USING AN ELECTRONIC VITAL SIGNS MONITOR

Posted by Admin in Tuesday, December 29, 2009


An electronic vital signs monitor allows you to track a patient's vital signs continually, without having to reapply a blood pressure cuff each time. In addition, the patient won't need an invasive arterial line to gather similar data.
Some automated vital signs monitors are lightweight and battery-operated and can be attached to an I.V. pole for continual monitoring, even during patient transfers. Newer models can also display patient temperature and pulse oximetry as well as blood pressure. A built in printer is also available on certain models. Make sure that you know the capacity of the monitor's battery, and plug the machine in whenever possible to keep it charged.
Before using any monitor, check its accuracy. Determine the patient's pulse rate and blood pressure manually, using the same arm you'll use for the monitor cuff. Compare your results when you get initial readings from the monitor. If the results differ, call your supply department or the manufacturer's representative.
Preparing the device
  • Explain the procedure to the patient. Describe the alarm system so he won't be frightened if it's triggered.
  • Make sure that the power switch is off. Then plug the monitor into a properly grounded wall outlet. Secure the dual air hose to the front of the monitor.
  • Connect the pressure cuff's tubing into the other ends of the dual air hose, and tighten connections to prevent air leaks. Keep the air hose away from the patient to avoid accidental dislodgment.
  • Squeeze all air from the cuff, and wrap the cuff loosely around the patient's arm or leg, allowing 2 fingerbreadths between cuff and arm or leg. Never apply the cuff to a limb that has an I.V. line in place. Position the cuff's “artery” arrow over the palpated brachial artery. Then secure the cuff for a snug fit.
Selecting parameters
  • When you turn on the monitor, it will default to a manual mode. (In this mode, you can obtain vital signs yourself before switching to the automatic mode.) Press the AUTO/MANUAL button to select the automatic mode. The monitor will give you baseline data for the pulse rate, systolic and diastolic pressures, and mean arterial pressure.
  • Compare your previous manual results with these baseline data. If they match, you're ready to set the alarm parameters. Press the SELECT button to blank out all displays except systolic pressure.
  • Use the HIGH and LOW limit buttons to set the specific parameters for systolic pressure. (These limits range from a high of 240 to a low of 0.) You'll also do this three more times for mean arterial pressure, pulse rate, and diastolic pressure. After you've set the parameters for diastolic pressure, press the SELECT button again to display all current data. Even if you forget to do this last step, the monitor will automatically display current data 10 seconds after you set the last parameters.
Collecting data
  • You also need to tell the monitor how often to obtain data. Press the SET button until you reach the desired time interval in minutes. If you've chosen the automatic mode, the monitor will display a default cycle time of 3 minutes. You can override the default cycle time to set the interval you prefer.
  • You can obtain a set of vital signs at any time by pressing the START button. Also, pressing the CANCEL button will stop the interval and deflate the cuff. You can retrieve stored data by pressing the PRIOR DATA button. The monitor will display the last data obtained along with the time elapsed since then. Scrolling backward, you can retrieve data from the previous 99 minutes.

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EFFECTS OF AGE ON BLOOD PRESSURE

Posted by Admin in Sunday, December 27, 2009

EFFECTS OF AGE ON BLOOD PRESSURE
Systolic and diastolic blood pressure will vary according to the patient's age.
AGE
BLOOD PRESSURE (MM HG)
Neonate
Systolic: 50 to 52
Diastolic: 25 to 30
Mean: 35 to 40
3 years
Systolic: 78 to 114
Diastolic: 46 to 78
10 years
Systolic: 90 to 132
Diastolic: 56 to 86
16 years
Systolic: 104 to 108
Diastolic: 60 to 92
Adult
Systolic: 90 to 130
Diastolic: 60 to 85
Older adult
Systolic: 140 to 160
Diastolic: 70 to 90

