Health Care Module

Health Care Module

Divine Colleges of Malolos City

ASSESING BLOOD PRESSURE Definition : Blood pressure is the pressure exerted by blood against the inner walls of the arteries. Measuring a client’s blood pressure gives you information about health of the cardio vascular, circulations and renal system. (Hogan) Purposes : (Kozier) •

To obtain a baseline measure of arterial blood pressure for subsequent evaluation •

To determine the client’s hemodynamic status (e.g). stroke volume of the heart and the blood vessels resistance)

•

To identify and monitor changes in blood pressure resulting from a disease process and the medical therapy (i.e. presence or history of cardiovascular disease, renal disease, circulatory shock, or acute pain, rapid infusion of fluids or blood products)

Equipment and materials : •

Stethoscope

•

Blood pressure

•

Sphygmomanometer

•

Alcohol swab

•

Pen, pencil, vital sign, flow sheet or record form

Implementation

ACTION Explain the procedure to client.

RATIONALE This is done to alleviate anxiety and to ensure maximal cooperation.

Gather equipment

It

reduces

transmission

of

microorganisms. 3. Wash your hands. Select a blood pressure cuff that is the appropriate

Improper cuff size results in inaccurate

size for the client.

readings, if cuff is too small, it results in

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Health Care Module

Divine Colleges of Malolos City

false-high readings and tends to come loose as it is inflated, if the cuff is to large,

false-low

readings

may

be

recorded. Select appropriate arm for application of cuff (no intravenous infusion, breast or axilla

Inappropriate site selection may result

surgery on that side, csts, arterio-venous

in poor application of sounds., causing

shunt, or injured or disease limb.)

inaccurate

readings.

pressure

from

Application

inflated

of

bladder

temporarily impairs blood flow and can further

compromise

circulation

extremity that already has impairments. (Potter) If you can’t use one of the client’s arms Expose

the

area

or

brachial

artery

by

to

take

a

blood

pressure

reading,

removing garments or move a sleeve if it is

measure blood pressure at the popliteal

not to tight, above the area where the cuff

artery. (Hogan)

will be placed. It ensures proper cuff application. Tight Center the bladder cuff of the cuff over the

clothing causes congestion of blood and

brachial artery, approximately midway on the

can falsely elevate BP readings. (Potter)

arm, so that the lower edge of the cuff is about 2.5 cm to 5 cm (1 to 2 inches) above the inner aspect of the elbow. The tubing

Inflating the bladder cuff directly over

should extend fro the end of the cuff nearer

brachial

the client’s elbow.

pressure Loose

Wrap the cuff around the arm smoothly and

artery

ensures

is

applied

fitting

cuff

that

during causes

proper

inflation. flase-high

readings. (Potter)

smugly and fasten it securely or tuck the end of

the

cuff

well

under

the

preceding

wrapping. Do not allow any clothing to interfere with the proper placement of the cuff.

This

ensures

uniform

and

complete

compression of the brachial artery. A Check that the mercury manometer is in a

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cuff that is too loose will result in a

Health Care Module

Divine Colleges of Malolos City

vertical position. The mercury must be within

false-high reading. (Hogan)

zero area with the gauge at the eye level. If an aneroid is used, the needle should be within the zero mark. Positioning the manometer above eye Palpate the brachial or radical pulse by

level result in false

high reading.

pressing gently with fingertips.

Positioning it below eye level result in false low reading. (Hogan)

Tighten the screw valve on the air pump. Inflate the cuff while continuing to palpate

Inflating bladder directly over artery

the artery. Note the point in the gauge where

ensures

the pulse disappears.

during inflation. (Hogan)

proper

pressure

is

applied

It prevents air leak during inflation. (Hogan) Estimating prevents false-low readings, which may result from the presence of an auscultatory gap (inaudible sounds below the actual systolic pressure). This phenomenon occurs in about 5% of adults and is prevalent in individuals with hypertension. (Potter) Blood pressure measurements should be Deflate the cuff and wait for 15 seconds.

performed on each client whose blood pressure is being read for the first time. It ensures that the cuff is sufficiently

Place the stethoscope in the ear properly.

inflated to you in an accurate systolic reading by auscultation. It also provides information about an auscultatory gap.

Place

the

bell

or

diaphragm

of

the

stethoscope over the artery where the pulse is felt. Do not allow the stethoscope to touch

Gernalin/Tolentino/Carlos

Failure to identify such a gap results in a false low systolic reading. (Hogan)

Health Care Module

Divine Colleges of Malolos City

clothing or the cuff.

Deflating

cuff

prevents

venous

congestion

and

false-high

reading.

