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Vital Signs Body Temperature

1 Indication: • To determine the child’s temperature on admission as a base for comparing future measurements. • To monitor fluctuation in temperature. Equipment : • Cotton with alcohol & dry cotton • Container for waste • Water – soluble lubricant. • Thermometer 2 3 4 5 Comments

Oral Temperature
Method range Advantages Disadvantages Length of time Age 1. Wash hands. 2. Explain the procedure to the child or to his parents. 3. Check that the child has not just had a cold or hot drink. 4. Clean thermometer with alcohol swab 5. Check thermometer to see the reading is down below 35c. 6. Instruct the child to raise his/her tongue and put thermometer under it, , and ask him to close his lips without biting. 7. Instruct the child to close his/her mouth, hold thermometer for 5 minutes 8. Remove the thermometer and wipe it with dry cotton swabs 9. Read and record temperature. 10. Wash thermometer with soap and water and dry it. .Wash hands .11 Instructors Signature: Student Signature:

Method Range

Advantages

Disadvantages

Length of time

Age

1

Oral 36.4 – 37.4c

1. Easily accessible. 2. Replication of thermometer placement is easy. 3. Responds more quickly and regular to changes in arterial temperature than does rectal method. 4. More aesthetically pleasing.

1. Value is ready influenced by ingestion of hot or cold fluids, and oxygen therapy. 2. Requires child’s cooperation to keep mouth closed and not to bite the thermometer. 3. Contra indicated if child has oral injuries surgery or under the age of five years.

5 minutes

* More than 6 year's children.

Rectal Temperature
1 Indication: • To determine the child’s temperature on admission as a base for comparing future measurements. • To monitor fluctuation in temperature.
2

2

3

4

5

Comments

Measuring rectal temperature is generally unnecessary because of the risk of rectal perforation. Wash hands. Read and record temperature. 4. 3. Safe for children who are unable to co-operate and may bite the thermometer. 14. 12. 11. Wash hands. Hold for 3 minutes. B: 1. N. Clean the thermometer with soap and tape water. 2. 5. 13. 3. 9. Procedure should be done by rectal thermometer. Damage to rectal mucosa may occur. Grasp the infant’s ankle and placing index finger between the ankle bones. 6. Method of choice if child Disadvantages 1. Apply lubricant to thermometer.5cm. Dry it and keep in its container. 3. 8. Rectal temperature should not be used in children who having rectal surgery or receiving chemotherapy. Advantages 1. Optional response may be negative. 2. Instructors Signature: Student Signature: Method Range Rectal 37. 7. 10. Clean thermometer with alcohol swab 4. Not directly influenced by the ingestion of hot or cold fluids. Replication of 3 Length of time 3 minutes Age *New born * Infant.0 – 37.8c. Insert the thermometer bulb into the rectum 2.Equipment : • Cotton with alcohol & dry cotton • Container for waste • Water – soluble lubricant. Explain the procedure to the child and his family. Check thermometer to see the reading is down to 35c. Remove the thermometer and wipe it with dry cotton swabs. • Thermometer Method range Advantages Disadvantages Length of time Age 1. 3. 2. Clothe the child. Values may be altered by presence of stool. . 2.

5. • Thermometer Method range 4 2 3 4 5 Comments . Equipment : • Cotton with alcohol & dry cotton • Container for waste • Water – soluble lubricant. thermometer placement is difficult. Axially Temperature 1 Indication: • To determine the child’s temperature on admission as a base for comparing future measurements. • To monitor fluctuation in temperature.has seizure or breathing difficulties receiving oxygen therapy. or has oral surgery. Contra indicated when child has diarrhea and following rectal surgery.

2. Explain procedure to the child and infant’s family. 2. Age Less than 6 years children. 6. Length of time 10 minutes.8 – 36. Read and record temperature. Hold thermometer in place for 10 minutes. Avoids initiating the defecation stimulus. 10. Often recommended for infants. Wash hands. 5 . Value is more readily influenced by environmental temperature and air flow.6c Advantages 1. 11. 3. Check thermometer to see that reading is down to 35c. Clean thermometer with alcohol swab 5. 8. Wash hands. 7. 4. Dry it and keep in its container. Disadvantages 1. 3. Dry the axially area and then Place thermometer under axilla and bring arm across chest. Requires a relatively long period of time to obtain accurate reading. Safe and easily accessible. Avoids the danger of rectal or colon perforation. Clean the thermometer with soap and tape water. Remove the thermometer and wipe it with dry cotton swabs. Instructors Signature: Student Signature: Method Range Axillary 35. 9.Advantages Disadvantages Length of time Age 1. Assemble equipment. 4. 12. 2.

