Fundamentals of Nursing Course Notes 2023-2024 PDF

Part One 2023-2024  Asepsis Outlines: Introduction Types of microorganisms causing infections Types of infections Nosocomial infections Factors contribute to nosocomial infections Chain of infection...

Part One 2023-2024  Asepsis Outlines: Introduction Types of microorganisms causing infections Types of infections Nosocomial infections Factors contribute to nosocomial infections Chain of infection Body defenses against infections Factors increasing susceptibility to infection Nursing management Nursing intervention that break the chain of infection Preventing nasocomial infections Disinfecting and sterilizing Isolation precautions Personal protective equipment Disposal of soiled equipment and supplies principles and practices of surgical asepsis Infection control for health care workers 37  MODULE Module Title: Asepsis Intended Learning Outcomes (ILOS) A- Knowledge and Understanding: 1. Explain the concepts of medical and surgical asepsis 2. Identify anatomic and physiologic barriers that defend the body against microorganisms 3. Describe measures that break each link in the chain of infection B-Intellectual Skills 1. Differentiate active from passive immunity 2. Compare standard and transmission based precaution C-Professional and Practical Skills 1. Demonstrate factors contribute to nosocomial infections D-General and Transferable Skills 1. Appreciate the importance of standard precautions. Teaching And Learning Method Lecture Discussion Written assignments Case study 38  Asepsis Introduction - Microorganism exist everywhere: in water, in soil, and on body surfaces such as the skin, intestinal tract, and other areas open to the outside ( e.g. mouth, upper respiratory tract, vagina, and lower urinary tract). -Most microorganisms are harmless, and some are even beneficial in that they perform essential functions in the body. Some microorganisms produce substances that repress the growth of other microorganisms. -Some microorganisms are normal resident flora in one part of the body and produce infection to another. For example, Escherichia coli is a normal inhabitant of large intestine but a common cause of infection in the urinary tract. Infection Is an invasion of body tissue by microorganisms (infectious agent) and their growth there. If microorganism produces no clinical evidence of disease the infection is called asymptomatic or subclinical. A detectable alteration in normal tissue function, however, is called disease. Microorganisms vary in their virulence (their ability to produce disease). Microorganisms also vary in the severity of the disease they produce. If the infectious agent can be transmitted to an individual by direct or indirect contact or as an airborne infection, the resulting condition is called communicable disease. Pathogenicity is the ability to produce disease; thus a pathogen is a microorganism that causes disease. A true pathogen causes disease or infection in a healthy individual. An opportunistic pathogen causes disease only in a susceptible individual. Asepsis is the freedom from disease-causing microorganism. To decrease the possibility of transferring microorganism from one place to another, 39 aseptic technique is used. There are two basic types of asepsis: medical and surgical. Medical asepsis includes all practices intended to confine a specific microorganism to a specific, limiting the number, growth, and transmission of microorganisms. In medical asepsis, objects are referred to as clean or dirty. Surgical asepsis, or sterile technique, refers to those practices that keep an area or object free of all microorganisms; it includes practices that destroy all microorganisms and spores. Sepsis is the state of infection and can take many forms, including septic shock. Types of microorganisms causing infections Four major categories of microorganisms cause infection in humans: bacteria, viruses, fungi, and parasites. Bacteria are the most common infection-causing microorganisms. They can live and be transported through air, water, food, soil, body tissues and fluid and inanimate object. Viruses consist of nucleic acid and therefore must enter living cells in order to reproduce. Common viruses include rhinovirus, hepatitis, herpes, and human immunodeficiency virus. Fungi include yeasts and molds. Parasites live on other living organisms. They include protozoa such as thus causes malaria, helminthes, and arthropods. Types of infections -Colonization is the process by which strains of microorganisms become resident flora. In this state, the microorganisms may grow and multiply but do not cause disease. 40 -Infection can be local or systemic. A local infection is limited to the specific part of the body where the microorganisms remain. If the microorganisms spread and damage different parts of the body, it is systemic infection. When a culture of the person’s blood reveals microorganisms, this condition is called bacteremia. When bacteremia results in systemic infection, it is referred to as septicemia. -There are also acute or chronic infections. Acute infections generally appear suddenly or last a short time. A chronic infection may occur slowly, over a very long period, and may last months or years. Nosocomial infections -Are infections that are associated with the delivery of health care services in a health care facility. Nosocomial infection can either develop during a client’s stay in a facility or manifest after discharge. -The microorganisms that cause nosocomial infections can originate from the clients themselves (an endogenous source) or from the hospital environment and hospital personnel (exogenous sources). Most nosocomial infections appear to have endogenous source. Escherichia coli, staphylococcus aureus, and enterococci are the most common infecting microorganisms. Factors contribute to nosocomial infections 1. Iatrogenic infections are the direct result of diagnostic or therapeutic procedures. One example is bacteremia that results from an intravascular line. 2. Compromised host, that is, a client whose normal defenses have been lowered by surgery or illness. 