Vital Signs Lecture Notes PDF

**Subject:** MDW 101 -- Introduction to Health Care Title: Vital Signs (Body Temperature, Pulse Rate, Respiration Rate, Blood Pressure) =================================================================================== ASSESSING VITAL SIGNS --------------------- - VITAL SIGNS - The vital or...

**Subject:** MDW 101 -- Introduction to Health Care Title: Vital Signs (Body Temperature, Pulse Rate, Respiration Rate, Blood Pressure) =================================================================================== ASSESSING VITAL SIGNS --------------------- - VITAL SIGNS - The vital or cardinal signs are: 1. Body Temperature (T) 2. Pulse Rate (PR) 3. Respiration/ Respiratory Rate (RR) 4. Blood Pressure (BP) **NEWBORN:** RESPIRATORY RATE (RR) APICAL/PULSE RATE - CARDIAC RATE TEMPERATURE (T) #### Sign -- indicators of a particular disorder that is observed by a physician [ ] but is not apparent to the patient - ***Objective*** -- those that can be observed & measured #### Symptoms -- an indication of a disease or disorder noticed by the patient himself. - A presenting symptom is one that leads a patient to consult a doctor. \> ***Subjective*** -- those that can be described only the person experiencing it #### VITAL SIGNS: NORMAL RANGES FOR ADULTS **TEMPERATURE:** - DIFFERENT SITES: **ORAL** **37 C** **98.6 F** ---------- ---------- ------------ RECTAL 37.6 C 99.6 F AXILLA 36.4 C 97.6 F +-----------------------------------+-----------------------------------+ | **AVERAGE** | **120/80 mm Hg (millimeters of | | | mercury)** | +===================================+===================================+ | HYPERTENSION | SYSTOLIC -- above 140 mmHg | | | | | | DIASTOLIC -- ABOVE 90 mmHg | +-----------------------------------+-----------------------------------+ | HYPOTENSION | SYSTOLIC -- below 90 mmHg w/ | | | signs of: | | | | | | - Dizziness | | | | | | - Increased pulse | +-----------------------------------+-----------------------------------+ #### WHEN TO TAKE VS: 1. On the client's [admission] to health care facility 2. In a hospital on [a routine schedule] according to a physician's order or hospital policy 3. [Before & after] a surgical procedure 4\. **Before & after** an invasive diagnostic procedure. 5\. **Before & after** the administration of certain medications that affect: a. Cardiovascular b. Respiratory & c. Temperature-control functions 6\. When the client's general physical condition changes \- As with [loss of consciousness] or increased intensity of pain 7\. When a client reports nonspecific symptoms of [physical distress] BODY TEMPERATURE ---------------- TEMPERATURE - Is the "**hotness" or "coldness**" of a substance - The **[balance]** between the heat produced by the body & the heat lost from the body TWO (2) TYPES TEMPERATURE: +-----------------------------------+-----------------------------------+ | **1.CORE TEMPERATURE** | - **The temperature of the deep | | | tissues of the body.** | | | | | | - **Measured by taking oral & | | | rectal temperature.** | +===================================+===================================+ | 2\. SURFACE TEMPERATURE | - The temperature of the skin, | | | subcutaneous tissue & fat | | | | | | - Measured by taking axillary | | | temperature | +-----------------------------------+-----------------------------------+ BODY HEAT is primarily produced by metabolism. - The HEAT regulating center is found in the HYPOTHALAMUS. #### FACTORS THAT AFFECT THE BODY'S HEAT PRODUCTION: **1.BASAL METABOLIC RATE (BMR)** - The younger the person, the higher the BMR - The older the persons have lower body temperature than the younger persons. 2\. **MUSCLE ACTIVITY** \- Increases the metabolic rate therefore, exercise increases body heat production 3\. **THYROXINE OUTPUT** - Increases cellular metabolic rate -- chemical thermogenesis. 4\. **EPINEPHRINE, NOREPINEPHRINE & SYMPATHETIC STIMULATION** - Increase the rate of cellular metabolism. - norepinephrine - Hormone closely related to epinephrine & w/ similar actions, secreted by the medulla of adrenal gland & also released as a neurotransmitter by the sympathetic nerve endings. - **[Action:]** constriction of small blood vessels leading to an increase in BP, increased in blood flow #### NEURAL CONTROL (NERVOUS System) - The [hypothalamus] in the brain controls body temperature the same way that a thermostat works in the home \- A comfortable temperature is the "set point" at w/c heating system operates. - In the home a **fall** in the environmental temperature activates the furnace, whereas a **rise** in temperature shuts the system down \- The hypothalamus senses minor changes [ ] in body temperature - When body temperature deviates from the set point, the temperature center of the hypothalamus activates **heat loss** (cooling) or **heat production** so that the core temperature stays in a safe physiological change. - When nerve cells in the hypothalamus become heated, impulses are sent out top reduce body temperature. The body cools itself by sweating, vasodilation **VASODILATION** -- widening of blood vessels & **inhibition** of heat production - If the hypothalamus senses that the body's temperature is too low Signal are sent out to increase heat production & conservation through vasoconstriction **[VASOCONSTRICTION ]** \- Narrowing of blood vessels, muscle shivering & piloerection (erection of hairs) - [Vasodilation] -- heat inhibition - [Vasoconstriction] -- heat production **Lesions of trauma** to the hypothalamus or spinal cord which carries hypothalamic messages, can cause: \> **serious** alterations in temperature control #### PROCESS INVOLVED IN HEAT LOSS: 1. RADIATION 2. CONDUCTION 3. CONVECTION 4. EVAPORATION RADIATION - The transfer of heat from the surface of one object to the surface of another w/o contact between the two objects. CONDUCTION - The transfer of heat from one surface to another - It requires temperature difference between the two surfaces CONVECTION - The dissipation of heat by air currents EVAPORATION - The continuous vaporization of moisture from the skin, oral mucous, heat, respiratory tract \> Increases peripheral circulation thereby [increasing heat loss by evaporation ] #### FACTORS