Title: Vital Signs and Infection Prevention and Control Peggy Korman CNM Foundations of Nursing Practice
1Vital Signs and Infection Prevention and
ControlPeggy Korman CNMFoundations of Nursing
Practice
2Guidelines for Measuring Vital Signs
- Establish a baseline for future assessments.
- Be able to understand and interpret values.
- Appropriately delegate measurement.
- Communicate findings.
- Ensure equipment is in working order.
- Accurately document findings.
3VITAL SIGNS
- TEMPERATURE
- BLOOD PRESSURE
- PULSE
- APICAL
- RADIAL
- RESPIRATIONS
- PULSE OXIMETRY
- PAIN SCALE
4VITAL 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
5EQUIPMENT
- RN is responsible for assuring equipment is
functioning properly - Appropriate equipment
- Must be appropriate to patient age size
- Thermometer
- Stethascope Diaphragm (high-pitched sounds)
bell (low-pitched sounds) - BP cuff
- Pulse oximeter
6PATIENT HISTORY
- RN must know patient medical history, including
medications - These facts can affect vital signs
- RN is responsible for knowing the patients usual
vital sign range
7FREQUENCY 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
8INDICATIONS 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.
9COMPREHENSIVE 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.
10Temperature
- Represents the balance of heat produced by
metabolism, muscular activity, and other factors
and heat lost through the skin, lungs, and body
waste
- A stable temperature pattern promotes proper
function of cells, tissues, and organs a change
in this pattern usually signals the onset of
illness.
11TEMPERATURE
- Factors affecting body temp. (36-38C/96.8-100.4F
) - Age
- Infants 95.9 99.5 F 36.5-37.2C
- Elderly Average temp is 96.8 F Sensitive to
temp extremes - Exercise
- Hormone levels
- Circadian rhythm
- Stress
- Environment
12TEMPERATURE ALTERATIONS
- Afebrile
- Fever of unknown origin (FUO)
- Malignant hyperthermia hereditary, occurs during
anesthesia - Heatstroke medical emergency
- Heat exhaustion
- Hypothermia
- Frostbite
13Measurement of Temperature
- Electronic digital
- Chemical-dot
- Tympanic
- Oral 97-99.5F 36.1-37.5C
- Rectal (most accurate) is usually 1F or 0.6C
higher
- Axillary, least accurate 1-2F or0.6-1.1C lower
- Tympanic 0.5-1F higher
14TEMPERATURE Contd.
- Sites
- Core temp is measured in pulmonary artery,
temporal artery, esophagus, and urinary bladder - Mouth, rectum, tympanic membrane, and axilla
- Variety of types available electronic and
disposable - Antipyretics drugs that reduce fever
15- Using an oral electronic thermometer, the nurse
checks the early morning temperature of a client.
The client's temperature is 36.1 C (97 F). The
client's remaining vital signs are in the
normally acceptable range. What should the nurse
do next? - A) Check the client's temperature history. B)
Document the results temperature is normal. C)
Recheck the temperature every 15 minutes until
it is normal. D) Get another thermometer the
temperature is obviously an error.
16Equipment
- Electronic thermometer, chemical-dot thermometer
or tympanic thermometer - Facial tissue
- Disposable thermometer sheath or probe cover
- Alcohol pad
- If you are using an electronic thermometer, make
sure its been recharged
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21How to
- You can take an oral, rectal, or axillary temp
with various electronic digital thermometers or a
chemical-dot device - Use oral route for most adults who are awake,
alert, oriented and cooperative.
- For infants, young children, and confused or
unconscious pts, you may need to take the temp
rectally. - The tympanic route may be used on almost all pts.
