Gerontology Theory: Infection Control and Vital Signs Study Guide

Infection Prevention in the Home and Clinical Setting

Home Cleaning Solutions: The same disinfecting protocols used in hospitals can be applied at home. A standard cleaning solution consists of 1 part bleach to 10 parts water.
High-Touch Surfaces: Patients must be taught to disinfect high-touch surfaces frequently, including banners, railings, and doorknobs.
Sanitation Modes: Modern appliances such as dishwashers and clothes washers often have specific "sanitation modes" that should be utilized to kill bacteria.
Personal Hygiene and Items:
* Toothbrushes: Should be changed every six months. Additionally, they must be replaced immediately after a patient has had a cold or a cold sore breakout.
* Makeup and Compacts: Applicators and products must be cleaned regularly. If an infection occurs (e.g., a skin infection, a sty, or pink eye), all eye and face makeup should be discarded to prevent reinfection.
The Role of Friction: Friction is the primary mechanism for cleaning. Hand hygiene is not simply running water over the hands; it requires soap, water, and vigorous scrubbing to remove bacteria, similar to how scrubbing is required to remove peanut butter from the skin.
Sharps Management in the Home:
* Many patients use sharps for medications like insulin or GLP-1 receptor agonists (e.g., Mounjaro, Zepbound, Ozempic, various semaglutides).
* If a professional sharps container is unavailable, a thick milk jug or a laundry detergent jug can be used. Laundry detergent jugs are preferred because they possess a built-in childproof lock requiring the sides to be squeezed while twisting.

Isolation and Psychological Impact

Cleaning Protocols: Rooms should be cleaned via vacuuming and dusting. Dusting should never be done with a feather duster, as this merely spreads and fluffs the dust. Instead, a wet towel or rag should be used to capture and remove the dust.
Reverse or Protective Isolation: This is used for immunocompromised patients to protect them from external pathogens. Populations requiring this include:
    * Oncology patients (especially those receiving chemotherapy or radiation).
    * HIV/AIDS patients.
    * Autoimmune disease patients.
    * Organ transplant recipients.
Neutropenic Precautions: These are specific to patients with a very low Absolute Neutrophil Count ( $ANC$ ) and low white blood cell ( $WBC$ ) count. Caregivers with even minor illnesses (e.g., a cold) must avoid these patients.
Psychological Effects of Isolation: Isolation can be detrimental to a patient's mental health. Nurses often subconsciously avoid isolation rooms because of the effort required for gowning and gloving.
    * Symptoms of Isolation Distress: Pacing, signs of depression, and claustrophobia.
    * Signs of Depression/Anxiety: Hypersomnolence (oversleeping) or insomnia (inability to sleep), hallucinations, and talking to oneself.
    * Nursing Intervention: Spend extra time with isolated patients. Avoid asking "How do you feel?" (as they likely feel poorly) and instead use therapeutic conversation topics like vacation memories or hobbies.

Healthcare Safety and Bloodborne Pathogens

Bloodborne Pathogen Training: Healthcare providers must undergo annual education regarding disease spread.
Needle Stick Injuries: This is the most common way diseases spread to healthcare providers. Most sticks occur due to "sloppy nursing."
Exposure Protocol:
    1. Report the injury immediately to the charge nurse or manager.
    2. Report to the Emergency Room (ER) or Occupational Health.
    3. Testing: Both the provider and the patient are tested for bloodborne diseases.
    4. Prophylaxis: If the patient is positive, the provider may receive Post-Exposure Prophylaxis ( $PEP$ ), such as Truvada Antivirals. If taken within $72\,hours$ , there is a $99\%$ chance of preventing infection from HIV or Hepatitis.
Defining Exposure:
    * Closed skin contact with blood is not considered an exposure unless there is an open wound (e.g., cracked knuckles in winter).
    * Mucosal membranes (eyes, mouth) are high-risk areas.
    * Pathogen Persistence: HIV is a weak virus that dies within seconds outside the body. Hepatitis is more resilient and can live for $30\,days$ on an inanimate object.

