Midterm| Nursing Skills: Vital Signs Respiration: 15-25 - Body temperature is the difference

Blood Pressure: 95/75 between the

Times to Assess Vital Signs amount of heat produced by the body and
1. Upon admission 10yr the
2. Change in health status of the client Temperature: 37oC amount of heat lost to the environment,
3. Before and after surgery or an invasive Pulse: 75-110 measured
procedure Respiration: 15-25 in degrees. There are individual variations of
4. Before and/or after the administration of a Blood Pressure: 102/62 these
medication temperatures as well as normal changes
5. Before and after any nursing intervention Teens during
that could Temperature: 37oC the day, with core body temperatures being
affect the vital signs Pulse: 60-100 lowest
Respiration: 15-20 in the early morning and highest in the late
Age-Related Variation in Vital Signs Blood Pressure: afternoon (Porth & Matfin, 2009).

Newborn Adults Core Body vs Surface Body Temperature

Temperature: 36.8oC [Axillary] Temperature: 37oC CORE BODY TEMPERATURE
Pulse: 80-180 Pulse: 60-100 Measured in:
Respiration: 30-60 Respiration: 15-20 - Tympanic
Blood Pressure: 73/55 Blood Pressure: 120/80 - Rectal
[Esophagus, Pulmonary Artery, Bladder]
1-3yr >70yr
Temperature: 37.7oC [Rectal] Temperature: 36oC SURFACE BODY TEMPERATURE
Pulse: 80-140 Pulse: 60-100 Measured in:
Respiration: 20-40 Respiration: 15-20 - Oral
Blood Pressure: 90/55 Blood Pressure: 120/80 - Axillary
- Skin Surface
6-8yr Assessing Body Temperature
Temperature: 37oC Body Temperature Regulation of Body Temperature
Pulse: 75-120 - Shivering increases heat
production. - Dispersion of heat by air currents 5. Ensure the electronic or digital
2. Sweating is inhibited to - transfer of heat from the body to moving thermometer is in working condition.
decrease heat loss. liquid or air 6. Put on gloves, if appropriate or indicated.
3. Vasoconstriction decreases 7. Select the appropriate site based on
heat loss. EVAPORATION previous assessment data.
- Continuous vaporization of moisture from 8. Follow the steps as outlined below for the
Factors Affecting Body Temperature the respiratory tract and from the mucosa of appropriate type of thermometer.
- Basal Metabolic Rate (BMR) the mouth and from the skin 9. When measurement is completed, remove
2. Muscle Activity - sweat is vaporized at the skin surface gloves, if worn. Remove additional PPE, if
3. Thyroxin output used. Perform hand hygiene
4. Epinephrine and sympathetic stimulation Procedure in Taking Body Temperature
5. Age - Oral Measuring a Tympanic Membrane
6. Gender - Axillary Temperature
7. Diurnal variation - Rectal 10. If necessary, push the “on” button and
8. Exercise - Tympanic wait for the “ready” signal on the unit
11. Slide disposable cover onto the tympanic
Heat Loss Assessing the Body Temperature probe.
RADIATION 1. Check medical order or nursing care plan 12. Insert the probe snugly into the external
- Transfer of heat from the surface of one for frequency of measurement and route. ear using gentle but firm pressure, angling
object to the surface of another without More frequent temperature measurement the thermometer toward the patient’s jaw
contact between the two objects may be appropriate based on nursing line . Pull pinna up and back to straighten
- transfer of heat via electromagnetic waves judgment. Bring necessary equipment to the the ear canal in an adult.
bedside stand or over bed table. 13. Activate the unit by pushing the trigger
CONDUCTION 2. Perform hand hygiene and put on PPE, if button. The reading is immediate (usually
- Transfer of heat from one molecule to a indicated. within 2 seconds). Note the reading.
molecule of lower temperature 3. Identify the patient. 14. Discard the probe cover in an
- transfer of heat from the body to a cooler 4. Close curtains around bed and close the appropriate receptacle by pushing the probe-
surface by direct contact door to the room, if possible. Discuss the release button or use rim of cover to remove
procedure with patient and assess the from probe . Replace the thermometer in its
CONVECTION patient’s ability to assist with the procedure. charger, if necessary.
 17. Assist the patient to a side-lying position. 27. Return the thermometer to the charging
Assessing Oral Temperature Pull back the covers sufficiently to expose unit.
10. Remove the electronic unit from the only the buttocks.
charging unit, and remove the probe from 18. Remove the rectal probe from within the Assessing Axillary Temperature
within the recording unit. recording unit of the electronic 28. Move the patient’s clothing to expose
11. Cover thermometer probe with thermometer. Cover the probe with a only the axilla.
disposable probe cover and slide it on until it disposable probe cover and slide it into place 29. Remove the probe from the recording
snaps into place. until it snaps in place. unit of the electronic thermometer. Place a
12. Place the probe beneath the patient’s 19. Lubricate about 1 inch of the probe with disposable probe cover on by sliding it on
tongue in the posterior sublingual pocket. a water-soluble Lubricant. and snapping it securely.
Ask the patient to close his or her lips around 20. Reassure the patient. Separate the 30. Place the end of the probe in the center
the probe. buttocks until the anal sphincter is clearly of the axilla . Have the patient bring the arm
13. Continue to hold the probe until you hear visible. down and close to the body
a beep. Note the temperature reading. 21. Insert the thermometer probe into the 31. Hold the probe in place until you hear a
14. Remove the probe from the patient’s anus about 1.5 inches in an adult or 1 inch in beep, and then carefully remove the probe.
mouth. Dispose of the probe cover by a child Note the temperature reading.
holding the probe over an appropriate 22. Hold the probe in place until you hear a 32. Cover the patient and help him or her to
