NR 224: Final Exam Concept Blueprint

A. Medication Administration Chapter 31

1.) 7 rights of medication administration

• Right Medication
• Right Dose
• Right Patient
• Right Route
• Right Time
• Right Documentation
• Right Indication

2.) How many times do you check medications prior to giving them? Describe each of those times and why it is needed?

• You should check meds 3 times.

3.) How to open packages skills procedure-from your book:

• Safety (ampules, needles)
  • Snap off ampule neck
  • Aspirate medication into syringe
  • Replace filter needle with appropriate size needles device
  • Admin injection
• Aseptic technique (vials)
  • If dry, use solvent or diluent as needed
  • Inject air into vial
  • Label multidose vials after mixing
  • Refrigerate remaining doses if needed
• Aseptic technique topical medications
  • Ask pts if they take any topical meds
  • When applying a transdermal patch, ask pt if they have an existing patch
  • Wear disposable clean gloves when removing and applying transdermal patches
  • If the dressing or patch is difficult to see, apply a noticeable label to the patch
  • Document patch or med location on the MAR and document the Removal
  • Checking packages for integrity/expiration date & proper labeling

4.) Factors affecting different routes of administration:

• Absorption
  • Absorption occurs when medication molecules pass into the blood from the site of medication administration. Factors that influence absorption are route of the administration (different rate of absorption), the ability of the medication to dissolve (depends largely on its form of preparation), blood flow to the site of administration (it will determine how quickly the body can absorb a medication), body surface area (it is absorbed at a faster rate), liquid solubility (highly lipid-soluble medications cross cell membranes easily and are absorbed quickly)
• Metabolism
  • After a medication reaches the site of action, it becomes metabolized into a less active or inactive form that is easier to excrete. Biotransformation occurs under the influence of enzymes that detoxify, break down, and remove biologically active chemicals.
• Distribution
  • After a medication is absorbed, it is distributed within the body to tissues and organs and ultimately to its specific site of action. The rate and extent of distribution depend on the physical and chemical properties of the person.
  • Circulation: once a medication enters the bloodstream, it is carried throughout the tissues and organs. How fast it reaches depends on vascularity. Patients with HF have impaired circulation, which slows medication delivery.
  • Membrane permeability: refers to the ability of a medication to pass through tissues and membranes to enter target cells. Blood-brain barrier allows only fat-soluble medications to pass into the brain and cerebral spinal fluid.
  • Protein binding: the degree in which medications bind to serum proteins such as albumin affects their distribution. Patients with liver disease or malnutrition have decreased albumin, which causes them to be at higher risk for medication activity, toxicity, or both.
• Elimination
  • After medications are metabolized, they exit the body through the kidneys, liver, bowel, lungs, and exocrine glands. Chemical makeup of a medication determines the organ of excretion.
  • Gaseous and volatile compounds such as nitrous oxide and alcohol exit through the lungs.
  • GI tract is another route for medication excretion. Factors that increase peristalsis accelerate medication excretion through the feces, whereas factors of slow peristalsis often prolong the effects of a medication.

5.) How to describe procedure for different routes of administration. Use the book skills procedure and rationale for all of these!!!