22Taking a Temp
- Hand hygiene
- Confirm pts identity with two pt identifiers
- Explain procedure to pt
- If pt has had hot or cold liquids, chewed gum or
smoked, wait 15 minutes before taking an oral temp
23Taking a Tympanic Temp
- Make sure the lens under the probe is clean and
shiny. Attach a disposable probe cover. - Examine the pts ear. It should be free from
cerumen to obtain and accurate reading. If the
pt has any visible lesion or drainage STOP
- Stabilize the pts head gently pull the ear up
and back. - Insert the tenmometer until the ear canal is
sealed. Insert like an otoscope. - Press the button to activate. Hold 1 second.
24Taking an Oral Temp
- Position the thermometer under the pts tongue,
as far back as possible on either side of the
frenulum linguae. (promotes contact with
superficial blood vessels and contributes to
accurate reading)
- Instruct pt to close lips but avoid biting down
with teeth. - Leave a chemical-dot in place for 45 sec. Read
the last dot that has changed color. - Wait until maximum temp is displayed on
electronic thermometer.
25Taking an Axillary Temp
- Position the pt with axilla exposed.
- Gently pat the axilla dry with a facial tissue
because moisture conducts heat. - Avoid harsh rubbing, which generates heat
- Ask the pt to reach across chest and grasp the
opposite shoulder, lifting elbow.
- Position the thermometer in the center of the
axilla. - Tell pt to keep grasping shoulder and lower elbow
against chest. This promotes skin contact with
the thermometer probe
26Remember
- Axillary temps take longer to register than oral
or rectal temps because the thermometer isnt
enclosed in a body cavity. - Dispose of the probe cover.
- Perform hand hygiene
- Clean or disinfect the electronic model after use
to prevent cross-contamination. - Perform hand hygiene.
- Document the procedure.
27Special Considerations
- Make sure the probe cover doesnt have any
wrinkles, they interfer with the reading. - Oral measurement is contraindicated in pts who
are unconscious, disoriented, or seizure-prone
in young children and infants and in pts who
must breathe through their mouths.
- Use the same thermometer for repeats to avoid
spurious variations - Dont avoid oral temps in pts receiving nasal
oxygen (Oxygen administration raises oral temp
only 0.3F or 0.17C - Make sure you document where the temp as taken.
28Pulse
- Blood is pumped into an already-full aorta during
ventricular contraction creates a fluid wave that
travels from the heart to the peripheral
arteries. - This recurring wave is called a pulse and can be
palpated at locations on the body where an artery
crosses over bone on firm tissue.
- In adults and children older than age 3 and in
adults with a suspected cardiac disorder that
affects the pts heart rate and rhythm, the
radial artery is the most common palpation site. - In infants and children younger than age 3, a
stethoscope is used to listen to the heart
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30Apical-Radial Pulse
- Taken simultaneously counting apical and radial
beats - First by auscultation at the apex of the heart
- Second by palpation at the radial artery
- Some heartbeats detected at the apex cannot be
detected at peripheral sites
- When this occurs, the apical pulse rate is higher
than the radial the difference is the pulse
deficit.
31What to Assess
- Determine the rate (number of beats per minute)
- Rhythm (pattern or regularity of the beats)
- Volume (amount of blood pumped with each beat.
- If the pulse is faint or weak, use a Doppler
ultrasonic blood flow detector if available.
32PULSE
- 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
33Taking a Radial Pulse
- You will need a watch with a second hand, a
stethoscope alcohol pad. - If not using your own stethoscope disinfect
earpieces - Confirm pt identity
- Hand hygiene
- Tell pt you intend to take his pulse
- Make sure pt is comfortable relaxed because an
awkward, uncomfortable position may affect heart
rate. - Place pt is a sitting or supine position, with
arm at the side or across the chest.
34Radial Pulse Taking
- After locating the pulse, count the beats for 60
seconds, or 30 sec and multiply by 2. - Counting for a full minute provides a more
accurate picture of irregularities. - If you detect an irregularity, repeat the count,
and note whether it occurs in a pattern or
randomly. If in doubt, take an apical pulse. - Document
- Gently press your index, middle and ring fingers
on the radial artery, inside the pts wrist. You
should feel a pulse with only moderate pressure
excessive pressure may obstruct blood flow distal
to the pulse site. - Dont use your thumb. Why?
