Measuring and recording pose and respirations

Preparing for the Procedure

  • Hand Hygiene: Always wash your hands before interacting with a patient.

  • Equipment Gathering: Collect necessary tools to measure vital signs. This may include:

    • Patient's electronic medical record

    • A watch with a second hand

    • An electronic device for measuring pulse (if using one).

Introduction to the Patient

  • Greeting: Introduce yourself warmly. Example: "I'm Kelly. Good to meet you. Taking some information for me today."

  • Patient Identification: Verify the patient’s identity by asking for their full name.

Explaining the Procedure

  • Routine Explanation: Communicate clearly about what is going to happen. Say: "So what I'm gonna do now is take your vitals, and I'll start with your pulse first."

  • Confidentiality: Do not inform the patient that you are counting their respirations. This is crucial to avoid changing their natural breathing rate.

Patient Positioning

  • Comfortable Position: Ask the patient to sit or lie down comfortably. Their arm should rest with the palm facing downward.

  • Observation Setup: Position yourself to observe or feel the chest movements easily.

Measuring Pulse

  • Finding Pulse Location: Place 2 to 3 fingers on the radial pulse site:

    • Locate the radial bone on the thumb side of the wrist.

    • Slide fingers into the groove on the inside of the wrist to feel the pulse.

  • Counting Interval: Count the pulse for:

    • 15 to 30 seconds if it is regular.

    • 1 full minute if the pulse is irregular, noting rhythm and volume.

  • Documentation: Remember the counted number for recording.

Observing Respirations

  • Simultaneous Observation: Without letting go of the wrist, observe for respirations for 1 full minute.

  • Assessment: Note the rhythm, volume, and effort of the patient's breathing.

Recording Results

  • Finalizing Measurements: Once both numbers are confirmed, release the wrist and proceed to document:

    • If measuring pulses or respiration for less than a minute, calculate as follows:

      • Multiply count in 30 seconds by 2

      • Or if counting for 15 seconds only, multiply by 4.

    • Always record the date and time of the measurements.

Reporting Findings

  • Significant Changes: Report any findings that differ significantly from previous results or fall outside normal values as required.