L1: Infection Control and Prevention 1.

Biological agents (living organisms invading the

host, like bacteria, viruses, fungi, protozoa and
Key terms rickettsia)
o Aerobic 2. Chemical agents (substances that can interact
with the body like pesticides, food additives,
o Anaerobic
medication, and industrial chemicals)
o Asepsis
3. Physical agents (factors in the environment that
o Colonization
causes disease like heat, light, noise, radiation,
o Cough etiquette
and machinery)
o Disinfection
o Invasive DISEASES CAUSED BY BACTERIA:
o Medical asepsis
o Dental Decay
o Hand hygiene
o Periodontal Disease
o Sterilization
o Pneumonia
o Sterile field
o Rheumatic Fever
o Surgical asepsis
o Syphilis
o Susceptibility
o Tuberculosis
o Vector
o Virulence THE CHAIN OF INFECTION

Pathogens, Infection, and Colonization ● Virulence refers to the degree of strength of

that organism in its ability to produce disease
● Pathogenicity is the ability of a microorganism ● Numbers there must be a high enough number
to produce disease. of microorganism present to overwhelm the
● Microorganisms that cause diseases in humans body’s defenses
are called pathogens. ● Susceptible host is a person who is unable to
● Virulence is the degree of pathogenicity of an resist infection
infection’s microorganism. ● Portal of entry means of entering the body such
● Infection is an invasion and multiplication of as a needle stick
microorganisms in body tissue that results in
cellular injury. A host is a simple or complex organism that can be
affected by an agent.
These microorganisms are called infectious agents.
● A susceptible host is a person who lacks
● Communicable Disease resistance to an agent.
- The result of a communicable agent being ● A compromised host is a person whose normal
transmitted to a client by direct or indirect defense mechanisms are impaired and who is
contact, through a vehicle (or vector) or therefore susceptible to infection.
airborne route
● Colonization is the multiplication of The environment consists of everything other than the
microorganisms on or within a host that does agent and host.
not result in cellular injury. ● Water, food, plants, animals
● Flora are the vegetation of microorganisms on ● Housing conditions
the human body. ● Noise
- Resident flora ● Meteorological conditions
- Transient flora ● Environmental chemicals
Agent, Host, and Environment Infection Chain
Agents capable of causing disease: ● Microorganism (infectious agent)
● Source or reservoir
 ● Portal of exit from reservoir - Respiratory
● Mode of transmission - skin mucous membrane or wounds
● Portal of entry into host ● Transmission of disease from the host;
● Susceptible host - touching, kissing, and sexual intercourse

Infectious Agents (Microorganisms)

Agents that produce infections can consist of:

● bacteria
● viruses
● fungi
● protozoa
● rickettsia

Resident Infectious Agents

The ability of a microorganism to infect a client is
related to:

● Virulence of the agent

● Number of microorganisms’ present
● Ability of the agent to enter and live in the client by Direct Contact
● Susceptibility of the client - Skin, mucus membranes, urine, feces,
Microorganisms which are always present on skin. reproductive tract, blood by Direct
Contact
Can be reduced through handwashing, but not totally ● Occurs with the use of vehicles and vectors by
removed. indirect Contact
Transient Infectious Agents - Toys, hospital supplies, instruments,
dishes, cups, or surgical dressings, food,
● Agents that are picked up by the skin from fluids, blood -by Vehicles (fomites)
another person or object. ● Transmission of infectious agents through
● Attach themselves to the skin and then may be coughing, sneezing, dust particles - Airborne
transmitted to a susceptible host. Transmission
● Usually entry via the person’s respiratory tract
Reservoir
How to prevent Airborne Transmission
● Required for the microorganism to survive while
awaiting a host. ● door to remain shut
● May allow the organism to multiply, making it ● use mask with high efficiency particulate air
more dangerous. (HEPA) filter
- The human body is the most common ● clients transport must be limited
reservoir. ● clients wear mask during transport
- Food, plants, animals, and feces are
other common reservoirs Mode of Transmission

Portal of Exit ● Contact

● Airborne
● Pathway by which pathogens leave the body of ● Vehicle (fomites)
a host. ● Vectorborne
- Blood
- intestinal tract Portal of Entry
 ● Pathway by which infectious agents gain access ● The immune defense is categorized as
to the body Nonspecific and specific immune defenses work
in harmony to defend the host from pathogens.
Susceptible Host
Nonspecific Immune Defenses
● A person with a reduced immune response has
increased susceptibility. ● Protect the host from all microorganisms
● The immune response is the body’s natural ● Not dependent on prior exposure to the antigen
defense against infection.

