Results
· Under 10 breaths per minute – bradypnea;
· Above normal limits - tachypnea;
GENERAL ASSESSMENT
· We observe the patient's general condition and supervise all vital functions;
· We follow the time, the frequency, the effort of breathing;
· We notice if the patient is hoarse, if he has a cough or sputum;
· We observe if the patient makes an effort to breathe, if he has dyspnea, if he has pain during inspiration / breathing, fever, cyanosis, HTN, tachycardia;
· Position the patient in:
- Semi-sitting with absolute rest to reduce oxygen needs, if needed;
- Lying on the back without a pillow, with the head tilted sideways on the healthy side for aspiration of mucus and oro-pharyngeal secretions;
- Chin up to open the airway.
· Depending on the severity of the respiratory disorders, the doctor will decide:
- Airway clearance;
- BOropharyngeal / orotracheal intubation;
The temperature sheet is an appendix to the
observation sheet and is completed by the medical assistant.
It contains the following headings: breathing, blood pressure, pulse and temperature.
To complete the temperature sheet, start with the patient's data, which will be noted at the top, in the columns: cnp, name, first name, year, month, observation sheet number, salon number and bed number allocated to the patient in hospitalization period.
In the column "day" - fill in the calendar day, and in the column "day of illness" fill in the number of the day, day 1 being the day of hospitalization. D corresponds to the morning, and S to the evening period.
BREATHING COLUMN
· Starts from 35 and seconds from 5 to 10 breaths. Horizontally, each square represents a breath.
· Thus, we will be able to mark any number of breaths between 35-10 by counting the boxes. It is written with a green pen.
BLOOD TENSION COLUMN
· It starts at 30 and decreases from 5 in 5 to 5. Each square represents 1(0) units. 1/2 square = 5 mm/ Hg.
· The obtained values are noted on the temperature sheet with a red horizontal line, counting for each line of the sheet one unit of mercury column. Join the horizontal lines with vertical lines and hatch the resulting space.
· The top value represents systolic, and the bottom diastolic. In other medical documents it is written numerically.
· It is written with a blue or red pen.
PLUS COLUMN
· It starts from 160 and decreases smoothly 20 in 20 towards 60. Each square represents 4 pulses. ½ square represents 4 pulses. ½ square represents 2 pulses.
· The obtained value is recorded through a point on the temperature sheet, taking into account that each horizontal line represents 4 pulsations. The present value is joined with the previous one with a line, to obtain the curve. In some documents it is written numerically. It is written with a red pen.
TEMPERATURE COLUMN
· It starts from 41 and decreases one degree at a time to 36. Each square represents 1 degree / 5 ie 0.2 ½ square = 0.1 degrees.
· The marking of a point is done in the square equivalent to the measured value, corresponding to the date and time of day, counting, for each horizontal line of the sheet, 2 degree divisions. The present value is combined with the previous one to obtain the thermal curve. It is written with a blue pen.