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USING A DOPPLER DEVICE

Posted by Admin

USING A DOPPLER DEVICE
More sensitive than palpation for determining pulse rate, the Doppler ultrasound blood flow detector is especially useful when a pulse is faint or weak. Unlike palpation, which detects arterial wall expansion and retraction, this instrument detects the motion of red blood cells (RBCs).
  • Apply a small amount of coupling gel or transmission gel (not water-soluble lubricant) to the ultrasound probe.
  • Position the probe on the skin directly over the selected artery. In the illustration below left, the probe is over the posterior tibial artery.
  • When using a Doppler model like the one in the illustration below left, turn the instrument on and, moving counterclockwise, set the volume control to the lowest setting. If your model doesn't have a speaker, plug in the earphones and slowly raise the volume. The Doppler ultrasound stethoscope shown in the illustration below right is basically a stethoscope fitted with an audio unit, volume control, and transducer, which amplifies the movement of RBCs.
  • To obtain the best signals with either device, tilt the probe 45 degrees from the artery, being sure to put gel between the skin and the probe. Slowly move the probe in a circular motion to locate the center of the artery and the Doppler signal—a hissing noise at the heartbeat. Avoid moving the probe rapidly because this distorts the signal.
  • Count the signals for 60 seconds to determine the pulse rate.
  • After you've measured the pulse rate, clean the probe with a soft cloth soaked in antiseptic solution or soapy water. Don't immers the probe or bump it against a hard surface.



Doppler probe with amplifier

Doppler ultrasound stethoscope

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IDENTIFYING PULSE PATTERNS

Posted by Admin in Wednesday, December 16, 2009

IDENTIFYING PULSE PATTERNS
TYPE
RATE
RHYTHM (PER 3 SECONDS)
CAUSES AND INCIDENCE
NORMAL
60 to 80 beats/minute; in neonates, 120 to 140 beats/minute
o o o o
  • Varies with such factors as age, physical activity, and sex (men usually have lower pulse rates than women)
TACHYCARDIA
More than 100 beats/minute
o o o o o o o
  • Accompanies stimulation of the sympathetic nervous system by emotional stress, such as anger, fear, or anxiety, or by the use of certain drugs such as caffeine
  • May result from exercise and from certain health conditions, such as heart failure, anemia, and fever (which increases oxygen requirements and therefore pulse rate)
BRADYCARDIA
Less than 60 beats/minute
o o o
  • Accompanies stimulation of the parasympathetic nervous system by drug use, especially cardiac glycosides, and such conditions as cerebral hemorrhage and heart block
  • May also be present in fit athletes
IRREGULAR
Uneven time intervals between beats (for example, periods of regular rhythm interrupted by pauses or premature beats)
o o o o o o o
  • May indicate cardiac irritability, hypoxia, digoxin toxicity, potassium imbalance, or sometimes more serious arrhythmias if premature beats occur frequently
  • Occasional premature beats are normal

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TYPES OF THERMOMETERS

Posted by Admin


You can take an oral, rectal, or axillary temperature with such instruments as a mercury glass thermometer, a chemical-dot device, or various electronic digital thermometers. You may even have access to a tympanic thermometer.
You'll use the oral route most for adults who are awake, alert, oriented, and cooperative. For infants, young children, and confused or unconscious patients, you may need to take the temperature rectally.

