Fundamentals of Nursing Practice - Hand Hygiene, Vital Signs, and Pain Scaling

Hand Hygiene

Any action of hygienic hand antisepsis in order to reduce transient microbial flora

Hand Rubbing and Hand Washing

2 Classifications of Hand Hygiene

Quarter Size Amount

The amount of soap needed to be applied to the hand during hand washing

2 Happy Birthday Songs

The duration of hand washing, as dictated by a song

Towel

When turning off the faucet after hand washing, we should use _

Before Patient, Before Aseptic Technique, After Body Fluids Exposure Risks, After Patient Contact, and After Contact with Patient surroundings

5 moments for Hand Washing

Pain Assessment

An evaluation of the factors that alleviate or exacerbate patient's pain

Pain

an unpleasant sensory and emotional experience associated with actual or potential tissue damage

Pain

internal subjective experience that cannot be directly observed or measured by use of any physiological measures

Acute Pain

short-term, self-limiting, often predictable trajectory; stops after injury heals. SUDDEN and WITHIN 6 MONTHS

Chronic Pain

episode of pain that lasts for 6 months or longer; may be intermittent or continuous

Neuropathic Pain

pain from damage to neurons of either the peripheral or central nervous system

Nociceptive Pain

pain from a normal process that results in noxious stimuli being perceived as painful. Caused by stimulation of nociceptors

Somatic Pain

Pain that originates from skeletal muscles, ligaments, or joints.

Visceral Pain

pain originating in the internal organs in the thorax, cranium, or abdomen

site, onset, character, radiation, associations, time course, exacerbating/relieving factors, severity

SOCRATES type of questioning for Pain Assessment

Wong-Baker Face Scale

Used for small children with pain

Verbal Descriptive Scale

uses words to describe the patient's feelings and the meaning of the pain for the person

Visual Analog Scale

a pain rating scale using a straight line; the left end of the line represents no pain, the right end represents the worst pain, and patients mark the place on the line that best represents the severity of their pain

Vital Signs

Measurements of the body's most basic functions and useful in detecting or monitoring medical problems.

Vital Signs Assessment

A routine medical procedure, somehow determines internal functions of the body. An indication of the person's condition

Body Temperature

the balance between the heat produced by the body and the heat lost from the body.

oral, axillary, tympanic, temporal, rectal

in what body areas can we measure temperature?

Radiation

transfer of heat through space or without contact

Conduction

The direct transfer of heat from one substance to another substance that it is touching.

Convection

The transfer of thermal energy by the circulation or movement of a liquid or gas

Evaporation

The change of a substance from a liquid to a gas or moisture

Pyrexia, Hyperpyrexia, or Fever

An Increase in body temperature

Febrile

(adj.) feverish; pertaining to or marked by fever; frenetic

Afebrile

Absence of fever

Intermittent Fever

Fluctuating fever that returns to or below baseline then rises again. Alternating body tempt

Remittent Fever

Fluctuating, remains elevated and does not return to baseline. All are above normal

Relapsing Fever

the occurrence short febrile periods of a few days interspersed with periods of 1 or 2 days of normal temperature. The fever will go away then after a few days, it'll go back again.

Constant Fever

a state in which the body temperature fluctuates minimally but always remains above normal

Hypothermia

abnormally low body temperature

Mercury in Glass Thermometer

traditional one and most common used thermometer however, it is hazardous due to exposure to mercury

Electronic Thermometer

a battery-powered thermometer that registers temperature by electronic means.

Chemical Thermometer

contain chemicals that are heat sensitive and include disposable

Temperature Sensitive Strip

It is usually applied on the forehead or abdomen. The tape responds to the heat by changing color.

Infrared Thermometer

Infers temperature by measuring the thermal radiation that an object emits

Tympanic Thermometer

Specialized electronic thermometer that records the aural temperature in the ear.

Sublingual Fossa

This is where the thermometer is place inside the mouth to get the oral temp.

Respiration

Inhalation and exhalation of air.

Internal Respiration

exchange of gases between the blood and the cells of the body

External Respiration

exchange of gases between lungs and blood

Eupnea

Normal Breathing

Bradypnea

slow breathing

Tachypnea

fast breathing

Apnea

absence of breathing

Dyspnea

difficulty breathing

Blood pressure

the pressure that is exerted by the blood against the walls of blood vessels

Korotkoff's Sound

Sounds heard during blood pressure measurement.

Systolic Blood Pressure

the pressure created in the arteries when the left ventricle contracts and forces blood out into circulation

Diastolic Pressure

occurs when the ventricles are relaxed; the lowest pressure against the walls of an artery