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Chapter 27 & 31 Hygiene & Vital Signs

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At what age does the nurse use a soft toothbrush to provide oral care?
18 months of age to elder years
What precautions does the nurse take when providing oral care to the conscious or unconscious client?
suction at hand tipping the client’s head to the side moistening the interior of the mouth and lips to prevent altered skin integrity....
What is the correct temperature of bath water when bathing a client?
43-46 degC (110-115 degF)
What does the nurse do when needing to bathe a confused or agitated client?
Wait until they are less confused or agitated.
What are the primary causes of body odors?
Bacteria in moist areas of the body
How are odors managed by the nurse?
regular bathing and hygiene
What is the appropriate way for the nurse to provide foot and nail care during bathing?
The appropriate way for the nurse to provide foot and nail care during bathing is to clip the nails straight, and prevent hangnails and in-growns.
What client requires special care when providing nail care?
Diabetics or clients with perepheral vascular disease
How is ear care provided to remove cerumen?
applying irrigate to soften and remove ear wax.
How does bathing change when providing care to elder or infant?
infants are to be sponge bathed and dry immediately and the elderly, due to decreased skin secretions, might need fewer baths.
How does the nurse provide eye care to a client?
by wiping eyes clean of secretions.
How does that process change when providing care to the unconscious client?
This is altered by lubrication and if the client is brain dead, the eyes should be patched and lubricated.
Newborn normal temp?
36.8 (98.2) (axillary)
1 year normal temp?
36.8 (98.2) (axillary)
5-8 year normal temp?
37 (98.6)
10 year normal temp?
37 (98.6)
Teen normal temp?
37 (98.6)
Adult normal temp?
37 (98.6)
Older adult (>70 years) normal temp?
37 (98.6)
Newborn normal pulse?
130 (80-180)
1 year normal pulse?
120 (80-140)
5-8 year normal pulse?
100 (75-120)
10 year normal pulse?
70 (50-90)
Teen normal pulse?
75 (50-90)
Adult normal pulse?
80 (60-100)
Older adult (>70 years) normal pulse?
70 (60-100)
Newborn normal respirations?
35 (30-80)
1 year normal respirations?
30 (20-40)
5-8 year normal respirations?
20 (15-25)
10 year normal respirations?
19 (15-25)
Teen normal respirations?
18 (15-20)
Adult normal respirations?
16 (12-20)
Older adult (>70 years) normal respirations?
16 (15-20)
Newborn normal BP?
73/55
1 year normal BP?
90/55
5-8 year normal BP?
95/57
10 year normal BP?
102/62
Teen normal BP?
120/80
Adult normal BP?
120/80
Older adult (>70 years) normal BP?
Possible increased diastolic
Define Hypothermia
Temp below 36 C or 96.8 F
Define Pyrexia (Febrile)
Temp ranging from 38-41 C or 100.4 to 105.8 F
Define Hyperpyrexia
High temp above 41 C or 105.8 F
Define Bradycardia
pulse under 60 bpm
Define Tachycardia
pulse rate over 100 bpm
Define Bradypnea
abnormally slow respirations (under 12 breaths per minute)
Define Tachypnea (polypnea)
abnormally fast respirations (over 20 breaths per minute)
Define Apnea
Absence of breathing
Define Eupnea
Normal (12-20 bpm),
Define Hypertension
> than normal range,
Define Hypotension
< normal range (systolic b/n 85-100 mmHg.
What are the symptoms of Hypertension (HTN)?
i. BP persistently above normal ii. Usually asymptomatic iii. Predispose pt to heart attack, stroke, & renal disease iv. Can be primary (no known cause) or secondary (known cause).
What is an Irregular rhythm?
Dysrhythmia or Arrhythmia.
What factors influence body heat production?
BMR, Muscle Activity, thyroxine output, epinephrine, norepinephrine, sympathetic stimulation, fever, thermal regulation, age, diurnalvariations/circadium rhythms, exercise, hormones, stress, environment
How does the BMR influence body heat?
dependent upon energy utilization of the body to maintain essential functions; BMR decreases with age.
How does muscle activity influence body heat?
Shivering increases temperature
How does thyroxine output influence body heat?
