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Orders of Assembling Patients Chart

a. History sheet
b. Personal and social data
c. Order sheet
d. Doctor’s progress notes
e. Nurses notes
f. Vital sign sheet (graphics)
g. Intake and output recording sheet
h. Laboratory and other diagnostic reports

• Patients or relatives and friends of patients are not allowed to read the chart when necessary but can have access if allowed by patient.

Intake and out put
a. Intake: all fluids that is taken in to the body through the mouth, NG tube or parentrally
b. Output: all fluid that is excreted or put out of the body through the mouth. N/G tube, urethra, drainage tube or other route (GI-diarrhea, vomiting).

Purpose:
• To replace fluid losses
• To provide maintenance requirements
• To check for retention of body fluid

Fluid balance sheet
♦ 24 hrs the intake out put should be compared and the balance is recorded
Positive balance if intake >output
Negative balance if out put >intake

Study Questions
1. Explain at least three reasons for laboratory examination of urine.
2. Explain at least one reason for collecting specimens like sputum, blood or stool.
3. Mention purposes for sputum specimen collection.
4. Describe the process how to draw venous blood for laboratory investigation.
5. How can you obtain sterile urine specimen?
6. Differentiate between signs and symptoms.
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General Rules for Charting

• Spelling
- Make certain you spell correctly

• Accuracy
- Records must be correct in all ways, be honest

• Completeness
- No omission, avoid unnecessary words or statement

• Exactness
- Do not use a word you are not sure of

• Objective information
- Record what you see avoid saying (condition better)

• Legibility
- Print/write plainly and distinctively as possible

• Neatness
- No wrinkles, proper speaking of items
- Place all abbreviation, and at end of statement

• Composition / arrangement
- Chart carefully consult if in doubt avoid using of
- chemical formulas

• Sentences need to be complete and clear, avoid repetition
• Don’t overwrite
• Don’t leave empty spaces in between
• Time of charting
- Specific time and date

• Color of ink
- Black or blue (red for transfusion, days of surgery)

It should be recorded on the graphic sheet All orders should be written and signed. Verbal or telephone orders should be taken only in emergency verbal orders should be written in the order sheet and signed on the next visit.
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Observations and Recording of Signs and Symptoms of the Patient

1. Objective Symptoms (signs):
• Are symptoms, which could be seen by the health personnel?

E.g. swelling, redness, rash, body discharges (defecation, diaphoresis, emesis,)

2. Subjective Symptoms:
Are symptoms, which are felt by the patient

E.g. decrease of appetite, dizziness, deafness, burning sensation, nausea, etc

3. Chart
Definition: it is a written record of history, examination, tests, diagnosis, and prognosis response to therapy

Purpose of Patients Chart
a. For diagnosis or treatment of a patient while in the hospital (find after discharge) if patient returns for treatment in the future time
b. For maintaining accurate data on matters demanded by courts
c. For providing material for research
d. For serving an information in the education of health personnel (medical students, interns, nurses, dietitians, etc)
e. For securing needed vital statistics
f. For promoting public health
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Collecting Blood Specimen

The hospital laboratory technicians obtain most routine blood specimens. Venous blood is drown for most tests, but arterial blood is drawn for blood gas measurements. However, in some setting nurses draw venous blood.

Purpose
Specimen of venous blood are taken for complete blood count, which includes
• Hemoglobin and hemotocrit measurements
• Erythrocytes (RBC) count
• Leukocytes (WBC) count
• Differential counts

Equipment
• Sterile gloves
• Tourniquet
• Antiseptic swabs
• Dry cotton (gauze)
• Needle and syringe
• Specimen container with the required diluting or preservative agents, for example: anticoagulant.
• Identification/ labeling: name, age address, etc.
• Laboratory requisition forms

Procedure
1. Patient preparation
• Instruct the pt what to expect and for fasting (if required)
• Position the pt comfortably

