AXILLARY METHOD

Axillary Method - Many hospitals in the Philippines obtain client’s temperature by the axillary method.
Equipment: Same as oral method except for the axillary thermometer.

1.Tray containing: a. thermometer b. jar of CB in water c. jar with cut tissue paper d. waste receptacle

2. Client’s wash cloth

3.Jot down notebook and pen.

1.Read the chart to obtain data

2.Wash hands to deter the spread of microorganisms

3.Determine any previous activity that would interfere with accuracy of temperature measurement.
Smoking or oral intake of foods/fluids can cause false temperature reading.

4.Bring the tray to the bedside. Identify client and explain the procedure When the client knows what is
to be done, he will cooperate better

6.Expose arm and shoulder by removing one sleeve of client’s gown. Avoid exposing chest.

7.Rinse it by using CB with water in a firm twisting motion from the bulb to the stem and then dry using
same motion using dry CB or clean soft tissues. CB or soft tissue will approximate the surface and
twisting helps the tissue wipe to encounter the entire surface of thermometer.

8.Pat the client’s axilla dry with a face towel. Place the thermometer or probe into the center of axilla.
Place the client’s arm down close to his body and place his forearm over his chest. As The deepest area
of the axilla provides the most accurate temperature measurement.

9.Leave an electronic thermometer in place until signal is heard.

10.Remove, dry and read measurement on digital display of electronic thermometer. Push ejection
button to discard disposable sheath into receptacle and return probe to storage well.

11.Inform client of temperature reading

12.Assist client to put back the sleeve.

14.Cleanse the thermometer from the stem to the bulb using CB with water, then dry and return to the
container.

15.Dispose the used CB and tissue paper in the waste receptacle

16.Record reading and indicate site in the jot down notebook. Report to the CI/HN any unusualities.

17.Wash hands

18.Record the reading on the master list sheet and graphic chart
RADIAL PULSE

1.Explain the procedure to gain cooperation and makes client at ease

2.Have the client rest his arm alongside of his body with the wrist extended and the palm of the hand
downward, or place arm on top of the client’s upper abdomen. This position places the radial artery on
the inner aspect of the patient’s wrist. The nurse’s fingers rest conveniently on the artery with thumb in
a position to the outer aspect of the patient’s wrist.

3. Place your first, second and third fingers along the radial artery and press gently against the radius;
place the thumb on the back of the client’s wrist. The fingertips which are sensitive to touch will feel the
pulsation of the client’s radial artery. If the thumb is used to palpate the client’s pulse, the nurse may
feel his own pulse.

5.Using a watch with a second hand, count the number of pulsations for one full minute because
Sufficient time is necessary to determine irregularities or other defects.

6.If the pulse rate is abnormal in any way, repeat the counting to determine accurately the rate, the
quality and the volume. When the pulse is abnormal, longer counting and palpation are necessary to
identify most accurately the unusual characteristics of the pulse.

7.Record pulse rate on the jot down notebook

8.Refer anything unusual to the clinical instructors and head nurse

9.Record in client’s chart and master list.

Purpose: To obtain the respiratory rate per minute and an estimate the client’s respiratory status

1.While the fingertips are still in place after counting the pulse rate, observe the client’s respiration.
-As Counting the respiration while presumably still counting the pulse keeps the client from
becoming conscious of his breathing which can possibly alter his usual rate.

2.The rise and fall of the client’s chest with each respiration and expiration. This observation can be
made without disturbing the client’s bedclothes.

-The rationale behind this is that a complete cycle of inspiration and expiration constitutes one
act of respiration.

3.Using a watch with second hand, count the number of respirations for one minute.

-Sufficient time is necessary to observe rate, depth, and other characteristics.

4. If respirations are abnormal, repeat to determine accurately the rate of the characteristics of the
breathing

5.Record respiration rate on the jot down notebook.

6.Refer to the CI and Head nurse for any unusualities.

7.Record the result in the clients and the master list.

1.Explain the procedure to the client. Make sure that client has not smoked or ingested beverages that
contains caffeine within 30 minutes

-As Nicotine cause vasoconstriction in peripheral and coronary blood vessels, thus increase
blood pressure.

2.Place the client in a comfortable position with the forearm supported and the palm upward

-This position places the brachial artery so that a stethoscope can rest on it conveniently on the
antecubital area.

3.Position yourself so that the calibration of the apparatus can be more than 3 feet away.

-The rationale behind this is that An accurate reading is obtained when the head of the mercury
column is in direct vision

4. Place the cuff so that the inflatable bag is centered over the brachial artery so that the lower edge of
cuff is 2.5 – 5 cm above antecubital fossa.

-As the Pressure applied directly to the artery will yield most accurate readings.

5.Wrap the cuff smoothly and snugly around the arm with the end of the cuff secure

- As a twisted cuff and wrapping could produce inaccurate reading

6.Use the fingertips to feel a strong pulsation on the antecubital space.

-An Accurate blood pressure reading is possible when the stethoscope is directly over the artery

Place the diaphragm directly over the pulse

-As the Bell chest piece is more sensitive to low frequency sound that occurs with pressure
release.

7.Inflate the cuff to 30 mmHg where the pulsation disappears

-As This will prevent you from missing the first tap sound because of the auscultatory gap

8.Gradually deflate cuff all the way to zero taking note of the first and the last clear, loud sound.

-The First sound is the systolic BP and last sound is diastolic BP.

9.Remove the cuff and make client comfortable.

10.Record the reading on the jot down notebook

11.Report to the CI and Head nurse for any unusualities.