• Oral
  • Easiest and most desirable route
  • Food sometimes affects absorption
  • Protect patients from aspiration
  • Follow special precautions when administering medications to patients with enteral or small-bore feeding tubes
  • Follow tubing connection standards
  • Verify tube is compatible with medication absorption
  • Use liquid medications when possible
  • Flush between medications
• Sublingual
  • Administered under the tongue, sublingual pocket. Do not bite, let it dissolve.
• Buccal
  • Administered between cheek and molars.
• Ear instillation
  • Instill eardrops at room temperature
  • Use sterile solutions
  • Check with healthcare provider for eardrum rupture if patient has ear drainage
  • Never occlude the ear canal
  • Irrigation: Performed to remove cerumen that cannot be removed with wax softeners
  • Have pt stay with affected ear up for about 5 min after med admin
• Eye instillation
  • Avoid the cornea
  • Avoid touching the eye or eyelid with droppers or tubes
  • Use only on the affected eye
  • Never share eye medications
  • Intraocular instillation
    • Disk resembles a contact lens
    • Teach patients how to insert and remove the disk
    • Teach about adverse effects
    • Educate your patients and family caregivers about the proper techniques for administering them. Evaluate pts and family caregivers’ ability to self-administer through a return demonstration of the procedure.
    • Eyedrops administration: when you give eyedrops, you want to make sure that you are starting out with a clean area/eyes… so if there’s crust, etc., clean it. Never wipe toward the inner canthus (the tear duct), as it could cause infection. So remember to wipe from clean to dirty. Inner to outer. When handling an eyedropper, do not touch any part of the applicator. Keep a lid on it when you are not using it, and do not set the lid on something dirty. Use the dominant hand to hold the dropper and rest the palm of your hand on their forehead. Use the other hand to pull down the conjunctiva to administer drops. Once you administer, have the eyedropper 1-2 inches above the conjunctival sac. Put light pressure on the eye for a minute or two where you put the drops.

6.) Steps for drawing up medication from a vial

• Skills Procedure in book
  • Gather your supplies
  • Perform hand hygiene
  • Clean the vial’s top with alcohol prep
  • Attach the appropriate needle
  • Stick the needle using a technique to prevent coring of the rubber on the vial (start with a 45-degree angle and as you puncture the vial, rotate the needle to a 90-degree angle in one smooth motion)
  • Push air into the vial equal to the amount of medication you plan to draw
  • Invert the vial to withdraw medication
  • Remove air bubbles
  • Confirm that you have the proper amount of medication
  • Remove vial and needle
  • Apply a new needle

7.) Steps for drawing up Insulin

• Skills Procedure in book
  • You have to put air in the vial because it will be hard to take out
  • Clear is regular acting insulin
  • Cloudy is long/intermediate. NPH
  • The R is what you draw first. Then draw the N.
  • Air in NPH. Don’t take it out. Start with the R and then draw the N.
  • If you stick yourself with a needle just wash with soap and water
  • Check physician’s order
  • Check to see if you have the right medication
  • Patient teaching on subcutaneous injection
  • Perform hand hygiene
  • Don gloves
  • Mix NPH “cloudy” solution by gently rotating vial between the palms of the hands
  • Clean the top of vials (5-30 secs)
  • Remove the cap of syringe
  • Start with regular insulin and then go to cloudy
  • Inject air in cloudy insulin
  • Remove syringe
  • Inject air into regular insulin (do not remove syringe)
  • Flip vial and remove amount needed
  • Remove vial
  • Remove the amount needed from cloudy
  • Scoop technique if you’re not using it
  • Drawing up 2 different insulins - principles are “clear to cloudy” so remember how to draw up both. Inject air into cloudy, then inject air into and draw from regular (clear). Last draw from the other insulin bottle (cloudy).

8.) Patient teaching on subcutaneous injection

B.) Medication administration dosage calculations. Know this well because there are many dosage calculations on the exam, and you must be able to do them with some quickness (that means knowing your method of dosage calculation well—either proportion: ratio method, formula method, or dimensional analysis).

• 1 lb = 16 oz
• 1 oz = 30 mL
• 1 tsp = 5 mL
• 1 tbsp = 15 mL
• 1,000 mL = 1 L
• 30 mL = 1 oz
• 1,000 mcg = 1 mg
• 1,000 mg = 1 g
• 1,000 g = 1 kg
• 2.54 cm = 1 in.
• meQ (milli-equivalent and units do NOT convert, they are their own units of measurement)
• 1 cup = 8 oz = 240 mL
• AC = before meals
• PC = after meals
• QID = 4 X’s/ day
• h = hour
• TID = three times/ day
• BID = twice a day

1.) IV fluid rates - if you have x mL in 8 hours, how many mL per hour will you set the pump?

• READ DIRECTIONS FOR QUESTIONS CAREFULLY. Use proper rounding for whatever that question is asking!!

2.) When do I use a leading zero?

