Those first few check-offs can be absolutely terrifying. Mostly because you don’t know what to expect and partially because you might not be entirely sure what you’re doing. One of the first skills check-offs you will have pertains to taking accurate vital signs. If you’re like me, the only time I’d ever checked a temperature was when I was trying to get out of going to school or when I checked my heart rate while working out. With these tips, you can rock those skills check offs and take vitals in the clinical setting with complete confidence!
Taking an accurate temperature is pretty simple. After all, you’ve probably done it on yourself innumerable times and if you have kids then you’ve definitely done it more times than you can count. One thing to know about taking a temp is that there are several different places you can obtain a reading. Oral, axillary, tympanic (ear), temporal and rectal.
For an oral temp, make sure the sensor goes all the way underneath the tongue. I find that it’s really easy to misjudge this, so if my patient is able to help, I typically have them place the thermometer so I don’t accidentally jab them in that tender spot under the tongue.
For an axillary, tympanic and rectal temps, be aware that your reading will be different than what you would get via an oral route. Both rectal and tympanic readings are about 0.5 to 1.0 degrees F higher than an oral temp, while axillary and temporal readings are typically 0.5 to 1.0 degrees F lower than an oral temp.
If you’re taking a rectal temp, be sure to keep a VERY GOOD grip! Otherwise, you just bought your patient a ticket to the OR.
When taking a pulse it is MUCH easier to take an accurate reading on someone who is well hydrated. So, if you’re doing your check-off with a classmate, agree to hydrate well before class so you can help each other out with a nice, strong pulse! The tricky thing about pulses is that you’ll have to learn how to locate them in various locations in the body…here are a few tricks I’ve found to work well.
- Don’t press too hard! You can actually occlude the pulse if you press too firmly. Place just enough pressure to feel the pulse and then back off juuuuust a wee amount. Perfect!
- For a brachial pulse, be sure to straighten the arm allllll the way, which pushes that artery up toward the surface a bit. Start at the inner elbow and move outward about one inch…start searching there and move around in tiny increments until you catch it.
- Carotid pulses are handy because that’s typically the one you assess when you suspect your patient is pulseless. Large necks and the presence of central lines in the internal jugular may make this actually a bit tricky. Practice on necks of all shapes and sizes. Your landmark is the trachea…go just to the side of it and you should feel a nice solid pulse. If you don’t, consider starting CPR on yourself 😉
- The femoral pulse is another very handy pulse to palpate during a code situation. You gotta get IN THERE in order to feel it, so you can’t be shy. Always respect your patient’s privacy and modesty and be sure to explain what you’re doing and why you’re doing it.
- Popliteal pulses can be very tricky, and honestly I find it easier to use a Doppler than actually palpate it. But, just in case you need to palpate a popliteal pulse for your check-off, you’ll want to bend the knee a bit and get your fingertips into the popliteal fossa. The pulses will likely be pretty faint and difficult to palpate because they are covered in a fair amount of tissue. You’ll have to press harder here, but don’t stress if you can’t find it AS LONG AS the distal pulses are present.
- Posterior tibial pulses are right in that hollow behind the medial malleolus.
- The dorsals pedis pulses are just lateral of the extensor tendon of the great toe (which you can easily see if you have the patient flex their toe back). These take a bit of practice, so the first step is to spot that big tendon, and place your fingers laterally about half an inch or so mid-way up the foot. If you can’t feel it, just feel around gently…it can be very easy to obliterate this pulse by pushing too hard.
The trick with counting respirations is doing it without the patient knowing you’re doing it. Why? Because you don’t want them altering their natural breathing pattern…you just want a nice baseline reading. The trick to this is to count respirations right after taking their pulse. Keep your fingers on their radial artery and pretend you’re still taking their pulse as you sneakily count their respirations. If their rhythm is regular, you can probably get away with counting for 15 seconds and multiplying by 4…but note that your school may want you to count for 30 and multiply by 2. If the rhythm is irregular, count for the full sixty seconds.
To take an accurate blood pressure you need good ears. It’s all about those Korotkoff sounds and to hear them you need to be able to tune out all other distractions. My best tip for learning how to take blood pressures with confidence is to simply practice on a wide variety of individuals…different ages, different sizes, different genders…people with low blood pressure, people with high blood pressure, people with big arms, people with little tiny arms. Just get in there and take a ton of practice blood pressures and soon you’ll be a pro. When I was a student, I took my BP cuff over to friend’s houses and made everyone get a reading before dinner…it was a great way to practice and my friends got a mini checkup in the process. What can I say? I know how to party.
General tips for your skills check-off
- Practice on a wide variety of individuals
- Practice on yourself first (when you can!); gain confidence then seek out some volunteers!
- Hydrate before your check-off to help those pulses AND blood pressures
- Role play the whole skills check-off experience with a friend…fake it until you make it!
- And, of course, have fun!
Get this on audio in podcast episode 88.