Nursing Care: Client Mobility and Hygiene

Vital Signs

• Vital signs include temperature, pulse, respiration, and blood pressure
• These must be within normal limits to sustain life
• Graphic method shows a large amount of information, easily accessible for healthcare professionals
• Records of vital signs help in diagnoses and responding to changing situations
• Records include date, temperature, pulse rate, respiratory rate, blood pressure, and other important information
• Vital signs should be taken every 5, 10, or 15 minutes for patients in serious condition

Body Temperature

• Body temperature is the heat inside a person's body
• Balanced between heat produced and lost
• Oral temperature is usually around 37 degrees Celsius
• Can be measured in Celsius or Fahrenheit
• Signs of elevated temperature include flushed face, hot skin, bright eyes, restlessness, and chills, thirst

Fever Terminology

• Intermittent fever: fluctuates between fever and normal/subnormal readings
• Remittent fever: rises above normal and returns to normal/near normal
• Constant fever: stays elevated
• Crisis: rapid drop in temperature to normal
• Lysis: gradual return to normal temperature
• Relapsing fever: returns to normal for a day or more

Lowered Body Temperature

• Hypothermia: body temperature significantly below normal, possibly caused by overexposure to cold
• Lowered body temperature may be desirable in some surgical situations, slowing metabolism and oxygen need
• Clinical hypothermia is used for some surgical procedures
• Accidental hypothermia is life-threatening, requiring immediate treatment

Thermometers

• Electronic thermometers are most commonly used, but disposable thermometers are convenient for travel

Measuring Body Temperature

• Oral (mouth)
• Rectal (anus)
• Axillary (armpit)
• Tympanic (ear canal)
• Temporal (forehead)

Pulse

• Pulse rate: the number of heartbeats per minute (heart rate - HR)
• Normal adult heart rate: 60-80 BPM
• Newborn heart rate: 120-140 BPM
• Pulse rate changes during sleep, exercise, extreme emotion, or disease
• Tachycardia: consistently above 100 BPM, possibly signifying heart disease, heart failure, or hemorrhage
• Bradycardia: consistently below 55 BPM, possibly naturally occurring in well-conditioned athletes or due to abnormal conditions
• Pulse volume varies with blood volume in arteries, strength of heart contractions, and elasticity of blood vessels
• Normal pulse: felt with moderate finger pressure
• Full/rebounding pulse: difficult to obliterate
• Weak pulse: difficult to feel
• Pulse rhythm: the spacing of beats; intermittent/irregular pulse: when a beat is skipped
• Can be regular in rhythm but irregular in force, potentially due to disease or condition

Measuring Pulse (Auscultation)

• Apical pulse: counted using a stethoscope over the heart's apex
• Radial pulse: most convenient, commonly used for adult patients
• Apical-radial pulse: used when suspecting that the heart is not pumping effectively; takes both pulses simultaneously
• Pedal pulse: used to determine lower extremity circulation
• Carotid pulse: used when other pulses are not palpable; common measure

Measuring Pulse (Doppler)

• Ultrasonic Doppler device used to detect peripheral pulses with conductive gel

Respiration

• Respiratory Rate: measured in breaths per minute
• Normal respiratory rates vary by age: newborns (30-80 breaths/minute), early childhood (20-40 breaths/minute), late childhood (15-25 breaths/minute), adulthood (men 12-18 breaths/minute, women 16-20 breaths/minute)
• Eupnea: normal breathing
• Tachypnea: abnormally rapid breathing (more than 20-24 breaths/minute);
• Bradypnea: abnormally slow breathing (less than 10 breaths/minute)
• Snoring: partially blocked air passageway
• Stertorous breathing: air passing through secretions in air passages; often precedes death

Oxygen Saturation

• Oxygen saturation measures the oxygen circulating in the blood (hemoglobin saturation)
• Usually represented as SpO2
• Measured with a pulse oximeter
• Noninvasive; measures the amount of light transmitted by deoxygenated vs. oxygenated hemoglobin

Proper Body Mechanics

• Body mechanics: using the safest and most efficient ways to move and lift objects.
• Principles include center of gravity, base of support, and line of gravity
• Center of gravity: often in the pelvic area
• Base of support: the wider the base, the more stable the object
• Line of gravity: an imaginary line from the head, center of gravity and base of support

Positioning the Client

• Supine (dorsal recumbent): lying on the back
• Prone: lying on the abdomen
• Sims' (semi-prone): lying on the side (usually the left)
• Fowlers: lying on the back, head elevated
• Dorsal lithotomy: lying on the back, feet in stirrups
• Lateral: lying on the side

Joint Mobility and Range of Motion

• Range of motion: The amount of movement possible at a joint
• Exercises prevent joint deformities caused by prolonged muscle contractures