4. 6 . 7. Equipment: Watch with second hand. pattern of beats (rhythm. Report for any abnormalities. regularity & fullness.Pulse 1 Indication: To gather information on the heart rate. 6. Normal Heart Rate for different ages 2 3 4 5 Action Peripheral Pulse 1. Explain the procedure to the child and his family. Cotton with alcohol. 3. 5. 2. Place child in comfortable position. Wash hands. Record rate. rate and strength of pulse). Count for full minute. Stethoscope. Place the third finger along the appropriate artery and press gently.

5. Place the stethoscope between the infant’s left nipple and sternum between the 4th & 5th ribs. Listen and count for full minute. Remove stethoscope and cover the child chest. 4. Record: rate. Expose the chest over the apex of the heart. 2. Wipe the ears pieces & diaphragm with alcohol swabs and warm diaphragm. 6. Instructors Signature: Student Signature: Age Newborn 1–5 months 6–12 months 1–3 years 3–5 years 6–10 years 11–14 years 14+ years Normal heart rate (beats per minute) 100-160 90-150 80-140 80-130 80-120 70-110 60-105 60-100 1 2 3 4 5 Comments Instructors Signature: Student Signature: 7 . 7.Apical Pulse 1. 8. 3. Report any abnormal observation. fullness and regularity. Wipe earpieces and diaphragm with alcohol swabs.

Record rate. 2. Observe respiratory movement. Procedure 1. pattern and sound. and depth. Normal respiratory rate (breaths per minute) 30-50 25-40 20-30 20-30 20-30 1 1 2 3 4 5 Comments Age Newborn 1–5 months 6–12 months 1–3 years 3–5 years 2 3 4 5 Comments 8 . strength). pattern and sound. 4. Report for any abnormality.Respiration Action Indication: To determine respiratory rate and assess respiratory characteristics (rate. rhythm. Remove over cover to observe chest movement. To evaluate the child response to medication or treatments. Normal respiratory rate Equipment: Watch with second hand. 5. 3. rate. depth. Count the rate for one minute.

5. 8. Palpate brachial or radial artery with fingertips of one hand while inflating cuff rapidly to pressure 20mm Hg. Assemble the equipment. Explain the procedure to the child or to his mother. Formula of approximate average diastolic pressure in relation to child’s age. 9 2 3 4 5 Comments . Wash hands. 6. warp cuff evenly around upper arm. 2. 9. Be sure that manometer positioned vertically at the eye level observer (should be no further than 1 ml. not muffled. 3. Above point at which pulse disappears. Place stethoscope ear pieces in ears and be sure sounds are clear. Review child's previous blood pressure reading 4. 11.6–10 years 11–14 years 14+ years Instructors Signature: 15-30 12-20 12-20 Student Signature: Blood Pressure 1 Equipment: . Sites for measuring blood pressure Action 1.) 10. With cuff fully dilated. Slowly deflate the cuff.Measuring cuff and Stethoscope. Expose the site of measurement fully by removing clothes. Position the limb at the level of the heart. 7. nothing when the pulse is first heard (systolic pressure) and when the sound becomes muffled or disappears (diastolic pressure). -Alcohol swab Formulas of approximate average systolic pressure in relation to child’s age.

Remove equipment. Instructors Signature: Student Signature: 10 . 13. Hand wash. Record your observation. 14.12.

Thigh D.Sites for measuring blood pressure: A. Calf or ankle. Child’s Age 1 to 7 years 8 to 18 years Formula Age in years + 90 (2 X Age in years) + 83 • Formula of approximate average diastolic pressure in relation to child’s age. Upper arm B. • Formulas of approximate average systolic pressure in relation to child’s age. Child’s Age 1 to 5 years 6 to 18 years Formula 56 mmHg Age in years + 52 Sponge Bath 1 Purposes: 11 2 3 4 5 Comments . Lower arm C.

