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VITAL SIGNS

The Vital or Cardinal Signs are body temperature, pulse, respirations, and blood pressure.
A. BODY TEMPERATURE reflects the balance between the heat produced and
the heat lost from the body, measured in heat units called degrees.
Core temperature is the temperature of the deep tissues of the body, it is
under the control of the hypothalamus.
Surface temperature is the temperature just within the skin and can
easily be felt.
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&. To establish baseline data for subse'uent e(aluation.
). To identify whether the core temperature is within normal range.
*. To determine changes in the core temperature in response to specific
therapies.
+. To monitor clients at risk for imbalanced body temperature.
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&. Thermometer
). 0ater soluble lubricant for rectal thermometer
*. Cotton balls
+. Alcohol
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&. 0ash hands. "educes spread of microorganisms.
). 2ather all e'uipment. To sa(e time, energy and effort.
*. $3plain procedure to client. $ncourages cooperation and reduces
apprehension.
+. "emo(e the thermometer from its container and check the reading on the
thermometer. $nsure that the thermometer is ready for use if in case the
person who pre(iously used it failed to shake the mercury line to the lowest
marking.
4. Shake the thermometer until the mercury line reaches the lowest marking with
your thumb and forefinger, and with a strong wrist mo(ement. The mercury
will not drop unless shaken forcefully.
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6. lace the thermometer carefully in either left or right posterior sublingual
pocket at the base of the tongue. 0hen the bulb rests deeply in the superficial
blood (essels under the tongue and the mouth is closed, a reliable
measurement of body temperature can be obtained.
7. -nstruct the client to close lips gently and lea(e the thermometer in place for
*84 minutes. This will allow sufficient time for the mercury to e3pand and
achie(e a reliable measurement.
9. -nstruct client to open mouth and remo(e the thermometer.
:. 0ipe the thermometer with one stroke using a dry cotton ball from stem to
bulb using a firm twisting motion. Cleansing from an area of lesser
contamination to an area of greater contamination minimi;es the spread of
microorganisms to cleaner areas.
&<. =olding the temperature at eye le(el, read it without touching the bulb.
&&. Shake down the thermometer until the mercury line reaches the lowest
marking. Soak the thermometer in the bottle with soap sud solution.
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&. @ollow steps /o. & 4.
). Ae sure clientBs a3illary is dry, and insert tip of thermometer into center of
a3illa.
*. Ceep the clientBs arm tightly against the side of the chest for 48&< minutes.
+. "emo(e the thermometer, wipe off any remaining secretions and clean from
stem to bulb.
4. "ead thermometer at eye le(el.
6. Shake down thermometer and soak in a solution.
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&. @ollow steps /o. & 4.
). 1raw curtains or close room door. ro(ides pri(acy and minimi;es
embarrassment.
*. Assist client to side lying or SimBs position. @acilitates easy insertion.
+. 1rape and e3pose only the anal area. romotes self8esteem.
4. Apply disposable glo(es.
6. 1ip thermometerBs blunt end into lubricant.
7. 0ith non8dominant hand, separate clientBs buttocks to e3pose anus. Ask client
to breathe slowly and rela3.
9. 2ently insert thermometer into anus in the direction of umbilicus. 1o not
force thermometer.
:. -f resistance is felt during insertion, withdraw thermometer immediately.
&<. =old thermometer in place for &8) minutes. /e(er lea(e client unattended
when thermometer is in place.
&&. Carefully remo(e thermometer, wipe off any remaining secretions in rotating
fashion from stem to bulb.
&). "ead thermometer at eye le(el. Shake down thermometer and soak in
solution.
A. PULSE is a wa(e of blood created by contraction of the left (entricle of the
heart.
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&. To establish baseline data for subse'uent e(aluation.
). To identify whether the pulse rate is within normal range.
*. To determine whether the pulse rhythm is regular and the pulse (olume is
appropriate.
+. To compare the e'uality of corresponding peripheral pulses on each side
of the body.
4. To monitor and assess changes in the clientBs health status.
6. To monitor clients at risk for pulse alterations.
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0atch with second hand
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&. Assist client to assume a supine or sitting position.
). -f supine, place clientBs forearm straight alongside or across lower chest or
upper abdomen with wrist e3tended straight. -f sitting, bend clientBs elbow :<
degrees and support lower arm on chair or on nurseBs arm. Slightly e3tend or
fle3 wrist with palm down until strongest pulse is noted.