(Potter) Each earpiece should follow angle of ear canal to facilitate hearing. (Potter) Proper stethoscope placement ensures optimal sound reception. Stethoscope improperly positioned causes muffled Pump the pressure 30mmHg above the point

sounds that often result in false-low

at which the pulse disappers. Open the valve

systolic and false-high readings. (Potter)

of the manometer and allow air to escape slowly (allowing the gauge to drop 2 to 3 mmHg per heartbeat). The blood pressure is low-frequency sound, it is best heard with the bellshaped diaphragm. (Kozier) Note the point on the gauge at which there is

The auscultatory systolic blood pressure

an appearance of the first faint, but clear

should be slightly higher thatn the

sounds that slowly increase intensity. Note

palpatory reading. Slow inflation can

this number as the systolic pressure.

result in inaccurate reading. (Hogan)

Read

the

pressure

to

the

closest

even

number.

Too rapid or slow decline in pressure can cause

inaccurate with

readings.

Do not re-inflate the cuff once the air is being

interferes

precise

released to recheck the systolic pressure

Korotkoff phases (Potter)

Noise

hearing

of

reading. First korotkoff phase reflects systolic BP. Note

the

pressure

at

which

the

sound

becomes muffled. Also observe the point at which the sound completely disappears. This may occur separately or the same point.

Gernalin/Tolentino/Carlos

(Potter)

Health Care Module

Divine Colleges of Malolos City

Allow the remaining air to escape quickly. Repeat any suspicious readings, but wait for 30 to 60 seconds between reading to allow normal circulation to return to the limb. Be

Continuous cuff inflation causes arterial

sure to deflate the cuff completely between

occlusion, resulting in numbness and

attempts to check the blood pressure.

tingling of client’s arm. (Potter) Beginning of the 5th Korotkoff phase is

If it is difficult to hear sounds when checking

an indication of diastolic pressure with

the blood

pressure, raise the client’s arm

adults. The 4th Korotkoff phase involves

over his head for 15 seconds just before

distinct muffling sounds, and in children

rechecking the blood pressure.

it is recorded as the diastolic pressure. (Potter).

Inflate the cuff while the arm is elevated and then gently lower the arm while continuing to

If you attempt to obtain the blood

support it.

pressure

reading

too

soon

obtaining previous reading Position the stethoscope and deflate the cuff

after

you will

receive a false-high reading. (Hogan)

at the usual rate while listening to Korotkoff sounds. Remove

the

cuff,

clean

and

store

the

equipment Wash your hands. If an arm is unsupported, client performs isometric exercises that can increase diastolic pressure 10%. Placement of the arm above the level of the heart causes Record blood pressure.

low reading. (Potter) Rapid

inflation

ensures

accurate

reading. (Potter) 1. Too rapid or too slow a decline can cause inaccurate readings (Potter)

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Health Care Module

Divine Colleges of Malolos City

Cuff

can

become

significantly

contaminated. (Kozier) It

reduces

transmission

of

microorganism. (Potter) It serves as baseline for comparison and evaluation for change in condition and alterations. (Potter)

ASSISTING A CLIENT TO TRANSFER FROM BED TO CHAIR Purposes : (Kozier) 

To enable the nurse to change the client’s surroundings as well as position.



To increse opportunities for socialization

Equipment and Materials : 

Robe or appropriate clothing



Slippers or shoes with nonskid soles



Transfer belt



Chair, commode, wheelchair as appropriate to client need



Sliding board

Implementation ACTION 1. Explain the procedure to the

Gernalin/Tolentino/Carlos

RATIONALE It increases client participation and reduces

Health Care Module

Divine Colleges of Malolos City

client. Offer a bedpan and wash

transmission of microorganism. (Potter)

your hands. It determines client’s ability to assist as 2. Assess

the

assist

in

client’s

ability

transferring.

to

much possible to promote independence

Move

and a sense of control over situation.

equipment as necessary to make

(Potter)

room for the chair. Close the door or curtain. Having the bed in the lowest position 3. Position

the

bed

in

a

low

is

safest in case the client falls. (Hogan)

position. Non-skid soles decreases risk of slipping during transfer. Always have the client wear 4. Assist the patient

to put on a

robe and slippers with non-skid

shoes during transfer; bare feet increases risk of fall. (Potter)

soles. 4.1 Position the chair of at

Position

the bedside.:

transfer. (Potter)

a. For

a

client

chair

within

easy

access

for

with

unimpaired mobility: bring chair close to the bedside facing the foot of the bed and if possible, brace the

Having them get out of bed on the strong

back

side helps prevent loss of balance and

of

the

against

a

bedside table.

possible falls.

b. For a client with impaired mobility

:

chair facing

position

the

the head or

foot of the bed. When sitting on the side of the bed, the client should be able to stead self by using the hand on the affected side to grasp the arm of

