Vital Pain Infection ATI Engage Funds Notes

VITAL SIGNS Body temp Fever: body temperature above expected range, upward shift in hypothalmus gland -For adults: greater than 38c or 100.4f (usually infection) S/sx: flushed face, diaphoretic, hot skin, tachycardia & increased resp. rate With fever = Febrile W/o fever= Aferbril Interventions: antipyretic meds, sip cool fluids, remove excess clothes/blankets, decrease environmental temp for heat loss, assess interventions and notify provider if no change Hyperthermia: increase temp due to inability to stop heat production or stimulate heat loss, hypothalaumus cannot regulate temp S/sx: dizziness, weakness, thirst & nausea Untreated: hypotention, syncope, confusion, tachycardia & impaired coordination – organ failure are death to follow Interventions: move to cool area, remove exces clothes, cold packs (neck, axillae, groin), fan decrease body temp via convection, IV fluids decrease temo & hydration, monitor frequently & notify provider of changes Hypothermia: decree in core body temp due to cold exposure, inability to make heat S/sx: shivering, decreases motor skills, impaired peripheral perfusion- continues = confusion, poor concentration, dilated pupils & loss consciousness. Severe= medical emergency, loss of tendon reflex, coma, risk cardiac arrest Interventions: slightly low- warming mat (infants radiant warmer), mild -increase room temp for adding layers of close, hat on head, significant- warming mat/blanket, warm iv fluids (as prescribed), monitor frequesntly and determin effectiveness, let provide know if fails Oral Advantage: easy accessibility, accurate measure surface temp (X): risk of exposure body fluids, innacurate if ate drank smoked 30 min prior, not in new borns, infants, young children (safety concerns) Nurse Steps: apply dispoabel cover, ensure client hasn’t smoked or had anything to eat or drink 30 min prior, ask client to open mouth and raise tongue, put tip of probe in sublingual pocket, instruct to close lips and hold position until temp is displayed, remove probe, toss covering and record in med records Tympanic Membrane Advantage: easy access, less than 5 seconds, accurate core temp, not altered by enviro temp (X): inaccurate w/ cerumen or ear infection, difficult in new borns, infants, and children younfer than 3- anfle of eustachian tube, requires removal of hearing aids Temporal Artery Advantage: easy access, rapid, no inury risk, accurate all age, see rapid changes in core temp (X): affected by skin moisture, innacureat if head covering or hair on forehead Nurse Steps: ensure dry skin, gently move hair or headscarf, place center clients forhead above eyebrow level, start scan and move sensor to temple and touch sensor behind clients ear, measure and record, disinfect thermometer Axillary Advantage: accurate all ages, no injury risk (X): takes more time to obtain, no rapid change detection core temp change, can be alterd by enviro Nurse Steps: remove clothing that hinders access (ensure privacy), apply disposable cover to probe, raise cloents arm, place probe center of axilla and lower arm, and hold position until temp is displayed, remove probe, toss covering and record in med records Rectal Advantage: reliable results (X): risk of injury rectal mucosa, alters due to stool presence, unpleasant, not used w/ diarrhea, hemorrhoids, rectal surgery or coagulation disorders Nurse Steps: ensure privacy, inform client of need, position for access to rectum, cone clean gloves, cover probe and liberally coat with lube, nondominated hand to open buttocks and instruct client to take deep breath, Adults/Adolescents = 1in, infants & children = 1/2in, hold until temp reading, gently remove and wipe clean, return client to comfortable postion, remove gloves and preform hand hygenine, document and disinfect per facility policy Tympanic Thermometer: electronic, measure heat from tympanic membrane, hand-held & uses infrared scanning when inserted into auditoy canal, (highest temp detected) Nurse Steps: disposable cover, pull pinna of ear up and back from 3+, down and back for 3-, thermometer inserted and anterior angle into ear and rotated to fit snug in canal, hold until complete, gentle remove and record Temporal Thermometer: electronic, handheld, infrared tip measure temperature of blood flow through the temp