EXAM 1 Flashcards
HYGIENE/PRECAUTIONS/INF CTRL/HEARING AIDS/ VS/ ROM/TRANSFERS WEEKS 1-3
SKIN OVERVIEW
Largest organ in the body- Temperature regulation, Secretions, Sensation- touch, Vit Dsynthesis, Blood storage 10%, Communication- facial expressions, overall appearance
what are skin and mucosal cells responsible for
exchange oxygen, nutrients, & fluids with underlyingblood vessels
why is adequate nutrition, hydration and circulation important for the skin
to resist injury and disease
what does proper hygiene techniques promote for the skin
normal structure and function of these tissues
functions of the skin
Protection, secretion, excretion, temperature regulation, and sensation
primary layers of skin
epidermis
dermis
subcutaneous tissue
epidermis
shields underlying tissue (water loss, injury, new cells as shedding occursnormal flora- bacteria- that prevent growth of disease-causing microorganisms)
dermis
contains bundles of collagen, nerve fibers, blood vessels, sweat glands,sebaceous glands, and hair follicles. (Sebum- lubrication, bactericidal.)
subcutaneous tissue
Lies just beneath the skin; contains blood vessels, nerves,lymph, and loose connective tissue filled with fat cells. (Cushions and anchors,insulates).
Factors influencing hygiene/ Assessment
Social practices
Personal preferences
Body image
Socioeconomic status
Health beliefs and motivation
Cultural variables
Developmental stage
Physical condition
hygiene assessment
skin
Gums & teeth, hair
Feet, nails & cuticles- circulation
Ability
Safety Concerns- patient, nurse
emotional status
Current healthcare practices/education needs
skin assessment
color, hydration, turgor-elasticity, texture, lesions (pink, dry, intact)
ability
Dexterity, gait (injuries, joint deformities, contractures)
what all is involved in oral health
Mucous membrane, tongue, gums, teeth- moist, pink, intact (no open areas)
glossitis
inflamed tongue
chelitis
cracked lips
xerostomia
dry mouth
stomatitis
inflammation of oral mucos
saliva
is the liquid medium for digestion. It also has bacterial static property. For unconscious patients, the actions of swallowing saliva does not occur regularly. A risk of pneumonia from static oral secretions occurs
teeth
are used to chew (masticate) food particles. Teeth should be white, smooth, shiny ,and fairly well aligned. Note decay or edentulous.
dentures and denture care
Keep dentures covered in water when they are not wornStore in an enclosed, labeled cup with the cup placed on patient’s bedside stand
sensory organs
eyes
ears
nose
eyes
hygiene
cleansing from inner to outer canthus to prevent secretions from entering the nasolacrimal ducts, use different part of washcloth for each eye to prevent transferring microorganisms from one eye to the other. More frequently if unconscious and not blinking- secretions will build up. Glasses, dry eyes, allergies.
ears
hygiene
washing of ear and outer canal with wash cloth, Q-tips not recommended b/c potential damage to tympanic membrane (ear drum)
nose
hygiene
smell and taste. Very vascular mucous membrane. Mucous and cilia trap foreign matter to prevent it from entering the lungs. It is blown out or sneezed away
considerations for older adults
Wrinkles (decreased collagen)
Thinning of skin layers
Degeneration of elastin fibers
Decreased sweat production
Decreased oil production, drier skin
More skin lesions
Graying hair
Increase in facial hair
Dry brittle nails
considerations for older adults
hygiene
Weakening of periodontal membrane so increased risk of infection, disease
Dentures- pain, malnutrition- Ensure never thrown away or lost!
Dry mouth due to decreased saliva, meds
Malnutrition- due to socioeconomic status, limited ability to prepare healthy foods, dental problems
considerations for neonates
hygiene
skin is loosely bound, easily damaged. Layers bind together as infant gets older.
considerations for adolescents
hygiene
sex hormones- sebaceous glands-oil, sweat glands- odor. Hygiene
Hygiene Nursing Diagnosis/ Problems
Activity intolerance
Self-care deficit: Impaired Ability to Bath
Impaired mobility
Impaired skin integrity
Impaired oral mucous membranes
Risk for infection
r/t bathing, oral care, dressing, feeding, transfers, walking, turning in bed
critical thinking in hygiene
Integrate nursing knowledge.