receptacle and pressing the probe release beep, then carefully remove the probe. Note a position of comfort.
button. the temperature reading on the display. 33. Dispose of the probe cover by holding
15. Return the thermometer probe to the 23. Dispose of the probe cover by holding the probe over an appropriate waste
storage place within the unit. Return the the probe over an appropriate waste receptacle and pushing the release button.
electronic unit to the charging unit, if receptacle and pressing the release button. 34. Place the bed in the lowest position and
appropriate. 24. Using toilet tissue, wipe the anus of any elevate rails, as needed. Leave the patient
feces or excess lubricant. Dispose of the clean and comfortable.
Assessing Rectal Temperature toilet tissue. Remove gloves and discard 35. Return the electronic thermometer to the
16. Adjust the bed to a comfortable working them charging unit.
height, usually elbow height of the care 25. Cover the patient and help him or her to
giver. Put on non sterile gloves. a position of comfort. Assessing Temporal Artery Temperature
26. Place the bed in the lowest position; 36. Brush the patient’s hair aside if it is
elevate rails as needed. covering the temporal artery area.
37. Apply a probe cover. Alterations in Body Temperature 2. COURSE (PLATEAU PHASE)
38. Hold the thermometer like a remote Pyrexia: A body temperature above the usual 3. DEFERVESCENCE (FEVER
control device, with your thumb on the red range is called pyrexia, hyperthermia, or ( in ABATEMENT/FLUSH PHASE)
‘ON’ button. Place the probe flush on the lay terms) fever. A very high temperature,
center of the forehead, with the body of the e.g. 41Cº (105 ºF) is called hyperpyrexia. Nursing Interventions for clients with fever
instrument sideways (not straight up and - Monitor vital signs.
down), so it is not in the patient’s face. Common Types of Fever • Assess skin color and temperature.
39. Depress the ON button. Keep the button Intermittent Fever • Monitor white blood cell count, hematocrit
depressed throughout the measurement. - During this type of fever, the body value, and other pertinent laboratory
40. Slowly slide the probe straight across the temperature alternates at regular intervals reports for indications of infection or
forehead, midline, to the hair line. The between periods of fever and periods of dehydration.
thermometer will click; fast clicking indicates normal temperatures. • Remove excess blankets when the client
a rise to a higher temperature, slow clicking feels warm but provide extra warmth
indicates the instrument is still scanning, but Remittent Fever when the client feels chilled.
not finding any higher temperature. - During this type of fever, a wide range of • Provide adequate nutrition and fluids (e.g.,
41. Brush hair aside if it is covering the ear, temperature fluctuations occurs over the 2 2,500–3,000 mL/day) to meet the
exposing the area of the neck under the ear hour period, all of which are above normal. increased metabolic demands and prevent
lobe. Lift the probe from the forehead and dehydration.
touch on the neck just behind the ear lobe, Relapsing Fever • Measure intake and output.
in the depression just below the mastoid - In a relapsing fever, short febrile periods of • Reduce physical activity to limit heat
42. Release the button and read the a few days are interspersed with periods of 1 production, especially during the flush stage.
thermometer measurement. or 2 days of normal temperature. • Administer antipyretics (drugs that reduce
43. Hold the thermometer over a waste the level of fever) as ordered.
receptacle. Gently push the probe cover with Constant Fever • Provide oral hygiene to keep the mucous
your thumb against the proximal edge to - During a constant fever, the body membranes moist.
dispose of probe cover. temperature fluctuates minimally but always • Provide a tepid sponge bath to increase
44. Instrument will automatically turn off in remains elevated. heat loss through conduction.
30 seconds, or press and release the power • Provide dry clothing and bed linens.
button. Clinical Manifestations of FEVER
- ONSET (COLD OR CHILL PHASE) Alterations in Thermoregulation
Heat exhaustion visual disturbances. Loss of consciousness
Definitions: An increase in body temperature occurs if Nursing Interventions for clients with
in response to environmentalconditions that, untreated. hypothermia
in turn, causes diaphoresis (profuse - Provide a warm environment.
perspiration) Act Fast • Provide dry clothing.
Characteristics:Loss of excessive amounts of - Call 911 • Apply warm blankets.
water and sodium from perspiring leads to - Move person to a cooler area • Keep limbs close to body.
thirst, nausea, vomiting, weakness, and - loosen clothing and remove extra layers • Cover the client’s scalp with a cap or
disorientation. - cool with water or ice turban.
• Supply warm oral or intravenous fluids.
Act Fast - confusion, dizziness, becomes unconscious • Apply warming pads
- Move to a cooler area - heat stroke can cause death or
- loosen clothing permanently disability if emergency Sites for Assessing Temperature
- Sip cool water treatment is not given - Orally (Common Way) - 37 C° (3–5 min)
- seek medical help if symptoms don’t Alterations in Thermoregulation 2. Axillary (Safe Way)- 36 C° + 0.5 C° (10
improve Hypothermia min)
- A body temperature of 35C or lower 3. Rectal (Accurate Reading)- 37 C° – 0.5 C°
- Dizziness, Thirst, Heavy sweating, Nausea, resulting from cold weather exposure or (2 – 3 min)
weakness artificial induction 4. Tympanic Membrane (Quick and Minimally
- Heat exhaustion can lead to heat stroke - Decrease in metabolism leads to impaired Invasive)- (<1 min)
mental functioning and depressed pulse,
Heat stroke respiration, and blood pressure; can result in Advantages and Disadvantages of Sites Used
Definitions: A critical increase in body cardiac arrest if untreated. for Body Temperature Measurements
