Vital Signs and Infection Prevention and Control Peggy Korman CNM Foundations of Nursing Practice

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Vital Signs and Infection Prevention and
ControlPeggy Korman CNMFoundations of Nursing
Practice
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Guidelines for Measuring Vital Signs

• Establish a baseline for future assessments.
• Be able to understand and interpret values.
• Appropriately delegate measurement.
• Communicate findings.
• Ensure equipment is in working order.
• Accurately document findings.

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VITAL SIGNS

• TEMPERATURE
• BLOOD PRESSURE
• PULSE
• APICAL
• RADIAL
• RESPIRATIONS
• PULSE OXIMETRY
• PAIN SCALE

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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

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EQUIPMENT

• RN is responsible for assuring equipment is
  functioning properly
• Appropriate equipment
• Must be appropriate to patient age size
• Thermometer
• Stethascope Diaphragm (high-pitched sounds)
  bell (low-pitched sounds)
• BP cuff
• Pulse oximeter

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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

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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

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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.

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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.

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Temperature

• Represents the balance of heat produced by
  metabolism, muscular activity, and other factors
  and heat lost through the skin, lungs, and body
  waste

• A stable temperature pattern promotes proper
  function of cells, tissues, and organs a change
  in this pattern usually signals the onset of
  illness.

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TEMPERATURE

• Factors affecting body temp. (36-38C/96.8-100.4F
  )
• Age
• Infants 95.9 99.5 F 36.5-37.2C
• Elderly Average temp is 96.8 F Sensitive to
  temp extremes
• Exercise
• Hormone levels
• Circadian rhythm
• Stress
• Environment

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TEMPERATURE ALTERATIONS

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

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Measurement of Temperature

• Electronic digital
• Chemical-dot
• Tympanic
• Oral 97-99.5F 36.1-37.5C
• Rectal (most accurate) is usually 1F or 0.6C
  higher

• Axillary, least accurate 1-2F or0.6-1.1C lower
• Tympanic 0.5-1F higher

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TEMPERATURE Contd.

• Sites
• Core temp is measured in pulmonary artery,
  temporal artery, esophagus, and urinary bladder
• Mouth, rectum, tympanic membrane, and axilla
• Variety of types available electronic and
  disposable
• Antipyretics drugs that reduce fever

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• Using an oral electronic thermometer, the nurse
  checks the early morning temperature of a client.
  The client's temperature is 36.1 C (97 F). The
  client's remaining vital signs are in the
  normally acceptable range. What should the nurse
  do next?
• A) Check the client's temperature history. B)
  Document the results temperature is normal. C)
  Recheck the temperature every 15 minutes until
  it is normal. D) Get another thermometer the
  temperature is obviously an error.

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Equipment

• Electronic thermometer, chemical-dot thermometer
  or tympanic thermometer
• Facial tissue
• Disposable thermometer sheath or probe cover
• Alcohol pad
• If you are using an electronic thermometer, make
  sure its been recharged

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How to

• You can take an oral, rectal, or axillary temp
  with various electronic digital thermometers or a
  chemical-dot device
• Use oral route for most adults who are awake,
  alert, oriented and cooperative.

• For infants, young children, and confused or
  unconscious pts, you may need to take the temp
  rectally.
• The tympanic route may be used on almost all pts.

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Taking a Temp

• Hand hygiene
• Confirm pts identity with two pt identifiers
• Explain procedure to pt
• If pt has had hot or cold liquids, chewed gum or
  smoked, wait 15 minutes before taking an oral temp

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Taking a Tympanic Temp

• Make sure the lens under the probe is clean and
  shiny. Attach a disposable probe cover.
• Examine the pts ear. It should be free from
  cerumen to obtain and accurate reading. If the
  pt has any visible lesion or drainage STOP

• Stabilize the pts head gently pull the ear up
  and back.
• Insert the tenmometer until the ear canal is
  sealed. Insert like an otoscope.
• Press the button to activate. Hold 1 second.

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Taking an Oral Temp

• Position the thermometer under the pts tongue,
  as far back as possible on either side of the
  frenulum linguae. (promotes contact with
  superficial blood vessels and contributes to
  accurate reading)

• Instruct pt to close lips but avoid biting down
  with teeth.
• Leave a chemical-dot in place for 45 sec. Read
  the last dot that has changed color.
• Wait until maximum temp is displayed on
  electronic thermometer.