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RESPIRATION - Assessment

Posted by Admin

RESPIRATION
Controlled by the respiratory center in the lateral medulla oblongata, respiration is the exchange of oxygen and carbon dioxide between the atmosphere and body cells. External respiration, or breathing, is accomplished by the diaphragm and chest muscles and delivers oxygen to the lower respiratory tract and alveoli.
Four measures of respiration—rate, rhythm, depth, and sound—reflect the body's metabolic state, diaphragm and chest-muscle condition, and airway patency. Respiratory rate is recorded as the number of cycles (with inspiration and expiration comprising one cycle) per minute; rhythm, as the regularity of these cycles; depth, as the volume of air inhaled and exhaled with each respiration; and sound, as the audible digression from normal, effortless breathing.
Equipment
Watch with second hand.
Implementation
  • The best time to assess the patient's respirations is immediately after taking his pulse rate. Keep your fingertips over the radial artery, and don't tell the patient you're counting respirations. If you tell him, he'll become conscious of his respirations and the rate may change.
  • Count respirations by observing the rise and fall of the patient's chest as he breathes. Alternatively, position the patient's opposite arm across his chest and count respirations by feeling its rise and fall. Consider one rise and one fall as one respiration.
  • Count respirations for 30 seconds and multiply by 2 or count for 60 seconds if respirations are irregular to account for variations in respiratory rate and pattern.
  • As you count respirations, be alert for and record such breath sounds as stertor, stridor, wheezing, and an expiratory grunt. Stertor is a snoring sound resulting from secretions in the trachea and large bronchi. Listen for it in patients with neurologic disorders and in those who are comatose. Stridor is an inspiratory crowing sound that occurs with upper airway obstruction in laryngitis, croup, or the presence of a foreign body.
  • PEDIATRIC ALERT When listening for stridor in infants and children with croup, also observe for sternal, substernal, or intercostal retractions.
  • Wheezing is caused by partial obstruction in the smaller bronchi and bronchioles. This high-pitched, musical sound is common in patients with emphysema or asthma.
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  • PEDIATRIC ALERT In infants, an expiratory grunt indicates imminent respiratory distress.
  • ELDER ALERT In older patients, an expiratory grunt may result from partial airway obstruction or neuromuscular reflex.
  • Watch the patient's chest movements and listen to his breathing to determine the rhythm and sound of respirations. (See Identifying respiratory patterns.)
  • To detect other breath sounds—such as crackles and rhonchi—or the lack of sound in the lungs, you'll need a stethoscope.
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  • Observe chest movements for depth of respirations. If the patient inhales a small volume of air, record this as shallow; if he inhales a large volume, record this as deep.
  • Observe the patient for use of accessory muscles, such as the scalene, sternocleidomastoid, trapezius, and latissimus dorsi. Using these muscles reflects weakness of the diaphragm and the external intercostal muscles—the major muscles of respiration.

Special considerations
  • Respiratory rates of less than 8 or more than 40 breaths per minute are usually considered abnormal; report the sudden onset of such rates promptly. Observe the patient for signs of dyspnea, such as an anxious facial expression, flaring nostrils, a heaving chest wall, and cyanosis. To detect cyanosis, look for characteristic bluish discoloration in the nail beds or the lips, under the tongue, in the buccal mucosa, or in the conjunctiva.
  • In assessing the patient's respiratory status, consider his personal and family history. Ask whether he smokes and, if so, for how many years and how many packs per day.
  • PEDIATRIC ALERT A child's respiratory rate may double in response to exercise, illness, or emotion. Normally, the rate for neonates is 30 to 80 breaths/minute; for toddlers, 20 to 40; and for children of school age and older, 15 to 25. Children usually reach the adult rate (12 to 20) at about age 15.
Documentation
Record the rate, depth, rhythm, and sound of the patient's respirations.