Surgical Asepsis and Sterile Technique

Definition: Surgical asepsis is the highest level of sterility, intended to eliminate all organisms. It is required for procedures involving entry into the body, such as Foley catheter insertion, IV starts, and surgery.
Principles of Sterile Fields:
    * Always open sterile packages away from you first.
    * Never reach or lean over a sterile field.
    * The field must stay at waist height (the area above the hips near the belly button).
    * One must always face the sterile field; turning your back contaminates it because you can no longer guarantee its integrity.
    * The field must be dry; moisture creates a "tunnel" for bacteria to travel from the table to the sterile items.
Surgical Scrub: A specialized hand wash lasting $2$ to $5\,minutes$ per hand. It involves scrubbing the nails and every side of every finger. Hands must be kept upright above the elbows after scrubbing.

Vital Signs: Temperature Regulation

The Five Vital Signs: Temperature, Pulse, Respiration, Blood Pressure, and Pain (required by the Joint Commission). Oxygen Saturation ( $SpO_2$ ) is often considered the sixth.
Heat Production and BMR: Heat is a byproduct of metabolism. The Basal Metabolic Rate ( $BMR$ ) is primarily controlled by the thyroid hormone.
* Hyperthyroidism: Increased thyroid hormone leads to a high $BMR$ . These individuals may eat excessively without weight gain and are heat intolerant.
* Hypothyroidism: Low thyroid hormone leads to a low $BMR$ . These individuals are cold intolerant and struggle with weight loss.
Thermoregulation: Controlled by the Hypothalamus.
    * Pyrexia (Fever): Defined as a temperature above $100.2\,^{\circ}F$ . Moderate fevers ( $101\,^{\circ}F$ to $101.5\,^{\circ}F$ ) in adults are often left untreated to allow the body to "cook out" the infection.
    * Vasodilation: Blood vessels widen and move closer to the skin surface to radiate heat away (cooling).
    * Vasoconstriction: Blood vessels tighten and move toward the body's core to preserve heat (warming).
Heat Loss Mechanisms:
    * Radiation: Heat blowing off the body.
    * Conduction: Transfer of heat to a cold surface (e.g., lying on a cold floor).
    * Convection: Heat loss via air movement (e.g., a fan).
    * Evaporation: Sweating or water drying off the skin (losing approx. $800\,ml$ of fluid daily).
Measurement Sites:
    * Oral: Average $98.6\,^{\circ}F$ . Avoid food/drink/smoking for $30\,minutes$ prior.
    * Rectal (Red Probe): The most accurate; results are $1\,^{\circ}$ higher than oral ( $99.6\,^{\circ}F$ ). Inserted $2\,inches$ using water-based lubricant.
    * Axillary: Under the arm; results are $1\,^{\circ}$ lower than oral ( $97.6\,^{\circ}F$ ).
    * Tympanic: In the ear; excellent indicator of core temperature.

Vital Signs: Pulse and Cardiac Output

Cardiac Function: Initiated by the Sinoatrial ( $SA$ ) node (the pacemaker).
Stroke Volume ( $SV$ ): The amount of blood pushed per contraction, typically $60$ to $70\,ml$ .
Cardiac Output ( $CO$ ): Calculated as $CO = SV \times HR$ . A healthy adult pumps $2,000$ to $3,000\,liters$ per day.
Pulse Rates:
* Normal: $60$ – $100\,bpm$ .
* Bradycardia: < 60\,bpm. * Tachycardia: > 100\,bpm.
Pulse Deficit: The difference between the Apical pulse (heard at the 5th intercostal space, midclavicular line) and the Radial pulse. A significant difference may indicate atherosclerosis or circulation issues.
Pulse Quality Scale:
    * $1+$ : Weak or regular.
    * $2+$ : Strong.
    * $3+$ : Bounding.
    * Thready: Both weak and irregular.
Pulse Sites: Temporal, Carotid (never check both at once), Brachial, Radial, Femoral (largest, located in the groin), Popliteal (behind the knee), Dorsalis Pedis (top of the foot), and Posterior Tibialis (inside the ankle).

