Podcast
Questions and Answers
What is the lower baseline temperature range for older adults?
What is the lower baseline temperature range for older adults?
What is one factor influencing pulse?
What is one factor influencing pulse?
Activity, emotions, health status
Respirations in older adults are typically slightly elevated.
Respirations in older adults are typically slightly elevated.
True
Which measurement tool is used for blood pressure assessment?
Which measurement tool is used for blood pressure assessment?
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The normal body temperature range is ______.
The normal body temperature range is ______.
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What should a nurse do after removing gloves?
What should a nurse do after removing gloves?
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How should bed linens soiled with infectious material be washed?
How should bed linens soiled with infectious material be washed?
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When should the nurse remove the face mask when doffing PPE?
When should the nurse remove the face mask when doffing PPE?
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The UAP can leave the room with the stethoscope draped around their neck while in enteric contact precautions.
The UAP can leave the room with the stethoscope draped around their neck while in enteric contact precautions.
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Soiled dressings should be flushed down the commode.
Soiled dressings should be flushed down the commode.
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When should the nurse don gloves when entering a room with seeping skin wounds?
When should the nurse don gloves when entering a room with seeping skin wounds?
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Which of the following are focus areas of National Patient Safety Goals? (Select all that apply)
Which of the following are focus areas of National Patient Safety Goals? (Select all that apply)
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Standard precautions are used to prevent transmission of diseases between healthcare providers and patients.
Standard precautions are used to prevent transmission of diseases between healthcare providers and patients.
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What should be done to verify the correct patient before a procedure?
What should be done to verify the correct patient before a procedure?
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Patients should be repositioned at least every ______ hours to prevent pressure injuries.
Patients should be repositioned at least every ______ hours to prevent pressure injuries.
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What is Medical Asepsis?
What is Medical Asepsis?
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Match the following types of infection with their descriptions:
Match the following types of infection with their descriptions:
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Which of the following are components of hand hygiene? (Select all that apply)
Which of the following are components of hand hygiene? (Select all that apply)
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Standard Precautions are implemented for every patient to reduce infection risks.
Standard Precautions are implemented for every patient to reduce infection risks.
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List one method to interrupt the chain of infection.
List one method to interrupt the chain of infection.
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What is the proper sequence for Donning (Putting On) PPE?
What is the proper sequence for Donning (Putting On) PPE?
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What is the primary goal of using standard precautions?
What is the primary goal of using standard precautions?
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The normal pulse rate for adults is ___ beats per minute.
The normal pulse rate for adults is ___ beats per minute.
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What is the definition of Stroke Volume?
What is the definition of Stroke Volume?
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All medical instruments should be properly sterilized before reuse.
All medical instruments should be properly sterilized before reuse.
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What commonly leads to urinary tract infections (UTIs) in hospitalized patients? (Select all that apply)
What commonly leads to urinary tract infections (UTIs) in hospitalized patients? (Select all that apply)
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Bradycardia is defined as a pulse rate less than 60 beats per minute.
Bradycardia is defined as a pulse rate less than 60 beats per minute.
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What is one complication of infectious diseases that can be life-threatening?
What is one complication of infectious diseases that can be life-threatening?
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Which of the following is NOT a common pulse site?
Which of the following is NOT a common pulse site?
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C.difficile precautions require handwashing with ___ soap.
C.difficile precautions require handwashing with ___ soap.
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What are the two mechanisms of body temperature regulation?
What are the two mechanisms of body temperature regulation?
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Which equipment is typically used for blood pressure measurement?
Which equipment is typically used for blood pressure measurement?
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What is the role of the hypothalamus in temperature regulation?
What is the role of the hypothalamus in temperature regulation?
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Which statement correctly defines Surgical Asepsis?
Which statement correctly defines Surgical Asepsis?
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What actions should be taken first when donning PPE?
What actions should be taken first when donning PPE?
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Which condition is indicative of hyperthermia?
Which condition is indicative of hyperthermia?
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Which term describes a fever that fluctuates minimally but is always above normal?
Which term describes a fever that fluctuates minimally but is always above normal?