• When do leading zeros apply? Example: ½ is 0.5; it is never .5 (avoids errors). Never use a trailing zero.

3.) What is the safety principle for NOT using a trailing zero? What kind of mistakes can be made?

4.) Preventing Needle-stick injuries and what happens if a needle-stick happens to you?

• 1st thing you’re going to do is wash the area with soap and water.

C.) Bowel Elimination:

1.) Assessment of regular bowel habits

• 24-hour diet recall, including water.
• When was the last bowel movement?
• Regular pattern? Frequent? Barrier? Ambulation?
• Color? Consistency?
• Determine the usual elimination pattern:
  • Include frequency and time of day. Have a pt or caregiver complete a bowel elimination diary to provide an accurate assessment of bowel elimination patterns.
• Pt’s description of usual stool characteristics:
  • Determine whether the stool is normally watery or formed, soft or hard, and the typical color. Ask pt to describe the shape and # of stools per day. Use a tool such as the Bristol Stool Form Scale to get an objective measure of stool characteristics.
• Identification of routines followed to promote bowel elimination:
  • Ex: drinking hot liquids, specific foods, or taking time to defecate during a certain part of the day or use of laxatives, enemas, or bulk-forming fiber additives.
• Presence and status of bowel diversions:
  • If pt has an ostomy, assess frequency of emptying the ostomy pouch, character of feces, appearance and condition of the stoma (color, height at or above skin level), condition of perisomal skin, type of pouching system device used, and methods used to maintain the function of the ostomy.
• Changes in appetite:
  • Include changes in eating patterns and change in weight (ask if the pt intended to lose weight or if it happened unexpectedly).
• Diet history: Determine pt’s dietary preference. Determine intake of fruits, veggies, and whole grains and whether meal-times are regular or irregular.
• Description of daily fluid intake:
  • This includes the type and amount of fluid. Pts often estimate the amount using common household measurements.
• History of surgery or illnesses affecting the GI tract
• Medication history:
  • Ask the pt for a list of all meds they take and assess whether they take meds such as laxatives, antacids, iron supplements, and analgesics that alter defecation or fecal characteristics.
• Emotional state:
  • This can alter frequency, especially unusual stress.
• History of exercise:
  • Ask the pt to specifically describe the type and amount of daily exercise.
• Ask the pt whether there is a history of abdominal or anal pain
• Social history:
  • Where pts live can affect toileting habits, such as having a private or shared restroom.
• Mobility and dexterity:
  • Determine if they need help from personnel or assistive devices.

2.) Medications for bowel elimination

• Cathartics and laxatives
  • These have short-term action of emptying the bowel. Often used to cleanse the bowel for pts undergoing GI tests and abdominal surgery.
  • Bulk-forming. Should not be taken longer than 5 days.
  • Cathartics have a stronger and more rapid effect on the intestines than laxatives. CAUTION: Educate patients that laxatives are to be used short-term. (Long-term use can actually have the opposite effect)
  • Suppositories may act more quickly than oral medications due to the stimulant effect on the rectal mucosa. Suppositories such as bisacodyl act within 30 min. Give before a pt’s usual time to defecate or immediately after a meal.

3.) Bowel care

• Drink plenty of liquids
• Increase fiber
• Increase movement

4.) Constipation-causes, assessment, interventions

• Causes: Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation (e.g., pt receiving opioids for pain after surgery will often need stool softeners), also female gender and older age at higher risk for constipation.
• Causes of constipation: Overuse of laxatives can also cause constipation. Chronic overuse of laxatives causes the large intestine to lose muscle tone and become less responsive to stimulation by laxatives over time, and because of other factors (like dehydration, mobility, etc.), they become constipated and can be unresponsive to treatment.