AFFECTING TEMPERATURE: 1. **AGE** - The infant's body temperature is **greatly** affected by the temperature of the environment. Elder people are at risk of hypothermia \> Due to **decreased** thermoregulatory controls - Decrease subcutaneous fat - Inadequate diet & sedentary activity **2. DIURNAL VARIATIONS**\ *(Circadian Rhythms)* - **Highest temperature** is usually reached between 8:00 PM to 12 MN - **The lowest temperature** is reached between 4:00 am and 6:00 am **3. EXERCISE** - Strenuous exercise increases metabolic rate thus, the body temperature **4. HORMONES** - Progesterone increase body temperature - Estrogen decreases body temperature **5. STRESS** - Sympathetic nervous system stimulation increases the production off epinephrine & norepinephrine, thereby increase the metabolic rate & heat production - Sympathetic Nervous System - The part of the autonomic NS that contains chiefly adrenergic fibers & tends to depress secretion, decrease the tone & contractibility of smooth muscle & cause the contraction of blood vessels. FEVER ----- **FEBRILE** -- presence of fever **AFEBRILE** -- absence of fever **FEVER** - The simplest definition of a fever is a rectal temperature above 38C (100.4F) that is measured under resting conditions. - FEVER (pyrexia) - A rise in body temperature above the normal 1. Above an oral temperature: 37 C 2. Above rectal temperature: 37.2 FEVER May accompanied by: 1. Shivering 2. Headache 3. Nausea 4. Constipation or diarrhea A rise in temperature above 40.5 C may cause: 1. Delirium - (adult) 2. Convulsion - (young children) CAUSE OF FEVER: - BACTERIA - VIRAL INFECTION - ACCOMPANIED BY INFECTIOUS ILLNESS #### TYPES OF FEVER: +-----------------------------------+-----------------------------------+ | **1.INTERMITTENT** | **- The temperature fluctuates | | | between periods of fever & | | | periods of** | | | | | | **normal/subnormal temperature.** | +===================================+===================================+ | 2\. REMITTENT | \- The temperature fluctuates | | | w/in a wide range over the | | | 24-hour period but | | | | | | remains above normal range | +-----------------------------------+-----------------------------------+ | 3\. RELAPSING | \- The temperature is elevated | | | for few days, alternated w/ 1 or | | | 2 days of normal | | | | | | temperature | +-----------------------------------+-----------------------------------+ | 4\. CONSTANT | \- Body temperature is | | | consistently high | +-----------------------------------+-----------------------------------+ #### DECLINE OF FEVER: +-----------------------------------+-----------------------------------+ | **1. CRISIS** | - **or flush or defervescent | | | stage** | | | | | | - **- the sudden decline of | | | fever** | | | | | | - **- this indicates impairment | | | of the hypothalamus** | +===================================+===================================+ | 2\. LYSIS | - The gradual decline of fever | | | | | | - this indicates that the body | | | is able to maintain | | | hemeostasis | +-----------------------------------+-----------------------------------+ #### CLINICAL SIGNS OF FEVER: #### 1.Onset (*cold or chill stage*) a. Increased heart rate b. Increased RR & depth c. Shivering d. Pale, cold, skin e. Cyanotic nail bed f. Complaints of feeling cold g. "Goose flesh" appearance of the skin h. Cessation of sweating i. Rise in body temperature #### #### 2. Course a. Absence of chills b. Skin that feels warm c. Feeling of being neither hot nor cold d. Increased pulse & RR e. Mild to severe dehydration f. Simple, drowsiness, restlessness or delirium & convulsions g\. Herpetic lesions of the mouth h\. Loss of appetite to eat i\. Malaise, weakness & aching muscles #### 3. Defervescence (fever abatement) a. Skin that appears flushed & feels warm b. Sweating c. Decreased shivering d. Possible dehydration #### NURSING MEASURES FOR CLIENTS W/ FEVER: #### CHILL STAGE 1. **Reduce** frequency of activities that increase oxygen demand such as excessive turning & ambulation. \- Allow rest periods. 2. **Provide** supplemental oxygen therapy as ordered to improve oxygen delivery to body cells. 3. **Provide** measures to stimulate appetite & offer well-balanced meals to meet increases metabolic needs. 4\. **Offer** extra blankets & raise room temperature to keep client warm during chills. 4. **Provide** extra fluids to replace fluids lost through increased metabolism. 5. **Assess** onset & duration of chill. Take temperature immediately after episode #### COURSE OF FEVER 1\. Provide fluids (at least 3L/day for client w/ normal cardiac & renal function) \- To replace fluid lost through insensible water loss & diaphoresis 2**. Bathe** client w/ tepid water to reduce body's surface temperature Do not induce chills. - WET THEN DRY (parts of the body that being sponge) 5\. **Keep** clothing & bed linen **dry to increase heat loss** through conduction & convection. 6**. Control** environmental temperature w/o causing chills. Provide cool, circulating air. 7**. Limit** physical activity to minimize heat production 8\. **Administer** antipyretic medications as ordered to reduce manifestations of fever. - Temperature of 38.5C and above usually require administration of antipyretic. **ANTIPYRETIC** - Drugs that lowers the body temperature - Several analgesic drugs have antipyretic activity including: - Aspirin - Mefenamic acid - acetaminophen #### ASSESSMENT OF BODY TEMPERATURE #### COMMON SITES: 1. Oral/Mouth 2. Rectum 3. Axilla 1\. ORAL - ORAL/MOUTH/OREM - Most accessible & convenient - Wait 20-30 minutes to measure oral temperature after client ingests hot or cold liquids or foods, has been smoking , or has been involved in strenuous exercise. - Place thermometer the tongue, directed towards the side. - Wash the thermometer **BEFORE and use** **AFTER use**. - Can be reliably used as long as the client is able to close the mouth & breath through the nose. **CONTRAINDICATIONS TO ORAL TEMPERATURE TAKING:** 1. Oral lesions 2. Dyspnea 3. Cough 4. Nausea & vomiting 5. Presence of oro-nasal contraption 6\. Very young children 7\. Unconscious 8\. Restless, Disoriented, confused **2. RECTAL** - Most reliable - Assist client to assume lateral position - Take