Factors Influencing Production of an Infectious Disease

● Skin
● Age - Intact skin is the body’s first line of
- The elderly and children under two defense against infection.
years of age are at greatest risk. - Sebum is produced by the skin and
● Heredity contains fatty acids that kill some
- Conditions or diseases resulting in the bacteria.
absence of or inability to form immune ● Normal Flora
defenses. - Normal flora residing on the skin
● Stress compete with pathogenic flora for food
- Increase in metabolic rate which results and inhibit their multiplication.
in using up stored energy - Inappropriate antibiotic use may disrupt
- Elevation of blood cortisol, decreasing the balance of normal flora.
anti-inflammatory responses ● Mucous Membranes
- Continued stress produces exhaustion, - Mucus entraps infectious agents and
further depleting ability to ward off contains substances that inhibit
infection bacterial growth.
● Surgery - Cilia trap and propel mucus and
- Eliminates primary barrier of infection. microorganisms away from the lungs.
- Predisposes clients to surgical site ● Sneeze, Cough Reflexes
infections. - Physically expel mucus and
- Localized infection at wound site can microorganisms from the respiratory
progress to a systemic infection. tract and oral cavity with force
- Additional risks include catheters and ● Tearing Reflexes
tubes. - Protects the eyes by continually flushing
● Nutrition away microorganisms
- Insufficient protein consumption ● Elimination and
reduces antibody production and ● Acidic Environment
inhibits the body’s ability to ward off - Resident flora of the large intestines
infection. - Mechanical process of defecation
● Health Status - Flushing action of urination
- Clients with disease of their immune - Acidic environment of urine and vagina
system are at greater risk. ● Inflammatory Response
- Chronic diseases can predispose the - Tissue injury caused by bacteria,
client to infection. trauma, chemicals, heat, or any other
phenomenon
Normal Defense Mechanisms - Release of substances that produce
● Our body’s immune system serves as the secondary changes in the tissue
normal defense mechanism.
Overview of Immunity
- It has the ability to recognize “self” host
and “nonself” the antigents
The immune system is generally divided into INNATE 4 Stages of infection
and ACQUIRED
● Incubation period
● Innate immunity(nonspecific) - time between the infection agents enter
- Inherent within a species and develops in the host and the onset of symptoms.
regardless of exposure also called - the agent invades the tissue and started
Natural immunity. to multiply.
● Acquired immunity - Ex. chicken pox 1-12 days, common
- Not present at birth develops as a result colds 1-2days, influenza 1-5 days;
of exposure or through external source, mumps 12-26days
like colostrum ● Prodromal stage
- and. Injection of immunoglobulin - time interval from onset of nonspecific
- Also called adaptive or specific. – until the specific symptoms of the
because it develops and changes in infectious process begins to manifest.
response to the specific antigen. The agent continuously multiplying, the
● Adaptive immune responses and considered client now is infectious (like malaise,
either low grade fever, fatigue)
● Humoral-mediated – immunity that is mediated - ex. Herpes simplex begins with itching
by B lymphocytes, plasma cell and antibodies and tingling at the site before the lesion
● cell mediated immunity - refers to immunity appears.
mediated by T lymphocytes.
● the innate immune system can eliminate some Prodromal stage
threats by itself but if many invaders either HEALTH PROMOTION BEHAVIORS IS ENCOURAGED:
overwhelm it or evade detection, in these case
the adaptive immune system is required. ● Hand washing
- it takes 4-10 days for the adaptive ● avoid touching eyes, mouth, nose
immune system to response, but once ● have good sleep habits, rest period.
developed the adaptive immune system ● maintain a well hydrated state, including fruits
will retain some of its effectors cells as and vit, C rich food.
memory cells, so if one has subsequent ● practice stress management activity
exposure, the adaptive immune system ● eat a balance diet.
can mount response immediately.