Temperature resulting from exposure to high Oral
environmental temperature. Frostbite - Accessible and convenient
Characteristics: Dry, hot skin is the most - Freezing of the body’s surface areas - Thermometers can break if bitten
important sign. The person becomes (earlobes, fingers, and toes) in extremely low - Inaccurate if client has just ingested hot or
confused or delirious and experiences thirst, temperatures. cold food or fluid or smoked
abdominal distress, muscle cramps, and - Circulatory impairment may be followed by - Could injure the mouth following oral
gangrene. surgery
 - Requires electronic equipment that may be - carotid artery
Rectal expensive or unavailable. Variation in - brachial artery
- Reliable measurement technique needed if the client has - radial artery
- Inconvenient and more unpleasant for perspiration on the forehead - femoral artery
clients; difficult for client who cannot turn to - popliteal artery
the side Assessing the Pulse [Peripheral and Apical] - posterior tibial artery
- Could injure the rectum Pulse - dorsalis pedis artery
- Presence of stool may interfere with - Pulse is a wave of blood created by
thermometer placement contraction of the left ventricle of the heart. Characteristics of Pulse
The heart is a pulsate pump and the blood Quality
Axillary enters the arteries with each heartbeat, - Pulse quality refers to the ‘‘feel’’ of the
- Safe and noninvasive causing pulse waves. Pulse assessment is pulse, its rhythm and forcefulness
- The thermometer may need to be left in the measurement of a pressure pulsation
place a long time to obtain an accurate created when the heart contracts and ejects Rate
measurement blood into the aorta. - Pulse rate is an indirect measurement of
cardiac output obtained by counting the
Tympanic Membrane Factors affecting the Pulse number of apical or peripheral pulse waves
- Readily accessible; reflects the core - Age over a pulse point.
temperature; very fast 2. Sex - Normal pulse rate for adults: 60 to 100 BPM
- Can be uncomfortable and involves risk of 3. Exercise • Bradycardia: <60 BPM
injuring the membrane if the probe is 4. Fever • Tachycardia: >100 BPM
inserted too far 5. Medications Rhythm
• Repeated measurements may vary. Right 6. Hypovolemia/Dehydration - Pulse rhythm is the regularity of the
and left measurement can differ. 7. Stress heartbeat. It
• Presence of cerumen can affect the 8. Position describes how evenly the heart is beating
reading 9. Pathology - Regular: evenly spaced beats
• Irregular: not evenly spaced beats
Temporal Artery Pulse Point Assessment • Dysrhythmia/Arrhythmia: irregular r
- Safe and noninvasive; very fast - Temporal artery rhythm caused by an early, late, or missed
- facial artery heartbeat
 6. Select the appropriate peripheral site 2. Perform hand hygiene and put on PPE, if
Volume based on assessment data. indicated.
- Pulse volume is a measurement of the 7. Move the patient’s clothing to expose only 3. Identify the patient.
strength or amplitude of force exerted by the the site chosen. 4. Close curtains around bed and close the
ejected blood against the arterial wall with 8. Place your first, second, and third fingers door to the room, if possible. Discuss
each contraction. over the artery. Lightly compress the artery procedure with patient and assess patient’s
- Normal: Full, easily palpable so pulsations can be felt and counted. ability to assist with the procedure.
• Weak: thready, usually rapid 9. Using a watch with a second hand, count 5. Put on gloves, as appropriate.
• Strong: bounding the number of pulsations felt for 30 seconds. 6. Use alcohol swab to clean the diaphragm
Multiply this number by 2 to calculate the of the stethoscope. Use
Pulse Volume Scale rate for 1 minute. If the rate, rhythm, or another swab to clean the earpieces, if
0 - absent pulse amplitude of the pulse is abnormal in any necessary.
1 - weak and threeady pulse way, palpate and count the pulse for 1 7. Assist patient to a sitting or reclining
2 - normal pulse minute. position and expose chest area.
3 - bounding pulse 10. Note the rhythm and amplitude of the 8. Move the patient’s clothing to expose only
pulse. the apical site.
Procedure in Assessing the Pulse 11. When measurement is completed, 9. Hold the stethoscope diaphragm against
Assessing peripheral pulse through palpation remove gloves, if worn. Cover the patient the palm of your hand for a few seconds.
1. Check medical order or nursing care plan and help him or her to a position of comfort. 10. Palpate the space between the fifth and
for frequency of pulse assessment. More 12. Remove additional PPE, if used. Perform sixth ribs (fifth intercostal space), and move
frequent pulse measurement may be hand hygiene to the left mid-clavicular line. Place the
appropriate based on nursing judgment. diaphragm over the apex of the heart
2. Perform hand hygiene and put on PPE, if Assessing apical pulse through auscultation 11. Listen for heart sounds (“lub-dub”). Each
indicated. - Check medical order or nursing care plan “lub-dub” counts as one beat.
3. Identify the patient. for frequency of pulse assessment. More 12. Using a watch with a second hand, count
4. Close curtains around bed and close the frequent pulse measurement may be the heartbeat for 1 minute.
door to the room, if possible. Discuss the appropriate based on nursing judgment. 13. When measurement is completed,
procedure with patient and assess the Identify the need to obtain an apical pulse remove gloves, if worn.Cover the patient and
patient’s ability to assist with the procedure. measurement. help him or her to a position of comfort.
5. Put on gloves, as appropriate
14. Clean the diaphragm of the stethoscope - by assessing the degree of excursion or respirations, from very deep to very shallow
with an alcohol swab. movement in the chest wall; shallow, deep breathing and temporary apnea
