Chapter 32: Vital Signs
Download
Report
Transcript Chapter 32: Vital Signs
Chapter 32: Vital Signs
Bonnie M. Wivell, MS, RN, CNS
VITAL SIGNS
TEMPERATURE
BLOOD PRESSURE
PULSE
APICAL
RADIAL
RESPIRATIONS
PULSE OXIMETRY
PAIN SCALE
VITAL SIGNS ARE PART OF THE
PHYSICAL ASSESSMENT
Delegation of Duties to UAP
Unlicensed Assistive Personnel
RN is Responsible to Manage Care Based on
Physical Assessment
Administering medications
Communicating to other members of the health care
team
Supervising delegated tasks
EQUIPMENT
RN is responsible for assuring equipment is
functioning properly
Appropriate equipment
Must be appropriate to patient age size
Thermometer
Stethescope: Diaphragm (high-pitched sounds); bell (lowpitched sounds)
BP cuff
Pulse oximeter
PATIENT HISTORY
RN must know patient medical history,
including medications
These facts can affect vital signs
RN is responsible for knowing the patient’s
usual vital sign range
FREQUENCY OF VITAL SIGNS
Physicians order the frequency of vital signs
Could be ordered by protocol or policy
The RN can increase the frequency based on his/her
assessment
VITAL SIGNS can be an early warning sign that
complications are developing
INDICATIONS FOR MEDICATION
ADMINISTRATION
Many medications are administered when the
vital signs are within an acceptable range.
Accurate VITAL SIGNS are required in order to
make treatment decisions.
COMPREHENSIVE
ASSESSMENT FINDINGS
Compare VITAL SIGNS to assessment findings
and laboratory results to accurately interpret the
patient status.
Discuss your findings with peers and charge RN
before deciding on a plan of action.
TEMPERATURE
Factors affecting body temp. (36-38°C/96.8100.4°F)
Age
Infants: 95.9 – 99.5° F
Elderly: Average temp is 96.8° F; Sensitive to temp
extremes
Exercise
Hormone levels
Circadian rhythm
Stress
Environment
TEMPERATURE ALTERATIONS
Afebrile
Fever of unknown origin (FUO)
Malignant hyperthermia: hereditary, occurs during
anesthesia
Heatstroke: medical emergency
Heat exhaustion
Hypothermia
Frostbite
TEMPERATURE Cont’d.
Sites
Core temp is measured in pulmonary artery,
esophagus, and urinary bladder
Mouth, rectum, tympanic membrane, temporal
artery, and axilla
Variety of types available – electronic and
disposable
Antipyretics = drugs that reduce fever
PULSE
Sites
Increases in HR
Temporal, Carotid, Apical, Brachial, Radial, Femoral,
Popliteal, Posterior Tibial, Dorsalis Pedis
Short-term exercise, fever, heat, pain, anxiety, drugs, loss of
blood, standing or sitting, poor oxygenation
Decreases in HR
Long-term exercise, hypothermia, relaxation, drugs, lying
down
PULSE Cont’d.
Volume of blood pumped by the heart during 1 minute
is the cardiac output
When mechanical, neural or chemical factors are unable
to alter stroke volume, a change in heart rate will result
in change in cardiac output, which affects blood
pressure
HR ↑, less time for heart to fill, BP ↓
HR ↓, filling time is increased, BP ↑
An abnormally slow, rapid, or irregular pulse alters
cardiac output
RESPIRATIONS
Ventilation = the movement of gases in and out
of lungs
Diffusion = the movement of oxygen and CO2
between the alveoli and RBCs
Perfusion = the distribution of RBCs to and
from the pulmonary capillaries
Factors Influencing Character of
Respirations
Exercise
Acute Pain
Anxiety
Smoking
Body Position
Medications
Neurological injury
Hemoglobin function
RESPIRATIONS Cont’d.
Tachypnea = rapid breathing
Apnea = cessation of breathing
Cheyne-Stokes = rate and depth irregular,
alternate periods of apnea and hyperventilation
Kussmaul’s = abnormally deep, regular, and
increased in rate (associated with DM)
PULSE OXIMETER
Indirect measurement of oxygen saturation
Photodetector detects the amount of oxygen
bound to hemoglobin molecules and oximeter
calculates the pulse saturation
Only reliable when SaO2 is over 70%
BLOOD PRESSURE
Force exerted on the walls of an artery by the
pulsing blood under pressure from the heart
Systolic = maximum pressure when ejection
occurs
Diastolic = minimum pressure of blood
remaining in the arteries after ventricles relax
BLOOD PRESSURE Cont’d.