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What is the proper sequence for removing PPE?
What is the proper sequence for removing PPE?
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What is a primary characteristic of fever of unknown origin (FUO)?
What is a primary characteristic of fever of unknown origin (FUO)?
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What does the hypothalamus primarily regulate regarding body temperature?
What does the hypothalamus primarily regulate regarding body temperature?
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At what time is the body's temperature typically at its highest?
At what time is the body's temperature typically at its highest?
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Which of the following is NOT a method of heat transfer?
Which of the following is NOT a method of heat transfer?
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What characterizes relapsing fever?
What characterizes relapsing fever?
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What is the correct definition of cardiac output?
What is the correct definition of cardiac output?
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Which statement describes a bounding pulse?
Which statement describes a bounding pulse?
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During what positioning is the head of the bed raised to a 30-degree angle?
During what positioning is the head of the bed raised to a 30-degree angle?
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What is indicated by a pulse oximetry reading of less than 92%?
What is indicated by a pulse oximetry reading of less than 92%?
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What characterizes Cheyne-Stokes respiration?
What characterizes Cheyne-Stokes respiration?
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What is the typical respiration rate range for an adult described as eupnea?
What is the typical respiration rate range for an adult described as eupnea?
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In terms of infection control, what is the full meaning of BAMB?
In terms of infection control, what is the full meaning of BAMB?
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Which position is used primarily for cardiopulmonary assessments or respiratory distress?
Which position is used primarily for cardiopulmonary assessments or respiratory distress?
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Which of the following pulses can typically be palpated at the 2nd intercostal space right sternal border?
Which of the following pulses can typically be palpated at the 2nd intercostal space right sternal border?
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Which component is NOT included in the chain of infection?
Which component is NOT included in the chain of infection?
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What is the primary focus of the National Patient Safety Goals related to communications?
What is the primary focus of the National Patient Safety Goals related to communications?
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Which of the following is a recommended technique to prevent skin breakdown?
Which of the following is a recommended technique to prevent skin breakdown?
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What physiological response occurs when the body's temperature is low?
What physiological response occurs when the body's temperature is low?
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Which factor does NOT influence blood pressure?
Which factor does NOT influence blood pressure?
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How does the body regulate respiration when O2 levels are low?
How does the body regulate respiration when O2 levels are low?
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What is NOT a factor influencing pulse oximetry readings?
What is NOT a factor influencing pulse oximetry readings?
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What happens to the walls of the aorta with each stroke volume ejection?
What happens to the walls of the aorta with each stroke volume ejection?
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Which of the following statements about involuntary respiration is true?
Which of the following statements about involuntary respiration is true?
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Which of the following actions should NOT be taken to monitor a patient's temperature regulation?
Which of the following actions should NOT be taken to monitor a patient's temperature regulation?
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What physiological change occurs in the thermoregulatory response of older adults?
What physiological change occurs in the thermoregulatory response of older adults?
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What is a common reason for an irregular pulse in older adults?
What is a common reason for an irregular pulse in older adults?
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Which factor is a primary reason for increased respiratory effort in older adults?
Which factor is a primary reason for increased respiratory effort in older adults?
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What cardiovascular change is typically observed as older adults age?
What cardiovascular change is typically observed as older adults age?
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When are vital signs typically assessed in a clinical setting?
When are vital signs typically assessed in a clinical setting?
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Which of the following physiological changes is associated with decreased peripheral vasoconstriction in older adults?
Which of the following physiological changes is associated with decreased peripheral vasoconstriction in older adults?
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How does atherosclerosis affect the pulses of older adults?
How does atherosclerosis affect the pulses of older adults?
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In older adults, what change in respiratory function can be expected?
In older adults, what change in respiratory function can be expected?
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What impact does decreased sweat gland activity have on older adults?
What impact does decreased sweat gland activity have on older adults?
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What is a primary consequence of decreased sympathetic nervous system response in older adults?
What is a primary consequence of decreased sympathetic nervous system response in older adults?
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What is not an element of the chain of infection?
What is not an element of the chain of infection?
