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Temperature: Oral
- 98.6⁰F (Plus/Minus 1 Degree) 2 min to read
- (WAit 20-30 minutes after drinking anything hot or cold or smoking)
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Temperature: Axillary
97.6⁰F (Plus/Minus 1 Degree) 5-10 min to read
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Temperature: Rectal
99.6⁰F (Plus/Minus 1 Degree) 2 min to read
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Pulse
60 - 100 beats per minute
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Respiration
12-20 breaths per minute
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Blood Pressure
90/60 - 120/80
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Pre-hypertension
120/80 - 139/89
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Pulse Oximetry (0₂ Sat)
95% - 100% on room air
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Enema
- 100⁰ - 105⁰F
- (1000mL, left side, 12-18'' height, lube, insert 3-4 inches, clean gloves)
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Oil Retention Enema
120 mL @ room temp
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Harris Flush
- 100⁰ - 105⁰ F
- (1000 mL, Lube, 250-300 mL each time)
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Apical-Radial Deficit
Two nurses taking apical and radial pulse for 1 full minute simultaneously
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Foley Irrigation
Wipe the connection with alcohol before disconnecting. Use clean gloves
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Wound Irrigation
Use clean gloves to irrigate wound
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Anti-thrombus devices
- TED Hose Stockings, and Thromboguards (SCDs')
- Remove every 8 hours for 30 minutes or per hospital policy
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NG feeding
- Residuals: (Rate Dependent) The following will be used unless ordered otherwise:
- Check every 6 hours for placement
- 1. Auscultate
- for gurgling
- 3. Gastric
- content – pH of 4 or less
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NG Feeding: Less than 100% of rate
continued as ordered
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NG Feeding: 100% -200% of rate
- decrease rate by 50%, recheck in 3 hours
- After 3 hours if greater than 100% then STOP feeding
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NG Feeding: Greater than 200% of rate
STOP feeding, call physician per protocol
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NG Feeding: In the event of vomiting
STOP feeding, call physician per protocol
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