Vital Signs, Height, and Weight 359 8. Bring the necessary equipment into the room. Place the following items in an easy-to-reach place: • a watch or clock with a second hand (not a digital watch) • pen and pad, form, or digital device for documenting the pulse The Procedure 9. Provide privacy by closing the curtains, using a screen, or closing the door to the room. 10. If the resident is in bed, lock the bed wheels and then raise the bed to hip level. 11. Maintain safety during the procedure. If the resident is in a bed with side rails, raise and lock the rails on the opposite side of the bed from where you will be working. Lower the rail on the side you are working. 12. Have the resident sit or lie down. Select the hand and arm you use to take the pulse. Best Practice: If the resident has an IV in one arm, do not use that arm to take the pulse. Also, do not take the pulse on a weak arm. Some residents may have an arm that has been weakened by a stroke. 13. Position the hand and arm so they are well supported and rest comfortably. 14. Locate the radial artery by placing your middle finger and index finger toward the inside of the resident’s wrist on the thumb side (Figure 16.16). Figure 16.16 Best Practice: Do not use your thumb to feel for pulse. The thumb has its own pulse, which can be confused with the pulse you are taking. 15. Press your fingers gently on bare skin until you feel the pulse. Also, note the rhythm and quality of the pulse. 16. Start taking the pulse when you note the position of the second hand on your watch (Figure 16.17). Count pulse beats for one full minute or for 30 seconds and multiply the result by two. Follow the facility policy. Counting for one full minute is more accurate and should be done if the pulse rhythm seems weak or irregular. Figure 16.17 17. Document the pulse on a pad, on a form, or in the electronic record. 18. If the resident is in bed, check to be sure the bed wheels are locked. Then reposition the resident and lower the bed. 19. Follow the plan of care to determine if the side rails should be raised or lowered. Follow-Up 20. Wash your hands to ensure infection control. 21. Make sure the resident is comfortable and place the call light and personal items within reach. 22. Conduct a safety check before leaving the room. The room should be clean and free from clutter or spills. 23. Wash your hands or use hand sanitizer before leaving the room. Reporting and Documentation 24. Report any specific observations, complications, or unusual responses to the licensed nursing staff. Figure 16.16 Tyler Olson/Shutterstock.com Figure 16.17 michaeljung/Shutterstock.com Copyright Goodheart-Willcox Co., Inc.