15. Remove additional PPE, if used. Perform or normal.
hand hygiene. Ease or Effort
Rate • Dyspnea: difficult and labored breathing
Assessing Respiration - during
Respiration which the individual has a persistent,
- Pulmonary ventilation (breathing ): Rhythm unsatisfied
movement of air in and out of the lungs. - observes a full inspiration & expiration need for air and feels distressed
- Inhalation / Inspiration when counting • Orthopnea: ability to breathe only in
- Exhalation / Expiration upright
Characteristics of Normal and Abnormal sitting or standing positions
Factors Affecting Respirations Breathing Patterns
- Pain, anxiety, exercise . Rate Audible without amplification
2. Medications . • Eupnea: Easy, normal (age-specific) • Stridor: a shrill, harsh sound heard during
3. Trauma . breaths per inspiration with laryngeal obstruction
4. Infection. minute • Stertor: snoring or sonorous respiration,
5. Respiratory and cardiovascular disease . • Bradypnea: RR <10 CPM usually due to a partial obstruction of the
6. Alteration in fluids, electrolytes, acid- base • Tachypnea: RR >24 CPM upper airway
balances. • Apnea: Cessation of breathing • Wheeze: continuous, high-pitched musical
• Hypoventilation: Shallow squeak or whistling sound occurring on
Assessing Respiration • Hyperventilation: Deep, rapid respirations. expiration and sometimes on inspiration
- Inspection when air moves through a narrowed or
- Listening with stethoscope Volume partially obstructed airway
- Monitoring arterial blood gas • Hypoventilation: Shallow • Bubbling: gurgling sounds heard as air
Using a pulse • Hyperventilation: Deep, rapid respirations. passes through moist secretions in the
respiratory tract
NORMAL RANGE:12-20 CPM Rhythm
Depth • Cheyne-Stokes: rhythmic waxing and Characteristics of Chest Movements
waning of
- Intercostal retraction: indrawing between Cheyne-Stokes 5. Note the depth and rhythm of the
the ribs - Gradual increases and decreases in respirations.
• Substernal retraction: indrawing beneath respiration with period of apnoea 6. When measurement is completed, remove
the breastbone gloves, if worn. Cover the patient and help
• Suprasternal retraction: indrawing above Biot’s him or her to a position of comfort.
the clavicles - Abnormal breathing pattern with 7. Remove additional PPE, if used. Perform
groups/clusters of rapid respiration of equal hand
Characteristics of Secretions and Coughing depth and regular apnoea periods hygiene.
- Hemoptysis: the presence of blood in the
sputum Kussmaul’s Assessing Blood Pressure
• Productive cough: a cough accompanied - tachypnoea and hyperpnoea Brachial Artery Blood
by expectorated secretions - Blood pressure refers to the force of the
• Nonproductive cough: a dry, harsh cough Apneustic blood against arterial walls.. When the heart
without secretions - Prolonged inspiration phase with a rests between beats during diastole, the
prolonged expiratory phase pressure drops. The lowest pressure present
Eupnoea on arterial walls during diastole is the
- normal breathing rate and pattern Procedure in Assessing the Respiration diastolic pressure (Taylor et al., 2011). Blood
Assessing Respiration pressure is measured in millimeters of
Tachypnoea 1. While your fingers are still in place for the mercury (mm Hg) and is recorded as a
- increased respiratory rate pulse measurement, after counting the pulse fraction. The numerator is the systolic
rate, observe the patient’s respirations. pressure; the denominator is the diastolic
Bradypnoea 2. Note the rise and fall of the patient’s pressure. The difference between the two is
- decreased respiratory rate chest. called the pulse pressure.
3. Using a watch with a second hand, count
Apnoea the number of respirations for 30 seconds. Determinants of Blood Pressure
- absence of breathing Multiply this number by 2 to calculate the - Pumping action of the heart
respiratory rate per minute. 2. Peripheral vascular resistance
Hyperpnoea 4. If respirations are abnormal in any way, 3. Blood volume
- Increased depth and rate of breathing count the respirationsfor at least 1 full 4. Blood viscosity
minute.
Factors Affecting Blood Pressure - it is known as relaxation period of the heart Systolic: 140-159
- Age pump (ventricles) Diastolic: 90-99
2. Gender
3. Exercise NORMAL BLOOD PRESSURE Stage 2
4. Stress - 120/ 80 mmHg Systolic: ≥160
5. Race Diastolic: ≥100
6. Sex Hypotension
7. Medications - refers to a systolic blood pressure less than BLOOD PRESSURE ASSESSMENT ERRORS
8. Obesity 90 mm Hg or 20 to 30 mm Hg below the AND CONTRIBUTING CAUSES
9. Diurnal variations client’s normal systolic pressure. False Low
10. Medical conditions - Hearing deficit
11. Temperature Hypertension • Noise in the environment
- refers to a systolic blood pressure more • Viewing the meniscus from above eye level
Brachial Artery Blood Pressure than 120 mm Hg or 20 to 30 mm Hg more • Applying too wide a cuff
The series of sounds for which to listen when the client’s normal systolic pressure. • Inserting ear tips of stethoscope incorrectly
assessing blood pressure are called Korotkoff • Using cracked or kinked tubing
sounds (Phases 1-5). CATEGORIES FOR BLOOD PRESSURE LEVELS • Releasing the valve rapidly
IN • Misplacing the bell beyond the direct area
Phase 1 - A sharp thump ADULTS (AGES 18 AND OLDER) of the artery
Phase 2 - A blowing/whooshing sound Normal • Failing to pump the cuff 20 to 30 mm Hg
Phase 3 -A softer thump than phase 1 Systolic: <120 above the disappearance of the pulse
Phase 4 - A softer blowing sound that fades Diastolic:<80
Phase 5 - Silence False High
Prehypertension - Using a manometer not calibrated at the
Brachial Artery Blood Pressure Systolic: 120-139 zero mark
SYSTOLIC Diastolic: 80-89 • Assessing the blood pressure immediately
- it is known as the force to pump blood out after exercise
of the arteries • Viewing the meniscus from below eye level
