trust to
verify the client’s the nurse.
identity using Identifying
agency protocol. client’s
Explain to the identity will
client what you prevent error
are going to do, (on who to
why it is perform the
necessary, and procedure).
how he or she Explaining the
can participate. procedure will
Discuss how the help relieve
results will be client’s anxiety
used in planning and will also
further care or provide
treatments. comfort during
the procedure.
2. Perform hand This will help
hygiene and prevent the
observe other spread of
appropriate microorganism
infection
prevention
procedures.
3. Provide for This will
client privacy. provide
comfort to the
client.

4. Inquire if the Obtaining

client has any client’s history
history of the before
following: family performing
history of hearing procedure will
problems or loss; provide
presence of ear baseline data
problems or pain; that will help
medication the nurse to
history, especially know if there
if there are is any
complaints of complications
ringing in the that the nurse
ears (tinnitus); needed to
hearing difficulty: know
its onset, factors beforehand.
contributing to it,
and how it
interferes with
activities of daily
living; use of a
corrective hearing
device: when and
from whom it was
obtained.
5. Position the To provide
client client comfort
comfortably, and to aid for
seated if possible. easy access on
the part that
will be
examine.
AURICLES
6. Inspect the To assess if
auricles for color, the color is
symmetry of size, same as the
and position. To facial skin.
inspect position, To assess if
note the level at both auricle is
which the symmetrical
superior aspect of and aligned
the auricle with outer
attaches to the canthus of the
head in relation eye.
to the eye.
7. Palpate the To assess if
auricles for there is any
texture, lesions and
elasticity, and tenderness
areas of (that may
tenderness. indicate
• Gently pull the inflammation
auricle upward, or infection).
downward, and
backward.
• Fold the pinna
forward (it should
recoil).
• Push in on the
tragus. • Apply
pressure to the
mastoid process.
EXTERNAL EAR
CANAL AND
TYMPANIC
MEMBRANE
8. Inspect the To see if ear
external ear canal canal has
for cerumen, skin redness or any
lesions, pus, and discharges.
blood. Also to
examine if
there is any
impacted
cerumen that
might be
blocking the
ear canal.
9. Visualize the This achieves
tympanic maximum
membrane using vision of the
an otoscope. entire ear
• Attach a canal and
speculum to the tympanic
otoscope. Use the membrane.
largest diameter Straightening
that will fit the the ear canal
ear canal without facilitates
causing vision of the
discomfort. ear canal and
• Tip the client’s the tympanic
head away from membrane.
you, and This stabilizes
straighten the ear the head and
canal. For an protects the
adult, straighten eardrum and
the ear canal by canal from
pulling the pinna injury if a
up and back. quick head
• Hold the movement
otoscope either occurs.
(a) right side up, The inner two
with your fingers thirds of the
between the ear canal is
otoscope handle bony; if the
and the client’s speculum is
head, or (b) pressed
upside down, against either
with your fingers side, the client
and the ulnar will experience
surface of your discomfort.
hand against the
client’s head.
• Gently insert
the tip of the
otoscope into the
ear canal,
avoiding pressure
by the speculum
against either
side of the ear
canal.
10. Inspect the To assess if
tympanic there is any
membrane for discoloration
color and gloss. in the
tympanic
membrane.
GROSS
HEARING
ACUITY TESTS
11. Assess To know if the
client’s response client is able
to normal voice to apprehend
tones. If client what the
has difficulty nurse is telling
hearing the her.
normal voice,
proceed with the
following tests.
11A. Perform the To assess if
whisper test to client is able
assess high- to hear what
frequency the nurse is
hearing. whispering
• Have the client when one of
occlude one ear. the client’s ear
Out of the client’s is occluded.
sight, at a This testing
distance of 0.3 to provides a
0.6 m (1 to 2 ft), gross
whisper a simple assessment of
phrase such as cranial nerve
“The weather is VIII (acoustic
hot today.” nerve).
• Ask the client to
repeat the
phrase.
• Repeat with the
other ear using a
different phrase.
11B. Tuning Fork To determine
Tests. Perform whether
Weber’s test to unilateral
assess bone hearing loss is
conduction by conductive or
examining the sensorineural.
lateralization
(sideward
transmission) of
sounds.
• 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 and
index fingers. It
should be made
to ring softly.
• Place the base
of the vibrating
fork on top of the
client’s head and
ask where the
client hears the
noise.
Conduct the
Rinne test to
compare air
conduction to
bone conduction.
• Hold the handle
of the activated
tuning fork on the
mastoid process
of one ear until
the client states
that the vibration
can no longer be
heard.
• Immediately
hold the still
vibrating fork
prongs in front of
the client’s ear
canal. Push aside
the client’s hair if
necessary. Ask
whether the client
now hears the
sound. Sound
conducted by air
is heard more
readily than
sound conducted
by bone. The
tuning fork
vibrations
conducted by air
are normally
heard longer.
12. Document For future
findings in the reference. Also
client record to document
using printed or any
electronic forms unusualities
or checklists that have
supplemented by been acquired
narrative notes from the
when assessment.
appropriate.
Evaluation:
 Perform a detailed follow-up examination of other systems based on
findings that deviated from expected or normal for the client. Relate
findings to previous assessment data if available.
 Report deviations from expected or normal findings to the primary
care provider.
Health Education/Client Teachings: