HR RR SBP DBP Temp

60-100 12-20 <120 mm Hg <80 mm Hg See below

Adult Vital Signs: Normal

Temporal artery 37.0o-38oC (98.6o-100.4oF)Tympanic temperature 37.0o-38.1oC (98.6o-100.6oF)Oral temperature 36.4o-37.6oC (97.6o-99.6oF)Rectal temperature 37.0o-38oC (98.6o-100.4oF)Axillary temperature 35.9o-37.0oC (96.6o-98.6oF)

S.A.M.P.L.E. HistoryS Signs and symptoms

A Allergies (include food and environmental allergies)

M Medications (include OTC and herbal supplements)

P Pertinent medical or surgical history

L Last oral intake

E Events leading up to illness or injury

Pulse OximetrySpO2 Nursing Intervention

>95% • Considered normal and generally requires no invasive intervention

• Continue routine monitoring of Pt.

91%-94% • Considered borderline• Assess probe placement and adjust if neces-

sary• Begin oxygen at 2 L/min titrated to SpO2

>95%

85%-90% • 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

<85% • 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 drug-induced respiratory depression

Basic ECG Interpretation

Acid-Base Imbalance (See back side for lab values)

Imbalance pH PCO2 PO2 HCO3 Compensation

Respiratory Acidosis Kidneys conserve HCO3; eliminate H+ to increase pHUncompensated i h Normal Normal

Compensated Normal h h h

Respiratory Alkalosis Kidneys eliminate HCO3; conserve H+ to decrease pHUncompensated h i Normal Normal

Compensated Normal i i i

Metabolic Acidosis Hyperventilation to blow off excess CO2 and conserve HCO3

Uncompensated i Normal i i

Compensated Normal i i i

Metabolic Alkalosis Hypoventilation to increase CO2Kidneys keep H+ and excrete HCO3

Uncompensated h Normal h h

Compensated Normal h h h

Normal Pediatric Vital SignsAge 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

4 years 20-30 75-115 95-110 37.5

6 years 18-24 70-110 95-110 37

8 years 18-22 70-110 95-115 37

10 years 16-20 60-110 95-120 37

12 years 16-20 60-110 95-125 37

Teenager 12-20 60-100 95-135 37

Pediatric IM Injection SitesMuscle Needle Max Volume

Infant Vastus lateralis 5/8-7/8” 1 mL

Toddler Ventrogluteal or vastus lateralis 5/8-1” 1 mL

Older child Ventrogluteal or deltoid 5/8-1” 1 Ml

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