The person may be seriously injured if the flow rate is too fast or too slow. Move the IV bag to the side of the bed where the person is lying.
Focus on Practice Problem Solving
Vital Signs
Key Abbreviations
Measuring and Reporting Vital Signs
Factors Affecting Vital Signs
When the person complains of pain, dizziness, lightheadedness, feeling faint, shortness of breath, a fast pulse or feeling unwell. Unless otherwise ordered, take vital signs with the person at rest - lying down or sitting.
Focus on Communication Measuring and Reporting Vital Signs
Focus on Children and Older Persons
When measuring vital signs, the person with dementia may move, hit you, or grab equipment.
Body Temperature
Temperature Sites
Temperature Sites Oral Site
Focus on Communication Temperature Sites
Promoting Safety and Comfort Temperature Sites
Thermometer Types
A hollow glass tube filled with a substance that expands and rises in the tube when heated.
Teamwork and Time Management Thermometer Types
Focus on Long-Term Care and Home Care
Promoting Safety and Comfort Thermometer Types
Taking Temperatures
Delegation Guidelines Taking Temperatures
Promoting Safety and Comfort Taking Temperatures
Taking a Temperature With an Electronic Thermometer
18 Note the person's name, temperature and temperature location on your notebook or assignment sheet. 20 Help the person to put the gown back on (armpit temperature). a Wipe the anal area with toilet paper to remove lubricant.
Taking a Temperature With a Glass Thermometer
19 Record the person's name, temperature and place of temperature on a notepad or task sheet. Read the nearest degree (long line) to the left of the silver or red line.
Focus on Math
Turn it slowly back and forth until you see the silver or red line.
Pulse
Body Structure and Function Review
Pulse Sites
In children older than 2 years, the nurse may ask you to use the radial position.
Pulse Rate
Pulse Rhythm and Force
Using a Stethoscope
Focus on Communication Using a Stethoscope
Promoting Safety and Comfort Using a Stethoscope
Taking Pulses
Taking the apical and radial pulses simultaneously is called the apical-radial pulse.
Focus on Math Taking Pulses
NOTE: State competency tests require the use of a watch with a second [wiping] hand when taking pulses.).
Delegation Guidelines Taking Pulses
Heart rate – report a heart rate of less than 60 (bradycardia) or more than 100 (tachycardia) beats per minute at one time.
Promoting Safety and Comfort Taking Pulses
10 Note the following on your notepad or worksheet. a Person's name b Pulse location.
Taking an Apical Pulse and an Apical-Radial Pulse
12 For the apical-radial pulse, subtract the radial pulse from the apical pulse for the pulse deficit. For an apical-radial pulse, record the apical and radial pulses and pulse deficit.
Checking Pedal Pulses
13 Record the person's name, blink location(s), blink rate(s), and blink deficit on a notepad or task sheet.
Respirations
Respiration is the process of supplying the cells with oxygen and removing carbon dioxide from them. Then the blood returns to the heart and is pumped to the rest of the body.
Counting Respirations
Focus on Math Counting Respirations
Delegation Guidelines Counting Respirations
8 Record the person's name, breathing rate and other observations in a notebook or task sheet.
Blood Pressure
The diastolic pressure is the pressure in the arteries when the heart is at rest. For example, a systolic pressure of 120 mm Hg (millimeters of mercury) and a diastolic pressure of 80 mm Hg are written as 120/80 mm Hg.
Normal and Abnormal Blood Pressures
Factors Affecting Blood Pressure
For example, a systolic pressure of 120 mm Hg (millimeters of mercury) and a diastolic pressure of 80 mm Hg are described as 120/80 mm Hg. BP is higher in overweight people. When risk factors for heart disease are present, a systolic pressure of 130 mm Hg or higher or a diastolic pressure of 80 mm Hg or higher can be considered hypertension.
Focus on Communication Normal and Abnormal Blood Pressures
Blood Pressure Equipment
To inflate the cuff (fill it with air), turn the air release valve clockwise (to the right) to close the valve. Turn the valve counterclockwise (to the left) to deflate the cuff (let air out).