To give chance for play and talk with child. Take -off child’s clothes 14. hand wash 2. Clean diaper area. 5.5-40c according to the age and season. 12. Explain procedure to the mother 2. 8. Cord Care 1. then dry well in one direction. To Observe child’s body. 3. Dress the child clean clothes 18. 9. 3. 6. Wipe the scalp & dry it.1. Clean the lower extremities from bottom to top then dry well. check water temperature by thermometer or by elbow joint. (Change the water as needed). wipe around mouth and nose then go over her cheeks and forehead. abdomen. 4. Wipe each eye with moist sponge from the inner to the outer aspect then dry gently each one. Clean each ear over and behind only (not inside) 11. Wipe under axially from front to back and dry well. Clean the baby face. Provide safe environment (Free from drafts). 16. 13. Clean the chest. Close the doors and windows 4. To clean the skin and comfort the child. Clean hands from fingers then hands and dry well total. To increase circulation and metabolism. Wipe the neck thoroughly pays attention to creases. 2. Precede bathing from top to bottom. & back. 15. dry with sponge. position infant supine 12 . Assemble the equipment at the child bedside. 10. Wash hands. Equipment: • Bowl for warm water • Wash cloth or cotton (sponges) at least four wash cloth • Soft hair Brush • Bath towel • Baby clothes • Plastic bag • Mackintosh • Clear water • Baby lotion • Nail scissors • Cotton with alcohol Actions 1. Fill the bowl two-thirds full of water 36. 5. 17. To provide an opportunity to note child’s growth and development. 7. 19.

4. To satisfy the need for cleanliness. Dress the child clean clothes. 8. 3. 6. Clean area at base in circular motion with alcohol wipe or cotton ball. 10. Wipe the top of the cord with cotton with alcohol wipe or cotton ball. 5. 2. Squeeze cotton with alcohol over the tip of the cord. To relax the child’s muscles before physical 13 2 3 4 5 Comments . For therapeutic purpose as in burned child. Inspect the cord closely during the first 24 hours and then daily for any abnormalities. Record. 5.3. Wash hands. 4. Collect equipment’s and clean the surrounding environment. To help the new mother at home bath her newborn infant. 7. Instructors Signature: Student Signature: Table Tub Bath 1 Purpose: 1. 9. To inspect infant body.

6.Child’s cloth. and then dry it with clean dry cotton in one direction. using appropriate hold. 14. between toes. 6. 4. 3. Again lift the infant from the tub back to the towel and dry well.Baby tub . cheeks and mouth (clean inside the mouth if needed and nose with a moist cotton). Quickly soap the infant’s entire body except the head using another wash cloth paying special attention to body creases. starting from the far eye.Gauze swabs . Equipments: .8)-(40. Wipe the infant’s face.Mild soap . rinse thoroughly and if possible the ears should be covered with the nurse’s fingers. 13. 11. 2. To help remove dressings or crusts or to apply a certain soothing medication to the skin. . Inspect the ears if any discharge present cleans it with the corner of washcloth.Pitcher . Place the infant on the table and dry the head with a part of the folded bath towel. – Toy .Bath towel . 17. Remove the infant’s clothes. Water only. Soap the scalp. Wash hands Place the infant still dressed on the bath towel Wash the infant eye. 12.therapy. area under the chin and genitalia (revise the diaper care) Rinse the soap off the infant quickly.Soft hair brush or comb . 7.Wash cloth 2-3 . 18. feet first. support the infant using the football hold (the baby is supported under the nurse’s arm and no her hip) first lather your hand with soap then apply it to the scalp The infant’s head should be held over the wash basin. Fill the baby tub half to two third full of warm water (37. 16. Assemble equipment. 8.Baby Oil Actions 1. 5. Check room temperature and free from drafts (close windows and doors).Mackintosh.6c) if there is no water thermometer check it with your wrist. 14 9. . Explain the procedure to the child’s mother. Lift the baby carefully and gradually into the tub. 15. 10. Spread the bath towel on the bed or table. wipe the eye with moist cotton with water only from inner to outer aspect.Cotton Container . forehead.

• Oil or ointment. playing. comb his/her hair gently. Dress the infant. It may be inhaled leading to respiratory distress Instructors Signature: Student Signature: Diaper Care 1 Purpose: 1. Clean all used equipment and return to its place. Maintain the baby more comfortable by keeping him dry. Record time and observations. • Warm water. 5. 2. 3. Maintain healthy skin at diaper area.19. and talking with the infant to enjoy bathing. 4. Wash hands. • Plastic bag. • Apply lotion or oil to body creases avoids using of talcum powder. Observe any abnormal changes in the skin of the diaper area. 15 2 3 4 5 Comments . 22.(ascending infection) Equipment: • Kidney basin. 21. 20. NB: • Allow time for kicking. Protection against urinary tract infection. which retain body secretions and irritate the skin. • Talcum powder with oil makes a past. • Cotton/sponges or clean wash cloth. Inspect the infant’s body during the procedure.

