Exam2 Flashcards
What are the vital signs?
Temperature Respirations Blood Pressure Pulse Pain
What are the normal ranges for vital signs?
Temperature 98.6 Respirations 12-20 Blood Pressure 120/80 Pulse 60-100 Pain 0-10
When to asses vital signs?
On admission to any health care facility or institution
Based on facility or institutional policy and procedures
Any time there is a change in the patient’s condition
Any time there is a loss of consciousness
Before and after any surgical or invasive diagnostic procedure
Before and after activity that may increase risk, such as ambulation after surgery
Before administering medications that affect cardiovascular and respiratory function
What factors affect patients vital signs?
Patient’s medical diagnosis
Co-morbidities
Types of treatments received
Patient’s level of acuity
What are normal temperature for healthy adults?
Oral: 37.0°C, 98.6°F Rectal: 37.5°C, 99.5°F Axillary: 36.5°C, 97.7°F Tympanic: 37.5ºC, 99.5°F Forehead: 34.4°C, 94.0°F
Types of fever
Intermittent: temperature returns to normal at least once every 24 hours
Remittent: temperature does not return to normal and fluctuates a few degrees up and down
Sustained or continuous: temperature remains above normal with minimal variations
Relapsing or recurrent: temperature returns to normal for one or more days with one or more episodes of fever, each as long as several days
Heat Production
Primary source is metabolism.
Hormones, muscle movements, and exercise increase metabolism.
Epinephrine and norepinephrine are released when additional heat is required and alter metabolism.
Thyroid hormone and shivering also increase heat production.
Energy production decreases and heat production increases.
Sources of heat loss
Skin (primary source)
Evaporation of sweat
Warming and humidifying inspired air
Eliminating urine and feces
What factors affect body temperature?
Circadian rhythms Age and gender Physical activity State of health Environmental temperature
Pulse Physiology
Regulated by the autonomic nervous system through cardiac sinoatrial node
Parasympathetic stimulation—decreases heart rate
Sympathetic stimulation—increases heart rate
Pulse rate = number of contractions over a peripheral artery in 1 minute
Characteristics of the Peripheral Pulse
Rate: Normal, tachycardia, bradycardia
Amplitude and quality (strong or weak)
Rhythm
Volume of blood ejected with each heartbeat (stroke volume)
Sites for Detecting Pulse by Light Palpations
Respirations
Ventilation: movement of air in and out of lungs
Inhalation: breathing in
Exhalation: breathing out
Diffusion
Exchange of oxygen and carbon dioxide between the alveoli of lungs and circulating blood
Perfusion
Exchange of oxygen and carbon dioxide between circulating blood and tissue cells
Rate & Depth of breathing
Changes in response to tissue demands
Controlled by respiratory centers in the medulla and pons
Activated by impulses from chemoreceptors
Increase in carbon dioxide is the most powerful respiratory stimulant
Respiratory rates
Eupnea: normal, unlabored respiration; one respiration to four heartbeats
Tachypnea: increased respiratory rate; may occur in response to an increased metabolic rate (Diabetic acidosis)
Bradypnea: decreased respiratory rate; occurs in some pathologic conditions
Apnea: periods when no breathing occurs (sleep apnea, babies, people transitioning)
Dyspnea: difficult or labored breathing (COPD)
Orthopnea: changes in breathing when sitting or standing
Factors affecting blood pressure
Age, gender, race & genetic inheritance Circadian rhythm Food intake Exercise Weight Emotional state Body position Drugs/medications
How to asses blood prssure?
Listening for Korotkoff sounds with stethoscope
First sound is systolic pressure.
Change or cessation of sounds occurs—diastolic pressure.
The brachial artery and popliteal artery are commonly used.
What are classifications of hypertension?