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Which National Patient Safety Goal focuses on medication safety?
Which National Patient Safety Goal focuses on medication safety?
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Which technique is effective in preventing skin breakdown?
Which technique is effective in preventing skin breakdown?
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What is the role of the hypothalamus when body temperature is low?
What is the role of the hypothalamus when body temperature is low?
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How does involuntary respiration regulation primarily work?
How does involuntary respiration regulation primarily work?
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Which factor is least relevant to the regulation of pulse?
Which factor is least relevant to the regulation of pulse?
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What can affect blood oxygen saturation levels?
What can affect blood oxygen saturation levels?
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Which factor does not influence respiratory rate?
Which factor does not influence respiratory rate?
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Which of the following best describes how fever is regulated by the body?
Which of the following best describes how fever is regulated by the body?
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Which aspect is essential to assess the functional status of older adults?
Which aspect is essential to assess the functional status of older adults?
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What physiological change contributes to older adults being sensitive to temperature extremes?
What physiological change contributes to older adults being sensitive to temperature extremes?
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Which factor primarily causes an increase in systolic blood pressure as adults age?
Which factor primarily causes an increase in systolic blood pressure as adults age?
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How does the respiratory rate in older adults typically present?
How does the respiratory rate in older adults typically present?
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What is a common physiological change related to pulse in older adults?
What is a common physiological change related to pulse in older adults?
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What should be included in a nurse's assessment of vital signs?
What should be included in a nurse's assessment of vital signs?
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Which of the following best describes the change in thermoregulation in older adults?
Which of the following best describes the change in thermoregulation in older adults?
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During what situation might a nurse determine that vital signs should be reassessed?
During what situation might a nurse determine that vital signs should be reassessed?
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What is a common condition that makes older adults susceptible to orthostatic hypotension?
What is a common condition that makes older adults susceptible to orthostatic hypotension?
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Which factor commonly contributes to the increased work of breathing in older adults?
Which factor commonly contributes to the increased work of breathing in older adults?
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What best characterizes the nursing responsibilities when taking vital signs?
What best characterizes the nursing responsibilities when taking vital signs?
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Study Notes
National Patient Safety Goals
- Aims to improve patient safety through correct identification, effective communication, infection prevention, and risk identification.
- Standard precautions are critical to prevent disease transmission and safeguard both healthcare providers and patients.
Implementation of Infection Control Practices
- Follow protocols that ensure safe practices.
- Engage in proper hand hygiene, utilize personal protective equipment (PPE), and regularly clean equipment.
Patient Identification Protocols
- Verify patient identity by checking ID bands and asking patients to confirm their name and date of birth prior to procedures.
Infection Prevention and Control Steps
- Hand Hygiene: Thorough handwashing before and after patient contact is vital.
- PPE Use: Wear appropriate personal protective equipment based on exposure risks.
- Cleaning and Disinfection: Regularly clean and disinfect surfaces and equipment with effective disinfectants.
- Safe Handling of Sharps: Properly dispose of needles in designated containers to avoid injuries.
- Environmental Control: Maintain cleanliness and proper waste disposal in healthcare settings.
- Chain of Infection Awareness: Understand pathogen transmission and educate about infection control.
Positioning Techniques for Patients
- Utilize various therapeutic positions (e.g., Flat, Fowler's, Supine) for comfort and respiratory function.
- Key positions:
- Fowler's: 45-60 degrees for increased comfort and lung expansion.
- Prone: Laying face down for certain respiratory issues.
- Sims Position: Good for enemas and prevents pressure on greater trochanters.
Principles of Proper Body Mechanics
- Use wide base support and keep objects close to the body when lifting.
- Encourage patient participation whenever possible to minimize nurse strain.
Range of Motion (ROM) Movements
- Various movements include:
- Abduction/Adduction: Moving limbs away from or toward the midline.
- Flexion/Extension: Bending and straightening joints.
- Pronation/Supination: Rotating the forearm to face down or up.
Infection Chain Components
- Causative Agent: Pathogen causing infection (e.g., bacteria, viruses, fungi).