Consider developmental and cultural influences.
Think creatively.
Be nonjudgmental and confident.
Draw on your own experiences.
Rely on professional standards.
Use communication to promote the therapeutic relationship.
planning
hygiene
Who is involved in care? Community agencies needed? Amount of help required?
Partner with the patient and family
Measurable, achievable, individualized
goals and outcomes
hygiene
Set priorities based on assistance required, extent of problems, nature of diagnoses
Skin will be clean, dry, and intact with good turgor. No areas of inflammation will be noted
Skin will have no pressure, tear, or sheared areas
Skin will have no areas of infection
Oral mucosa will be moist, pink, and intact
implementation
hygiene
Provide privacy, professionalism, modesty, safety, warmth (water, room, bath blanket, mitt- loses less heat, prevents drag of washcloth across skin)
bathing daily
Primary reason-cleanse & reduce microbe count, remove dead skin, Secondary reasons- stimulate circulation, provide relaxation, enhance healing
types of baths
Complete, Partial (unable to tolerate), Therapeutic (soothe itchy skin)
technique of bathing
Wash with long, firm strokes from distal (away) to proximal (closest). Why? To promote venous circulation. (Light strokes if history of blood clots)
applying lotion
Apply lotion to all areas of skin- moisturizes (except in between toes- risk of skin irritation, maceration-softening)
Bacterial count and excess mucous in the mouth
increases the risk of HAI (Healthcare or Hospital Acquired Infections) (pneumonia), Oral moisturizers as needed. Tooth brushing twice daily, flossing once daily. Helps improve taste sensation & moisturizes
oral care technique
So Oral care twice a day OR Every 1-2 h for unconscious, ventilated, NPO- nothing by mouth (Toothbrushes most recommended for all oral care. Suction available for unconscious- risk of aspiration) (Check for gag reflex before care) Diabetes, artificial airways, unconscious, chemotherapy
CHG oral rinse/paste is antimicrobial effective against dental plaque biofilms, decrease HAI
chg use
Don’t use near eyes, ears, Use in basins-stops bacterial growth, Leave on for more antibacterial effects, to rinse or not
promote independence
allow the patient to do as much as they are able/willing
anticipate needs
considerations for the nurse in implemmenting hygiene
Keep dirty gown, linens away from uniform
Prevent fungal growth
Wash and dry areas breast, axillary, and abdominal folds well
comb/brush hair daily
to distribute oil. (Braid long hair to keep it from tangling.)
Combing is more effective than use of pediculicidal shampoos in the case of head lice
trim nails
in line with tip of finger as needed & cleanse dirt from nails- (short, clean nails are less likely to spread infection)
feet care for diabetics
daily- (inspection prevents unnoticed injuries from worsening)
backrub
help with sleep, relaxation (Effleurage- long, slow, gliding strokes of massage)
teaching/teach-back
relevant instruction, prevent injury/infection
perineal care
independently or with assistance, risk of infection- uncircumcised males, urinary catheters, post-rectal or genital surgery or childbirth
concerns of perineal care
burning during urination, soreness, excoriation (raw), pain, discharge- appearance, odor, amount. Risk for skin breakdown- incontinence, dressings, catheters, obesity.
how to perform perineal care
Cleanse from front to back to reduce chance of transmitting fecal organisms to urinary meatus. Use different sections of the washcloth for folds.
