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Frequency: Is the Number of Pulse Beats Counted In One Minute.

- Moderate fever: > 38 0 C < 39 0 C.

- High fever: 39 0 C 40 0 ​​C.

- Fever too high: > 40 0 ​​C

* Classification by fever nature:

- Prolonged fever: body temperature > 39 40 0 ​​C lasting for many days, but the temperature difference during the day does not exceed 1 0 C, seen in typhoid fever.

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- Fever: After a high fever, the temperature drops to normal or lower than normal as seen in malaria.

- Persistent fever: body temperature increases from 39 0 C - 40 0 ​​C, changes during the day from morning to afternoon from 1.5 0 C to 2 0 C, but the lowest temperature is still above normal, often seen in: pneumonia, acute pyelonephritis.

- Relapsing fever: Fever lasts for 5 to 7 days, then the patient has no fever, then another fever occurs.

Fever process:

Infectious fever goes through several stages:

- Infiltration period: Temperature suddenly increases gradually.

- High fever period: The temperature continues to rise for several days. This period is long or short depending on early or late treatment and the progression of the disease.

- Fever reduction period: There are two cases

+ A gradual decrease in fever is usually a good change. A sudden decrease in fever within 12 to 24 hours, with a decrease in temperature and other symptoms, is a good sign, as in pneumonia.

+ When the fever decreases quickly but the general condition of the disease has not improved: The patient gradually becomes weaker, has a rapid pulse, rapid breathing, and low blood pressure. These are signs of a serious illness that requires immediate notification to the doctor.

b. Hypothermia: 32 36 0 C.

Seen in patients: Cholera, acute blood loss, body too weak, sweating a lot, shock.

1.4. Effects of fever:

Circulatory - respiratory - urinary:

People with fever: rapid pulse, red face, rapid breathing, loss of water through breath and sweat, decreased urine excretion.

Digest:

Patients do not want to eat, have poor appetite, indigestion, vomiting, constipation, and white tongue.

Nerve:

Patients are easily agitated, have headaches, delirium, and epilepsy.

1.5. Care for patients with abnormal body temperature:

a. Care for patients with fever:

Measure temperature - notify doctor for treatment.

Take off some clothes and blankets.

Reduce the temperature by all means.

+ Wipe the patient with cool water.

+ Put the patient in a cold room.

+ Medicine as prescribed by doctor.

Let the patient lie in a quiet room.

Dry sweat, change clothes and bed sheets.

Give the patient easy-to-digest liquid foods and drink plenty of water.

b. Care for patients with low body temperature:

Warm up.

Give the patient warm sweet tea to drink.

Closely monitor the patient's condition.

Monitor temperature - pulse - blood pressure every 15 30 minutes.

1.6. Meaning of body temperature measurement:

Help doctors know the patient's condition

Help nurses plan patient care.

Accurate temperature measurement helps Doctors and Nurses evaluate work results.

1.7. Method of measuring body temperature:

a. Thermometer:

There are two types of body temperature units: degrees centigrade = 0 C and degrees F called Fareihet.

Ice freezes at 0 0 C or 32 0 F Water boils at 100 0 C or 212 0 F

Therefore, to convert degrees F to degrees C or vice versa, we have the formula: F = 9/5C + 32 ; C = (F – 32) 5/9

There are 3 types of thermometers to measure body temperature corresponding to 3 measuring positions: Oral thermometer: Small, long mercury bulb

Rectal thermometer: Round, short mercury bulb.

Armpit thermometer: The mercury bulb is larger and longer than the two types above.



NK Anus NK Mouth NK Armpit NK Electronic


1.8. General principles when taking temperature:

Let the patient rest for at least 15 minutes before measuring.

Take your temperature twice a day at the same time.

Temperature should be taken every 4 hours for patients with fever higher than 38 0 C, after anesthesia and a few days after surgery.

The thermometer must be shaken until the mercury level drops below 35 0 C or 94 0 F before placing it on the patient.

Take oral temperature within 5 minutes. Do not take oral temperature in the following cases: severe cough, difficulty breathing, mouth ulcers, inability to close mouth, hot or cold compress on neck, children, very old people, comatose patients, patients with convulsions, mental patients.

Take rectal temperature for 3-5 minutes. Do not take rectal temperature when: patient has hemorrhoids, rectal surgery, anal scabies, dysentery, diarrhea.