- Reservoir: Where the pathogen survives (e.g., humans, surfaces).
- Portal of Exit: Method of pathogen exit (e.g., respiratory, gastrointestinal).
- Mode of Transmission: Means by which the pathogen spreads (direct/indirect contact, airborne).
- Portal of Entry and Susceptible Host: Points of entry for pathogens and individuals who are at risk.
Infection Prevention Strategies
- Employ correct use of PPE, maintain cleanliness, and understand transmission modes.
- Direct Transmission: Through physical contact or droplets.
- Airborne Transmission: Involves fine particles that stay suspended in the air.
Types of Infections
- Local Infection: Confined to a specific body area (e.g., UTI).
- Systemic Infection: Affects multiple body systems (e.g., sepsis).
- Chronic vs Acute: Chronic infections develop slowly, while acute ones have a quick onset.
Breaking the Chain of Infection
- Strategies include eliminating pathogens, maintaining hygiene, covering wounds, and educating about infection control.
Physiological Defenses Against Infection
- Intact skin and mucous membranes act as barriers to infection, while inflammation responses help manage pathogens.
Skin Integrity and Infection Risk
- Factors affecting skin include moisture management, nutritional status, and avoiding injury.
- Regular repositioning of immobile patients and addressing incontinence are vital for maintaining skin integrity.
Medical Asepsis and Standard Precautions
- Medical Asepsis: Aims for the absence of disease-causing microorganisms.
- Standard precautions must be followed by all healthcare workers to reduce infection transmission risks.
Infection Prevention Techniques for Healthcare Providers
- Thorough hand hygiene, use of PPE, sterilization of equipment, and isolation practices prevent microorganism transfer.
Health Care-Associated Infections (HAIs)
- HAIs can be endogenous (from within the patient) or exogenous (from the healthcare environment).
- Commonly involved organisms include E. coli in urinary tract infections.
Patient Risk Factors for Infection
- Advanced age, cognitive decline, urinary incontinence, and the use of indwelling catheters increase infection susceptibility.
Skin Anatomy and Health Maintenance
-
Skin consists of layers including the epidermis and dermis, with special attention needed to prevent breakdown in vulnerable patients.### Donning and Doffing PPE
-
Donning Sequence:
- Perform hand hygiene before applying PPE.
- Gown should be tied securely to prevent exposure.
- Mask or respirator covering nose, mouth, and chin molded to the face.
- Goggles or face shield fitted snugly to block contamination.
- Gloves must be worn last to protect hands.
-
Doffing Sequence:
- Remove gloves by pinching and rolling them inside out.
- Untie and peel away gown from the body, inverting to avoid contamination.
- Remove goggles or face shield using ear pieces only.
- Remove mask by handling ear loops or ties.
- Perform hand hygiene immediately after each PPE piece removal.
Hand Hygiene Procedure
-
Preparation:
- Stand away from the sink to avoid contamination.
- Ensure a paper towel is within reach.
- Use a foot pedal or faucet to turn on water and adjust temperature to warm.
-
Washing Hands:
- Wet hands under running water, below elbow level.
- Apply 5–10 mL of liquid soap and rub vigorously for 20 seconds in a circular motion.
- Clean under fingernails with an orangewood stick.
- Rinse hands with fingers pointed downward.
-
Drying and Final Steps:
- Dry hands thoroughly using a paper towel with fingers pointing up.
- Turn off water faucet with the same dry paper towel without touching the faucet.
- Restart procedure if hands touch the sink.
-
Safety Alert: Use antimicrobial soap for resistant bacteria, except C.difficile and norovirus.
Vital Signs
- Indicate patient’s health status and provide baseline data.
- Should be taken upon admission, during routine PE's, before and after medications, with changes in condition, and based on nursing judgment or interventions.
Blood Pressure Measurement
-
2-Step Method:
- Extend patient’s arm to heart level.
- Choose the correct cuff size by checking the index line.
- Place cuff over the brachial artery, about 1 inch above the antecubital fossa.
- Locate the radial pulse before cuff inflation.