*. lace the tips of first two orDand middle three fingers of hand on the clientBs
artery and press gently against the radius, rest your thumb in opposition to
fingers at the back of clientBs wrist.
+. Apply enough pressure so that the clientBs pulsating artery can be felt
distinctly.
4. Count the number of pulsations felt for one full minute.
C. APICAL PULSE RATE is the assessment of the number and 'uality of apical
sounds in & minute.
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&. To obtain the heart rate of newborns, infants, children ) to * years old or
of an adult with an irregular peripheral pulse.
). To establish baseline data for subse'uent e(aluation.
*. To determine whether the cardiac rate within normal range and the rhythm
is irregular.
+. To monitor clients with cardiac disease and those recei(ing medications to
impro(e heart action.
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&. 0atch with second hand
). Stethoscope
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&. 0ash hands.
). $3plain the procedure to client.
*. ro(ide pri(acy.
+. Assist in a comfortable sitting or supine position.
4. 5ocate the apical pulse or the point of ma3imal impulse.
6. lace diaphragm of stethoscope in palm of hand for 4 to &< seconds.
7. place diaphragm of stethoscope o(er .- at the fifth -CS, at the left .C5,
and auscultate. Count heartbeats for one full minute.
9. "eplace clientBs gown, and assist to comfortable position.
:. 0ash hands.
1. RESPIRATION is the act of breathing.
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&. To ac'uire baseline data against which future measurements can be
compared.
). To monitor abnormal respirations and respiratory patterns and identify
changes.
*. To assess respirations before the administration of a medication.
+. To monitor clients at risk for respiratory alterations.
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&. 0atch with a second hand.
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&. Assess respirations after pulse measurement, while the fingertips are still in
place.
). #bser(e clientBs respiration.
*. Count the respiration in one full minute.
+. "elay results to client.
$. BLOOD PRESSURE is the force e3erted by the blood against the (essel wall.
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&. To obtain baseline measure of arterial blood pressure for subse'uent
e(aluation.
). To determine the clientBs hemodynamic status.
*. To identify and monitor changes in blood pressure resulting from a disease
process and medical therapy.
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&. Stethoscope
). Alood pressure cuff
*. Spygmomanometer
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&. =a(e the client assume a comfortable sitting position with the forearm
supported at the le(el of the heart and the plam of the hand upward.
). $3pose the area of the brachial artery by remo(ing the garment or folding the
slee(es.
*. Center the inflatable area of the cuff o(er the brachial artery, appro3imately
midway on the arm so that the lower edge of the cuff is ).484cm abo(e the
inner aspect of elbow.
+. 0rap the cuff around the arm smoothly and snugly, then fasten it securely or
tuck the end of the cuff well under the preceding wrapping.
4. Check the mercury manometer is in (ertical position.
6. Assume a position that is not more than * feet from the gauge.
7. lace the stethoscope earpiece in the ear.
9. alpate the brachial pulse by pressing gently with the fingertips. lace the
diaphragm of the stethoscope firmly but with a little pressure as possible o(er
the artery where the pulse is felt.
:. Tighten the screw (al(e on the air pump.
&<. ump the (al(e until the mercury raises appro3imately *<mm=g abo(e
clientBs anticipated pressure.
&&. Slowly release (al(e and allow mercury or needle of aneroid to fall at a rate of
) to * mm=gDsec.
&). /ote the point on the gauge at which there is an appearance of the first clear
sound, which slowly increases in intensity.
&*. Continue to deflate gradually noting point on the gauge at which there is an
appearance of the first clear sound, which slowly increases in intensity.
&+. "emo(e cuff from clientBs arm unless measurements must be repeated.
&4. Assist the client in returning to comfortable position.
&6. 0ash hands.
BEDMAKING
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&. To promote the clientBs comfort.
). To pro(ide a clean neat en(ironment for the client.
*. To pro(ide a smooth, wrinkle8free bed foundation, thus minimi;ing source of
skin irritation.
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&. =old soiled linen away from uniform.
). 1o not shake soiled linen in the air because shaking can disseminate
secretions and e3cretions and the microorganisms they contain.
*. 5inen for one client is ne(er placed on another clientBs bed.