41 3. The hands of personnel are a common vehicle for the spread of microorganisms. Insufficient hand cleansing is thus an important factors contributing to the spread of nosocomial microorganisms. Chain of infection ****** Six links make up the chain of infection (figure 1): 1- Etiologic agent (Microorganism); 2 – the place where the microorganism naturally resides (Reservoir or Source); 3-Portal of exit from reservoir; 4-Method (mode) of transmission; 5-Portal of entry to the susceptible host; 6- Susceptible host 1- Etiologic agent (Microorganism) 6 2 – Reservoir Susceptible host (Source) 5 Portal of entry to the susceptible 3 Portal of exit host from reservoir 4 Method of transmission Figure 1 chain of infection 1. Etiologic agent The extend to which microorganism is capable of producing an infectious process depends on the number of microorganisms present, the virulence and potency of the microorganism, the ability of the microorganisms to enter the body, the susceptibility of the host and the ability of the microorganism to live in the host’s body. 42 2. Reservoir There are many reservoirs, or sources of microorganisms. Common sources are humans, the client’s own microorganisms, plants, animals, or the general environment. People are the most common sources of infection for others and for themselves. A carrier is a person or animal reservoir of a specific infectious agent that usually does not manifest any signs of disease. The anopheles mosquito reservoir carries the malaria parasite but is unaffected by it. Food, water, and feces also can be reservoir. 1. Portal of exit from reservoir Before an infection can establish itself in a host, the micoorganisms must leave the reservoir. Common human reservoirs and their associated portal of exit are summarized in table 1 Body area reservoir Portal of exit Respiratory tract Nose or mouth through coughing, breathing or talking Gastrointestinal tract Mouth :saliva, vomits; anus: feces; ostomies Urinary tract Urethral meatus and urinary diversion Reproductive tract Vagina: vaginal discharge; urinary meatus: semen, urine Blood Open wound, needle puncture site, any disruption of intact skin or mucous membrane surfaces. Tissue Drainage from cut or wound 43 4- method of transmission There are three mechanisms: 1. Direct transmission involves immediate and direct transfer of microorganism from person to person through touching, biting, kissing, or sexual intercourse. Droplet spread is also a form of direct transmission but can occur only if the source and host are within 3 feet of each others. Sneezing, coughing, spitting, singing, or talking can project droplet spray into conjunctiva or onto the mucous membranes of the eye, nose, or mouth of another person. 2. Indirect transmission may be either vehicle-born or vector-borne. 1.Vehicle-borne transmission. A vehicle is any substance that serves as an intermediate means to transport and induce infectious agent into a susceptible host through a suitable portal of entry. Fomites (inanimate material or objects), such as handkerchiefs, toys, soiled clothes, cooking, or eating utensils, and surgical instrument or dressing can act as a vehicles. Water, food, blood, serum, and plasma are other vehicles. 2. Vector-born transmission. A vector is an animal or flying or crawling insect that serves as an immediate means of transporting the infectious agent. Transmission may occur by injecting salivary fluid during biting or by depositing feces or other materials on the skin through the bit wound or a traumatized skin area. 3. Airborne transmission may involve droplets or dust. Droplet nuclei, the residue of evaporated droplets emitted ay an infected host such as someone with tuberculosis, can remain in the air for long periods. The material is transmitted by air currents to a suitable portal of entry, usually the respiratory tract, of another person. 44 4. Portal of entry to susceptible host The skin is a barrier to infectious agents; however, any break in the skin can readily serve as a portal of entry. Often, microorganism entre the body of the host by the same route they used to leave the source. 5. Susceptible host Susceptible host is any person who is at risk for infection. a compromised host is a person at increased risk, an individual who for one or more reasons is more reasons is more likely than others to acquire infection. Examples include age (the very young or very old); clients receiving immune suppression treatment for cancer, for chronic illness, or following a successful organ transplant; and those with immune deficiency conditions. Body defenses against infections Individuals normally have defenses that protect the body from infection. These defenses can be categorized as nonspecific and specific. Nonspecific defenses protect the person against all microorganisms, regardless of prior exposure. Specific (immune) defenses, by contrast, are directed against identifiable bacteria, viruses, fungi, or other infectious agents. Nonspecific defenses include anatomic and physiologic barriers, and the inflammatory response. Anatomic and physiologic barriers Intact skin and mucous membranes are the body’s first line of defense against microorganisms. Nasal passages have a defensive function. As entering air comes in contact with moist mucus membranes and cilia. These trap 45  microorganisms, dust, and foreign materials. The lungs have macrophages (phagocytes) which ingest microorganisms, other cells, and foreign particles. Each body orifice also has protective mechanisms. The oral cavity regularly sheds mucosal epithelium to rid the mouth of colonizers. The follow of saliva and its partially buffering action help prevent infections. The eye is protected from infection by tears, which wash microorganisms away and contain inhibiting lysozome. The gastrointestinal tract also has defenses against infection. The high acidity of the stomach normally prevents microbial growth. Peristalsis tends to move microbes out of the body. Vagina has natural defenses against infection. Low vaginal PH of 3.5 to 4.5 inhibits the growth of many disease producing microorganisms. It is believed that the urine flow has a flushing and bacteriostatic action that keeps the bacteria from ascending the urethra. An intact mucosal surface also acts as a barrier. Inflammatory response Inflammation is local and nonspecific defensive response of the tissues to an injurious or infectious agent. It is an adaptive mechanisms that destroys or dilutes the injurious agent, prevents further spread of injury, and promotes the repair of damaged tissue. It is characterized by five signs: pain, swelling, redness, heat, and impaired function of the part, if the injury is severe. Words with the suffix- itis describe an inflammatory process. For example appendicitis means inflammation of the appendix. 