You are caring for a non–English-speaking male patient. When preparing to assist him with personal hygiene, you should:
A. use soap and water on all types of skin.
B. ensure that culture and ethnicity influence hygiene practices.
C. shave facial hair to make the patient more comfortable.
D. know that all patients need to be bathed daily.
medical devices
hygiene
(Oxygen tubing- check what? …….) Cleaning ear gently with washcloth. Hearing aid maintenance
shampoo/shaving
when to use electric razor
cleaning eyeglasses
$, lens or soft cloth, cool water, no paper towels
care for contacts
clean hands, contact solution
caring for artificial eyes
warm normal saline (NS) to rinse eye, NS or water on soft gauze to rinse eye socket, Store in tap water or NS- labeled container. Observe for S& S of infection.
diabetic foot care part 1
Inspect feet and between the toes daily-thoroughly (Use mirror if needed)
Lukewarm water, thorough drying- do not soak feet due to risk of infection
Lotion to feet but NOT between the toes b/c or risk of skin irritation & breakdown
If can see and reach nails on their own, they should trim nails straight across, file edges smooth (HCW file but don’t cut- HCP order in healthcare facility)
diabetic foot care part 2
Cotton socks, comfortable & sturdy shoes
Do not apply heating pad to feet
Elevate legs when sitting.
Don’t cross legs for long periods.
Avoid smoking.
Wiggle toes and move ankles up & down for 5 minutes 2-3 times daily.
Contact HCP (healthcare provider) if concerns
evaluation of hygiene part 1
Through the patient’s eyes-
Were the patient’s expectations met?
Patient outcomes
Evaluate after each hygiene intervention. Use teach back.
If outcomes were not met, revise the care plan
Bathed
evaluation of hygiene part 2
Moisturized
Teeth brushed twice a day; flossed once a day (ADA)
Eyes, ears, nose without redness or drainage
Nails clean and trimmed
Feet have no areas of breakdown
Safety Guidelines for Nursing Skills part 1
hygiene
Identify the patient with two identifiers.
Move from the cleanest to less clean areas.
Use clean gloves for contact with nonintact skin, mucous membranes, secretions, excretions, or blood.
Safety Guidelines for Nursing Skills part 2
hygiene
Test the temperature of water or solutions.
Use principles of body mechanics and safe patient handling.
Give proper direction to UAP- unlicensed assistive personnel- when delegating.
the chain of infection
A sequence of necessary pieces for an infection to occur.
Includes an infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host.
infectious agent
something that contains bacteria, fungi, virus, parasite, or prion.
reservoir
the habitat of the infectious agent and is where it lives, grows, and reproduces itself or replicates.
portal of entry
can be any body orifice (for example, ears, nose, mouth) or can even be through the skin, and it provides a place for the infectious agent to replicate or for the toxin to act.
portal of exit
is the means by which the infectious agent can leave the reservoir
susceptible host
is required for the infectious agent to take hold and become a reservoir for infection. Not everyone who is exposed to an infectious agent gets sick.
modes of transmission
contact
droplet
airborne
contact
modes of transmission
occurs when microorganisms move from an infected person to another person.
droplet
modes of transmission
occurs when airborne droplets from the respiratory tract of a client travel through the air and into the mucosa of a host
airborne
mode of transmission
occurs when small particulates move into the airspace of another person.
There are two types of contact transmission:
direct and indirect
direct contact transmission
occurs when microorganisms are directly moved from the infected person to another person without having a contaminated object or person between the two.
indirect contact transmission
occurs when microorganisms are moved from the infected person to another person with a contaminated object or person between the two.
Nonspecific immunity
Nonspecific immunity refers to neutrophils and macrophages and their work as phagocytes.
phagocytes
eat and destroy microorganisms, thereby helping to protect the body from harm
when are neutrophils and macrophages released
during the inflammatory response.
specific immunity
refers to the work of antibodies (also called immunoglobulins) and lymphocytes. Antibodies bind to infectious agents and call to the white blood cells and complement to destroy them
The Inflammatory Response
- Pattern receptors on the surface of cells recognize harmful stimuli.
- Inflammatory pathways are activated.
- Inflammatory markers are released.