Promoting Safety and Comfort Blood Pressure Equipment
Measuring Blood Pressure
Measuring Blood Pressure—
Guidelines
Focus on Math Measuring Blood Pressure
Delegation Guidelines Measuring Blood Pressure
Measuring Blood Pressure With an Aneroid Manometer
Measuring Blood Pressure With an Electronic Manometer
18 Follow the agency's policy on where to store the cuff (in the person's room or with the BP monitor).
Pulse Oximetry
Pain
Reporting and Recording
Focus on Pride
Unless otherwise instructed, allow the person to choose to sit or lie down when vital signs are taken.
Review Questions
Breaths are usually counted a After the temperature is taken b Before the pulse is taken c After the pulse is taken.
Exercise and Activity
You assist the nurse and health team in promoting exercise and activity for all people to the extent possible.
Bed Rest
Complications From Bed Rest
Postural hypotension is abnormally low (hypo) blood pressure when a person stands up suddenly (posturally).
Focus on Communication Complications From Bed Rest
Promoting Safety and Comfort Complications From Bed Rest
Positioning Devices
The foot end is placed so that the soles of the feet lie flat against it (fig. Footboards also serve as bed cradles by holding the top linen off the feet and toes. A bath blanket or bath towel is folded to the desired length and rolled up tightly.
Exercise
Range-of-Motion Exercises
Range-of-Motion Exercises Joint Movements
Focus on Surveys Range-of-Motion Exercises
Delegation Guidelines Range-of-Motion Exercises
Promoting Safety and Comfort Range-of-Motion Exercises
Performing Range-of-Motion Exercises
Fold the top clothes with a fan at the foot of the bed. a Place your hands over your ears to support your head. Do this if the person is in a chair with a straight back or is standing.) e Abduction - move the straight arm away. Place the other hand under the ankle. d Repeat flexion and extension 5 times—or the number of times specified in the care plan.
Ambulation
Canes
For example, if the left leg is weak, the cane is held in the right hand. For correct cane position, the cane is held to the side and in front of the strong foot. Side - the cane tip is about 6 to 10 inches to the side of the strong foot.
Walkers
Promoting Safety and Comfort Walkers
Assisting With Ambulation
Focus on Communication Assisting With Ambulation
If you start to fall, I will use the leash to pull you close to me and gently lower you to the ground.
Delegation Guidelines Assisting With Ambulation
Promoting Safety and Comfort Assisting With Ambulation
If using a walker, warn the person not to pull the walker to stand. Encourage the person to stand erect (upright) with head up and back straight. The person should use the handrail on the strong side (unless using a walker or cane).
Other Walking Aids
Loose clothes and long skirts can hang in front and block the person's view of the legs and tips of the crutch. Resist the urge to do things the person can safely do alone or with some help. T F When using a walker with wheels, the walker is pushed 6 to 8 inches in front of the person's feet.
Comfort, Rest, and Sleep
Comfort
Focus on Communication Comfort
That is, you cannot see, hear, touch, or feel or smell another person's pain or distress.
Factors Affecting Pain
Caring About Culture Pain
Radiating pain is felt at the site of tissue damage and spreads to other areas. Gallbladder disease can cause pain in the right upper abdomen, the back, and the right shoulder (Fig. 35-1). Ask the person if the pain is anywhere else and point to those areas.
Words Used to Describe Pain
Pain—Signs and Symptoms Body Responses
Focus on Communication Signs and Symptoms
Focus on Surveys Signs and Symptoms
Comfort and Pain-Relief Measures
We teach the person to breathe deeply and slowly and to contract and relax muscle groups.
Delegation Guidelines The Back Massage
Before you get a back massage, you need this information from your nurse and care plan.
Promoting Safety and Comfort The Back Massage
Giving a Back Massage Quality of Life
Stroke upwards from the lower back to the shoulders, down the upper arms, back to the upper arms, over the shoulders, and down to the lower back. a Grasp the skin between your thumb and fingers. 17 Apply lotion to bony areas. movements with the tips of your index and middle fingers. Do not massage reddish legs.) 18 Use quick movements to stimulate. movements to relax the person.