Vital Signs: Respirations and Lung Sounds

Regulation: Controlled by the Medulla and the Pons in the brainstem. In healthy people, the drive to breathe is triggered by increased Carbon Dioxide ( $CO_2$ ) levels.
Measurement: One full inhalation and exhalation equals one breath. Count for $30\,seconds$ and multiply by $2$ for normal breathing, or a full minute for irregular breathing.
Respiratory Terms:
    * Eupnea: Normal breathing.
    * Dyspnea: Difficulty breathing.
    * Apnea: Absence of breathing.
    * Cheyne-Stokes: Difficulty breathing followed by periods of apnea.
    * Kussmaul: Deep, gasping breaths often seen in those near death.
Adventitious (Abnormal) Lung Sounds:
    * Crackles: Sound like Rice Krispies or hair rubbing together; indicates fluid.
    * Rhonchi: Rattling/snoring sound caused by partial obstruction.
    * Wheezing: Whistling/harmonica sound (common in asthma).
    * Stridor: Crowing sound indicating a partial airway obstruction (e.g., croup).
Pulse Oximetry ( $SpO_2$ ): Measures infrared light through the capillary bed. Normal range is $90\%$ to $100\%$ . Note that COPD patients may normally sit at $88\%$ . Circulation, cold hands, jaundice, and nail polish can interfere with readings.

Vital Signs: Blood Pressure and Pain

Blood Pressure ( $BP$ ):
    * Systolic: Top number; pressure during heart contraction.
    * Diastolic: Bottom number; pressure while the heart fills.
    * Normal: $120/70\,mmHg$ .
    * Hypertension: > 140/90\,mmHg. Can lead to kidney damage, stroke, and blindness.
    * Hypotension: < 90/60\,mmHg. Common in dehydration or hemorrhage.
Orthostatic Hypotension: A drop of more than $20\,mmHg$ when changing from lying to sitting or sitting to standing positions.
Korotkoff Sounds: The sounds heard while deflating a BP cuff. The first tapping sound is the systolic; the final sound before silence is the diastolic.
Pain (5th Vital Sign): Always subjective ("Pain is what the patient says it is"). Measured on a Likert scale of $0$ (no pain) to $10$ (worst life pain).

Physical Assessment Techniques and Nursing Responsibilities

Types of Assessment:
* Initial/Comprehensive: Detailed, covers all systems and social history. Only a Registered Nurse ( $RN$ ) can perform this.
* Focused/Sequential: Targeted assessment on a specific problem (e.g., checking a broken leg or pneumonia lungs). Licensed Practical Nurses ( $LPN$ ) perform these reassessments.
Assessment Order: Look (Inspection), Listen (Auscultation), and then Feel (Palpation). Percussion is an advanced technique involving tapping.
RNs HOPE Mnemonic:
    * R: Rest and Activity.
    * N: Nutrition and Fluids.
    * S: Safety and Security.
    * H: Hygiene.
    * O: Oxygenation.
    * P: Psychosocial.
    * E: Elimination.
Specific Assessments:
    * Heart Sounds Mnemonic: "All People Enjoy Time Magazine" (Aortic, Pulmonic, Erb's Point, Tricuspid, Mitral).
    * Abdomen: Listen to all four quadrants starting in the Lower Right Quadrant. Normal is $5$ to $30\,sounds/minute$ .
    * Capillary Refill: Should be less than $3\,seconds$ .
    * Weight: Weight gain of $2\,pounds$ in $2\,days$ is indicative of fluid retention, not fat.

Health Promotion: Breast and Testicular Self-Exams

Breast Self-Examination ( $BSE$ ):
    * Should be performed monthly, $3$ to $4\,days$ after the period ends (hormones make breasts lumpy before/during the period).
    * Visually inspect in the mirror: check for symmetry, dimpling (Pead d'orange/orange skin texture), or inverted nipples.
    * Palpation: Arm up, use four fingers to spiral from the armpit (Tail of Spence) to the nipple. Squeeze the nipple for discharge.
Testicular Self-Examination ( $TSE$ ):
* Monthly in the shower. Use three fingers to feel the testicle and spermatic cord for lumps or changes in texture.

Questions & Discussion

Question: What kind of patient needs protective isolation?
* Response: Immunocompromised patients, such as those with HIV, oncology patients on active chemo, or transplant patients.
Question: What is the protocol for a needle stick?
* Response: Report immediately to a charge nurse, go to Employee Health/ER, and test both parties. Prophylactic medication (PEP) is available if the patient is positive.
Question: Is blood splashed on a closed arm considered an exposure?
* Response: Non-intact skin (open wounds) is an exposure; intact, closed skin is not.
Question: Where do we check for pulse in a child?
* Response: Typically the Brachial site is preferred for infants/young children.
Question: Does skin color affect pulse oximetry?
* Response: It does not discriminate based on race, but jaundice (yellowing) or very high bilirubin levels can affect the accuracy.