rectal temperature Insert 1.2cm (1/2 in) -- infant - Insert 3.5cm (11/2 in) - adult - **Lubricate thermometer before** insertion - Instruct client **to take a deep breath** during insertion of the thermometer to relax the internal sphincter - **Do not force insertion** of thermometer into a newborn. **CONTRAINDICATIONS TO RECTAL TEMPERATURE TAKING:** 1. Anal/Rectal conditions or surgeries 2\. Diarrhea 3\. Clients who cannot be positioned for proper thermometer placement. **3. AXILLARY** \- Safest method because noninvasive - Pat dries the axilla - Place the thermometer in the client's axilla - Place the arm tightly across the chest to keep the thermometer in place for: #### NURSING DIAGNOSIS #### CLIENT'S WITH ALTERED BODY TEMPERATURE: **a. HIGH RISK FOR ALTERED BODY TEMPERATURE RELATED TO**: - [Illness or trauma] affecting temperature regulation - [Medication] causing vasoconstriction, vasodilation, altered metabolic state or sedation. - [Inactivity] or vigorous activity. b\. **HYPERTHERMIA RELATED TO:** - Exposure to excessively warm environment - Increased metabolic rate - Dehydration c\. **HYPOTHERMIA related to:** - Exposure to excessively cool environment - Debilitating illness or trauma - Lack of adequate clothing & shelter d**. INEFFECTIVE THERMOREGULATION RELATED TO:** - Decreased basal metabolism secondary to aging - Trauma or illness #### THERMOMETERS - 4 TYPES OF THERMOMETER: 1. MERCURY IN GLASS 2. ELECTRONIC 3. DISPOSABLE 4. TYMPANIC MEMBRANE 5. DIGITAL THNERMOMETER 1\. MERCURY IN GLASS THERMOMETER - The most familiar - It consist of a glass tube sealed at one end & a mercury-filled bulb at the other - Exposure of the bulb to heat causes the mercury to expand & rise in the enclosed tube - The length of the thermometer is marked w/ Fahrenheit & Centigrade calibrations - The mercury will not fluctuate or fall unless the thermometer is shaken vigorously - A glass thermometer is read by holding it w/ the fingertips horizontally at eye level, with the bulb pointed to the left - The bulb should not be touched. - The thermometer is ROTATED slowly until the column of silver mercury appears. - The calibrated line ate the end of the mercury column is the temperature reading. **GLASS THERMOMETERS** **( are all available w/ Centigrade or Fahrenheit measurements)** ORAL or SLIM TIPPED - Slender, **allowing greater exposure of the bulb** against the blood vessels in the mouth. - It usually has a blue tip. STUBBY - Shorter & thicker than the oral type - It can be used to measure temperature at any site PEAR-SHAPED RECTAL - Has a blunt end designed to prevent trauma during rectal insertion - It is usually has a red tip **ADVANTAGES** of mercury-in glass thermometer: 1. Low price 2. Wide availability 3. Reliable accuracy **DISADVANTAGES** of mercury-in glass thermometer: 1. Time delay for recordings 2. Easy breakability -- HARMFUL (MERCURY CONTENT) **2. ELECTRONIC THERMOMETER** - Consist of a battery-powered display unit - A **thin wire cord** & a temperature-sensitive probe covered by a disposable plastic sheath to prevent transmission of infection - Separate probes are available for oral & rectal use - Within only a few seconds of insertion a reading appears on the display unit. - Temperature readings appear in Fahrenheit, Centigrade or both - An electronic thermometer is **NOT necessarily more accurate than a glass thermometer** - Lubricant should be avoided w/ rectal electronic thermometer because it can cause a falsely elevated reading. - May be less accurate because the sensor probe is inserted for a shorter time. 1. They can be inserted immediately. 2. Their readings appear w/ in seconds & they are easy to read 3. The duration of the client's discomfort is also minimized **3. DISPOSABLE THERMOMETER** - SINGLE use thermometer - Are **thin strips of plastic w/ chemically impregnated paper.** - They are used for oral & axillary temperature particularly w/ children - They can be inserted in the same way as an oral thermometer or can be **applied to the skin** - The chemical dots on the thermometer change color to reflect the temperature reading - Only 45 seconds are needed to record the temperature. - Chemically **treated paper thermometers** are generally **less accurate**, but they are useful in providing a general temperature range. 4.**TYMPANIC MEMBRANE THERMOMETERS** - INFRARED EAR - Are small hand-held devices similar to otoscope - With disposable speculums, infrared sensing electronics & liquid crystal displays - Most are battery operated & rechargeable - Results are displayed 1-2 seconds after placing the speculum in the outer third of the ear canal - Accuracy appears to be good, but studies have been conflicting. 5.BASAL DIGITAL THERMOMETER  **Digital thermometers** are temperature-sensing instruments that are easily portable, have permanent probes, and a convenient **digital** display. The way a **digital thermometer** works depends upon its type of sensor. #### GUIDELINES FOR TAKING TEMPERATURE - When measuring body temperature at any site, the ff basic principles should be carefully followed to maintain the client's safely & ensure accuracy in measurement. 1. The **most appropriate** site for measuring temperature is assessed. 2. **All necessary equipment is assembled** to ensure an uninterrupted procedure. 3. **The hands are washed** using medically aseptic technique to prevent spread of infection. - **Gloves are worn** to prevent exposure to microorganisms in saliva. **CONVERTION** - TO CONVERT FAHRENHEIT TO CENTIGRADE: - Subtract 32 from the Fahrenheit reading & multiplies the result by 5/9: - TO CONVERT CENTIGRADE TO FAHRENHEIT: - Multiply the centigrade reading by 9/5 and add 32 to the product: - TO CONVERT FAHRENHEIT TO CENTIGRADE: C = (F -- 32) x 5/9 PULSE ----- #### HUMAN SITE pulse site #### PULSE RATE **55-100** **REST** ------------ ---------- 60-100 ACTIVE **PULSE** \- It is a **wave of blood** created by contraction of the left ventricle of the heart. - The pulse is the palpable bounding of blood flow noted at various points on the body. - It is an indicator of circulatory status. - - **Circulation** is the means by w/c cells receive nutrients & remove waste products of metabolism. - **For cells to function normally**, there must be a continuous blood flow & an appropriate volume & distribution of blood to cells that need nutrients. PULSE SITES 1. TEMPORAL 2. CAROTID 3. APICAL 4. BRACHIAL 5. RADIAL 6. ULNAR 7. FEMORAL 8. POPLITEAL 9. POSTERIOR TIBIAL 10. DORSALIS PEDIS 11. 