Chapter 19- 26

Temperature

Normal adult temperature is 98.6°F (37°C) orally, with a normal range of 96.4°F to 99.1°F (35.8°C to 37.3°C). Older adults may have slightly lower temperatures.

Pulse

Normal pulse rate for adults is 60 to 100 beats per minute (bpm).

Respirations

Normal respiratory rate for adults is 12 to 20 breaths per minute.

Blood Pressure

Normal blood pressure for adults is less than 120/80 mmHg.

Oxygen Saturation (SpO2)

Normal oxygen saturation is 95% to 100%. It is measured using a pulse oximeter.

Tachycardia

Condition where heart rate exceeds 100 bpm.

Tachypnea

Condition where respiratory rate exceeds 20 breaths per minute.

Bradycardia

Condition where heart rate is less than 60 bpm.

Hypertension

High blood pressure, often defined as a reading higher than 130/80 mmHg.

Hyperthermia

High body temperature, typically above 100.4°F (38°C).

Hypotension

Low blood pressure, usually defined as a reading less than 90/60 mmHg.

Hypothermia

Low body temperature, generally below 95°F (35°C).

Pulse Oximeter

A device used to measure oxygen saturation (SpO2) noninvasively by emitting light waves that pass through blood vessels.

Inspection

Physical assessment technique involving visual observation of the patient's overall appearance, including posture, gait, skin color, and signs of illness.

Palpation

Physical assessment technique involving touch to assess skin temperature, texture, moisture, tenderness, or swelling.

Percussion

Physical assessment technique where the nurse taps on the body to assess the size, density, and location of underlying organs.

Auscultation

Physical assessment technique involving listening to body sounds, such as heart, lung, or bowel sounds, using a stethoscope.

Subjective Data

Information collected from the patient, including their symptoms, concerns, and experiences.

Objective Data

Information gathered through observation, physical assessment, and diagnostic tests.

History

Part of a patient encounter where the nurse gathers past medical history, family history, and current medications.

Interview

Structured conversation where the nurse collects subjective data from the patient.

CC (Chief Complaint)

The primary reason a patient seeks healthcare services.

Assessment

Involves a physical examination and the collection of objective data through inspection, palpation, percussion, and auscultation.

Plan of Care

A detailed nursing plan that includes nursing diagnoses, goals, interventions, and evaluations based on the assessment.

Falls

A significant safety risk in healthcare settings, particularly for elderly patients or those with mobility impairments.

Risk Factors for Falls

Include advanced age, a history of falls, impaired mobility, medications affecting balance, and environmental hazards.

Fall Precautions

Interventions such as assessing fall risk, using assistive devices, and keeping the patient's bed in the lowest position to reduce fall risk.

Seizures

A sudden surge of electrical activity in the brain, potentially causing physical manifestations. Types include partial/focal or generalized.

Status Epilepticus

A prolonged seizure, which is a medical emergency requiring immediate intervention.

Seizure Safety Measures

Include staying with the patient, maintaining airway, timing the seizure, and positioning the patient on their side.

Seizure Precautions

Include keeping the bed in a low position, raising side rails, and having oxygen and suction equipment nearby.

Restraints

Devices or medications used to limit a patient's movement, typically used as a last resort.

Physical Restraints

Mechanical devices such as vests, belts, or limb restraints that restrict a patient's movement.

Chemical Restraints

Medications, such as sedatives or psychotropic drugs, used to control a patient's behavior.

Negative Outcomes of Restraints

Include circulation problems, skin damage, mental status changes, respiratory difficulties, and muscle atrophy.

Restraint Prescription Requirements

Include specifying the reason, location, type of restraint, and time limits (e.g., 4 hours for adults).

PRN Orders for Restraints

Orders for restraints on an as-needed basis are not allowed; restraints must be prescribed for specific durations.

Alternatives to Restraints

Include using distractions, environmental modifications, or reducing agitation through family presence or medication.

Medication Administration

Encompasses the process of ensuring safe medication practices, including adhering to the "10 rights of medication administration."

The 10 Rights of Medication Administration

Include the right medication, dose, time, patient, route, assessment, documentation, evaluation, right to refuse, and education.

Strategies for Safe Medication Administration

Include checking labels three times, verifying calculations with a colleague, and educating the patient about their medication.

Infection Control

Refers to practices used to prevent the spread of infection in healthcare settings, including hand hygiene, PPE, and environmental cleaning.

Hand Hygiene

The most effective measure to prevent the spread of infection, involving proper handwashing or use of alcohol-based sanitizer.

Standard Precautions

Include using personal protective equipment (PPE) when there is a risk of contact with blood or body fluids.

Isolation Precautions

Additional precautions implemented based on the mode of transmission of a suspected or confirmed infection.

Environmental Cleaning

Regular cleaning and disinfection of surfaces and equipment to reduce the spread of infections.

Safe Injection Practices

Using sterile needles and syringes for each injection and properly disposing of sharps.

Brachytherapy

A form of internal radiation therapy where radioactive material is placed near the tumor inside the body.

Brachytherapy Safety Precautions

Include placing the patient in a private room, limiting care time, wearing a dosimeter badge, and restricting visitor access.

Handwashing Need

Handwashing is essential before and after patient contact, handling medications, performing invasive procedures, and after contact with body fluids.

Chain of Infection

The sequence of events that must occur for infection to spread: infectious agent, reservoir, portal of exit, transmission, portal of entry, susceptible host.

Infectious Agent

The pathogen responsible for causing infection, such as bacteria, viruses, fungi, or parasites.

Reservoir

The environment where the infectious agent lives and multiplies, which could be a human, animal, or inanimate object.

Portal of Exit

The route through which the infectious agent exits the reservoir, like through respiratory, gastrointestinal, or skin openings.

Mode of Transmission

The way an infectious agent is spread from one host to another, such as contact, droplet, or airborne transmission.

Portal of Entry

The route through which an infectious agent enters a susceptible host, like through the respiratory tract, gastrointestinal tract, or breaks in the skin.

Susceptible Host

A person who is vulnerable to developing an infection due to factors like age, immune status, or other conditions.

PPE (Personal Protective Equipment)

Includes gloves, gowns, masks, and eye protection, used to protect healthcare workers and patients from infection.

Donning PPE

Proper order for putting on PPE includes gown, mask, goggles, and gloves.

Doffing PPE

Proper order for removing PPE includes gloves, goggles, gown, and mask.

Contact Precautions

Used for infections that spread through direct or indirect contact, such as MRSA or C. difficile.

Droplet Precautions

Used for infections spread by respiratory droplets, such as influenza or COVID-19, requiring masks and sometimes face shields.

Airborne Precautions

Used for infections spread through the air, such as tuberculosis, requiring N95 masks and patient isolation in a negative pressure room.

Vector Transmission

Involves the spread of infection via insects or animals that carry the pathogen, such as mosquitoes transmitting malaria.

Common Vehicle Transmission

Involves transmission of infection through contaminated food or water, such as in cases of salmonella or cholera.