46 Specific defenses Specific defenses of the body involve the immune system. An antigen is a substance that induces a state of sensitivity or immune responsiveness (immunity). If the proteins originate in a person’s own body, the antigen is called an autoantigen. The immune response has two components: antibody-mediated defenses and cell-mediated defenses. Antibody- mediated defenses There are two major types of immunity: active and passive. In active immunity, the host produces antibodies in response to natural antigens (e.g., infectious microorgnisms) or artificial antigens (e.g., vaccines). B cells are activated when they recognize the antigen. They then differentiate into plasma cells, which secret the antibodies and serum proteins that bind specifically to the foreign substance and initiate a variety of elimination responses. With passive (or acquired) immunity, the host receives antibodies produced by another source: natural antibody (from a nursing mother) or artificial antibody (e.g., from an injection of immune serum). Cell-mediated defenses Cell-mediated defenses, or cellular immunity, occur through the T- cell system. On exposure to an antigen, the lymphoid tissues release large numbers of activated T cells into lymph system. These T cells pass into the general circulation. There are three main groups of T cells: helper T cells, which help in the function of immune system; cytotoxic T cells, which attack and kill microorganisms and sometimes the body own cells; and suppressor T cells, which can suppress the functions of the helper T cells and cytotoxic T cells. 47 Factors increasing susceptibility to infection Whether a microorganism causes an infection depends on a number of factors. One of the most important factors is host susceptibility, which is affected by age, hereditary level of stress, nutritional status, current medical therapy, and preexisting disease processes. Age influences the risk of infection. Infections are a major cause of death of newborns, who have immature immune systems and are protected only for the first 2 or 3 months by immunoglobulins passively received from the mother. With advancing age, the immune responses again become weak. Heredity influences the development in that some people have a genetic susceptibility to certain infections. The nature and duration of physical and emotional stressors can influence susceptibility to infection. Stressors elevate blood cortisone. Which decreases anti-inflammatory responses, depletes energy stores, lead to a state of exhaustion, and decrease resistance to infection. Resistance to infection depends on adequate nutritional status. The ability to synthesize antibodies may be impaired by inadequate nutrition, especially when protein reserves are depleted. Some medical therapies predispose a person to infection. for example, radiation treatments for cancer destroy not only cancerous cells but also some normal cells, therapy rendering them more vulnerable to infection. Certain medications also increase susceptibility to infection. antineoplastic (anticancer) medications may depress bone marrow function, resulting in inadequate production of white blood cells necessary to combat infections. 48  Certain antibiotics can also induce resistance in some strain of organisms. Any disease that lessens the body’s defenses against infection places the client at risk. Examples are chronic pulmonary disease, which impairs ciliary action and weakness the mucous barrier and burns which impair skin integrity. Nursing management Assessing Nursing history During the nursing history, the nurse assess (a) the clients at risk of developing an infection through collecting data regarding the factors influencing the development of infection, especially existing disease process, history of recurrent infections, current medications and therapeutic measures, current emotional stressors, nutritional status, and history of immunizations. (b) any client complaints suggesting the presence of an infection. Physical assessment Signs and symptoms of an infection vary according to the body area involved. For example, sneezing, watery and mucoid discharge from the nose, and nasal stuffiness commonly occur with an infection of the nose and sinuses; urinary frequency and possible cloudy or discolored urine often occur with a urinary infection. commonly the skin and mucous membranes are involved in a local infectious process, resulting in the following: 1. localized swelling 2. localized redness 3. pain or tenderness with palpation or movement 49  4. palpable heat at infected area 5. Loss of function of the body part affected, depending on the site and extent of involvement. In addition, open wound may exude drainage of various colors; signs of systemic infection include the following: 1. Fever 2. Increased pulse and respiratory rate if the fever is high 3. Malaise and loss of energy 4. Anorexia and, in some situations, nausea and vomiting 5. Enlargement and tenderness of lymph nodes that drain the area of infection Laboratory data 1. Elevated leukocyte (white blood cell or WBC) count (4,500 to 11,000 /ml is normal. 2. Increased in specific types of leukocytes. 3. Elevated erythrocyte sedimentation rate (ESR). The rate of red blood cells settles increases in the presence of inflammatory process. 