Highblood Pressure • Applying a cuff that is too narrow
DIASTOLIC Stage 1 • Releasing the valve too slowly
• Re-inflating the bladder during auscultation bedside table. If the patient is sitting, have Estimating Systolic Pressure
the patient sit back in the chair so that the 12. Palpate the pulse at the brachial or radial
chair supports his or her back. In addition, artery by pressing gently with the fingertips
Procedure in Assessing the Respiration make sure the patient keeps the legs 13. Tighten the screw valve on the air pump.
Assessing Blood Pressure uncrossed. 14. Inflate the cuff while continuing to
1. Check physician’s order or nursing care 8. Expose the brachial artery by removing palpate the artery. Note the point on the
plan for frequency of blood pressure garments, or move a sleeve, if it is not too gauge where the pulse disappears.
measurement. More frequent measurement tight, above the area where the cuff will be 15. Deflate the cuff and wait 1 minute.
may be appropriate based on nursing placed.
judgment. 9. Palpate the location of the brachial artery. Obtaining Blood Pressure Measurement
2. Perform hand hygiene and put on PPE, if Center the bladder of the cuff over the 16. Assume a position that is no more than 3
indicated. brachial artery, about midway on the arm, so feet away from the gauge.
3. Identify the patient. that the 17. Place the stethoscope earpieces in your
4. Close curtains around bed and close the lower edge of the cuff is about 2.5 to 5 cm (1 ears. Direct the earpieces forward into the
door to the room, if possible. Discuss to 2 inches) above the inner aspect of the canal and not against the ear itself.
procedure with patient and assess patient’s elbow. Line the artery marking on the cuff up 18. Place the bell or diaphragm of the
ability to assist with the procedure. Validate with the patient’s brachial artery. The tubing stethoscope firmly but with as little pressure
that the patient has relaxed for several should extend from the edge of the cuff as possible over the brachial artery. Do not
minutes. nearer the patient’s elbow allow the stethoscope to touch clothing or
5. Put on gloves, if appropriate or indicated. 10. Wrap the cuff around the arm smoothly the cuff.
6. Select the appropriate arm for application and snugly, and fasten it. Do not allow any 19. Pump the pressure 30 mm Hg above the
of the cuff. clothing to interfere with the proper point at which the systolic pressure was
7. Have the patient assume a comfortable placement of the cuff. palpated and estimated. Open the valve on
lying or sitting position with the forearm 11. Check that the needle on the aneroid the manometer and allow air to escape
supported at the level of the heart and the gauge is within the zero mark. If using a slowly (allowing the gauge to drop 2 to 3 mm
palm of the hand upward. If the mercury manometer, check to see that the per second).
measurement is taken in the supine position, manometer is in the vertical position and 20. Note the point on the gauge at which the
support the arm with a pillow. In the sitting that the mercury is within the zero level with first faint, but clear, sound appears that
position, support the arm yourself or by the gauge at eye level. slowly increases in intensity. Note this
using the
number as the systolic pressure. Read the SIDE EFFECT/SECONDARY EFFECT
pressure to the closest 2 mm Hg. Factors Affecting Oxygen Saturation - Unintended effect. Side effects are usually
21. Do not re-inflate the cuff once the air is Readings predictable and may be either harmless or
being released to recheck the systolic - Hemoglobin potentially harmful.
pressure reading. • Circulation
22. Note the point at which the sound • Activity ADVERSE EFFECT/REACTIONS
completely disappears • Carbon Monoxide Poisoning - Severe side effects; may justify the
23. Allow the remaining air to escape discontinuation of a drug.
quickly. Repeat any suspicious reading, but
wait at least 1 minute. Deflate the cuff DRUG TOXICITY
completely between attempts to check the - harmful effects of a drug on an organism or
blood pressure. tissue; results from overdosage, ingestion of
24. When measurement is completed, a drug intended for external use, or buildup
remove the cuff. Remove gloves, if worn. of the drug in the blood because of impaired
Cover the patient and help him or her to a Midterm| Medications metabolism or excretion (cumulative effect).
position of comfort. MEDICATION
25. Remove additional PPE, if used. Perform - a substance administered for the diagnosis, DRUG ALLERGY
hand hygiene. cure, treatment, or relief of a symptom or for -an immunologic reaction to a drug.
26. Clean the diaphragm of the stethoscope prevention of disease. - Mild: rashes, diarrhea etc(few mins to 2
with the alcohol wipe. Clean and store the weeks)
sphygmomanometer, according to facility DRUG - Severe: Anaphylactic reaction (can be fatal)
policy. - has the connotation of an illicitly obtained
substance such as heroin, cocaine, or DRUG TOLERANCE
Oxygen Saturation amphetamines. - person who exhibits an unusually low
- Blood oxygen level is the amount of oxygen physiological response to a drug and who
circulating in the blood. Oxygen saturation Effects requires increases in the dosage to maintain
refers to the percentage of oxygen in a THERAPEUTIC/DESIRED EFFECT a given therapeutic effect.
person’s blood. Medical professionals often - the primary effect intended, that is, the
use a device called a pulse oximeter for reason the drug is prescribed. CUMULATIVE EFFECT
either a quick test or continuous monitoring.
- increasing response to repeated doses of a - Drug abuse CHEMICAL NAME
drug that occurs when the rate of - Drug dependence [Physiological, - name by which the chemist knows a drug;
administration exceeds the rate of Psychological] describes the constituents of the drug
metabolism or excretion - Drug habituation - Ex: N-acetyl-p-aminophenol