High levels increase cell metabolism; Low levels decrease cell metabolism
How does epinephrine/norepinpephrine/sympathetic stimulation influence body heat?
Hormones increase cell metabolism; Directly affects liver & muscle cells
How does fever influence body heat?
Increased temperature results in increased cell metabolism rate
How does thermal regulation influence body heat?
Hypothalmus controls the body core temperature; Vasoconstriction, shivering, and release of epinephrine occurs when the body senses cold (This results in increased heat production and cell metabolism).
How does age influence body heat?
Newborn/infants are greatly influenced by temperature & need pretection from cold. Children & Elders-Sensitive to environmental temperature changes and are at risk for hypothermia. Elders have inadequate diet, loss of SQ fat, lack of activity, and reduced thermoregulatory control.
How does exercise influence body heat?
Temp increases with hard work or strenuous exercise
How do hormones influence body heat?
Women body temp increases by 0.3-0.6 degree C (0.5-1.0 degree F) during ovulation due to increased progesterone production.
How does stress influence body heat?
sympathetic nervous system (SNS) can increase the production of epinephrine/norepinephrine, thereby increasing metabolic activity and heat production (i.e icreased temp w/anxious client).
How does the environment influence body heat?
Extremes heat w/out modification causes an increased body temp.
What is normal pulse oximetry?
95%-100%
What do you do for alterations in SaO2 levels?
check to see if reading is consistent with client’s other vitals; determine if the oximeter is functioning properly; make sure it is correctly applied to an appropriate location;
What factors can alter an SaO2 reading?
low hemoglobin levels impaired circulation, hypotension, excess movement, hypothermia, use of vasoconstrictive meds, thickened nails, artificial nails & nail polish
Which SaO2 sensor location is the best and why?
the nose sensor improves accuracy, but it is irritating to a client. Fingers and toes work really well.
When can pulse oximetry be inaccurate?
Low hemoglobin levels, impaired circulation, hyoptension, excess movement, hypothermia, use of vasoconstrictive meds, thickened nails, artificial nails, & nail polish.
What is the correct procedure and methods to take a temperature?
1. Explain to client. 2. Wash hands.. 3. Provide client privacy. 4. Appropriate position placement. 5. Apply protective sheath/probe cover (Lubricate a rectal themometer) Use appropriate thermometer placement 6. Appropriate time. 7. Remove thermometer, discard cover and/or wipr with tissue/alcohol if necessary. 8. Read temp & record. Redo temp if necessary 9. Wash thermometer & return to storage. 10. Document temp in client record.
What is the placement of thermometer for an oral reading?
Place bulb on either side of the frenulum;
What is the placement of thermometer for an axillary reading?
Pat the axilla dry if very moist and place bulb in the center of the axilla;
What is the placement of thermometer for a rectal reading?
Apply clean gloves. Instruct client to take a slow deep breath during insertion. Never force the thermometer if resistance is felt. Insert 1.5 inches in adults and 1 inch in children. Use lubricant.
What is the placement of thermometer for a tympanic reading?
Pull pinna slightly upward and backward (for children pull the pinna back and up). Point the probe slightly anteriorly, toward the eardrum. Insert the probe slowly using a circular motion until snug.
What is the time for an oral/rectal glass thermometer reading?
2-3 min
What is the time for an axillary glass thermometer reading?
6-9 min
What is the time for an electronic/tympanic thermometer reading?
light/sound indicator
What is the time for a chemical dot/tape thermometer reading?
read package
What is the advantage(s) of taking a temp rally?
accessible and convenient.
What is the advantage(s) of taking a temp rectally?
a reliable measurement.
What is the advantage(s) of taking an axillary temp?
safe and noninvasive.
What is the advantage(s) of taking a tympanic temp?
readily accesible, very fast and it reflects the core temperature.
What is the disadvantage(s) of taking a temp rally?
Glass thermometers can break if bitten, it is inaccurate if client had just ingested hot or cold food or fluid or smoked and it could injure the mouth following oral surgery.
What is the disadvantage(s) of taking a temp rectally?
Inconvenient and more unpleasent for clients; difficult for slient who cannot turn to the side; could injure the rectum following rectal surgery. A rectal glass thermometer does not respond to changes in arterial temps as quickly as an oral themometer, a fact that may be potentially dangerous for febrile clients because misleading information may be acquired. Presence of stool may interfere with thermometer placement. If the stool is soft, the thermometer may be embedded in stool rather than against the wall of the rectum.
