CENTRO ESCOLAR UNIVERSITY

COLLEGE OF NURSING
MENDIOLA, MANILA

DATE: JANUARY 18, 2010

TIME: 4:00 PM
Blood pressure is the higher when the blood is viscous, that is, Considerations: • possible, particularly when the person is
outside.
when the proportion of RBC to the plasma is high. • Whenever it is necessary to remove all the
• It is not just the pulse rate that is recorded - its
person's clothing, minimize the exposure
Classification of blood pressure rhythm and strength are also measured. time
• - The rhythm should be regular in a healthy • Cover a person when bathing; a single bath
Normal: 120/80 blanket is insufficient protection against
person.
hypothermia for a frail elder.
Prehypertension: 120-139/80-89 • - The pulse should be strong and easily palpated - • Following a bath, dry the person completely,
if it is bounding or weak then this is an indication clothe them before leaving the bathing area.
HPN stage 1: 140-159/90-99
that there is a possible problem. • Dry wet hair quickly with an electric hair
HPN stage 2: >160/>100 dryer; do not let wet hair air dry.
PROCEDURE • If the person is incontinent of urine, use
Factors affecting blood pressure: absorbent pads, checking often for wet
clothing or bedding.
1. Age • You will need a watch that has a second hand. • Encourage exercise to help the person
2. Exercise • Ensure that the patient is as relaxed as possible generate heat from muscle activity.
• Provide hot, high protein meals and bedtime
• Count the pulse for a full minute in order to
3. Stress snacks to sustain heat production during the
detect any arrhythmias day and evening.
4. Race • Place your 2 first fingers at the wrist where • Bring to the clinic in case the temperature
pulsation is evident doesn’t go to normal.
5. Gender
Nursing interventions for fever:
6. Medications Body temperature is taken with a thermometer. The most common
places to measure temperature include the mouth (oral temperature),
7. Obesity . Decrease Body Heat Production:
under the arm (axillary temperature. In general, the normal oral
temperature 37 degrees Centigrade. The axillary temperature which
8. Disease process  Advise patient to take a complete rest to
has a normal value of 36.4-37.4 degree celcius. Below 36.4 or 35C
minimise unnecessary energy expenditure
Nsg mgt: indicates hypothermia, while increased in 37.4 indicates hyperthermia
which may increases body temperature.
or fever. Body temperature is lower in the morning than it is in late
• Avoid smoking afternoon and evening. Temperature can vary with other factors, such  Anticipate patient's needs and keep things
as exercise, drinking hot or cold fluids, sitting in a cold room, fighting within reach to avoid activity on his part.
• Exercise within 30mins an infection, and by the accuracy and type of thermometer used.  Inform patient of his condition and treatment
to reduce apprehension and anxiety.
• Increase fluid intake Nursing interventions for hypothermia: (most common at risk are the 
children and elderly) 2. Promote Body Heat Lost:
• Adequate rest

• Balance diet • Limit the time that a person is exposed to a cold  Dress the patient with lightweight clothing.
area.
 Keep the patient cool by providing a fan or
• Minimize heat loss from the head by providing a
nurse him in air-conditioner room.
hat or scarf to cover the head and neck when
Pulse Rate – the normal findings in taking a pulse rate is 60-100 possible, particularly when  Sponge the patient with tepid water.
Note: Avoid shivering in the attempt to cool the
bits per minute.