Physiology of arterial blood pressure
Factors influencing BP
Cardiac Output, Peripheral resistance, Blood
volume, Viscosity, Elasticity
Age, Stress, Ethnicity, Gender, Daily Variation,
Meds, Activity, Weight, Smoking
Hypertension
Hypotension
Orthostatic or postural hypotension
Chapter 34: INFECTION
PREVENTION and CONTROL
CHAIN OF INFECTION
MODES OF TRANSMISSION
DIRECT
PERSON TO PERSON (FECAL-ORAL)
HEPATITIS A
STAPH
INDIRECT
CONTACT WITH CONTAMINATED OBJECT
HEPATITIS B AND C
HIV
RSV
MRSA
MODES OF TRANSMISSION
DROPLET TRANSMISSION
LARGE PARTICLES
CAN TRAVEL UP TO 3 FEET
INFLUENZA
RUBELLA (3-day/GERMAN MEASLES)
BACTERIAL MENINGITIS
SNEEZE
OR COUGH
MODES OF TRANSMISSION
AIRBORNE
DROPLETS SUSPENDED IN AIR AFTER COUGHING
AND SNEEZING OR CARRIED ON DUST PARTICLES
TB
CHICKEN POX
MEASLES (RUBEOLA)
ASPERGILLUS
VECTOR
EXTERNAL MECHANICAL TRANSFER
MOSQUITO,, LOUSE, FLEA, TICK, FLY
WEST NILE VIRUS
MALARIA
LYME DISEASE
NORMAL DEFENSES
INFLAMMATORY RESPONSE
NORMAL BODY FLORA
CILIA IN LUNGS
INTACT SKIN
pH OF BODY FLUIDS
ACIDIC GASTRIC SECRETIONS
ALKALINE VAGINAL SECRETIONS
Types of Infections
Heath Care-Associated Infections (HAIs – formerly
called nosocomial): result from delivery of health
services in a health care facility
Iatrogenic: a type of HAI from a diagnostic or
therapeutic procedure
Exogenous: an infection that is present outside the
client, i.e. a post-op infection
Endogenous: an infection that occurs when part of
the client’s flora becomes altered or overgrowth results,
i.e. C. Diff, vaginal yeast infection
VIGNETTE
An older adult, hospitalized with a GI disorder
is on bedrest and requires assistance for
uncontrolled diarrhea stools.
Following one episode of cleaning the patient
and changing the bed linens, the nurse went to a
second patient to provide tracheostomy care.
The nurses hands were not washed before
assisting the second patient
29
VIGNETTE ANALYSIS
INFECTIOUS AGENT
RESERVOIR
PORTAL OF EXIT
MODE OF
TRANSMISSION
PORTAL OF ENTRY
SUSCEPTIBLE HOST
ESCHERICHIA COLI
LARGE INTESTINES
FECES
NURSE’S HANDS
TRACHEOSTOMY
OLDER ADULT WITH
TRACHEOSTOMY
NURSING PROCESS
ASSESSMENT
PATIENT
CLIENT SUSCEPTIBILITY
Status of DEFENSE MECHANISMS (smoker?)
AGE – very young and very old
NUTRITIONAL STATUS – decreased protein intake
reduces the body’s defenses against infection and impairs
wound healing
STRESS – lowers immunity
DISEASE PROCESS – HIV, Leukemia, Lymphoma
LABORATORY DATA
CLIENT NEEDS RELATED TO DISEASE
STATUS
NURSING PROCESS
NURSING DIAGNOSIS
RISK FOR INFECTION R/T COMPROMISED
DEFENSE MECHANISM AS EVIDENCED
BY PRESENCE OF TRACHEOSTOMY
NURSING PROCESS
PLANNING
GOAL
PATIENT WILL REMAIN FREE FROM INFECTION
EXPECTED OUTCOME
PATIENT WILL REMAIN AFEBRILE
CLIENT WILL HAVE NO SIGNS/SYMPTOMS OF
INFECTION
NURSING PROCESS
IMPLEMENTATION
STANDARD PRECAUTIONS WILL BE
FOLLOWED FOR ALL PATIENT CONTACT
NURSING PROCESS
EVALUATION
DID
PATIENT REMAIN INFECTION
FREE?
YES
– GOOD JOB!
NO – - REASSESS PATIENT AND
ENVIRONMENT TO DETERMINE WHERE
THE CHAIN OF INFECTION WAS
BROKEN
Break The Chain!