- Close valve, inflate cuff until radial pulse stops, and note systolic reading.
- Deflate cuff for 1 minute, palpate brachial artery, and set up for auscultation.
- Inflate cuff 30 mmHg above prior systolic reading and deflate slowly for recording.
Pulse Measurement
-
Pulse is the palpable blood flow sensation.
-
Key Terms:
- Pulse Rate: Pulsations per minute.
- Heart Rate: Beats per minute.
- Stroke Volume: 60-70 mL of blood ejected per contraction.
- Cardiac Output: Heart rate multiplied by stroke volume.
-
Assessment Timing: Routine checks, condition changes, or post-intervention.
Pulse Rate Insights
- Normal: 60-100 bpm; variations include tachycardia (>100 bpm) due to exercise or stress, and bradycardia (<60 bpm) from medications or conditioning.
- Older Adults: Normal rate remains 60-100 bpm but may vary due to age-related factors.
Common Pulse Sites
- Radial and Apical: For routine measurements.
- Carotid: In emergencies.
- Brachial: Specifically for infants.
Assessing Pulses Techniques
- Radial Pulse: Use fingertips and count for 30 seconds (regular) or 60 seconds (irregular).
- Brachial Pulse: Found on the ulnar side at the antecubital space.
- Carotid Pulse: Located along the sternocleidomastoid muscle (one side at a time).
- Apical Pulse: Auscultated at the apex using landmarks like the 5th intercostal space.
Heart Sounds
- S1 ("Lub"): Closure of mitral/tricuspid valves, best heard at the apex.
- S2 ("Dub"): Closure of pulmonic/aortic valves, best heard at the heart's base.
Nursing Responsibilities in Vital Signs
- Accurately measure and interpret vital signs.
- Report abnormal results or changes in patient conditions.
Regulation of Vital Signs
- Body Temperature: Maintained by the hypothalamus; involves heat production and loss via conduction, convection, radiation, and evaporation.
- Pulse and Blood Pressure: Controlled by the autonomic nervous system; influenced by cardiac output and resistance.
Temperature Measurement Variations
- Types: Oral, rectal, axillary, tympanic/temporal.
- Normal Range: 36°C - 38°C (96.8°F - 100.4°F).
Vital Signs and Older Adults
- Temperature may have a lower baseline.
- Pulse can be slower or irregular.
- Elevated blood pressure due to arterial stiffness.
- Slightly increased respiration rate linked to reduced lung function.
Clinical Practice Guidance
- Understand when and how to properly take vital signs.
- Use proper positioning and body mechanics to prevent strain and ensure patient safety.
- Engage with unlicensed personnel in vital sign monitoring while supervising for accuracy and safety protocol adherence.
Aseptic Techniques
- Aseptic techniques are vital nursing strategies to reduce the transmission of pathogens between individuals.
Medical Asepsis
- Medical asepsis includes practices to control the spread of microorganisms.
Surgical Asepsis
- Surgical asepsis involves maintaining a sterile environment free from all microorganisms.
Standard and Transmission-Based Precautions
- Standard Precautions (Tier 1) are applied to all patients, regardless of infection status.
- Transmission-Based Precautions (Tier 2) target patients with confirmed or suspected infections.
National Patient Safety Goals
- Established by the Joint Commission to enhance patient safety and address healthcare issues.
Hand Hygiene
- Critical medical asepsis practice: wash hands with soap for at least 20 seconds, dry with a disposable towel.
PPE Application Sequence
- Start with hand hygiene, followed by gown, mask or respirator, goggles or face shield, and finally gloves.
PPE Removal Sequence
- Remove gloves first, then goggles or face shield, followed by gown, mask, and finish with hand hygiene.
Vital Signs Order
- Vital signs are assessed in the sequence: Temperature, Pulse, Respiratory rate (TPR), Blood Pressure, Pulse Oximetry, and Pain.
Temperature Regulation
- Body temperature is managed through heat production and loss, regulated by the hypothalamus.
Temperature Patterns
- Normal range: 36°C - 38°C (96.8°F - 100.4°F).