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BLOOD PRESSURE - Assessment

Posted by Admin

BLOOD PRESSURE
Defined as the lateral force exerted by blood on the arterial walls, blood pressure depends on the force of ventricular contractions, arterial wall elasticity, peripheral vascular resistance, and blood volume and viscosity. Systolic, or maximum, pressure occurs during left ventricular contraction and reflects the integrity of the heart, arteries, and arterioles. Diastolic, or minimum, pressure occurs during left ventricular relaxation and directly indicates blood vessel resistance.
Pulse pressure—the difference between systolic and diastolic pressures—varies inversely with arterial elasticity. Rigid vessels, incapable of distention and recoil, produce high systolic pressure and low diastolic pressure. Normally, systolic pressure exceeds diastolic pressure by about 40 mm Hg. Narrowed pulse pressure—a difference of less than 30 mm Hg—occurs when systolic pressure falls and diastolic rises. These changes reflect reduced stroke volume, increased peripheral resistance, or both. Widened pulse pressure—a difference of more than 50 mm Hg between systolic and diastolic pressures—occurs when systolic pressure rises and diastolic pressure remains constant, or when systolic pressure rises and diastolic pressure falls. These changes reflect increased stroke volume, decreased peripheral resistance, or both.
Blood pressure is measured in millimeters of mercury with a sphygmomanometer and a stethoscope, usually at the brachial artery (less often at the popliteal or radial artery). Lowest in the neonate, blood pressure rises with age, weight gain, prolonged stress, and anxiety. (See Effects of age on blood pressure.)
Frequent blood pressure measurement is critical after serious injury, surgery, or anesthesia, and during any illness or condition that threatens cardiovascular stability. (Frequent measurement may be done with an automated vital signs monitor.) Regular measurement is indicated for patients with a history of hypertension or hypotension, and yearly screening is recommended for all adults.
Equipment
Mercury or aneroid sphygmomanometer • stethoscope • alcohol pad • automated vital signs monitor (if available).
The sphygmomanometer consists of an inflatable compression cuff linked to a manual air pump and a mercury manometer or an aneroid gauge. The mercury sphygmomanometer is more accurate and requires calibration less frequently than the aneroid model but is larger and heavier. To obtain an accurate reading, you must rest its gauge on a level surface and view the meniscus at eye level; you can rest an aneroid gauge in any position but must view it directly from the front.
Hook, bandage, snap, or Velcro cuffs come in six standard sizes ranging from neonate to extra-large adult. Disposable cuffs are available.
The automated vital signs monitor is a noninvasive device that measures pulse rate, systolic and diastolic pressures, and mean arterial pressure at preset intervals. (See Using an electronic vital signs monitor.)
Preparation of equipment
Carefully choose a cuff of appropriate size for the patient. An excessively narrow cuff may cause a false-high pressure reading; an excessively wide one, a false-low reading. If you aren't using your own stethoscope, disinfect the earpieces with an alcohol pad before placing them in your ears to avoid cross-contamination.
To use an automated vital signs monitor, collect the monitor, dual air hose, and pressure cuff. Then make sure the monitor unit is firmly positioned near the patient's bed.
Implementation
  • Tell the patient that you're going to take his blood pressure.
  • The patient can lie supine or sit erect during blood pressure measurement. His arm should be extended at heart level and be well supported. If the artery is below heart level, you may get a false-high reading. Make sure the patient is relaxed and comfortable when you take his blood pressure so it stays at its normal level.
  • Wrap the deflated cuff snugly around the upper arm.
  • If necessary, connect the appropriate tube to the rubber bulb of the air pump and the other tube to the manometer. Then insert the stethoscope earpieces into your ears.
  • Locate the brachial artery by palpation. Center the bell of the stethoscope over the part of the artery where you detect the strongest beats, and hold it in place with one hand. The bell of the stethoscope transmits low-pitched arterial blood sounds more effectively than does the diaphragm. (See Positioning the blood pressure cuff.)
  • Using the thumb and index finger of your other hand, turn the thumbscrew on the rubber bulb of the air pump clockwise to close the valve.
  • Then pump air into the cuff while auscultating for the sound over the brachial artery to compress and, eventually, occlude arterial blood flow. Continue pumping air until the mercury column or aneroid gauge registers 160 mm Hg or at least 10 mm Hg above the level of the last audible sound.
  • Carefully open the valve of the air pump, and then slowly deflate the cuff—no faster than 5 mm Hg per second. While releasing air, watch the mercury column or aneroid gauge and auscultate for the sound over the artery.
  • When you hear the first beat or clear tapping sound, note the pressure on the column or gauge. This is the systolic pressure. (The beat or tapping sound is the first of five Korotkoff
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    sounds. The second sound resembles a murmur or swish; the third sound, crisp tapping; the fourth sound, a soft, muffled tone; and the fifth, the last sound heard.)
  • Continue to release air gradually while auscultating for the sound over the artery.
  • Note the diastolic pressure—the fourth Korotkoff sound. If you continue to hear sounds as the column or gauge falls to zero (common in children), record the pressure at the beginning of the fourth sound. This is important because, in some patients, a distinct fifth sound is absent.
  • Rapidly deflate the cuff. Record the pressure, wait 15 to 30 seconds, and then repeat the procedure and record the pressures to confirm your original findings. After doing so, remove and fold the cuff, and return it to storage.