- Inflammatory cells are recruited.
stages of infection
incubation
prodromal
acute illness
decline
convalescence
incubation stage of infection
An infection enters host and begins to multiply
prodromal phase of infection
The client begins having symptoms.
acute illness stage of infection
Manifestations of the specific infectious disease process are obvious and may become severe.
decline stage of infection
Manifestations begin to wane as the degree of infectious disease decreases.
convalescence stage of infection
The client returns to a normal or a “new normal” state of health.
A nurse holds dirty linen away from the body during transport to an appropriate receptacle. The nurse is intervening to break the chain of infection for which link?
A. Etiological agent
B. Reservoir
C. Portal of entry to susceptible host
D. Susceptible host
A client complains of feeling very tired, having aching muscles, and a slight headache. The nurse recognizes the client may be experiencing which phase of the infectious process ?
A. Incubation stage
B. Prodromal stage
C. Illness stage
D. Convalescent stage
LOCAL INFECTIONS
are confined to one area of the body. Local infections can be treated with topical antibiotics and oral antibiotics
SYSTEMIC INFECTIONS
start as local infections and then spread to the bloodstream to infect the entire body
SEPSIS
is systemic inflammatory response syndrome resulting from body’s response to a serious infection due to microorganisms (usually bacterial
hand hygiene
broad term to cover any type of cleansing of hands
what exactly is hand hygiene? how is it performed?
Handwashing- 15-20 sec. Soap and water for diarrheal disease (c-diff spore potential), Sanitizer >70% alcohol, lotion to prevent dermatitis- itchy, dry skin/ irritation
when should you perform hand hygiene
Hands are soiled, before & after pt contact, before sterile gloving, contact with body fluids, each time gloves removed
When should hand hygiene be performed?
When can hand sanitizer be used and when should it not be used?
medical asepsis
(clean technique) is a term used to define the elimination of and absence of disease-causing microorganisms
surgical asepsis
sterile technique
Principles of Surgical Asepsis (Sterile Field)
A sterile object is free of all microorganisms.
All objects on a sterile field must be sterile.
sterile items below the waist or out of the field of vision are not sterile
avoid talking, laughing, sneezing, and prolonged air over sterile field
how to open a sterile field
1st open flap or side furthest away from you using, 2nd & 3rd flaps on either side using closest hand, 4th side closest to you- Why?
what does moisture do to a sterile field
Moisture contaminates a sterile field. Water-proof barriers are used. Wet objects become contaminated by capillary action. Pour from sterile solution into container. Make sure cap of bottle set face up on clean surface.
outer edges of sterile fields
Outer 1 inch of a sterile field is considered unsterile b/c touches surfaces and can be touched by non-sterile hands. Outer edges of containers considered contaminated.
standard precautions
is a term used to describe the infection prevention practices applied to all clients, whether or not they are known to have an infectious agent
ppe
It is the nurse’s responsibility to know what type(s) of Personal Protective Equipment (PPE) are needed to care for clients and to don and doff PPE appropriately.
