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HANDWASHING

1. Hand hygiene is the most effective way to help prevent the spread of organism. The term hand hygiene is now preferred and applies to either handwashing w/ plain soap and water, use of antiseptic handscrubs including alcohol-based products, or surgical hand antisepsis.

2. Two types of bacterial flora are normally found on the hands: Transient Bacteria and Resident Bacteria. Transient bacteria, normally picked up by the hands in the usual activities of daily living, are relatively few (in number and type) on clean and exposed areas of the skin. They are attached loosely on the skin, usually in grease, fats and dirt, and are found in greater numbers under the fingernails. Transient bacteria can be removed with relative ease by washing the hands thoroughly and frequently. Resident bacteria, normally found in the skin, are relatively stable in number and type. They cling tenaciously to the skin by adhesion and absorption, requiring considerable friction with a brush for removal. They are less susceptible to antiseptics than transient bacteria. Transient bacteria may adjust to the environment of the skin when they are present in large numbers over a long period. They then become resident bacteria. If pathogenic organisms become resident bacteria on the skin, the hands then become carriers of the particular organisms. This is the manner how these bacteria effect the transmission of infection.

3. Cleaning agents can reduce the incidence of bacterial transmission by its routine mechanical cleansing of the hands and its removal of most transient bacteria. They also help remove soil because they lower surface tension and act as emulsifying agents in order to reduce the incidence of bacterial transmission.

4. If a health care worker’s hands are visibly soiled or contaminated w/ blood or body fluids, washing the hands w/ soap and water is required. If the hands are not visibly soiled, an alcohol-based hand rub can be used.

5. Most guidelines recommend removing all jewelry except wedding bands, where bacteria tend to accumulate. Rings also increase the likelihood that gloves may tear when donned over the jewelry. Nails are to be kept short, with close attention to the area beneath the fingernails, because most organisms are found under and around the nails. Nail polish does not appear to increase the number of microorganisms as long as the polish is not chipped. A clear polish is preferable to color because the area under the nails is more visible. Artificial nails are not recommended because they harbor more bacteria than natural nails, place the wearer at risk for developing a fungal infection in the nail bed, and are associated with less rigorous scrubbing.

6. Cleansing, disinfection, and sterilization help to break the cycle of infection and prevent disease. Bacterial control via sterilization is different from bacterial control via disinfection. Bacterial control via sterilization is the process by which all microorganisms, including spores, are destroyed while Bacterial control via disinfection destroys all pathogenic organisms except spores.

7. Summary of CDC Recommended Practices for Standard and Transmission Based Precautions Standard Precautions (Tier 1) - Follow hand hygiene techniques. - Wear clean non-sterile gloves. When touching blood, body fluids, excretions or secretions, contaminated items, mucous membrane, and non-intact skin. Change gloves between tasks on the same patient as necessary and remove gloves promptly after use. - Wear personal protective equipment such as mask, eye protection, face shield, or fluid-repellent gown during procedures and care activities that are likely to generate splashes or sprays of blood or body fluids. Use gown to protect skin and prevent soiling of clothing. - Avoid recapping used needles. If you must recap, never use two hands. Use a needle-recapping device or the one-handed scoop technique. Place needles, sharps and scalpels in appropriate puncture-resistant containers after use. - Handle used patient care equipment that is soiled with blood or identified body fluids, secretions and excretions carefully to prevent transfer of microorganisms. Clean and reprocess items appropriately if used for another patient. - Use adequate environmental controls to ensure that routine care, cleaning and disinfection procedures are followed. - Review room assignments carefully. Place patients who may contaminate the environment in private rooms. (such as an incontinent patient)