2. Select and prepare the vein sites to be punctured
• Put on gloves
• Select the vein to be punctured. Usually the large superficial veins used such as, brachial and median cubital veins.
• Place the veins in dependent positions
• Apply tourniquet firmly 15-20 cm about the selected sites. It must be tight enough to obstruct vein blood flow, but not to occlude arterial blood flow.
• If the vein is not sufficiently to dilate massage (stroke) the vein from the distal towards the site or encourage the pt to clench and unclench repeatedly.
• Clean the punctured site using antiseptic swabs

3. Obtain specimen of the venous to blood
• Adjust the syringe and needles
• Clean/disinfect the area with alcohol swab, dry with sterile cotton swab
• Puncture the vein sites
• Release the tourniquet when you are sure in the vein
• Withdraw the required amount of venous blood specimen
• Withdraw the needle and hold the sites with dry cotton (to apply pressure)
• Put the blood into the specimen container
• Made sure not to contaminate outer part of the container and not to distract the blood cells while putting it into the container

4. Recomfort the patient

5. Care of the specimen and the equipment
• Label the container
• Shake gently (if indicated to mix)
• Send immediately to laboratory, accompanying the request
• Give care of used equipments

6. Documentation and reporting
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Collecting sputum specimen

Sputum is the mucus secretion from the lungs, bronchi and trachea, but it is different from saliva. The best time for sputum specimen collection is in the mornings up on the patient’s awaking (that have been accumulated during the night). If the patient fails to cough out, the nurse can obtain sputum specimen by aspirating pharyngeal secretion using suction.

Purpose
Sputum specimen usually collected for:
• Culture and sensitivity test (i.e. to identify the microorganisms and sensitive drugs for it)
• Cytological examination
• Acid fast bacillus (AFB) tests
• Assess the effectiveness of the therapy

Equipments Required
• Disposable gloves
• Specimen container
• Laboratory requisition form
• Mouth care (wash) tray

Procedure
1. Patient preparation
• Before collecting sputum specimen, teach pt about the difference between sputum and saliva, how to cough deeply to raise sputum.
• Position the patient, usually sitting up position and splinting may help. Also postural drainage can be used.
• Give oral care, to avoid sputum contamination with microorganisms of the mouth. Avoid using tooth past because it alter the result.

2. Obtain sputum specimen
• Put on gloves, to avoid contact with sputum particularly it hemoptysis (blood in sputum) present.
• Ask pt to cough deeply to raise up sputum
• Take usually about 15-30 ml sputum
• Ask pt to spit out the sputum into the specimen container
• Make sure it doesn't contaminate the outer part of the container. If contaminated clean (wash) with disinfectant
• Cover the cape tightly on the container

3. Recomfort the patient
• Give oral care following sputum collection (To remove any unpleasant taste)

4. Care of the specimen and the equipments used
• Label the specimen container
• Arrange or send the specimen promptly and immediately to laboratory.
• Give proper care of equipments used

5. Document the amount, color, consistency of sputum, (thick, watery, tenacious) and presence of blood in the sputum.
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Collecting a Timed Urine Specimen

Purpose
• For some tests of renal functions and urine compositions, such as:- measuring the level of or hormones, such as adrenocortico steroid hormone creatinine clearance or protein quantitation tests.

Equipments Required
• Urine specimen collecting materials (usually obtained from the laboratory and kept in the patient's bathroom.)
• Format for recording the time, date started and end, and the amount of urine collected on each patient's voiding during the specified period for collection.

Procedure
1. Patient preparation
• Adequate explanation to the patient about the purpose of the test, when it begins and what to do with the urine
• Place alert signs about the specimen collection at the patient's bedside or bathroom.
• Label the specimen container to include date and time of each voiding as well as patient's identification data
• Containers may be numbered sequentially (e.g. 1st, 2nd, 3rd etc) in case of 24-hours urine collection.

