Procedure 37-2

OSHA Guideline: Wash hands and have a biohazard waste bin nearby for use

Procedure Goal: To accurately measure a patient’s pulse and respirations while keeping the patient unaware the respirations are being counted

Measuring and Recording Pulse & RespirationsPROCEDURE 37-2

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Materials: A watch with a second hand, patient’s chart or progress note, black pen if recording in a paper chart

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Explain that you will be taking the patient’s vital signs. Do not tell them you are counting the respirations.

Step 3

Drop the object directly into an approved puncture-proof container for sharps. Engage safety device, if indicated.

Step 4

Document results with the date and time (example: 6/1 8/2023 P 88 regular and strong R 1 6 regular).

Step 10

Introduce yourself and identify the patient.

Step 2

Gather the equipment and wash your hands.

Step 1

Position yourself so you can observe and/or feel the chest wall movements. You may want to lay the patient’s arm over the chest to feel the respiratory chest movements.

Step 5

Report any findings that are a significant change from a previous result or outside the normal values.

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Place two or three fingers on the radial pulse site. Find the radial bone on the thumb side of the wrist; then slide your fingers into the groove on the inside of the wrist to locate the pulse.

Step 6

Without letting go of the wrist, observe and feel the respirations, counting for 30 seconds—if irregular, count for a full minute. Observe for rhythm, volume, and effort.

Step 8

Ask the patient to sit or lie in a comfortable position. Have the patient rest their arm on a table.

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Once you are certain of both numbers, release the wrist and record them. If the pulse or respirations were counted for less than 1 m inute, obtain the number of beats per minute. Multiply the number of beats counted in 30 seconds by 2.

Step 9

Count the pulse for 30 seconds if regular. Note the rhythm and volume. If irregular, count for 1 full minute. Remember or note the number. Do not be obvious when counting respirations (it may cause the patient to alter their respiratory pattern and rate). Also, staring intently at the chest of a patient may make them uncomfortable.

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