artery (core body temp) Chemical Dot Thermomete: single use or multiuse strip with chemicals sensitive to color change, orally, axilla or rectally if covered Temp-sensitive patch or tape: determins surface temp, contains liquid crystles that change color, apply to dry area, forhead or abdomen, enviro may effect Respiration The act of breathing, inspiration & expiration, cannot occur by self-inflation, can only expand when expansion of the thoracic cavity. Diaphram & intercostal muscles pull ribs up and out during inspiration and relaxation of diaphragm and intercostal muscles relax during expiration Inspiration: intake of air to oxygenate tissues & support cellular function (lungs, bronchi, bronchioles, alveoli) Respiration: expulsion of carbon dioxide from lungs Nurse should take close look at clinets respiratory status, easiest vital sign to measure, bad data can cause serious negative outcomes. Healthy client = minimal effort. Should be assess when client is relaxed and at rest. Respiratory Rate: a count of sets of inspirations and expirations to determine breath per minute Healthy Client; nurse can ausculate respirations and multiply by 2 Unhealthy: should assess for full minute Nurse should not warn client as it may alter clients breathing Eupnea: respiratory rate that is within expected range Newborn – 30-60/min Infant (1mo-1yr) 25-30/min Toddler (1-3yr) 25-30/min Preschooler (3-6yr) 20-25/min School age (6-12yr) 20-25/min Adolescent (12-20yr) 16-20/min Adult (20+ yr) 12-20/min Tachypnea: higher respiratory rate than expected, shallow respirations Caused by: increased physical activity, pain, infection (pneumonia), asthma S/sx: dizziness, tingling hands Intervention: based on underlying casue, analgesic and position change with ice or heat application, asthma treatment is bronchodialator and sitting upright, reevaluate and see if intervetions were effective Bradypnea: lower than expected respiratory range Caused by: various alteration in body function, intracranial pressure, hypothyroidism and shock also alcohol toxicity, opioids or sedatives and morbid obesity S/sx: dizziness, fatigue, weakness, confusion, impared coordination and hold position until temp is displayed, remove probe, toss covering and record in med records Interventions: naloxone (opiod antagonist), decrease pressure in head by eleveating or administering medications, nurse should monitor interventions and evaluate efficacy Apnea: cessation of resperations Caused by: opiod toxicity, trauma, neurologic dysfuction, persistent casues respiratory arrest & medical emergency Intervention: determine if due to altered rhythm, observe abdominal movemnets Cheyne-Stokes: irregular and consist of a cycle pattern of breath from shallow to deep, hyperventilation and episode of apnea Causes: intracranial pressure, brain tumor, stroke and heart failure Kussmal Respirations: regular in rhythm, deep and rapid – labored breathing or respiratory distress Casues: severe metabolic acidosis, diabetic ketoacidosis or severe kidney disease Retractions: use of accessory muscles in neck, substernally, subcostal or intercostal muscles which cause the tissue to be pulled inward during inspiration Oxygen Saturation (SpO2): esitamted oxygen bounf to hemoglobin, 95%-100% Pulse Oximeter: used to measure oxygen saturation Nurse Steps: choose site with adequate capillary refill, <2 seconds, children & adults= finger, newborns and young infants = foot or wrist, make sure finger is dry, no dark nailpolish or acrylics, apply to finger and do not move, leave on for 15-30 seconds Pulse Oximeter Ear Lobe: client of any age, more reliable with decreased peripheral perfusion, steps same as those for finger Adhesive Probe: forhead, foot or wrist, ensure clean dry area and applied snugly and not to inhibit circulation Dyspnea: short of breath or difficulty breathing Hypoxia: not enough oxygen is supplied to tissues S/sx: decrease mental alertness or confusion, hypoxemia- decrease oxygen level in blood Decrease in oxygen saturation can be caused by pneumonia, chronic lung disease, hypothermia or decree in the perfusion die to poor CO, S/Sx: dyspnea, frequent cough, tachycardia, & confusion Nurse Interventions: depends on the underlying cause (SLIGHT) place in upright position and instruct slow deep breaths, cough to remove secretions, provider