This is done to avoid accidental moving of

the chair. (Figure 14)

the chair and the bed while transferring the

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Divine Colleges of Malolos City

patient. (kozier) 5. Lock the wheel of the chair and bed; if appropriate , raise the foot pedals on the wheelchair to

The client can sit up move easily if the head

the upward position.

of bed is up. (Hogan)

6. Raise the head part of the bed to the highest position.

Moving

their

legs

reduces

friction

or

shearing from the sheets while increasing the force of the movements;; supporting

7. Assist the client to get to the side

their upper body keeps them from falling

of the bed by supporting the

backward. Moving from lying position to

patient’s

sitting

moving

head and neck while the

patient’s

legs

position

can

cause

postural

to

hypotension, which can lead to dizziness

dangle on the edge of the bed.

and a subsequent fall unless the client has

(Figure 14.1)

time gather equilibrium. (Hogan) When you help clients stand, they can assist you by balancing against your shoulder while using their leg muscle to stand or by

8. Assist the client to rise to a standing position.

a. For

the

pushing off the mattress with their hands. Keeping your knees against the client’s

client

with

unimpaired mobility :

knees prevents them from buckling, thus reducing the risk of a fall. (Hogan)

face the patient and brace your

feet

and

knees

against the patient. Place your

hand

around

the

patient’s waist while the client

holds

onto

you

between the shoulder and the waist. Use your legs

Ability to stand can be maintained in

to

paralyzed or weak limb with support of the

help

you

raise

the

patient to the standing position.

Gernalin/Tolentino/Carlos

knee. (Potter)

Health Care Module

Divine Colleges of Malolos City

b. For

the

client

with

impaired mobility : face the your

patient

and

feet

and

brace knees

against the patient. Place your hands around the patient, especially against the

affected

extremity.

Place your hands around the patient’s wrist. Pivot The patient may place the

prevent

twisting

your

spine

and

causing injury. (Hogan)

unaffected arm to reach for the arm of the chair and

to

rising

push to

up

the

while

standing

It increases client’s stability and prevents injury

position. (Figure 14.3)

to

the

nurse

from

poor

body

mechanics (Potter) 9. Pivot

the

patient

(on

the

affected limb if applicable) into

Moving slowly helps prevent dizziness or other discomforts. (Hogan)

the position in front of the chair with legs position against the chair. 10. The patient may use one arm (the

unaffected

limb

if

applicable) and place on the arm of the chair and steady self while

It prevents injury to client from poor body

slowly

alignment (Potter)

lowering

to

sitting

position. Continue to brace the patients’s knees and flex your own

hips

and

seating the client.

knees

when Increased activity may result in symptoms associated with activity intolerance. These clients may find transfer very fatiguing and will need post transfer interventions to

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Divine Colleges of Malolos City

restore their level of comfort. (Potter) 11. Adjust

the

patient’s

position

using pillows where necessary. Position the call bell so it is available

for

use

wash

your

hands. 12. Document any observation on the patient’s response to the procedure and length of time in the chair.

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Health Care Module

Divine Colleges of Malolos City

MOVING A PATIENT UP IN BED : TWO OR THREE PERSON – ASSIST Implementation ACTION

RATIONALE

1. Assess the client’s need and ability to participate.

It provides a baseline to determine ability to assist caregivers and assess the client’s progress

toward

improved

activity

tolerance and muscle endurance (Potter) 2. Identify the client.

This is done to make sure that you are performing the procedure to the right client. (Kozier)

3. Explain

to

the

patient

the

rationale for the procedure.

It decreases anxiety and increases client cooperation. (Potter)

4. Raise bed to the height at the center of the gravity.

It provides greater stability for the nurse during working. (Potter)

5. Put bed in flat position. Repositioning

from

a

flat

position

decreases friction and possible shear on the client’s skin. (Potter) 6. Remove the pillow and place at the head of the bed. It 7. Move the client to one side of

reduces

interference

from

bedding

during positioning procedure. (Potter)

the bed. It ensures proper body mechanics and prevents muscle and back strain for the 8. Have the client bend the knee and place the sole of the feet

Gernalin/Tolentino/Carlos

nurse (Potter)

Health Care Module

Divine Colleges of Malolos City

firmly on the surface of the bed. (Figure 16)

It positions client to exert effort when mobbing up in the bed. (Potter)

9. Nurse 1 slides his or her arm under the client’s head and shoulders. This nurse faces the

It

foot of the bed.

musculoskeletal

system

shoulders

hip

10. Nurse 2 slides his or her arm

prevents

trauma

and

to

the by

joints

client’s

supporting and

every

distributing weight. (Potter)

under client’s hips from the same side of the bed. This nurse also faces the foot of the bed. 11. The nurse with the heavier burden (usually nurse 2) counts

Counting coordinates movement of both

and both pull the client up in

nurses. (Potter)

bed at the same time) 12. On the count, client pulls with the arms and pushes with the

Client’s assistance reduces friction and work load. (Potter)

feet as you pull. From your position

you

will

pull

the

patient up in the bed. In pulling you use your strong muscles effectively. It maintains client’s comfort and body 13. Position client comfortably.

alignment. (Potter) It protects client from falling out of bed.

