Skills 1 Flashcards
(32 cards)
- Compare and contrast the indications for use of soap and water
versus alcohol-based waterless antiseptic agent when
performing hand hygiene.
- C-diff., before medical and surgical asepsis, when in contact with bodily fluids
- if hands are not visibly soiled hand sanitizer is fine unless you know you have been in contact with bodily fluids
- wash hands if the person is on contact precautions
**Bacterial Flora on the Hands:
Transient:
- Characteristics: occur on hands with ADL’s, relatively few in number on clean and exposed areas of skin, attached loosely on skin usually in grease, fats, and dirt, found in greatest number under the fingernails, can be pathogenic or nonpathogenic
- Effective Hand Hygiene Measures: Can be removed easily with frequent and proper handwashing.
**Bacterial Flora on the Hands:
Resident:
- Characteristics: normally found in skin creases, usually stable in number and type, cling tenaciously to skin by adhesion and absorption.
- Effective Hand Hygiene Measures: considerable friction with a brush is required to remove them, less susceptible to antiseptics than transient bacteria.
-When to take vital signs:
screenings at health fairs and clinics, in home health, admission to health care facility, medications that affect cardiac rate and rhythm, before and after invasive diagnostic and surgical procedures, in emergency situations. Take vitals as often as needed. For example; assessment, or for the patients uniques situation and medical diagnosis, comorbidities, types of treatments received, and level of acuity.
-Normal Adult Vitals:
- Temperature (oral): 96.4
- Pulse BPM: 60-100
- Respirations (breaths/min): 12-20
- Blood Pressure (mm Hg): 120/80
- SpO2 or SaO2: 95% - 100%
- Interpret the following abbreviations: TPR, BP, O2 saturation.
TPR: temperature, pulse, respirations
BP: blood pressure
O2 saturation: SpO2 or SaO2
- Discuss the six (6) vital signs routinely measured and assessed
on the hospitalized patient.
-T, P, R, BP, Pain, and pulse oximetry (SpO2) or oxygen in the blood.
Temperature (T)
1. Summarize the critical items to assess prior to taking a
Temperature.
-hot or dry skin, flushed face, respiration or pulse rate increases, confusion, delirium, seizures. Assess health history and medications.
- Describe the various methods for obtaining a temperature.
- rectal, oral, tympanic, axillary, temporal
- rectal and tympanic will be 1 degree higher than oral route
- axillary and temporal will be 1 degree lower than oral route
- Identify causes of hyperthermia.
-hyperthermia: hypothalamic set point is not changed, but in situations of extreme heat exposure or excess heat production (exercise) the mechanisms that control temp are ineffective.
- Explain the benefit of an elevated temperature.
-destruction of disease causing microorganisms, increased susceptibility of disease causing microorganisms to anti-infective agents, and enhanced response by immune system
- Identify when an elevated temperature should be treated.
-hyperpyrexia: greater than or equal to 106. This is a medical emergency and body must be cooled immediately to prevent brain damage.
- Describe nursing interventions for a patient with an elevated
Temperature.
- determine the cause of fever and treat the underlying cause because fever is an important part of the defense mechanism against infection.
- increase patient comfort and prevent complication
- if fever is result of bacterial or microbial infection treat with antibiotic or anti-infective
- antipyretic (asprin, ibuprofen, acetaminophen) prescribed in certain situations
- modify the external environment to increase heat transfer (internal to external); cool sponge bath, cool packs, hypothermia blankets.
- increaseoral fluids to maintaincellular and intravascular status and prevent dehydration.
- include simple carbohydrates to prevent tissue breakdown during hypermetabolic state
- Explain what causes a pulse.
-blood being pumped into the arterial circulation by the contraction of the left ventricle. Smooth muscle in arteries expands to compensate for an increase in pressure. Peripheral pulses are felt where the artery passes over bone or cartilage.
-Factors that influence pulse rates:
- age and biologic sex: women usually have a higher pulse, pluse decreases with age due to metabolic rate.
- Physical Activity: pulse increases with exercise, but well conditioned athletes may have a significantly decreased pulse (due to strength of heart muscle)
- Fever and stress: elevated temp. causes increased pulse due to metabolic demands. Increased levels of stress (pain, fear, anxiety) increase pulse.
- Medications: can increase or decrease pulse
- Disease: some diseases like COPD/ pneumonia impair oxygen and alter pulse rate.
Pulse sites
apical pulse, apical-radial pulse (2 person job), temporal, carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial
- Identify the pulse sites assessed when a patient’s condition
Deteriorates.
- emergency assessments (shock/cardiac arrest): use carotid pulse
- if peripheral pulses are weak assess apical pulse.
- Explain what causes a person to breathe.
- breathing or ventilation is autonomic and voluntary.
- rate and depth can change in response to tissue demands by respiratory centers in the brain.
- Identify factors that influence the character of respiration.
- respiratory rate abnormalities are important predictors of deteriorating patient conditions and serious events including cardiac arrest and intensive care admission.
- factors affecting rate, movements, and depth: exercise, respiratory/cardiovascular disease, alterations in fluid, electrolyte, acid-base balances, medications, trauma, infection, pain, emotions, age, exercise, brain lesions, altitude, anemia, medications, acute pai
- Explain how to assess respirations.
-count the amount of times the chest rises for one minute
- State the normal range for respiratory rate.
12-20
- Explain what causes blood pressure.
- force of moving blood against arterial wall
- the highest pressure created during ventricular contraction is systolic pressure
- the heart rests between beats during ventricular diastole, the lowest pressure on arterial walls at this time is diastolic pressure.
- Explain how to measure blood pressure by palpation.
- Using the BP cuff manually, Sphygmomanometer
- inflate cuff 30 mmHg abovethe point where the pulse disappeared. Release the air as normal and feel for when the pulse returns. Record this as the systolic and no diastolic will be recorded.
- Discuss the difference between systolic and diastolic
Measurements.
- the highest pressure created during ventricular contraction is systolic pressure
- the heart rests between beats during ventricular diastole, the lowest pressure on arterial walls at this time is diastolic pressure.