35Taking an Apical Pulse
- Help the pt to a supine position and drape
- Warm the diaphragm or bell of the stethoscope in
your hand. A cold stethoscope may startle the pt
and momentarily increase heart rate. - Place diaphragm over apex of heart.
- Where? 5th intercostal space, left of the
midclavicular line - Count for 60 seconds, note rate, rhythm, volume
and intensity. - Make pt comfortable
- Clean stethoscope
- Document
36PULSE Contd.
- 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
37- The nurse decides to take an apical pulse instead
of a radial pulse. Which of the following client
conditions influenced the nurse's decision? - A) The client is in shock. B) The client has
an arrhythmia. C) The client underwent surgery
18 hours earlier. D) The client showed a
response to orthostatic changes.
38Taking an Apical-Radial Pulse
- Two nurses work together to obtain the
apical-radial pulse - One palpates the radial pulse while the other
auscultates the apical pulse with a stethoscope. - Both must use the same watch when counting beats.
39Pulse Patterns
- Normal 60-100 beats/minute in neonates
120-140 beats/minute - Varies with such factors as age, physical
activity and gender - Men usually have lower pulse rates than women
40Tachycardia
- More than 100 beats/minute
- Accompanies stimulation of the sympathetic
nervous system by emotional stress, such as
anger, fear, or anxiety, or by the use of certain
drugs such as caffeine. - May result from exercise and from certain health
conditions, such as heart failure, anemia, and
fever (which increase oxygen requirements and
therefore increase pulse rates)
41Bradycardia
- Less than 60 beats/minute
- Accompanies stimulation of the parasympathetic
nervous system by drug use, especially digoxin,
and such conditions as cerebral hemorrhage and
heart block. - May also be present in fit athletes.
42Irregular Pulse
- Uneven time intervals between beats (for example,
periods of regular rhythm interrupted by pauses
or premature beats) - May indicate cardiac irritability, hypoxia,
digoxin toxicity, potassium imbalance, or
sometimes more serious arrhythmias if premature
beats occur frequently - Occasional premature beats are normal
43Special Considerations
- When peripheral pulse is irregular, take an
apical - If pulse is weak or faint get a Doppler
- If taking an apical-radial alone, hold
stethoscope in place with the hand that holds th
watch while palpating the radial with the other
hand - Document pulse rate, rhythm, and volume as well
as time of measurement. Full/Boundingincreased
volume - Weak/Threadydecreased volume
- A/R 80/76
44RESPIRATIONS
- 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
45Respiration
- Controlled by the respiratory center in the
lateral medulla oblongata - Exchange of O2 and CO2 between the atmosphere and
body cells - Accomplished by the diaphragm and chest muscles
- Four measures
- Rate
- Rhythm
- Depth
- Sound
- Reflect bodys metabolic state, diaphragm and
chest muscle condition and airway patency
46Implementation
- Hand hygiene
- After taking pulse keep your fingertips over the
radial artery and dont tell the pt you are
counting respirations - Observe chest rise and fall
- Count for 30 seconds x2 or 1 full minute.
- Be alert for and record breath sounds such as
stridor, stertor, wheezing and an expiratory
grunt.