donning ppe
- gown
- mask/respirator
- goggle/face shield
- gloves
removing ppe
- gloves
- goggles/face shield
- gown
- mask/respirator
- hand hygiene
airborne
precautions-stopping spread
for diseases that transmit via the air, either as molecules less than 5 microns or by riding on dust particles that small. Molecules remain suspended in the air. N95 particulate respirator-fit-testing, Negative pressure room (HEPA filtration) (TB, chicken pox, COVID, Ebola)
droplet
precautions-stopping spread
for pathogens that are transmitted by particles larger than 5 microns. And drop to the floor or fomites within 3 feet of the host (sick person). Mask required. (Influenza, pertussis)
contact
precautions-stopping spread
for pathogens that are transmitted by direct or indirect contact with the host. All items and fomites (furniture) are contaminated within 24 hours of the host being place in the room. (Always gown, gloves, hand-washing, mask if risk of splashing) (MRSA)
contact plus
precautions-stopping spread
same as contact but wipe down room surfaces routinely & thoroughly to kills spores- Clostridium difficilie/c.diff)
protective environment
precautions- stopping spread
private room, positive airflow, high-efficiency particulate air (HEPA) filtration, mask when out of room, no live plants or flowers due to aspergillosis mold- can cause infection (Immunosuppressed/ Neutropenic)
Limit patient movement outside of room, clean gown, mask (PPE) on patient for transport if needed, door closed
Psychological implications, bagging of trash, patient care items, specimen collection
specifics of contact precautions
hand hygiene
gown and gloves
*if risk of splash/spray, wear face and eye protection
specifics of contact plus precautions
hand hygiene- not foam but requires soap and water
gown
gloves
if risk of splash/spray, wear eye and face protection
*twice daily cleaning of high touch surfaces
specifics of droplet and contact precautions
hand hygiene
mask
eye protection
gown
gloves
specifics of droplet precautions
hand hygiene
standar precautions but add mask
specifics of airborne precautions
hand hygiene
standard precautions
n95 respirator
Pt must be in negative pressure room with door closed
specifics of protective precautions
no one with an infection may visit
hand hygiene
Pt wears a surgical mask when out of room
no live plants/flowers
In addition to standard precautions, what precautions are required for a client with tuberculosis
In addition to standard precautions, what precautions are required for a client with pertussis?
In addition to standard precautions, what precautions are required for a client with MRSA? C-difficicile?
Which commonly used household cleaner is effective against bacteria, TB, spores, fungi, and viruses?
The four major HAIs are:
Central Line-associated Bloodstream Infections (CLABSIs)
Catheter-associated Urinary Tract Infections (CAUTIs)
Surgical Site Infections (SSIs)
Ventilator-assisted Pneumonias (VAPs)
Health Care-Associated Infections (HAIs)
Morbidity, mortality, cost——Not reimbursed
types of hai infections
Iatrogenic—from a procedure
Exogenous—from microorganisms outside the individual
Endogenous—when the patient’s flora becomes altered and an overgrowth results
HAI & Antibiotic resistance-
Invasive procedures, altered immune defenses, older adults, antibiotic administration, multi-drug resistant organisms (mdro)
Gene mutations after surviving antibiotic therapy (mdro)
Spread to sputum, bloodstream, urinary tract
examples of antibiotic resistant microorganisms
MRSA (methicillin-resistant S. aureus) colonizes is nose, skin
VRE (vancomycin-resistant Enterococcus)
C-difficile (soap & water) to kill spores
broad spectrum antibiotis
to treat infection may eliminate or change normal flora, leading to a superinfection- overgrowth of harmful bacteria.
normal flora
Microorganisms- found in skin, saliva, oral mucosa, and intestinal walls.
Maintain sensitive balance with other microorganisms to prevent infection. Disruption of balance increases risk for acquiring of illness/disease.
hai/mdro prevention
Hand hygiene, conservative antibiotic use, universal precautions, transmission-based precautions, proper disposal of PPE, not sharing patient items, antimicrobial dressings, no artificial fingernails, limit urinary catheterizations, careful monitoring- Limit/Intervene/Break the chain of infection
Nursing Diagnoses (Problems)——Nursing Actions
hygiene
Risk for Infection
Imbalanced Nutrition: Deficient Food Intake
Impaired Oral Mucous Membrane
Impaired Skin Integrity
Social Isolation
Impaired Tissue Integrity
Readiness for Enhanced Immunization Status
patient safety
hygiene
Separate personal care items
Handling exudate
Wound cleaning
Cough etiquette
Dirty linen- never on floor
Maintain skin integrity
Perineal care after toileting
Urinary catheters and drainage sets
Teach back
Occupational Safety and Health Administration (OSHA)-
regulations to protect employees whose jobs put them at risk for exposure to blood/infectious agents
human body fluids
saliva, fluids contaminated with blood, semen, vaginal secretions, cerebrospinal fluids, synovial fluid, pericardial fluid, amniotic fluid, unfixed tissue or organs, cultures containing HIV/Hep B/Hep C, infected animals
standard precautions
providing care for all persons to reduce the risk of microbial transmission from one person to another- handwashing, safe disposal of Sharps- never recap used needle, PPE
ppe
Protect skin, mucous membranes, respiratory tract. Gloves, masks, gowns, shoe covers, goggles (not just eye glasses). Don’t touch face. Guidelines are to remove gloves, remove gown by only touching it on inside, remove mask, wash hands.