Take the temperature in the armpit for 10 minutes and add 0.5 0 C. Only take the temperature in the armpit when it is not possible to take the temperature in the mouth or rectum.

The temperature curve is drawn in blue.

1.9. How to wash and disinfect a thermometer:

Soak the thermometer in soap.

Use cotton soaked in soapy water to wash each thermometer tube, wiping from top to bottom one cotton ball at a time.

Rinse with clean water, dry and soak in disinfectant solution: Zephiran 1% 0 for 15 minutes or Alcohol iodine for 10 minutes

Soak the thermometer in water for the right amount of time, take it out, wash it, dry it and put it back in its original place.

2. CIRCUIT:

2.1. Definition:

It is the feeling of a rhythmic heartbeat when we press our hand on an artery, helping us know the strength of the heartbeat and the general condition of circulation.

2.2. Monitoring and observing the circuit:

When counting pulse we need to monitor:

2.2.1. Frequency: Is the number of pulse beats counted in one minute.

- Normal :

+ Adults: 70 - 80 times/minute.

+ Newborn: 120 - 140 times/minute.

- Physiological changes:

Age: Children have faster pulse than adults.

Rest, exercise - emotion

Digestion: Hunger beats faster than fullness.

Rapid breathing.

- Pathological changes:

Fast: Infection - bleeding - cardiovascular disease.

Slow: Digitaline poisoning, brain tumors, cholestatic jaundice.

2.2.2. Rhythm:

In healthy people, the interval between two beats is equal, the regular beat is called regular pulse.

The interval between two beats, sometimes long and sometimes short, is called arrhythmia, often seen in cardiovascular disease.

Forms of arrhythmia: premature beats, complete arrhythmia, pulse

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2.2.3. Intensity:

Weak pulse strength that we feel in our hand when counting the pulse.

- Rapid pulse pulsation and collapse are seen in aortic valve regurgitation.

- Weak pulse when: Heavy bleeding, severe dehydration, dying.

- Pulse is sometimes strong, sometimes weak, found in circulatory disorders.

2.2.4. Circuit tension:

The hardness or softness of the vascular wall, normally the vascular wall is smooth and has resistance,

Just press with one finger and the pulse stops.

There are cases where the hardened veins require strong pressure to collapse, commonly seen in: High blood pressure, arteriosclerosis.

2.3. Correlation between circuit and temperature:

Normally there is a relationship between pulse and temperature.

Pulse increases with temperature, temperature increases by 1 0 C pulse increases 10 times. 37 0 C 70 - 80 times/minute, 38 0 C 80 - 90 times/minute.

39 0 C 90 - 100 times/minute, 40 0 ​​C 100 - 110 times/minute.

Dissociation between pulse and temperature is a valuable clinical sign.

For example: In typhoid fever, the fever is 40 0 ​​C but the pulse is not very high. On the contrary, in blood loss, the pulse is fast and the temperature drops.

2.4. General principles when counting pulses:

- The patient should rest for at least 15 minutes before counting.

- Patient lying or sitting.

- Use 3 fingers: 2-3-4 to count the pulse, do not use the thumb because it is easy to confuse it with the patient's pulse.

- When counting the pulse, pay attention to: Rhythm, intensity, frequency.

- Count to 1 minute.

- Take the pulse twice a day at a certain time to stabilize the patient.

Every 4 hours for severe patients, every 15 - 30 minutes for patients who have not yet regained consciousness

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- Circuit diagram is written in red ink.

2.5. Areas for counting pulses:

Usually take the pulse where the superficial artery lies on a firm, flat surface.

on the bone surface.

Places to take the pulse: both temples, external carotid artery, internal carotid artery, arms, wrists, abdomen, groin, elbows, ankles, insteps of the feet.

3. BREATHING:

3.1. Definition:

Inhalation and exhalation form one breath.

- Normal breathing: smooth and regular. Average adult: 16 - 20 times/minute.

children: 25 - 30 times/minute.

Newborn: 40 - 50 times/minute.

- Physiological changes:

Age: Children breathe faster than adults.

Sleep, rest: Breathe slowly.

Labor, emotion: Rapid breathing.

- Pathological changes: Some diseases affect breathing → rapid breathing, breathing disorders, difficulty breathing.

3.2. Classification of dyspnea:

When the patient has difficulty breathing, the nurse observes and monitors each point.

- Difficulty breathing gradually or suddenly.

- Difficulty breathing at night or during the day.

- Difficulty breathing fast or slow.