5.) Bowel interventions

• Increase liquid, increase fiber (broccoli, oatmeal, bran, apples), increase movement.
• Prune juice, decrease caffeine intake if dehydrated.
• Laxatives (2nd option).
• Enema (last resort).
• High-fiber foods increase the bulk of fecal contents, which, in turn, increases peristalsis and improves the movement of intestinal contents through the GI tract.
• Bran as flakes or fiber supplements add bulk to the feces and increase the number of soft-formed stools. Dietary fiber, through diet or supplement, reduces the need for laxatives.
• Cooking facilities are necessary for the preparation of selected food preferences.
• Caffeinated beverages cause the body to increase the excretion of fluids and dehydrate the patient. Fluids help to keep the fecal mass soft and increase stool bulk, causing an increase in colon peristalsis.
• With aging, some normal changes are noted in rectal sensation, and the body needs larger volumes to elicit the sensation to defecate. Using the normal gastrocolic reflex, which results in the movement of colon contents approximately 1 hour after a meal, assists in establishing routine bowel habits.
• To maintain normal elimination patterns in the hospital, instruct pt to defecate 1 hr after meals; mass peristalsis pushes undigested food toward the rectum. These movements occur only 3-4 times daily, with the strongest during the hour after mealtime.

6.) Emergency bowel dehiscence-assessment and interventions, priority

7.) Stool specimen collection - (skills procedure and rationales in book)

• Stool specimen collection: You set the hat in the toilet to create a bowl, and you’ll use a tongue blade to get a scoop and put it in the cup. You do not ask the pt to poop in that small cup, lol. You’ll put the lid on, label it, and then put it in a biohazard plastic bag and get it sent to the lab immediately.
• Some tests require the specimen to be placed in chemical preservatives, some require it to be refrigerated or placed on ice after collection and before delivery to the lab (helps prevent bacterial growth). Use medical aseptic technique during collection. Most tests require a small amount of stool (1 inch or 15-30 mL if liquid stool).
• Use a wooden stick – test for parasites, etc.

8.) Guaiac stool test—purpose, technique

• When we do a stool collection and they are testing for guaiac, what are they testing for when they have a guaiac order? Blood in the stool. Usually, a small sample of stool is placed on special cards coated with a chemical substance called guaiac, which causes the sample to change color (blue color = positive = blood in sample of feces).

9.) Pathogens affecting bowel & isolation precautions

• Clostridium difficile – Produces symptoms above the skin ranging from mild diarrhea to severe colitis. Most common healthcare-related infection in America. Can acquire from antibiotics and contact with C. difficile organism. Hand hygiene with soap and water is effective for removal.
• Bacteria
• Worms
• Virus

10.) Enemas: When are enemas needed? What conditions would they be used for?