What is the disadvantage(s) of taking an axillary temp?
The thermometer must be left in place a long time to obtain an accurate measurement.
What is the disadvantage(s) of taking a tympanic temp?
Can be uncomfortable and involves risk of injuring the membrane if the probe is inserted too far. & Repeated measurements may vary. Right and left measurements can differ. Presence of cerumen can affect the reading.
What is the correct technique for taking a pulse rate?
1) Explain to the client what & why. Discuss results. 2) Wash hands. 3) Provide for client privacy. 4) Select the pulse point. Normally-radial pulse; unless circulation to another area needs assessed 5) comfortable resting position for client. 6) Palpate and count the pulse 7) Assess the pulse rhythm and volume.
What pulses can you assess for pulse rate?
brachial, radial, temporal, carotid, femoral, popliteal, posterior tibial, and pedal
What do you do if the radial pulse is not accessible?
Use another pulse site. Temporal, apical
Where is the location of an apical pulse?
Apical, at the apex of the heart.adult-left side of the chest, 8 cm (3 in.) left of the sternum (breastbone) & the fourth, fifth, or sixth intercostals space. 7-9 y.o. apical pulse is located at the fourth or fifth intercostals spaces. < 4 yrs-left of the MCL; 4-6 yrs, at the MCL
What is the significance of taking an apical-radial pulse?
may need to be assessed for clients with certain cardiovascular disorders. Normally, rates are identical. abnormal indicates blood thrust is too feeble to be felt at the peripheral pulse site, can indicate vascular disease is preventing transmission.
What do you do if the apical-radial pulse difference is abnormal?
Promptly report the discrepency to a physician.
What is a pulse deficit?
A discrepancy between the apical and radial pulse rates. In no instance is the radial pulse greater than the apical pulse.
What is the first and second sound heard when taking a BP?
first sound is systolic-pressure (pressure of blood from contraction of heart ventricle); second sound is diastolic-pressure (pressure when the heart ventricles are at rest)
Who is prone to developing a decreased for elevated or elevated BP?
Age-BP increases with age, Exercise-Increases BP (*Wait 20-30 minutes after exercise for BP), Stress, Race-increased in African Americans, Gender, Medications-Antihypertensives decrease BP; Cardiac meds decrease BP; Some meds can increase BP (dopamine), Diurnal Variations-Lowest in morning, Obesity-Increases especially in children, Disease process-Cardiac; Vascular; Conditions affecting blood volume; blood viscosity; Decreased cardiac output (shock i.e absence of O2 to the body systems); Hormonal (Adrenal alterations i.e. epinephrine, norepinephrine)
How do you calculate a pulse pressure and what is the significance of it?
the difference between the diastolic and the systolic pressures. The difference is ideally 40. Higher pulse pressures have been correlated with an increased occurrence of cardiovascular events.
What is a normal pulse pressure?
Ideal difference is 40
What have higher pulse pressures been correlated with?
an increased occurrence of cardiovascular events
24. What are the risk factors for hypertension?
include thickening of the arterial walls (reducuction of the arterial lumen size &arterial inelasticity; also lifestyle factors- cigarette smoking, obesity, and heavy alcohol consumption, lack of physical exercise, high blood pressure
What is cardiac output?
Cardiac output – the volume of blood pumped into the arteries by the heart; = SV *HR/min. For example, 65 mL x 70 bpm = 4.55 L/min
What is stroke volume?
(SV) – the amount of blood ejected with each cardiac contraction
What is ejection fraction?
the ratio of the volume of blood the heart empties during systole to the volume of blood in the heart at the end of diastole expressed as a percentage usually 50- 80 %
How is cardiac output calculated?
Stroke volume times Heart Rate
Describe the factors that affect the vital signs & accurate measurement of them.
Age: older people and infants are greatly influenced by temperature. People over 75 years are at the risk of hyperthermia (below 96.8 or 36o) for a vary reasons like inadequate diet loss of subcutaneous fat lack of activity etc. Diurnal variations (circardian rhythms) temperature change through out the day. It is high in the morning and Afternoon and low at sleeping time (4-6Am). Exercise: hard work or exercise increases the temperature.