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Taking an Axillary Temp

• Position the pt with axilla exposed.
• Gently pat the axilla dry with a facial tissue
  because moisture conducts heat.
• Avoid harsh rubbing, which generates heat
• Ask the pt to reach across chest and grasp the
  opposite shoulder, lifting elbow.

• Position the thermometer in the center of the
  axilla.
• Tell pt to keep grasping shoulder and lower elbow
  against chest. This promotes skin contact with
  the thermometer probe

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Remember

• Axillary temps take longer to register than oral
  or rectal temps because the thermometer isnt
  enclosed in a body cavity.
• Dispose of the probe cover.
• Perform hand hygiene

• Clean or disinfect the electronic model after use
  to prevent cross-contamination.
• Perform hand hygiene.
• Document the procedure.

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Special Considerations

• Make sure the probe cover doesnt have any
  wrinkles, they interfer with the reading.
• Oral measurement is contraindicated in pts who
  are unconscious, disoriented, or seizure-prone
  in young children and infants and in pts who
  must breathe through their mouths.

• Use the same thermometer for repeats to avoid
  spurious variations
• Dont avoid oral temps in pts receiving nasal
  oxygen (Oxygen administration raises oral temp
  only 0.3F or 0.17C
• Make sure you document where the temp as taken.

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Pulse

• Blood is pumped into an already-full aorta during
  ventricular contraction creates a fluid wave that
  travels from the heart to the peripheral
  arteries.
• This recurring wave is called a pulse and can be
  palpated at locations on the body where an artery
  crosses over bone on firm tissue.

• In adults and children older than age 3 and in
  adults with a suspected cardiac disorder that
  affects the pts heart rate and rhythm, the
  radial artery is the most common palpation site.
• In infants and children younger than age 3, a
  stethoscope is used to listen to the heart

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Apical-Radial Pulse

• Taken simultaneously counting apical and radial
  beats
• First by auscultation at the apex of the heart
• Second by palpation at the radial artery
• Some heartbeats detected at the apex cannot be
  detected at peripheral sites

• When this occurs, the apical pulse rate is higher
  than the radial the difference is the pulse
  deficit.

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What to Assess

• Determine the rate (number of beats per minute)
• Rhythm (pattern or regularity of the beats)
• Volume (amount of blood pumped with each beat.

• If the pulse is faint or weak, use a Doppler
  ultrasonic blood flow detector if available.

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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

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Taking a Radial Pulse

• You will need a watch with a second hand, a
  stethoscope alcohol pad.
• If not using your own stethoscope disinfect
  earpieces
• Confirm pt identity
• Hand hygiene

• Tell pt you intend to take his pulse
• Make sure pt is comfortable relaxed because an
  awkward, uncomfortable position may affect heart
  rate.
• Place pt is a sitting or supine position, with
  arm at the side or across the chest.

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Radial Pulse Taking

• After locating the pulse, count the beats for 60
  seconds, or 30 sec and multiply by 2.
• Counting for a full minute provides a more
  accurate picture of irregularities.
• If you detect an irregularity, repeat the count,
  and note whether it occurs in a pattern or
  randomly. If in doubt, take an apical pulse.
• Document

• Gently press your index, middle and ring fingers
  on the radial artery, inside the pts wrist. You
  should feel a pulse with only moderate pressure
  excessive pressure may obstruct blood flow distal
  to the pulse site.
• Dont use your thumb. Why?

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Taking an Apical Pulse

• Help the pt to a supine position and drape
• Warm the diaphragm or bell of the stethoscope in
  your hand. A cold stethoscope may startle the pt
  and momentarily increase heart rate.
• Place diaphragm over apex of heart.

• Where? 5th intercostal space, left of the
  midclavicular line
• Count for 60 seconds, note rate, rhythm, volume
  and intensity.
• Make pt comfortable
• Clean stethoscope
• Document

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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

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• The nurse decides to take an apical pulse instead
  of a radial pulse. Which of the following client
  conditions influenced the nurse's decision?
• A) The client is in shock. B) The client has
  an arrhythmia. C) The client underwent surgery
  18 hours earlier. D) The client showed a
  response to orthostatic changes.

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Taking an Apical-Radial Pulse

• Two nurses work together to obtain the
  apical-radial pulse
• One palpates the radial pulse while the other
  auscultates the apical pulse with a stethoscope.
• Both must use the same watch when counting beats.