47Refresher
- Stridor inspiratory crowing sound that occurs
with upper airway obstruction in laryngitis,
croup, or the presence of a foreign body - Wheezing caused by partial airway obstruction in
the smaller bronchi and bronchioles. This
high-pitched musical sound is common in pts with
emphysema asthma
- Stertor snoring sound resulting from secretions
in the trachea and large bronchi - Listen for it in pts with neurologic disorders
and those who are comatose
48Elder Alert
- In older pts, an expiratory grunt may result from
partial airway obstruction or neuromuscular reflex
49Assessment
- Observe chest movements for depths of
respirations. Shallow vs Deep - Listen with stethoscope to determine rhythm and
sound of respirations. Crackles/rhonchi or lack
of sound - Observe the use of accessory muscles scalene,
sternocleidomstoid, trapezius, and latissimus
dorsi. Reflects weakness of diaphragm and
intercostals
50Patterns
- Apnea periodic absence (mechanical/brain)
- Apneustic prolonged, gasping inspiration,
followed by extremely short, inefficient
expiration (lesions of respiratory center) - Bradypnea slow, regular respirations (sleep,
opiates, ETOH, tumors, metabolic disorders - Cheyne-Stokes Fast, deep puncuated by periods of
apnea lasting 20 to 60 seconds (inc ICP, severe
heart failure, meningitis, drugOD, cerebral
anoxia.
51Patterns
- Eupnea normal rate rhythm
- Kussmauls Fast (over 20 breaths/minute), deep
(resembling sighs), labored without pause (renal
failure or metabolic acidosis, DKA - Tachypnea rapid respirations. Rate rises with
body temperature about 4 breaths/minute for
every degree F above normal. (PNA, respiratory
insufficiency, lesions of respiratory center,
salicylate poisoning)
52Special considerations
- Rate lt 8 or gt 40 are abnormal. Report ASAP
- Observe for dyspnea anxious facial expression,
nasal flaring, heaving chest wall, cyanosis. - To detect cyanosis check nail beds, lips, under
the tongue, buccal mucosa, conjunctiva. - Consider personal and family hx. Smoker? ? Pack
years?
53Factors Influencing Character of Respirations
- Exercise
- Acute Pain
- Anxiety
- Smoking
- Body Position
- Medications
- Neurological injury
- Hemoglobin function
54Pulse Oximetry
- Noninvasive estimation of arterial oxyhemoglobin
saturation - Emits 2 wavelengths of light, one red, one
infared. Well oxygenated blood absorbs light
differently from deoxygenated blood - Oximeter determines amount of light absorbed by
the vascular bed and calculates saturation SpO2
55Pulse Ox
- Saturation of 90 is equivalent to an arterial
blood gas value of 60 torr - Early detector of impending hypoxemia
- Rapid response time between changes in pt status
and reading on pulse ox - Accurate within the range of 65 - 95 saturation
with only a 1-2 error - Able to assess pt draped in darkened room
56Uses
- ICU
- Pre/Peri operative areas where sedation decreases
LOC, might mask hypoxemia - Assessed routinely with VS
- Exercise testing
57Prepare site
- Remove fingernail polish, cleanse skin
- Area of probe placement should be checked for
proper circulation with good cap refill. - Pts with poor cap refill secondary to PVD will be
better monitored utilizing earlobes, nose or
forehead.
58Probes
- Probes can be permanent or disposable
- Recheck probe location for cap refill after probe
placement and intermittently during pt
monitoring. - Not on same arm as BP cuff
- No information on pts ventillatory status
- If O2 sat is below 65, the monitor will
overestimate the saturationproviding inaccurate
measurement
59Locations for Pulse Ox
- Repetitive studies has shown probes placed on
earlobes are more accurate and have faster
response times. - Earlobes, nose, forehead, toe
- If Hgb variants are present/ carboxyhgb values
are less. Other factors that effect oximetry
motion, anemia, bright flourescent lights,
artificial fingernails, dark skin color
60Situations in which Pulse oximetry is limited
- Severe hypothermia
- Pt is receiving intravascular dyes, impact
short-lived, but need other methods to ensure
oxygenation - Significant hypotension
- Vasoconstrictive drug use
- Arterial compression/pulsating venous blood
- Anemia
- Carbon monoxide posioning
- Muscular contraction
61PULSE 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
- Certain conditions may give an inaccurate reading
62- A client is being monitored with pulse oximetry.
