Nursing Procedure: How to Take a Radial (wirst) Pulse Rate

Definition: 

One of method to get heart rate using a radial palpation technique.

Equipment:

• Watch with second hand
• Stethoscope
• Alcohol swabs
• Non Steril Gloves

Goals:

1. To know the number of heart rate
2. To know rhythm

Nursing Action (Procedure):

HOW TO TAKE A RADIAL (WRIST) PULSE RATE

• Wash hands/hand hygiene. Rationale: Reduces transmission of microorganisms.

• Inform client of the site(s) where pulse will be measured. Rationale:Encourages participation and allays anxiety.

• Flex client’s elbow and place lower part of arm across chest. Maintains wrist in full extension and exposes artery for palpation. Rationale: Placing client’s hand over chest will facilitate later respiratory assessment without undue attention to the nurse’s action. (It is difficult for any person to maintain a normal breathing pattern when someone is observing and measuring).         

• Support client’s wrist by grasping outer aspect with thumb. Rationale:Stabilizes wrist and allows for pressure to be exerted.

• Place index and middle fingers on inner aspect of client’s wrist over the radial artery, and apply light but firm pressure until pulse is palpated. Fingertips are sensitive, facilitating palpation of pulsating pulse. The nurse may feel his or her own pulse if palpating with thumb. Rationale: Applying light pressure prevents occlusion of blood flow and pulsation.

• Identify pulse rhythm. Palpate pulse until rhythm is determined. Rationale:Describe as regular or irregular.

• Determine pulse volume. Quality of pulse strength is an indication of stroke volume. Rationale: Describe as normal, weak, strong, or bounding.

• Count pulse rate by using second hand on watch. For a regular rhythm, count number of beats for 30 seconds and multiply by 2. For an irregular rhythm, count number of beats for a full minute, noting number of irregular beats. Rationale: An irregular rhythm requires a full minute of assessment to identify the number of inefficient cardiac contractions that fail to transmit a pulsation, referred to as a ‘‘skipped’’ or irregular beat.

Source: www.nursingprocedure.blogspot.co.id

Nursing Procedure: How to Take an Apical Pulse Rate

Definition:

One method to calculate heart rate (Pulse) using palpation techniques.

Equipment:

• Watch with second hand
• Stethoscope
• Alcohol swabs
• Non Steril Gloves

 
Goals:

1. To know the number of heart rate
2. To know rhythm

Nursing Action (Procedure):

How to take an apical pulse

• Wash hands/hand hygiene. Rationale: Reduces transmission of microorganisms.

• Raise client’s gown to expose sternum and left side of chest. Rationale:Allows access to client’s chest for proper placement of stethoscope.

• Cleanse earpiece and diaphragm of stethoscope with an alcohol swab.Rationale: Decreases transmission of microorganisms from one prescribing practitioner to another (earpiece) and from one client to another (diaphragm).

• Put stethoscope around neck. Rationale: Ensures stethoscope is nearby for frequent use.

• Locate apex of heart:

1. With client lying on left side, locate suprasternal notch. Rationale: Identification of landmarks facilitates correct placement of the stethoscope at the fifth intercostal space in order to hear PMI.
2. Palpate second intercostal space to left of sternum.
3. Place index finger in intercostal space, counting downward until fifth intercostal space is located. Rationale: Ensures correct placement of stethoscope.
4. Move index finger along fourth intercostal space left of the sternal border and to the fifth intercostal space left of the midclavicular line to palpate the point of maximal impulse (PMI)
5. Keep index finger of nondominant hand on the PMI.

• Inform client that his or her heart will be listened to. Instruct client to remain silent. Rationale:  Elicits client support. Stethoscope amplifies noise.

• With dominant hand, put earpiece of the stethoscope in ears and grasp diaphragm of the stethoscope in the palm of the hand for 5 to 10 seconds.Rationale:  Dominant hand facilitates psychomotor dexterity for placement of earpiece with one hand. Heat warms metal or plastic diaphragm and prevents startling client.

