Download Chapter 32: Vital Signs

Chapter 32: Vital Signs
Bonnie M. Wivell, MS, RN, CNS
VITAL SIGNS
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TEMPERATURE
BLOOD PRESSURE
PULSE
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APICAL
RADIAL
RESPIRATIONS
PULSE OXIMETRY
PAIN SCALE
VITAL SIGNS ARE PART OF THE
PHYSICAL ASSESSMENT
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Delegation of Duties to UAP
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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
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RN is responsible for assuring equipment is
functioning properly
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Appropriate equipment
Must be appropriate to patient age size
 Thermometer
 Stethescope: Diaphragm (high-pitched sounds); bell (lowpitched sounds)
 BP cuff
 Pulse oximeter
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PATIENT HISTORY
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RN must know patient medical history,
including medications
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These facts can affect vital signs
RN is responsible for knowing the patient’s
usual vital sign range
FREQUENCY OF VITAL SIGNS
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Physicians order the frequency of vital signs
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Could be ordered by protocol or policy
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The RN can increase the frequency based on his/her
assessment
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VITAL SIGNS can be an early warning sign that
complications are developing
INDICATIONS FOR MEDICATION
ADMINISTRATION
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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
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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
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Factors affecting body temp. (36-38°C/96.8100.4°F)
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Age
Infants: 95.9 – 99.5° F
 Elderly: Average temp is 96.8° F; Sensitive to temp
extremes
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Exercise
 Hormone levels
 Circadian rhythm
 Stress
 Environment
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TEMPERATURE ALTERATIONS
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Afebrile
Fever of unknown origin (FUO)
Malignant hyperthermia: hereditary, occurs during
anesthesia
Heatstroke: medical emergency
Heat exhaustion
Hypothermia
Frostbite
TEMPERATURE Cont’d.
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Sites
Core temp is measured in pulmonary artery,
esophagus, and urinary bladder
 Mouth, rectum, tympanic membrane, temporal
artery, and axilla
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Variety of types available – electronic and
disposable
Antipyretics = drugs that reduce fever
PULSE
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Sites
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Increases in HR
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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
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Long-term exercise, hypothermia, relaxation, drugs, lying
down
PULSE Cont’d.
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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
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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
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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
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Exercise
Acute Pain
Anxiety
Smoking
Body Position
Medications
Neurological injury
Hemoglobin function
RESPIRATIONS Cont’d.
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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
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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
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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.
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Physiology of arterial blood pressure
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Factors influencing BP
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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
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DIRECT
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PERSON TO PERSON (FECAL-ORAL)
HEPATITIS A
 STAPH
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INDIRECT
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CONTACT WITH CONTAMINATED OBJECT
HEPATITIS B AND C
 HIV
 RSV
 MRSA
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MODES OF TRANSMISSION
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DROPLET TRANSMISSION
LARGE PARTICLES
 CAN TRAVEL UP TO 3 FEET
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INFLUENZA
 RUBELLA (3-day/GERMAN MEASLES)
 BACTERIAL MENINGITIS
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SNEEZE
OR COUGH
MODES OF TRANSMISSION
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AIRBORNE
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DROPLETS SUSPENDED IN AIR AFTER COUGHING
AND SNEEZING OR CARRIED ON DUST PARTICLES
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TB
CHICKEN POX
MEASLES (RUBEOLA)
ASPERGILLUS
VECTOR
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EXTERNAL MECHANICAL TRANSFER
MOSQUITO,, LOUSE, FLEA, TICK, FLY
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WEST NILE VIRUS
MALARIA
LYME DISEASE
NORMAL DEFENSES
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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
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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
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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
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INFECTIOUS AGENT
RESERVOIR
PORTAL OF EXIT
MODE OF
TRANSMISSION
PORTAL OF ENTRY
SUSCEPTIBLE HOST
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ESCHERICHIA COLI
LARGE INTESTINES
FECES
NURSE’S HANDS
TRACHEOSTOMY
OLDER ADULT WITH
TRACHEOSTOMY
NURSING PROCESS
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ASSESSMENT
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PATIENT
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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
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NURSING PROCESS
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NURSING DIAGNOSIS
RISK FOR INFECTION R/T COMPROMISED
DEFENSE MECHANISM AS EVIDENCED
BY PRESENCE OF TRACHEOSTOMY
NURSING PROCESS
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PLANNING
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GOAL
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PATIENT WILL REMAIN FREE FROM INFECTION
EXPECTED OUTCOME
PATIENT WILL REMAIN AFEBRILE
 CLIENT WILL HAVE NO SIGNS/SYMPTOMS OF
INFECTION
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NURSING PROCESS
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IMPLEMENTATION
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STANDARD PRECAUTIONS WILL BE
FOLLOWED FOR ALL PATIENT CONTACT
NURSING PROCESS
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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!
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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)
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MEDICAL ASEPSIS
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A clean technique that limits the number of pathogens
that could cause infections
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Aseptic technique: practices/procedures that assist in reducing the
risk for infection
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3 components to the technique:
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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
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Disinfection = the process that eliminates many
or all microorganisms, with the exception of
bacterial spores, from inanimate objects
Disinfection of surfaces
 High-level disinfection
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Alcohols, chlorines, glutaraldehydes, hydrogen peroxide
Sterilization = complete elimination or
destruction of all microorganism, including
spores
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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
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STANDARD PRECAUTIONS
TIER 1
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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
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Number one defense against infection
Soap and water if hands are visibly soiled
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Friction for 15 seconds
After 3-5 uses of hand gel
Alcohol-based hand products are accepted if hands not
visibly soiled
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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
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Contact = private room or cohort clients, gloves and
gowns
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Droplet = private room or cohort clients, mask is
required
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Strept, pertusis, mumps, flu
Airborne = private room, negative airflow, hepa
filtration; N95 respirator mask required
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MDRO, C-Diff, RSV
TB, chickenpox, measles
Protective Environment = private room, positivepressure room; hepa filtration; gloves, gowns, mask
(controversial); NO flowers or potted plants
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Stem cell transplant
STANDARD PRECAUTIONS
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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
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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:
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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
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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.
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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
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Opening sterile packages
Preparing a sterile field
Pouring sterile solutions – label to palm, “lip” it
Donning sterile gown and gloves