Nursing

• Temperature
• Pulse
• Respirations (TPR)
• Blood Pressure
• Pain

• On admission
• Change in health status
• Before and after any surgury
• Rouninely once a shift
• Before and after certain Meds

98.6 (37.c)

High Fever

Very High Fever

Fever

No Fever

Fever due to brain injury. Non infectious.

Fever fluctuates from Fever - Normal - Below normal

Never falls to afebrile. Fluctuates in febrile range.

Fever breaks then comes back.

• Loss Of appetite
• Headache
• Dry hot skin
• Malaise
• Flushed Face/Thirst

• Dehydration
• Decreased urine output
• Rapid heart rate

• Monitor Vitals every 4 hours or more
• Supply blanket when cold/remove when hot
• Provide adequate nutrition
• Provide adequate Fluids (2500-300mL/day)
• Monitor I/o
• Reduce Physical Activity
• Rest
• Administer antipyretics as ordrered
• Moisten oral cavity
• Tepid sponge bath
• Cooling blanket
• Linen Change

• Oral
• Rectal
• Axillary
• Tympanic

• Children less than 5 years
• Confused/Comatose
• Oral Surgury
• Oral Infection
• Mouth Breathers
• O₂B mask

• Gather equipt.
• ID patient
• Wash Hands
• Privacy
• Saftey

• Rectal Surgury
• Cardiac disorders
• Diarrhea
• Hemmorrhoids
• Clotting disorder
• Immunosirppressed

Respitory receptors - Medulla/pons

Chemoreceptors - Medulla/Carotid and aortic bodies - Respond to O₂ CO₂ and H_⁺ In arterial blood

Normal Breathing

Less than normal rate

Faster than normal breathing

no breathing

Slow to fast breathing returning to slow and stopping then speeding up again. Repeat.

Abnormal Pattern of breathing charaterized by groups of quick, shallow inspirations followed by irregular periods of apnea.

Caused by damage or disfunction to nervous system

Chronic Pain. Not releived by ordinary medical surgical or nursing measures.

Attributed to a body part that does not exist.

• Nonivasive
• Estimates Arterial Blood Oxygen (SpO₂)
• Detects Hypoxia before signs and symptoms
• Sensor, photodetector, pulse, oximeter unit.