E1 - Infection control, Vitals, & Nursing Process

The Nursing Process: a framework for critical thinking

1) Assessment

2) Diagnosis

3) Planning

4) Implementation

5) Evaluation

Step 1: Assessment

•Assess data over time for changes (trending)

•Subjective and objective data

-Health Hx & ROS

-Ongoing

-Your Physical Assessment of the patient

-VS, Labs, x-rays, CT scans– any diagnostics

•Organize data

Step 2: Diagnosis

Informally, what do YOU think is going on with the patient?

Step 3: Formulate a Plan

*if you already know what needs to be done, do it (Step 4 = intervene)

As a student, you will be learning interventions each week to help with health concerns in each body system.

Step 4: Intervention

1st, check resources available: current orders, standing orders for overseeing physician, PRN orders, “call the MD if…” pts, if you need an order for an intervention call the MD with all the information you gathered

Step 5: Evaluation

Did our intervention work? → Was it effective in improving the patients status?

Time frame: ex) Tylenol will help the fever now, but other interventions (ABTs) may take a day or two to see improvement.

On-going

We evaluate everything — from water pitchers to active bleeding

ANA Code of Ethics

A set of guidelines established by the American Nurses Association that outlines ethical principles and standards of conduct for nurses, emphasizing patient advocacy, professionalism, and integrity in nursing practice.

Veracity (honesty), Beneficence (benefit others), Non-maleficence (do not harm)

Governing Organizations for Nursing

HIPAA

American Nurses Association (ANA) - Code of Ethics

National Council of State Boards of Nursing (NCBSN)

Occupational Safety and Health Administration (OSHA)

The Joint Commission (TJC)

Center for Disease Control (CDC)

Medical asepsis (clean technique) vs. surgical asepsis (sterile technique)

medical asepsis: reduction of pathogens as much as possible

surgical asepsis: elimination of pathogens completely

Evidence-based Practice

What nursing standards are based on

-systematically conducted research studies

Examples of medical asepsis

handwashing, clean gloves, providing bed baths, perineal hygiene, etc.

Examples of surgical asepsis

creating a sterile filed and donning sterile gloves to insert a urinary cath or perform care of an artificial airway

Asepsis

absence of pathogenic (disease-producing) microorganisms

Surgical Asepsis

aka. sterile asepsis or sterile technique

-ZERO microorganisms present

0% sterile or 100% sterile

“Break” in sterility

Goal: reduce hospital-acquired infections (HAI)

Examples of Breaks in Sterility

Turning your back on the field

Hands fall below the waist

Outside of gloves brush against anything non-sterile

Touching anything non-sterile w/ sterile gloves

Reaching over/under sterile field

What to don with Droplet Precautions

Wear a surgical mask and eye protection

What to don with Airborne Precautions

Wear a fitted N95 respirator and eye protection

What to wear with Contact Precautions

Gown and gloves

Entering a Pts. Room

Wash hands/Hand sanitize: Infection Control

Knock on door/Ask permission to enter if curtain: Privacy/Dignity

Introduce yourself to the pt: Communication

Check the pts. ID band for 2 identifiers: Safety

Building rapport and trust with your patient starts NOW: Respect/Trust

When do we take vitals

-admissions

-initial shift assessment

-q 4 hrs in hospital

-when THEY experience anything that might ALTER them

-when WE do anything that might ALTER them

(procedures, meds, blood transfusion)

Normal temp

97-100.4 F

Normal Pulse/HR

60-100bpm

Normal RR

12-20

Normal BP

120/80 mmHg

Normal O2 sat on room air

95-100

(>93% typically, 90% for COPD)

What makes up the vitals

Temp, Pulse, RR, BP, O2 Sat, Pain

When you see a variance in a vital…

Ask pt: “what is normal for you?”

Check their Hx

it is up to YOU to judge how CRITICAL the variance is

What do you think might be causing it based on the pts. cause??
→ KNOW YOUR PTS BASELINES

Taking a temporal temp. (forehead)

Dry perspiration.