Rest
Sleep
Factors Affecting Sleep
Circadian Rhythm
Sleep Disorders
Sleep Disorders—Signs and Symptoms
Insomnia is a chronic condition in which a person cannot sleep or sleeps through the night. Sleep deprivation is when the quantity and quality of sleep is inadequate, resulting in decreased performance and alertness. Nursing tubes (intravenous, catheters, feeding) can cause injury if pulled out of the body when a person gets out of bed.
Teamwork and Time Management
Help him or her back to bed even if not assigned to the person's care.
Promoting Sleep
Give the person time to pray before meals or before bedtime if he or she values it. It is common to wait 30 minutes after administering an analgesic medication to perform procedures and provide care. Because you did not report the pain, the person did not receive any pain-relieving measures.
Admissions, Transfers, and
In some agencies, this also means moving the person to a new room within the agency.
Teamwork and Time Management Admissions, Transfers, and Discharges
Delegation Guidelines
Promoting Safety and Comfort Admissions, Transfers, and Discharges
Admissions
Preparing the Room
Preparing the Person's Room Procedure
Admitting the Person
Admitting the Person Quality of Life
Ask family or friends to leave the room, unless the person prefers someone to stay. 17 Label the person's property and personal care items with his or her name (if not done by family).
Weight and Height
Focus on Math Weight and Height
If the person is taller than the lower part, read the height from the movable part of the height bar. If it is not divided evenly by 12, the remaining number is the number of inches.
Teamwork and Time Management Weight and Height
Measuring Weight and Height With a Standing Scale
13 Move the lower and upper weights until the balance marker is in the center (see Fig. 36-6). 20 Help the person put on a dressing gown and non-slip footwear if he or she wants to be up.
Measuring Height—The Person Is in Bed
13 Place the ruler flat over the top of the person's head and across the tape measure (Fig. 36. This is the point where the bottom edge of the ruler touches the tape measure.
Moving the Person to a New Room
The doctor, nurse or social worker explains the reasons for the move to the person and the family. If the new room is in another nursing unit, the person does not know the staff.
Transfers and Discharges
The nurse tells you when to start the transfer or discharge procedure and when the person is ready to leave.
Transferring or Discharging the Person
How will you make the person feel that he or she is the most important at that time. When the person arrives in the room, you a Record the person's identifying information b Measure vital signs. When you discharge a person, you can a Teach the person about diet and medications b Arrange care at home.
Assisting With the Physical
Examination
Your Role
Equipment
Otoscope—a lighted instrument (scope) used to examine the outer ear (oto) and the eardrum (tympanic membrane).
Preparing the Person
If not, collect the items listed in the procedure: Preparing the Person for Examination, p.
Focus on Communication Preparing the Person
Or the person may want a family member to be present for the examination and interpretation of the results.
Delegation Guidelines Preparing the Person
Promoting Safety and Comfort Preparing the Person
Preparing the Person for an Examination
Omit this step for an exam in the person's room.) 10 Measure weight and height (Chapter 36).
Positioning and Draping
Exam Positions
Assisting With the Exam
Assisting With the Physical Exam
Focus on Communication Assisting With the Exam
The parent may need to hold and hold a child still during certain parts of the exam.
After the Exam
Teamwork and Time Management After the Exam
Make sure the exam room is clean and supplies and equipment are ready for the next exam. Talking about an exam with family, friends, or staff not involved in the person's care violates the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Collecting and
Testing Specimens
Collecting Specimens
Teamwork and Time Management Collecting and Testing Specimens
Promoting Safety and Comfort Collecting and Testing Specimens
Urine Specimens
Delegation Guidelines Urine Specimens
Promoting Safety and Comfort Urine Specimens
The Random Urine Specimen
Collecting a Random Urine Specimen
The sample pan is at the front of the toilet on the toilet rim for a urine sample.
The Midstream Specimen
Focus on Communication The Midstream Specimen
Promoting Safety and Comfort
Collecting a Midstream Specimen
15 For a female—wipe the perineal area with a towel. a Spread your lips with your thumb and forefinger. 16 For a man - clean the penis with a towel. a Hold the penis with your non-dominant hand.
The 24-Hour Urine Specimen
Promoting Safety and Comfort The 24-Hour Urine Specimen
Collecting a 24-Hour Urine Specimen