14. Make sure safety devices are in

(Potter)

place. 15. Wash your hands.

It reduces transmission of microorganism. (Potter)

16. Evaluate

the

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client

for

Health Care Module

alignment and comfort.

Divine Colleges of Malolos City

Prompt identification of poor alignment reduces

risk

to

client’s

skin

and

musculoskeletal system.

MOVING A PATIENT CLOSER TO ONE SIDE Purposes : (Kozier) To facilitate proper body mechanics when performing essentials nursing procedure. Implementation ACTION

Gernalin/Tolentino/Carlos

RATIONALE

Health Care Module

1. Assess

Divine Colleges of Malolos City

client’s

needs

and

ability to participate.

It provides a baseline to determine ability to assist caregivers and assess the client’s progress

toward

improved

activity

tolerance and muscle endurance (Potter) 2. Identify the client.

This is

done to make sure that you are

performing the procedure to right client. (Kozier) 3. Explain

to

the

patient

the

rationale for the procedure.

It decreases anxiety and increases client cooperation (Potter)

4. Raise bed to the height at the center of the gravity.

It provides greater stability for the nurse during working. (Potter)

5. Put bed in flat position. Repositioning

from

a

flat

position

decreases friction and possible shear on 6. Slide your arms under client’s head and that

client’s skin. (Potter)

shoulders and pull

section

of

the

body

towards you. Be sure to bend

It maintains proper body alignment. It

your hips and knees, keeping

brings you closer to the object to be

your back straight. (Figure 17)

moved. It lowers center of gravity. It uses thigh muscle rather that back muscle.

7. Move your hands and arms

(Potter)

down to the client’s hips and pull that section of the body. Keep you back straight and your hips and

knees flexed.

(Figure 17.1) 8. Move

your

hand

and

arms

under the client’s legs and pull

Facing the direction of the movement

towards you. (Figure 17.2)

ensures proper balance. Flexing the knees lowers your center of gravity and uses thigh

Gernalin/Tolentino/Carlos

muscles

rather

then

your

back

Health Care Module

Divine Colleges of Malolos City

9. Repeat in sequence until the

muscles.

client is in correct position to the bed. 10. Make sure safety devices are in place.

It protects clients from falling out of bed. (Potter)

11. Wash your hands. 12. Evaluate

the

client

alignment and comfort.

for

It reduces transmission of microorganisms. (Potter) Prompt identification of poor alignment reduces

risk

to

client’s

skin

and

musculoskeletal. System (Potter)

TRANSFERRING A CLIENT FROM BED TO STRETCHER (THREE-CARRIER LIFT) Gernalin/Tolentino/Carlos

Health Care Module

Divine Colleges of Malolos City

Purposes : (Kozier) A stretcher or gurney is used to transfer supine clients from one location to another. Whenever the client is capable of accomplishing the tansfer from bed to stretcher independently, either by lifting onto it or by rolling onto it, the client should be encourae to do. If the client cannot move on the stretcher independently, at least two nurses if client is totally helpless or is heavy. Equipment : •

Stretcher

•

Linen

•

Sliding board (optional)

I Implementation ACTION 1. Explain

the

procedure

RATIONALE to

the

client.

This is done to alleviate anxiety and to ensure maximal cooperation. (Kozier)

2. Place the stretcher at the right angle to the foot of the bed. Lock

It is done to align stretcher and bed for

the wheels of the bed and wheels

safety transfer. (Potter)

of the stretcher. Raise the bed to the height of the stretcher. (Figure

It is easier to the client to move down a

18)

slant. (Kozier)

3. Decide on the responsibility for the lift. Each person must support

In this procedure, each nurse bears only

the section of the body.

a third of the client’s weight. (Hogan)

a. head, shoulders and chest. b. Hips

The wider the base of support and lower

c. Thigh and legs

center of gravity, the grate stability when

4.

lifting .(Kozier) It

distributes

client’s

forearms of lifter. (Potter)

Gernalin/Tolentino/Carlos

weight

over

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Divine Colleges of Malolos City

It moves work load over lifter’s to work together and safely lift the client. (Potter)

Gernalin/Tolentino/Carlos