Nurs 100 Week 1 Pt 1

Vital Signs

• Vital signs are measurements of the body's most basic functions: temperature, pulse, respiration/oxygen saturation, blood pressure, and pain.
• Vital signs are assessed on admission, with changes in patient condition, before and after surgery or procedures, before and after activities that increase risk, and before administering medications affecting cardiovascular and respiratory function.

Blood Pressure

• Reflects the force of blood against artery walls during contraction (systole) and relaxation (diastole).
• Systolic BP: Maximum pressure during ventricular contraction.
• Diastolic BP: Minimum pressure during ventricular relaxation.
• Normal range: 80/60 to 120/80 mmHg.
• Determinants of BP: Cardiac output and systemic vascular resistance.
• Hypotension: BP below normal range (diastolic < 60 mmHg, systolic < 80 mmHg).
• Hypertension: BP above normal range (systolic > 120 mmHg, diastolic > 80 mmHg).
• Pulse pressure: Difference between systolic and diastolic readings.
• Orthostatic hypotension: BP drops significantly when changing positions (lying to sitting to standing).

Nursing Considerations for Blood Pressure

• Infants have lower BP than older children, and older adults have slightly higher BP due to decreased arterial elasticity.
• Stress, medications (e.g., opiates, oral contraceptives, alcohol, antidepressants), and exercise can affect BP.
• Males generally have higher BP than females.
• African Americans may have a higher incidence of hypertension.
• Obesity and family history are risk factors for hypertension.

Measuring Accurate Blood Pressure

• Client preparation includes resting for 5 minutes and avoiding nicotine and caffeine for 30 minutes beforehand.
• Sit in a chair with feet flat and arm supported at heart level.
• Estimation: Palpate radial pulse to estimate BP. Inflate cuff until pulse disappears.
• Auscultation: Use stethoscope and appropriately sized cuff. Inflate 30 mmHg above estimated pressure and slowly deflate.
• Multiple readings: Take at least two readings 2 minutes apart. If readings differ by 5 mmHg, repeat.
• Avoid: Measuring BP in an arm with an IV, mastectomy, arteriovenous shunt, or fistula.

Temperature

• Measurement of heat balance between production and loss.
• Normal range: 96.5°F to 99.5°F.
• Sites: Skin, mouth, axilla (armpit).
• Difference: Oral temperature is typically 0.9°F higher than axillary temperature.

Temperature Measurement

• Temporal, Tympanic, and Rectal: These measurements are core temperatures.
• Rectal readings are 0.9°F higher than oral and tympanic.

Factors Affecting Temperature

• Age/Developmental Stage: Newborns lose heat rapidly, older adults lose heat more easily due to fat loss.
• Hormonal Changes: Temperature rises slightly during ovulation and menstruation.
• Activity, Exercise, and Dehydration: Can lead to hyperthermia.
• Illness and Injury: Can cause a fever in response to infection.

Nursing Considerations for Temperature

• Equipment: Electronic thermometers (disposable, rectal, temporal, oral, tympanic).
• Cleaning: Clean reusable thermometers with each use.
• Placement: Place thermometers correctly and wait for readings. Discard disposable thermometers after use.
• Oral Readings: Wait 20-30 minutes for accurate reading after eating.

Temporal Temperature Checks

• Cleaning: Wipe the lens with alcohol.
• Placement: Hold the probe flat against the forehead over the temporal artery and drag toward the ear or lift and place behind the earlobe.
• Reading: Release the scan button for the reading.

Temperature Complications

Hyperthermia

• Definition: Abnormally high temperature above 104°F due to thermoregulation failure.
• Nursing Interventions: Obtain cultures, administer antibiotics, provide fluids and rest, use cooling blankets, give antipyretics (avoid aspirin in children due to Reye's Syndrome), maintain environmental temperature at 70-80°F.

Hypothermia

• Definition: Body temperature less than 95°F.
• Nursing Interventions: Maintain warm environment, use heated humidified oxygen, use warming blankets or warmed IV/oral fluids, keep the head covered, continuous cardiac monitoring, have emergency resuscitation equipment on standby.

