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

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

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 29

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