2. Collecting the urine
• Usually it begin in the morning
• Before you begin the timing, the patient should void and do not use this urine (It is the urine that has been in the bladder some time)
• Then all urine voided during the specified time (e.g. the next 24 hours) is collected in the container
• At the end of the time (e.g. 24 hours period) the patient should void the last specimen, which is added to the rest.
• Ensure that urine is free of feces
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Collecting Urine Specimen

Types of urine specimen collection
1. Clean voided urine specimen (Also called clean catch or midstream urine specimen)
2. Sterile urine specimen
3. Timed urine specimen

• It is two types
Short period → 1-2 hours
Long period → 24 hours

Purpose
• For diagnostic purposes
  - Routine laboratory analysis and culture and sensitivity tests

Equipments Required
• Disposable gloves
• Specimen container
• Laboratory requisition form (Completely filled)
• Water and soap or cotton balls and antiseptic solutions (swabs).

For patients confined
• Urine receptacles (i.e. bedpan or urinals)
• Bed protecting materials
• Screen (if required)

Procedure
For ambulatory patients
Give adequate instruction to the patient about
• The purpose and method of taking specimen
• Assist the patient to move to the toilet

For patient confined in bed
1. Prepare the patient unit providing privacy
2. Prepare the patient
• Put on gloves
• Place bed protecting materials under patient's hips
• Assist the patient to position in bed and in positioning the receptacles
• Assist the patient or clean the vulva or penis thoroughly using soap and water or antiseptic swabs (Follow the steps of giving and receiving bed pan/urinal and cleaning the genitalia)

3. Obtain urine specimen
• Ask patient to void
• Let the initial part of the voiding passed into the receptacle (bed pan or urinal) then pass the next part (the midstream) into the specimen container.
• Hold the vulva or penis apart from the specimen container while the patient voids to decrease urine contamination.
• Don't allow the container to touch body parts
• Collect about 30-60 ml midstream urine
• Handle the outside parts of the container and put on the cover tightly on specimen container
• Clean the outside parts of the container with cotton if spillage occurs
• Remove the glove

4. Recomfort the patient

5. Care of the specimen and the equipment
• Handle and label the container correctly
• Send the urine specimen to the laboratory immediately together with the completed laboratory requested forms
• Empty the receptacles content properly
• Give appropriate care for the used equipments

6. Document pertinent data and report, such as
• Specimen collected, amount, time and date.
• Consistency of the urine
• Patients experience during voiding

Sterile urine specimen 
collected using a catheter in aseptic techniques (The whole discussion for this procedure presented on the catheterization part)
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Collecting Stool Specimen

Purpose
• For laboratory diagnosis, such as microscopic examination, culture and sensitivity tests.

Equipments required
◘ Clean bedpan or commode
◘ Wooden spatula or applicator
◘ Specimen container
◘ Tissue paper
◘ Laboratory requests
◘ Disposable glove, for patients confined in bed
◘ Bed protecting materials
◘ Screen

Procedure
For ambulatory patient
Give adequate instruction to the patient to
• Defecate in clean bedpan or commode (toilet)
• Avoid contaminating the specimen by urine, menstrual period or used tissue papers, because these may affect the laboratory analysis.
• Void before collecting the specimen
• Transfer the sample (specimen) to the container using spatula or applicator

For patients confined in bed
1. Prepare the patient's unit
• Provide privacy by drawing screen, closing windows and doors (To provide privacy)

2. Prepare the patient
• Put on gloves
• Position the patient
• Place bed protecting materials under the patient's hips
• Assist the patient and place the bed pan under the patient's buttocks (follow the steps under "Giving and removing bedpan")
• Give patient privacy by leaving alone, but not far
• Instruct the patient about how to notify you when finished defecation.
• Remove the bedpan and keep on safe place by covering it
• Recomfort the patient

3. Obtain stool sample
• Take the used bedpan to utility room/toilet container using spatula or applicator without contaminating the outside of the container.
• The amount of stool specimen to be taken depends on the purpose, but usually takes.
o 3.5 gm sample from formed stool
o 15.30 ml sample from liquid stool
• Visible mucus, pus or blood should be included into sample stool specimen taken.

4. Care of equipments and the specimen collected.
• Handle and label the specimen correctly
• Send the specimen to the laboratory immediately, unless there is an order for its handling. Because fresh specimen provides the most accurate results.
• Dispose the bedpan's content and give proper care of all equipments used.