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Pulse Patterns

• Normal 60-100 beats/minute in neonates
  120-140 beats/minute
• Varies with such factors as age, physical
  activity and gender
• Men usually have lower pulse rates than women

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Tachycardia

• More than 100 beats/minute
• Accompanies stimulation of the sympathetic
  nervous system by emotional stress, such as
  anger, fear, or anxiety, or by the use of certain
  drugs such as caffeine.
• May result from exercise and from certain health
  conditions, such as heart failure, anemia, and
  fever (which increase oxygen requirements and
  therefore increase pulse rates)

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Bradycardia

• Less than 60 beats/minute
• Accompanies stimulation of the parasympathetic
  nervous system by drug use, especially digoxin,
  and such conditions as cerebral hemorrhage and
  heart block.
• May also be present in fit athletes.

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Irregular Pulse

• Uneven time intervals between beats (for example,
  periods of regular rhythm interrupted by pauses
  or premature beats)
• May indicate cardiac irritability, hypoxia,
  digoxin toxicity, potassium imbalance, or
  sometimes more serious arrhythmias if premature
  beats occur frequently
• Occasional premature beats are normal

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Special Considerations

• When peripheral pulse is irregular, take an
  apical
• If pulse is weak or faint get a Doppler
• If taking an apical-radial alone, hold
  stethoscope in place with the hand that holds th
  watch while palpating the radial with the other
  hand
• Document pulse rate, rhythm, and volume as well
  as time of measurement. Full/Boundingincreased
  volume
• Weak/Threadydecreased volume
• A/R 80/76

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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

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Respiration

• Controlled by the respiratory center in the
  lateral medulla oblongata
• Exchange of O2 and CO2 between the atmosphere and
  body cells
• Accomplished by the diaphragm and chest muscles

• Four measures
• Rate
• Rhythm
• Depth
• Sound
• Reflect bodys metabolic state, diaphragm and
  chest muscle condition and airway patency

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Implementation

• Hand hygiene
• After taking pulse keep your fingertips over the
  radial artery and dont tell the pt you are
  counting respirations
• Observe chest rise and fall
• Count for 30 seconds x2 or 1 full minute.

• Be alert for and record breath sounds such as
  stridor, stertor, wheezing and an expiratory
  grunt.

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Refresher

• Stridor inspiratory crowing sound that occurs
  with upper airway obstruction in laryngitis,
  croup, or the presence of a foreign body
• Wheezing caused by partial airway obstruction in
  the smaller bronchi and bronchioles. This
  high-pitched musical sound is common in pts with
  emphysema asthma

• Stertor snoring sound resulting from secretions
  in the trachea and large bronchi
• Listen for it in pts with neurologic disorders
  and those who are comatose

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Elder Alert

• In older pts, an expiratory grunt may result from
  partial airway obstruction or neuromuscular reflex

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Assessment

• Observe chest movements for depths of
  respirations. Shallow vs Deep
• Listen with stethoscope to determine rhythm and
  sound of respirations. Crackles/rhonchi or lack
  of sound
• Observe the use of accessory muscles scalene,
  sternocleidomstoid, trapezius, and latissimus
  dorsi. Reflects weakness of diaphragm and
  intercostals

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Patterns

• Apnea periodic absence (mechanical/brain)
• Apneustic prolonged, gasping inspiration,
  followed by extremely short, inefficient
  expiration (lesions of respiratory center)
• Bradypnea slow, regular respirations (sleep,
  opiates, ETOH, tumors, metabolic disorders
• Cheyne-Stokes Fast, deep puncuated by periods of
  apnea lasting 20 to 60 seconds (inc ICP, severe
  heart failure, meningitis, drugOD, cerebral
  anoxia.

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Patterns

• Eupnea normal rate rhythm
• Kussmauls Fast (over 20 breaths/minute), deep
  (resembling sighs), labored without pause (renal
  failure or metabolic acidosis, DKA
• Tachypnea rapid respirations. Rate rises with
  body temperature about 4 breaths/minute for
  every degree F above normal. (PNA, respiratory
  insufficiency, lesions of respiratory center,
  salicylate poisoning)

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Special considerations

• Rate lt 8 or gt 40 are abnormal. Report ASAP
• Observe for dyspnea anxious facial expression,
  nasal flaring, heaving chest wall, cyanosis.
• To detect cyanosis check nail beds, lips, under
  the tongue, buccal mucosa, conjunctiva.
• Consider personal and family hx. Smoker? ? Pack
  years?

