Normal vitals

TEMPERATURE PULSE RESPIRATIONS Peads airway difference:

Newborn 36-38 Newborn 100-170 (140) Newborn 30-50 (40) Large tongue, obligate nose breathers, short neck and trachea, compensatory
Adult 36-38 1yr 80-160 (120) 1yr 20-40 (30) method less effective, higher metabolic rate, thin chest wall, poorly developed
>65 35.5-38 2 yr 80-120 (110) 2 yr 20-30 (25) intercostals, flat diaphragm, fewer alveoli
Norm 35.8-37.3 6 yr 70-115 (100) 6 yr 16-22 (19)
Oral: 36-38 (37) 10 yr 70-110 (90) 10 yr 16-20 (18) Altered Nutritional and hydration status impacts
Rectal: 36.7-38 14 yr 60-110 (85-90) 14 yr 14-20 (17)
Axillary: 35.4-37.4 Adult 60-100 (72) Adult 12-20 (18) Impaired immunity leads to an increased risk of hospital acquired infection.
Elderly: 12-24 Over//under nutrition and hydration leads to an unsteady gait, decreased ROM
BLOOD PRESSURE OXYGEN SATURATION PAIN – subjective & and impaired mobility which increases the risk of falls and injury.
individual – verbal + Decreased protein and energy, and decreased skin hydration leads to decreased
Newborn 64/41 >95% cell repair and mobility. This leads to an increased risk of impaired skin
non-verbal report.
1yr 72-104/37-56
2 yr 86-106/42-63 PQRST +WONG
integrity, pressure injury and delayed healing.
6 yr 97-115/57-76 BAKER FACES +
10 yr 102-120/61-80 ABBEY PAIN SCALE Hydration young v old
14 yr 110-131/64-83 Young - infants have a great proportion of water/kg, less ability to preserve fluid
Adult 120/80
by concentrating urine (matures with ages 2-12), cannot access fluids
Depression vs. dementia independently.
Older adult - decreased renal flow, function and filtration leading to a poorly
Depression: Person complains of poor memory, Loss of interest/enjoyment of maintained fluid balance; poor coping mechanisms/capacity to adapt when
activities, Appetite changes/weight changes, Agitation greater earlier in day, Decreased stressed; medication and chronic disease can change/interfere with status, thirst
energy levels, Social withdrawal/isolation related to feelings of self-worth. responses impaired with age (30% over 60 years).
Dementia: Family, others report poor memory, Limited capacity to plan or initiate Nurses
sswwww role in hydration
activities but enjoys them once involved, Definite weight loss over disease course
despite adequate intake, agitated greater later in day, Energy appears normal for self, Actions/Interventions - offer frequent
Dehydration/hypovolaemia abnormalsmall amounts of
assessment water or rehydration
data
Unintentional withdrawal/isolation solution, modified fluids and food,
Low urine output, fatigue, headache, dizziness, sunken eyes, decreased
Monitoring - FBC QID, weighing
skin turgor, absent tears, activation of stress response to hypovolaemia
What assessment tools can be used to identify a cognitive impairment and Evaluation - reassessment, skin turgor, mucus, fluid balance, urine output,
(increased HR, increased RR, decreased BP, decreased cap refill), dry
delirium? oedema, vital signs
mucous membranes, heavily concentrated urine, sunken eyes, furrowed
Cognitive testing: Modified Mini Mental Exam (MMSE)* The Alzheimer’s Disease Interventions:
and dry tongue.appropriate referral to dietitian/GP, assistance for
Assessment Scale – Cognition (ADAS-Cog), General Practitioner Assessment of Cognition eating/drinking/dental care, increase/decrease intake of food and fluids,
(GPCOG), Psychogeriatric Assessment Scale (PAS), Rowland Universal Dementia medications (diuretics/antidiuretic, antiemetics, insulin), dysphagia (thickened
Assessment Scale (RUDAS), Confusion Assessment Method (CAM), Assessment test for fluids, textured meals), dietary supplements, enteral feeds
delirium & cognitive impairment: 4AT
Drug considerations for older adults
Methods of assessment
Cardiovascular – inspect colour, cap refill, oedema, hydration, palpate pulse, Altered absorption due to decreased gastric pH, delayed emptying of stomach
auscultate chest. and decreased splanchnic blood flow. Altered distribution due to decreased water
Respiratory – history, triggers, inspect colour, RR, sounds, Sp02, auscultate lungs for volume and serum albumin. Altered metabolism due to decreased liver volume
breath sounds, chest expansion symmetry, skin, cap refill. and hepatic blood flow. Altered elimination due to decreased mass, size and
Gastrointestinal – look for abnormalities, palpation, reaction, pain, auscultate number of nephrons, decreased blood flow and glomerular filtration. Altered
quadrants for bowel movement, bowel sounds. response.
Renal/urinary – frequency, urgency, incontinence, fbc, hydration, weight, BP, diet, What actions can a nurse take to reduce the risk of developing pressure
skin, urinalysis, bloods. injuries? (Week 7)
Musculoskeletal – gait, posture, symmetry, abnormalities, motion, joints, palpate limbs
Governance and systems for the prevention and management of pressure injuries:
for strength, tone, pain, tenderness.
policy and procedure – risk assessment, quality Preventing pressure injuries:
Skin/integument – colour, bruise, wound, pressure injury, moles, palpate skin for temp,
identify risk, comprehensive skin assessment, monitor and review
turgor, oedema, abnormalities.
Neurological system – assess gcs, movement symmetry, pupil size, shape and reaction, What actions can a nurse take to minimise falls risk? (Week 3)
GCS motor
observe (1- don’t
-eyeskills, open, 2-functions.
and sensory open to pain, 3- open to voice, 4- open
spontaneously) Screening & assessing risks of falls and harm from falling – accurate & ongoing
-verbal (1- no response, 2- incomprehensible, 3- inappropriate words, 4- assessment using appropriate tools. Preventing falls & harm from falls –
confusion, 5- orientated) strategies to minimise risk. Communicating with patients & carers –
-motor (1- no response, 2- decerebrate posture to pain [flex], 3- decorticate communicate identified risk and engagement in falls prevention plan
posture to pain [extension], 4- withdrawal from pain, 5- localises to pain, 6-
obeys command) Standard 3: Preventing and Controlling Healthcare Associated Infections
Severe <8-9, moderate 9-12, minor >13 Standard 4: Medication Safety
PERRLA – pupil equal and round reacting to light and accommodation. Should be Standard 5: Patient Identification and Procedure Matching
around 2-6mm Standard 6: Clinical Handover
Standard 8: Preventing and Managing Pressure Injuries
Standard 10: Preventing Falls and Harm from Falls
Priority Nurse Intervention Collaborative intervention
problem

