PPE, Respiration, Temperature, Pulse, BP Flashcards
Donning PPE
- hand hygiene
- cap or hood
- mask
- gown
- gloves
Doffing PPE
- remove/untie gown
- gloves are removed with gown when sleeves are pulled
- fold contaminated surface of gown inward
- discard gown and gloves
- remove mask
- remove cap or hood
- hand hygiene
Respiration
Exchanges oxygen and carbon dioxide between the external environment and blood circulation in the body
What is a full respiration?
1 inspiration + 1 expiration
Respiration rate for an adult and infant?
Adult: 12-20 breaths/min
Infant: 30-60 breaths/ min
Should be quiet, effortless and uniform
4 things to observe during respiration?
Rate: how many breaths per min?
Depth: shallow or deep?
Quality: supplying the O2 needs to the patient?
Pattern: rapid or staggered? (Air hungry)
Assessing Respiration
- keep pt in current position
- pt should be unaware you are counting respiration
- observe the chest wall for symmetry of movement
- should be even rise and fall of the chest, with no involvement of muscles
- observe skin colour
- count number of times pt’s chest rises and falls for 1 full minute
- cross the pt’s arm across the chest
Respiration of fewer than 10 breaths/min for an adult may result in:
- cyanosis
- apprehension
- restlessness
- change in level of consciousness (LOC)
Factors that affect respiration:
- medication
- illness and pathologies
- exercise
- age
- emotion
Bradypnea
Slow breathing with fewer than 12 breaths per minute
Dyspnea
Difficulty in breathing, shortness of breath, using more than the normal effort to breathe, abnormal respiration rate
Orthopnea
An abnormal condition in which a person to breath deeply or comfortably must sit or stand
Tachypnea
Rapid breathing in excess of 20 breaths per minute
Body temperature
The physiologic balance between heat produced in the body (by chemical processes that result from metabolic activity) and heat lost to the environment
Pyrexia or fever
A pt whose body temp is elevated beyond normal limits
Hypothermia
A pt whose body temperature is below normal limits
Factors that affect body temperature:
- Environment: slightly higher in hot environment
- Time of day: lower in the morning
- Infection/disease/injury
- Age: decreases slightly with age
- Emotional status: increases with stress
- Menstrual cycle: higher during time of ovulation
- Physical activity: slight increase but plateaus
- Site of measurement: oral vs. rectal
Normal body temperatures for adults:
- Oral: 37*C
- Tympanic: 36.4*C
- Rectal: 37.5*C
- Axillary: 36.4-36.7*C
Allow for + or - 0.5-1*C variation
Normal Body Temperature for children:
- 3 months - 3 years: 37.2-37.7*C
- 5 - 13 years: 36.7-37*C
Death can occur above and below normal temp.
Body temperature locations (4):
- Oral: not always appropriate. Depends on pt and their condition
- Axillary: pt preferred, but it’s slower and less accurate
- Rectal: accurate and faster but has pt contraindications
- Tympanic and temporal artery: common for children and confused pts
Oral
- easily accessible site
- should NOT be use for pts who:
- may be injured during the procedure by biting on the thermometer
- are unable to hold the thermometer under the tongue with closed lips for the specified period of time
Axillary
- safest method
- non-invasive
- commonly used for infants
- somewhat unreliable (time and placement precision needed to be accurate
- electronic, disposable or glass thermometer with a blunt tip may be used
Rectal
- provides most reliable reading
- should not be used if the pt is restless or has rectal pathology
- use thermometer with a blunt tip
- least preferred method by the pt
How to chart a temperature:
Record the time and site it was taken. Oral - O Axillary - AX Tympanic - T Rectal - R
Ex: a tympanic temp of 97.6* is written as 97.6 T
Types of thermometers:
- Digital/electronic (used for oral, Axillary, and rectal)
- Tympanic
- Temporal artery
- Disposable (Primarily for children, ICU, and isolation pts. Consists of a strip of temperature sensitive paper with adhesive backing that may be attached to the forehead)
Pulse and heart rate
Expulsion of blood when the left ventricle contracts - can be felt by holding an artery beneath the skin against a solid surface such as bone
Factors affecting pulse rate:
- age
- gender
- emotions
- temperature
- posture
- activity
- medication
- stimulants
- alcohol
- music
Pulse locations:
- radial: most common site
- carotid: next site if radial is difficult to count
- femoral
- brachial
- temporal
- dorsalis pedal
- posterior tibial pulse
- apical pulse
Less common pulse sites:
- temporal
- popliteal
- apical
Conditions that increase a pt’s resting heart rate:
- activity
- fever
- stress
- hyperthyroidism/hypothyroidism
- anemia
- stimulants
- asthma
- medications
- diet pills
- various forms of heart disease
- heart medications
- fitness programs with aerobic exercise
Issues with heart rate:
- weak pulse: a sign of a problem with the heart’s ability to pump as much blood as needed. May also be a sign of shock or a circulation problem, such as a partially blocked or narrowed blood vessel
- weak/absent pulse in a leg: may be a sign of significant blood vessel disease in the leg (eg: peripheral arterial disease)
- a healthy blood vessel feels soft when checking pulse. A hard blood vessel suggests hardening of the arteries (eg: atherosclerosis)
Average adult pulse rate?
60-100 BPM
