Vital Signs Body Temperature

1 Indication: To determine the childs temperature on admission as a base for comparing future measurements. To monitor fluctuation in temperature. Equipment : Cotton with alcohol & dry cotton Container for waste Water soluble lubricant. Thermometer 2 3 4 5 Comments

Oral Temperature
Method range Advantages Disadvantages Length of time Age 1. Wash hands. 2. Explain the procedure to the child or to his parents. 3. Check that the child has not just had a cold or hot drink. 4. Clean thermometer with alcohol swab 5. Check thermometer to see the reading is down below 35c. 6. Instruct the child to raise his/her tongue and put thermometer under it, , and ask him to close his lips without biting. 7. Instruct the child to close his/her mouth, hold thermometer for 5 minutes 8. Remove the thermometer and wipe it with dry cotton swabs 9. Read and record temperature. 10. Wash thermometer with soap and water and dry it. .Wash hands .11 Instructors Signature: Student Signature:

Method Range

Advantages

Disadvantages

Length of time

Age

Oral 36.4 37.4c

1. Easily accessible. 2. Replication of thermometer placement is easy. 3. Responds more quickly and regular to changes in arterial temperature than does rectal method. 4. More aesthetically pleasing.

1. Value is ready influenced by ingestion of hot or cold fluids, and oxygen therapy. 2. Requires childs cooperation to keep mouth closed and not to bite the thermometer. 3. Contra indicated if child has oral injuries surgery or under the age of five years.

5 minutes

* More than 6 year's children.

Rectal Temperature
1 Indication: To determine the childs temperature on admission as a base for comparing future measurements. To monitor fluctuation in temperature.
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Comments

Equipment : Cotton with alcohol & dry cotton Container for waste Water soluble lubricant. Thermometer Method range Advantages Disadvantages Length of time Age 1. Wash hands. 2. Explain the procedure to the child and his family. 3. Clean thermometer with alcohol swab 4. Check thermometer to see the reading is down to 35c. 5. Apply lubricant to thermometer. 6. Grasp the infants ankle and placing index finger between the ankle bones. 7. Insert the thermometer bulb into the rectum 2.5cm. 8. Hold for 3 minutes. 9. Remove the thermometer and wipe it with dry cotton swabs. 10. Read and record temperature. 11. Clothe the child. 12. Clean the thermometer with soap and tape water. 13. Dry it and keep in its container. 14. Wash hands. N. B: 1. Rectal temperature should not be used in children who having rectal surgery or receiving chemotherapy. 2. Procedure should be done by rectal thermometer. 3. Measuring rectal temperature is generally unnecessary because of the risk of rectal perforation. Instructors Signature:

Student Signature:

Method Range Rectal 37.0 37.8c.

Advantages 1. Safe for children who are unable to co-operate and may bite the thermometer. 2. Not directly influenced by the ingestion of hot or cold fluids. 3. Method of choice if child

Disadvantages 1. Values may be altered by presence of stool. 2. Optional response may be negative. 3. Damage to rectal mucosa may occur. 4. Replication of
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Length of time 3 minutes

Age *New born * Infant.

has seizure or breathing difficulties receiving oxygen therapy, or has oral surgery.

thermometer placement is difficult. 5. Contra indicated when child has diarrhea and following rectal surgery.

Axially Temperature
1 Indication: To determine the childs temperature on admission as a base for comparing future measurements. To monitor fluctuation in temperature. Equipment : Cotton with alcohol & dry cotton Container for waste Water soluble lubricant. Thermometer Method range
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Comments

Advantages Disadvantages Length of time Age 1. Wash hands. 2. Assemble equipment. 3. Explain procedure to the child and infants family. 4. Clean thermometer with alcohol swab 5. Check thermometer to see that reading is down to 35c. 6. Dry the axially area and then Place thermometer under axilla and bring arm across chest. 7. Hold thermometer in place for 10 minutes. 8. Remove the thermometer and wipe it with dry cotton swabs. 9. Read and record temperature. 10. Clean the thermometer with soap and tape water. 11. Dry it and keep in its container. 12. Wash hands. Instructors Signature: Student Signature:

Method Range Axillary 35.8 36.6c

Advantages 1. Safe and easily accessible. 2. Avoids the danger of rectal or colon perforation. 3. Avoids initiating the defecation stimulus. 4. Often recommended for infants.

Disadvantages 1. Value is more readily influenced by environmental temperature and air flow. 2. Requires a relatively long period of time to obtain accurate reading.

Length of time 10 minutes.

Age Less than 6 years children.

Pulse
1 Indication: To gather information on the heart rate, pattern of beats (rhythm, rate and strength of pulse). Equipment: Watch with second hand. Stethoscope. Cotton with alcohol. Normal Heart Rate for different ages 2 3 4 5

Action Peripheral Pulse

1. Wash hands. 2. Explain the procedure to the child and his family. 3. Place child in comfortable position. 4. Place the third finger along the appropriate artery and press gently. 5. Count for full minute. 6. Record rate, regularity & fullness. 7. Report for any abnormalities.
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Apical Pulse
1. Expose the chest over the apex of the heart. 2. Wipe the ears pieces & diaphragm with alcohol swabs and warm diaphragm. 3. Place the stethoscope between the infants left nipple and sternum between the 4th & 5th ribs. 4. Listen and count for full minute. 5. Remove stethoscope and cover the child chest. 6. Wipe earpieces and diaphragm with alcohol swabs. 7. Record: rate, fullness and regularity. 8. Report any abnormal observation. Instructors Signature: Student Signature:

Age Newborn 15 months 612 months 13 years 35 years 610 years 1114 years 14+ years

Normal heart rate (beats per minute) 100-160 90-150 80-140 80-130 80-120 70-110 60-105 60-100

Comments

Instructors Signature:

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Respiration
Action Indication: To determine respiratory rate and assess respiratory characteristics (rate, rhythm, strength). To evaluate the child response to medication or treatments. Normal respiratory rate Equipment: Watch with second hand. Procedure 1. Remove over cover to observe chest movement. 2. Observe respiratory movement, rate, and depth, pattern and sound. 3. Count the rate for one minute. 4. Record rate, depth, pattern and sound. 5. Report for any abnormality. Normal respiratory rate (breaths per minute) 30-50 25-40 20-30 20-30 20-30 1 1 2 3 4 5 Comments

Age Newborn 15 months 612 months 13 years 35 years

Comments

610 years 1114 years 14+ years Instructors Signature:

15-30 12-20 12-20 Student Signature:

Blood Pressure
1 Equipment: - Measuring cuff and Stethoscope. -Alcohol swab Formulas of approximate average systolic pressure in relation to childs age. Formula of approximate average diastolic pressure in relation to childs age. Sites for measuring blood pressure Action 1. Assemble the equipment. 2. Wash hands. 3. Review child's previous blood pressure reading 4. Explain the procedure to the child or to his mother. 5. Expose the site of measurement fully by removing clothes. 6. Position the limb at the level of the heart. 7. Place stethoscope ear pieces in ears and be sure sounds are clear, not muffled. 8. With cuff fully dilated, warp cuff evenly around upper arm. 9. Be sure that manometer positioned vertically at the eye level observer (should be no further than 1 ml.) 10. Palpate brachial or radial artery with fingertips of one hand while inflating cuff rapidly to pressure 20mm Hg. Above point at which pulse disappears. 11. Slowly deflate the cuff, nothing when the pulse is first heard (systolic pressure) and when the sound becomes muffled or disappears (diastolic pressure).
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Comments

12. Remove equipment. 13. Hand wash. 14. Record your observation. Instructors Signature: Student Signature:

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Sites for measuring blood pressure: A. Upper arm B. Lower arm C. Thigh D. Calf or ankle.