4. Urine, blood, sputum, or other drainage cultures that indicate the presence of pathogenic microorganisms. Diagnosing Planning 50 Implementing Nursing intervention that break the chain of infection Link Intervention Etiologic agent -Ensure that articles are correctly cleaned and (microorganism) disinfected or sterilized before use. Educate clients about this. Reservoir - change dressings when they are soiled or wet. (source) - assist clients to carry out hygiene. - dispose soiled linens appropriately. - dispose of feces and urine in appropriate receptacles. - Ensure that fluid containers are covered. The end of the shift. Portal of exit - Avoid talking, coughing, or sneezing over open from the wounds or sterile field, and cover mouth and nose reservoir when coughing and sneezing. Method of - cleanse hands between client contacts, after touching transmission body substances, and before performing invasive procedures or touching open wound. - wear gloves when handling secretions and excretions. - wear gowns if there is danger of soiling clothing with body substances. - place discarded soiled material on moisture-proof refuse bags. - Initiate and implement aseptic precautions for all clients. 51  Factors affecting the body’s heat production: 1. Basal metabolic rate (BMR) is the rate of energy utilization in the body required to maintain essential activities such as breathing. Metabolic rates decrease with age. In general, the younger the person, the higher the metabolic rate. 2. Muscle activity including shivering, increases the metabolic rate. 3. Thyroxine output: increased thyroxine output increases the rate of cellular metabolism throughout the body. This effect is called chemical thermogenesis, the stimulation of heat production in the body through increased cellular metabolism. 4. Epinephrine, norepinephrine, and sympathetic stimulation / stress response. These hormones immediately increase the rate of cellular metabolism in many body tissues. 5. Fever increases the cellular metabolic rate and thus increases the body temperature future. Ways of heat loss Heat is lost from the body through radiation, conduction, convection and vaporization. Radiation is the transfer of heat from the surface of one object to the surface of another without contact between the two objects, mostly in the form of infrared rays. Conduction is the transfer heat from one molecule to a molecule of lower temperature. Conductive transfer cannot take place without contact between the molecules and normally accounts for minimal heat loss expected, for example, when the body is immersed in cold water. Convection is the dispersion of heat by air current. The body usually has a small amount of warm air adjacent to it. This warm air rises 82  and is replaced by cooler air, and so people always lose a small amount of heat through convection. Vaporization is continuous evaporation of moisture from the respiratory tract and from the mucosa of the mouth and from the skin. This continuous and unnoticed water loss is called insensible water loss, and the accompanying heat loss is called insensible heat loss. Insensible heat loss accounts for about 10% of basal heat loss. When the body temperature increases, vaporization accounts for greater than loss. Temperature measurement: health care professionals commonly use the Fahrenheit and Centigrade scales. The Fahrenheit scale is generally used in the United States to measure and report temperature. While the Centigrade scale is used more in scientific research. Nurses are required to use both scales occasionally and convert between the two measurements. To convert Fahrenheit to Centigrade use the formula: C= (F-32) X 5/9. EX. When Fahrenheit reading is 100 C= (100-32) X5/9 = 68 X 5/9 = 37.8 To convert Centigrade to Fahrenheit, use the formula: F=(C X 9/5)+32 EX. When centigrade reading 40 F= (40 X 9/5) +32 = 72+32= 104 Regulation of body temperature The system regulates body temperature has three main parts: sensor in the shell and in the core, an integrator of hypothalamus, and an effector system that adjusts the production and loss of heat. Most sensors and sensory receptors are in the skin. The skin has more receptors for cold than warmth. 83 When the skin becomes chilled over the entire body, three physiologic processes to increase the body temperature take place: 1. Shivering increases heat production. 2. Sweating is inhibited to decrease heat loss. 3. Vasoconstriction decreases heat loss. The hypothalamic integrator, the centre that controls the core temperature, is located in preoptic area of the hypothalamus. When the sensors in the hypothalamus detect heat, they send out signals intended to reduce the temperature, that is, to decrease heat production and increase heat loss. In contrast, when the cold sensors are stimulated, signals are sent out to increase heat production and decrease heat loss. The signals from the cold-sensitive receptors of the hypothalamus initiate effectors, such as vasoconstriction, shivering, and the release of epinephrine, which increases cellular metabolism and hence heat production. When the warmth-sensitive receptors in the hypothalamus are stimulated, the effectors system sends out signals that initiate sweating and peripheral vasodilatation. Also, when this system is stimulated, the person consciously makes appropriate adjustments, such as putting on additional clothing in response to cold or turning on a fan in response to heat. Factors affecting body temperature 1. Age. The infant is greatly influenced by the temperature of the environment and must be protected from extreme changes. Many older people, particularly those over 75 years, are at risk of hypothermia for a variety of reasons, such as inadequate diet, loss of subcutaneous fat, lack of activity, and reduced thermoregulatory efficiency. Elderly are also sensitive to extremes in the environmental temperature due to decreased thermoregulatory controls. 84 2. Diurnal variations (circadian rhythms). Body temperatures normally change throughout the day, varying as much as 1.0˚C between the early morning and the late afternoon. The point of highest body temperature is usually reached between 4:00 PM and 6:00 Pm, and the lowest point is reached during sleep between 4:00 Am and 6:00 AM. 3. Exercise. Hard work or strenuous exercise can increase body temperature to as high as 38.3˚C to 40˚C measured rectally. 4. Hormones. Women usually experience more hormone fluctuations than men. In women, progesterone secretion at the time of ovulation raises body temperature by about 0.3˚C to 0.6˚C above basal temperature. 