Transmission - Based Precautions (Tier 2) The ff. precautions are recommended in addition to standard precautions: Airborne Precautions - Use these for patients who have infections that spread through the air, such as tuberculosis, varicella (chicken pox), and rubeola (measles). - Place patient in private room that has monitored negative air pressure in relation to surrounding areas, 6-12 air changes per hour, and appropriate discharge of air outside or monitored filtration if air is recirculated. Keep door closed and patient in room. - Use respiratory protection when entering room of patient with known or suspected tuberculosis. If patient has known or suspected rubeola (measles) or varicella (chicke pox), respiratory protection should be worn unless person entering room is immune to these diseases. - Transport patient out of room only when necessary and place a surgical mask on the patient if possible. - Consult CDC Guidelines for the additional prevention strategies for tuberculosis. Droplet Precautions - Use these for patient with an infections that is spread by large-particle droplets, such as rubella, mumpas, diphtheria, and the adenovirus infection in infants and young children. - Use a private room, if available. Door may remain open. - Wear a mask when working within 3 feet of patient. - Transport patient out of room only when necessary and place a surgical mask on the patient if possible. - Keep visitors 3 feet from the infected person. Contact Precautions - Use these for patients who are infected or colonized by a microorganism that spread by direct or indirect contact, such as MRSA, VRE or VISA. - Place the patient in a private room if available. - Wear gloves whenever you enter the room. Change gloves after having contact with infective material. Remove gloves before leaving the patient’s environment, and wash hands with an antimicrobial or waterless antiseptic agent. - Wear a gown if contact with inbfectious agent is likely or patient has diarrhea, an ileostomy, colostomy or wound drainage not contaminated by a dressing. - Limit movement of the patient out of the room. - Avoid sharing patient-care equipment.

8. Steps in Hand Washing and its Rationale

Step 1. Stand in front of the sink. Do not allow your clothing to touch the sink during the washing procedure. Rationale - The sink is considered contaminated. Clothing may carry organisms from place to place.

Step 2. Remove jewelry, if possible, and secure in a safe place or allow plain wedding band to remain in place. Rationale - Removal of jewelry facilitates proper cleansing. Microorganisms may accumulate in settings of jewelry. If jewelry was worn during care, it should be left on during handwashing.

Step 3. Turn on water and adjust force. Regulate the temperature until the water is warm. Rationale - Water splashed from the contaminated sink will contaminate your clothing. Warm water is more comfortable and has less tendency to open pores and remove oils from the skin. Organisms can lodge in roughened and broken areas of chapped skin.

Step 4. Wet the hands and wrists area. Keep hands lower than elbows to allow water to flow toward fingertips. Rationale - Water should flow from the cleaner toward the more contaminated area. Hands are more contaminated than forearms.

Step 5. Use about 1 teaspoon liquid soap from dispenser or rinse bar of soap and lather thoroughly. Cover all areas of hands with the soap product. Rinse soap bar again and return to soap dish. Rationale - Rinsing the soap before and after use removes the lather that may contain microorganisms.

Step 6. With firm rubbing and circular motions, wash the palms and back of the hands, each finger, the areas between the fingers, the knuckles, wrists, and forearms. Wash at least 1 inch above the area of contamination. If hands are not visibly soiled, wash to 1 inch above the wrists. Rationale - Friction caused by firm rubbing and circular motion helps to loosen dirt and organisms that can lodge between the fingers, in skin crevices of knuckles, on palm and backs of the hands, and on the wrists and forearms. Cleansing less contaminated areas (forearms and wrists) after hands are clean prevents spreading organisms form the hands to the forearms and wrists.

Step 7. Continue this friction motion for at least 15 seconds. Rationale - Length of handwashing is determined by degree of contamination.

Step 8. Use fingernails of the other hand or a clean orangewood stick to clean under fingernails. Rationale - Area under nails has a high microorganism count, and organism may remain under the nails where they can grow and be spread to others.

Step 9. Rinse thoroughly. Rationale - Running water rinses organisms and dirt into the sink.

Step 10. Dry hands, beginning with the fingers and moving upward toward forearms, with a paper towel and discard it immediately. Use another clean towel to turn off the faucet. Discard towel immediately without touching other clean hand. Rationale - Drying the skin well prevents chapping. Dry hands first because they are the cleanest and least contaminated area. Turning the faucet off with a clean paper towel protects the clean hands from contact with a soiled surface.

