7. Sites (P&P p. 216) 2-3 seconds Rapid measurement Easy assessibility Cerumen impaction distorts reading Otitis media can distort reading Ear Close to hypothalmus – sensitive to core temp. changes Adult - Pull pinna up & back Child – pull pinna down & back Leave in place 2-3 min. Measures 0.5 C higher than oral When unsafe or inaccurate by mouth (unconscious, disoriented or irrational) Side lying position – leg flexed Rectal Side lying with upper leg flexed, insert lubricated bulb (1-11/2 inch adult) (1/2 inch infant) Leave in place 5-10 min. Measures 0.5 C lower than oral temp. Non invasive – good for children. Less accurate (no major bld vessels nearby) Axillary Bulb in center of axilla Lower arm position across chest Leave in place 3 min No hot or cold drinks or smoking 20 min prior to temp. Must be awake & alert. Not for small children (bite down) Oral Posterior sublingual pocket – under tongue (close to carotid artery)
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11. Normal Heart Rate Heart Rate (Beats/min) Age 60-100 Adult 60-90 Adolescent 75-100 School agers 80-110 Preschoolers 90-140 Toddlers 120-160 Infants
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14. Assessing Respiration Digressions from normal effortless breathing Dyspnea – difficult or labored breathing Cheyne-Stokes – alternating periods of apnea and hyperventilation, gradual increase & decrease in rate & depth of resp. with period of apnea at the end of each cycle. Character Regularity of inhalation/exhalation Normal (very little variation in length of pauses b/w I&E Rhythm Amt. of air inhaled/exhaled normal (deep & even movements of chest) shallow (rise & fall of chest is minimal) SOB shortness of breath (shallow & rapid) Depth # of breathing cycles/minute (inhale/exhale-1cycle) N – 12-20 breaths/min – adult - Eupnea – normal rate & depth breathing Abnormal increase – tachypnea Abnormal decrease – bradypnea Absence of breathing – apnea Rate
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18. Procedure – B/P Palpate brachial pulse Position cuff 1inch above pulse - Arm at level of heart, wrap snugly around arm Manometer at eye level Implementation Expected outcome Have pt rest 5 min before taking B/Pa Wash hands Planning Decreased cardiac output Fluid volume excess Fluid volume deficit Nursing Diagnosis Determine best site & baseline B/P Assessment
19. Procedure (cont.) Inflate cuff while palpating brachial Artery. Note reading at which pulse disappears continue to Inflate cuff 30 mmHg above this point. Deflate cuff slowly and note when reading when pulse is felt. Deflate cuff completely and wait 30 sec. With stethoscope in ears locate the brachial artery – place diaphragm over site Close valve of pressure bulb. Inflate cuff 30 mm hg above palpated systolic pressure Slowly release valve Note point on manometer when first clear sound is heard (1 st phase Korotkoff) – systolic pressure Continue to deflate noting point @ which sound disappears – 5 th phase Korotkoff (4 th korotkoff in children Deflate & remove cuff Implementation
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22. Procedure – Vital Signs Explains procedure to client Temperature tympanic - thermometer Pulse - Position client’s arm @ side or across chest, palpate radial artery Resp – Keeps fingers on wrist – count respirations Documents TPR on graphic sheet B/P – correct position, client’s arm supported @ heart level Document Implementation Obtain equipment – thermometer, watch, stethosope, B/P cuff & graphic sheet Wash hands Planning Route of temperature – po, tympanic, axilla, rectal Determines if client has had anything hot/cold to drink or smoked (20 min) Assessment
23. Vital Signs (cont.) You are assessing a client’s pulse and the rate is irregular. How would you proceed? Critical Thinking V/S within normal range Evaluation
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