5. Stress. Stimulation of sympathetic nervous system can increase the production of epinephrine and norepinephrine, thereby increasing metabolic activity and heat production. 6. Environment. Extreme in environmental temperatures can affect a person’s temperature regulatory systems. If the temperature is assessed in a very warm room and the body temperature cannot be modified by convection, conduction, or radiation, the temperature will be elevated. Similarly if the client has been outside in cold weather without suitable clothing, the body temperature may be low. Alteration in body temperature Pyrexia A body temperature above the usual range is called pyrexia, hyperthermia or fever. A very high fever, such as 41˚C is called hyperpyrexia. The client who has a fever is referred to as febrile; the one who doesn’t is afebrile. Four common types of fevers are intermittent, remittent, relapsing, and constant. During intermittent fever, the body temperature alternates 85 at regular intervals between periods of fever and periods of normal or subnormal temperatures, as malaria. During remittent fever as cold or influenza, a wide range of temperature fluctuations (more than 2˚C) occurs over the 24 hours period, all of which are above normal. In relapsing fever, short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature. During a constant fever, the body temperature fluctuates minimally but always remains above normal, as typhoid fever. A temperature that rises to fever level rapidly, following a normal temperature and then returns to normal within a few hours is called a fever spike, as bacterial blood infections. In some conditions, an elevated temperature is not a true fever. Two examples are heat exhaustion and heat stroke. Heat exhaustion is a result of excessive heat and dehydration. Signs of heat exhaustion include paleness, dizziness, nausea, and vomiting, fainting and moderately increased temperature. Persons experiencing heat stroke generally have been exercising in hot weather, have warm flushed skin and do not sweat. They usually have higher temperature and may be delirious, unconscious, or having seizures. Clinical signs of fever Onset (cold or chill phase) Increased heart rate Increased respiratory rate and depth Shivering Pallid, cold skin Complaint of feeling cold Cyanotic nail bed Cessation of sweating 86 Course (plateau phase) Absence of chills Skin that feels warm Photosensitivity Glassy-eyed appearance Increased pulse and respiratory rates Increased thirst Mild to sever dehydration Drowsiness, restlessness, delirium, or convulsions Herpetic lesions of the mouth Loss of appetite Malaise, weakness, and aching muscles Deferevescence (fever Abatement/ flush phase) Skin that appears flushed and feels warm. Sweating Decreased shivering Possible dehydration Nursing intervention for clients with fever Monitor vital signs Assess skin color and temperature Monitor white blood cell count, hematocrit value, and other laboratory reports for indications of infection or dehydration. Remove excess blankets when client feels warm but provide extra warmth when the client feels chilled. Provide adequate nutrition and fluids (e.g., 2500- 300 ml per day) to meet the increased metabolic demands and prevent dehydration. 87  Measure intake and output Reduce physical activity to limit heat production, especially during flush stage. Administer antipyretic as ordered Provide oral hygiene to keep the mucus membranes moist. Provide bath to increase heat loss through conduction Provide dry clothing and bed linens. Hypothermia It is a core body temperature below the lowest limit of normal. The three physiologic mechanisms of hypothermia are (a) excessive heat loss. (b) Inadequate heat production to counteract heat loss, and (c) impaired hypothalamic thermoregulation. The clinical signs of hypothermia Decreased body temperature, pulse, and respirations. Severe shivering Feeling of cold and chills Pale, cool and waxy skin Hypotension Decreased urinary out put Lack of muscle coordination Disorientation Drowsiness progressing to coma Nursing intervention for clients with hypothermia Provide a warm environment Provide dry clothing Apply warm blankets 88  Keep limbs close to body Cover the client scalp Supply warm oral or intravenous fluids Apply warming pads. Pulse ` The pulse is a wave of blood created by contraction of the left ventricle of the heart. Compliance of the arteries is their ability to contract and expand. When a person’s arteries lose their distensibility, as can happen in old age, greater pressure is required to pump the blood into the arteries. Cardiac output is the volume of blood pumped into the arteries by the heart and equals the result of the stroke volume times the heart rate per minute. For example 65 ml x 70 beats per minute = 4.55 L per minute. When an adult is resting the heart pumps about 5 liters of blood each minute. A peripheral pulse is a pulse located away from the heart, for example, in the foot or wrist. The apical pulse in contrast, is a central pulse, that is, it is located at the apex of the heart. It is also referred to as the point of maximal impulse (PMI). In a healthy person, the pulse reflects the heartbeat. However in some types of cardiovascular disease, the heartbeat and pulse rates can differ. For example, a client’s heart may produce very weak or small pulse waves that are not detectable in a peripheral pulse far from the heart. Factors affecting pulse: 1- Age: as age increases, the pulse rate gradually decreases overall. 89 2-Gender: after puberty, the average male pulse rate is slightly lower than the females. 3-Exercise: pulse rate normally increases with activity. The rate of increase in the professional athlete is often less than in the average person because of greater cardiac size, strength, and efficiency. 4-Fever: the pulse rate increases (a) in response to the lowered blood pressure that results from peripheral vasodilatation associated with elevated body temperature and (b) because of the increased metabolic rate. 5-medications: Some medications decrease it and others increase it as digitalis slow heart rate, while epinephrine increase it. 6- Hypovolemia: blood loss increases the pulse rates. In adults the loss of blood volume results in an adjustment of the heart rate to increase blood pressure as the body compensate for the lost blood volume. Adults can usually lose up to 10% of their normal circulating volume without adverse effect. 