On review of the following factors, the nurse
suspects that the values will be influenced by
which of the following? - A) The placement of the sensor on the
extremityB) A diagnosis of peripheral vascular
diseaseC) A reduced amount of artificial light
in the roomD) The increased ambient temperature
of the clients room
63BLOOD 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
64BP Depends ON
- Force of ventricular contractions
- Arterial wall elasticity
- Peripheral vascular resistance
- Reflects integrity of the heart, arteries,
arterioles - Diastolic or minimal pressure occurs during left
ventricular relaxation and directly indicates
blood vessel resistance
65BLOOD PRESSURE Contd.
- 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
66Frequent BP Measurement
- After serious injury, surgery, anesthesia and
during illness or condition that threatens CV
stability - Unstable pts
- Pts receiving blood transfusion
- Pts receiving oral or IV meds to stabilize BP
67Classification of BP
Category SBP mmHg DBP mmHg
Normal lt120 And lt80
Prehypertension 120-139 Or 80-89
Hypertension, stage 1 140-159 Or 90-99
Hypertension, stage 2 160 or higher Or 100 or higher
68Prepare Equipment
- Choose appropriate size cuff bladder should
encircle at least 80 of the upper arm - Excessively narrow cuff may cause a falsely high
reading an excessively wide one, a falsely low
reading. - Palpate brachial artery. Position cuff 1 above
site of pulsation, center above artery. Wrap
snug. - Confirm pt identity.
69Pre-Procedure
- Have pt rest for at least 5 minutes.
- No smoking or caffeine
- Explain to pt
- Supine or sitting OK. No crossed legs
- Extend arm at level of heart. If below could get
false-high reading - Forearm and thigh alternative option
- Inflate cuff til radial pulse disappears, add
30mmHg. Deflate cuff. Place stethoscope over
brachial artery
70Procedure
- Pump cuff to determined level.
- Carefully open valve and slowly deflate, no
faster than 2-3mmHg/second. - Ausculatate sound over artery.
- First beat SBP (first of 5 Korotkoff sounds,
second is swish, third crisp tapping, fourth a
soft muffle and fifth the last sound heard) - Note pressure where sound disappearsDBP
71Special Considerations
- If you cant auscultate BP you can estimate SBP
by palpation. Palpate brachial or radial, inflate
cuff til you no longer detect the pulse - If pt is crying or anxious defer
- Occasionally BP is measured in both arms or with
pt in two different postions - Measure BP of pts taking antihypertensives in
sitting position.
72Complications
- Dont take BP in arm of the affected side of a
mastectomy, may decrease already compromised
lymphatic circulation, worsen edema, damage arm. - Dont take BP in same arm of AV fistula or
hemodialysis shunt blood flow through vascular
device may be compromised.
73- The nurse is assessing a clients blood pressure
during a routine visit. When asked, the client
volunteers that when he took his pressure at home
yesterday it was 126/72 mmHg. The nurse
determines that the clients pressure today is
134/70 mmHg. The nurse recognizes that the most
likely cause of the elevation is due to which of
the following? - A) The difference between the monitoring
equipment being used - B) The clients inability to hear the first
Korotkoff sound - C) The client may be experiencing mild anxiety
regarding the check-up - D) The client is not inflating the cuff
sufficiently to detect the systolic pressure
74Critical Thinking Exercise
- Mr. Coburn, a 56-year-old schoolteacher who was
seen earlier in the week for hyperthermia,
arrives at the walk-in clinic complaining of
feeling dizzy and nauseated. You immediately
note that her appears to be having some
difficulty catching his breath during coughing
spells. - List in priority order the vital signs to be
measured for Mr. Colburn.
75Priority Order
- 1. SpO2
- 2. BP
- 3. heart rate
- 4. respiratory rate
- 5. temperature
- Which of the vital signs do you delegate to the
nursing assistant?
76Delegation
- Temperature. The pt has signs and symptoms of
unstable hemodynamics and the nurse should obtain
other vital signs. - The electronic blood pressure machine alarm is
sounding. You note that it is flashing 72
systolic with no diastolic reading. What
actions do you take?
