Question

1. Prior to starting measurement of vital signs it is important to assess for history of: Smoking, A/V Fistula, Mastectomy, and whether patient had recent hot/cold drink; and whether patient has finger nail polish. Explained the reasoning for assessment of each element.

1. Explain what the acronym “PQRST” means and phrase how you would ask the patient each letter of the pain assessment.

1. Explain how to take a temperature in the Tympanic Membrane vs Temporal

1. In your own words explain how to find the radial pulse on a patient. Name two other areas of the body where the pulse can be measured, and explain how you would find those pulses correctly.

1. How long should you count the heart rate for?

1. Explain how you would measure the patients’ respirations without letting them know you are doing it and risking inaccurate measurement.

1. Explain how to take a manual blood pressure using the two-step method. In your opinion is it more accurate to take a one-step or two-step blood pressure?

1. Fill in the blank:

____________________________ appropriate vascular access until consistent reading and/or waveform appears

1. Is it important to tell the patient what their vital signs were? Why or why not?

1. Once you have performed vital signs what must you do prior to leaving the patients’ room

Answer 1

Q1

Answer: Prior to the surgery it is necessary

-to check the smoking history because smoking person may have a high chance to have cardiac problem that may leads to reduce blood flow and heart attack and also slow down the healing process of the surgical incision.

- Assess for cold or hot drink before surgery. It is because the patient should be NPO from midnight before the surgery because drinking of hot or cold drink may aspirate the patient during the surgery and relax of body part occurs due to anesthesia.

- Fingers nail: Decrease of oxygen during the surgery can be identify by seeing the nail bed. if the color of the nail is pale or brushing means that there is lack of oxygen.

Q2

Answer: PQRST is the mnemonic use for the pain management. P -palliative and precipitating factors, Q -quality of pain, R- region or radiation of pain, S- subjective description of pain by the patient, T - time for the pain occurrence.

Q3

Answer: The temperature of tympanic membrane is collected by setting the digital temperature measure instrument inside the ear and check the temperature whereas the temperature of temporal is check from the forehead or temporal part of the head by using digital temperature checking instrument.

Q 4

Answer: For checking the radial pulse use the opposite side index finger and middle finger. Keep the two fingers at the base of the thump just 2 cm below in the groove in the wrist and pressing lightly. The other pulse that can be asses in carotid pulse and femoral pulse. To assess the place two finger index and middle finger in the neck lateral to Adams apple or thyroid gland. You can feel the pulse. For femoral pulse, the nurse should keep the fingers on to the femoral part, make deeper press and press should be placed below the inguinal ligament and about midway between the symphysis pubis and anterior superior iliac spine. Then you can able to feel the pulse.

Q5

Answer: The heart rate should be count for 1 minute. The number of heart beat count in a minute is the actual heart rate of the patient.

Q6

Answer: Always check the respiration along with the pulse. While checking the radial pulse, hold the wrist by placing the patient hand in the patient chest. Just act like checking the pulse for 2 minutes. one minute for the pulse and one minute for the respiration. When the nurse check the pulse by keeping the hand on chest, this can able to feel the chest movement and respiratory rate can be assess without the knowledge of the patient.

Q7

Answer: The blood pressure can be taken with two step method. In this two method, secure the cuff first, one hand will inflate the valve and another hand will palpate the radial or brachial pulse and identify when the pulse stop. Deflate all the air. Again after that stethoscope is use and continue to inflate 30 mm of Hg more than the mm of Hg where it stop during the palpation of pulse in the first step and deflate the valve. This will give accurate systolic and diastolic pressure.

According to my opinion, two step is more accurate because in one step the nurse will direct check by using stethoscope without any palpation of the pulse.

Q8

Answer: As a nurse, it is very importance to tell the exact blood pressure to the patient. The patient have the right to understand his own condition and the nurse should maintain transparency in the treatment process with the patient.