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FoundationII
Vital Signs and Hygiene Ch. 14, 28
| Question | Answer |
|---|---|
| Vital Signs | Temperature, Pulse, Respiration, Blood pressure, Oxygen saturation, Pain |
| Significance of Vital Signs | Information about the physiology of the body. Indicates change in client’s condition. Basis for clinical problem solving. Basis for formulating nursing diagnosis |
| When to take Vital Signs | Admission to the health care facility. Complete physical assessment. A change in a client’s condition. Before and after a procedure /invasive test or procedure. Blood administration. Before medications. “feel funny”. Routines/orders. Ambulation |
| Temperature | Acceptable Ranges: 36° C to 38° C, 96.8° F to 100.4° F. • Surface temp. fluctuates = range |
| Body Temp Regulation (Thermoregulation) | Hypothalamus, Blood vessels /skin surface, Vasodilation, Vasoconstriction, Muscles |
| Heat Production | Basal metabolic rate, At rest, basal metabolism generates heat produced. BMR depends on body surface area. Exercise & Activity. Shivering |
| Radiation | Transfer w/out physical contact |
| Conduction | Transfer w/ direct contact |
| Convection | Away by air movement, increased loss w/ moist skin |
| Evaporation | When a liquid changes to a gas. (600-900ml/day of water) |
| True fever | A change in hypothalamus “set point” |
| Pyrogens | Trigger the immune system by stimulating release of hormones that cause the hypothalamus to set point. |
| Hyperthermia | Increased temp. r/t inability to promote heat loss or decrease heat production. |
| Heat stroke | Prolonged sun exposure or high temps. Heat decrease hypo. ability to function. |
| Hypothermia | Caused by prolonged exposure to cold. Amt. of heat loss decreases body’s ability to produce heat. |
| Fever (Nursing Care) | Assess, Obtain cultures, if ordered, Antibiotics, Lower room temperature, Increase air flow in room, Force fluids, Antipyretics, Corticosteroids |
| Heat Stroke (Nursing Care) | Move to a cooler environment, Reduce clothing covering the body, Place wet towels on skin, Oscillating fans, Emergency tx: hypothermia blankets, IV fluids, stomach & lower bowel irrigation w/ cool solutions. |
| Hypothermia (Nursing Care) | Remove wet clothes & replace w/ dry, Wrap in blankets, heated if available, Hot liquids, Keep head covered, Warm person |
| Patterns of Fever | Sustained, Intermittent, Remittent, Relapsing |
| Core temp sites | Pulmonary artery, Esophagus, Urinary bladder |
| Intermittent temp sites | Mouth, Rectum (1o higher than oral), Axilla (1o lower than oral), Tympanic membrane, Temporal artery (1o lower than oral) |
| Pulse | Palpable bounding of the blood flow in an artery from L heart ventricle |
| Stroke volume | Amount of blood entering aorta w/ ea. contraction. |
| Cardiac output | Amount of blood pumped by the heart in 1 min. Cardiac output = stroke volume x heart rate. |
| PULSE SITES | Temporal, Carotid, Apical, Brachial, Radial, Ulnar, Femoral, Popliteal, Dorsalis pedis, Posterior tibial |
| Measurement of Pulse | Radial – 30 sec x 2 if regular. If IRREGULAR take for 1 minute. Apical – 30 sec x 2 if regular. If IRREGULAR count x 1 minute |
| Tachycardia | greater than 100 beats/min adults |
| Bradycardia | less than 60 beats/min adults |
| Strength and equality | Reflects the volume and pressure of blood ejected against the arterial wall with each beat |
| Factors influencing pulse | Exercise, Temperature, Body position, Emotions, Stimulants, Drugs, Hemorrhage, Postural changes |
| Blood Pressure | Force exerted on the arterial walls by pulsing blood. Blood flows because of pressure changes: moving from increased to decreased pressure areas. Systolic - Peak of max. pressure w/ ejection |
| Pulse pressure | Difference btw. systolic & diastolic pressures |
| MAP | Mean arterial pressure. MAP =(SBP + 2 DBP) ÷ 3 |
| Determinant Physiology of BP | Cardiac output, Peripheral resistance, Blood volume, Viscosity, Elasticity |
