12/27/13

Procedures of Assessing Body Temperature

Procedures of Assessing Body Temperature

Equipment:
■ Thermometer (generally, blue tip indicates oral and red tip indicates rectal) and cover.
■ Tissues.
■ Add as needed:
1 Rectal: Procedure gloves and water-soluble lubricant.
2 Axillary:Towel.
3 Be Safe! Do not use a glass-and-mercury thermometer.

Assessment:
■ Assess for signs and symptoms of temperature alterations (e.g., diaphoresis).
■ Assess for contraindications to the chosen site:
1 Oral: Do not use oral route for patients who cannot hold the thermometer properly, children, or those who use mouth breathing. If the patient has smoked, eaten, had a drink, or chewed gum, wait 20 to 30 minutes before taking oral temperature.
2 Tympanic: Assess for impacted earwax or hearing aid.
3 Rectal: Check the patient record for diarrhea or impacted stool.
4 Axillary: Check the record for presence of fever or hypothermia.
5 Skin: Assess for conditions that require an accurate, reliable reading (e.g., fever, hypothermia).

Key Points:
■ If the thermometer is not disposable, clean it before and after using.
■ Select the appropriate site and thermometer, considering comfort, safety, and accuracy.
■ Turn on, or otherwise ready the thermometer.
■ Insert the thermometer in its sheath, or use a thermometer designated only for the patient.

■ Insert. Leave an electronic thermometer in place until it beeps; for other thermometers use the recommended times.
1 Glass thermometer: Read at eye level after 5 to 8 minutes.
2 Rectal site: Read at eye level after 3 to 5 minutes.

■ Be Safe! Do not use an oral thermometer to take a rectal temperature. Hold a rectal thermometer securely in place, and never leave it unattended.
1 Axillary site: Dry the axilla before inserting the thermometer.
2 Tympanic site: Refer to figures below for placement.

■ Cleanse and store in recharging base (store glass thermometers safely to prevent breakage).

Documentation:
■ You will usually record temperature on a graphic or flowsheet.
■ If you need to write a nursing note (e.g., because of a fever), notify the primary provider of the abnormal findings, and document according to agency policy:
1 Temperature, indicating the route of measurement.
2 Supporting findings, such as “Skin is hot and dry,” and whether the temperature reading is consistent with the patient’s condition.
3 Note previous recordings, if any.

■ When evaluating, compare to normal range for developmental stage, site used, and patient’s baseline data. Look for trends to identify potential concerns.

Oral thermometer placement
Tympanic thermometer For a child, pull the pinna down and back
Tympanic thermometer For an adult, pull the pinna up and back
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Discharging a Patient From Healthcare Facility

Discharging a Patient From Healthcare Facility

Equipment:
■ Medical record.
■ Discharge form with patient instructions.
■ Supplies for ongoing treatments.
■ Patient’s medications, clothes, personal care articles, and other belongings.
■ Utility cart.
■ Wheelchair.

Assessment:
■ Make a final, brief focused assessment, including:
■ Mobility.
■ Emotional and physical distress.
■ Ability to communicate and understand.

Key Points:
Day or Two Days Before Discharge
■ Arrange for or confirm transportation, and services and equipment needed at home. Also make necessary referrals.
■ Teach patient/family about: patient’s condition and medications, and how to use necessary equipment.
■ Ask caregiver/family to bring clothing for patient to wear home.

Day of Discharge:
■ Perform and document final assessments.
■ Be Safe! Confirm that patient has house keys, heat is turned on, and food is available.
■ Make final notifications (e.g., transportation, community agencies).
■ Pack patient’s personal items and treatment supplies.
■ Be Safe! Label take-home medications before giving to the patient.
■ Provide prescriptions, instruction sheets, and appointment cards.
■ Be Safe! Review discharge instructions with patient/family especially regarding “high-risk” drugs such as anticoagulants, antibiotics, and sedatives.
■ Answer any questions.
■ Document final nursing note and complete the discharge summary.
■ Accompany the patient out of the institution.
■ Notify admissions department of the discharge.
■ Ensure records are sent to the medical records department.

Documentation:
■ Complete the admission database and nursing notes.
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Admitting a Patient to Nursing Unit

Admitting a Patient to Nursing Unit

Equipment:

  1. Identifying wristband.
  2. Chart.
  3. Nursing admission database.
  4. Thermometer.
  5. BP cuff.
  6. Stethoscope.
  7. Scales.
  8. Patient gown.
  9. Admission pack (bath basin, pitcher, soap, comb, toothbrush, etc.). 


Key Points:

  1. Introduce yourself, assist the patient into a hospital gown, weigh, assist him into the bed.
  2. Be Smart! Allow extra time if patient is an older adult.
  3. Be Smart! Validate patient identity.
  4. Obtain a translator, if needed.
  5. Complete the nursing assessment, including VS; validate the admission list of medications.
Provide information on:

  • Room.
  • Equipment.
  • Routines.
  • Nurse call system.
  • Advance directives.
  • Health Insurance Portability and Accountability Act (HIPAA).
  • Answer any questions and provide printed information.
  • Complete nursing admission forms according to agency policy.
  • Complete or ensure that admission orders have been completed.

    6.   Inventory the patient belongings; send home or lock up valuables.
    7.   Finish the admission process: Ensure patient comfort (water, positioning, pain).
    8.   Be Safe! Make one last safety check: call light, bed position, siderails; and ask: “Is there anything else           I can do for you?”
    9.   Be Safe! Post “special needs” alerts for other caregivers (e.g., NPO, I&O).


Documentation:

  1. Complete the admission database and nursing notes as needed.
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After the Procedure

After the Procedure

  1. Evaluate the patient’s response to the procedure.
  2. Leave the patient in a comfortable, safe position with the call light within reach.
  3. Return the bed to low position and raise the siderail (if appropriate).
  4. Dispose of supplies and materials according to agency policy.
  5. Wash hands again before leaving the room.
  6. Document that the procedure was done; document patient responses.
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During the Procedure

During the Procedure

  1. Wash hands before touching the patient, before gloving, and after removing gloves.
  2. Observe universal precautions (e.g., don and change gloves when needed).
  3. Maintain sterility when needed.
  4. Maintain correct body mechanics. Provide patient safety (e.g., keep siderail up on far side of the bed).
  5. Continue to observe the patient while performing the procedure steps and pause or stop the procedure if the patient is not tolerating it.
  6. Follow correct procedure steps.


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Prepare the Patient

Prepare the Patient

  1. Introduce yourself, and any assistants, to the patient.
  2. Identify the patient: Read the wristband and ask the patient to state his name.
  3. Make relevant assessments to ensure that the patient still requires the procedure and can tolerate it, and that there are no contraindications.
  4. Explain the procedure to the patient, including what he will feel and need to do (e.g., “You will need to lie very still.”).
  5. Provide privacy (e.g., ask visitors to step out, drape the patient).
  6. Use good body mechanics; position bed or treatment table to a working level; lower the near siderail.
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Before Approaching the Patient

Before Approaching the Patient

  1. Check medication records or obtain a prescription, if necessary.
  2. Follow agency protocols.
  3. Obtain a signed, informed consent, if needed.
  4. Wash your hands; don procedure gloves, if needed.
  5. Gather necessary supplies and equipment.
  6. Obtain assistance, if needed (e.g., to move a patient).
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