Formulas of approximate average systolic pressure in relation to childs age. Childs Age 1 to 7 years 8 to 18 years Formula Age in years + 90 (2 X Age in years) + 83

Formula of approximate average diastolic pressure in relation to childs age. Childs Age 1 to 5 years 6 to 18 years Formula 56 mmHg Age in years + 52

Sponge Bath
1
Purposes:
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2 3

Comments

1. To clean the skin and comfort the child. 2. To increase circulation and metabolism. 3. To Observe childs body. 4. To give chance for play and talk with child. 5. To provide an opportunity to note childs growth and development. Equipment: Bowl for warm water Wash cloth or cotton (sponges) at least four wash cloth Soft hair Brush Bath towel Baby clothes Plastic bag Mackintosh Clear water Baby lotion Nail scissors Cotton with alcohol Actions 1. Explain procedure to the mother 2. Wash hands. 3. Close the doors and windows 4. Assemble the equipment at the child bedside. 5. Provide safe environment (Free from drafts). 6. Fill the bowl two-thirds full of water 36.5-40c according to the age and season, check water temperature by thermometer or by elbow joint. (Change the water as needed). 7. Precede bathing from top to bottom. 8. Wipe each eye with moist sponge from the inner to the outer aspect then dry gently each one. 9. Clean the baby face, wipe around mouth and nose then go over her cheeks and forehead, dry with sponge. 10. Clean each ear over and behind only (not inside) 11. Wipe the scalp & dry it. 12. Wipe the neck thoroughly pays attention to creases. 13. Take -off childs clothes 14. Clean hands from fingers then hands and dry well total. 15. Wipe under axially from front to back and dry well. 16. Clean the chest, abdomen, & back, then dry well in one direction. 17. Dress the child clean clothes 18. Clean the lower extremities from bottom to top then dry well. 19. Clean diaper area. Cord Care 1. hand wash 2. position infant supine
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3. Inspect the cord closely during the first 24 hours and then daily for any abnormalities. 4. Clean area at base in circular motion with alcohol wipe or cotton ball. 5. Wipe the top of the cord with cotton with alcohol wipe or

cotton ball.
6. Squeeze cotton with alcohol over the tip of the cord. 7. Dress the child clean clothes. 8. Collect equipments and clean the surrounding environment. 9. Wash hands. 10. Record.

Instructors Signature:

Student Signature:

Table Tub Bath

1 Purpose: 1. To satisfy the need for cleanliness. 2. To help the new mother at home bath her newborn infant. 3. To inspect infant body. 4. For therapeutic purpose as in burned child. 5. To relax the childs muscles before physical
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Comments

therapy. 6. To help remove dressings or crusts or to apply a certain soothing medication to the skin. Equipments: - Baby tub - Bath towel - Wash cloth 2-3 - Mild soap - Childs cloth. - Soft hair brush or comb - Mackintosh. Toy - Pitcher - Cotton Container - Gauze swabs - Baby Oil

Actions
1. 2. 3. 4. 5. 6. 7. 8. Explain the procedure to the childs mother. Check room temperature and free from drafts (close windows and doors). Assemble equipment. Fill the baby tub half to two third full of warm water (37.8)-(40.6c) if there is no water thermometer check it with your wrist. Spread the bath towel on the bed or table. Wash hands Place the infant still dressed on the bath towel Wash the infant eye, starting from the far eye, wipe the eye with moist cotton with water only from inner to outer aspect, and then dry it with clean dry cotton in one direction. Water only. Wipe the infants face, forehead, cheeks and mouth (clean inside the mouth if needed and nose with a moist cotton). Soap the scalp; support the infant using the football hold (the baby is supported under the nurses arm and no her hip) first lather your hand with soap then apply it to the scalp The infants head should be held over the wash basin, rinse thoroughly and if possible the ears should be covered with the nurses fingers. Place the infant on the table and dry the head with a part of the folded bath towel. Inspect the ears if any discharge present cleans it with the corner of washcloth. Remove the infants clothes. Lift the baby carefully and gradually into the tub, feet first, using appropriate hold. Quickly soap the infants entire body except the head using another wash cloth paying special attention to body creases, between toes, area under the chin and genitalia (revise the diaper care) Rinse the soap off the infant quickly. Again lift the infant from the tub back to the towel and dry well.
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9. 10.

11. 12. 13. 14. 15. 16.

17. 18.

19. 20. 21. 22.