Primary (essential)
Characterized by an increase above normal in both systolic and diastolic pressures
No known cause
Secondary
Caused by another disease conditions
Common causes include kidney disease, adrenal cortex disorders, and aorta disorders
Categories of Antihypertensive Medications
Diuretics (to decrease fluid volume)
Beta-adrenergic blockers (to block sympathetic stimulation and decrease cardiac output)
Vasodilators and calcium channel blockers (to relax smooth muscles of arterioles and decrease peripheral vascular resistance)
ACE inhibitors (to prevent vasoconstriction by angiotensin II and decrease circulatory fluid volume by reducing aldosterone production)
What are the components of the infection cycle
Infectious agent: bacteria, viruses, fungi
Reservoir: natural habitat of the organism
Portal of exit: point of escape for the organism
Means of transmission: direct contact, indirect contact, airborne route
Portal of entry: point at which organisms enter a new host
Susceptible host: must overcome resistance mounted by host’s defenses
Mention 3 infectious agents
Bacteria: most significant and most prevalent in hospital settings
Virus: smallest of all microorganisms
Fungi: plant-like organisms present in air, soil, and water
Common portals of exit of Infections
Respiratory Gastrointestinal Genitourinary tracts Breaks in skin Blood and tissue
Stages of infection
Incubation period: organisms growing and multiplying
Prodromal stage: person is most infectious, vague and nonspecific signs of disease
Full stage of illness: presence of specific signs and symptoms of disease
Convalescent period: recovery from the infection
Outcome Identification and Planning/Infection Control
Demonstrate effective hand hygiene and good personal hygiene practices.
Identify the signs of an infection.
Maintain adequate nutritional intake. (high in protein)
Demonstrate proper disposal of soiled articles.
Use appropriate cleansing and disinfecting techniques.
What are the cardinal signs of ACUTE infection?
Redness Swelling Pain Heat Loss of function
Lab data indicating infection?
Elevated WBC count
Elevated Erythrocyte sedimentation
5 moments or hand hygiene (WHO)
Before touching a patient Before a clean or aseptic procedure After a body fluid exposure risk After touching a patient After touching patient surroundings
Bacterial Flora
Resident creases in skin
Transient attached loosely
Four Categories Responsible for Majority of Hospital-Acquired Infections (HAIs)
CAUTI
CLABSI
VAP
SSI
CAUTI
Catheter associated UTI
Vap
Ventilator associated pneumonia
CLABSI
Central line associated bloodstream infection
SSI
Surgical site infection
Risk Factors for Vancomycin-Resistant Enterococci (VRE)
Compromised immune systems Recent surgery Invasive devices Prolonged antibiotic use (especially vancomycin) Prolonged hospitalization
Recommendations to Prevent C. difficile infection (CDI)
PPE
Placing patients in private rooms; cohort patients with the same strain of CDI
Performing meticulous hand hygiene
Most use soap and water!!!!!
Body’s defense against infection
Body’s natural flora
Inflammatory response
Immune response
Standard precaution
Used in the care of all hospitalized patients regardless of their diagnosis or possible infection status
Transmission-Based Precautions
Used in addition to standard precautions for patients in hospitals with suspected infection with pathogens that can be transmitted by airborne, droplet, or contact routes.
Aseptic technique
Includes all activities to prevent or break the chain of infection
Two categories
Medical asepsis: clean technique
Surgical asepsis: sterile technique
Patient Teaching for Medical
Asepsis at Home
Wash hands before preparing or eating food.
Prepare foods at high enough temperatures.
Use care with cutting boards and utensils.
Keep food refrigerated.
Wash raw fruits and vegetables.
Use pasteurized milk and fruit juices.
Wash hands after using bathroom.
Use individual care items.
Evaluating Patient Goals
Use techniques of medical asepsis.
Identify health habits and lifestyle patterns promoting health.
State signs and symptoms of an infection.
Identify unsafe situations in the home environment.
COPD is a chronic or acute illlnes?
Chronic Illnes
What is the most significant causing agent in the healt system?
Bacteria
Does antibiotics work on viruses?
No
Fungi can cause what tupe of infection?
Yeast infection
What is sepsis?
A condition where microorganism have travel in the blood.
Can narcitics affect respirations?
Yes
What is fever?
Fever is the body’s way of creating an enviroment that is harmfuk for germs.
Where is core temp taken?
Rectal
What isnthe regular pulse for infants
100-160
What is Capillary refill?
Cardiac output ( squeeze nail bed) count secs until color returns
A way to take patient respirations?
Placin their hand on their abdomen
What ABC stands for?
Airway
Breathing
Circulation
What BP measures?
The amount of force been placed on artery by blood
ACE inhibitors
Allergic reaction can take years.
