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Quick Nursing Student Notes

Published on February 2017 | Categories: Documents | Downloads: 2 | Comments: 0
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Normal Pediatric Vital Signs

Adult Vital Signs: Normal

Age

RR

HR

SBP

Temp (oC)

Preterm

50-70

140-180

40-60

36.8-37.5

Newborn

30-60

110-120

60-90

36.8-37.5

6 months

25-35

110-180

85-105

37.5

1 year

20-30

80-160

95-105

37.5

2 years

20-30

80-130

95-105

37.5

S.A.M.P.L.E. History

4 years

20-30

75-115

95-110

37.5

S

Signs and symptoms

6 years

18-24

70-110

95-110

37

A

Allergies (include food and environmental allergies)

8 years

18-22

70-110

95-115

37

M

Medications (include OTC and herbal supplements)

10 years

16-20

60-110

95-120

37

P

Pertinent medical or surgical history

12 years

16-20

60-110

95-125

37

L

Last oral intake

Teenager

12-20

60-100

95-135

37

E

Events leading up to illness or injury

Pediatric IM Injection Sites

HR

RR

SBP

DBP

Temp

60-100

12-20

<120 mm Hg

<80 mm Hg

See below

Temporal artery
Tympanic temperature
Oral temperature
Rectal temperature
Axillary temperature

37.0o-38oC (98.6o-100.4oF)
37.0o-38.1oC (98.6o-100.6oF)
36.4o-37.6oC (97.6o-99.6oF)
37.0o-38oC (98.6o-100.4oF)
35.9o-37.0oC (96.6o-98.6oF)

Pulse Oximetry

Muscle

Needle

Max Volume

SpO2

Nursing Intervention

Infant

Vastus lateralis

5/8-7/8”

1 mL

>95%



Toddler

Ventrogluteal or vastus lateralis

5/8-1”

1 mL

Older child

Ventrogluteal or deltoid

5/8-1”

1 Ml

91%-94%





85%-90%






<85%





Considered borderline
Assess probe placement and adjust if necessary
Begin oxygen at 2 L/min titrated to SpO2
>95%
Immediate intervention for SpO2 <91%.
Elevate head and encourage Pt. to cough and
breathe deeply
Assess airway and suction as needed
Administer oxygen and titrate to SpO2 >95%
If condition worsens or fails to improve, assist
ventilations manually and prepare to intubate
Administer 100% oxygen, set Pt upright,
encourage coughing and deep breathing and
suction as needed
Assist ventilations manually and prepare
to intubate if condition worsens or fails to
improve
Consider reversal agents for possible druginduced respiratory depression

Basic ECG Interpretation

Acid-Base Imbalance
Imbalance

pH

PCO2

(See back side for lab values)

PO2

HCO3

Compensation

Normal

Kidneys conserve
HCO3; eliminate H+ to
increase pH

Respiratory Acidosis
Uncompensated
Compensated

i

h

Normal

h

Normal
h

h

Respiratory Alkalosis
Uncompensated
Compensated

h

i

Normal

i

Normal

Normal

i

i

i

i

i

i

h

h

h

h

Metabolic Acidosis
Uncompensated
Compensated

i
Normal

Normal
i

Metabolic Alkalosis
Uncompensated
Compensated

h
Normal

Normal
h

IM Injection Sites



Considered normal and generally requires no
invasive intervention
Continue routine monitoring of Pt.

Kidneys eliminate
HCO3; conserve H+ to
decrease pH
Hyperventilation to
blow off excess CO2
and conserve HCO3
Hypoventilation to
increase CO2
Kidneys keep H+ and
excrete HCO3

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