Special considerations
  • If you can't auscultate blood pressure, you may estimate systolic pressure. To do this, first palpate the brachial or radial pulse. Then inflate the cuff until you no longer detect the pulse. Slowly deflate the cuff and, when you detect the pulse again, record the pressure as the palpated systolic pressure. When measuring blood pressure in the popliteal artery, position the patient so that you can assess the area, wrap a cuff around the middle of his thigh, and proceed with blood pressure measurement.
  • Palpation of systolic blood pressure may also be important to avoid underestimating blood pressure in patients with an auscultatory gap. This gap is a loss of sound between the first and second Korotkoff sounds that may be as great as
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    40 mm Hg. You may find this in patients with venous congestion or hypotension.
  • Another alternative to auscultating with a stethoscope is to use Doppler ultrasound to hear Korotkoff sounds. This is useful when the blood pressure is diminished or when the pulse is nonpalpable.
  • If the patient is crying or anxious, delay blood pressure measurement, if possible, until he becomes calm to avoid falsely elevated readings.
  • If your facility considers the fourth and fifth Korotkoff sounds as the first and second diastolic pressures, record both pressures.
  • Remember that malfunction in an aneroid sphygmomanometer can be identified only by checking it against a mercury manometer of known accuracy. Be sure to check your aneroid manometer this way periodically. Malfunction in a mercury manometer is evident in abnormal behavior of the mercury column. Don't attempt to repair either type yourself; instead, send it to the appropriate service department. (For information on other situations that can cause false-high or false-low readings, see Correcting problems of blood pressure measurement.)
  • Occasionally, blood pressure must be measured in both arms or with the patient in two different positions (such as lying and standing or sitting and standing). In such cases, observe and record any significant difference between the two readings and record the blood pressure and the extremity and position used.
  • Measure the blood pressure of a patient taking antihypertensive medication while he's in a sitting position to ensure accurate measurements.
Complications
Don't take a blood pressure in the arm on the affected side of a mastectomy patient because it may decrease already compromised lymphatic circulation, worsen edema, and damage the arm. Likewise, don't take a blood pressure on an arm with an arteriovenous fistula or hemodialysis shunt because blood flow through the vascular device may be compromised.
Documentation
On the patient's chart, record blood pressure as systolic over diastolic pressures, such as 120/78 mm Hg; if necessary, record systolic pressure over the two diastolic pressures such as 120/78/20 mm Hg. Chart an auscultatory gap if present. If required by your facility, chart blood pressures on a graph, using dots or checkmarks. Document the extremity used and the patient's position. If the blood pressure was palpated or auscultated using a Doppler device, record this as well.

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PULSE - Assessment

Posted by Admin in Tuesday, December 15, 2009

PULSE
Blood pumped into an already-full aorta during ventricular contraction creates a fluid wave that travels from the heart to the peripheral arteries. This recurring wave—called a pulse—can be palpated at locations on the body where an artery crosses over bone on firm tissue. In adults and children over age 3, the radial artery in the wrist is the most common palpation site. (See Pulse points.) In infants and children under age 3, a stethoscope is used to listen to the heart itself rather than palpating a pulse. Because auscultation is done at the heart's apex, this is called the apical pulse.
An apical-radial pulse is taken by simultaneously counting apical and radial beats—the first by auscultation at the apex of the heart, the second by palpation at the radial artery. Some heartbeats detected at the apex can't be detected at peripheral sites. When this occurs, the apical pulse rate is higher than the radial; the difference is the pulse deficit.
Pulse taking involves determining the rate (number of beats per minute), rhythm (pattern or regularity of the beats), and volume (amount of blood pumped with each beat). If the pulse is faint or weak, use a Doppler ultrasound blood flow detector if available. (See Using a Doppler device.)
Equipment
Watch with a second hand • stethoscope (for auscultating an apical pulse) • Doppler ultrasound blood flow detector if necessary.
Preparation of equipment
If you aren't using your own stethoscope, disinfect the earpieces with an alcohol pad before and after use to prevent cross-contamination.
Implementation
  • Wash your hands, and tell the patient that you intend to take his pulse.
  • Make sure the patient is comfortable and relaxed because an awkward, uncomfortable position may affect the heart rate.
Taking a radial pulse
  • Place the patient in a sitting or supine position, with his arm at his side or across his chest.
  • Gently press your index, middle, and ring fingers on the radial artery, inside the patient's wrist. You should feel a pulse with only moderate pressure; excessive pressure may obstruct blood flow distal to the pulse site. Don't use your thumb to take the patient's pulse because your thumb's own strong pulse may be confused with the patient's pulse.
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  • After locating the pulse, count the beats for 60 seconds, or count for 30 seconds and multiply by 2. Counting for a full minute provides a more accurate picture of irregularities. While counting the rate, assess pulse rhythm and volume by noting the pattern and strength of the beats. If you detect an irregularity, repeat the count, and note whether it occurs in a pattern or randomly. If you're still in doubt, take an apical pulse. (See Identifying pulse patterns.)