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Factors Influencing Character of Respirations

• Exercise
• Acute Pain
• Anxiety
• Smoking
• Body Position
• Medications
• Neurological injury
• Hemoglobin function

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Pulse Oximetry

• Noninvasive estimation of arterial oxyhemoglobin
  saturation
• Emits 2 wavelengths of light, one red, one
  infared. Well oxygenated blood absorbs light
  differently from deoxygenated blood
• Oximeter determines amount of light absorbed by
  the vascular bed and calculates saturation SpO2

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Pulse Ox

• Saturation of 90 is equivalent to an arterial
  blood gas value of 60 torr
• Early detector of impending hypoxemia
• Rapid response time between changes in pt status
  and reading on pulse ox
• Accurate within the range of 65 - 95 saturation
  with only a 1-2 error
• Able to assess pt draped in darkened room

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Uses

• ICU
• Pre/Peri operative areas where sedation decreases
  LOC, might mask hypoxemia
• Assessed routinely with VS
• Exercise testing

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Prepare site

• Remove fingernail polish, cleanse skin
• Area of probe placement should be checked for
  proper circulation with good cap refill.
• Pts with poor cap refill secondary to PVD will be
  better monitored utilizing earlobes, nose or
  forehead.

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Probes

• Probes can be permanent or disposable
• Recheck probe location for cap refill after probe
  placement and intermittently during pt
  monitoring.
• Not on same arm as BP cuff
• No information on pts ventillatory status
• If O2 sat is below 65, the monitor will
  overestimate the saturationproviding inaccurate
  measurement

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Locations for Pulse Ox

• Repetitive studies has shown probes placed on
  earlobes are more accurate and have faster
  response times.
• Earlobes, nose, forehead, toe
• If Hgb variants are present/ carboxyhgb values
  are less. Other factors that effect oximetry
  motion, anemia, bright flourescent lights,
  artificial fingernails, dark skin color

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Situations in which Pulse oximetry is limited

• Severe hypothermia
• Pt is receiving intravascular dyes, impact
  short-lived, but need other methods to ensure
  oxygenation
• Significant hypotension
• Vasoconstrictive drug use
• Arterial compression/pulsating venous blood
• Anemia
• Carbon monoxide posioning
• Muscular contraction

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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
• Certain conditions may give an inaccurate reading

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• A client is being monitored with pulse oximetry.
  On review of the following factors, the nurse
  suspects that the values will be influenced by
  which of the following?
• A) The placement of the sensor on the
  extremityB) A diagnosis of peripheral vascular
  diseaseC) A reduced amount of artificial light
  in the roomD) The increased ambient temperature
  of the clients room

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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

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BP Depends ON

• Force of ventricular contractions
• Arterial wall elasticity
• Peripheral vascular resistance
• Reflects integrity of the heart, arteries,
  arterioles
• Diastolic or minimal pressure occurs during left
  ventricular relaxation and directly indicates
  blood vessel resistance

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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

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Frequent BP Measurement

• After serious injury, surgery, anesthesia and
  during illness or condition that threatens CV
  stability
• Unstable pts
• Pts receiving blood transfusion
• Pts receiving oral or IV meds to stabilize BP

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Classification of BP
Category SBP mmHg DBP mmHg
Normal lt120 And lt80
Prehypertension 120-139 Or 80-89
Hypertension, stage 1 140-159 Or 90-99
Hypertension, stage 2 160 or higher Or 100 or higher
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Prepare Equipment

• Choose appropriate size cuff bladder should
  encircle at least 80 of the upper arm
• Excessively narrow cuff may cause a falsely high
  reading an excessively wide one, a falsely low
  reading.
• Palpate brachial artery. Position cuff 1 above
  site of pulsation, center above artery. Wrap
  snug.
• Confirm pt identity.

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Pre-Procedure

• Have pt rest for at least 5 minutes.
• No smoking or caffeine
• Explain to pt
• Supine or sitting OK. No crossed legs
• Extend arm at level of heart. If below could get
  false-high reading
• Forearm and thigh alternative option
• Inflate cuff til radial pulse disappears, add
  30mmHg. Deflate cuff. Place stethoscope over
  brachial artery

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Procedure

• Pump cuff to determined level.
• Carefully open valve and slowly deflate, no
  faster than 2-3mmHg/second.
• Ausculatate sound over artery.
• First beat SBP (first of 5 Korotkoff sounds,
  second is swish, third crisp tapping, fourth a
  soft muffle and fifth the last sound heard)
• Note pressure where sound disappearsDBP

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Special Considerations

• If you cant auscultate BP you can estimate SBP
  by palpation. Palpate brachial or radial, inflate
  cuff til you no longer detect the pulse
• If pt is crying or anxious defer
• Occasionally BP is measured in both arms or with
  pt in two different postions
• Measure BP of pts taking antihypertensives in
  sitting position.