Implement ASEPSIS: absence of diseaseproducing microorganisms; refers to
practices/procedures that assist in reducing the
risk of infection
2 Types
Medical (clean technique)
Surgical (sterile technique)
MEDICAL ASEPSIS
A clean technique that limits the number of pathogens
that could cause infections
Aseptic technique: practices/procedures that assist in reducing the
risk for infection
3 components to the technique:
Hand washing,
Barriers of PPE (gloves, gowns, mask, protective eyewear)
Routine environmental cleaning
Contaminated area: one suspected of containing
pathogens eg. used bedpan, wet gauze, soiled linen,
laboratory specimens, etc
Disinfection/Sterilization
Disinfection = the process that eliminates many
or all microorganisms, with the exception of
bacterial spores, from inanimate objects
Disinfection of surfaces
High-level disinfection
Alcohols, chlorines, glutaraldehydes, hydrogen peroxide
Sterilization = complete elimination or
destruction of all microorganism, including
spores
Steam under pressure, ethylene oxide gas (ETO)
CDC GUIDELINES
Standard
Precautions apply to:
Blood
All body fluids and secretions (feces, urine,
mucus, wound drainage) except sweat
Non-intact skin
Mucous membranes
Respiratory secretions
STANDARD PRECAUTIONS
TIER 1
Hand Hygiene: see next slide
Gloves: for touching blood, body fluids, secretions,
excretions, non-intact skin, mucous membranes or
contaminated areas
Masks, Eye Protection or Face Shields: if in contact
w/ sprays or splashes of body fluids
Gowns: to protect your clothing
Contaminated Linen: place in leak-proof bag so no
contact with skin or mucous membranes
Respiratory Hygiene/Cough Etiquette: provide
client with tissues and containers for disposal; stand ~3
feet away from coughing; use masks prn
Hand Hygiene
Number one defense against infection
Soap and water if hands are visibly soiled
Friction for 15 seconds
After 3-5 uses of hand gel
Alcohol-based hand products are accepted if hands not
visibly soiled
Before and after providing client care
Before eating
After contact with body fluids or excreta
After contact with inanimate objects in immediate area of the
client
Before procedures
After removing gloves
Is NOT effective against C-Diff
ISOLATION PRECAUTIONS
TIER 2
Contact = private room or cohort clients, gloves and
gowns
Droplet = private room or cohort clients, mask is
required
Strept, pertusis, mumps, flu
Airborne = private room, negative airflow, hepa
filtration; N95 respirator mask required
MDRO, C-Diff, RSV
TB, chickenpox, measles
Protective Environment = private room, positivepressure room; hepa filtration; gloves, gowns, mask
(controversial); NO flowers or potted plants
Stem cell transplant
STANDARD PRECAUTIONS
HANDWASHING
GLOVES (PPE)
MASKS (PPE)
EYE PROTECTION (PPE)
GOWNS (PPE)
LEAKPROOF LINEN BAGS
PUNCTURE PROOF CONTAINERS
IN A YEAR YOU WILL HAVE
SWALLOWED 14 INSECTS WHILE
SLEEPING
WHERE ARE WE IN THE CHAIN
OF INFECTION?
PORTAL OF EXIT
SUSCEPTIBLE HOST
RESERVOIR
CRITICAL THINKING!!
Surgical Asepsis
Sterile technique that prevents contamination of an
open wound, serves to isolate the operative area from
the unsterile environment, and maintains sterile field
for surgery
Includes procedures used to eliminate all
microorganisms, including pathogens and spores from
an object or area
Used in the following situations:
Procedures requiring perforation of the skin
When the skin’s integrity is broken as a result of trauma,
surgery or burns
During procedures that involve insertion of catheters or
surgical instruments into sterile body cavities
Principles of Surgical Asepsis
A sterile object remains sterile only when touched by another
sterile object
Only sterile objects may be placed on a sterile field
A sterile object or field out of the range of vision or an object
held below a person’s waist is contaminated
A sterile object or field becomes contaminated by prolonged
exposure to air
When a sterile surface comes in contact with a wet,
contaminated surface, the sterile object or field becomes
contaminated by capillary action
Fluid flows in the direction of gravity so a sterile object becomes
contaminated if gravity causes a contaminated liquid to flow
over the object’s surface
The edges of a sterile field or container are considered to be
contaminated – a 1 inch border around the drape is considered
contaminated
LAB Practice: Isolation Precautions
Demonstrate
donning Isolation Gown, Mask,
Gloves, Eyewear
Demonstrate removing Isolation Gown, Mask,
Gloves, Eyewear
Demonstrate proper disposal of PPE before
leaving Isolation Room
When performing care/treatments use hospital
provided stethoscope and leave in the room
Lab Practice Cont’d.
Practice pretending you are entering patient
room (use curtains) and give Complete Bed Bath
and do Bed Linen Change wearing PPE (gown,
mask, gloves)
Remember to dispose of PPE INSIDE the
patient’s room before you leave
Practice bringing in all the supplies you need so
you can stay in the room & not have to leave
(de-gown etc) and come back in (re-gown etc)
LAB Practice: Sterile Procedures
Opening sterile packages
Preparing a sterile field
Pouring sterile solutions – label to palm, “lip” it
Donning sterile gown and gloves