Describe other factors that affect the vital signs & accurate measurement of them.
Hormones: women have a more fluctuations than men in there temperature due to hormones change. Secretion of hormones increases the temp. Environment: if the room temperature is high the body temperature will be high and vice versa.
Measurement of vital signs: pulse, respiration, B/P,
PULSE: a wave of blood created by contraction of the left vertical of the heart RESPIRATION: act of breathing Blood PRESURE: the pressure excreted by the blood as it flows
Factors Influcing the body’s heat production & loss
Heat production: basal metabolic rate (BMR) rate of energy utilize in the body required to maintain esstentional activities such as breathing .BMR is decrease with the age. Thyroxin output: stimulation of heat production in the body increase through the metabolism. Hormones: increase rate of cellular metabolism. Fever: increase in cellular metabolic rate increase the body temperature.
Heat Loss:
Radiation: transfer of heat from surface of one object to the other (ex nude person in room temperature loss 60% of body heat) Conduction: transfer heat from one molecule to lower temperature (ex when body immersed in cold water.) Convection: dispersion of heat by air current Vapor ration: continues evaporation of moistures the respiratory tract mucosa of mouth & from the skin.
Name two kind of Body temperature
Core Temperature: is the Temp of the deep tissue of the body such as abdominal cavity pelvic it remains relatively constant. Surface temperature: Temp of the skin the subcutaneous tissue and fat. It raises and falls in response to environment
Compare Oral, tympanic , axillary and rectal temperature .
Oral: refers more quickly affected by food, fluid and smoking. Rectal: very accurate contradicted for diarrhea, rectal surgery clothing disorder or hemorrhoids Axillary: referred for new born, inappropriate for adults with wired jaws oval surgery . Tympanic : tissue of ear canal .core body temp. risk of injury
Explain how to measure the Appical Pulse?
1) Explain to client. 2) Observe infection control. 3) Provide a privacy. 4) Position the client appropriately in comfortable Supine position expose the area of the chest over the apex of the heart. 5) locate the apical impulse (PMI) 6) Insulate and count heart beats (S1 & S2) 7) if rhythm is regular count heart beats for 30 seconds & multiply by 2,if it is irregular count 60 complete sec.8) access the rhythm and strength of the heart beat. 9) document the pulse site ,rate ,rhythm,& volume .
Identify the 9 site to use asses the pulse & state the reason for their use
Temporal: where the temporal artery passes over the temporal bone. It is used when radial pulse is not accessible. Carotid: neck, where the carotid artery . it is used in the case of cardiac arrest (CPR) and circulation Apical: apex of the heart. (left side of the Chest abt 8 cms left of breast bone. Sternum. Used for infants & also used for discrepancies of radial pulse. Popliteal: artires pass behind the knee. It is easy to check the circulation to the lower leg. Pedal (Dorsal): where the dorsal of pedal artery passes over the bones of the foot . It is readily accessible determine the circulation to the foot. Brachial: inner aspects of biceps muscles of the arm. Used in measured the B/P and cardiac arrest of infants Posterior tibal: medial surface of the ankle where the tibial aretery passes. Easy to check circulation
List characteristics that should be included when accessing pulse .
Factors affecting the Pulse: AGE: increase in age lower the pulse rate is Gender: after puberty male pulse lower than females. Fever: pulse are high and B/P is lower vasodilatation high BMR. Exercise: pulse are high due to activity, but athletes is less often than a normal person because of greater cardiac size and strength & efficiency Medication: medications make the low pulse or it may be high Hypovolemia: loss of blood cause the high pulse rate and high B/P. Stress: sympathetic nervous stimulate high pulse; over activity of the heart. Position change: sitting or standing pools the blood flow low and lower the pulse Pathology: certain disease can cause lower pulse.. Impair the oxygen
Describe the mechanism of the breathing & control respiration
During inhalation : Diaphragm contracts & the ribs moves upward & downwards the sternum moves outward that enlarge the thorax and permit the lungs to expand. Exhalation: diaphragm relaxes, the ribs moves downward and inwards and sternum moves inwards decrease the size of thorax.
Identify the components of a respiratory assessment.