Step 11. Use lotion on hands if desired. Rationale - Oil-free lotion helps to keep the skin soft and prevents chapping. It is best applied after the patient care is complete and from small, personal containers. Oil-based lotions should be avoided because they can cause deterioration of gloves.

9. Hand washing is considered as a universal precaution because it has many benefits for our body. Through hand washing, we can have a healthy body and a fruitful, long life.

VITAL SIGNS

Body Temperature

1. The normal range of body temperature of adults is 37 degree C.

2. Hypothermic - low body temperature; Hyperthermic - high body temperature 3. A variety of different factors affect body temperature. These factors include: Cicadian Rhythms, Age, Gender, Stress and Environmental Temperatures. Circadian Rhythms are some events in humans that recur at 24-hr intervals, referred to as circadian rhythms (meaning nearly every 24 hrs). Predictable fluctuations in measurements of body temperature and blood pressure are examples of functions that have a circadian rhythm. Through the factor, our temperature (body) varies within 24 hrs. For instance, body temperature is usually about 0.6 degree C (1 degree - 2 degree F) lower in the early morning than in the late afternoon and early evening. Age and Sex also affect Body Temperature. Both the very young and the very old are more sensitive to changes in environmental temperature. The body temperature of infants and children changes more rapidly in response to both heat and cold air temperatures. Older adults loose thermoregulatory control and are at risk for harm from extremes of temperature. Women tend to have more fluctuations in body temperature than men, probably the result of changes in hormones. The increase of progesterone secretions at ovulation increases body temperature as much as one half to one degree. Environmental Temperature also affects our Body Temperature. Most of us respond to changes in environmental temperature by wearing clothing that either allows increased heat loss when it is hot or retains heat when it is cold. When one is exposed to extreme cold without adequate protective clothing, however, heat loss may be increased to the point of hypothermia (low body temperature). Similarly, if one is exposed to extremes of heat for long periods of time, hyperthermia (high body temperature) may result. Both hypothermia and hyperthermia may cause serious illness or death.

4. Physical Effects of Increased Body Temperature - Patients with pyrexia usually experience loss of appetite, headache, hot, dry skin, flushed face, thirst and general malaise. Young children or other people with high fevers may experience periods of delirium or seizure. Observing for other potentially dangerous manifestations of a fever, such as dehydration, decreased urinary output, and rapid heart rate, is an important nursing assessment.

5. Hypothermia (decreased body temperature) is the body temperature below the lower limit of normal. Death may occur when the temperature falls below about 24 degree C (93.2 degree F), but survival has been reported on isolated cases when body temperatures have fallen in the range of severe hypothermia (28 degree C or 82.4 degree F). This may happen to a person drowning in cold water or buried by snow. Rates of chemical reactions in the body are slowed, thereby decreasing the metabolic demands for oxygen.

6. The thermoregulation center of the body is the Skin (or Integument).

7. The part of the brain where temperature is interpreted is the hypothalamus.

8. The time of the day when temperature is highest is in the late afternoon and early evening.

9. The time of the day when temperature is lowest is in the early morning.

10. The two types of temperature are: Increased Body Temperature and Decreased Body Temperature.

11. Surface Temperature: tongue, axilla (armpit) ; Core Temperature -ears, anal canal.

12.

a. from to degree C to degree F

F = [(9/5) (degree C)] + 32 degree

b. from degree F to degree C	C = (5/9) [degree F - 32 degree]

13. Average Normal Temperature for Healthy Adults at Various Sites

Oral	Rectal	Axillary	Tympanic	Forehead 37 C	37.5 C	36.5 C	37.5 C	34.4 C 98.6 F	99.5 F	97.6 F	99.5 F	94 F The average normal tympanic temperature depends on the calibration and mode setting of the tympanic membrane thermometer. Most older children and adults have normal forehead temperature between 93 and 95 degrees F.