Wipe away feces with wash cloth then using a moist baby clean wash cloth. For a male: a. clean thoroughly in the creases at the tops of baby's legs and at the base of genitals wiping away from the body. keeping a finger between ankles wipe over the backs of thighs too then remove the diaper . Instructors Signature: Student Signature: 16 . Apply a barrier of cream or zinc oxide ointment. clean all over her stomach up to her umbilical stump. 7. 6. wiping away from the body. 13. Clean his penis. Fold diaper so that it does not cover the cord stump.• Disposable diaper or cloth diaper. Lift the baby’s legs to clean anus and buttocks. place front part of diaper next to baby’s skin bring back of diaper over front tuck it. 10. Lift her legs up with a finger between her ankles and wipe the vulva from front to back. 3 Wash hands with soap and water. Wash hands. Discard the old diaper. With clean wash cloth. Pause for a couple of seconds with the diaper held over his penis. 4. For uncircumcised boy pull the fore-skin back gently clean it then replace the retracted skin to prevent paraphimosis (edema of the glands). leave the area clean and tidy. repeat if baby still unclean 8. Explain to the parents the procedure in the purpose of teaching them. Dry baby's bottom with a clean wash cloth 9. 5. 14. b. Put the baby on a mat or changing table. Action 1. 2. being careful to place your finger between the baby and the diaper. . b. Prepare all the needed equipment. collect your equipment’s. 11. For a female : a. Place the new clean diaper under the infant’s buttocks and sides in between his legs. Bring diaper up over abdomen. Wipe off the feces with the corner of the unclean diaper and fold the diaper down under the baby’s legs. 12.then clean scrotum change cloth as needed.

Action Prepare the needed equipment. (if it stored in the refrigerator). Equipment: • For a fully bottle-fed baby you will need at least eight full-size (250 ml) bottle with suitable nipples. 2. . Principles of Bottle Feeding: 1. 17 2 3 4 5 Comments 1. Persons who prepare the formula must wash hands well. • Measuring cup for mixing powder formula. 3. The formula is prepared and bottled immediately before each feeding. • Plastic knife for leveling off scope of powder formula.Bottle Feeding 1 Indication: Extra indications to breast-feeding exist. • Bottlebrush needed to clean thoroughly inside the bottle. • Plastic spoon stirring formula. Warming the formula is optional. • Plastic funnel useful for pouring formula.

If the baby doesn’t want to let go of the empty bottle. 8. Instructors Signature: Student Signature: 18 . Hand washing by soap and running water. a. Place the baby in sitting position put a towel beneath the chin support the chest and head with one hand gently rub the back with the other hand. 14. don’t hurry the baby or force the infant to feed too much. Record the amount type of formula and baby reactions. if a baby cannot be removed from the crib. 13. Provide mouth care after feeding.2. 17. Burp the baby halfway through the feeding and at the end by one of the following methods: Place a small towel over your shoulder to protect your gown. 15. place the baby firmly against your shoulder and pat the back. Hold the bottle so that the nipple and neck of the bottle are full of formula. 3. b. 9. During feeding. 11. and elevate his /her head. 12. Prepare formula as prescribed. Let a few drops of formula fall in the inner aspect of your wrist to Test formula for temperature Hold the baby unless contraindicated in a semi up right position. 4. hold the bottle firmly so that the baby can pull against it as he/she sucks. The feeding should take 15 to 20 minutes. Stroke the nearest cheek of the baby. 7. slide the little finger between the baby gums and nipple to release the sucking. Put cotton under the baby’s chin. 16. 10. Do not contaminate the nipple a much as possible. or let some drops of formula touches the baby’s lips. sit the baby. Check amount of formula on straight surface. 5. 6. Place the baby on the abdomen or on right side position at least one hour. shoulders.