Hyperventilation: refers to a very deep ,rapid respirations. Hypoventiliation: refers to vary shallow respiration
Respiratory rhythm:
: refers to very deep ,rapid respiration and the inspiration
Respiratory quality
refers to those aspects of breathing that are different from the normal ,effortless breathing , using breathing does not required efforts but it does than it is known as Labored breathing.
Breathing Patterns:
Rate, Volume, Rhythm, Ease or effort, Breath Sounds Chest movement.
Tachypnea:
quick shallow breathing.
Bradypnea:
abnormal slow breathing
Apnea:
: cessation of breathing
Cheyne stokes breathing:
: rhythmic waxing and waning of respirations, from very deep to very shallow breathing and temporary apnea.
Dyspnea:
: difficult or labored breathing during which the individual has a persistent, unsatisfied need for air and feels distressed
Orthopnea:
ability to breath in upright sitting or standing positions.
Stridor:
: a shrill harsh sound heard during inspiration with larygeal obstruction.
Stertor:
: snoring. Usually due to partial obstruction of the upper airway
Wheeze
: continuous high pitched musical squeak or whistling sound occurring on expiration and sometimes on inspiration when air moves through a narrow obstructed airway.
Bubbling:
gurgling sounds as air passes through the moist secretions in the respiratory tract.
CHEST MOVEMENTS:
intercostals retraction: in drawing between the ribs.
Substernal retraction:
: in drawing beneath the breastbone.
Suprasternal:
indrawing above the clavicles.
SECREATIONS & COUGHING
Hemoptysis: the presence of the blood in the sputum. PRODUCTIVE COUGH: a cough accompany by expectorated secretions NONPRODUCTIVE COUGH: a dry harsh cough without secretions.
BLOOD PRESSURE:
is a measure of the pressure expected by the blood as it flows through the arteries. SYSTOLIC B/P: is the pressure of the blood as a result of contraction of the ventricles and it is the height of the blood wave. DIASTOLIC: is the pressure which is the pressure when ventricles rest. PULSE PRESSURE: the difference between the diastolic and systolic pressure
Describe the various site and methods of Blood Pressure
The blood pressure is usually assessed in the client’s arm using the brachial artery and a std. stethoscope .the following are the conditions when B/P can be asses on the pt. THIGH: if can’t be measured on any arm (due to burns or other trauma) , it can not be measured on thigh in following condition: the shoulder, arm, or hand (the hip, knee or ankle ) is injured or ceased ; a cast or the bandage is on any part of the limb. The client had a removal of the axilla or hip or lymph nodes. The client has a infusion in the limb
Methods of the assessing the B/P
Direct: (invasive monitoring) measurements involves the insertion of the of a catheter in to the brachial or radial or femoral artery. Two invasive indirect methods of B/P anscultatory:is most common method used in the hospitals ,a sphygmonometer a cuff and a stethoscope . it is most accurate way of assessing the B/P.
KOROTKOFF’S Sound
Phase 1: A SHARP TAPPING the pressure level is first faint, clear tapping or thumping sounds that heard. Phase 2 A SWISHING WHOOSHING SOUND the period during deflation when the sounds have a muffled whooshing or swishing quality Phase 3: A THUMP SOFTER THAN A TAPPING the period during the blood flows freely through an increasingly open artery, & sound become more crisper and intense. Phase 4: A SOFTER BLOWING the time when sounds become modified and have a soft , blowing quality. Phase 5: the pressure level when the sound is heard and is follow by a silence.
WHAT ARE THE FACTORS THAT AFFECT THE BLOOD PRESSURE?
Age, Exercise, Stress, Race, gender, medications, Diurnal variations, diseases process.
Factors that affect 02 saturations
Hemoglobin: if the hemoglobin is fully saturated with o2, the SAO2 will appear normal even if the total hemoglobin level is low if the pt is anemic and has an inadequate. 02 supply to the tissue but pulse oximeter would return a normal value. Circulation: the oximeter will not return accurate reading if the area under the sensor has impaired circulation. Activity: shivering or excessive movement of the sensor site may interfere with accurate readings.