DRUG TOLERANCE Therapeutic Actions GENERIC NAME

- a person who exhibits an unusually low Palliative - name given before a drug becomes official
physiological response to a drug and who -Relieves the symptoms of a disease but - Ex: paracetamol acetaminophen
requires increases in the dosage to maintain does not affect the disease itself
a given therapeutic effect. OFFICIAL NAME
- Cumulative effect: drug buildup Curative - name under which it is listed in one of the
- Cures a disease or condition official publications
IDIOSYNCRATIC EFFECT - Ex: United States Pharmacopeia (USP)
- is one that is unexpected and may be Supportive
individual to a client. Underresponse and - Supports body function until other BRAND NAME
overresponse to a drug may be idiosyncratic treatments or the body's response can take - also called the TRADEMARK; name given by
over the drug manufacturer
DRUG INTERACTION - Ex: Tylenol
- occurs when the administration of one Substitutive
drug before, at the same time as, or after - Replaces body fluids or substances Actions of Drugs
another drug alters the effect of one or both - Half-life: the time interval required for the
drugs. Chemotherapeutic body’s elimination processes to reduce the
- Potentiating effect, Inhibiting effect, - Destroys malignant cells concentration of the drug in the body by
Synergistic effect one-half.
Restorative
IATROGENIC DISEASE - Returns the body to health
- disease caused unintentionally by medical ONSET OF ACTION
therapy Research on different types of drug - the time after administration when the
preparations body initially responds to the drug
DRUG MISUSE Types of Drug Names
PEAK PLASMA LEVEL - sex -Intra-arterial
- the highest plasma level achieved by a - genetic and biological factors - Intra-articular
single dose when the elimination rate of the - psychological factors (ex. placebo) - Intra-peritoneal
drug equals the absorption rate - pathology - Intracardiac
- environment
DRUG HALF-LIFE (ELIMINATION HALF-LIFE) - timing of administration Topical-Local Route
- the time required for the elimination - Cream
process to reduce the concentration of the Drug Classifications - Lotion
drug to one-half what it was at initial THERAPEUTIC USE OR CLINICAL INDICATION - Ointment
administration - ex. antacids, antibiotics, laxatives - Gel
- Irrigation and Inhalation
PLATEAU PHYSIOLOGIC EFFECT OR CHEMICAL ACTION
- A maintained concentration of a drug in the - ex. Calcium channel blockers Others
plasma during a series of scheduled doses - Vaginal
PRESCRIPTION OR NON-PRESCRIPTION - Topical
Pharmacodynamics OROVER-THE-COUNTER DRUGS (OTC) - Transdermal
- the mechanism of drug action and the - Inhalation
relationships between drug concentration Routes of Administration
and responses in the body Enteral Route Research on the advantages and
- Receptor: Drug's specific target - Oral disadvantages of different medical
- Agonist vs Antagonist - Sublingual administration route
- Buccal Types of Medication Orders
Pharmacokinetics - Rectal STAT ORDER
- the study of the absorption, - indicates that the medication is to be given
distribution,bio-transformation, and Parenteral Route immediately and only once
excretion of drugs. - Subcutaneous
- Intramuscular SINGLE ORDER
Factors Influencing the effects of a - Intradermal - one-time order is for medication to be
medication - Intravenous/Intravascular given once at a specified time
- weight - Intrathecal
STANDING ORDER Prescription Abbreviations - Expiration date
- may or may not have a termination date. - OD – once a day
May be carried out indefinitely - BID – 2x a day SECOND CHECK
- TID – 3x a day - while preparing the medication
PRN ORDER - QID 4x a day
- As needed order - Q (every) 6hrs THIRD CHECK
- Q (every) 12 hrs - Before returning the medication to the
Guidelines for Administering Medications - RTC – round the clock storage or before giving the medication to
- Full name, address, license number, phone - PRN – If necessary the client
number of prescribing physician - STAT orders
- Name of medication - HS – hours of sleep 10 RIGHTS OF MEDICATION ADMINISTRATION
- Date of order - OU – both eyes - RIGHT MEDICATION
- Strength - OS – left eye >The medication given was the medication
- Dosage of drug - OD - right eye ordered.
- Frequency - AC – before meals
- Indication - PC – after meals - RIGHT DOSE
- Stop dates if applicable - P.O. – per orem >The dose ordered is appropriate for the
- Physician signature - NPO – nothing per orem client.
- Verbal orders should be written correctly in - IM – intramuscular • Give special attention if the calculation
a separate POS and - ID – intradermal indicates multiple pills/tablets or a large
- Topical quantity of a liquid medication. This can be
Essential Parts of a Drug Order - IV – intravenous an indication that the math calculation may
- full name of the client - SQ - subcutaneous be incorrect.
- date and time the order is written • Double-check calculations that appear
- name of the drug to be administered Check 3x for Safe Medication Administration questionable.
- dosage of the drug FIRST CHECK • Know the usual dosage range of the
- frequency of administration - Read the MAR medication.
- route of administration - Verify the client • Question a dose outside of the usual
- signature of the person writing the order - Compare label dosage range.
- Dosage
- RIGHT TIME and explain the reason and follow-through - REPUBLIC ACT 8423 – TRADITIONAL AND
> Give the medication at the right frequency activities in nursing notes. ALTERNATIVE MEDICINE ACT (TAMA OF
and at the time ordered according to agency • If a medication is not given, follow the 1997)
policy. agency’s policy for documenting the reason - REPUBLIC ACT 6675 – GENERICS ACT OF
• Medications should be given within the why. 1988
agency guidelines. - REPUBLIC ACT 7394 – THE CONSUMER ACT
- RIGHT TO REFUSE OF THE PHILIPPINES
- RIGHT ROUTE > Adult clients have the right to refuse any
> Give the medication by the ordered route. medication. LEGAL ASPECTS OF DRUG ADMINISTRATION
• Make certain that the route is safe and • The nurse’s role is to ensure that the client IN THE PHILIPPINES
appropriate for the client. is fully informed of the potential - Nurses are responsible for their own actions
consequences of refusal and to regardless of whether there is written order
- RIGHT CLIENT communicate the client’s refusal to the - If a physician writes an incorrect order, a
> Medication is given to the intended client. health care provider. nurse who administers the written incorrect
• Check the client’s identification band with dosage is responsible for the error as well as
each administration of a medication. - RIGHT ASSESSMENT the physician
• Know the agency’s name alert procedure > Some medications require specific - Nurses should question/validate any order
when clients with the same or similar last assessments prior to administration that appears unreasonable and refuse to
names are on the nursing unit. • Medication orders may include specific give the medication until the order is
parameters for administration clarified
- RIGHT CLIENT EDUCATION
>Explain information about the medication - RIGHT EVALUATION
to the client (e.g., why receiving, what to > Conduct appropriate follow-up (e.g., was
expect, any precautions). the desired effect achieved or not? Did the
client experience any side effects or adverse
- RIGHT DOCUMENTATION reactions?).
>Document medication administration after
giving it, not before. Drug Legislations in the Philippines
• If time of administration differs from
prescribed time, note the time on the MAR
 - The ROM of the joint is the maximum
movement that is possible for that joint.