• Instillation of solution into rectum and sigmoid colon, primary reason is to promote defecation by stimulating peristalsis.
• The volume of fluid helps break up the fecal mass, stretch the rectal wall, and initiates the defecation reflex.
• Used commonly for immediate relief of constipation, emptying the bowel before diagnostic tests or surgery, and beginning a program of bowel training.
• Enemas: What do you do when you are giving an enema and the pt starts complaining of abdominal cramping? Lower the bag to slow down the rate (gravity is causing the rate to go faster, so lowering it slows down the rate). You don’t want to stop the enema, and you don’t want them to release the fluid yet because the enema may not work.
• Name of position when pt is receiving enema? The left Sims position. Left side with the right leg flexed. Helps with insertion and the flow of the solution (AKA side-lying position).
• Enema administration: Sterile technique is unnecessary. Stool is full of normal flora. Wear gloves! Explain the procedure, positioning, precautions to avoid discomfort, and length of time necessary to retain the solution before defecation.
• Digital removal of stool: Use if enemas fail to remove an impaction. Last resort in managing severe constipation.
• Tap water enema (skills procedure and rationales in book):
  • Tap water is hypotonic and exerts an osmotic pressure lower than fluid in interstitial spaces. The tap water escapes into the interstitial space; the infused volume stimulates defecation before large amounts of water leave the bowel. Use caution because water toxicity or circulatory overload develops if the body absorbs large amounts of water.
• Soapsuds enema (skills procedure and rationales in book):
  • You add soapsuds to tap water or saline to create the effect of intestinal irritation to stimulate peristalsis. Use only pure castile soap that comes in liquid form, included in most soapsuds enema kits. Use caution with pregnant women and the elderly; electrolyte imbalance or damage to the intestinal mucosa.
• Fleets enema (skills procedure and rationales in book):
  • Saline solution. Physiologically, normal saline is the safest solution to use because it exerts the same osmotic pressure as fluids in interstitial spaces surrounding the bowel. The volume infused saline stimulates peristalsis giving saline enemas lessens the danger of excess fluid absorption.
  • Review the order for enema and clarify the reason for administration.
  • Review the med record and assess the last bowel movement, normal versus most recent bowel pattern, presence of hemorrhoids, and presence of abdominal pain or cramping.
  • Assess pt’s mobility and ability to turn and position on the side.
  • Assess pt for an allergy to any active ingredients of fleet enema.
  • Hand hygiene.
  • Inspect, palpate the abdomen for the presence of distention, and auscultate bowel sounds. Assess pt or family caregiver’s knowledge, experience, and health literacy.
  • Provide privacy and prepare the bedside environment, organizing enema equipment at the bedside.
  • Place bedpan or bedside commode in an easily accessible position.
  • Explain enema administration procedure.
  • Check the accuracy and completeness of each med admin record with the healthcare provider’s written order, pt’s name, type of enema, and time for administration. Compare MAR with the label of enema solution (if medicated enema, cannot delegate to AP).
  • Hand hygiene.
  • With the side rail raised on pt’s right side and the bed raised to working height, help pt turn onto the left side-lying (Sims position) with the right knee flexed. Ensure that the pt is comfortable and encourage pt to remain in position until the procedure is complete. (The child will be in the dorsal recumbent position). The Sims position allows enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum. Improves retention of solution.
  • Apply clean gloves, and place the waterproof pad, absorbent side up, under hips and buttocks. Cover pt with a bath blanket, exposing only the rectal area, clearly visualizing the anus.
  • Separate buttocks and examine the perianal region for abnormalities, including hemorrhoids, anal fissure, and rectal prolapse (prolapse contraindicates enema).
  • Remove the plastic cap from the tip of the container, tip may already be lubricated. Apply more water-soluble lubricant as needed (helps prevent irritation or trauma. With hemorrhoids, extra lubrication provides added comfort).
  • Gently separate buttocks and locate the anus, instruct pt to breathe out slowly through the mouth (this promotes relaxation of the external sphincter).
  • Hold the container upright and expel any air from the enema container.
  • Insert the lubricated tip of the container gently into the anal canal toward the umbilicus (adult 3-5 inches).
  • Squeeze and roll the plastic bottle from bottom to tip until all of the solution has entered the rectum and colon. Instruct pt to retain the solution until the urge to defecate occurs, usually 2-5 minutes. (Prevents instillation of air into the colon and ensures that all content enters the rectum. Hypertonic solutions require only small volumes to stimulate defecation.)
  • If using a standard enema bag, raise it about 12 inches above the anus and 18 inches above the mattress. May use IV pole once you establish a slow flow of fluid. (Raising it too high causes rapid instillation and can cause possible painful distention. High pressure can result in bowel rupture.)
  • Tell pt the procedure is completed and that you will remove the tubing.
  • Place layers of toilet tissue around the tube at the anus and gently withdraw the rectal tube and tip.
  • Explain that some distention and cramping is normal and ask pt to retain the solution as long as possible until the urge to defecate occurs. Usually takes a few minutes. Stay at the bedside.
  • Discarded enema container and tubing in the proper receptacle. Remove gloves and perform hand hygiene.
  • Help pt to the bathroom or commode if possible. If using a bedpan, apply clean gloves.
  • Observe the character of stool and solution (to determine if the enema was effective).
  • Help pt wash the anal area with warm soap and water (for comfort and also because fecal contents irritate the skin).
  • Remove gloves, and hand hygiene.
  • Palpate for abdominal distention.
  • Record time, type, and volume of enema administered, pt’s signs and symptoms, response to enema, results including color, amount, and appearance of stool.