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Complications

• Dont take BP in arm of the affected side of a
  mastectomy, may decrease already compromised
  lymphatic circulation, worsen edema, damage arm.
• Dont take BP in same arm of AV fistula or
  hemodialysis shunt blood flow through vascular
  device may be compromised.

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• The nurse is assessing a clients blood pressure
  during a routine visit. When asked, the client
  volunteers that when he took his pressure at home
  yesterday it was 126/72 mmHg. The nurse
  determines that the clients pressure today is
  134/70 mmHg. The nurse recognizes that the most
  likely cause of the elevation is due to which of
  the following?
• A) The difference between the monitoring
  equipment being used
• B) The clients inability to hear the first
  Korotkoff sound
• C) The client may be experiencing mild anxiety
  regarding the check-up
• D) The client is not inflating the cuff
  sufficiently to detect the systolic pressure

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Critical Thinking Exercise

• Mr. Coburn, a 56-year-old schoolteacher who was
  seen earlier in the week for hyperthermia,
  arrives at the walk-in clinic complaining of
  feeling dizzy and nauseated. You immediately
  note that her appears to be having some
  difficulty catching his breath during coughing
  spells.
• List in priority order the vital signs to be
  measured for Mr. Colburn.

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Priority Order

• 1. SpO2
• 2. BP
• 3. heart rate
• 4. respiratory rate
• 5. temperature
• Which of the vital signs do you delegate to the
  nursing assistant?

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Delegation

• Temperature. The pt has signs and symptoms of
  unstable hemodynamics and the nurse should obtain
  other vital signs.
• The electronic blood pressure machine alarm is
  sounding. You note that it is flashing 72
  systolic with no diastolic reading. What
  actions do you take?

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Nursing Response

• Check pt for LOC and palpate for pulse. Check to
  make sure that electronic BP machine is attached
  to pt, and all connections are intact. Repeat BP
  measurement using electronic machine.
• Mr. Colburns BP according to the machine is
  82/38 mmHg. His radial pulse is 1, slightly
  irregular, and 112 BPM What actions do you take?

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Nursing Response

• Obtain BP manually with sphygmomanometer. Obtain
  remaining vital signs including SpO2, RR.
  Administer oxygen if ordered or on protocol.
  Notify nurse in charge or health care provider.
• You have difficulty auscultating Mr. Coburns
  blood pressure in his left upper arm. List three
  actions that you take?

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Possible Nursing Actions

• Take BP in right upper arm
• Obtain Doppler ultrasound to obtain BP
• Ask a colleague to measure BP

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Chapter 34 INFECTION PREVENTION and CONTROL
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CHAIN OF INFECTION
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MODES OF TRANSMISSION

• Direct
• Person to Person (Fecal-Oral)
• Hepatitis A
• Staph

• Indirect
• Contact with contaminated object
• Hepatitis B and C
• HIV
• RSV
• MRSA

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MODES OF TRANSMISSION

• Droplet transmission
• Large particles
• Can travel up to 3 feet
• Influenza
• Rubella (3-day/German Measles)
• Bacterial Meningitis

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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
• Hanta Virus

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NORMAL DEFENSES

• Inflammatory Response
• Normal body flora
• Cilia in lungs
• Intact skin
• pH of body fluids
• Acidic gastric secretions
• Alkaline vaginal secretions

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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

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• Which of the following is an example of a nursing
  intervention that is implemented to reduce a
  reservoir of infection for a client?
• A) Covering the mouth and nose when sneezingB)
  Wearing disposable glovesC) Isolating clients
  articlesD) Changing soiled dressings

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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

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VIGNETTE ANALYSIS

• Infectious agent ? Escherichia Coli
• Reservoir ? Large Intestines
• Portal of Exit ? Feces
• Mode of Transmission ? Nurses Hands
• Portal of Entry ? Tracheostomy
• Susceptible Host ? Older Adult with Trach

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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

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NURSING PROCESS

• Nursing Diagnosis
• Risk for infection R/T compromised defense
  mechanism as evidenced by (AEB) presence of
  tracheostomy

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NURSING PROCESS

• Planning
• Goal
• Patient will remain free from infection during
  hospital stay
• Interventions
• Nurse will monitor temperature every 4 hours
  (Expectation Patient will remain afebrile)
• Nurse will monitor for signs/symptoms of
  infection every shift (Expectation Patient will
  have no s/s of infection)
• Nurse will maintain standard precautions for all
  patient contact