+. To a(oid unnecessary trips to the linen supply area, gather all linen before
starting to strip a bed.
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&. Aottom sheet
). "ubber sheet
*. 1raw sheet
+. Top sheet
4. illow case
6. Aed co(er
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&. Assess the clientBs readiness to be out of bed.
). $3plain procedure to client.
*. 0ash hands.
+. Assemble and arrange linen in order of use.
4. Adjust the bed to an appropriate working height.
6. Strip the bed.
7. lace bottom sheet at the foot of the bed.
9. Smooth o(er the mattress and tuck at the heat part.
:. .iter the corner of the head part of the bed.
&<. 5ay rubber sheet halfway along center line of mattress and top and bottom
edges e3tend from the middle of the clientBs back to the area of the midthigh
or knee.
&&. lace draw sheet o(er rubber sheet in the same manner.
&). Tuck the remainder of the bottom sheet, rubber and draw sheet under the
mattress all the way to the foot part.
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&*. Straighten the top sheet, tuck the foot part or make a toe pleat and miter the
corner, lea(ing the side hanging free.
&+. Co(er the pillow.
&4. -f a(ailable, a bedco(er is placed on top to co(er the entire bed.
&6. Assist client to bed.
&7. 0ash hands.
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&. $3plain the procedure to client and how he or she can cooperate.
). 0ash hands.
*. Assemble e'uipment and arrange in order of use.
+. 1raw curtain or close room door.
4. Adjust bed to comfortable working position.
6. 5oosen top linen at foot bed.
7. "emo(e bedspread, if soiled place them in linen bag, if to be reused, fold in
'uarters and place o(er back of chair.
9. Co(er client with bath blanket.
:. osition client on the far side of bed, facing away from you. Ae sure side rail
is up.
&<. 5oosen bottom linens, mo(ing from head to foot.
&&. 0ith seam side down, fanfold draw sheet, rubber sheet, and bottom sheet
toward client.
&). !nfold bottom sheet lengthwise along center of the bed. @anfold top layer
toward center of bed alongside the client.
&*. .iter bottom sheet at head of bed.
&+. Tuck remaining portion of sheet under mattress, mo(ing toward foot of bed.
Ceep linen smooth.
&4. lace rubber sheet, with centerfold against clientBs side. @anfold top layer
toward client.
&6. lace draw sheet o(er rubber sheet in the same manner.
&7. Tuck rubber sheet and draw sheet under the mattress.
&9. "oll client slowly toward you, o(er the layers of linen. "aise side rail and go
to the other side.
&:. 5oosen edges of soiled linen from under mattress.
)<. "emo(e soiled linen by folding it into bundle with soiled side turned in.
)&. ull clean, fanfold linen smoothly o(er edge of mattress from head to foot of
bed.
)). .iter top corner of bottom sheet. Ae sure sheet is smooth and free of wrinkles.
)*. Smooth fanfolded draw sheet out o(er bottom sheet.
)+. Assist client in rolling back into supine position. "eposition pillow.
)4. lace top sheet o(er client with centerfold lengthwise down middle of bed.
)6. Change pillowcase. lace pillow under clientBs head.
)7. 1iscard dirty linens in hamper and wash hands.
GLOVING
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&. #pen the sterile package correctly.
). Touch only the inside of the dominant cuff of the first glo(e with the
fingers when picking up.
*. -nsert the hands into the glo(e and draws it on, lea(ing the cuff turned
o(er the hands.
+. Slip the fingers of the glo(ed hand under the turned8back cuff of the
other glo(e.
4. -nsert the hand into glo(e and draw it on.
6. 0ith fingers of the dominant hand, pull the cuff of the other glo(e o(er
the cuff or hand of the slee(es.
7. "epeat for the other hand.
9. "est glo(ed hands inside the gownBs breast pocket.
BED BATH
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Aed bath is a type of bath where the nurse washes the entire body of an
independent patient in bed.
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&. To cleanse, refresh and gi(e comfort to the patient who must remain in bed.
). To stimulate circulation and aid in elimination.
*. To pro(ide an opportunity to inspect the patients body for any sign of
abnormality.
+. To help the patient ha(e some mo(ement and e3ercise.
4. To pro(ide an opportunity for the nurse8patient interaction.
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&. A(oid unnecessary e3posure and chilling.