11.) Conditions concerning bowel

• Ulcerative colitis—what is it? What problems would you anticipate for the patient? How can you prevent problems with skin irritation? Patient education.
  • Inflammation and ulcers of the inner lining of the large intestine and rectum. Pt may experience urgent bowel movements, diarrhea, and blood in stool.
  • Pt may experience dehydration from the frequent stools and possibly pain from the ulcers.
  • Urgent BMs.
  • Low RBCs (anemia), loss of weight.
  • Cramps in the abdomen (very painful).
  • Electrolyte imbalance, Elevated temperature.
  • Rectal bleeding.
  • Severe diarrhea with blood, pus, and mucus.
  • Treatment: Surgery, medications, and diet.
    • Diet education (watch these foods that can cause or increase the risk of flare-ups):
      • High-fiber foods.
      • Hard to digest foods.
      • Dairy, spicy, or high fats.
      • Eat low fiber and high protein and stay hydrated as well.
      • Regular colon cancer screenings.
      • Ostomy care.
• Bowel Diversions–what is it? What problems would you anticipate for the patient? How can you prevent problems with skin irritation? Patient education.
  • A temporary or permanent opening (stoma) is created surgically by bringing part of the intestine through the abdominal wall. These surgical openings are called an ileostomy or colostomy, depending on which part of the intestinal tract is used to create the stoma. Newer surgical techniques allow more pts to have parts of their small and large intestines removed and the remaining parts reconnected so they will still defecate through the anal canal.
  • Bowel diversions (temporary or permanent).
  • Ostomies - Ileostomy (near ileum in the small intestine) and colostomy (at the sigmoid colon in the large intestine).
  • The location of an ostomy determines stool consistency, in the small intestine - stool watery; transverse colon - mix of watery and soft consistency; descending or sigmoid colon—more formed.
  • The fecal matter that drains is called effluent.
  • Opening to the external is called a “stoma”—different types of stomas are made depending on whether it is temporary or permanent.
  • Other procedures:
    • Ileoanal pouch anastomosis—used for patients with ulcerative colitis or familial adenopolyposis; in this diversion, the small intestine is attached to the pouch at the anus.
    • Ileostomies or colostomies are emptied several times per day.
    • Skin integrity is key! Making sure that the stoma stays clean and does not become red and irritated by pouch tape, poor fit of pouch, or fecal matter (effluent) being left on the stoma too long to cause irritation.
    • Ostomy pouches and skin barriers. A, SenSura® one-piece pouch with Velcro closure. B, SenSura® two-piece pouching system with separate skin barrier and attachable pouch. NOTE: Skin barriers need to be custom cut according to stoma size.
    • Bowels are not working enough, diverted into a bag.
    • Skin assessment. Treat it like a wound.

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D. Infection Control:

• Aseptic technique (skills procedure and rationales in book)
  • Always wear gloves and maintain standard precautions.
  • Always clean before and after each use.
• Principles of sterile technique (skills procedure and rationales in book)
  • Opening up sterile packs. When doing a sterile procedure with a Foley catheter, clean the bedside table. The outside of the package is not sterile; open away first, then side, side, and then toward yourself.
• Infection control - delegating to unlicensed assistive personnel:
  • AP can bathe the patient and tell you findings, but the nurse must reassess and provide wound care.
• Isolation precautions for all the different levels (skills procedure and rationales in book):
  • Standard Precautions:
    • Don gloves. Use when touching blood, body fluids, secretions, excretions, contaminated items; for touching mucous membranes and non-intact skin.
    • Gown. Use during procedures and patient care activities when contact of clothing/exposed skin with blood/body fluids, secretions, or excretions is anticipated.
  • Contact Precautions:
    • Gown and gloves for contact with patient or environment of care (e.g., medical equipment, environmental surfaces). In some instances, these are required for entering the patient’s environment.
  • Airborne Precautions:
    • N95 mask and negative pressure room. Wear a gown and gloves.
  • Droplet Precautions:
    • Surgical mask and hand hygiene.
    • Droplet: mask.
    • Airborne: N95, negative pressure room, private room.
    • Contact: gloves and gown (C. diff).
    • Chickenpox: N95, gown, gloves.
• Controlling the spread of pathogens in hospital/care settings:
  • Infection control & safety: One possible issue with nursing is handling needles. We could get a needle stick, which is why we do the one-handed slide into the lid, or use the clip safety, etc. But sometimes needle sticks happen. What would be your biggest concern if you had an accidental needle stick? The first thing you’re going to do is wash the area with soap and water.

