NRSG-2201C

• how do we document vitals?

  BP, HR, TEMP, RR, SpO2
• Bed bath


  ensure privacy

  from cleanest to dirtiest

  proper perineal care

  equipment

  • wash cloths and bath towels
  • bath blanket
  • bar or liquid soap
  • toiletry items
  • disposable wipes
  • warm water
  • clean hospital gown
  • laundry bag
  • clean gloves
  • wash basin
• bed making


  do not shake linen

  do not hold linen close to the body

  always work at an appropriate height

  equipment

  • mattress pad
  • bottom sheet
  • top sheet
  • blanket
  • bedspread
  • pillowcases
• closed bed: a bed completely made with bedspread and blankets in place
• open bed: a bed made with linen folded down to the foot of the bed
• routine practices

  • hand hygiene before applying ppe and after removing ppe
  • wear a long sleeved gown if contamination of skin or clothing is anticipated
  • wear gloves if there is a risk of contact with blood, body fluids, non intact skin or mucous membranes
• contact precautions

  • hand hygiene
  • gown
  • gloves
• droplet precautions

  • hand hygiene
  • gown
  • mask
  • goggles
  • gloves
• airborne precautions

  • hand hygiene
  • gown
  • N95 mask
  • gloves
• donning PPE

  • hand hygiene
  • gown
  • mask (n95 for airborne)
  • goggles (droplet)
  • gloves
• doffing PPE

  • gloves
  • hand hygiene
  • gown
  • hand hygiene
  • goggles (droplet)
  • mask (n95 airborne)
  • hand hygiene (soap and water for contact)
• normal temperature ranges

  • infants and young children - 35.5 to 37.7 C
  • adults - 36.5 to 37.5 C
• explain the variance in temperature between oral, axillary, and rectal routes

  • rectal temperatures are generally 0.8 to 0.6 c higher than oral temp
  • axillary are generally 0.3 to 0.6 c lower than oral temp
• heart rate normal ranges

  • newborns to 1 mon - 100 to 175 bpm
  • 1 mon to 2 yr - 90 to 160 bpm
  • 2 yr to 6yr - 70 to 150 bpm
  • 7 to 11 yr - 60 to 130 bpm
  • adolescents - 50 to 110 bpm
  • adults - 60 to 100 bpm
• explain the importance of assessing rate, rhythm, amplitude or strength


  rate: indicates the number of heartbeats per minute abnormal rates can signal cardiac issues

  rhythm: regularity of the beats, irregular rhythms may suggest arrhythmias

  amplitude/strength: reflects the blood flow and pressure with each beat. weak pulses can indicate poor blood flow or blockages
• blood pressure normal ranges

  • 120/80 mmHg
• why do we use the two step method?

  we use the two-step method so that we don't under or over inflate the cuff, this provides the most accurate blood pressure reading
• why do we keep arm at level of the heart?

  if the arm is below heart level we will get a falsely high reading, if the arm is above heart level we will get a falsely low reading, if the arm is not supported we get a falsely high reading
• why is it important to have the correct cuff size, and how the cuff is applied not too tight or too loose

  if the cuff is too wide we get a falsely low reading. if the cuff is too narrow or too short we get a falsely high reading. if the cuff is wrapped too loosely or unevenly we will get a falsely high reading