14. The thermometer should be kept 15 to 30 minutes.

Respiratory Rate

1. Pulmonary Ventilation - (breathing) is movement of air in and out of the lungs. Inspiration - (inhalation) is the act of breathing in. Expiration - (exhalation) is the act of breathing out. External Respiration - is the exchange of Oxygen and Carbon Dioxide between the alveoli of the lungs and the circulating blood through diffusion. Internal Respiration - is the exchange of Oxygen and Carbon Dioxide between the circulating blood and tissue cells. Apnea - refers to periods during which there is no breathing. Dyspnea - is difficult or labored breathing. Orthopnea - is a condition where Dyspneic people can often breathe more easily in an upright position.

2. Factors Affecting Respiratory Rate, Depth and Movements - Age: The respiratory rate decreases with age, ranging from a normal range of 30-60 breaths/min. in a newborn to 12-20 breaths/min in an adult. - Gender: In males, respiratory movements are primarily diaphragmatic, whereas in women, there is greater intercostals muscle movement. - Exercise: Exercise increases respiratory rate and depth. - Acid-Base Balance: Alterations in Acid-Base Balance (especially acidosis) commonly result in increased rate and depth of respirations (hyperventilation). - Brain Lesions: Lesions of the brain (such us hemorrhage and tumors) or brain stem can cause a change in both the depth and rate of respirations, most commonly manifested as Cheyne - Stokes Respirations. - Increased Altitude: As an adaptation to higher altitudes, healthy people may exhibit Cheyne - Stokes Respirations, especially when asleep. Higher altitudes also increase respiratory rate, depth, prior to adaptation by increasing hemoglobin levels. - Respiratory Diseases: Any alterations in the normal respiratory structures may result in changes in respiratory rate, depth and patterns most often manifested as difficult breathing using accessory muscles of respirations (such as intercostals muscles) and increased rate. The depth may be shallower. Smoking can alter the pulmonary airway, resulting in an increased in respiratory rate at rest. - Anemia: Anemia, a decrease in oxygen carrying hemoglobin, may result in an increased rate of respiration. - Anxiety: Anxiety can cause sighing type of respirations (increase depth) and increase rate. - Medications: Medications such as narcotics, sedatives, and general anesthetic slow respiratory rates and depth. Other drugs, including amphetamines and cocaine may increase rate and depth. - Acute Pain: Acute pain increase respiratory rate but may decrease respiratory depth.

3. Under normal conditions, healthy adults breathe about 12-20 times each minute, whereas infants and young children breathe more rapidly. Normal respiration is called Eupnea. The relationship of one respiration to 4 heart beats is fairly consistent in healthy people. Respiratory rate increases in response to exercise, pain and emotion.

4. Tachypnea, an increased respiratory rate, occurs in response to the increased metabolic rate during fever (pyrexia). Cells require more oxygen at this time and have more carbon dioxide that must be removed. The rate increases as much as 4 beats per minute with every 0.6 degree C (1 degree F) that the temperature rises above normal. Any condition causing an increase in carbon dioxide and a decrease of oxygen in the blood also tends to increase the rate and depth of respirations.

5. Bradypnea, a decreased in respiratory rate, occurs in a response characteristically occurs in some pathologic conditions. An increased in intra cranial pressure depresses the respiratory center, resulting in irregular or shallow breathing, slow breathing, or both. Certain drugs such as narcotics also depress the respiratory rate.

6.

7. Assessing the Respiratory Rate Step 1. While your fingers are still in place after counting the pulse rate, observe the patient’s respirations. Step 2. Note the rise and fall of the patient’s chest. Step 3. Using a watch with a second hand, count the number of respirations for a minimum of 30 sec. Multiply this number by 2 for the respiratory rate per minute. Step 4. If respirations are abnormal in any way, count the respirations for at least 1 full minute. Step 5. Document respiratory rate on paper, the flow sheet or the computerized record. Report any abnormal findings to the appropriate person. Step 6. Perform hand hygiene.

Pulse Rate

1. The pulse rate increases or decreases in response to a variety of physiologic mechanisms. It also might be altered by activity, medications, emotions, pain, heat and cold, and disease processes. The normal pulse rate ranges from 60 to 100 beats per minute.

2. Assessing the Pulse The pulse may be assessed by palpating peripheral arteries or by ausculcating the apical pulse with a stethoscope. The nurse needs to know how to use a stethoscope and which site and method are appropriate.

