Vital Signs

- Also known as Cardinal Signs w/c includes body temperature, pulse, respiration's and blood pressure.


A. Body Temperature (36.5C - 37.5C)

- Reflects the balance between the heat produced and the heat lost from the body measured in heats called degrees.

Core temperature- is the temperature of the deep tissue of the bidy, it is under the control of the hypothalamus.

PURPOSE:

• To establish baseline data
• To identify whether the core temperature is with in the normal range.
• To determine changes in the core temperature in response to specific therapies.
• To monitor clients at risk for imbalanced body temperature.

B. Pulse (60 - 100 BPM)

-Is a wave of blood created by contraction of the left ventricle of the heart.

PURPOSE:

• To establish baseline data.
• To identify whether pulse is in the normal range.
• To determine whether pulse rhythm is regular and the pulse volume is appropriate.
• To compare the equality of corresponding peripheral pulse on each side of the body.
• To monitor and assess changes in the client's health status.
• To monitor client's @ risk for pulse alterations.

C. Respirations (16-20 CPM)

-Is the act of breathing.

External Respiration- interchange of gases between aveoli of the lungs and pulmonary blood.

Internal Respiration- interchange of gases between circulating blood and cells of the bdy tissues.


PURPOSE:

• To acquire baseline data.
• To monitor abnormal respiration's and respiratory patterns and identify changes.
• To assess respiration's before the administration of a medication.
• To monitor client's @ risk for respiratory alteraton.

D. Blood Pressure (120/ 80)

-Is the force exerted by the blood against the vessel wall.

Arterial BP- is a measure of the blood as it flows through the arteries.

Sstolic Pressure- pressure of the blood as a result of the contraction of the ventricles.

Diastolic Pressure- the pressure when the ventricles are at rest.

PURPOSE:

• To obtain a baseline measure of arterial BP.
• To determine the client's hemo dynamic status.
• To identify and monitor changes in blood pressure resulting from a disease process and medical therapy.

Total Bed Bathing

Last Monday we had learned how to do total bed bath to a patient. Our prefessor shows us how to do it first then she gave us 30 mins for us to review it then we need to do it as what she did (return demo). Every student spend 20- 30 mins before we finish it. I got 99% in my grade and this grade is for our prelim exam. I ask my self, why is can't get perfect 100% in my fundamentals of nursing?

Bed Making

Purpose:

1. Promote client's comfort.
2. Provide clean and neat environment for the client.
3. Provide smooth, wrinkle- free bed foundation thus minimizing sources of ski irritation.

Considerations:

1. Hold soiled linen away from uniform.
2. Do not shake soiled linen in the air because it can disseminate secretions an micro-organisms they contain.
3. Linen for one client is never placed on another client's bed.
4. To avoid unnecessary trips to the linen supply area, gather all linen before to strip a bed.

Equipments: In order of Use:

1. Bottom sheet- Folded @ right side in
2. Rubber sheet- Folded @ right side in
3. Draw sheet- Folded @ right side in
4. Top sheet- Folded @ wrong side in
5. Pillow case

Surgical Asepsis (Sterile Technique)

Includes procedures to eliminate micro-organisms from an area.


Principles of Aseptic Technique

1. All objects used in a sterile field must be sterile.
2. Sterile objects become unsterile when touched by unsterile objects.
3. Sterile objects can become unsterile by prolonged exposure to airborne micro-organisms.
4. If there's any question or doubt of an item sterility, the items is considered to be unsterile.
5. Once a sterile package is open 1 inch border around the edge are unsterile because the edges are in contact with unsterile surfaces.
6. The skin cannot be sterile and is unsterile.
7. Movement around and in the sterile field must not contaminate the sterile field.
8. Conscientiousness, alertness and honesty are essential guidelines in maintaining surgical asepsis.

Handwashing

- is the vigorous, brief rubbing together of all surfaces of the hands lathered in soap followed by rinsing under a stream of water.



Purpose:

1. To remove soil and transient organisms from the hands.
2. To reduce total microbial counts over time.
3. To prevent pathogenic micro-organisms from spreading patient to patient.
4. To protect the healthcare provider.

Handwashing Should be done in all of the ff:

1. At the beginning of every work shift.
2. Before and after client contact.
3. Before and after the performance of invasive procedure.
4. Before and after handling dressing or touching open wounds.
5. After contact with body substances even when gloves are worn.
6. After handling contaminated equipment.
7. At the end of every shift before leaving the health facility.

CONSIDERATIONS:

• Provide a wide base of support and move closer to the sink during the activity but making sure your clothes doesn't touch the sin.
• Friction, running water and a cleansing agent are necessary to remove micro-organisms or other material that may present on the hands.
• Assemble all articles needed near the sink.
• Use lotion if needed for dry skin although it is not recommended because it is excellent medium for bacterial growth.