American Nurses Association advocated for
federal regulations instituting needless devices to promote needlestick safety and prevention- prevent puncture wounds
Health Promotion for Immune System
part 1
A diet with fresh fruits, vegetables, whole grains, nuts, & legumes; fewer processed foods; decrease allergies- early solid foods
Adequate rest and Exercise at least three times a week for 30 minutes at a moderate or strenuous level
Maintain a weight that is suitable for height so that Body Mass Index –Ideal BMI ranges from 18.5 – 24.9
Stress management and reduction by effective positive means
Health Promotion for Immune System
part 2
Use of alcohol, drugs, cigarettes, and unprotected sex increase the risk of a compromised immune system (triggers, stds)
Immunizations are protective from communicable diseases by mounting an immune response (antigen-antibody) (active immunity- long-lasting)
Treating ongoing disease whether related to infection or immune system
placement of hearing aids
Hearing aids are often forced into the incorrect ears. Red is for right. Blue is for left.
batteries for hearing aids
Don’t keep batteries by medications!!!
-Battery doors should be open when the hearing aids are not being worn.
when should you clean hearing aids
It is important that the hearing aids are cleaned as often as possible (ideally daily when removed).
storing hearing aids
Labeled nighttime storage containers. May be locked in secure spot.
trouble shooting hearing aids
9 times out of 10 when a patient reports hearing aids are not working, they are not clean.
Inspect for wax.
If possible, change wax guard or clean out tubing.
squealing hearing aids
If the canal contains excessive cerumen, or is occluded the hearing aids will produce feedback.
Referral for cerumen management.
realistic expectations of hearing aids
Just because your patient has hearing aids, does not mean they have normal hearing.
Volume VS. Clarity
Presence of background noise.
The aging brain.
Tips for communicating with the hearing impaired
Get their attention!
Say their name.
Alert them if the topic has changed.
Be in an area with good lighting where they can access all visual cues
Movements of the mouth, body language
Eliminate noise sources.
Tips for communicating with the hearing impaired.
part 2
Decrease your rate of speech.
Talking loudly is not the answer.
Complete your words.
Slight pause between sentences.
Rephrase.
If they did not understand you the first time, do not repeat what you said. Rephrase and say it another way.
Expand on what you are saying.
Be patient!
It can be frustrating for both parties.
If worse comes to worse, write it down!
objective data
vital signs
temp
hr
rr
bp
SaO2
subjective data
vital signs
pain is the 6th vs
objective with pain scale
can nurses delegate vs
yes, but nurse is ultimately responsible and must follow up on values obtained
when should a nurse not delegate vs
unstable/changing condition
meds given that affect vs
uncontrolled bleeding
cold/clammy/pale skin
suspected change/reaction such as shock, pe, stroke, mi, fall, injury
nurse must be aware and is responsible for
vs
base line vs
pmh
normal/abnormal vs for age
factors that influence vs
appropriate interventions in collaboration with the dr
minimizing environmental factors
why, how, when, who
when are vs taken
part 1
upon admission (initial assessment)
check ups with dr
with any change in status
per facility policy
as ordered by dr
if Pt reports non specific symptoms
when are vs taken
part 2
before/during/and after:
surgical procedures
receiving blood products
receiving certain meds
afebrile
when a fever breaks
fever of unknown origin
fuo
fever from undetermined cause
what constitutes a fever
100.4 F
how to treat a fever
cool juices/drinks
cool room
light/no covers (sheet only)
antipyretics (tylenol, ibuprophen)
antibiotics (once cultures obtained)
cool them off
frost bite
occurs when the body is exposed to subnormal temps
hypothermia Tx
warming measures
s/s of hypothermia
shivering
pale/cool/puffy
decreased hr and rr
irregular hr
decreased sensation and bility to think –> confused
malignant hyperthermia
hyperthermia-hereditary condition of uncontrolled heat production (likely after anesthetics). MEDICAL EMERGENCY
hyperthermia Tx
cooling measures
oral temperature procedures
Place thermometer to right or left of frenulum at the base of the tongue in the sublingual pocket.