Pulse/Heart Rate

• Measurement of heart rate and rhythm, reflecting blood flow.
• Provides information about circulatory status.
• Normal Range: 60-100 beats per minute (BPM). (Newborns have higher ranges that vary with age)
• Rate: Number of heartbeats per minute.
• Rhythm: Regularity of heart impulses. Irregularities can indicate an irregular heart rate.
• Strength: Volume of blood ejected with each contraction (graded 0-4).
• Equality: Peripheral pulses should be symmetrical. Inequality can suggest a thrombus or aortic dissection.

Nursing Considerations for Pulse/Heart Rate

• Equipment: Device for counting seconds and a stethoscope.

Dysrhythmia:

• Irregular heart rhythm with an irregular radial pulse.
• Pulse deficit: Difference between apical rate and radial rate (count simultaneously)

Complications:

Tachycardia

• Heart rate above 100 bpm or above expected.
• Factors: Exercise, fever, heat exposure, medications, position changes, acute pain, anemia, hypoxemia, hypovolemia, shock, heart failure, hemorrhage.
• Nursing interventions: Monitor for pain, anxiety, low cardiac output, medication side effects, and protect patients from injury.

Bradycardia

• Heart rate below expected or below 60 bpm.
• Factors: Long-term physical fitness, hypothermia, medications, position changes, chronic severe pain, hypothyroidism, relaxation.
• Nursing interventions: Monitor for manifestations of low cardiac output, medication side effects, and protect patients from injury.

Respiration (RR)

• The body's mechanism for oxygen and carbon dioxide exchange between the atmosphere and blood/cells.
• Normal range: 12-20 breaths per minute (BPM).
• Chemoreceptors in the carotid arteries and aorta monitor blood carbon dioxide levels.
• Ventilation: Exchange of oxygen and carbon dioxide in the lungs (inspiration and expiration).
• Diffusion: Exchange of oxygen and carbon dioxide between alveoli and red blood cells.
• Perfusion: Flow of red blood cells to and from pulmonary capillaries (measured by pulse oximetry).
• Observe chest wall movement for rate, depth, and rhythm during measurement.

Factors Affecting RR

• Age: Respiration rate decreases with age.
• Gender: Males and children often have diaphragmatic breathing; females have thoracic breathing.
• Pain: Pain increases respiration.
• Anxiety: Anxiety increases respiration rate.
• Medications: Opioids, sedatives, and bronchodilators can affect breathing rate.
• Anemia and high altitudes: Increase the depth and rate of respiration to compensate.

Pain

• Subjective experience
• Pain threshold: Point at which pain is perceived.
• Pain tolerance: Length of time or intensity of pain endured before responding.
• Phantom pain: Pain without tissue involvement.

Acute Pain

• Symptoms: Rapid respiration, increased heart rate (HR), increased blood pressure (BP), diaphoresis, grimacing, guarding, flushing, pallor, sweating.
• May last hours to days.
• Usually has a known cause (e.g., surgery, injury).

Chronic Pain

• Symptoms: Withdrawal, depression, low self-esteem, flat affect, irritability, anxiety.
• Months to years.
• Can be disabling, affecting living, socialization, and mood.
• Pain is a stressor to the body, taking energy to manage.
• Often associated with depression and fatigue.

Pain Assessment and Documentation

• Use OLDCARTS mnemonic to ask clients about pain:
  • Onset
  • Location/Radiating
  • Duration
  • Characteristics
  • Agggravating factors
  • Relieving/provoking
  • Treatment
  • Severity

Pain Rating Scales

• Numbered scale
• Visual scale (e.g., Wong-Baker faces)
• Color scale (e.g., with descriptions)
• Pieces of pain scale (e.g., poker chips)
• Behavioral pain scale (e.g., FLACC)

Pain Management/Treatment

• Includes pharmacological and non-pharmacological approaches for comfort.

Pharmacological Approaches

• Analgesic medications (opioids): Oral, transdermal patches, IV analgesics, patient-controlled analgesia (PCA pump).

Non-Analgesic Medications

• Antidepressants
• Chemotherapeutic agents and immunosuppressants
• Anticonvulsants
• Muscle relaxants
• Marijuana

Nursing Considerations for Pain Management

• Constipation (related to opioids)

Cultural Considerations in Nursing

• Culture: Shared beliefs, values, and practices within a community (includes economic factors, religion, worldview).
• Elements of Culture Affecting Health: Communication, space, time orientation, social organization, biological variations, environmental control.
• Nursing Cultural Considerations: Cultural awareness (recognizing external signs of diversity), cultural sensitivity (demonstrating respectful and considerate attitudes).
• Addressing Health Disparities: Nurses encounter diverse patients and need to understand and respect beliefs to provide effective care.