7- Stress: in response to stress, sympathetic nervous stimulation increases the overall activity of the heart. Stress increases the rate as well as the force of the heartbeat. Fear and anxiety as well as the perception of severe pain stimulate the sympathetic system. 8- Position changes: when a person assumes a sitting or standing, blood usually pools in the dependent vessels of the venous system that results in a transient decrease in the venous blood return to the heart and subsequent reduction in blood pressure and increase in heart rate. 9- Pathology: certain diseases such as some heart conditions or those that impair oxygenation can alter the resting pulse rate. 90 Pulse sites 1. Temporal: Over temporal bone of head, above and lateral to eye 2. Carotid: at the site of the neck between the trachea and sternocleidomastoid muscle. 3. Apical: at the apex of the heart. In an adult this is located on the left side of the chest, about 8 cm to the left of the sternum and at the fourth, fifth or sixth intercostal space. 91 4. Brachial: at the inner aspect of the biceps muscles at of the arm or medially to antecubital fossa. 5. Radial, where the radial artery runs along the radial bone or thumb side of the inner aspect of the wrist. 6. Femoral, where the femoral artery passes alongside the inguinal ligament. 7. Popliteal, where the popliteal artery passes behind the knee. 8. Posterior tibial on the medial surface of the ankle, where the posterior tibial artery passes behind the medial malleolus. 9. Pedal (Dorsalis pedis): over the bone of the foot, on imaginary line drawn from the middle of the ankle to the space between the big and second toes. When assessing the pulse, the nurse collects the following data; the rate, rhythm, volume, arterial wall elasticity, presence or absence of bilateral equality. An excessively fast hart rate (e.g., over 100 BPM in an adult) is referred to as tachycardia. A heart rate in an adult of less than 60 BPM is called bradycardia. If the client has either bradycardia or tachycardia the apical pulse should be assessed. An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a pulse deficit. To assess a pulse deficit you and a colleague assess radial and apical rates simultaneously and then compare rates. The difference between the apical and radial pulse rates is the pulse deficit. The pulse rhythm is the pattern of the beats and the intervals between the beats. Equal time elapses between beats of a normal pulse. A pulse with an irregular rhythm is referred to as dysrhythmia or arrhythmia. When a dysrhythmia is detected, the apical pulse should 92  be assessed. An electrocardiogram is necessary to define the dysrhythmia further. Pulse volume, also called the pulse strength or amplitude, refres to the force of blood with each beat. Usually, the pulse volume is the same with each beat. It can range from absent to bounding. Document the pulse strength as bounding (4+); full or strong (3+); normal and expected (2+); diminished or barely palpable (1+); or absent (0). The elasticity of arterial wall reflects its expandability or its deformities. A healthy, normal artery feels straight, smooth, soft, and pliable. When assessing a peripheral pulse to determine the adequacy of blood flow to a particular area of the body (perfusion), the nurse should assess the corresponding pulse on the other side of the body. The second assessment gives the nurse data with which to compare the pulse. If the client’s right and left pulses are the same, the client’s pulses are bilaterally equal. When a peripheral pulse is located, it indicates that pulses more proximal to that location will also be present. Respiration Respiration: is the act of breathing. Inhalation or inspiration refers to the intake of air into the lungs. Exhalation or expiration refers to breathing out or movement of gases from the lungs to the atmosphere. Ventilation is also used to refer to the movement of air in and out of the lungs. There are basically two types of breathing: costal (thoracic) breathing and diaphragmatic (abdominal breathing). Costal breathing involves the external intercostal muscles and other accessory muscles, such as the sternocleidomastoid muscles. It can be observed by the movement of the chest upward and outward. By contrast, diaphragmatic breathing 93 involves the contraction and relaxation of the diaphragm, and it is observed by the movement of the abdomen, which occurs as a result of the diaphragm’s contraction and downward movement. Mechanics and regulation of breathing During inhalation, the following processes normally occur: the diaphragm contracts, the ribs move upward and outward, the sternum moves outward, thus enlarging the thorax and permitting the lungs to expand. During exhalation, the diaphragm relaxes, the ribs move downward and inward, and the sternum moves inward, thus decreasing the size of thorax as the lungs are compressed. A normal breathing is carried out automatically and effortlessly. Respiration is controlled by (a) respiratory centre in the medulla oblongata and pons of the brain chemoreceptors located centrally in the medulla and peripherally in the carotid and aortic bodies. These centers and receptors respond to changes in the concentrations of oxygen, carbon dioxide, and hydrogen in the arterial blood. Factors affecting respiration Exercise: increases rate and depth to meet the body’s need for additional oxygen and to rid the body of CO2. Acute Pain: Pain alters rate and rhythm of respirations; breathing becomes shallow. Patient inhibits or splints chest wall movement when pain is in area of chest or abdomen. Anxiety: increases respiration rate and depth as a result of sympathetic stimulation. 