1\. TEMPORAL - Over temporal bone of head, above & lateral to eye - Easily accessible site is used to assess pulse in children 2\. CAROTID - At the level aspect of the neck, below the ear lobe - Easily accessible site is used to assess: a. character of pulse peripherally b. during shock or cardiac arrest when other sites are not palpable. 3\. APICAL - At the left midclavicular line (MCL) -- apex of the HEART - 5^th^ intercostals space (ICS)for auscultation - Site is used for auscultation of heart sounds 4\. BRACHIAL - At the inner aspect of the upper arm (biceps muscles) or medially at the antecubital space - Sites is used to assess: a\. status of circulation to lower arm & auscultate blood pressure 5\. RADIAL - Radial or thumb side of forearm at wrist. - Common site is used to assess: a\. character of pulse peripherally & b\. status of circulation to hand. 6\. ULNAR - Ulnar side of forearm at wrist. - Site is used to assess status of circulation to ulnar side of hand. 7\. FEMORAL - Below inguinal ligament - Midway between symphysis pubis & antero superior iliac spine - **Site is used to assess:** - Character of pulse during physiological shock or cardiac arrest when other pulses are not palpable - & to assess status of circulation to leg 8\. POPLITEAL - At the back of the knee - Site is used to assess status of circulation to lower leg 9\. POSTERIOR TIBIAL - Inner side of each ankle, below medial malleolus - Site is used to assess: CIRCULATION OF FOOT 10\. DORSALIS PEDIS - Along top of foot between extension tendons of great & first toe - Site is used to assess status of circulation to foot RADIAL & CAROTID ARTERIES - Are the [most accessible] peripheral pulse sites for assessment - When a client's condition suddenly deteriorates, the carotid artery in the neck is the best site for finding a pulse quickly. RADIAL & CAROTID ARTERIES - The heart will continue delivering blood thru the carotid artery to the brain as long as possible, whereas peripheral pulses weaken. RADIAL & APICAL PULSES - Are the [most common sites for assessment of vital signs ] RADIAL & CAROTID SITES - Are used by persons learning to monitor their own heart rates APICAL PULSE - **If the radial pulse at the wrist is abnormal** or intermittent resulting from dysrhythmias - Or if it is **inaccessible** because of a dressing, cast or other encumbrance, the apical pulse is assessed. APICAL PULSE - **When a client takes medication** that affects the [heart rate], the [apical pulse] may provide a more accurate assessment of heart function - The apical pulse is **the best site for assessing an infant's or young child's pulse** **\>** because the peripheral pulses are deep & difficult to palpate accurately. FIRST TWO (2) FINGERS - The 1^st^ 2 fingers of the hand are [used to palpate a peripheral pulse.] - **The tips** are [the most sensitive] parts of the fingers for detecting the pulsation of the arterial wall. - Beginning students sometimes apply excessive pressure over the artery & totally obliterate the pulse. - It helps to imagine the anatomical position of the artery when attempting to locate it. - If the pulse **is not** easily located on one side, the other can be tried. - The client's extremity should be **kept in a relaxed position** to permit full exposure of an artery. FOR ASSESSMENT OF THE RADIAL ARTERY: - For assessment of radial artery, the client's **wrist should be extended & relaxed** - This position ensures that the artery lies superficially above the radius DOPPLER ELECTRONIC STETHOSCOPE - If the nurse is unable to palpate a pulse: \> A Doppler electronic stethoscope can be used - This instrument magnifies sounds produced by the heart & blood vessels for easier evaluation STETHOSCOPE - When assessing the apical pulse the nurse uses an acoustical stethoscope - Sounds waves originating from an internal organ usually reach the body's surface & are dissipated into the air. - Unless the sounds are of high amplitude, the unassisted ear cannot hear them clearly. THE 4 MAJOR PARTS: - EARPIECES - BINAURAL - PLASTIC or RUBBER TUBING - CHEST PIECE EARPIECES & BINAURAL - The **[earpieces]** should fit snugly & comfortable in the nurse's ears. - The **[binaural]** should be angled & strong enough so that the earpieces stay firmly in the ears w/o causing discomfort - To ensure the best reception of sound, the earpieces [follow the contour of the ear canal] - For most persons therefore the earpieces should [point toward the face as the stethoscope is put on ] RUBBER or PLASTIC TUBING - The rubber or plastic tubing should be flexible & **30-40 cm** (12 to 18) in length - **Longer tubing** [decreases] the transmission of sound waves - The [tubing should have a thick wall to help eliminate transmission of noises] when the tubing rubs against other surfaces. CHEST PIECE - The chest piece consists of : 1\. bell 2\. diaphragm **DIAPHRAGM** - Is the **circular, flat** surfaced portion of the chest piece & has a thin plastic disk on the end. - It transmit high pitched sounds such as: a. Bowel and b. Lung sounds - The examiner holds the diaphragm firmly against the skin for full sound amplication **BELL** - Transmit LOW-PITCHED SOUND such as: a\. heart b\. vascular sounds - It is held lightly against the skin - **Compressing the bell** against the skin reduces sound amplification - **The bell & diaphragm are rotated** into position on the chest piece depending on the part that the nurse chooses to use - DIAPHRAGM or BELL - Must be in proper position during use for the nurse to hear sound through the stethoscope. **CHARACTER OF THE PULSE** Assessment of the radial pulse includes measurement of the: 1. RATE 2. RHYTHM 3. STRENGTH 4. EQUALITY Auscultating an APICAL PULSE the nurse assesses only the: 1. HEART RATE 2. RHYTHM **[RATE ]** - Before measuring a pulse, the nurse should know the baseline heart rate for comparison - Pulse rate vary depending on: a. age b. level of activity & c. variety of other factors - SINOATRIAL (SA) NODE IN THE HEART IS THE PRIMARY PACEMAKER OF THE HEART, setting the heart rate faster or slower depending on the metabolic demands of the body - **To obtain a baseline pulse**, the client should be at rest during measurement of the pulse because physical activity increases the heart rate. - It maybe necessary to wait 5-10 min after activity before measuring pulse - Some practitioners prefer to make baseline measurements of the pulse rate as the client assumes: - sitting - Standing - Lying positions - **Postural changes** cause changes in PR resulting from alterations in blood volume & distribution sympathetic activity - **[The HR typically increases]** when a person moves from a lying to a sitting or standing position - APICAL PULSE - The nurse assesses an apical pulse by listening for heart sounds. 