Impaired 1. Sitting patient in high fowler's position with arms resting on table – tripod Administration of oxygen
oxygenation position. Rationale: Due to consolidation, oxygenation is impaired due to
due to reduced perfusion which leads to reduced diffusion of oxygen around the body.
Rationale: Increase the concentration of oxygen during inspiration which
consolidation The intervention promotes greater air entry (inspiration) to increase
increases available oxygen for perfusion.
in lower lobe oxygenation.
of L) lung.
2. Encourage deep breathing and coughing. Rationale: deep breathing increases
amount of air entering the lungs and can stimulate coughing to promote
expectoration to reduce airway obstruction and promote increased air entry.
Reassess skin integrity and pain, perform prescribed treatment for patients hand
Painful hand 1. Analgesics medication (prescribed by Dr)
(wound or meds), rest, ice, compress and elevate
due to fall.

Encourage rest and support the area. Rationale: Resting the knee’s and
Painful knees 1. Diet and exercise plan (with nutritionist and physiotherapist)
supporting them is a means to relieve pressure and stress on the affected joint.
(4/10)
To therefore reduce pain. Rationale: Longer term intervention in order to help the patient lose weight/
secondary to
prevent weight gain to relieve pressure and stress on the joints.
osteoarthritis.
2. Apply heat / cold packs to the joint. Rationale: Heat packs may improve 2. Anti-inflammatory medication (prescribed by GP)
circulation, lubricate joints and relax muscles to reduce pain; Cold packs may Rationale: Non-steroidal anti-inflammatory drugs (NSAIDs) reduce
numb the pain and reduce swelling and inflammation. inflammation and relieve pain.

Falls risk due Keep their bed at lowest position at all times, use bed and chair alarm as Physiotherapy, nutritious meals, effective medication
to aloc needed, move patient closer to nurse station to keep an eye on, utilise more fall
score to assess their risk each shift.
 Priority Nurse Intervention Collaborative intervention
problem

Impaired 1. Sitting patient in high fowler's position with arms resting on table – tripod Administration of oxygen
oxygenation position. Rationale: Due to consolidation, oxygenation is impaired due to
due to reduced perfusion which leads to reduced diffusion of oxygen around the body.
Rationale: Increase the concentration of oxygen during inspiration which
consolidation The intervention promotes greater air entry (inspiration) to increase
increases available oxygen for perfusion.
in lower lobe oxygenation.
of L) lung.
2. Encourage deep breathing and coughing. Rationale: deep breathing increases
amount of air entering the lungs and can stimulate coughing to promote
expectoration to reduce airway obstruction and promote increased air entry.
Reassess skin integrity and pain, perform prescribed treatment for patients hand
Painful hand 1. Analgesics medication (prescribed by Dr)
(wound or meds), rest, ice, compress and elevate
due to fall.

Encourage rest and support the area. Rationale: Resting the knee’s and
Painful knees 1. Diet and exercise plan (with nutritionist and physiotherapist)
supporting them is a means to relieve pressure and stress on the affected joint.
(4/10)
To therefore reduce pain. Rationale: Longer term intervention in order to help the patient lose weight/
secondary to
prevent weight gain to relieve pressure and stress on the joints.
osteoarthritis.
2. Apply heat / cold packs to the joint. Rationale: Heat packs may improve 2. Anti-inflammatory medication (prescribed by GP)
circulation, lubricate joints and relax muscles to reduce pain; Cold packs may Rationale: Non-steroidal anti-inflammatory drugs (NSAIDs) reduce
numb the pain and reduce swelling and inflammation. inflammation and relieve pain.

Falls risk due Keep their bed at lowest position at all times, use bed and chair alarm as Physiotherapy, nutritious meals, effective medication
to aloc needed, move patient closer to nurse station to keep an eye on, utilise more fall
score to assess their risk each shift.