With button pressed and good contact with the skin, sweep across forehead then touch skin behind ear

Taking a Tympanic temp (ear)

Use probe cover, pull ear up and back, then point thermometer towards nose

Taking a rectal temp

PRIVACY!!!!

Use probe cover, lubricate, and insert 1 and ½ inch. DO NOT FORCE

Taking an Oral temp

Wait 15-30 min after eating, drinking, chewing gum, or smoking

-if a mouth breather dont take oral temp

Always use a probe cover!

Taking an axillary temp

Dry perspiration, probe cover, close axilla around probe

Reverse/Protective Isolation “Neutropenic precautions”

-immunocompromised, private room, filtered air

-protecting the pt. from microorganisms bc they have a weak immune system

-taken in addition to standard precautions

-use PPE

Standard/Universal Precautions

-used for ALL patients, all the time

-don PPE if you anticipate contact w/: body fluids, non-intact skin, mucous membranes, equipment with body fluids on it

Examples of contact precautions

Direct pt. or environment contact

ex) VRE, MRSA, C Diff, Scabies, Varicella zoster, RSV

Examples of droplet precautions

droplets >5 microns

spread within 3ft of a pt.

Ex) Flu, Diphtheria, Pertussis, Rubella, some PNAs

Examples of airborne precautions

Droplets <5 microns

Ex) TB, varicella, measles

Donning order

gown, mask, goggles, gloves

Doffing order

gloves, goggles, gown, mask

Factors that can cause variations in vitals

Age, Race, Physical activity, hydration status, medical condition/infection, emotions, position, (orthostatic vitals - “orthostats” → standing, sitting, lying)

lifestyle (smoking, diet, caffeine)

time of day

What pulses are easiest to palpate

carotid and radial

What pulse is most reliable

apical pulse

When attempting to obtain a RADIAL pulse rate, the nurse notes it is irregular. What is the nurse’s next action?

Obtain an apical pulse for 1 full minute

Gathering Respiratory Rate

Assessing thoracic movements of chest + abdomen

1 inspiration + 1 expiration = 1 respiration

Pair with Pulse Oxi (O2 sat)

*if RR is irregular assess for 1 full min

If an extremity is affected by any of the following we should NOT take a blood pressure using that extremity:

IV fluids infusing

Shunt/Fistula

Breast/Axillary surgery

Disease/Trauma

Casts/Bandages

If both brachial arteries are unaccessible to take BP due to various factors, what should we use instead?

Lower extremities

What can cause a False-LOW bp reading

Cuff too large

Deflating too quickly

Arm above heart level

Not adequately inflating

What can cause a False-HIGH bp reading

Cuff too small

Cuff too loose or unevenly applied

Arm not supported

Deflating or inflating too SLOWLY

Arm below heart level

Repeated measurements too quickly

Crossed legs

Helpful tips for taking a BP

Palm facing UP

Cuff can go over thin shirt, stethoscope must be on SKIN
No talking SHUT UPPPP

What are we listening for when taking a BP

The sounds of Korotkoff, which indicate systolic and diastolic blood pressure as the cuff deflates.

Systolic: 1st beat heard, max pressure during beat

Diastolic: Last beat heard, pressure between beats

Taking Pulse Oxi/O2 Sat

-Remove nail polish

-Breathe normally, wait for smooth pleth

*Avoid sites with skin or circulation issues

<90% require immediate intervention

Pain Scales

-patient must have the mental capacity and understanding of what the numbers mean

-Wong Baker FACES pain scale

-Pain assessment in Advanced Dementia Scale (PAINAD)

-Non-communicative patient’s pain assessment instrument (NOPPAIN)

Scope of Practice for Infection Control and Vitals

UAPs adhere to same standard precautions and transmission-based precautions as all health care personnel

RN has the durty to educate/reinforce/remind when needed

→ special considerations

Delegation for Infection Control/Vitals

UAPs can obtain vitals

RN has the duty to notify UAP of…

-appropriate methods of obtaining VS for each patient

-any contraindications of certain methods and parameters to notify you of special considerations

What rate should the sphygmomanometer dial be released at?

2-3mmHg/sec