Pain Management Medications

• Opioids: Slow peristalsis (increase oral fluids, stool softeners may help), report allergic reactions immediately and discontinue medication, respiratory depression can occur (resuscitate immediately, use Naloxone [Narcan] to reverse).
• Acetaminophen and NSAIDs: Educate patients about risks of liver damage or bleeding, particularly for older patients (use with caution in conjunction with anticoagulants).

Cultural Competency and Pain Management Beliefs Across Cultures

• Cultural competency: Proficiency in understanding and responding to diverse individuals.
• Key Principles: Be open-minded, acknowledge differences, assess client beliefs, understand nonverbal cues, utilize qualified interpreters.
• Dominant Cultural Practices (examples): Indigenous Americans (harmony with nature), Asian and Pacific Islander (physical and spiritual harmony), Black or African American (disharmony due to food choices or luck), Hispanic or Latino (reward for good behavior or luck), White or European (contamination, hereditary, psychosomatic, or supernatural).

Cultural Considerations Regarding Pain

• A person's cultural background influences pain perception and expression.
• Cultures may view pain as natural, honorable, or a consequence of immoral behavior.
• Cultures may value stoicism and discourage expressing pain openly.

Cultural Beliefs Affecting Pain Perception and Treatment (examples)

• White (European): Men often display stoicism, may fear addiction to medication.
• Hispanic/Mexican American: May believe pain is "God's will", expression may be perceived as weakness.

Cultural Perspectives on Pain

• Highlight variations in how different cultural groups perceive and express pain.
• Examples:
  • Hispanic groups (expressive, may favor injections),
  • Black (African American, African native) (pain is seen as a symptom),
  • Asian (stoicism, may view pain as a matter of family honor),
  • Native American (endure pain),
  • Arab (pain is to be controlled and treated promptly).

Infection Prevention and Control

• An infection occurs when a pathogen is present and intact, leading to a chain of events.
• A nurse uses infection control practices to break the chain and stop the spread.

Types of Pathogens or Agents

• Bacteria: Examples include Staphylococcus aureus, Escherichia coli, and Mycobacterium tuberculosis.
• Viruses: Examples include HIV, hepatitis, herpes zoster, and herpes simplex virus (HSV).

Pathogens

• Fungi: Candida albicans and Aspergillus
• Prions: Creutzfeldt-Jakob disease
• Parasites:
  • Protozoa (malaria and toxoplasmosis)
  • Helminths (flatworms, roundworms, and flukes)

Virulence

• Ability of a pathogen to invade and harm a host.

Infection Process (Chain of Infection)

• Causative Agent: Organisms that cause infection (bacteria, viruses, fungi, prions, parasites).
• Reservoir: Humans, animals, food, organic matter on inanimate surfaces, water, soil, and insects.
• Portal of Exit: The means by which the pathogen leaves the host (respiratory, gastrointestinal, genitourinary tracts, skin/mucous membranes, blood/body fluids, transplacental).
• Mode of Transmission: How the pathogen moves from one host to another (contact, indirect contact, fecal-oral, droplet, airborne, vector-borne).
• Portal of Entry: Path of entry into a new host (often the same as the portal of exit).
• Susceptible Host: Individuals with compromised defense mechanisms (e.g., immunocompromised, breaks in skin).

Stages of Infection

• Incubation Stage: Interval between pathogen entry and first symptoms.
• Prodromal Stage: Interval with general symptoms before more specific symptoms.
• Illness Stage: Interval with specific findings of an infection.
• Convalescence Stage: Interval when symptoms disappear. Recovery can take days to months.