. usual size for premature 5 French and 8 French for other children). 5.Gavages Feeding 1 Purposes: 1. Measuring from the nose to the ear lobe and then to point midway between the xiphoid process and the umbilicus 3. Carry out diagnostic procedures. medications that cannot be given by mouth. Non allergic tape. 2. 3. Action Prepare the needed equipment. Use on age suitable restraining 19 2 3 4 5 Comments 1. 2. 9. A sterile suitable tube selected according to the size of the child and the viscosity of the solution (e.g. Container for the fluids. Gloves. 3. 7. The solution of feeding. 3. Hand wash by soap under running water. 2. 10. A stethoscope. 8. A pacifier. Measurements: 1. Explain the procedure to the parent and the child if he can understand. 6. Restraining equipment. The same measure from the mouth to insert oral tube. Conserve energy of infant. Equipments: 1. Introduce fluids. Sterile water for lubrication. 4. alternatively you may also measure from the bottom 2. In case of prematurity or illness or congenital deformity or at risk of aspiration. 5ml – 10ml syringes. Measuring from the tip of the nose to the tip of the earlobe and then to the end of xiphoid process.

9. 23. b. Mark the point with a small piece of tape. Slide the tube backward and inwards gently along the floor of the nose until predetermined mark. 8. Check the formula temperature to be as the room temperature. 25. 10. 12. Just before the syringe is empty. The rate of flow 5-10ml/min in premature. Connect the syringe barrel into the tube. 18.5-1m in premature to 5m older children into the tube while listening with a stethoscope over the stomach area and then withdraw air. Instructors Signature: Student Signature: 20 . 7. 19. Pour formula into the barrel of the syringe attached to the tube. 14 15. To start flow. and 10ml/min in older infants and children. If the tube is to be removed pinch it firmly and withdraw the tube quickly. Check the position of the tube by using at least two methods (Clamp indwelling tube before using any method): Attach the syringe to the feeding tube and apply negative pressure aspiration of stomach content indicate proper placement (Notify physician if a gastric residue is greater than 25% of the pervious feeding) by the syringe inject a small amount of air 0. Lubricate the tube by sterile water. Clamp indwelling tube & remove the syringe. the water during breathing if bubbling occur withdraw and reinsert. Position the baby on right side or abdomen at least one hour. 20. a. Remove equipment. 22. 13. 17. give gentle push with the plunger and allow the fluid to flow into the stomach by gravity. Provide mouth care with gauze and normal saline. Flush the tube with sterile water or G5% 1-2cm. 21. A pacifier is used or place the infant’s finger in his mouth Insert the rounded end of the tube into clearest nostril. c. 11. 6. type of formula and amount of gastric residue. 5. Check that the nostrils are patent. If the tube is fixed.4. Raise the syringe barrel 20-25cm from the bed. pinch the tube by fingers. Place the child supine with head slightly hyperflexed Measure the tube for approximate length of insertion. 16. stabilize the tube by holding or taping it to the cheek by adhesive tape. Record the amount. Emerge the end of the tube into a container containing clean water. leave area clean and tidy. 24.

Dressing or piece of cotton . Prepare the needed equipment 4. Measure residual stomach contents 7. Attach syringe and aspirate stomach contents. Wash your hands.Gastrostomy Feeding 1 Providing nourishment and fluids via a tube that is surgically induced through an incision made through the abdominal wall into the stomach for those requiring tube feedings for an extended period of time. either flat or with head slightly elevated 9. . 5. Apply clamp before water level reaches end of reservoir 14. Residual fluid may be returned to stomach or discarded. A pacified can be given. Elevate tube and syringe to 10–12 cm above abdominal wall Do not apply any pressure to start flow 12. Instill clear water 1-30o of clear water. b.Gauze for mouth care .Feeding formula . 13. Attach reservoir syringe to tube and fill syringe with feeding fluid to unclamping tube. . 11. Feed slowly taking 20-45 min fill reservoir with fluid before it is empty to avoid instillation of air. depending on amount. 6. Explain to the child or to the family the feeding procedure 2.Reservoir syringe or funnel .Tape Action 1.Syringe for aspirating. Check residual stomach contents before feeding. When feeding is completed: a. Place the child on comfortable position. 10. 3. 21 2 3 4 5 Comments . Place the child in comfortable position. 8. Equipment .Pacifier.

Instructors Signature: Student Signature: 22 . route of feeding and any changes or abnormality and report to the doctor.15. Record the feeding time formula content. Wash your hands 17. Mouth Care 16.