Professional Documents
Culture Documents
Sacdalan
Nursing
Responsibilities
Wash
hands before and after taking vital
signs
Gather equipment (like watch with a
second hand, thermometer with cover, BP
apparatus with stethoscope/dynamap,
alcohol swab, pen etc)
Properly identify patient, explain procedure
Assist to a comfortable resting position
Document and transfer readings to TPR
sheet after every vital signs monitoring
Inform the doctor for abnormal vital signs
BODY
TEMPERATURE
the
balance
between
the heat
produced
by the body
and the
heat lost
from the
TEMPERATURE NORMAL
VALUES
Age
0-1
Age
16
Age
6 - 11
Age
11 16
Adult
36.1
37.4
degrees
Celcius
36.9
37.5
degrees
Celcius
36.3
37.6
degrees
Celcius
36.4
37.6
degrees
Celcius
36.4
37.4
degrees
Celcius
Age
Stress
Medications
Environment
Fever
Heat stroke
Hyperpyrexia/hyperthermia
Hypothermia
ORAL ROUTE
- thermometer is
placed under the
tongue
Nursing
Considerations:
Allow 15 minutes to
elapse between
clients intake of hot or
cold food or smoking
and the measurement
of oral temperature
AXILLARY ROUTE
- safest and most noninvasive method
Nursing
Considerations:
Pat dry the axilla. Rubbing
causes friction and will
increase temperature in
the area
Place thermometer in the
center of clients axilla
Place the arm tightly
across the chest to keep
the thermometer in place.
TYMPANIC ROUTE
- measurement of
temperature via
ears
Nursing
Considerations:
RECTAL ROUTE
most accurate measurement of
temperature
Indications:
-
RECTAL ROUTE
CONTRAINDICATIONS
Diarrhea
Patients with cardiac problems (due to stimulation
of vagal nerve that could trigger arrythmia)
Hemorrhoids
Imperforated anus
Rectal surgery
Patients with bleeding tendencies
Fecal impaction
Age related contraindications (80 years above) it
causes tissue damage to the rectum
RECTAL ROUTE
Pediat
ric
Adult
position in lateral
position upper legs
flexed, wear gloves,
and lubricate the tip
of the thermometer.
Instruct the patient
to breath slowly and
relax. Insert the
thermometer at
least 2.5 cm, do not
force thermometer if
there is resistance
-
- It is the rhythmic
expansion and
Normal Pulse Rate
Values
recoil of elastic
Age Age Age Age
artery caused by Adul
6-11 1-6
0-1
t
11the ejection of
16
60- 55- 70- 75- 80blood from the
100 110 115 130 160
ventricle. Palpated bp bp bp bp bp
where an artery
m
m
m
m
m
near the body
surface can be
pressed against
PULSE POINTS
Temporal
Carotid
Apical
Brachial
Apical
Radial
Femoral
Popliteal
Dorsalis Pedis
Pedal
Dysrythmia
- It is an irregular rhythm
- Pulse volume (amplitude) strength of
the pulse
Normal pulse ca be felt with moderate
pressure
Full or bounding pulse can be obliterated
only by great pressure
Thready pulse can easily be obliterated
(weak or feeble)
Arterial wall elasticity: the artery feels
straight, smooth, soft and pliable
Presence/absence of bilateral equality:
BRADYCARDIA TACHYCARDIA cardiac rate less than cardiac rate more than
60 beats per minute
100 beats per minute
RESPIRATION
It is the exchange of
oxygen and carbon
dioxide between
cells of the body and
the atmosphere.
A respiration
consists of
inhalation and
expansion and the
pause which follow.
The act of breathing.
BRADYPNEA
respiratory
rate less than
12 breaths
TACHYPNEA
- respiratory
rate more than
20 breaths
Normal
Values
Age
Adult 1116
Age
6-11
Age
1-6
Age
0-1
breat
hs
breat
hs
breat
hs
breat
hs
BLOOD PRESSURE
force that blood
exerts against the
wall of the blood
vessels
SYSTOLIC first
clear sound heard
when the valve of
the
sphygmomanomet
er is released
DIASTOLIC - the
point at which the
BP NORMAL VALUES
Adult
Age
11
16
-/+ 120
15
88
120
80
112
- 74
100
Systolic
-/+ 80 80 58 80 50 80 50 70 50 Diastolic
15
GLASGOW COMA
SCALE
Interpretation
Brain injury is classified as:
Severe, with GCS < 9
Moderate, GCS 912
Minor, GCS 13.
RESPONSE (M)
1 - No motor response
2 - Extension to pain
(decerebrate
response)
3 - Abnormal flexion
to pain ( decorticate
response)
4 - Flexion/Withdrawal
to pain
5 - Localizes to pain
6 - Obeys commands