Clients at High Risk for Infection

• Inadequate hand hygiene (client and caregivers)
• Compromised health/defenses (immunocompromised)
• Indwelling devices
• Breaks in the skin
• Poor oxygenation

Types of Exudates

• Serous: Clear
• Sanguineous: Contains red blood cells
• Serosanguinous: Mixture of serous and sanguineous
• Purulent: Contains leukocytes and bacteria; has a greenish-yellowish odor

Systemic Infection

• Affects the entire body through the circulatory system.
• Symptoms:
  • Fever
  • Chills
  • Sweating
  • Increased heart rate
  • Increased respiratory rate
  • Malaise
  • Fatigue
  • Anorexia
  • Nausea
  • Vomiting
  • Abdominal cramping
  • Diarrhea

Localized Infection

• Affects a specific area or organ.
• Stages of inflammatory response:
  1. Redness (from blood vessel dilation)
  2. Warmth (palpation)
  3. Edema
  4. Pain/tenderness
  5. Loss of function of the affected body part

Older Adults and Infection

• Slower Response to Antibiotics
• Weakened Immune Response
• Subcutaneous Tissue Loss
• Reduced Vascularity
• Delayed Wound Healing
• Reduced Cough and Gag Reflexes
• Chronic Illnesses
• Gastric Acid Production Decreased
• Reduced Mobility
• Bowel/Bladder Incontinence
• Dementia
• Increased Incidence of Invasive Devices (e.g., urinary catheters, feeding tubes)

Factors Affecting Infection Response

• Impaired Circulation
• Chronic Disease (diabetes mellitus, adrenal or renal failure, hepatic failure, chronic lung disease)
• Poor Personal Hygiene & Nutrition
• Smoking or Alcohol Use
• Stress
• Overcrowding
• IV Drug Use & Needle Sharing
• Unprotected Sex
• Exposure to Diseases Endemic to Different Regions/Countries
• Poor Sanitation
• Mosquito-borne diseases
• Parasitic diseases

Laboratory Tests for Infection

• Elevated White Blood Cells (WBCs): A WBC count greater than 10,000/µL (leukocytosis) is a sign of infection.
• Increased WBCs on differential (left shift) = increase in neutrophils
• Elevated erythrocyte sedimentation rate (ESR) over 20 mm/hr: indicates an active infection or inflammatory process.

Nursing Care Considerations for Infection Control

• Hand Hygiene: Frequent and effective hand hygiene before and after care is essential.
• Immunizations: Educate patients about necessary immunizations and where to obtain them, targeting children, older adults, those with chronic diseases, and immunocompromised individuals.
• Oral Hygiene: Educate patients on good oral hygiene. Good oral hygiene decreases the protein in the oral cavity (attracting microorganisms), thereby decreasing microorganism growth.
• Fluid Intake: Encourage sufficient fluid intake to prevent urinary stasis and maintain hydration. Adequate fluid intake prevents microorganism growth and keeps skin from breaking down.
• Pulmonary Hygiene (for immobile clients): Every 2 hours, or as prescribed, perform pulmonary hygiene (turning, coughing, deep breathing, incentive spirometry) to avoid stasis of pulmonary excretions, stimulate ciliary movement, and clear lungs.
• Aseptic Technique and PPE: Use aseptic technique and proper personal protective equipment (gloves, masks, gowns, goggles) for all clients to prevent unnecessary exposure to microorganisms.
• Respiratory Hygiene/Cough Etiquette: Teach and practice respiratory hygiene/cough etiquette for all patients and visitors to minimize contamination, especially in waiting areas. This includes covering the mouth and nose when coughing/sneezing, using tissues promptly, and maintaining distance.

Healthcare-Associated Infections (HAIs)

• Definition: HAIs are infections that occur while receiving care in a healthcare setting. They can emerge from exogenous (outside) or endogenous (inside) sources.
• Common Sites: Common sites include the urinary tract (often caused by Escherichia coli, Staphylococcus aureus, and enterococci), surgical wounds, the respiratory tract, and the bloodstream.
• Iatrogenic Infections: Some HAIs can be iatrogenic meaning they result from a diagnostic or therapeutic procedure.
• Prevention: Frequent and effective hand hygiene is the best way to prevent HAIs.

Isolation Guidelines

• Purpose: Isolation guidelines include hand hygiene and barrier precautions to minimize the transmission of infectious organisms.
• Application: Precautionary measures apply to all clients, regardless of diagnosis, and are applied whenever contact with a potentially infectious material is anticipated.
• PPE Changes: Protective equipment should be changed after contact with each client, and between procedures with the same client if substantial blood or body fluids exposure is anticipated.

Standard Precautions

• Standard precautions are a general approach to patient care. They focus on minimizing contamination risks.