- Highest temperature typically occurs between 5:00-7:00 PM.
- Lowest temperature generally occurs from 2:00-6:00 AM.
Fever Types
- Pyrexia indicates the body temperature exceeds normal.
- Conditions like febrile indicate an elevated temperature, while afebrile shows a normal temperature.
Fever of Unknown Origin (FUO)
- Refers to a fever without an identifiable source.
Temperature Measurement Sites
- Axillary: 36.5°C
- Oral & Tympanic: 37.0°C
- Rectal & Temporal: 37.5°C
Pulse and Heart Rate
- Pulse indicates blood flow; normal pulse rate ranges from 60-100 bpm.
- Stroke Volume is the amount of blood pumped per contraction, typically 60-70 mL.
- Cardiac Output is calculated from heart rate multiplied by stroke volume.
Respiratory Assessment
- Normal respiratory rate (Eupnea) is 12-20 breaths per minute.
- Assess respiratory rate, depth, rhythm, and character.
Stethoscope Usage
- Use the diaphragm for high-pitched sounds and the bell for low-pitched sounds.
Heart Sounds
- S1 ("Lub"): closure of mitral and tricuspid valves; dominant at the apex of the heart.
- S2 ("Dub"): closure of pulmonary and aortic valves; dominant at the base of the heart.
Pulse Oximetry
- Measures oxygen levels in arterial blood; normal values are above 96%.
- Values below 92% indicate potential oxygen needs.
Infection Transmission
- Methods of transmission: Direct, Indirect, and Airborne.
Healthcare-Associated Infections
- Infections related to health services provided in facilities like hospitals/nursing homes.
Body Fluid Precautions (BAMB)
- BAMB includes Blood, All body fluids, Mucous membranes, and Broken skin.
Body Mechanics
- Techniques to prevent musculoskeletal injuries during patient handling.
Patient Positioning
- Semi-Fowler: 30-degree elevation.
- Fowler: 45-60 degrees.
- High Fowler: 60 degrees.
- Orthopenic: 90 degrees for easier breathing.
- Trendelenburg: head lowered, foot raised for venous circulation.
Pulse Sites
- Common pulse sites include Radial, Apical, Carotid, Brachial, Femoral, Popliteal, Posterior Tibial, and Dorsalis Pedis.
Pulse Palpation Challenges
- Elderly patients may have difficulty with pulse palpation due to decreased elasticity and atherosclerosis.
Chain of Infection
- Infectious Agent: Pathogen capable of causing disease (e.g., bacteria, viruses).
- Reservoir: Natural habitat where infectious agents live and multiply (e.g., humans, animals).
- Portal of Exit: Pathway by which the infectious agent leaves the reservoir (e.g., respiratory tract, blood).
- Mode of Transmission: The way in which the pathogen is transferred to a host (e.g., direct contact, airborne).
- Portal of Entry: The route through which the infectious agent enters a susceptible host (e.g., mucous membranes, skin).
- Susceptible Host: An individual who is at risk of infection due to various factors (e.g., weakened immune system).
National Patient Safety Goals
- Identity Patients Correctly: Ensure accurate identification using at least two identifiers (e.g., name, date of birth).
- Improve Staff Communication: Promote effective communication among healthcare staff regarding patient care.
- Use Medicines Safely: Follow protocols for prescribing, dispensing, and administering medications.
- Use Alarms Safely: Respond appropriately to alarms and alerts to ensure patient safety.
- Prevent Infections: Implement measures to reduce the risk of healthcare-associated infections.
- Identify Patient Safety Risks: Regularly assess and address potential safety threats.
- Prevent Mistakes in Surgery: Follow guidelines to prevent errors during surgical procedures.
Basic Techniques to Prevent Skin Breakdown
- Change Positions Every Two Hours: Reduces prolonged pressure on any area of the skin.
- Keep Skin Dry and Clean: Regular hygiene to prevent moisture-related skin issues.
- Minimize Direct Pressure: Use cushioning and proper support to relieve pressure points.
- Moisture Barrier Ointment: Apply to protect skin from irritants.
