What is normal respiration range?
12-20
What is a normal pulse range?
60-80
What is normal BP ranges?
Systolic less than 120
Diastolic less than 80
What do you tell the patient you are doing when you walk in?
Today I am here to give you your 8 o’clock medications,complete a head to toe assessment and take some vital signs. Do you have any questions?
Before you take vital signs what info will you get?
Oxygen saturation level
What will you do if it’s low/below 90?
- put head of bed up
- look for PRN for oxygen
Before you take vitals you will get patients pain scale
- Are you having any pain right now?
- If you were to rate that pain on a 0-10 scale with zero being no pain and 10 being the most pain where would you place that pain
- Check for PRN pain med
- Ask if they want it
- Ask if anything makes the pain better or worse
True or false
Include apical pulse with vital signs
True
What order should you do vitals?
- Radial pulse (1st 30 secs)
- Respiratory rate (2nd 30 secs)
- BP
- Apical pulse (listen under gown!) listen for 30 if regular, 1 min for some meds…digoxin…or if it’s irregular
Now check IV
For lines, drains, airways
- Check IV
Is that causing you any pain or discomfort?
I don’t see any redness, heat or swelling at the site.
- Check IV rate (0.9% sodium chloride aka normal saline…..rate is 50 an hour)
A&O x 3
- Do you know where you’re at today?
- Do you know what day it is today?
- State your name for me again?
When giving medications….
- Look at order sheet, compare to MAR
- Note allergies
- Set up meds
What are the 3 checks?
- Check bottle label with MAR
- Open bottle pour pill into cap , compare label with MAR
- Dump pill into container, check label with MAR again
Before you give meds what must you do?
Recheck patients wristband!!!!!
Compare name and medical record number
Teach about meds….ask if they have any questions and ask if they have difficulty swallowing…..have them sip water ask if it went down ok
Head to toe assessment ….
- Look/feel head
- Look at eyes penlight….say sclera is white..no drainage
- Look at ears penlight
- Look at mouth, nose penlight
- Position bed at 30 degree angle
- Note any neck vein distention
- Check IV again
- Note skin temp: dry, warm, pink in color and check skin turgor
- Check capillary refill: less than 3 seconds
- Test strength: squeeze hand
- Push up against hands, press down against hands
- Put arms strain out in front close eyes, look for arm drift…. Check pulses
- Listen for lung sounds: 3 locations on front and verbalize 6 locations on back…. Note that you would look for skin integrity
- Ask about cough, SOB
- Recheck O2 sats
- Ask about bowel movement and gas
- Look at abdomen, note areas of distention
- Listen for bowel sounds, note active in all 4 quadrants
- Palpate abdomen
- Put on gloves
- Check foley catheter( if patient has one)
- Inspection insertion site, leakage?, inspect bag note color, quantity, quality
- If they don’t have a catheter (when you pass urine do you have any pain,burning or itching ? Have you been independent up to he bathroom.)
- Check patient leg: skin warm, dry, edema?
- Check capillary refill on toes on both feet
- Check pedal pulses ( note if they are equal and present)
- Check for deep vein thrombosis (assist them in pointing toes to head and ask if there’s any pain in calf)
- Have them point toes away and towards chin( pull / push)
- Ask what toes your holding
- If you give a pain med specifically state you will be back in 30-60 min to reassess, checking pain rating
Head to toe assessment: head
- Look/feel head
- Look at eyes penlight….say sclera is white..no drainage
- Look at ears penlight
- Look at mouth, nose penlight
- Position bed at 30 degree angle
- Note any neck vein distention
Head to toe assessment: musculoskeletal arms
- Check IV again
- Note skin temp: dry, warm, pink in color and check skin turgor
- Check capillary refill: less than 3 seconds
- Test strength: squeeze hand
- Push up against hands, press down against hands
- Put arms strain out in front close eyes, look for arm drift…. Check pulses
Head to toe assessment: respiratory
- Listen for lung sounds: 3 locations on front and verbalize 6 locations on back…. Note that you would look for skin integrity
- Ask about cough, SOB
- Recheck O2 sats
Head to toe assessment : abdomen
- Ask about bowel movement and gas
- Look at abdomen, note areas of distention
- Listen for bowel sounds, note active in all 4 quadrants
- Palpate abdomen
- Put on gloves
- Check foley catheter( if patient has one)
- Inspection insertion site, leakage?, inspect bag note color, quantity, quality
- If they don’t have a catheter (when you pass urine do you have any pain,burning or itching ? Have you been independent up to he bathroom.)
Head to toe assessment : musculoskeletal legs
- Check patient leg: skin warm, dry, edema?
- Check capillary refill on toes on both feet
- Check pedal pulses ( note if they are equal and present)
- Check for deep vein thrombosis (assist them in pointing toes to head and ask if there’s any pain in calf)
- Have them point toes away and towards chin( pull / push)
- Ask what toes your holding
- If you give a pain med specifically state you will be back in 30-60 min to reassess, checking pain rating
Coumadin
Reduces ability of the blood to clot
Helps prevent pulmonary embolisms, MI, rheumatic heart disease, prosthetic heart valves, and chronic atrial fibrillation
Christina is taking it for CAD and atrial fibrillation
Aricept
Temporarily improved cognitive function in patients with Alzheimer’s disease
Christina is taking it for dementia/Alzheimer’s
Prednisone
Relieves airway inflammation
Christina is taking it for her COPD
Prilosec
Relieve symptoms caused by excessive gastric acid
Christina is taking it
Correction Scale qid ac meals and hs:
Aspart Novolog Flex Pen
Blood Glucose 0-100 give 0 units
101-150 give 2 units
151-200 give 4 units
201-250 give 6 units
251-300 give 8 units
301 or > contact Physician