| Hypertension | Persistently elevated: 140/90 |
| Hypotension | Systolic less than 90mmHg |
| Factors Affecting BP | Age/ gender, Stress, Race, Hemorrhage, Daily variations, Medications, Activity, Pain, Smoking / Weight |
| Korotkoff sound | A clear, rhythmic tapping that corresponds to pulse rate. Onset corresponds w’ systolic pressure. Disappearance corresponds w/ diastolic pressure. |
| Common Errors in BP Measurements | Bladder or cuff to wide or narrow, Deflating cuff to slowly or quickly, Arm not supported, Inaccurate inflation level, Cuff wrapped too loosely taking orb/p on same arm to soon after previous one |
| Ventilation | Mechanical movement of gases into and out of the lungs. |
| Perfusion | Distribution of RBC’s to & from the pulmonary capillaries |
| Diffusion | Movement of O2 & CO2 btw. alveoli & RBC’s |
| Bradypnea | less than 12 breaths/min. |
| Tachypnea | Greater than 20 breaths/min. |
| Factors influencing respiration | Age, Emotions, Physical activity, Pain, Narcotics, Disease, Fever, Smoking |
| Purposes of Bathing | Important to consider the Delegation of this care to your staff. Cleanse body of perspiration, sebum, bacteria. Stimulate circulation. Relax client. Assess skin, general condition. Assess mental and emotional status. Teach good hygienic practices |
| What influences Hygiene? | Culture, Physical condition, Personal preferences, Social practices, Body image, Socioeconomic status, Knowledge, Age |
| Bathing guidelines | Provide privacy, Maintain safety, Maintain warmth, Promote independence, Anticipate needs, Clean to dirty (Gloves), Proximal to Distal |
| Who needs daily 2% CHG bathing? | Patients on Contact Precautions. Patients w/Central Lines |
| How to bathe | Use 2 oz (1/2 bottle) in approximately 1500 cc water (1/2-3/4 full basin). Wet wash cloth and apply to skin rubbing gently allowing a 5 minute contact time with skin. Rinse skin thoroughly. Pat dry |
| How to bathe (Note) | Do not use product to bathe above the neck (avoid eyes/nose/ears). Avoid bathing genital area ( use separate wash cloth with mild soap and water only on genitals). Discontinue use if skin becomes red or irritated and document. |
| During hygiene | Assess physical status and limitations. Assess client’s readiness to learn. Provide privacy. Foster physical well being. Hygiene care is never routine. |
| Common skin problems | Dry skin. Acne. Hirsutism. Skin rashes. Contact dermatitis. Abrasion |
| Perineal Care | Most in need: Foley catheters, incontinent. Assess ability to cleanse self. Male: uncircumcised. Female: Front to back. Be alert to discharge, skin irritation, and odors. |
| Perineal Care | Good perineal care prevents skin irritation and breakdown. Professional, dignified attitude |
| Foot and Nail Care | Soak and soften cuticles. Cleanse and dry the feet thoroughly. Trim nails straight across (check agency policy regarding trimming of nails). Inspect for lesions, dryness, and signs of infection. Diabetic clients are at risk for impaired circulation. |
| Foot and Nail Problems | Callus, Corn, Plantar warts, Ingrown toenails, Foot odors, Athlete’s foot, Ram’s horns, Fungal nail infections |
| Prevention of Foot Problems | Correctly fitting shoes. Wash and dry feet daily. Cotton socks (white). Lotion. No bare feet |
| Oral hygiene | Caries, Peridontal disease, Stomatitis, Glossitis, Gingivitis, Halitosis, Malignancy |
| Risk factors for oral problems | Paralyzed, Seriously ill, Chemotherapy/radiation therapy, Diabetics, NPO, Immunosuppressed |
| Hair Care Common Problems | Dandruff, Lice, Pediculosis capitis, Pediculosis corporis, Pediculosis pubis, Alopecia |
| Room Environment | Maintain comfort, Good positioning, Good ventilation, Control noise level, Room lighting, Room equipment, Call light, bed, lights, phone, TV, thermostat, over-bed table, chair(s) |
| Common Bed Positions | Fowler’s. Semi-Fowler’s. Trendelenburg. Reverse Trendelemburg • Flat |
Created by:
maggardba
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