ACTIVITY-EXERCISE PATTERN
- refers to a person’s routine of exercise,
activity, leisure, and recreation.
- activities of daily living (ADLs)
- the type, quality, and quantity of exercise,
including sports

NORMAL MOVEMENT

01
Body Alignment (posture)

02
Joint Mobility

03
Balance

04
Coordinated Movement
Load center of gravity
Midterm| Mobility and Activity Center of gravity
MOBILITY Line of Gravity
- The ability to move freely, easily, Base of support
rhythmically and purposefully Combined line of gravity
Combined center of gravity
RANGE OF MOTION
 * Dynamic exercise in which the muscle IMPAIRED PHYSICAL MOBILITY
TYPES OF JOINT MOVEMENT shortens to produce contraction and Complications of Immobility
Flexion, Extension & Hyperextension movement - CONTRACTURES, ATROPHY AND STIFFNESS
Abduction, Adduction & Circumduction - FOOT DROP
Rotation [Lateral and Medial Rotation] - DVT
Inversion & Eversion ISOMETRIC - HYPOSTATIC PNEUMONIA
Dorsiflexion & Plantar Flexion * Are those in which there is a change in - PRESSURE ULCERS, SKIN BREAKDOWN,
Protrusion & Retraction muscle tension but NO CHANGE in muscle - REDUCED SKIN TURGOR
Pronation & Supination length Tensing, extending and pressing - MUSCLE ATROPHY
exercises - OSTEOPOROSIS
FACTORS AFFECTING BODY ALLIGNMENT - DEPENDENT EDEMA
- Growth and development ISOKINETIC - URINE STASIS
- Nutrition * Involves muscle contraction or tension - CONSTIPATION
- Personal values and attitudes against a resistance
- External factors NURSING PROCESS
- Prescribed limitation AEROBIC Assessment
* Activity during which the amount of oxygen - Ability to move
EXERCISE taken into the body is greater than that used - Muscle tone, strenght
- Exercise is defined as any movement that to perform the activity. - Joint movement and positioning
makes your muscles work and requires your
body to burn calories. There are many types BENEFITS OF EXERCISE Interventions
of physical activity, including swimming, - Increases joint flexibility, tone and ROM - Positioning
running, jogging, walking, and dancing, to - Bone density is maintained - Maintain muscle strenght and joint mobility
name a few. Being active has been shown to - Increases cardiac output and perfusion - Promote independent mobility
have many health benefits, both physically - Prevents pooling of secretions in the lungs - Assist with transfer
and mentally. - Improves appetite and facilitate peristalsis - Assist in preparation for ambulation
- Elevates the metabolic rate - Assist patient in crutch ambulation
ISOTONIC - Prevents stasis of urine - Assist in crutch GAIT
- Produces a sense of well-being - Assist patient in ambulation with a
walkerand/or cane
- Improve: mobility, tissue perfusion, Crutch GAIT
nutritional status 4 point Gait (Safest) Swing-through gait
- Reduce: Friction & shear, irritating moisture - Requires weight bearing on both legs - Move BOTH crutches together Lift body
- Move RIGHT crutch ahead (6 inches) Move weight by the arms and swing forward,
Assisting patient with transfer LEFT foot forward at the level of the RIGHT ahead of the crutches (beyond the level)
- In general, the equipments are placed on crutch Move the LEFT crutch forward Move
the side of the STRONGER , UNAFFECTED the RIGHT foot forward Walker and Cane
body part . Correct Height
- Nurses assist the patient to move 3-point Gait - Walker: 20-30 degrees of elbow flexion
TOWARDS the stronger side - Requires weight bearing on the - Cane: 30 degrees of elbow flexion
- In moving the patient, move to the UNAFECTED leg (measure length from hand to 6 in. lateral tip
direction FACING the nurse - Move BOTH crutches and the WEAKER LEG of the 5th toe)
forward
Crutch Ambulation - Move the STRONGER leg forward SUPPORT DEVICES
- Measure correct crutch length - Pillows.
2-point Gait (Faster than 4 point) - Mattresses
LYING DOWN - Requires more balance - Suspension or heel guard boot.
- Measure from the Anterior Axillary - Partial bearing on BOTH legs - Hand roll.
- Fold to the HEEL of the foot then - Move the LEFT crutch and RIGHT foot - Abduction pillow.
- Add 1 inch (Kozier) FORWARD together
- Add 2 inches (Brunner and Suddarth) - Move the RIGHT crutch and LEFT foot
forward together
STANDING
- (Kozier) Make sure that the shoulder-rest of Swing-to gait
the crutch is at least 1- 2 inches below the - Usually used by client with paralysis of both
axilla legs
- Height minus 40cm or 16 inches - Prolonged use results in atrophy of unused
- Hand piece- allow 20-30 degrees elbow muscle. Move BOTH crutches together
flexion - Lift body weight by the arms and swing to
the crutches (at the level)
 hygiene is the self-care by which people
attend to such functions as bathing,
toileting, general body hygiene, and
grooming.