5. Documentation and report
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General Considerations for Specimen Collection

When collecting specimen, wear gloves to protect self from contact with body fluids.

1. Get request for specimen collection and identify the types of specimen being collected and the patient from which the specimen collected.

2. Give adequate explanation to the patient about the purpose, type of specimen being collected and the method used.

3. Assemble and organize all the necessary materials for the specimen collection.

4. Get the appropriate specimen container and it should be clearly labeled have tight cover to seal the content and placed in the plastic bag or racks, so that it protects the laboratory technician from contamination while handling it.
• The patient's identification such as, name, age, card number, the ward and bed number (if in-patient).
• The types of specimen and method used (if needed).
• The time and date of the specimen collected.

6. Put the collected specimen into its container without contaminating outer parts of the container and its cover. All the specimens should be sent promptly to the laboratory, so that the temperature and time changes do not alter the content.


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Specimen Collection

Learning Objectives:
At the end of this chapter, students will be able to:

• Identify at least three reasons for laboratory examination of urine.
• Demonstrate correct collection of the following urine specimens: midstream, 24-hours, fractional, and indwelling urine catheter.
• Explain at least one reason for collecting specimen like sputum, blood or stool.
• Demonstrate correct collection of a stool specimen.
• Demonstrate correct collection of a sputum specimen.

Key Terminology:
Hemoglobine
Hematocrite
Leukocyte
Occult
Stroke
Urinalysis

Specimen Collection:
refers to collecting various specimens (samples), such as, stool, urine, blood and other body fluids or tissues, from the patient for diagnostic or therapeutic purposes. Various types of specimen collected from the patient in the clinical settings, either in out patient departments (OPD) or in-patient units, for diagnostic and therapeutic purposes. These includes, stool, urine, blood and other body fluid or tissue specimens.

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Assessing Blood pressure

Purpose
◘ To obtain base line measure of arterial blood pressure for subsequent evaluation
◘ To determine the clients homodynamic status
◘ To identify and monitor changes in blood pressure resulting from a disease process and medical therapy.

EQUEPMENT
◘ Stethoscope
◘ Blood pressure cuff of the appropriate size
◘ Sphygmomanometer

Procedure
1. Prepare and position the patient appropriately
• Make sure that the client has not smoked or ingested caffeine, with in 30 minutes prior to measurement.
• Position the patient in sitting position, unless otherwise specified. The arm should be slightly flexed with the palm of the hand facing up and the fore arm supported at heart level
• Expose the upper arm

2. Wrap the deflated cuff evenly around the upper arm.
• Apply the center of the bladder directly over the medial aspect of the arm. The bladder inside the cuff must be directly over the artery to be compressed if the reading to be accurate.
• For adult, place the lower border of the cuff approximately 2 cm above antecubital space.

3. For initial examination, perform preliminary palipatory determination of systolic pressure
• Palpate the brachial artery with the finger tips
• Close the valve on the pump by turning the knob clockwise.
• Pump up the cuff until you no longer feel the brachial pulse
• Note the pressure on sphygmomanometer at which the pulse is no longer felt
• Release the pressure completely in the cuff, and wait 1 to 2 minutes before making further measurement

4. Position the stethoscope appropriately
• Insert the ear attachments of the stethoscope in your ears so that they tilt slightly fore ward.
• Place the diaphragm of the stethoscope over the brachial pulse; hold the diaphragm with the thumb and index finger.

5. Auscultate the client's blood pressure
• Pump up the cuff until the sphygmomanometer registers about 30 mm Hg above the point where the brachial pulse disappeared.
• Release the valve on the cuff carefully so that the pressure decreases at the rate 2-3 mmHg per second.
• As the pressure falls, identify the manometer reading at each of the five phases
• Deflate the cuff rapidly and completely
• Repeat the above step once or twice as necessary to confirm the accuracy of the reading.

