Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
EQUIPMENTS:
Thermometer
Glass or electronic and disposable protective sheath;
Disposable (chemical)
Tympanic
Tissues
Two pairs of non-sterile gloves
Lubricant (rectal, glass thermometer)
ACTION
1. Review medical record for baseline
data and factors that influence vital
signs.
2. Explain to the client that vital signs
will be assessed. Encourage client to
remain still and refrain from drinking,
eating, or smoking.
3. Assess clients toileting needs and
proceed as appropriate.
4. Gather equipment as indicated above.
5. Provide for privacy.
6. Wash hands and don gloves.
RATIONALE
1. Establishes parameters for clients
normal measurements, provides
direction in device selection, and
determines site to use for measurement.
2. Encourages participation, allays
anxiety, and ensures accurate
measurements. Cold or hot liquids and
smoking alter circulation and body
temperature.
3. Prevents interruptions during
measurements, communicates caring,
and promotes client comfort.
4. Facilitates organized assessment and
measurement.
5. Decreases embarrassment.
6. Hands are washed before and after
every contact with a client. Gloves are
worn to avoid contact with all bodily
secretions and to reduce transmission of
microorganisms.
7. Promotes comfort and site access for
all measurements.
Activity and movement can elevate
heart and respiratory rates.
k. Reduces transmission of
microorganisms.
f. Reduces transmission of
microorganisms.
h. Reduces transmission of
microorganisms.
l. Decreases transmission of
microorganisms.
instructions).
c. Record reading and indicate method.
c. Promotes accurate documentation for
data comparison.
13.Tympanic Temperature: Infrared Thermometer
a. Position client in Sims position.
a. Promotes access to ear.
b. Remove probe from container and
attach probe cover to tympanic
thermometer unit.
c. Turn clients head to one side. For an
adult, pull pinna upward and back; for a
child, pull down and back. Gently insert
probe with firm pressure into ear canal.
d. Remove probe after the reading is
displayed on digital unit (usually 2
seconds).
e. Remove probe cover and replace in
storage container.
f. Return tympanic thermometer to
storage unit.
g. Record reading and indicate site as
ET.
b. Prevents contamination.