94 Smoking: Chronic smoking changes pulmonary airways, resulting in increased rate of respirations at rest when not smoking. Body Position : A straight, erect posture promotes full chest expansion. A stooped or slumped position impairs ventilatory movement. Lying flat prevents full chest expansion. Medications Opioid analgesics, general anesthetics, and sedative hypnotics depress rate and depth. Amphetamines and cocaine sometimes increase rate and depth. Bronchodilators slow rate by causing airway dilation. Neurological Injury Injury to brainstem impairs respiratory center and inhibits respiratory rate and rhythm. Hemoglobin Function Decreased hemoglobin levels (anemia) reduce oxygen-carrying capacity of the blood, which increases respiratory rate. Increased altitude lowers amount of saturated hemoglobin, which increases respiratory rate and depth. Abnormal blood cell function (e.g., sickle cell disease) reduces ability of hemoglobin to carry oxygen, which increases respiratory rate and depth. Characteristic of respiration: Rate: (a)bradypnea: slow than normal respiratory rate at rest. (b) normal: 14-24 cycle/minute ©tachypnea: rapid respiratory rate. Rhythm: regular or irregular Depth: deep, normal and shallow. 95 Alteration in breathing pattern Bradypnea : Rate of breathing is regular but abnormally slow (less than 12 breaths/min). Tachypnea: Rate of breathing is regular but abnormally rapid (greater than 20 breaths/min). Hyperpnea: Respirations are labored, increased in depth, and increased in rate (greater than 20 breaths /min) (occurs normally during exercise). Apnea: Respirations cease for several seconds. Persistent cessation results in respiratory arrest. Hyperventilation: Rate and depth of respirations increase. Hypocarbia sometimes occurs. Hypoventilation: Respiratory rate is abnormally low, and depth of ventilation is depressed. Hypercarbia sometimes occurs. Cheyne-Stokes respiration: Respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. Respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth. The pattern reverses; breathing slows and becomes shallow, climaxing in apnea before respiration resumes. Kussmaul’s respiration: Respirations are abnormally deep, regular, and increased in rate. Biot’s respiration: Respirations are abnormally shallow for two to three breaths followed by irregular period of apnea. Dyspnea: difficult and labored breathing during which the individual has a persistent, unsatisfied need for air and feels distressed. Orthepnea: ability to breathe only in upright sitting or standing positions. 96 The peripheral vascular resistance Peripheral resistance can increases blood pressure. The diastolic pressure especially is affected. Some factors that create resistance in the arterial system are the capacity of the arterioles and capillaries, the compliance of the arteries, and the viscosity of the blood. The internal diameter or capacity of arterioles and the capillaries determines in great part the peripheral resistance to the blood. The smaller the space within a vessel, the greater the resistance. Normally, the arterioles are in a state of partial constriction. Increased vasoconstriction, such as occurs with smoking, raise the blood pressure, where decreased vasoconstriction lowers the blood pressure. If the elastic and muscular tissues of the arteries are replaced with fibrous tissue, the arteries lose much of their ability to constrict and dilate. This condition, most common in middle-aged and elderly adults, is known as arteriosclerosis. Blood volume When blood volume decrease (as hemorrhage or dehydration), the blood pressure decreases because of decreased fluid in the arteries. Conversely, when the volume increases (as rapid intravenous infusion), the blood pressure increases because of the greater fluid volume within the circulatory system. Blood viscosity Blood pressure is higher when the blood is highly viscous (thick), that is, when the proportion of red blood cells to the blood plasma is high. This proportion is referred to as the hematocrit. The viscosity increases markedly when the hematocrit is more than 60% to 65%. 98 Factors affecting blood pressure 1. Age. Newborn have a mean systolic pressure of about 75 mm hg. The pressure rises with age, reaching a peak at the onset of puberty, and then tend to decrease somewhat. In elders, elasticity of arteries is decreased- the arteries are more rigid. This produces an elevated systolic pressure. Because the walls no longer retract as flexibly with decreased pressure, the diastolic pressure may also be high. 2. Exercise. Physical activity increases the cardiac output and hence the blood pressure; thus 20 to 30 minutes of rest following exercise is indicated before the resting blood pressure can be reliably assessed. 3. Stress. Stimulation of the sympathetic nervous system increases cardiac output and vasoconstriction of the arterioles, thus increasing the blood pressure; however, sever pain can decrease blood pressure greatly by inhibiting the vasomotor centre and producing vasodilatation. 4. Race. African American males over 35 years have higher blood pressures than European American males of the same age. 5. Gender. After puberty, females usually lower blood pressure than males of the same age; this difference is thought to be due to hormonal variations. After menopause, women have higher blood pressures than before. 6. Medication. Some medications directly or indirectly affect blood pressure. Before blood pressure assessment ask whether the patient is receiving antihypertensive or other cardiac medications, which lower blood pressure. Another class of medications affecting blood pressure is opioid analgesics, which can lower it. Vasoconstrictors and an excess volume of intravenous pressure fluids increase it. 99 7. Diurnal variations. Pressure is usually lowest early in the morning, when the metabolic rate is lowest, then rises throughout the day and peaks in the late afternoon or early evening. 