6. Remove the cuff from the client’s arm

7. For initial determination, repeat the procedure on the client's other arm, there should be a difference of no more than 5 to 10 mmHg between the arms. The arm found to have the higher pressure, should be used for subsequent examinations

8. Document and report pertinent assessment data, report any significant change in client's blood pressure to the nurse in charge. Also report these finding:

A. Systolic blood pressure (of adult) above 140 mmHg.
B. Diastolic blood pressure (of an adult) above 90 mmHg
C. Systolic blood pressure of (an adult) below 100mmHg

Study questions
1. Explain vital sings and list what it includes.
2. Identify important times to assess vital signs.
3. Mention some of the factors affecting body temperature.
4. What does pulse deficit mean?
5. Define arterial blood pressure.
6. Explain the two methods of assessing blood pressure.
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Methods of Measuring Blood Pressure

Blood pressure can be assessed directly or indirectly

1. Direct (invasive monitoring) measurement involves the insertion of catheter in to the brachial, radial, or femoral artery. The physician inserts the catheter and the nurse monitors the pressure reading. With use of correct placement, it is highly accurate.

1. Indirect (non invasive methods)
A. The auscultatory
B. The palpatory, and

The auscultatory method is the commonest method used in health activities. When taking blood pressure using stethoscope, the nurse identifies five phases in series of sounds called Korotkoff's sound.

Phase 1: The pressure level at which the 1st joint clear tapping sound is heard, these sounds gradually become more intense. To ensure that they are not extraneous sounds, the nurse should identify at least two consecutive tapping sounds.

Phase 2: The period during deflation when the sound has a swishing quality

Phase 3: The period during which the sounds are crisper and more intense

Phase 4: The time when the sounds become muffled and have a soft blowing quality

Phase 5: The pressure level when the sounds disappear
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Three types of blood pressure

1. Systolic pressure: is the pressure of the blood as a result of contraction of the ventricle (is the pressure of the blood at the height of the blood wave);

2. Diastolic blood pressure: is the pressure when the ventricles are at rest.

3. Pulse pressure: is the difference between the systolic and diastolic pressure Blood pressure is measured in mm Hg and recorded as fraction. A number of conditions are reflected by changes in blood pressure.

• An increase in blood pressure is called hypertension; a decrease is called hypotension.

Conditions Affecting Blood Pressure
Fever   Increase
Stress        "
Arteriosclerosis               "
Obesity                           "
Hemorrhage                 Decrease
Low hematocrit               "
External heat                   "
Exposure to cold           Increase

Sites for Measuring Blood Pressure
1. Upper arm - using brachial artery (commonest)
2. Thigh around - popliteal artery
3. Fore arm - using radial artery
4. Leg - using posterior tibial or dorsal pedis
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Types of Breathing

A. Rate: is described in rate per minute (RPM) Healthy adult RR = 15- 20/ min. is measured for full minute, if regular for 30 seconds. As the age decreases the respiratory rate increases.

1. Eupnea- normal breathing rate and depth
2. Bradypnea- slow respiration
3. Tachypnea - fast breathing
5. Apnea - temporary cessation of breathing

B. Rhythm: is the regularity of expiration and inspiration
Normal breathing is automatic & effortless.

C. Depth: described as normal, deep or shallow.
Deep: a large volume of air inhaled & exhaled, inflates most of the lungs.
Shallow: exchange of a small volume of air minimal use of lung tissue.

Blood Pressure: Blood pressure is the pressure exerted by blood against the wall of blood vessels. It includes arterial, venous and capillary pressures.

Arterial BP: it is a measure of a pressure exerted by the blood as it flows through the arteries. Arterial blood pressure (BP) = cardiac output (CO) x total peripheral resistance (TPR).
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Two Types of Breathing

1. Costal (thoracic)
• Involves the external muscles and other accessory muscles (sternoclodio mastoid)
• Observed by the movement of the chest up ward and down ward. Commonly used for adults

2. Diaphragmatic (abdominal)
• Involves the contraction and relaxation of the diaphragm, observed by the movement of abdomen. Commonly used for children.

Assessment
• The client should be at rest
• Assessed by watching the movement of the chest or abdomen.
• Rate, rhythm, depth and special characteristics of respiration are assessed
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Procedure for measuring radial pulse

• Wash hands

• Explain the procedure to the client

• Position the client’s fore arm comfortably with the wrist extended and the palm down

• Place the tips of your first, second, and third fingers over the client’s radial artery on the inside of the wrist on the thumb side.