Taking an apical pulse
  • Help the patient to a supine position, and drape him if necessary.
  • Warm the diaphragm or bell of the stethoscope in your hand. Placing a cold stethoscope against the skin may startle the patient and momentarily increase the heart rate. Keep in mind that the bell transmits low-pitched sounds more effectively than the diaphragm.
  • Place the diaphragm or bell of the stethoscope over the apex of the heart (normally located at the fifth intercostal
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    space left of the midclavicular line). Then insert the earpieces into your ears. Count the beats for 60 seconds (or count for 30 seconds and multiply by 2) and note their rhythm, volume, and intensity (loudness).
  • Remove the stethoscope and make the patient comfortable.
Taking an apical-radial pulse
  • Two nurses work together to obtain the apical-radial pulse; one palpates the radial pulse while the other auscultates the apical pulse with a stethoscope. Both must use the same watch when counting beats.
  • Help the patient to a supine position and drape him if necessary.
  • Locate the apical and radial pulses.
  • Determine a time to begin counting. Then each nurse should count beats for 60 seconds.

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TEMPERATURE - Assessment

Posted by Admin in Sunday, December 13, 2009

TEMPERATURE
Body temperature represents the balance between heat produced by metabolism, muscular activity, and other factors and heat lost through the skin, lungs, and body wastes. A stable temperature pattern promotes proper function of cells, tissues, and organs; a change in this pattern usually signals the onset of illness.
Temperature can be measured with a mercury, an electronic digital, or a chemical-dot thermometer. Oral temperature in adults normally ranges from 97° to 99.5° F (36.1° to 37.5° C); rectal temperature, the most accurate reading, is usually 1° F (0.6° C) higher; axillary temperature, the least accurate, reads 1° to 2° F (0.6° to 1.1° C) lower; and tympanic temperature reads 0.5° to 1° (0.3° to 0.6° C) higher.
Temperature normally fluctuates with rest and activity. Lowest readings typically occur between 4 and 5 a.m.; the highest readings occur between 4 and 8 p.m. Other factors
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also influence temperature, including gender, age, emotional conditions, and environment. Keep the following principles in mind. Women normally have higher temperatures than men, especially during ovulation. Normal temperature is highest in neonates and lowest in elderly persons. Heightened emotions raise temperature; depressed emotions lower it. A hot external environment can raise temperature; a cold environment lowers it.
Equipment
Thermometer (mercury, electronic, chemical-dot, or tympanic) • water-soluble lubricant or petroleum jelly (for rectal temperature) • facial tissue • disposable thermometer sheath or probe cover (except for chemical thermometer) • alcohol pad.
Preparation of equipment
If a thermometer is included in the admission pack, keep it at the patient's bedside and, on discharge, allow him to take it home. Otherwise, obtain a thermometer from the nurses' station or central supply department. If you use an electronic thermometer, make sure it's been recharged. (See Types of thermometers.)
Implementation
  • Explain the procedure to the patient, and wash your hands. If the patient has had hot or cold liquids, chewed gum, or smoked, wait 15 minutes before taking an oral temperature.
Using a mercury thermometer
  • Hold the thermometer between your thumb and index finger at the end opposite the bulb.
  • If the thermometer has been soaking in a disinfectant, rinse it in cold water. Rinsing removes chemicals that may irritate oral or rectal mucous membranes or axillary skin. Avoid using hot water because it expands the mercury, which could break the thermometer. Using a twisting motion, wipe the thermometer from the bulb upward.