3. Temporal, Carotid, Brachial, Radial, Femoral, Popliteal, Posterior Tibial and Dorsalis Pedis are the different sites of our body where can we take the pulse rate.

4. Pulse Deficit is a difference between the apical and radial pulse rates.

5. Variations in Pulse Rate, Amplitude, Quality and Rhythm Many factors can affect both the heart rate and volume; however, compensatory mechanisms attempt to maintain a sufficient supply of blood to the cells at all times. For example, when the stroke volume decreases, such as when the blood volume is decreased because of hemorrhage, the heart rate increases to try to maintain the same cardiac output. Conversely, in a physically fit athlete whose heart pumps a maximum volume of blood per stroke, the heart rate may be at the low range or below the range of normal, yet the body cells remain adequately supplied. Therefore, stroke volume and pulse volume affects pulse rate

6. Pulse - is a throbbing sensation that can be palpated over a peripheral artery or ausculcated (listened to) over the apex of the heart. Trachycardia - a rapid rate, decrease cardiac filling time, which, in turn, decreases sroke volume and cardiac output. Bradycardia - is a pulse rate below 60 beats/min in an adult. Dysrhythmia - an irregular pattern of heart beats.

7. Normal pulse - pulsation is easily felt, takes moderate pressure to cause it to disappear.

8. Normal Pulse Rates (Beats per minute) at Various Ages

Age	Approximate Range	Approximate Average Newborn to 1 months	120 - 160	140 1 to 12 months	80-140	120 12 months to 2 yrs. 80-130	110 2 to 6 yrs. 75-120	100 6 to 12 yrs. 75-110	95 Adolescence to Adult	60-100	80

Blood Pressure

1. Blood pressure refers to the force of the blood against arterial walls.

2.

3. Factors Contributing to Blood Pressure Variations in Healthy People - Age: The older adult has decreased elasticity of the arteries, which increases peripheral resistance and therefore increases blood pressure. - Circadian Rhythm: Normal fluctuations occur during the day. The blood pressure is usually lowest on arising in the morning. The blood pressure has been noted to rise as much as 5 to 10 mmHg by late afternoon, and it gradually falls again during sleep. - Sex: Women usually have lower blood pressure than men of the same age until menopause. - Exercise: Systolic blood pressure rises during periods of exercise and strenuous activity. - Weight: Blood pressure is usually higher in people who are obese than in those who are thin. - Emotional State: Emotions, such as anger, fear, excitement, and pain, generally cause the blood pressure to rise, but the pressure falls to normal when the situation passes. - Body Position: A person’s blood pressure tends to be lower in a prone or supine position than when sitting or standing. - Race: Race is a factor in increased blood pressure (hypertension), which is more prevalent and more severe in African-American men and women. - Drugs/Medications: Oral contraceptives cause a mild increase in blood pressure in many women.

4. Korotkoff Sounds - the series of sounds for which the nurse listens when measuring the blood pressure. Phase I. Characterized by a first appearance of pain but clear tapping sounds that gradually increase in intensity; the first tapping sound is the systolic pressure. Phase II. Characterized by muffled or swishing sounds; these sounds may temporarily disappear especially in hypertensive people; the disappearance of the sound during the latter part of phase I and during pahase II is called the auscultatory gap and may cover a range of as much as 40 mmHg; failing to recognize this gap may cause serious errors of underestimating systolic pressure or over estimating diastolic pressure. Phase III. Characterized by distinct, loud sounds as the blood flows relatively freely through an increasing open artery. Phase IV. Characterized by a distinct, abrupt, mopping sound with a soft, flowing quality; in adults, the onset of this phase is considered to be the first diastolic figure. Phase V. The last sound heard before a period of continuous silence; the pressure at which the last sound is heard is the second diastolic measurement.

5. Assessing the Blood Pressure Guidelines for Implementing and Documenting Blood Pressure

Step 1. Identify the patient Step 2. Explain the procedure to the patient. Step 3. Gather equipments. Step 4. Perform hand hygiene. Step 5. Follow the procedure as outlined below. (Guidelines for Assessing Blood Pressure) Step 6. Perform hand hygiene. If gloves are worn, discard them in the proper receptacle. Step 7. Record findings on paper, flow sheet, or computerized record. Report abnormal findings to the appropriate person. Identify sign of assessment if other than brachial.