What are the 6 Vital signs?
temp., pulse, respiration, BP, Pain, oxygen saturation
When do you take vital signs?
on adm to facility, as sch, before/after surgery, when blood given, chg in current status, with meds that affect card., resp, and temp control
Body temperature definition
difference b/t amt. of heat produced by body and amt. of heat lost to external environment
Normal body temp range
96.8 - 100.4 F
Average oral temp
96.8 F
Which temp. is more reliable
core
What controls body temperature and where is it located?
hypothalmus, middle brain
What happens when there is an increase in temp above a set point?
vasodilatation, sweating
What happens when there is a decrease in temp below a set point?
vasoconstriction, muscle shivering, heat conservation
What is the Basal Metabolic Rate (BMR)?
heat produced by body at absolute rest (sleeping, watching tv)
What can increase BMR by up to 50x's the norm.
Exercise
What can increase BMR 4x's normal?
shivering
What are the 4 types of heat loss?
radiation, conduction, convection, evaporation
What is radiation?
the transfer of heat b/t 2 objects w/o physical contact
What is an example of radiation?
sun, x-ray
What is conduction?
Transfer of heat from one object to another with direct contact
What is convection?
Transfer of heat away from objects
What is an example of convection?
circulating (fans)
What is evaporation?
transfer of energy when liquid is changed to gas
What is an example of evaporation?
sweat, ventilation
What is pyrexia?
fever
What causes pyrexia?
when heat loss mechanisims are unable to keep pace w/ excess heat production resulting in an abnormal rise in body temp
When does a fever become harmful?
over 102 f
Is a single temp reading indictative of a fever?
no
Why is pyrexia important?
it is an immune defense, stimulates WBC production
What is hyperthermia?
elevated body temp r/t body's inability to promote heat loss or reduce heat production
When does hyperthermia occur?
after prolonged heat exposure
What are the s/s of hyperthermia?
N/V hot Dry skin, confusion
Who is most at risk for hyperthermia?
outside workers, elderly
What is hypothermia?
heat loss r/t prolonged cold exposure
What are the s/s of hypothermia?
uncontrolled shivering, loss of memory, depression, poor judgment, sleepy, extremities numb
When a person is hypothermic how low is their temp?
below 93.2 F
What falls when a person is hypothermic?
temp, resp, BP,
How fast should you warm a person with hypothermia?
gradually
Where are the intermittent temp sites?
tympanic membrane, mouth, rectum, axilla, or skin patch
What is the degree difference for rectal temps? axilla temps?
up 0.9 rectal, down 0.9 axilla
What is the F to C formula?
(104F - 32F) x 5/9 (0.56)=40C
What are the types of thermometers?
electronic, disposable, glass/Mercury
What is good about an electric thermometer?
fastest read time
What is good about a disposable thermometer?
single use, good w/ kids
Tell about glass/Mercury thermometer.
slowest, mercury toxic
What is the advantage to a tympanic temp?
sensitive to core temp, unaffected by food/drink
What is the advantage to a oral temp?
fast, easy
What is the advantage to a rectal temp?
reflects core
What is the advantage to an axilla temp?
safe, noninvasive
What is the advantage to a skin temp?
inexpensive
What is the disadvantage to an tympanic temp?
must remove hearing aids and have had no otic sx
What is a disadvantage to oral temps?
no food/drink 30 min before
What is a disadvantage to rectal temp?
no incontinence
What is a disadvantage to a axilla temp?
lags behind core temp
What is a disadvantage to a skin temp?
sweating unusable
What is pulse?
the palpable bounding of blood flow in a peripheral artery
What is the pulse rate?
the amount of pulsing sensations in one minute
HR X SV
cardiac volume
What is the average cardiac volume?
50-75 ml
What are the 4 parts to a stethoscope?
earpieces, tubing, diaphragm, bell
What is the normal pulse rate in an infant?
120-150
What is the normal pulse rate in a school age child?
75-100
What is the normal pulse rate for an adult?
60-100
What is tachycardia
abnormally elevated heartrate over 100
what is bradycardia?
abnormally low HR under 60
What is the normal pulse rhythm?
regular interval between each beat
What is dysrhythmia?
interval interrupted by early or late beats
Pulse deficit?
difference b/t apical and radial pulse
What is the pulse strength?
volume of blood ejected against arterial wall w/ each heart contraction
What are the 4 types of pulse strength?
Thready 1+, Strong 2+, Full 3+, Bounding 4+
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