• Place diaphragm of stethoscope over the PMI and auscultate for sounds S1 and S2 to hear lub-dub sound. Rationale:  Movement of blood through the heart valves creates S1 and S2 sounds. Listen for a regular rhythm (heartbeats are evenly spaced) before counting.

• Note regularity of rhythm. Rationale:  Establishment of a rhythmic pattern determines length of time to count the heartbeats to ensure accurate measurement.

• Start to count while looking at second hand of watch. Count lub-dub sound as one beat:

1. For a regular rhythm, count rate for 30 seconds and multiply by 2.
2. For an irregular rhythm, count rate for a full minute, noting number of irregular beats.

Rationale:  Ensures sufficient time to count irregular beats.

• Share findings with client. Rationale:  Promotes client participation in care.

• Record by site the rate, rhythm, and, if applicable, number of irregular beats. Rationale:  Record rate and characteristics at bedside to ensure accurate documentation.

• Wash hands/hand hygiene. Rationale:  Reduces transmission of microorganisms.

Nursing tips when taking an apical pulse

• If taking an apical pulse, have the client breathe normally through the nose; breathing through the nose decreases breath sounds and makes the heart sounds easier to hear.

Source : www.nursingprocedure.blogspot.co.id

New Method / Formula to Giving Vascon (Noradrenaline)

NORADRENALIN

For example : Levoped, Levosol dan Vascon

SUPPLY

1 cc = 1 mg

INDICATION

Severe hypotension with peripheral resistance
lowering the total dose.

FUNCTION

Vasoconstrictor that increases blood pressure and
Inotropic strong (ß receptor stimulator).

DOSE

0,05 µg/kg/min

A FORMULA

DOSAGE REQUESTED X WEIGHT X 60           NUMBER OF DILUTIONS

EXAMPLE : Give the 0.01 mcg / kg weight / min with
Vascon dosage of 4 ml (4 mg) in 50 cc NaCl 0.9%
with patient weight 40 kg?

Method: Total Dilution = 4 mg = 0,08 mg

                                             50 cc

                                                      = 80 µg/cc

So : 0,01 µg x 40 kg x60 = 0,3 cc/jam

                  80 µg/cc

New Method / Formula to Corection of Hypernatremia

KOREKSI HIPERNATREMIA

• I : Fluid thats the body needs = kgBB x 0,6 = …… Liters

• II : Normal Natrium   x Fluid thats the body needs =… Liters

     Patient Natrium

•III :  Result I – Result II = ……….. Liters

Half given out in 10 hours

Can use Nacl 0.9%, Dex 5 % or RL Fluid

If use Dex 5 % check your patient blood sugar every 4 hours

You must check your patient electrolytes every 4 hours to

Example :

Patient weight 60 kg, Natrium 170

Answer :

 I. Fluid thats the body needs = 60 x 0,6 = 36 Liters

II. 140 x 36 Liter = 29,6 Liters

     170

III. 36 Liter – 29,6 Liter = 6,4 Liter
(Given half)

Nursing Procedure: How to Care Women's Catheters

PROCEDURE CARE WOMEN'S CATHETERS
STANDAR OPERATING PROCEDURE
DEFINITIONS	Perform the maintenance action in the area genetal women who catheterized
GOALS	Preventing infection Providing a sense of comfort
POLICY	Female patients were catheterized
EMPLOYEE	Nurse
EQUIPMENT	Bak instrument containing sterile swab Sterile gloves Disinfectant Warm water, washcloths, towels Perlak and pengalas Crooked
PROCEDURE IMPLEMENTATION	Phase Pra Interaction Checking the therapy program Washing hands Setting up the instrument Phase Orientation Greets the patient and the patient's name sapa Describe the purpose and implementation procedures Asking for consent / patient readiness Work Phase Sampiran installing / maintaining privacy Preparing patients with dorcal recumbent position and fired under the patient's clothing Installing perlak , pengalas Wearing gloves Clean the genitalia with warm water Ensure the position of the catheter is properly installed ( pull carefully , catheters are retained ) Provide disinfectant with a swab on the end of the catheter Removing pengalas and gloves Tidying patients Phase Termination Evaluating new measures do Saying goodbye to the client Clean up and return the device Washing hands Noting the activities in the nursing record sheet