- Shortness of breath on exertion or spontaneously.

- Shortness of breath, intermittent or continuous.

- Difficulty breathing when lying or sitting.

- Difficulty breathing deeply or shallowly.

- Difficulty breathing regularly or irregularly.

3.3. Care for patients with difficulty breathing:

The nurse's job when a patient has difficulty breathing is to help the patient breathe easily again.

- Find the cause of shortness of breath, characteristics, duration, and progression of shortness of breath.

- Determine the degree of O2 deficiency

- Clear airways, loosen tight clothing, ties, belts.

- Let the patient lie with head elevated and ventilated.

- Notify the doctor if the patient has difficulty breathing.

- Give O2 ( if needed).

- Nurses always closely monitor patients when they have apnea to provide timely care to prevent complications of respiratory failure.

3.4. Some types of dyspnea:

- Cheyne-Stocks breathing:

Consists of 2 consecutive cycles, each cycle lasts about 1 minute. Phase I: Stop breathing for 15 - 20" due to inhibition of the respiratory center.

Phase II: Start with light shallow breathing, then gradually become fast, deep and strong, then exhale gently and gradually become shallow, then stop breathing and start another cycle:

Due to respiratory arrest when CO2 accumulates in the brain, stimulating the respiratory center.

Common in: cerebral hemorrhage, brain tumor, uremia, morphine poisoning.



- Kussmaul breathing:

Consists of a deep inhale, a short pause, a quick exhale, followed by a long pause to continue another breath.

Seen in diabetic coma patients.



3.5. General principles when counting breaths: The patient should rest for 15 minutes before counting breaths. Do not let the patient know you are counting breaths.

Count respirations twice a day at set times for stable patients.

Severe patient, post-operative anesthesia not applied every 15 minutes.

Count your breaths for 1 full minute.

Pencil graph.

Never count breaths while the patient is walking or standing.

If the child is crying, wait until he or she stops crying before counting. It is best to wait until the child is asleep before counting. Count the breathing rate before taking the temperature and pulse.

4. ARTERIAL BLOOD PRESSURE:

4.1. Definition:

Arterial blood pressure is the pressure of blood on the artery walls, this pressure is created by 3 basic factors:

Contractility of the heart, elasticity of large arteries.

Blood volume, blood viscosity, arterial wall resistance. Neurological factors.

4.2. Elements of blood pressure:

Maximum blood pressure: 90 - 139 mmHg, also known as systolic blood pressure. Minimum blood pressure: 40 - 90 mmHg, also known as diastolic blood pressure. Blood pressure is usually recorded in fractional form. Example: 120/60 mmHg

Blood pressure difference or blood pressure difference: maximum blood pressure minus minimum blood pressure.

Clamp blood pressure: difference between maximum and minimum blood pressure ≤ 20 mmHg.

4.2.1 . Physiological changes:

Age: Elderly, infants have high blood pressure. Gender: Women have lower blood pressure than men.

Exercise - mental work - worry a lot, highland

Use sympathomimetic drugs: Syncortyl, adrenaline high blood pressure. Antisympathomimetic drugs: Prostigmine, gardénal low blood pressure.

4.2.2. Pathological changes:

High blood pressure or hypertension, when maximum blood pressure is ≥ 140 mmHg and minimum blood pressure is > 90 mmHg.

Occurs in diseases: Heart - kidney - arteriosclerosis - lead poisoning - diabetes... Low blood pressure: when maximum blood pressure < 90 mmHg, minimum blood pressure < 40 mmHg.

Seen in diseases: Malnutrition, acute dehydration - acute blood loss - anemia.



Stethoscope and watch blood pressure monitor Mercury blood pressure monitor


Electronic blood pressure monitor Electronic wrist blood pressure

4. 3. General principles when measuring blood pressure :

- Let the patient rest for 15 minutes before measuring.

- Measure blood pressure twice a day at the same time.

- Measure with the same machine, same position.

- Measure away from the meal, the patient's arm is comfortable, at heart level.

- If in doubt about the result, measure again after 30 minutes.

- If you don't have a stethoscope, you can use your hand to take the pulse. In this case, you can only hear the maximum blood pressure but it is not accurate.

- If you can't measure on your arm, measure on your knee.

- Children should use a separate machine.

5. MONITORING PERCEPTION:

5.1. Perception and understanding:

Is patient contact, asking if the patient answers correctly or vaguely incorrectly.

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