• Press gently against the client’s radial artery to the point where pulsation can be felt distinctly

• Using a watch, count the pulse beats for 30 seconds and multiply by two to get the rate per minute

• Count the pulse for full minute if it is abnormal in any way or take an apical pulse

• Record the rate (BPM) on paper or the flow sheet. Report any irregular findings to appropriate person

• Wash your hands

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Pulse Sites

Temporal: is superior (above) and lateral to (away from the midline of) the eye

1. Carotid: at the side of the neck below tube of the ear (where the carotid artery runs between the trachea and the sternoclidiomastoid muscle)

2. Temporal: the pulse is taken at temporal bone area.

3. Apical: at the apex of the heart: routinely used for infant and children < 3 yrs

In adults – Left midclavicular line under the 4th, 5th, 6th intercostals space
Children < 4 yrs of the Lt. mid clavicular line

4. Brachial: at the inner aspect of the biceps muscle of the arm or medially in the antecubital space (elbow crease)

5. Radial: on the thumb side of the inner aspect of the wrist – readily available and routinely used

6. Femoral: along the inguinal ligament. Used or infants and children

7. Popiliteal: behind the knee. By flexing the knee slightly

8. Posterior tibial: on the medial surface of the ankle

9. Pedal (Dorslais Pedis): palpated by feeling the dorsum (upper surface) of the foot on an imaginary line drawn from the middle of the ankle to the surface between the big and 2nd toes
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Factors Affecting Pulse Rates

1. Age: as age increase the PR gradually decreases. New born to 1 month – 130 BPM 80-180 (range) Adult 80 BPM (beat per minute) – 60 – 100 BPM (beat per minute)

2. Sex: after puberty the average males PR is slightly lower than female

3. Exercise: PR increase with exercise

4. Fever: increases PR in response to the lowered B/P that results from peripheral vasodilatation – increased metabolic rate

5. Medications: digitalis preparation decreases PR, Epinephrine– increases PR

6. Heat: increase PR as a compensatory mechanism

7. Stress: increases the sympathetic nerve stimulation – increases the rate and force of heart beat

8. Position changes: when a patient assumes a sitting or standing position blood usually pools in dependent vessels of the venous system. Pooling results in a transient decrease in the venous blood return to heart and subsequent decrease in BP increases heart rate.

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3 types of Pulse

It is a wave of blood created by contraction of the left ventricle of the heart. i.e. the pulse reflects the heart beat or is the same as the rate of ventricular contractions of the heart – in a healthy person. In some types of cardiovascular diseases heartbeat and pulse rate differs. E.G. Client's heart produces very weak or small pulses that are not detectable in a peripheral pulse far from the heart

Peripheral Pulse: is a pulse located in the periphery of the body e.g. in the foot, and or neck

Apical Pulse (central pulse): it is located at the apex of the heart The PR is expressed in beats/ minute (BPM)

Pulse Deficit- It is a difference that exists between the apical and radial pulse
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Tympanic Temperature Procedure

The tympanic temperature is placed snugly in to the client’s outer ear canal. It records temperature in 1 to 2 seconds. Many pediatric and intensive care units use this type of thermometer because it records a temperature so rapidly.

Procedure
• Wash the hands
• Explain the procedure to the client to ensure cooperation and understanding
• Hold the probe in the dominant hand. Use the client’s same ear as your hand (e.g. use the client’s right ear when you use your right hand).
• Select the desired mode of temperature. Use the rectal equivalent for children under 3 years of age Wait for “ready” message to display.
• With your nondominant hand, grasp the adult’s external ear at the midpoint. Pull the external ear up and back. For a child of 6 years or younger, use your nondominant hand to pull the ear down and back.
• Slowly advance the probe in to the client’s ear with a back and forth motion until it seals the ear canal.
• Point the probe’s tip in an imaginary line from the client’s sideburns to his or her opposite eyebrow.
• As soon as the instrument is in correct position, press the button to activate the thermometer.
• Keep the probe in place until the thermometer makes a sound or flashes a light.
• Read the temperature and discard the probe cover. Replace the thermometer and wash your hands.
• Record the temperature on the client’s record.