oral temperature is contraindicated if
Excessive talker
Hx seizures
Mouth breathers
Uncooperative
Unconscious
Infant or small children
Had oral surgery
STOP! If client has been chewing gum, smoking, or eating hot/cold food or drinks.
why use a rectal temperature (red)
closer to the accurate core temp
why not use a rectal temperature
- Site can be embarrassing.
- Can puncture GI mucosa.
- Avoid if having diarrhea, has hemorrhoids, rectal surgery etc.
-Avoid if patient has neutropenia or low platelet count.
- Can puncture GI mucosa.
axillary temperature
preferred site for an infant and child
Safer for adults with seizures or if oral is unsafe
contraindications of axillary temp
a recent bath, rubbing of area, and poor circulation can affect results.
axillary temp procedure
Place thermometer under arm and ensure it is in contact with skin and hold in place for duration of measurement.
pulse sites
temporal
carotid
brachial (antecubital space)
radial
femoral
popliteal
posterior tibialis
dorsalis pedis
carotid
pulse site
Carotid- Used during CPR/MI * Do not assess both carotids at same time- cuts off blood supply to the brain.
brachial (antecubital space)
pulse site
Brachial (antecubital space)- Used for B/P or to assess pulse in infants/children.
radial
pulse site
most common
radial pulse side
used during cpr/mi
popliteal
pulse site
Popliteal- flex leg to palpate, Used if can’t use arms for B/P
doppler D
Doppler (D)- is used if you can’t palpate a pulse—don’t document absent—document unable to palpate and get the doppler if available.
normal hr for adult
60-100
pulse assessment scale
0- Absent
1+ weak and thready
2+ normal
3+ strong/bounding
apical heart rate
apical pulse
Apical heart rate (Apical pulse) most accurate and is located left of the sternum, at or below the fifth rib, and midline with the clavicle.
how to asses apical pulse
Count for 1 minute. This is the point of maximum impulse. 60-100
when to assess apical pulse
Used if radial pulse irregular or weak
Used if heart rate altering drugs being given (Digoxin).
heart sounds
apical pulse
S1- low pitched “lubb” (when tri and bi cuspid valves slam shut)
S2-short sound-”dupp”(when pulmonary and aortic valves close)
These two sounds represent one heartbeat
how to asses rr
When assessing Respirations –count at least 30 seconds—one minute if irregular—you need to determine:
normal rr of adult
12-20
rate per minute
respirations
Rate per minute- includes one inspiration and one expiration. Watch rise and fall of chest or abdomen. Hold arm across chest.
depth
respirations
Depth –chest expansion with each breath.
rhythm
respirations
Rhythm- is it a consistent pattern. Regular or irregular?
respiratory effort
respirations
Respiratory effort- how hard are they working to breathe? Should be effortless.
charting respirations
Always 2 parts! Ex. “Regular, Nonlabored, Rate 16”
hypoxemia
ex: copd
drive to breath
pulse ox/o2 saturation
noninvasive technique to monitor the o2 sat of the blood
pulse ox procedure
attach to finger, earlobe, toe, nose. make sure area is clean, dry, warm, and has good circulation. they need to remain still. remove nail polish and artificial nails
normal SaO2
95-100%
concern is less than 90%
assessment of pain
site/location
characteristics
pain scale
site
pain
Site or location- don’t assume; ALWAYS ask.