77Nursing Response
- Check pt for LOC and palpate for pulse. Check to
make sure that electronic BP machine is attached
to pt, and all connections are intact. Repeat BP
measurement using electronic machine. - Mr. Colburns BP according to the machine is
82/38 mmHg. His radial pulse is 1, slightly
irregular, and 112 BPM What actions do you take?
78Nursing Response
- Obtain BP manually with sphygmomanometer. Obtain
remaining vital signs including SpO2, RR.
Administer oxygen if ordered or on protocol.
Notify nurse in charge or health care provider. - You have difficulty auscultating Mr. Coburns
blood pressure in his left upper arm. List three
actions that you take?
79Possible Nursing Actions
- Take BP in right upper arm
- Obtain Doppler ultrasound to obtain BP
- Ask a colleague to measure BP
80Chapter 34 INFECTION PREVENTION and CONTROL
81CHAIN OF INFECTION
82MODES OF TRANSMISSION
- Direct
- Person to Person (Fecal-Oral)
- Hepatitis A
- Staph
- Indirect
- Contact with contaminated object
- Hepatitis B and C
- HIV
- RSV
- MRSA
83MODES OF TRANSMISSION
- Droplet transmission
- Large particles
- Can travel up to 3 feet
- Influenza
- Rubella (3-day/German Measles)
- Bacterial Meningitis
84MODES 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
- Hanta Virus
85NORMAL DEFENSES
- Inflammatory Response
- Normal body flora
- Cilia in lungs
- Intact skin
- pH of body fluids
- Acidic gastric secretions
- Alkaline vaginal secretions
86Types 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 clients flora becomes altered or overgrowth
results, i.e. C. Diff, vaginal yeast infection
87- Which of the following is an example of a nursing
intervention that is implemented to reduce a
reservoir of infection for a client? - A) Covering the mouth and nose when sneezingB)
Wearing disposable glovesC) Isolating clients
articlesD) Changing soiled dressings
88VIGNETTE
- 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
89VIGNETTE ANALYSIS
- Infectious agent ? Escherichia Coli
- Reservoir ? Large Intestines
- Portal of Exit ? Feces
- Mode of Transmission ? Nurses Hands
- Portal of Entry ? Tracheostomy
- Susceptible Host ? Older Adult with Trach
90NURSING PROCESS
- Assessment
- Patient
- Client Susceptibility
- Status of defense mechanisms (smoker?)
- Age very young and very old
- Nutritional status decreased protein intake
reduces the bodys defenses against infection and
impairs wound healing - Stress lowers immunity
- Disease process HIV, Leukemia, Lymphoma
- Laboratory Data
- Client needs related to disease status
91NURSING PROCESS
- Nursing Diagnosis
- Risk for infection R/T compromised defense
mechanism as evidenced by (AEB) presence of
tracheostomy
92 NURSING PROCESS
- Planning
- Goal
- Patient will remain free from infection during
hospital stay - Interventions
- Nurse will monitor temperature every 4 hours
(Expectation Patient will remain afebrile) - Nurse will monitor for signs/symptoms of
infection every shift (Expectation Patient will
have no s/s of infection) - Nurse will maintain standard precautions for all
patient contact
93NURSING PROCESS
- Evaluation
- Did patient remain infection free?
- YES Good job!
- NO ? - Reassess patient and environment to
determine where the chain of infection was broken
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95Break 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)
96 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
97Disinfection/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)
98CDC 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
99STANDARD 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
100Hand 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
101Happy Birthday or Zacharys Song
- to Row, Row, Row your boat
- Wash, Wash, Wash your hands
- Play my handy game
- Rub and Scrub, scrub and rub,
- Germs go down the drain!