  • Then quickly snap your wrist several times while holding the thermometer to shake it down to below 98° F (36.7° C). Shaking causes the mercury to descend into the bulb. The mercury will then expand in response to the patient's body temperature and be forced upward.
  • To use a disposable sheath, disinfect the thermometer with an alcohol pad. Insert it into the disposable sheath opening; then twist to tear the seal at the dotted line. Pull it apart.
Using an electronic thermometer
  • Insert the probe into a disposable probe cover. If taking a rectal temperature, lubricate the probe cover to reduce friction and ease insertion. Leave the probe in place until the maximum temperature appears on the digital display.
Using a chemical-dot thermometer
  • Remove the thermometer from its protective dispenser case by grasping the handle end with your thumb and forefinger, moving the handle up and down to break the seal, and pulling the handle straight out. Keep the thermometer sealed until use.
Using a tympanic thermometer
  • Make sure the lens under the probe is clean and shiny. Attach a disposable probe cover.
  • Stabilize the patient's head; then gently pull the ear straight back (for children up to age 1) or up and back (for children age 1 and older to adults).
  • Insert the thermometer until the entire ear canal is sealed. The thermometer should be inserted toward the tympanic membrane in the same way that an otoscope is inserted. Then press the activation button and hold it for 1 second. The temperature will appear on the display.
  • PEDIATRIC ALERT For infants younger than age 3 months, take three readings and use the highest.
Taking an oral temperature
  • Position the tip of the thermometer under the patient's tongue, as far back as possible on either side of the frenulum linguae. Placing the tip in this area promotes contact with superficial blood vessels and contributes to an accurate reading.
  • Instruct the patient to close his lips but to avoid biting down with his teeth. Biting can break the thermometer, cutting the mouth or lips or causing ingestion of broken glass or mercury.
  • Leave a mercury thermometer in place for at least 2 minutes or a chemical-dot thermometer in place for 45 seconds to register temperature; for an electronic thermometer, wait until the maximum temperature is displayed.
  • For a mercury thermometer, remove and discard the disposable sheath; then read the temperature at eye level, noting it before shaking down the thermometer. For an electronic thermometer, note the temperature; then remove and discard the probe cover. For the chemical-dot thermometer, read the temperature as the last dye dot that has changed color, or fired; then discard the thermometer and its dispenser case.
Taking a rectal temperature
  • Position the patient on his side with his top leg flexed, and drape him to provide privacy. Then fold back the bed linens to expose the anus.
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  • Squeeze the lubricant onto a facial tissue to prevent contamination of the lubricant supply.
  • Lubricate about ½″ (1.3 cm) of the thermometer tip for an infant, 1″ (2.5 cm) for a child, or about 1½″ (3.8 cm) for an adult. Lubrication reduces friction and thus eases insertion. This step may be unnecessary when using disposable rectal sheaths because they're prelubricated.
  • Lift the patient's upper buttock, and insert the thermometer about ½″ (1.3 cm) for an infant or 1½″ (3.8 cm) for an adult. Gently direct the thermometer along the rectal wall toward the umbilicus. This will avoid perforating the anus or rectum or breaking the thermometer. It will also help ensure an accurate reading because the thermometer will register hemorrhoidal artery temperature instead of fecal temperature.
  • Hold the mercury thermometer in place for 2 to 3 minutes, or the electronic thermometer until the maximum temperature is displayed. Holding the thermometer prevents damage to rectal tissues caused by displacement or loss of the thermometer into the rectum.
  • Carefully remove the thermometer, wiping it as necessary. Then wipe the patient's anal area to remove any lubricant or feces.

