Contain special chemicals or dots that change colors
To record temperature:
986 is an oral reading
996 (R) is a rectal reading
976 (Ax) is an axillary reading
986 (T) is an aural reading
Eating, drinking hot or cold liquids, or smoking can alter oral temperature. Be sure it has been 15 minutes since the patient did any of those things before taking the temperature.
Measuring and Recording Pulse
The pressure of blood pushing against the wall of an artery as the heart beats and rests.
Dorsalis Pedis Artery
Taken with a stethoscope at the apex of the heart
Actual heartbeat heard and counted
Tips of earpieces and diaphragm of stethoscope should be cleaned with alcohol before use
Heart sounds heard resemble “lubb-dupp”
Pulse Terminology Bradycardia – Under 60 beats per minute
Tachycardia – Over 100 beats per minute
Rhythm – Regularity of the pulse (regular or irregular)
Volume – Strength or intensity (strong, weak, thready, or
Pulse can be increased by:
Pulse can be decreased by:
Measuring and Recording Respiration Process of taking in Oxygen (O2) and expelling Carbon Dioxide (CO2)
1 inspiration + 1 expiration = 1 respiration
Normal rate = 14 – 18 per minute
Character – depth and quality of respirations
Dyspnea – difficult or labored breathing
Apnea – absence of respirations
Cheyne-Stokes – periods of dyspnea followed by periods
of apnea; noted in the dying patient
Rales – bubbling or noisy sounds caused by fluids or
mucus in the air passages
Leave your hand on the pulse while counting respirations and be sure the patient doesn’t know you are counting the respirations.
To convert degreesF to degreesC use the formula: (o F – 32) 5/9
To convert degree C to degreesF use the formula: (o C x 9/5) + 32
Convert the following Fahrenheit temperatures to Celsius temperatures and round off answers to the nearest tenth or one decimal point.
1. 140o F = 140-32=108 108 X 5/9 (or 0.5556) = 60 60o C
2. 88o F ________________________________ ______
3. 45o F ______________________________________
4. 98.2o F ________________________________________________
5. 64o F ______________________________________
6. 73.4o F _____________________________________ ___________
7. 212o F ________________________________________________
8. 116o F _________________________________________________
9. 97o F ______________________________________
10. 101o F _______________________________________________
11. 100o F _____________________________________ __________
12. 104.6o F ______________________________________________
Convert the following Celsius temperatures to Fahrenheit temperatures and round off answers to the nearest tenth or one decimal point.
13. 65. o C 65.6 x 9/5 (or 1.8) = 118.1 118.1 + 32 = 150.1 150.1o F
14. 42.8o C ____________________________________ __________
15. 54o C _____________________________________ __________
16. 8o C _____________________________________ __________
17. 91o C _____________________________________ __________
18. 0o C _____________________________________ __________
19. 72o C _____________________________________ __________
20. 99.8o C ____________________________________ __________
21. 59.2o C ____________________________________ __________
22. 63o C _____________________________________ __________
23. 85.8o C ____________________________________ __________
24. 103o C _____________________________________ __________
Recording and Reporting Health care workers must listen carefully AND make observations. They use their senses to: See Color of skin, swelling or edema
Presence of rash or sore
Color of urine or stool
Amount of food eaten Smell Body odor - Unusual odors of breath, wounds, urine or stool Touch Pulse
Speech Observations should be reported accurately – use facts and report what you saw, not the reasons. NOT – “Mr. Cromwell is in pain.” INSTEAD – “Mr. Cromwell is moaning and holding his side.” Observations on a patient’s health record (chart) should be accurate, concise, and complete. Objective observations – what was seen.
DO NOT record what you feel or think. If a patient’s statement is recorded, use the patient’s words and use quotation marks. Sign entries with name and title of the person recording the information. Cross-out errors neatly with a straight line, write error, and initial error.
Accurate Recording/Reporting Read the following communication statements in Column II and select the appropriate observation in Column I by placing the letter beside the number.