Nursing Procedure: How to Give Eat Patient Via NGT

FEED PATIENTS VIA NGT STANDAR OPERATING PROCEDURE DEFINITIONS Incorporating liquid food / drug via naso gastric tube GOALS Maintaining nutritional status Administration of drugs POLICY Patients who can not eat by mouth EMPLOYEE Nurse EQUIPMENT Boiled water Liquid food / medicine Funnel 5/10 cc syringe Tissue Perlak / pengalas Crooked Gloves PROCEDURE IMPLEMENTATION Phase Pra Interaction To verify the data previously when there Washing hands Placing the device near the patient correctly Phase Orientation Greet and say hello to the patient's name Describe the purpose and procedures of action on the family / patient Asking for consent and readiness of clients Work Phase Maintaining privacy Adjust the position of the patient in semi-Fowler position /          Fowler (if no contraindications) Wearing gloves Installing pengalas on your chest Determine the position of NGT by aspiration of gastric contents installing funnel Entering boiled water, open the clamp, elevate 30 cm, before the expiry of the clamp back Incorporating liquid food, open clamps, elevating 30 cm, clamps back before it runs out Entering boiled water, open the clamp, elevate 30 cm, before the water runs out the clamps back Closing the end of NGT with syringe / clamps Clean the leftovers in patients tidying patients Phase Termination  To evaluate actions  Saying goodbye to the client Tidy tools  Washing hands  Noting the activities in the nursing record sheet

Nursing Procedure: How to Take a Bath Patient in Bed

HOW TO BATH A PATIENT IN A BED
STANDAR OPERATING PROCEDURE
DEFINITIONS	Clean the patient's body with clean water and soap
GOALS	Cleaning the skin and eliminate body odor Carry out personal hygiene Providing a sense of comfort
POLICY	Patients who need help bathing in bed
EMPLOYEE	Nurse
EQUIPMENT	1 sets of clean clothes The shower basin 2 pieces Hot and cold water Washcloth 2 pieces Perlak and small towels 1 piece Great towels 2 pieces Blanket bath / slipcover plastic apron An enclosed place for dirty clothes Bath soap Powder Clean gloves Bedpan / urinal and pengalas bottle cebok
PROCEDURE IMPLEMENTATION	Phase Pre Interaction To verify the client's treatment program Washing hands Placing the device near the patient correctly Phase Orientation A greeting as a therapeutic approach Describe the purpose and procedures of action on the client / family Asking the client's readiness before the activities carried out Work phase Maintaining privacy Washing hands Replacing the covers clients with a blanket bath Undress on clients washing face Waving a small perlak and a small towel under the head Offers patients using soap or not Cleansing the face, ears with a damp washcloth in the drain anaesthetized Scrolling perlak and towels wash ARM Lose belly client gets a bath blanket Installing a large towel over the chest transversely clients and clients both hands placed on the towel Moisten hands of the client with a washcloth to clean water, lathered, rinsed with warm water (do starting from the farthest extremity client) Wash CHEST AND STOMACH To undress under the client and lowered the blanket to the lower abdomen, hands placed over the head, unfurling a towel on the client side Wash armpits and chest and abdomen with a wet washcloth, lathered, rinsed with warm water and dried, then cover with a towel wash BACK Tilting the patient towards nurses Waving a towel behind the back to the buttocks Moisten the back until the buttocks with a washcloth, lathered, rinsed with warm water and dried Giving powder on the back Reverting to the supine position, and then help the patient to wear washing feet Issued a blanket feet of the patient from the bathroom properly Waving a towel under the leg, bending the knee Moisten the legs from the ankle to the groin, lathered, rinsed with clean water, then dried Do the same for the other foot Wash Fold THIGH AND GENITAL REGION Waving a towel under the buttocks, then opened the bottom blanket bath Moisten the groin and genital area with water, lathered, rinsed, then dried Lifting the towel, helped wear down clients Tidy up the client, replace the bath with a blanket bed blankets Phase Termination Evaluating the results of the action Saying goodbye to patients Clean up and return the device to its original place Washing hands Noting the activities in the nursing record sheet