Hygienic care involves

- Skin, Hair, and Nails
- Teeth, Oral, and Nasal cavities
- Eyes
- Ears
- Perineal-Genital Area

Types of Hygienic Care

- Early Morning
- Morning
- As needed [PRN]
- Hours of Sleep (HS) or PM

Factors Influencing Personal Hygiene

- Culture
- Religion
- Environment
- Developmental Level
- Health and Energy
- Personal Preference
Midterm| Hygiene
Hygiene Bed making
Hygiene is the science of health and its - Provide smooth, wrinkle-free bed
maintenance. Personal foundation
- Place the bedside table/over-bed table - Plantar warts
within reach - Fissures, or deep grooves, Planning
- Leave the bed in the high position if - Athlete’s foot, or tinea pedis - Nurse and, if appropriate, the client and/or
returning by stretcher - An ingrown toenail family set goals/desired outcomes
- Leave in the low position if returning to bed - Nurse identifies interventions to assist the
after being up Diagnosing client to achieve the designated outcomes
- When turning the client to the side while - Bathing Self-Care Deficit (foot care) related
making an occupied bed, raise the side rail to: Implementing
nearest the client a. Visual impairment Interventions
- To ensure continued safety of the client b. Impaired hand coordination • Assisting dependent clients with hygiene
after making an occupied bed: – Raise the c. Other related or contributing factors activities
side rails • Educating clients and/or family about
- Place the bed in the low position – Put - Risk for Impaired Skin Integrity related to: appropriate hygienic practices
items used by the client within easy reach – a. Altered tissue perfusion: peripheral • Demonstrating use of assistive equipment
Attach the signal cord (associated with edema,inadequate arterial and adaptive activities
circulation) • Assessing and monitoring physical and
Nursing Process b. Poorly fitting shoes. psychological responses
Assessment
Nursing History: - Risk for Infection related to: Eye Care
- normal nail and foot care practices, a. Impaired skin integrity (ingrown toenail, - Cleanse the eyes from the inner canthus to
- type of footwear worn, corn, trauma) the outer canthus. Use a new cotton ball for
- self-care abilities, b. Deficient nail or foot care. each wipe.
- presence of risk factors for foot problems, To prevent contamination of the
- any foot discomfort, - Deficient Knowledge (diabetic foot care) nasolacrimal ducts.
- any perceived problems with foot mobility related to: - If the client is comatose, cover the eyes
a. Lack of teaching/learning activities about with sterile moist compresses. To prevent
Physical assessment - of the feet, and diabetic foot care dryness and irritation of the cornea.
identifying clients at risk for foot problems. b. Newly established medical diagnosis - Eyeglass should be cleaned with warm
- Callus (diabetes) and necessary foot hygiene water and soap; dried with soft tissue
- Corn practices.
- To remove artificial eyes, wear clean - Floss the teeth daily. Ensure adequate o For male clients, wear clean gloves
gloves, depress the client’s lower eyelid. intake of food rich in calcium, phosphorous,
- Hold the artificial eye with thumb and index Vit. A, C and D and fluoride.
finger - Avoid sweet foods and drinks between Peri-care: Female
- Clean the artificial eye with warm normal meals - Wipe labia majora (outer) from front to
saline, then place in a container with water - Eat coarse, fibrous foods (cleansing foods) back in downward motion using clean
or saline solution. such as fresh fruits and raw vegetables. surface of wash cloth for each swipe. Wipe
- Avoid rubbing the eyes. This may cause - Have dental check up every 6 months. labia minora (inner) from front to back in
infection. - Have topical fluoride applications as downward motion using clean surface of
- Maintain adequate lighting when reading. prescribed by the dentists wash cloth for each swipe Wipe down the
- Avoid regular use of eye drops center of the meatus from front to back. If
- If dirt/ foreign bodies get into eyes, clean Hair Care catheter in place, clean around catheter in
them with copious, clean, tepid water as an - The appearance of the hair may reflect a circular fashion, using clean surface of wash
emergency treatment. person’s sense of well being and health cloth for each swipe. Wash inner thighs from
status. proximal to distal.
Nose Care - Brushing and combing the hair stimulate
- Clean nasal secretions by blowing the nose circulation of blood in the scalp; distribute - Rinse with warm to tepid water using pour
gently into the soft tissue. the oil along the hair shaft; help to arrange from peri-bottle if available.
- Both nares should be open when blowing the hair. - Pat dry using clean towel in same order as
the nose to prevent forcing debris into the wash
middle ear, via Eustachian tube. Perineal/Genital Care - Remove bedpan if one is used
- May use cotton tipped applicator moistened - Inform the client and explain purpose of the - Verbalize turning patient on side to wash
with saline or water to remove encrusted, procedure. anal area from front to back and dry
dried secretions. Insert only up to cotton tip. - Provide privacy. To maintain client dignity.
- Position and drape the client as follows: Peri-care: Male
Oral Care o Female: dorsal recumbent position; drape - Wash around the urinary meatus in a
- Brush the teeth thoroughly after meals and the client diagonally. circular motion, using clean surface of
at bedtime. o Male: supine position washcloth for each stroke and around the
o For female clients, use forceps to hold head of penis in circular motion.
cotton balls for cleansing the perineum.
- Wash down shaft of penis toward the thighs
changing washcloth position with each
stroke.
- Wash scrotum – front to back
- Wash inner thighs
- Rinse with clean wash cloth or peri-bottle
using warm water in same sequence as the
wash
- Dry with clean towel in the same sequence
- Replace foreskin, as appropriate
- Turn patient on side to wash anus from
front to back and dry

Foot and Nail Care

- Teach patient and family that nails should
be cut–straight across.
- May need to get a referral if no one
available to cut nails.
- Show close attention to the feel and nails of
the diabetic patient and the elderly**
- If feet and nails are in bad condition-notify
doctor so a consult can be ordered with a
podiatrist