Thermoregulation LA
1. Practice taking different types of temperatures. a. Oral-- i. Wait 20-30 minutes if client has been eating, drinking, chewing gum, smoking, or exercising before taking temp. ji. Place thermometer under tongue along gumline in order to come in contact with large vessels under tongue. b. Axillary -- i. Dry axilla if necessary as moisture may give false reading ii. Place thermometer in center of axillae and lower arm down across chest C. Rectal - Wear gloves ii. Place cover over probe and lubricate with ky gel iii. Position client on side facing away from you. Separate buttocks, instruct client to take a deep breath, and insert covered and lubricated probe %- / inch
through anal sphincter.
iv. Position probe to side of rectum to ensure contact with tissue wall Temporal i. Do not use on diaphoretic patients ii. Two types- no touch- place up to 2" from clients center of clients forehead, touch requires a gentle stroke across forehead and a tap behind ear iii. Press power button to turn on iv. Press and hold scan button in appropriate location v. Release scan button e. Tympanic i. Turn client's head to one side and stabilize head. ii. Pull pinna up and back for an adult or down and back for a child to gain better access to ear canal iii. Center probe and gently advance into ear canal to make a firm seal directing probe toward tympanic membrane iv. Press and hold temperature switch until reading displays V. Clean with alcohol wipe on completion 2. Inserting suppositories a. Provide privacy b. Don gloves C. Remove suppository from foil; lubricate tip of suppository to prevent tissue damage and ease insertion. Also lubricate index fingertip of non-dominant hand glove d. Instruct client to breathe through mouth as this relaxes anal sphincter e. Gently insert suppository with pointed end first and place in rectum beyond external and internal sphincters approx. 3-fi inches. Push against side of rectal wall Do not place the suppository into a fecal mass as it will not be effective because it cannot be absorbed g. Withdraw finger and press client's buttocks together for a few minutes to prevent expulsion
h. Have patient remain in Sims (side-lying) position for 5 minutes i. Remove and discard gloves. j. Place bedside commode within reach if administering to assist BM 3. Hanging IV antibiotics and using IV pumps a. Reconstitute solution b. Label IV bag C. Calculate IV drip rate d. Hang antibiotic and IV at correct drip rate fi. Collecting blood and blood cultures a. Order of draw i. Blood culture -- anaerobic and aerobic always need two sets ii. PT/PTT - light blue top ii. CBC - purple top iv. Renal -- green top V. Chemistry -- red top vi. Ammonia -- green top placed on ice vii. Blood bank -- red top (10 mL) place blood band b. Collecting a blood culture -- Done when MD suspects infectious process or septicemia, Check bottle expiration dates. Lo