- Repeat
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103ISOLATION 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
104N95 Respirator
105STANDARD PRECAUTIONS
- Handwashing
- Gloves (PPE)
- Masks (PPE)
- Eye Protection (PPE)
- Gowns (PPE)
- Leak-proof linen bags
- Puncture proof containers for sharps
106Donning and Removing PPE
- Donning
- Gown
- Mask or respirator
- Goggles/face shield
- Gloves
- Keep hands away from face
- Work from clean to dirty
- Lime surfaces touched
- Change when torn or heavily soiled
- Removing
- Gloves
- Goggles/face shield
- Gown
- Mask or respirator
- Remove at doorway before leaving pt. room
- Perform hand hygiene immediately after removing
all PPE
107IN A YEAR YOU WILL HAVE SWALLOWED 14 INSECTS
WHILE SLEEPING
108WHERE ARE WE IN THE CHAIN OF INFECTION?
- Portal of Exit
- Susceptible Host
- Reservoir
- USE CRITICAL THINKING!!
109Surgical 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 skins 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
110Principles 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 persons 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
objects surface - The edges of a sterile field or container are
considered to be contaminated a 1 inch border
around the drape is considered contaminated
111- For which procedure would the nurse use aseptic
technique and which would require the nurse to
use sterile technique? - A) Aseptic technique for urinary catheterization
in the hospital and sterile technique for
cleaning surgical wound - B) Aseptic technique for changing the patients
linen and sterile technique for assisting in
surgery - C) Aseptic technique for food preparation and
sterile technique for starting an IV line - D) Aseptic technique for a spinal tap and
sterile technique for placing a central line
112LAB 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
113Lab Practice Contd.
- 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 patients
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)
114LAB Practice Sterile Procedures
- Opening sterile packages Flap fartherest away
from nurse first, then sides, then flap closest
to nurse - Preparing a sterile field
- Pouring sterile solutions label to palm, lip
it - Donning sterile gown and gloves
115QUESTIONS?
116Critical Thinking Exercise
- Mrs. Jaycock had an indwelling urethral catheter
for 1 week. The catheter has now been out for 24
hours. She complains of frequency and pain on
urination. Mrs. Jaycock suggests reinsertion of
the catheter because of the need to get up
frequently. What can frequency or pain on
urination be an indication of?
117Answer
- UTI
- Should the catheter be reinserted?
- Why or why not?
118Answer
- No reinserting the catheter may aggravate the
infection and promote the spread of the infection
to the bloodstream. - Describe at least one appropriate assessment
measure and one independent nursing action or
intervention for Mrs. Jaycock
119Nursing Response
- Increase her fluid intake if not clnically
contraindicated - Check her urinalysis
120Situation
- You are caring for Mr. Huang, who has a large
open, and draining abdominal wound. You notice
another health care worker changing Mr. Huangs
dressing without wearing gloves or using sterile
technique. When you question the health care
worker regarding his or her practice, this person
says, Dont worry, the wound is already
infected, and the antibiotics and drainng will
take care of any contaminants. How would you
respond to this comment?
121Response
- It is important to not only protect Mr. Huang
from additional infection, but also to protect
ourselves from becoming contaminated. - What would your next steps be in following up on
this incident?
122Situation
- Mrs. Niles is 83 years of age and lives alone.
She has difficulty walking and relies on a church
volunteer group to deliver lunches during the
week. Her fixed income limits her ability to buy
food. Last week, Mrs. Niles 79-year-old sister
died. The two sisters had been very close. As a
home care nurse, explain the factors that might
increase Mrs. Niles risk for infection.
123Response
- Age
- Potential for poor nutrition
- Potential for depression
124Situation
- Mr. Vargas is admitted to the facility with a
history of recent weight loss, a cough that has
persisted for 2 months, and hemoptysis. His
chest x-ray film shows a cavity lesion in one
lung, and his physician suspects tuberculosis.
What type of isolation precautions would you use
for Mr. Vargas? What protection would you use to
provide care? What education would you provide
to the family?
125Response
- Airborne precautions
- Wear an N95 mask
- Keep the door closed
- Educate the pt and family on transmission of TB
and reason for isolation.