1. The nurse tries to identify the 1^st^ & 2^nd^ heart sounds (S1 and S2) **S1** -- at normal slow rate \- low pitched \- dull in quality \- sounding like "LUB" **S2 :** - Is a higher pitched - Shorter & creates the sound "DUB" - Using the diaphragm or bell of the stethoscope the nurse counts the number of "lub-dubs" occuring in a minute **ONE LUB-DUB equals [1 heartbeat ]** - NORMAL HEART RATES **RATE** - The NORMAL PULSE per minute are as follows: - NORMAL: 55-100 bpm/60-100 bpm **TACHYCARDIA** - Pulse rate above 100 beats/min (adult) **BRADYCARDIA** \> Pulse rate of 60 beats/min or less (adult) **[RHYTHM ]** - The pattern & intervals of beat. - Dysrhythmia is irregular rhythm - Successive heartbeat normally occur at regular intervals. - If an interval is INTERRUPTED by an early beat or if a beat is LATE or MISSED , the individual has an ABNORMAL RHYTHM (dysrhythmia) - DYSRHYTHMIA - A **[dysrhythmia]** alters the heart's ability to pump properly, particularly if it occurs repetitively. - If dysrhythmia is present, the regularity of its occurrence is assessed. - It maybe **INTERMITTENT** -- occasional missed beats - It may be **IRREGULARY IRREGULAR** -- variation in frequency - Note: - Children often have **SINUS DYSRYTHMIA** [- w/c is an irregular heartbeat that speeds up with INSPIRATION & slows DOWN W/ EXPIRATION.] \> This is a NORMAL FINDING & can be verified by having the child hold the breath; the HEART RATE should then become REGULAR. **PULSE DEFICIT** - When palpating for an irregular peripheral pulse, the nurse should also assess for a PULSE DEFICIT, w/c occurs WHEN THE HEART EJECTS a volume of blood so small that it goes to the brain & peripheral pulse waves cannot be felt - The PULSE DEFICIT is evaluated by measuring the : **APICAL -- RADIAL PULSE** \> This is usually done **by 2 people** , however 1 midwife can do it w/ some difficulty. - PROCEDURE -- PULSE DEFICIT 1. **One midwife** counts the APICAL PULSE impulses heard w/ a stethoscope while another counts the palpated RADIAL PULSE at exactly the same time. 2. **Any VARIATION** is considered the pulse deficit & should be reported to the client's physician. - example APICAL RATE = 92 (-) RADIAL RATE = 78 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 14. **eats (PULSE DEFICIT**) **[STRENGTH (]**Amplitude,Volume) - The strength & amplitude of pulse **reflects the volume of blood ejected against the arterial wall** w/ each heart contraction - Assessing the pulse strength is a subjective process & requires considerable practice - Normally the pulse strength remains the same with each hearthbeat - NORMAL PULSE - Can be felt with moderate pressure, full, easily palpable & not easily obliterated by the assessor's finger's. - BOUNDING PULSE - Easily palpated & difficult to obliterate only by great pressure. - WEAK PULSE - Is difficult to palpate & easy for the assessors to lose during palpation - Weak pulse is thready & often rapid **[EQUALITY ]** - Pulses on both sides of the peripheral vascular system should be assessed. - The midwife assesses both RADIAL PULSES to compare the characteristic of each. - A pulse in one extremity maybe UNEQUAL in strength or absent in many disease states - Example: - Thrombus (clot) formation - Aberrant blood vessels #### FACTORS INFLUENCING PULSE RATE 1. EXERCISE - SHORT TERM -- increases PR - LONG-TERM -- strengthens heart muscle, resulting in a lower-than-normal rate at rest & a quicker return to the resting rate after exercise - FEVER & HEAT - Increases the PR because of increased metabolic rate - ACUTE PAIN & ANXIETY \> increase the PR because of sympathetic stimulation - UNRELIEVED SEVERE & CHRONIC PAIN \> Decrease the PR because of parasympathetic stimulation - MEDICATIONS - Some medication alter PR - AGE - The PR decreases as the aging process progresses from infancy thru puberty to adulthood - METABOLISM - Certain diseases [hyperthyroidism]s or cardiomyopathy can cause a chronic elevated PR - [Hypothyroidism] can cause a slowing of the pulse - HEMORRHAGE - Loss of blood increases the PR because of sympathetic stimulation - POSTURAL CHANGES - Lying down decreases the PR RESPIRATION ----------- **RESPIRATORY SYSTEM** - The combination of [ORGANS & TISSUES] associated [w/ breathing]. #### Involves 2 distinctly different processes: 1.EXTERNAL RESPIRATION - The movement of air between the environment and lungs 2\. INTERNAL RESPIRATION \- The movement of oxygen between hemoglobin and single cells. - **EXTERNAL RESPIRATION** - Further involves the following complex but interrelated processes: **VENTILATION** -- the mechanical movement of air to and from the lungs and the exchange of respiratory gases a. Inhalation (inspiration) b. Exhalation (Expiration) **CONDUCTION** -- the movement of air through the airways of the lungs **DIFFUSION** -- movement of oxygen and carbon dioxide between alveoli and RBC **PERFUSSION** -- distribution of blood through the pulmonary capillaries. a. **EUPNEA** -- normal respiration that is quiet, rhythmic and effortless. b. **TACHYPNEA-** rapid respiration marked by quick, shallow breathes. c. **BRADYPNEA** -- slow breathing d. **HYPERVENTILATION** -- prolonged & deep breathes. e. **DYSPNEA** -- difficult and labored breathing f. **ORTHOPNEA** -- ability to breath only in upright position BLOOD PRESSURE -------------- +-----------------------------------+-----------------------------------+ | **AVERAGE** | **120/80 mm Hg (millimeters of | | | mercury)** | +===================================+===================================+ | HYPERTENSION | SYSTOLIC -- above 140 mmHg | | | | | | DIASTOLIC -- ABOVE 90 mmHg | +-----------------------------------+-----------------------------------+ | HYPOTENSION | SYSTOLIC -- below 90 mmHg w/ | | | signs of: | | | | | | - Dizziness | | | | | | - Increased pulse | +-----------------------------------+-----------------------------------+ - A measure of the pressure exerted by the blood as it pulsates through the arteries. - SYSTOLIC PRESSURE - Is the pressure of blood as a result of contraction of the ventricles - DIASTOLIC PRESSURE \- Is the pressure when the ventricles are at rest - PULSE PRESSURE - \- is the difference between the systolic & diastolic pressure - AVERAGE BP of healthy adult: 120/80 mmHg - HYPERTENSION - An abnormally high blood pressure over 140 mmHg systolic and/or 90 mmHg diastolic for at least two consecutive readings. - HYPOTENSION -- an abnormally low blood pressure, systolic pressure below 90 mmHg. **FACTORS AFFECTING BLOOD PRESSURE** A. **AGE** -- older people have higher BP due to decreased elasticity of blood vessels B. **EXERCISE** - increases cardiac output, hence the BP C. **STRESS** -- sympathetic nervous system stimulation causes increased BP D. **RACE** -- hypertension is one of the 10 leading causes of death among the Filipinos. E. **OBESITY** -- BP generally is elevated among overweight and obese people. F. **MEDICATIONS** -- some medications may increase or decrease BP. G. **DIURNAL VARIATIONS** -- BP is lowest in the morning and highest in the late afternoon or early evening. H. **DISEASE PROCESS** -- diabetes mellitus, renal failure, hyperthyroidism **KOROTKOFF SOUND** \- Sound heard during BP taking. CHECKLIST IN ASSESSING VITAL SIGNS (ADULT) ------------------------------------------ +---------+---------+---------+---------+---------+---------+---------+ | **Proce | L | 1 | 2 | 3 | 4 | 5 | | dure** | | | | | | | +=========+=========+=========+=========+=========+=========+=========+ | 1.Assem | | | | | | | | ble | | | | | | | | equipme | | | | | | | | nt | | | | | | | | & | | | | | | | | supplie | | | | | | | | s: | | | | | | | | | | | | | | | | a. | | | | | | | | Digital | | | | | | | | thermom | | | | | | | | eter | | | | | | | | | | | | | | | | b. | | | | | | | | Cotton | | | | | | | | balls, | | | | | | | | alcohol | | | | | | | | | | | | | | | | c. Pen, | | | | | | | | flow | | | | | | | | sheet/r | | | | | | | | ecord | | | | | | | | form | | | | | | | | | | | | | | | | d. | | | | | | | | Watch | | | | | | | | w/ | | | | | | | | second | | | | | | | | hand | | | | | | | | | | | | | | | | e. | | | | | | | | Sphygmo | | | | | | | | manomet | | | | | | | | er | | | | | | | | & | | | | | | | | stethos | | | | | | | | cope | | | | | | | | | | | | | | | | f. | | | | | | | | Blood | | | | | | | | Pressur | | | | | | | | e | | | | | | | | cuff | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 2. | | | | | | | | Introdu | | | | | | | | ce | | | | | | | | self, | | | | | | | | verify | | | | | | | | client' | | | | | | | | s | | | | | | | | identit | | | | | | | | y. | | | | | | | | Explain | | | | | | | | procedu | | | | | | | | re | | | | | | | | to the | | | | | | | | patient | | | | | | | |. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 3. | | | | | | | | Perform | | | | | | | | hand | | | | | | | | hygiene | | | | | | | | and | | | | | | | | observe | | | | | | | | other | | | | | | | | appropr | | | | | | | | iate | | | | | | | | infecti | | | | | | | | on | | | | | | | | control | | | | | | | | procedu | | | | | | | | res. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 4. | | | | | | | | Provide | | | | | | | | client | | | | | | | | privacy | | | | | | | |. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | **ASSES | | | | | | | | SING | | | | | | | | BODY | | | | | | | | TEMPERA | | | | | | | | TURE** | | | | | | | | | | | | | | | | **Digit | | | | | | | | al | | | | | | | | Thermom | | | | | | | | eter** | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 5. | | | | | | | | Sterili | | | | | | | | ze | | | | | | | | the | | | | | | | | thermom | | | | | | | | eter | | | | | | | | with | | | | | | | | alcohol | | | | | | | | before | | | | | | | | use. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 6. Then | | | | | | | | switch | | | | | | | | it on. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | **Takin | | | | | | | | g | | | | | | | | the | | | | | | | | axillar | | | | | | | | y | | | | | | | | tempera | | | | | | | | ture.** | | | | | | | | | | | | | | | | 7. Hold | | | | | | | | the | | | | | | | | client | | | | | | | | in your | | | | | | | | arm or | | | | | | | | lay her | | | | | | | | on the | | | | | | | | bed. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 8. Put | | | | | | | | the end | | | | | | | | of the | | | | | | | | thermom | | | | | | | | eter | | | | | | | | in firm | | | | | | | | &direct | | | | | | | | contact | | | | | | | | with | | | | | | | | her | | | | | | | | armpit. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 9. Hold | | | | | | | | the | | | | | | | | thermom | | | | | | | | eter | | | | | | | | in | | | | | | | | place | | | | | | | | by | | | | | | | | pressin | | | | | | | | g | | | | | | | | client' | | | | | | | | s | | | | | | | | arm | | | | | | | | against | | | | | | | | her | | | | | | | | body. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 10. | | | | | | | | Keep | | | | | | | | the | | | | | | | | thermom | | | | | | | | eter | | | | | | | | in | | | | | | | | place | | | | | | | | until | | | | | | | | you | | | | | | | | hear | | | | | | | | the | | | | | | | | beeps. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 11. | | | | | | | | Remove | | | | | | | | the | | | | | | | | thermom | | | | | | | | eter | | | | | | | | & wipe | | | | | | | | off any | | | | | | | | moistur | | | | | | | | e | | | | | | | | w/ | | | | | | | | cotton | | | | | | | | balls. | | | | | | | | | | | | | | | | Dispose | | | | | | | | of | | | | | | | | cotton | | | | | | | | balls. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 12. | | | | | | | | Read | | | | | | | | the | | | | | | | | thermom | | | | | | | | eter | | | | | | | | at eye | | | | | | | | level. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 13. | | | | | | | | Record: | | | | | | | | Tempera | | | | | | | | ture | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | **ASSES | | | | | | | | SING | | | | | | | | PULSE | | | | | | | | RATE | | | | | | | | (PR)** | | | | | | | | | | | | | | | | Locate | | | | | | | | the | | | | | | | | pulse | | | | | | | | on the | | | | | | | | thumb | | | | | | | | side of | | | | | | | | the | | | | | | | | wrist | | | | | | | | with | | | | | | | | the | | | | | | | | tips of | | | | | | | | the | | | | | | | | first | | | | | | | | three | | | | | | | | fingers | | | | | | | |. | | | | | | | | | | | | | | | | "You | | | | | | | | should | | | | | | | | not use | | | | | | | | the | | | | | | | | thumb | | | | | | | | since | | | | | | | | it | | | | | | | | contain | | | | | | | | s | | | | | | | | a pulse | | | | | | | | w/c may | | | | | | | | confuse | | | | | | | | d | | | | | | | | w/ the | | | | | | | | patient | | | | | | | | 's | | | | | | | | pulse. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 1. When | | | | | | | | pulse | | | | | | | | is | | | | | | | | felt, | | | | | | | | exert | | | | | | | | slight | | | | | | | | pressur | | | | | | | | e | | | | | | | | & count | | | | | | | | for 1 | | | | | | | | min. | | | | | | | | Record: | | | | | | | | PR | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | **ASSES | | | | | | | | SING | | | | | | | | RESPIRA | | | | | | | | TIONS | | | | | | | | (RR)** | | | | | | | | | | | | | | | | Be sure | | | | | | | | client' | | | | | | | | s | | | | | | | | chest | | | | | | | | is | | | | | | | | visible | | | | | | | |. | | | | | | | | | | | | | | | | Observe | | | | | | | | complet | | | | | | | | e | | | | | | | | respira | | | | | | | | tory | | | | | | | | cycle | | | | | | | | (1 | | | | | | | | inspira | | | | | | | | tion | | | | | | | | & 1 | | | | | | | | expirat | | | | | | | | ion) | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 1. | | | | | | | | Count | | | | | | | | for 1 | | | | | | | | min. | | | | | | | | Record: | | | | | | | | RR | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | **ASSES | | | | | | | | SING | | | | | | | | BLOOD | | | | | | | | PRESSUR | | | | | | | | E** | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 1. | | | | | | | | Support | | | | | | | | left | | | | | | | | arm-pal | | | | | | | | m | | | | | | | | upward | | | | | | | | on bed | | | | | | | | or | | | | | | | | table. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 2. Roll | | | | | | | | sleeve | | | | | | | | of gown | | | | | | | | up | | | | | | | | about | | | | | | | | 5" | | | | | | | | above | | | | | | | | elbow. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 3. | | | | | | | | Apply | | | | | | | | the | | | | | | | | cuff | | | | | | | | above | | | | | | | | the | | | | | | | | elbow & | | | | | | | | directl | | | | | | | | y | | | | | | | | over | | | | | | | | the | | | | | | | | brachia | | | | | | | | l | | | | | | | | artery. | | | | | | | | | | | | | | | | The 2 | | | | | | | | tubes | | | | | | | | should | | | | | | | | be in | | | | | | | | the | | | | | | | | directi | | | | | | | | on | | | | | | | | of the | | | | | | | | hand. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 4. Wrap | | | | | | | | the | | | | | | | | rest of | | | | | | | | the | | | | | | | | armband | | | | | | | | smoothl | | | | | | | | y | | | | | | | | around | | | | | | | | the | | | | | | | | arm. | | | | | | | | Tuck | | | | | | | | the | | | | | | | | ends | | | | | | | | under a | | | | | | | | fold. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 5. | | | | | | | | Locate | | | | | | | | the | | | | | | | | brachia | | | | | | | | l | | | | | | | | artery | | | | | | | | w/ the | | | | | | | | fingers | | | | | | | |. | | | | | | | | Place | | | | | | | | stethos | | | | | | | | cope | | | | | | | | directl | | | | | | | | y | | | | | | | | over | | | | | | | | the | | | | | | | | artery. | | | | | | | | | | | | | | | | Place | | | | | | | | earpiec | | | | | | | | es | | | | | | | | in | | | | | | | | ears. | | | | | | | | | | | | | | | | (No | | | | | | | | sound | | | | | | | | will be | | | | | | | | heard, | | | | | | | | but the | | | | | | | | pulsati | | | | | | | | on | | | | | | | | will be | | | | | | | | felt). | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 6. | | | | | | | | Close | | | | | | | | needle | | | | | | | | valve | | | | | | | | attache | | | | | | | | d | | | | | | | | to hand | | | | | | | | & | | | | | | | | inflate | | | | | | | | balloon | | | | | | | | above | | | | | | | | where | | | | | | | | pulse | | | | | | | | ceases | | | | | | | | to be | | | | | | | | heard. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 7. Open | | | | | | | | needle | | | | | | | | valve | | | | | | | | of pump | | | | | | | | & let | | | | | | | | the air | | | | | | | | escape | | | | | | | | slowly | | | | | | | | until | | | | | | | | the | | | | | | | | 1^st^ | | | | | | | | snappin | | | | | | | | g | | | | | | | | is | | | | | | | | heard. | | | | | | | | | | | | | | | | At this | | | | | | | | 1^st^ | | | | | | | | sound, | | | | | | | | note | | | | | | | | reading | | | | | | | | on | | | | | | | | manomet | | | | | | | | er. | | | | | | | | This is | | | | | | | | systoli | | | | | | | | c | | | | | | | | pressur | | | | | | | | e. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 8. | | | | | | | | Continu | | | | | | | | e | | | | | | | | to | | | | | | | | release | | | | | | | | the air | | | | | | | | pressur | | | | | | | | e | | | | | | | | until | | | | | | | | there | | | | | | | | is | | | | | | | | abrupt | | | | | | | | change | | | | | | | | of the | | | | | | | | sound | | | | | | | | from | | | | | | | | very | | | | | | | | loud to | | | | | | | | soft. | | | | | | | | | | | | | | | | The | | | | | | | | reading | | | | | | | | at w/c | | | | | | | | this | | | | | | | | change | | | | | | | | is | | | | | | | | heard | | | | | | | | is the | | | | | | | | diastol | | | | | | | | ic | | | | | | | | pressur | | | | | | | | e. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 9. | | | | | | | | Remove | | | | | | | | cuff, | | | | | | | | expel | | | | | | | | the air | | | | | | | | & | | | | | | | | replace | | | | | | | | apparat | | | | | | | | us. | | | | | | | | | | | | | | | | Record: | | | | | | | | BP | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | TOTAL: | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ CHECKLIST IN ASSESSING VITAL SIGNS (INFANT) ------------------------------------------- +---------+---------+---------+---------+---------+---------+---------+ | **Proce | L | 1 | 2 | 3 | 4 | 5 | | dure** | | | | | | | +=========+=========+=========+=========+=========+=========+=========+ | 1.Assem | | | | | | | | ble | | | | | | | | equipme | | | | | | | | nt | | | | | | | | & | | | | | | | | supplie | | | | | | | | s: | | | | | | | | | | | | | | | | a. | | | | | | | | Digital | | | | | | | | thermom | | | | | | | | eter | | | | | | | | | | | | | | | | b. | | | | | | | | Cotton | | | | | | | | balls, | | | | | | | | alcohol | | | | | | | | | | | | | | | | c. Pen, | | | | | | | | flow | | | | | | | | sheet/r | | | | | | | | ecord | | | | | | | | form | | | | | | | | | | | | | | | | d. | | | | | | | | Watch | | | | | | | | w/ | | | | | | | | second | | | | | | | | hand | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 2. | | | | | | | | Introdu | | | | | | | | ce | | | | | | | | self, | | | | | | | | verify | | | | | | | | client' | | | | | | | | s | | | | | | | | identit | | | | | | | | y. | | | | | | | | Explain | | | | | | | | procedu | | | | | | | | re | | | | | | | | to the | | | | | | | | patient | | | | | | | |. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 3. | | | | | | | | Perform | | | | | | | | hand | | | | | | | | hygiene | | | | | | | | and | | | | | | | | observe | | | | | | | | other | | | | | | | | appropr | | | | | | | | iate | | | | | | | | infecti | | | | | | | | on | | | | | | | | control | | | | | | | | procedu | | | | | | | | res. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 4. | | | | | | | | Provide | | | | | | | | client | | | | | | | | privacy | | | | | | | |. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | **ASSES | | | | | | | | SING | | | | | | | | BODY | | | | | | | | TEMPERA | | | | | | | | TURE** | | | | | | | | | | | | | | | | **Digit | | | | | | | | al | | | | | | | | Thermom | | | | | | | | eter** | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 5. | | | | | | | | Sterili | | | | | | | | ze | | | | | | | | the | | | | | | | | thermom | | | | | | | | eter | | | | | | | | with | | | | | | | | alcohol | | | | | | | | before | | | | | | | | use. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 6. Then | | | | | | | | switch | | | | | | | | it on. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | **Takin | | | | | | | | g | | | | | | | | the | | | | | | | | axillar | | | | | | | | y | | | | | | | | tempera | | | | | | | | ture.** | | | | | | | | | | | | | | | | 7. Hold | | | | | | | | the | | | | | | | | client | | | | | | | | in your | | | | | | | | arm or | | | | | | | | lay her | | | | | | | | on the | | | | | | | | bed. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 8. Put | | | | | | | | the end | | | | | | | | of the | | | | | | | | thermom | | | | | | | | eter | | | | | | | | in firm | | | | | | | | & | | | | | | | | direct | | | | | | | | contact | | | | | | | | with | | | | | | | | her | | | | | | | | armpit. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 9. Hold | | | | | | | | the | | | | | | | | thermom | | | | | | | | eter | | | | | | | | in | | | | | | | | place | | | | | | | | by | | | | | | | | pressin | | | | | | | | g | | | | | | | | client' | | | | | | | | s | | | | | | | | arm | | | | | | | | against | | | | | | | | her | | | | | | | | body. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 10. | | | | | | | | Keep | | | | | | | | the | | | | | | | | thermom | | | | | | | | eter | | | | | | | | in | | | | | | | | place | | | | | | | | until | | | | | | | | you | | | | | | | | hear | | | | | | | | the | | | | | | | | beeps. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 11. | | | | | | | | Remove | | | | | | | | the | | | | | | | | thermom | | | | | | | | eter | | | | | | | | & wipe | | | | | | | | off any | | | | | | | | moistur | | | | | | | | e | | | | | | | | w/ | | | | | | | | cotton | | | | | | | | balls. | | | | | | | | | | | | | | | | Dispose | | | | | | | | of | | | | | | | | cotton | | | | | | | | balls. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 12. | | | | | | | | Read | | | | | | | | the | | | | | | | | thermom | | | | | | | | eter | | | | | | | | at eye | | | | | | | | level. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 13. | | | | | | | | Record: | | | | | | | | Tempera | | | | | | | | ture | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | **Takin | | | | | | | | g | | | | | | | | rectal | | | | | | | | tempera | | | | | | | | ture** | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 1.Steri | | | | | | | | lize | | | | | | | | the | | | | | | | | thermom | | | | | | | | eter | | | | | | | | first | | | | | | | | and | | | | | | | | apply | | | | | | | | some | | | | | | | | lubrica | | | | | | | | nt | | | | | | | | over | | | | | | | | the | | | | | | | | sensor | | | | | | | | end. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 2. For | | | | | | | | newborn | | | | | | | | s | | | | | | | | and | | | | | | | | young | | | | | | | | infants | | | | | | | | lay | | | | | | | | them on | | | | | | | | the bed | | | | | | | | when | | | | | | | | taking | | | | | | | | rectal | | | | | | | | tempera | | | | | | | | ture. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | 3. | | | | | | | | Insert | | | | | | | | thermom | | | | | | | | eter | | | | | | | | into | | | | | | | | her | | | | | | | | anus to | | | | | | | | about | | | | | | | | 1.3 to | | | | | | | | 2.5 cm | | | | | | | | that | | | | | | | | is, | | | | | | | | about | | | | | | | | half to | | | | | | | | full | | | | | | | | length | | | | | | | | of your | | | | | | | | finger | | | | | | | | tip. | | | | | | | +---------+---------+---------+---------+---------+---------+---------+