Assessing Functional Status of Older Adults
- Utilize assessments to determine normal aging changes and those caused by illness or disability.
Physiology of Temperature Regulation
- Low Temperature: Hypothalamus activates heat promotion center, causing vasoconstriction and shivering to raise body temperature.
- High Temperature: Hypothalamus activates heat loss center, stimulating sweat production and blood vessel dilation to lower body temperature.
Physiology of Pulse Regulation
- Pulse waves are generated with heart contractions, felt in peripheral arteries, indicating stroke volume ejection.
Involuntary Regulation of Respiration
- Controlled by medulla and pons; CO2 levels trigger increased respiratory rate and depth as necessary.
- Hypoxia leads to stimulation of respiration through aortic and carotid receptors.
Voluntary Regulation of Respiration
- Can be consciously controlled during activities like talking or singing, although involuntary mechanisms take precedence.
Influencing Factors on Blood Pressure
- Cardiac Output: Volume of blood the heart pumps per minute.
- Peripheral Vascular Resistance: Resistance in blood vessels affecting blood flow.
- Blood Volume: Total volume of blood in circulation.
- Blood Viscosity: Thickness of blood influencing flow resistance.
- Artery Elasticity: Ability of blood vessels to expand and contract.
Factors Influencing Pulse Oximetry
- Dark Nail Polish: Can interfere with light transmission.
- Patient Movement: Affects the accuracy of readings.
- Decreased Circulation: Can result in lower readings.
- Placement of Sensor: Correct placement is crucial for accurate measurement.
Influences on Respiratory Rate
- Exercise: Increases demand for oxygen, raising respiratory rate.
- Stress: Can lead to rapid breathing.
- Anxiety: Often results in increased respiratory rate.
- Pain: May affect breathing patterns.
- Medication: Some drugs depress or stimulate respiration.
- Neuro Injury: Can impair respiratory function.
Changes in Temperature in Older Adults
- Reduced thermoregulatory response leading to:
- Lower core body temperatures.
- Increased sensitivity to temperature extremes.
- Decreased ability for vasoconstriction/vasodilation.
- Reduced subcutaneous fat for insulation.
Changes in Pulse in Older Adults
- Irregularities may occur due to conditions like atrial fibrillation.
- Decreased elasticity and atherosclerosis affecting blood flow.
- Diminished sympathetic nervous system response.
Changes in Respiratory Rate in Older Adults
- Normal range remains but chest expansion decreases.
- Elastic recoil of lungs declines, increasing respiratory effort.
- Lower physiologic reserve affects respiratory capacity.
Changes in Blood Pressure in Older Adults
- Generally increases with age, with higher systolic pressure due to less elastic arteries.
- Increased risk of orthostatic hypotension.
Nursing Responsibilities in Assessing Vital Signs
- Include measurements of temperature, respiration, blood pressure, pulse, and pulse oximetry.
- Vital signs provide essential health indicators and baseline data for patient care.
Timing of Vital Sign Assessment
- Conducted on a routine schedule, prior and post procedures or medications, after patient condition changes, and based on nursing judgment or interventions.
Chain of Infection
- Infectious Agent: Pathogen capable of causing disease (e.g., bacteria, viruses).
- Reservoir: Natural habitat where infectious agents live and multiply (e.g., humans, animals).
- Portal of Exit: Pathway by which the infectious agent leaves the reservoir (e.g., respiratory tract, blood).
- Mode of Transmission: The way in which the pathogen is transferred to a host (e.g., direct contact, airborne).
- Portal of Entry: The route through which the infectious agent enters a susceptible host (e.g., mucous membranes, skin).
- Susceptible Host: An individual who is at risk of infection due to various factors (e.g., weakened immune system).
National Patient Safety Goals
- Identity Patients Correctly: Ensure accurate identification using at least two identifiers (e.g., name, date of birth).
- Improve Staff Communication: Promote effective communication among healthcare staff regarding patient care.
- Use Medicines Safely: Follow protocols for prescribing, dispensing, and administering medications.
