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Vital signs measurements that show how well the vital organs of the body are working; consist of body temperature, pulse, respirations, blood pressure, and level of pain.
Transparency 7-1: Normal Ranges for Vital Signs Temperature Oral Rectal Axillary Fahrenheit 97.6-99.6 98.6-100.6 96.6-98.6 Celsius 36.5-37.5 37.0-38.1 36.0-37.0
Pulse: 60-100 beats per minute Respirations: 12-20 respirations per minute Blood Pressure: Normal: Systolic 100-119 Diastolic 60-79 Prehypertension: Systolic 120-139 Diastolic 80-89 High: 140/90 or above Low: Below 100/60
Radial pulse the pulse located on the inside of the wrist, where the radial artery runs just beneath the skin. Brachial pulse the pulse inside the elbow, about 1 to 1 1/2 inches above the elbow.
Restraints were Keep person Keep person Keep person Prevent falls
in the past for the following reasons: hurting self or others pulling out tubing wandering
REMEMBER: Restraint usage is illegal in many states. Restraints can only be used with a doctors order. It is against the law for staff to apply restraints for convenience or discipline.
Transparency 7-2: Problems from Restraint Use Reduced blood circulation Stress on the heart Incontinence Constipation Weakened muscle and bones Loss of bone mass Muscle atrophy Pressure sores Risk of suffocation Pneumonia Possible Injury or death
Handout 7-3: Restraint Alternatives Improve safety measures. Keep call light within reach. Answer call lights promptly. Ambulate the person when he or she is restless. Provide activities for those who wander at night. Encourage activities and independence. Give frequent help with toileting. Offer food or drink. Offer reading materials.
Transparency 7-4: Conversion Table A milliliter (mL or ml) is a unit of measure equal to one cubic centimeter (cc). 1 oz. = 30 cc or 30 ml 2 oz. = 60 cc 3 oz. = 90 cc 4 oz. = 120 cc 5 oz. = 150 cc 6 oz. = 180 cc 7 oz. = 210 cc 8 oz. = 240 cc cup = 2 oz. = 60 cc cup = 4 oz. = 120 cc 1 cup = 8 oz. = 240 cc
Lack of sleep can cause the following problems: Decreased mental function Reduced reaction time Irritability Decreased immune system function
Watch for these things when a resident is not sleeping well: Sleeping too much during the day Consuming too much caffeine Dressing in night clothes during the day Eating too late at night Refusing medication ordered for sleep Taking new medications TV, radio, or light on late at night Pain
Consider these reasons for careful bedmaking: Damp and wrinkled sheets keep the resident from sleeping well. Microorganisms thrive in moist, warm places and damp, unclean bedding may cause infection or disease. Sheets that are not flat increase risk for pressure sores.
Remember these guidelines for bedmaking: Keep linens wrinkle-free and tidy. Wash hands before handling clean linen. Hold soiled linens away from your body. If dirty linen touches your uniform, your uniform becomes contaminated. Do not shake linen or clothes. Put on gloves before removing bed linens. Look for personal items before removing linens. When removing linens, fold or roll linen so the dirtiest area is inside.
Guidelines for bedmaking (contd.): Bag soiled linen at point of origin and do not take it to other residents rooms. Sort soiled linen away from care areas. Place wet linen in leak-proof bags. Disposable bed protectors or pads are used for incontinent residents. Change them as soon as they are soiled or wet and dispose of them properly.