can prescribe supplmental oxygen and meds, bronchodilatorys to increase SpO2, cloesly monitor (SEVERE) continuous monitoring os SpO2, HR & RR, rhythm and quality, ausculate lungs to monitor change, administer high flow oxygen, continuslous monitor for manifestations of repiratory arrest, ensure intubation equipment ready INFECTION CONTROL & ISOLATION Chain of Infection A sequence of factors needed for an infection to occur Infectious Agent – Reservoir – Portal of Exit from reservoir – Mode of transmission – Portal of entery to enter susceptible host Infectious Agent Bacterium, fungus, virus, parasite, prion Resident flora can be infectious if moves to different place on body Break the chain by destroying infectious agent (disinfecting, sterilizing, cleaning, antimicrobial treatment Reservoir Habitat of infectious agent Animate – people, insects, birds, animals Inanimate – soil, water, food, medical equipment, IV fluids and feces Humans may not show s/sx but can pass along pathogen Break chain by disruptin resevoirs in health care settings (proper hand hygiene, preop skin prep prior surgery, clinical or surgical enviro cleaned properly to prevent infection) Portal of Exit Route by which pathogen leaves reservoir Body orifice- ear, nose, mouth, skin Other- blood or body fluids, gastrointestinal tracts, respiratory tract, skin, others Portal of exit & portal of entery can be same in some cases (flu) Break the chain at portal of exit (careful containment of body fluids, decease body secretions) Modes of Transmission Engaged to move bacteria, viruses, fungi, parasites, prions from place to place Contact, droplet, airborne, vehicle, vector-borne transmission Transmitted by one or more Break transmission with proper barrier devise and hand hygiene Portal of Entry Required to get an infection Orfice- ear, nose, mouth, breaks in muscous membranes, skin) Can be same as exit Invasive lines and devices provide a portal of entry into body Susceptible Host Required for infectious agent to take hold & become resevoir Not everyone exposed becomes ill May be come colonized w/o s/sx and does not cause problems Others show mild s/sx, others die Break link of infection by increase host defense (immunizations, proper nutrition, dietary supplements, proper hygiene, blood sugar control) Determining Factors of Infection Level of immunity @ exposure Healthy- sleeping well, and eating quality foods = better immunity Poor health- little sleep, poor nutrition = less immunity Virulent: how efficient an infectious agent is at making people ill Increased Susceptibility Age, underlying disease, HIV/AIDS, malignanacy, transplants, medications, surgical proceduers, radiations therapy, indwelling devices Modes of Transmission Direct Contact Transmission Micro-organisims (such as herpes) move directly from one person to another person rather than from an object Indirect Contact Transmission From infected person to another person via contaminated object or person PPE can transmit if not disposed of properly or wearing same gloves/mask from patient to patient or not performing hand hygein Droplet Transmissions Infectious droplets travel through air and come in contact with mucosa of host (ex. Influenza/Bordetella pertussis) Sneezing, coughing, singing, talking CPR, endotracheal intubation, chest physiotherapy Airborne Transmission Small particles found in air move into air space of another person carrying infectious agent Particles can travel far and potential for others to inhale Patients places in private room, negative air space (Ex. TB, rubeola, varicella) Some droplet infections (influenza, rotavirus) can be found airborne but do not require negative space, drroplet precautions adequate enough Vehicle Transmission Contaminated items to multiple persons, such as when water becomes contaminates (Ex. E.Coli) Vector-borne Transmission Moquitoes and rats, are not infected but carry micro-organisms from one location or person to indivduals Physical & Chemical Barriers Intact skin most important to fight infection Keep lipid layer on skin intact to reduce water loss & help body fight infection Minimize disruption to skin from chemcials, abrassions, tapes, unintentional injury Nonspecific Immunity Neutrophils and macrophages (WBC) work as phagocytes Specific Immunity Antibodies (immunoglobins) & lymphocytes