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 patient’s 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. (36-38°C/96.8-100.4°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

10. TEMPERATURE ALTERATIONS Afebrile Fever of unknown origin (FUO) Malignant hyperthermia: hereditary, occurs during anesthesia Heatstroke: medical emergency Heat exhaustion Hypothermia Frostbite Heat stroke: High mortality rate, very young or very old, CV disease, hypothyroidism, DM, alcoholism S/S: giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, incontinence Temp sometimes as high as 113with an increase in pulse and decrease in BP Hot, dry skin is important sign Don’t sweat due to severe electrolyte loss and hypothalamic malfunction Can cause permanent neuro damage Hypothermia: May be unintentional or intentional (surgery) S/S: uncontrolled shivering, loss of memory, depression, poor judgment, VS decreased, cyanosis If progresses, develop dysrhythmias, loss of consciousness, and unresponsive to painful stimuli Frostbite: Ice crystals form inside the cell, permanent circulatory and tissue damage occurs Areas of susceptibility include earlobes, tip of nose fingers and toes Area becomes white, waxy and firm to touchHeat stroke: High mortality rate, very young or very old, CV disease, hypothyroidism, DM, alcoholism S/S: giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, incontinence Temp sometimes as high as 113with an increase in pulse and decrease in BP Hot, dry skin is important sign Don’t sweat due to severe electrolyte loss and hypothalamic malfunction Can cause permanent neuro damage Hypothermia: May be unintentional or intentional (surgery) S/S: uncontrolled shivering, loss of memory, depression, poor judgment, VS decreased, cyanosis If progresses, develop dysrhythmias, loss of consciousness, and unresponsive to painful stimuli Frostbite: Ice crystals form inside the cell, permanent circulatory and tissue damage occurs Areas of susceptibility include earlobes, tip of nose fingers and toes Area becomes white, waxy and firm to touch

11. 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

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 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

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 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)

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 Cont’d. 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 Electronic device not always appropriate Irregular HR Peripheral vascular obstruction (clots) Shivering Seizures Excessive tremors Inability to cooperate BP less than 90 systolicElectronic device not always appropriate Irregular HR Peripheral vascular obstruction (clots) Shivering Seizures Excessive tremors Inability to cooperate BP less than 90 systolic

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

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 client’s 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

30. 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

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 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

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

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

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

47. IN A YEAR YOU WILL HAVE SWALLOWED 14 INSECTS WHILE SLEEPING

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 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

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 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

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 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)

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