characteristics of pain
Characteristics- describe: is it sharp, dull, aching, cramping, tender, constant, intermittent, stabbing, burning? Ask When does it occur, what makes worse/better ?
pain scale
Pain Scale (Severity)– 0- no pain to 10 worse pain ever. Scales vary for children and nonverbal patients.
ex: numerical, faces
acute pain
Acute pain is sudden onset, can be severe, lasts a short time.
chronic pain
Chronic pain- hangs around with little change; may be life long; does not affect VS as much as acute pain does.
what is bp an indication of
Indicator of cardiovascular health
how to document manual bp
If taking manually must be documented in even numbers. If electronic can be uneven.
bp assessment sites
Usually obtained on the brachial artery but can use other sites.
- Can use popliteal artery behind the knee.
- Can use lower arm and radial artery.
- Must document where B/P obtained.
may need to choose optional bp site if pt has had
- a mastectomy
- bilateral upper extremity amputation
- shunt/graft for dialysis - casts, braces, dressings, etc.
- Vascular surgery or trauma
- IV infusion site
- bilateral upper extremity amputation
manual bp procedures
Sphygmomanometer bladder width must cover at least 40% of patients upper arm, and the bladder length must wrap around 80-100% of the arm circumference.
If the cuff does not fit appropriately, results will be inaccurate.
parts of a stethoscope
Review parts of Stethoscope —ear tips are
positioned downward and forward towards face.
Ear pieces are cleaned with alcohol between users and the diaphragm cleaned between patients.
positions of pt for taking bp
May also need to collect B/P in lying, sitting, and standing positions.
normal adult bp
Less than 120/80
Tx for HTN
Quit smoking, weight management, medications.
steps to bp
assess- palpate brachial pulse, assess pt
place- cuff 1-2 inches above antecubital area
needle on manometer should be at 0, keep at eye level, inflate to 20 mmHg above palpated systolic pressure or up to 200
review factors affect bp
hypotension
less than 90/x
orthostatic hypotension
change in patient position causes bp drop- lying, sitting, standing
- 0.3 g = ________________mg
- 250 mg = ______________g
- 0.4 mg = _______________mcg
- 325 mcg=_______________mg
- 2 oz = _____________mL
- 3 tsp=_____________mL
- 5 tbsp=____________mL
- 30 mL=____________tbsp
- Change to military time 9am ________
- Change to traditional time 0050 _________
a supervising/charge nurse observes a new nurse performing nursing care for several clients.
Which action requires further education?
-OR-
Which action would the charge nurse question?
(Look for wrong action)
a. Lowering the head of bed before moving a client up in bed
b. Wearing gloves when leaving a client’s room to get clean linen
c. Wearing a mask with eye protection when performing oral suctioning
d. Donning a gown and gloves before entering the room of a client on Contact Precautions
b
A supervising/charge nurse discusses PPE and precautions with a novice nurse.
Which action shows that teaching was effective? (Look for correct action)
a. Removing goggles as the first step of PPE removal
b. Performing hand hygiene each time gloves are removed
c. Wearing a mask with eye protection to ask the client about their medical history
d. Sanitizing hands after providing care for a client on Contact Plus Precautions
b
A supervising/charge nurse discusses PPE with a novice nurse.
Which actions show that teaching was effective? Select all that apply. (Look for correct actions as in is it True or False. Select what is True because these apply. There may be 1 or ALL correct answers for these questions)
a. Removing gloves first when removing PPE
b. Wearing gloves to quickly leave the room and grab clean linen
c. Wearing a mask with eye protection when performing oral suctioning
d. Donning a gown and gloves before entering the room of a client on Contact Precautions
e. Donning a gown and gloves before entering the room of a client on Droplet Precautions
f. Donning a surgical mask before entering the room a client on Airbourne Precautions
a, c, d