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Axillary Procedure

Procedure
• Wash hands
• Make sure that the client’s axilla is dry, If it is moist, pat it dry gently before inserting the thermometer.
• After placing the bulb of the thermometer in to the axilla, bring the client’s arm down against the body as tightly as possible, with the forearm resting across chest.
• Hold the glass thermometer in place for 8 to 10 minutes. Hold the electronic thermometer in place until the reading registers directly
• Remove and read the thermometer. Dispose of the equipment properly. Wash hands
• Record the reading
N.B. The axillary method is safest and most noninvasive.
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Oral Procedure

Procedure
• Explain the procedure to the patient

• Wash hands and assemble necessary equipment and bring to the patient bedside.

• Position the person comfortably and request the patient to open the mouth;

• Hold the thermometer firmly with the thumb and fore finger; shake it with strong wrist movements until the mercury line falls to at least 35 oc .

• Place the bulb of the thermometer well under the client’s tongue. Instruct the client to close the lips (not the teeth) around the bulb. Ensure that the bulb rests
well under the tongue, where it will be in contact with blood vessels close to the surface.

• Remove the thermometer after 3 to 5 minutes, according to the agency guidelines.

• Remove the thermometer, wipe it using it once a firm twisting motion

• Hold the thermometer at eye level. Read to the nearest tenth

• Dispose the tissue. Wash the thermometer in lukewarm, soapy water. Dry and replace the thermometer in a container at bedside. Wash your hands.

• Record temperature on paper or flow sheet. Report an abnormal reading to the appropriate person.

Contraindication
• Child below 7 yrs
• If the patient is delirious, mentally ill
• Unconscious
• Uncooperative or in severe pain
• Surgery of the mouth
• Nasal obstruction
• If patient has nasal or gastric tubs in place
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Rectal Temperature Procedure

Readings are considered to be more accurate, most reliable, is > 0.650 c (1 0F) higher than the oral temperature.

Procedure
• Explain the procedure to the patient
• Wash hands and assemble necessary equipment and bring to the patient bedside.
• Position the person laterally;
• Apply lubricant 2.5 cm above the bulb;
• Insert the thermometer 1.5 – 4 cm into the anus. For an infant 2.5cm, for a child 3.7 cm – for an adults 4 cm
• Measured for 2-3 minutes
• Remove the thermometer and read the finding
• Clean the thermometer with tissue paper
• A rectal thermometer record does not respond to changes in arterial temperature as quickly as an oral thermometer

Contraindications
• Rectal or perineal surgery;
• Fecal impaction – the depth of the thermometer insertion may be insufficient;
• Rectal infection;
• Neonates –can cause rectal perforation and ulceration;

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Measuring Body Temperature

Sites to Measure Temperature
Most common are:
• Oral
• Rectal
• Axillary
• Tympanic

Thermometer: is an instrument used to measure body temperature

Types
1. Oral thermometer
   • Has long slender tips
2. Rectal thermometer
   • Short, rounded tips
3. Axillary
   • Long and slender tip
4. Tympanic

In other way it is also divided as mercury, digital and electronic types. In developed countries, mercury type thermometers are no more use in hospital setup but in our context still very important.
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Factors Affecting Body Temperature

1. Age
• Children’s temperature continue to be more labile than those of adults until puberty
• Elderly people, particularly those > 75 are at risk of hypothermia
• Normal body temperature of the newborn if taken orally is 37 0C.

2. Diurnal variations (circadian rhythms)
• Body temperature varies through out the day
• The point of highest body temperature is usually reached between 8:00 p.m. and midnight and lowest point is reached during sleep between 4:00 and 6:00 a.m.

3. Exercise
• Hard or strenuous exercise can increase body temperature to as high as 38.3 – 40 c – measured rectally

4. Hormones
• In women progesterone secretion at the time of ovulation raises body temperature by about 0.3 – 0.6oc above basal temperature.