6. Categories for Blood Pressure Levels in Adults (Ages 18 and older)

Category	Blood Pressure Level (mmHg) Systolic	Diastolic Normal (in regard to risk of heart disease, 	 	 optimal is defined as less than	 	 120/180 mmHg)	<120	<80 High Blood Pressure Prehypertension	120 - 139	80 - 89 Stage 1	140 - 159	90 - 99 Stage 2	greater than and	greater than and equal to 160	equal to 100

7. Blood Pressure Assessment Errors and Contributing Causes

Error

Falsely low assessments                            - Hearing deficit - Noise in the environment. - Viewing the meniscus from above eye level. - Applying too wide a cuff. - Inserting eartips of the stethoscope incorrectly - Using cracked and kinked tubing. - Releasing the valve rapidly. - Misplacing the bell beyond the direct area of the artery. - Failing to pump the cuff 20 - 30 mmHg above the disappearance of                                                                        the pulse.

False high assessments                              - Using a manometer not calibrated at the zero mark. - Assessing the blood pressure immediately after exercise. - Viewing the meniscus from below eye level. - Applying a cuff that is too narrow. - Releasing the valve too slowly. - Reinflating the bladder during auscultation.

Hi mga frends. Kamusta kau dian? Grabe. Ang hirap ng binigay na assignment sa inyo. Pero favorable naman dahil maaga… d kau maxiado mahihirapan unlike nung nakaraan. Xenxia na poh kung hanggang vital signs muna… tsaka na ung iba cguro sa Tuesday na lang yun. Remember this: Bring your notebook with the answers to the guide questions on your first RLE day and submit to your clinical instructor. Related Learning Experience will start on June 10, 2008. You may accomplish guide questions from Handwashing to Vital Signs first. Kindly read on Social Graces as well (no specific reference for this).

so… pwede muna tayong mag submit nang hanggang vital signs. Galingan neo pong lahat. Sna dis material will help you in some ways. Gud luck sa mga AHSE 2nd Yr Students. Yung mga hindi pa nakakabili ng libro…. gamitin neo po muna ung konting help na mai sha2re q. At para dun sa mga nagagalit.. Wag na kayong mag amok plz. lng. D neo din kc aq makikilala. Sori nga pla kung di aq pede magpakilala sa inyo. Madedemanda kc aq ng author ng libro ninyo pate na ang FEU….. Worst un dba? So I’ll keep my personality and self confidential. Dun sa mga tamad, minsan naman sipagan neo… kokopyahin neo nlang 2 ka2tamaran neo pa! Ewan… Basta I’m sure tama lahat yan. Aq pa…… Basta sa Tuesday ko pa ata mai upload ung 2nd part. Yaka neo yan go…. Yung mga magkokoments send lang kau ng msg. s e-mail ko.. Ui ingat kau ha bka mahuli kau. Atin2 lng po ito. Okk? Ingatz kau ulit….

Im also acknowledging Kozier and Erb pati na rin cla Carol Taylor, Carol Lillis and Priscilla Le Mone thanks po sa book na ginawa neo and sori po kung na expose ko sa public ang ilan sa mga page ng buk neo.. mga 2 lng naman e. Higit sa lahat sori po sa FEU… Wag kau mag-alala di neo ko matu2nton kc di nmn aq nag-aaral dian. Wish neo lang PUP toh noh! Kala neo ha? Pero sori po tlga.. mahal kc ng tuition neo. Gusto ko lng nmn matulungan ung iba…. ung mga mahihirap na nag aaral sa inyo.. yung mga di pa nakakabili ng buks. Kaya para sa mga tamad. Swerte neo noh! Sori din sa AHSE office….. Sori den sa IN pinagawa lang to ng cousin ko…. Sori tlga promiz. Ngaung yr lng na toh! O bye mga tol gud luck.