8. Disease process. Any condition affecting the cardiac output, blood volume, blood viscosity, and or compliance of the arteries has a direct effect on the blood pressure. Classification of Blood Pressure Diastolic BP Category Systolic BP MM HG MM HG Normal < 120 and < 80 Prehypertension 120-139 or 80-89 Stage 1 140–159 or 90–99 Hypertension Stage 2 160 or 100 Hypertension From the seventh report of the joint national committee for the detection, evaluation, and treatment of high blood pressure by national institute of health, national heart, lung, and blood institute, 2004 Hypertension A blood pressure that is persistently above normal is called hypertension. A single elevated blood pressure reading indicates the need for reassessment. Hypertension cannot be diagnosed unless an elevated blood pressure is found when measured twice at different time. It is usually a symptomatic and is often a contributing factor to myocardial infraction. An elevated blood pressure of unknown cause is called primary hypertension. An elevated blood pressure of known cause is called secondary hypertension. Individuals with diastolic blood pressures of 80 to 89 mm hg or systolic blood pressures of 120 to 139 mm hg should be 100 considered prehypertensive and, without intervention, may develop cardiac disease. When systolic and diastolic blood pressures fall into different categories, the higher category should be used to classify blood pressure level. For example, 160/80 mmHg would be stage 2 hypertension. Factors associated with hypertension include thickening of arterial walls, which reduces the size of arterial lumen and inelasticity of the arteries as well as such lifestyle factors ass cigarette smoking, obesity, heavy alcohol consumption, lack of physical exercise, high blood cholesterol levels, and continued exposure to stress. Follow up care should include lifestyle changes conducive to lowering the blood pressure as well as monitoring the pressure itself. Life style modification to prevent and manage hypertension Modification Recommendation -Weight reduction Maintain normal body weight (body mass index 18.5–24.9 kg/m2). Adopt DASH (Dietary Consume a diet rich in fruits, vegetables, and Approaches low-fat dairy products with a reduced content to Stop Hypertension) eating of saturated and total fat. plan Dietary sodium reduction Reduce dietary sodium intake to no more than 100 mmol/day (2.4 g sodium or 6 g sodium chloride). Physical activity Engage in regular aerobic physical activity such as brisk walking (at least 30 min/day, most days of the week). Limit consumption to no more than 2 drinks Moderation of alcohol (eg, 24 oz beer, 10 oz wine, or 3 oz 80-proof consumption whiskey) per day in most men and to no more than 1 drink per day in women and lighter- weight people. 101 Hypotension Is a blood pressure that below normal, that is, a systolic reading consistently between 85 and 110 mm hg in an adult whose normal pressure is higher than this. Orthostatic hypotension is a blood pressure that falls when the client sits or stands. It is usually the result of peripheral vasodilatation in which blood leaves the central body organs, especially the brain, and move to the periphery, often causing the person to feel faint. Hypotension can also be caused by analgesics, bleeding, severe burns, and dehydration. It is important to monitor hypotensive clients carefully to prevent falls, when assessing for orthostatic hypotension: Place client in supine position for 10 minutes. Record the client’s pulse and blood pressure. Assist the client to slowly sit or stand. Support the client in case of faintness. Immediately recheck the pulse and blood pressure in the same sites as previously. 102  Follow up activities for Vital signs 1- A patient has a temperature of 40 degree Centigrade and complains of feeling cold. 1- What are nursing problem that patient suffers from and nursing care? 2- Discuss three factors affecting body temperature? II- Multiple Choice Questions 1- Core temperature means:- a- The temperature of the deep tissues b- The temperature of the skin c- The temperature of the subcutaneous tissues d- None of the above 2- Surface temperature means:- a- The temperature of the deep tissues b- The temperature of the skin c- The temperature of the subcutaneous tissues d- None of the above 3- What method of the heat loss? a- Conduction b- Muscle activity c- Basal metabolic rate d- Sympathetic stimulation 4- What integrator responsible for Regulation of body temperature a- hypothalamus, and an effect or system b- Sympathetic system c- Parasympathetic system d- All of the above 5- Intermittent fever means:- a- the body temperature alternates at regular intervals between periods of fever b- the body temperature alternates at irregular intervals between periods of fever c- the body temperature alternates and above normal d- the body temperature alternates among normal range 103  6- A peripheral pulse means:- a- Pulse located away from the heart b- Pulse located at the heart c- Pulse located near from the heart d- None of the above 7- Pulse deficit is difference between a- Apical and radial pulse b- Apical and brachial pulse c- Radial and brachial pulse d- Non of the above 8- An elevated blood pressure of known cause is called a- Hypertension b-Hyperthermia c- Hypotension d- Primary hypertension 9- Why blood pressures decrease during hypovolemia? a- Decreased fluid in the arteries. b- Increase fluid in the arteries. c - Decreased or increase fluid in the arteries. d- All the above 10- What about the rate of blood pressure among prehypertensive patient? a- Systolic BP 120- 139mmhg b- Diastolic BP 80-89mmhg c- a and b d- All the above Part (III) - Read each statement carefully &put (T) if the statement is correct and (F) if the statement is false. 1. Axillary temperature is usually more accurate than rectal temperature. 2. When measuring a patient’s pulse, the nurse should assess its rate, rhythm, quality, and strength. 3. Blood pressure is the force exerted by the circulating volume of blood on the arterial walls. 104  4. Increase cardiac output lead to increase blood pressure. 5. The smaller the vessel lumens size the increase blood pressure. 6. a Thyroxin output increases the rate of cellular metabolism throughout the body. 7. A peripheral pulse is a pulse located near from the heart 8. Hypovolemia means blood loss that decreases the pulse rates. 10. The difference between the apical and radial pulse rates is the pulse deficit. 11. A pulse with an irregular rhythm is referred to as dysrhythmia. 12. Orthostatic hypotension the blood pressure that falls when the client sits or stands. 13.An elevated blood pressure of unknown cause is called secondary hypertension. 14. Pulse pressure is the difference between the diastolic and the systolic pressure. 15.After puberty, females usually lower blood pressure than males. 105