- Use Alarms Safely: Respond appropriately to alarms and alerts to ensure patient safety.
- Prevent Infections: Implement measures to reduce the risk of healthcare-associated infections.
- Identify Patient Safety Risks: Regularly assess and address potential safety threats.
- Prevent Mistakes in Surgery: Follow guidelines to prevent errors during surgical procedures.
Basic Techniques to Prevent Skin Breakdown
- Change Positions Every Two Hours: Reduces prolonged pressure on any area of the skin.
- Keep Skin Dry and Clean: Regular hygiene to prevent moisture-related skin issues.
- Minimize Direct Pressure: Use cushioning and proper support to relieve pressure points.
- Moisture Barrier Ointment: Apply to protect skin from irritants.
Assessing Functional Status of Older Adults
- Utilize assessments to determine normal aging changes and those caused by illness or disability.
Physiology of Temperature Regulation
- Low Temperature: Hypothalamus activates heat promotion center, causing vasoconstriction and shivering to raise body temperature.
- High Temperature: Hypothalamus activates heat loss center, stimulating sweat production and blood vessel dilation to lower body temperature.
Physiology of Pulse Regulation
- Pulse waves are generated with heart contractions, felt in peripheral arteries, indicating stroke volume ejection.
Involuntary Regulation of Respiration
- Controlled by medulla and pons; CO2 levels trigger increased respiratory rate and depth as necessary.
- Hypoxia leads to stimulation of respiration through aortic and carotid receptors.
Voluntary Regulation of Respiration
- Can be consciously controlled during activities like talking or singing, although involuntary mechanisms take precedence.
Influencing Factors on Blood Pressure
- Cardiac Output: Volume of blood the heart pumps per minute.
- Peripheral Vascular Resistance: Resistance in blood vessels affecting blood flow.
- Blood Volume: Total volume of blood in circulation.
- Blood Viscosity: Thickness of blood influencing flow resistance.
- Artery Elasticity: Ability of blood vessels to expand and contract.
Factors Influencing Pulse Oximetry
- Dark Nail Polish: Can interfere with light transmission.
- Patient Movement: Affects the accuracy of readings.
- Decreased Circulation: Can result in lower readings.
- Placement of Sensor: Correct placement is crucial for accurate measurement.
Influences on Respiratory Rate
- Exercise: Increases demand for oxygen, raising respiratory rate.
- Stress: Can lead to rapid breathing.
- Anxiety: Often results in increased respiratory rate.
- Pain: May affect breathing patterns.
- Medication: Some drugs depress or stimulate respiration.
- Neuro Injury: Can impair respiratory function.
Changes in Temperature in Older Adults
- Reduced thermoregulatory response leading to:
- Lower core body temperatures.
- Increased sensitivity to temperature extremes.
- Decreased ability for vasoconstriction/vasodilation.
- Reduced subcutaneous fat for insulation.
Changes in Pulse in Older Adults
- Irregularities may occur due to conditions like atrial fibrillation.
- Decreased elasticity and atherosclerosis affecting blood flow.
- Diminished sympathetic nervous system response.
Changes in Respiratory Rate in Older Adults
- Normal range remains but chest expansion decreases.
- Elastic recoil of lungs declines, increasing respiratory effort.
- Lower physiologic reserve affects respiratory capacity.
Changes in Blood Pressure in Older Adults
- Generally increases with age, with higher systolic pressure due to less elastic arteries.
- Increased risk of orthostatic hypotension.
Nursing Responsibilities in Assessing Vital Signs
- Include measurements of temperature, respiration, blood pressure, pulse, and pulse oximetry.
- Vital signs provide essential health indicators and baseline data for patient care.
Timing of Vital Sign Assessment
- Conducted on a routine schedule, prior and post procedures or medications, after patient condition changes, and based on nursing judgment or interventions.
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Description
This quiz covers essential National Patient Safety Goals, focusing on areas such as correct patient identification, effective communication, and infection prevention. It emphasizes the importance of standard precautions to protect both healthcare providers and patients. Discover key protocols for ensuring safety in healthcare settings.