Passive ROM

• If clients are unable to move, the nurse/therapist assists the joints through their range of motion
• Non-forcible, purposeful movement

Active ROM

• Clients actively move their joints through their full range of motion
• May need supervision to ensure complete motion of muscles/joints

Client Positioning for Comfort

• Functional body alignment
• Client safety
• Reassurance and cooperation
• Assistance and movement of clients
• Following provider orders

Use of the Transfer Belt

• Secures clients, providing safety

Client Falls Risk

• Clients with difficulty moving or walking, or recent falls need close monitoring

Client in Danger of Falling

• Assist client to a sitting position if feeling faint
• Nurse must avoid letting the client grab himself while falling

Positioning the Client for Comfort (cont)

• Maintain the functional body alignment of clients
• Obtain the client’s safety and cooperation
• Follow the provider’s orders

Special Mouth Care: Dependent Client

• Oral hygiene is important to prevent choking
• Perform mouth care frequently

Routine Eye Care

• Tears protect the eyes from foreign matter and lubricate them
• Washing routine is dependent on client's needs/condition

Caring for Fingernails and Toenails

• Emotional issues and infections may affect nail care routine

Caring for Clients with Different Hair Types

• Daily hair care varies with hair type
• Encouraging clients to care for their hair as they desire provides emotional support

Skin Infections

• Pediculosis, scabies: common skin infections
• Causes intense itching, requiring treatment
• Washing and treating with special shampoos may be necessary for removal

Skin Care

• Maintaining intact skin is crucial, especially in preventing infections
• Addressing inflammation should be performed routinely

Elimination

• Urine: formed by the kidneys; total adult output is 500-2,400 mL/day average.
• Edema: excess interstitial fluid
• Feces: solid waste products of digestion
• Characterized by color, consistency, shape, odor, and density

Bowel Elimination

• Bowel Elimination occurs at regular intervals.
• Patterns vary by individual; can be affected by illness or immobility

Urine Elimination

• Collect specimen containers with client data before collection
• Record fluid intake and output (I&O)
• Include food and fluid intake and output measurement (daily measurement of fluid/food intake and output)
• Urine Characteristics (clarity, color, odor, and volume)

Collecting Specimens

• Label specimen containers properly
• Adhere to safe handling/transport procedures
• Record the collection and forwarding of specimens to the laboratory (client health record)

Intake and Output Records

• Records of fluid intake and output (I&O) helps the providers decisions about increasing or decreasing fluids/foods
• To measure total intake, read amounts directly from containers or measure the amount of water in a container

Measuring Fluid Intake

• Measure all fluids taken through GI or IV
• Document all fluids consumed

Measuring Fluid Output

• Measure all fluids excreted from the body: wound drainage, emesis, vomiting, bleeding, diarrhea, urine, and nasogastric suction tube

Measuring Urine Specific Gravity

• Measures concentration of urine compared to pure water.

Specialized Urine Specimens

• Single voided: to determine kidney efficiency
• Clean-catch: to obtain urine with minimal contamination.
• 24-hour urine: measures 24-hour urine output, providing detailed information about waste excretion by the kidneys
• Fractional urine: measures urine during specific periods of the day

Stool Specimen

• Provides information on the gastrointestinal system and its accessory organs
• Common test for occult (hidden) blood in stool

Sputum Specimen

• Often collected in the early morning for better accuracy
• Collected before eating or using oral hygiene products.

Pain Management

• Pain is a subjective symptom reported by the client, and is the best indicator for pain management.
• Pain may be classified as acute, referred, cancer, or chronic
• Pain can be successfully managed through various methods(pharmacological, interventions for pain and nursing interventions.)

Heat and Cold Applications

• Normothermia: normal body temperature (critical for maintaining function and preventing complications during invasive procedures/surgery)
• Hypothermia: abnormally low body temperature.
• Heat dilates blood vessels; cold constricts them.
• Moist applications are more effective than dry

Bandages

• Purposes include supporting a limb or joint, securing dressings, immobilizing a limb, providing compression, and preventing contractures.
• Essential for wound care, safety, preventing problems, etc.

Evaluating Falls Risk

• Assessing risk of falling in clients with difficulty moving or walking, or recent falls is crucial

Medical Devices

• Items used for assistive care for individuals who face physical challenges, including wheelchairs, canes, and walkers.

Pain Rating Scales

• Pain is assessed and documented using pain scales like the Wong-Baker FACES pain rating scale or FLACC.

Cold Therapies

• Cold, moist compresses reduce swelling and inflammation from soft tissue injuries and after dental procedures
• Ice bags, ice collars/caps, or ice packs can also be used
• Tepid (warm/cool) sponge baths can lower high temperatures.