Dress the infant; comb his/her hair gently. Clean all used equipment and return to its place. Wash hands. Record time and observations. NB: Allow time for kicking, playing, and talking with the infant to enjoy bathing. Apply lotion or oil to body creases avoids using of talcum powder. Talcum powder with oil makes a past, which retain body secretions and irritate the skin. It may be inhaled leading to respiratory distress Instructors Signature: Student Signature:

Diaper Care
1 Purpose: 1. Maintain the baby more comfortable by keeping him dry. 2. Maintain healthy skin at diaper area. 3. Observe any abnormal changes in the skin of the diaper area. 4. Inspect the infants body during the procedure. 5. Protection against urinary tract infection.(ascending infection) Equipment: Kidney basin. Warm water. Cotton/sponges or clean wash cloth. Plastic bag. Oil or ointment.
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Comments

 Disposable diaper or cloth diaper.

Action 1. 2. 3 Wash hands with soap and water. Prepare all the needed equipment. Explain to the parents the procedure in the purpose of teaching them. 4. Put the baby on a mat or changing table. 5. Wipe off the feces with the corner of the unclean diaper and fold the diaper down under the babys legs. 6. With clean wash cloth, clean thoroughly in the creases at the tops of baby's legs and at the base of genitals wiping away from the body. For a female : a. Wipe away feces with wash cloth then using a moist baby clean wash cloth, clean all over her stomach up to her umbilical stump. b. Lift her legs up with a finger between her ankles and wipe the vulva from front to back. For a male: a. Pause for a couple of seconds with the diaper held over his penis. b. Clean his penis, wiping away from the body. For uncircumcised boy pull the fore-skin back gently clean it then replace the retracted skin to prevent paraphimosis (edema of the glands),then clean scrotum change cloth as needed. 7. Lift the babys legs to clean anus and buttocks, keeping a finger between ankles wipe over the backs of thighs too then remove the diaper , repeat if baby still unclean 8. Dry baby's bottom with a clean wash cloth 9. Apply a barrier of cream or zinc oxide ointment. 10. Place the new clean diaper under the infants buttocks and sides in between his legs. 11. Bring diaper up over abdomen, place front part of diaper next to babys skin bring back of diaper over front tuck it. , being careful to place your finger between the baby and the diaper. 12. Fold diaper so that it does not cover the cord stump. 13. Discard the old diaper, collect your equipments; leave the area clean and tidy. 14. Wash hands.

Instructors Signature:

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Bottle Feeding
1 Indication: Extra indications to breast-feeding exist. Principles of Bottle Feeding: 1. Persons who prepare the formula must wash hands well. 2. The formula is prepared and bottled immediately before each feeding. 3. Warming the formula is optional. (if it stored in the refrigerator). Equipment: For a fully bottle-fed baby you will need at least eight full-size (250 ml) bottle with suitable nipples. Measuring cup for mixing powder formula. Plastic funnel useful for pouring formula. Plastic spoon stirring formula. Plastic knife for leveling off scope of powder formula. Bottlebrush needed to clean thoroughly inside the bottle. Action Prepare the needed equipment.
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Comments

1.

2. 3. 4. 5. 6.

7. 8. 9. 10. 11. 12. a. b. 13. 14. 15. 16. 17.

Hand washing by soap and running water. Prepare formula as prescribed. Check amount of formula on straight surface. Let a few drops of formula fall in the inner aspect of your wrist to Test formula for temperature Hold the baby unless contraindicated in a semi up right position, if a baby cannot be removed from the crib, sit the baby, and elevate his /her head, shoulders. Put cotton under the babys chin. Do not contaminate the nipple a much as possible. Stroke the nearest cheek of the baby, or let some drops of formula touches the babys lips. Hold the bottle so that the nipple and neck of the bottle are full of formula. During feeding, hold the bottle firmly so that the baby can pull against it as he/she sucks. Burp the baby halfway through the feeding and at the end by one of the following methods: Place a small towel over your shoulder to protect your gown, place the baby firmly against your shoulder and pat the back. Place the baby in sitting position put a towel beneath the chin support the chest and head with one hand gently rub the back with the other hand. The feeding should take 15 to 20 minutes, dont hurry the baby or force the infant to feed too much. If the baby doesnt want to let go of the empty bottle, slide the little finger between the baby gums and nipple to release the sucking. Provide mouth care after feeding. Place the baby on the abdomen or on right side position at least one hour. Record the amount type of formula and baby reactions. Instructors Signature: Student Signature:

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Gavages Feeding
1 Purposes: 1. Introduce fluids, medications that cannot be given by mouth. 2. Carry out diagnostic procedures. 3. Conserve energy of infant, In case of prematurity or illness or congenital deformity or at risk of aspiration. Equipments: 1. A sterile suitable tube selected according to the size of the child and the viscosity of the solution (e.g. usual size for premature 5 French and 8 French for other children). 2. A stethoscope. 3. The solution of feeding. 4. Non allergic tape. 5. Sterile water for lubrication. 6. Container for the fluids. 7. 5ml 10ml syringes. 8. A pacifier. 9. Restraining equipment. 10. Gloves. Measurements: 1. Measuring from the tip of the nose to the tip of the earlobe and then to the end of xiphoid process, alternatively you may also measure from the bottom 2. Measuring from the nose to the ear lobe and then to point midway between the xiphoid process and the umbilicus 3. The same measure from the mouth to insert oral tube. Action Prepare the needed equipment. Hand wash by soap under running water. Explain the procedure to the parent and the child if he can understand. Use on age suitable restraining
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Comments

1. 2. 3.

4. 5. 6. 7. 8. 9. 10. a.

b. c. 11. 12. 13. 14 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25.

Place the child supine with head slightly hyperflexed Measure the tube for approximate length of insertion. Mark the point with a small piece of tape. Lubricate the tube by sterile water. Check that the nostrils are patent. A pacifier is used or place the infants finger in his mouth Insert the rounded end of the tube into clearest nostril. Slide the tube backward and inwards gently along the floor of the nose until predetermined mark. Check the position of the tube by using at least two methods (Clamp indwelling tube before using any method): Attach the syringe to the feeding tube and apply negative pressure aspiration of stomach content indicate proper placement (Notify physician if a gastric residue is greater than 25% of the pervious feeding) by the syringe inject a small amount of air 0.5-1m in premature to 5m older children into the tube while listening with a stethoscope over the stomach area and then withdraw air. Emerge the end of the tube into a container containing clean water, the water during breathing if bubbling occur withdraw and reinsert. If the tube is fixed, stabilize the tube by holding or taping it to the cheek by adhesive tape. Check the formula temperature to be as the room temperature. Connect the syringe barrel into the tube. Pour formula into the barrel of the syringe attached to the tube. Raise the syringe barrel 20-25cm from the bed. To start flow, give gentle push with the plunger and allow the fluid to flow into the stomach by gravity. The rate of flow 5-10ml/min in premature, and 10ml/min in older infants and children. Just before the syringe is empty, pinch the tube by fingers. Flush the tube with sterile water or G5% 1-2cm. Clamp indwelling tube & remove the syringe. If the tube is to be removed pinch it firmly and withdraw the tube quickly. Position the baby on right side or abdomen at least one hour. Provide mouth care with gauze and normal saline. Record the amount, type of formula and amount of gastric residue. Remove equipment, leave area clean and tidy.

Instructors Signature:

Student Signature:

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Gastrostomy Feeding
1 Providing nourishment and fluids via a tube that is surgically induced through an incision made through the abdominal wall into the stomach for those requiring tube feedings for an extended period of time. Equipment - Feeding formula - Pacifier. - Reservoir syringe or funnel - Syringe for aspirating. - Dressing or piece of cotton - Gauze for mouth care - Tape Action 1. Explain to the child or to the family the feeding procedure 2. Wash your hands. 3. Prepare the needed equipment 4. Check residual stomach contents before feeding. 5. Attach syringe and aspirate stomach contents. 6. Measure residual stomach contents 7. Residual fluid may be returned to stomach or discarded, depending on amount. 8. Place the child on comfortable position, either flat or with head slightly elevated 9. A pacified can be given. 10. Attach reservoir syringe to tube and fill syringe with feeding fluid to unclamping tube. 11. Elevate tube and syringe to 1012 cm above abdominal wall Do not apply any pressure to start flow 12. Feed slowly taking 20-45 min fill reservoir with fluid before it is empty to avoid instillation of air. 13. When feeding is completed: a. Instill clear water 1-30o of clear water. b. Apply clamp before water level reaches end of reservoir 14. Place the child in comfortable position.
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Comments

15. Mouth Care 16. Wash your hands 17. Record the feeding time formula content, route of feeding and any changes or abnormality and report to the doctor. Instructors Signature:

Student Signature:

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