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Chapter 32: Vital Signs

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Chapter 32: Vital Signs Bonnie M. Wivell, MS, RN, CNS TEMPERATURE Factors affecting body temp. (36-38 C/96.8-100.4 F) Age Infants: 95.9 99.5 F Elderly ... – PowerPoint PPT presentation

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Title: Chapter 32: Vital Signs


1
Chapter 32 Vital Signs
  • Bonnie M. Wivell, MS, RN, CNS

2
VITAL SIGNS
  • TEMPERATURE
  • BLOOD PRESSURE
  • PULSE
  • APICAL
  • RADIAL
  • RESPIRATIONS
  • PULSE OXIMETRY
  • PAIN SCALE

3
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

4
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 (low-pitched sounds)
  • BP cuff
  • Pulse oximeter

5
PATIENT HISTORY
  • RN must know patient medical history, including
    medications
  • These facts can affect vital signs
  • RN is responsible for knowing the patients usual
    vital sign range

6
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

7
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.

8
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.

9
TEMPERATURE
  • Factors affecting body temp. (36-38C/96.8-100.4F
    )
  • 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

10
TEMPERATURE ALTERATIONS
  • Afebrile
  • Fever of unknown origin (FUO)
  • Malignant hyperthermia hereditary, occurs during
    anesthesia
  • Heatstroke medical emergency
  • Heat exhaustion
  • Hypothermia
  • Frostbite

11
TEMPERATURE Contd.
  • 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

12
PULSE
  • Sites
  • Temporal, Carotid, Apical, Brachial, Radial,
    Femoral, Popliteal, Posterior Tibial, Dorsalis
    Pedis
  • Increases in HR
  • 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

13
PULSE Contd.
  • 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

14
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

15
Factors Influencing Character of Respirations
  • Exercise
  • Acute Pain
  • Anxiety
  • Smoking
  • Body Position
  • Medications
  • Neurological injury
  • Hemoglobin function

16
RESPIRATIONS Contd.
  • Tachypnea rapid breathing
  • Apnea cessation of breathing
  • Cheyne-Stokes rate and depth irregular,
    alternate periods of apnea and hyperventilation
  • Kussmauls abnormally deep, regular, and
    increased in rate (associated with DM)

17
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

18
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

19
BLOOD PRESSURE Contd.
  • Physiology of arterial blood pressure
  • Cardiac Output, Peripheral resistance, Blood
    volume, Viscosity, Elasticity
  • Factors influencing BP
  • Age, Stress, Ethnicity, Gender, Daily Variation,
    Meds, Activity, Weight, Smoking
  • Hypertension
  • Hypotension
  • Orthostatic or postural hypotension

20
Chapter 34 INFECTION PREVENTION and CONTROL
21
CHAIN OF INFECTION
22
MODES OF TRANSMISSION
  • DIRECT
  • PERSON TO PERSON (FECAL-ORAL)
  • HEPATITIS A
  • STAPH
  • INDIRECT
  • CONTACT WITH CONTAMINATED OBJECT
  • HEPATITIS B AND C
  • HIV
  • RSV
  • MRSA

23
MODES OF TRANSMISSION
  • DROPLET TRANSMISSION
  • LARGE PARTICLES
  • CAN TRAVEL UP TO 3 FEET
  • INFLUENZA
  • RUBELLA (3-day/GERMAN MEASLES)
  • BACTERIAL MENINGITIS

24
SNEEZE OR COUGH
25
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

26
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27
NORMAL DEFENSES
  • INFLAMMATORY RESPONSE
  • NORMAL BODY FLORA
  • CILIA IN LUNGS
  • INTACT SKIN
  • pH OF BODY FLUIDS
  • ACIDIC GASTRIC SECRETIONS
  • ALKALINE VAGINAL SECRETIONS

28
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 clients flora becomes altered or overgrowth
    results, i.e. C. Diff, vaginal yeast infection

29
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
30
VIGNETTE ANALYSIS
  • INFECTIOUS AGENT
  • RESERVOIR
  • PORTAL OF EXIT
  • MODE OF TRANSMISSION
  • PORTAL OF ENTRY
  • SUSCEPTIBLE HOST
  • ESCHERICHIA COLI
  • LARGE INTESTINES
  • FECES
  • NURSES HANDS
  • TRACHEOSTOMY
  • OLDER ADULT WITH TRACHEOSTOMY

31
NURSING PROCESS
  • ASSESSMENT
  • PATIENT
  • CLIENT SUSCEPTIBILITY
  • Status of DEFENSE MECHANISMS (smoker?)
  • AGE very young and very old
  • NUTRITIONAL STATUS decreased protein intake
    reduces the bodys defenses against infection and
    impairs wound healing
  • STRESS lowers immunity
  • DISEASE PROCESS HIV, Leukemia, Lymphoma
  • LABORATORY DATA
  • CLIENT NEEDS RELATED TO DISEASE STATUS

32
NURSING PROCESS
  • NURSING DIAGNOSIS
  • RISK FOR INFECTION R/T COMPROMISED DEFENSE
    MECHANISM AS EVIDENCED BY PRESENCE OF TRACHEOSTOMY

33
NURSING PROCESS
  • PLANNING
  • GOAL
  • PATIENT WILL REMAIN FREE FROM INFECTION
  • EXPECTED OUTCOME
  • PATIENT WILL REMAIN AFEBRILE
  • CLIENT WILL HAVE NO SIGNS/SYMPTOMS OF INFECTION

34
NURSING PROCESS
  • IMPLEMENTATION
  • STANDARD PRECAUTIONS WILL BE FOLLOWED FOR ALL
    PATIENT CONTACT

35
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

36
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37
Break The Chain!
  • Implement ASEPSIS absence of disease-producing
    microorganisms refers to practices/procedures
    that assist in reducing the risk of infection
  • 2 Types
  • Medical (clean technique)
  • Surgical (sterile technique)

38
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

39
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)

40
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

41
STANDARD PRECAUTIONSTIER 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

42
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

43
ISOLATION PRECAUTIONSTIER 2
  • Contact private room or cohort clients, gloves
    and gowns
  • MDRO, C-Diff, RSV
  • Droplet private room or cohort clients, mask is
    required
  • Strept, pertusis, mumps, flu
  • Airborne private room, negative airflow, hepa
    filtration N95 respirator mask required
  • TB, chickenpox, measles
  • Protective Environment private room,
    positive-pressure room hepa filtration gloves,
    gowns, mask (controversial) NO flowers or potted
    plants
  • Stem cell transplant

44
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45
STANDARD PRECAUTIONS
  • HANDWASHING
  • GLOVES (PPE)
  • MASKS (PPE)
  • EYE PROTECTION (PPE)
  • GOWNS (PPE)
  • LEAKPROOF LINEN BAGS
  • PUNCTURE PROOF CONTAINERS

46
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47
IN A YEAR YOU WILL HAVE SWALLOWED 14 INSECTS
WHILE SLEEPING
48
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49
WHERE ARE WE IN THE CHAIN OF INFECTION?
  • PORTAL OF EXIT
  • SUSCEPTIBLE HOST
  • RESERVOIR
  • CRITICAL THINKING!!

50
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 skins 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

51
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 persons 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
    objects surface
  • The edges of a sterile field or container are
    considered to be contaminated a 1 inch border
    around the drape is considered contaminated

52
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

53
Lab Practice Contd.
  • 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 patients
    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)

54
LAB Practice Sterile Procedures
  • Opening sterile packages
  • Preparing a sterile field
  • Pouring sterile solutions label to palm, lip
    it
  • Donning sterile gown and gloves
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