5. Stress
• Stimulation of skin can increases the production of epinephrine and nor epinephrine – which increases metabolic activity and heat production.

6. Environment
• Extremes in temperature can affect a person’s temperature regulatory systems.

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Common Types of Fevers

1. Intermittent fever: the body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperature.

2. Remittent fever: a wide range of temperature fluctuation (more than 2 0c) occurs over the 24 hr period, all of which are above normal

3. Relapsing fever: short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature.

4. Constant fever: the body temperature fluctuates minimally but always remains above normal
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There are Two Kinds of Body Temperature

1. Core Temperature
• Is the Temperature of the deep tissues of the body, such as the cranium, thorax, abdominal cavity, and pelvic cavity
• Remains relatively constant
• Is the Temperature that we measure with thermometer

2. Surface Temperature
• The temperature of the skin, the subcutaneous tissue and fat
Alterations in Body Temperature
Normal body temperature is 370 C or 98.6 0F (Average) the range is 36-38 0c (96.8 – 100 0F)

Pyrexia: a body temperature above the normal ranges 38 0c – 410 c (100.4 – 105.8 F)

Hyper pyrexia: a very high fever, such as 410 C > 42 0c leads to death. A client who has fever is referred as febrile; the one who has not is afebrile.

Hypothermia: – body temperature between 34 0c – 35 0c, < 34 0c is death
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Times to Assess Vital Signs

1. On admission – to obtain baseline date
2. When a client has a change in health status or reports symptoms such as chest pain or fainting
3. According to a nursing or medical order
4. Before and after the administration of certain medications that could affect RR or BP (Respiratory and CVS (Cardio Vascular System))
5. Before and after surgery or an invasive diagnostic procedures
6. Before and after any nursing intervention that could affect the vital signs. E.g. Ambulation
7. According to hospital /other health institution policy.

Temperature – Body temperature is the measurement of heat inside a person’s body (core temperature); it is the balance between heat produced and heat lost. Normal body temperature using oral (O; or per os, PO) measurement remains as appropriately 370 celsius or 98.6 0 F.

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Vital Signs (Cardinal Signs)

Vital signs reflect the body’s physiologic status and provide information critical to evaluating homeostatic balance. The term “vital” is used because the information gathered is the clearest indicator of overall health status.

Vital sign Includes: T (temperature), PR (Pulse Rate), RR (Respiratory Rate), and BP (Blood Pressure)

Key Terminology
- apical pulse - Korotokoff’
               - tympanic
- apex - oral
- apnea - orthopnea
- axilla - palpation
- bradycardia - pedal pulse
- bradypnea - popliteal pulse
- carotid pulse - pulse
- cheyne-stokes respiration - pulse pressure
- cyanosis - radial pulse
- diastole - rectal
- dyspnea - sphygmomanometer
- eupnea - stetoscope
- femoral pulse - systolic
- fever - tachycardia
- hypertension - temperature
- hypotension - thermometer

Acronyms
BP - PR - PO - oc
RR - CVS - B - oF
T - O - BPM

Purposes:
• To obtain base line data about the patient condition
• To aid in diagnosing patient condition (diagnostic purpose)
• For therapeutic purpose so that to intervene accordingly

Equipment
• Vital sign tray
• Stethoscope
• Sphygmomanometer
• Thermometer (glasses, electronic and tympanic)
• Second hand watch
• Red and blue pen
• Pencil;
• Vital sign sheet
• Cotton swab in bowel
• Disposable gloves if available
• Dirty receiver kidney dish
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Vital Signs

Learning Objectives

At the end of the unit the learner will be able to:
• Describe the procedures used to assess the vital signs: temperature, pulse, respiration, and blood pressure.
• Identify factors that can influence each vital sign.
• Identify equipment routinely used to assess vital signs.
• Identify rationales for using different routes for assessing temperature.
• Identify the location of commonly assessed pulse sites.
• Take vital signs and interpret the finding.
• Document the vital signs.
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