Taking an axillary temperature
  • Position the patient with the axilla exposed.
  • Gently pat the axilla dry with a facial tissue because moisture conducts heat. Avoid harsh rubbing, which generates heat.
  • Ask the patient to reach across his chest and grasp his opposite shoulder, lifting his elbow.
  • Position the thermometer in the center of the axilla, with the tip pointing toward the patient's head.
  • Tell him to keep grasping his shoulder and to lower his elbow and hold it against his chest. This promotes skin contact with the thermometer.
  • Remove a mercury thermometer after 10 minutes; remove an electronic thermometer when it displays the maximum temperature. Axillary temperature takes longer to register than oral or rectal temperature because the thermometer isn't enclosed in a body cavity.
  • Grasp the end of the thermometer and remove it from the axilla.

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TRANSFER - Fundamental Procedures

Posted by Admin in Monday, December 7, 2009

TRANSFER
Patient transfer—either within your facility or to another one—requires thorough preparation and careful documentation. Preparation includes an explanation of the transfer to the patient and his family, discussion of the patient's condition and care plan with the staff at the receiving unit
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or facility, and arrangements for transportation if necessary. Documentation of the patient's condition before and during transfer and adequate communication between nursing staffs ensure continuity of nursing care and provide legal protection for the transferring facility and its staff.
Equipment
Admission inventory of belongings • patient's chart, medication record, and nursing Kardex • medications • bag or suitcase • wheelchair or stretcher, as necessary.
Implementation
  • Explain the transfer to the patient and his family. If the patient is anxious about the transfer or his condition precludes patient teaching, be sure to explain the reason for the transfer to his family members, especially if the transfer is the result of a serious change in the patient's condition. Assess his physical condition to determine the means of transfer, such as a wheelchair or a stretcher.
  • Using the admissions inventory of belongings as a checklist, collect the patient's property. Be sure to check the entire room, including the closet, bedside stand, overbed table, and bathroom. If the patient is being transferred to another facility, don't forget valuables or personal medications that have been stored.
  • Gather the patient's medications from the cart and the refrigerator. If the patient is being transferred to another unit, send the medications to the receiving unit; if he's being transferred to another facility, return them to the pharmacy.
  • Notify the business office and other appropriate departments of the transfer.
  • Have a staff person notify the dietary department, the pharmacy, and the facility telephone operator about the transfer (if within the facility).
  • Contact the nursing staff on the receiving unit about the patient's condition and drug regimen and review the patient's nursing care plan with them to ensure continuity of care.

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Admitting the pediatric patient

Posted by Admin in Friday, December 4, 2009

Admitting the pediatric patient
  • Your initial goal will be to establish a friendly, trusting relationship with the child and his parents to help relieve fears and anxiety, which can hinder treatment. Remember that a child under age 3 may fear separation from his parents; an older child may worry about what will happen to him.
  • Speak directly to the child, and allow him to answer questions before obtaining more information from his parents.
  • While orienting the parents and child to the unit, describe the layout of the room and bathroom, and tell them the location of the playroom, television room, and snack room, if available.
  • Teach the child how to call the nurse. Stress that she'll always be available to take care of his needs, such as helping him to the bathroom.
  • Explain the facility's rooming-in and visiting policies so the parents can take every opportunity to be with their child.
  • Inquire about the child's usual routine so that favorite foods, bedtime rituals, toileting, and adequate rest can be incorporated into the routine.
  • Encourage the parents to bring some of their child's favorite toys, blankets, or other items to make the child feel more at home amid unfamiliar surroundings.

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USING PATIENT CARE REMINDERS

Posted by Admin in Wednesday, December 2, 2009

USING PATIENT CARE REMINDERS
When placed at the head of the patient's bed, care reminders call attention to the patient's special needs and help ensure consistent care by communicating these needs to the hospital staff, the patient's family, and other visitors.
You can use a specially designed card or a plain piece of paper to post important information about the patient, such as:
  • allergies
  • dietary restrictions
  • fluid restrictions
  • specimen collection
  • patient deaf or hearing-impaired in right ear
  • foreign-language speaker.
You can also use care reminders to post special instructions, such as:
  • complete bed rest
  • no blood pressure on right arm
  • turn every 1 hour
  • nothing by mouth.
Never violate the patient's privacy by posting his diagnosis, details about surgery, or any information he might find embarrassing.

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