). #bser(e the patientBs body closely for physical sign such as% rashes, swelling,
discoloration, pressure sores, burns, discharges, body lice, etc.
*. 2i(e special attention to the following areas% behind the ears, a3illa, under the
breast, umbilicus, pubic region, groin, spaces between the fingers and toes.
+. 1o the bath 'uickly but unhurriedly, and use e(en, smooth but firm strokes.
4. !se ade'uate amount of water and change it as necessary.
6. -f possible, do such procedure as (aginal douche, enema, shampoo, and oral
care, before bath.
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&. itcher or warm water
). Aath basin
*. Two face towel
+. Two towels
4. Soap in a dish
6. Toiletry items
7. Clean hospital gown
9. lastic sheet
:. @resh clean linen
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&. -dentify the client.
). Check the chart for any information related to the patientBs ability to
participate in the procedure being planned.
*. -nform the patient about the procedure.
+. ro(ide patientBs pri(acy by screening the bed if you are doing this in the
general ward.
4. Adjust the temperature and (entilation of the room.
6. "emo(e unnecessary articles on the bed and clear up the work area.
7. #ffer bedpan or urinal.
9. 0ash hands.
:. Adjust the bed to the appropriate working le(el, bring the client toward side
closest to you.
&<. 5oosen top sheet and place bath blanket o(er top sheet. -f possible, ha(e the
client hold the bath blanket with withdrawing sheet.
&&. "emo(e clientBs gown, unaffected side first if e3tremity is injured. -f with
intra(enous access, remo(e gown from arm without -V first.
&). "emo(e pillows, spread bath blanket under clientBs head, place second towel
o(er clientBs chest.
&*. 0et and fold the washcloth around the fingers of the nurse to form a mitt.
&+. 0ash and dry the eyes from the inner canthus to the outer canthus using
separate corner of the wash cloth.
&4. !sing S stroke wash the face using soap with clientBs permission, rinse and
dry well.
&6. Clean the area behind and around the ears and neck, soap, rinse at least )
times and pat dry.
&7. "emo(e bath blanket from arm farthest from you, place towel lengthwise
under arm, wash with soap and water using long, firm strokes, from distal to
pro3imal.
&9. "inse and dry arm and a3illa. Apply deodorant of client desires.
&:. lace basin lined with bath towel beside the client. -mmerse hands in water.
Allow hand to soak for *84 minutes, soap and wash paying attention to
interdigital spaces.
)<. "epeat procedure on the nearer arm.
)&. Check temperature of water and replace if necessary.
)). lace bath towel across chest fold down to umbilicus. 0ith one hand, lift edge
of towel away from chest, with mitted hand bath chest. Take special care to
wash skin folds under female breast.
)*. lace bath towel o(er chest and abdomen. 0ith one hand lift towel, with
mitted hand, bathe abdomen gi(ing special attention to umbilicus and
abdominal folds. Stroke from side to side. 0ash, rinse and dry well.
)+. Co(er chest and abdomen with top of top blanket. $3pose near leg by folding
blanket toward midline. Ae sure perineum is draped.
)4. Aend clientBs leg at knee by positioning nurseBs arm under leg. lace towel
lengthwise under leg. 0ash the leg from distal to pro3imal using long, firm,
strokes paying attention to popliteal area, rinse and pat dry.
)6. lace basin lined with towel on bed, raise lower log and slide basin under
lifted foot. .ake sure foot is firmly placed on bottom of basin. Soak well.
Soap and wash, making sure to bathe between toes. "inse and dry well.
)7. "aise side rails, and mo(e to the other side, repeat the procedure in other leg.
)9. Assist client in prone or side8lying position. lace towel lengthwise side.
0ash, rinse, and dry back from neck to buttocks using long, firm strokes. ay
special attention to folds buttocks and anus. 2i(e back rub. Change bath
water.
):. 0ear disposable glo(es if necessary. Assist in supine position, co(er upper
areas of the body e3posing only the perineum, if client can wash co(er with
bath blanket, if not, wash, rinse and dry perineum, pay special attention to
skin folds.
*<. 1ispose glo(es properly.
*&. Assist in dressing, comb clientBs hair.
*). Clean and replace bathing e'uipment.
**. 0ash hands.

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