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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

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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)

96
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

97
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)

98
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

99
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

100
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

101
Happy Birthday or Zacharys Song

• to Row, Row, Row your boat
• Wash, Wash, Wash your hands
• Play my handy game
• Rub and Scrub, scrub and rub,
• Germs go down the drain!
• Repeat

102
(No Transcript)
103
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

104
N95 Respirator
105
STANDARD PRECAUTIONS

• Handwashing
• Gloves (PPE)
• Masks (PPE)
• Eye Protection (PPE)
• Gowns (PPE)
• Leak-proof linen bags
• Puncture proof containers for sharps

106
Donning and Removing PPE

• Donning
• Gown
• Mask or respirator
• Goggles/face shield
• Gloves
• Keep hands away from face
• Work from clean to dirty
• Lime surfaces touched
• Change when torn or heavily soiled

• Removing
• Gloves
• Goggles/face shield
• Gown
• Mask or respirator
• Remove at doorway before leaving pt. room
• Perform hand hygiene immediately after removing
  all PPE

107
IN A YEAR YOU WILL HAVE SWALLOWED 14 INSECTS
WHILE SLEEPING
108
WHERE ARE WE IN THE CHAIN OF INFECTION?

• Portal of Exit
• Susceptible Host
• Reservoir
• USE CRITICAL THINKING!!

109
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

110
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

111

• For which procedure would the nurse use aseptic
  technique and which would require the nurse to
  use sterile technique?
• A) Aseptic technique for urinary catheterization
  in the hospital and sterile technique for
  cleaning surgical wound
• B) Aseptic technique for changing the patients
  linen and sterile technique for assisting in
  surgery
• C) Aseptic technique for food preparation and
  sterile technique for starting an IV line
• D) Aseptic technique for a spinal tap and
  sterile technique for placing a central line

112
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

113
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)

114
LAB Practice Sterile Procedures

• Opening sterile packages Flap fartherest away
  from nurse first, then sides, then flap closest
  to nurse
• Preparing a sterile field
• Pouring sterile solutions label to palm, lip
  it
• Donning sterile gown and gloves

115
QUESTIONS?
116
Critical Thinking Exercise

• Mrs. Jaycock had an indwelling urethral catheter
  for 1 week. The catheter has now been out for 24
  hours. She complains of frequency and pain on
  urination. Mrs. Jaycock suggests reinsertion of
  the catheter because of the need to get up
  frequently. What can frequency or pain on
  urination be an indication of?

117
Answer

• UTI
• Should the catheter be reinserted?
• Why or why not?

118
Answer

• No reinserting the catheter may aggravate the
  infection and promote the spread of the infection
  to the bloodstream.
• Describe at least one appropriate assessment
  measure and one independent nursing action or
  intervention for Mrs. Jaycock

119
Nursing Response

• Increase her fluid intake if not clnically
  contraindicated
• Check her urinalysis

120
Situation

• You are caring for Mr. Huang, who has a large
  open, and draining abdominal wound. You notice
  another health care worker changing Mr. Huangs
  dressing without wearing gloves or using sterile
  technique. When you question the health care
  worker regarding his or her practice, this person
  says, Dont worry, the wound is already
  infected, and the antibiotics and drainng will
  take care of any contaminants. How would you
  respond to this comment?

121
Response

• It is important to not only protect Mr. Huang
  from additional infection, but also to protect
  ourselves from becoming contaminated.
• What would your next steps be in following up on
  this incident?

122
Situation

• Mrs. Niles is 83 years of age and lives alone.
  She has difficulty walking and relies on a church
  volunteer group to deliver lunches during the
  week. Her fixed income limits her ability to buy
  food. Last week, Mrs. Niles 79-year-old sister
  died. The two sisters had been very close. As a
  home care nurse, explain the factors that might
  increase Mrs. Niles risk for infection.

123
Response

• Age
• Potential for poor nutrition
• Potential for depression

124
Situation

• Mr. Vargas is admitted to the facility with a
  history of recent weight loss, a cough that has
  persisted for 2 months, and hemoptysis. His
  chest x-ray film shows a cavity lesion in one
  lung, and his physician suspects tuberculosis.
  What type of isolation precautions would you use
  for Mr. Vargas? What protection would you use to
  provide care? What education would you provide
  to the family?

125
Response

• Airborne precautions
• Wear an N95 mask
• Keep the door closed
• Educate the pt and family on transmission of TB
  and reason for isolation.