Addendum

Card Set Information

Author:
stephrigu
ID:
65107
Filename:
Addendum
Updated:
2011-02-08 20:52:22
Tags:
vital signs
Folders:

Description:
normal values for adult vital signs and addendum to required readings
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  1. Temperature: Oral
    • 98.6⁰F (Plus/Minus 1 Degree) 2 min to read
    • (WAit 20-30 minutes after drinking anything hot or cold or smoking)
  2. Temperature: Axillary
    97.6⁰F (Plus/Minus 1 Degree) 5-10 min to read
  3. Temperature: Rectal
    99.6⁰F (Plus/Minus 1 Degree) 2 min to read
  4. Pulse
    60 - 100 beats per minute
  5. Respiration
    12-20 breaths per minute
  6. Blood Pressure
    90/60 - 120/80
  7. Pre-hypertension
    120/80 - 139/89
  8. Hypertension
    140/90
  9. Pain Scale
    Scale 0 - 10
  10. Pulse Oximetry (0₂ Sat)
    95% - 100% on room air
  11. Enema
    • 100⁰ - 105⁰F
    • (1000mL, left side, 12-18'' height, lube, insert 3-4 inches, clean gloves)
  12. Oil Retention Enema
    120 mL @ room temp
  13. Harris Flush
    • 100⁰ - 105⁰ F
    • (1000 mL, Lube, 250-300 mL each time)
  14. Apical-Radial Deficit
    Two nurses taking apical and radial pulse for 1 full minute simultaneously
  15. Foley Irrigation
    Wipe the connection with alcohol before disconnecting. Use clean gloves
  16. Wound Irrigation
    Use clean gloves to irrigate wound
  17. Anti-thrombus devices
    • TED Hose Stockings, and Thromboguards (SCDs')
    • Remove every 8 hours for 30 minutes or per hospital policy
  18. NG feeding
    • Residuals: (Rate Dependent) The following will be used unless ordered otherwise:
    • Check every 6 hours for placement

    • 1. Auscultate
    • for gurgling

    • 2. Aspirate
    • contents

    • 3. Gastric
    • content – pH of 4 or less
  19. NG Feeding: Less than 100% of rate
    continued as ordered
  20. NG Feeding: 100% -200% of rate
    • decrease rate by 50%, recheck in 3 hours
    • After 3 hours if greater than 100% then STOP feeding
  21. NG Feeding: Greater than 200% of rate
    STOP feeding, call physician per protocol
  22. NG Feeding: In the event of vomiting
    STOP feeding, call physician per protocol

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