E. Vital Signs:

1.) Recognizing normal ranges: Temperature, Pulse, Respirations, Blood Pressure, Oxygen saturation, Pain (assessment).

• Pulse:
  • 60-100 bpm normal.
  • Greater than 100 bpm Tachycardia.
  • Less than 60 bpm Bradycardia.
  • Pulse deficit: insufficient heart contraction. Compare radial to apical pulse at the same time for one minute, then subtract the radial pulse rate from the apical pulse rate. Abnormal pulse: dysrhythmia.
  • Pain increases heart rate, as well as nicotine (stimulant).
• Pulse Oximetry:
  • SpO2: finger, toe, earlobe. Should be greater than or equal to 95%.
• Respirations:
  • Normal: 12-20/min.
  • Tachypnea: abnormally rapid breathing >20/min.
  • Bradypnea: < 12/min (can be from neuro injury, or meds that depress the respiratory system like opiates).
• Temperature: 98.6°F.
• Blood Pressure (BP): 120/80 mmHg.
• With the patient in pain, pulse rate goes up, etc., but prolonged vitals may change. Respirations may change, dilation of pupils, nausea, vomiting, pallor.

2.) Proper technique for taking all types of vital signs:

• Temperature-Oral (skills procedure and rationales in book):
  • Most reliable posterior sublingual pocket (96.8-100.4°F range).
  • Make sure the patient has not consumed anything.
  • If the patient has had some ice, what do you do?
  • Hand hygiene.
  • Don clean gloves.
  • Make sure the thermometer is clean.
  • Place under the tongue.
  • Remove and clean.
• Temperature-Rectal (skills procedure and rationales in book):
  • Lubricate 3.5 cm and insert. Clean perineal area, hand hygiene (99.5°F).
  • Hand hygiene.
  • Don clean gloves.
  • Place thermometer cover on.
  • Lubricate the tip.
  • Position the patient on their back with knee bent.
  • Insert 1 inch.
  • Remove and clean.
• Temperature-Axillary (skills procedure and rationales in book):
  • Expose the area and have them close the arm; sweat messes with the temperature (97.7°F).
  • Perform hand hygiene.
  • Don clean gloves.
  • Make sure the thermometer is clean.
  • Lift the patient’s arm and place the thermometer under the armpit.
  • Remove and clean.
• Temperature-Other methods (skills procedure and rationales in book):
  • Tympanic:
    • Hand hygiene.
    • Place probe filter.
    • Insert in the ear.
    • Pinna of the ear, pull up and back. If the patient is 12 months of age, you should pull down and back.
    • Measure temperature.
    • Remove probe filter off and clean.
  • Temporal Artery:
    • Hand hygiene.
    • Clean before and after use.
    • Scan thermometer on the forehead.
    • Remove and clean.
• Pulse - locations, qualities to chart, what to do if abnormal (skills procedure and rationales in book):
  • If the patient has a wound to extremities, do pulse ox on the earlobe.
• Respirations - technique, recognize abnormal signs/symptoms (skills procedure and rationales in book).
• Blood Pressure - technique, recognize abnormal levels, patient teaching (skills procedure and rationales in book).
  • Remember that a large cuff on a kid will result in a false high reading.
• Stages of hypertension (pre-hypertension, stage I, stage II) recognize vitals in these ranges:
  • Stage 1 Hypertension: Systolic BP 130-139 mmHg, or Diastolic BP 80-89 mmHg.
  • Stage 2 Hypertension: Systolic BP ≥140 mmHg, or Diastolic BP ≥90 mmHg.
  • Pre-hypertension: Systolic BP 120-129 mmHg.
  • Hypertension can be asymptomatic. Diagnosis requires 2 or more occasions to be elevated over 120/80.