Overview of Immunity ● Illness stage

● Antigen – are molecule that caused antibodies - when the client is manifesting specific
to generated, and it needs an immunogen - a symptoms of an infection.
molecule to elicit an immune response (viruses, - ex. strep throat is manifested by sore
bacteria, pollen, toxins, transplanted organs etc. throat, pain &swelling; mumps is
manifested by high fever, parotid gland
Localized versus systemic infections enlargement or swelling.
● Convalescence stage:
Systemic means affecting the entire body, rather than a
- Interval when acute symptoms of
single organ or body part.
infection disappear
● For example, systemic disorders, such as high - recovery depends on the severity of
blood pressure, or systemic diseases, such as infection and patients’ host resistance;
influenza, affect the entire body. may takes several days to months.
● an infection that is in the bloodstream.
Anatomy of the Immune System
● Localized infection that has not spread but
remains contained near the entry site. ● Physical barriers
● Leukocytes
 ● Monocytes-macrophages - Practices to reduce the number, growth,
● Dendritic cells and spread of microorganisms
● Mast cells o The most common cause of
● Granulocytes nosocomial infections is
● Natural killer cells contaminated hands of health
● Lymphocytes care providers.
- B lymphocytes and antibodies o Wash hands before and after
- T lymphocytes every client contact.
Primary Lymphoid Organs Handwashing
Secondary lymphoid tissue ● Rubbing together of all surfaces and crevices of
● Spleen the hands using a soap or chemical and water.
● Lymph nodes - Three elements: Soap/Chemical, Water,
● Epithelial lymphoid tissue and Friction
● Surgical Asepsis
Chemical Components - Practices that eliminate all
microorganisms and spores from an
● Cytokines
object or area:
● Chemokines
o Sterile field
● Complement
o Donning sterile gloves
Physiology of the Immune System o Donning surgical attire
o Surgical handwashing
● Innate Immune Response
o Gowning and closed gloving
● Adaptive Immunity
● Cell-Mediated Immune Response Reduce or Eliminate Infectious Agents
● Humoral-Mediated Immune Response
● The Total Immune Response Infection control practices to break the chain of
● Immunological Memory infection

Nosocomial Infections ● Cleansing

- Removal of soil or organic material from
● Infections acquired in a health care setting that instruments and equipment used in
were not present or incubating at the time of providing care
the client’s admission - Water, mechanical action, detergent
● Disinfection
Procedures identified as possible sources of infection
- Elimination of pathogens, except
are:
spores, from inanimate objects
● Inadequate handwashing - Use of germicides and antiseptics.
● Catheterization technique ● Sterilization
● Improper suctioning technique - Methods used for total elimination of all
● Improper dressing-change technique microorganisms including spores are:
● Contamination of closed drain system - Moist heat or steam (autoclave, boiling
water)
Ensure Asepsis
o Radiation
● Asepsis o Chemicals
- is the absence of microorganisms. o Ethylene oxide gas
● Aseptic technique
Home Health Care Considerations
- is the infection control practice used to
prevent the transmission of pathogens. ● Adapting acute care infection control practice to
● Medical Asepsis the home care setting involves:
 - Cleaning and disinfecting equipment - Specific follow-up for blood-borne
- Using clean versus sterile technique pathogens
- Handling of the nursing supply bag - Post exposure prophylaxis only in cases
of highest risk
Disposal of Infectious Waste in the Home
Alternative Therapies Used to Treat Infections
● Biological Hazard Symbol
● OSHA Regulations ● Herbal Products
- Antimicrobial action
Guidelines for Standard Precautions
- Augment and vitalize the body’s own
● Barrier Precautions defenses
- Use of masks, gowns, and gloves to ● Client’s alternative practices should be
minimize the risk of exposure to blood documented.
and body fluids ● Possible adverse reactions are possible when
● Body Substances used with prescribed drugs.
- Blood
PATHOGENS
- All body fluids
- Secretions ● clostriduim perfringers
- Contaminated items regardless of ● escherichia coli
whether or not they contain visible ● staphylococcus aureus
blood ● clostridium difficile
- Nonintact skin ● Mycobacterium tuberculosis
- Mucous membranes ● neisseria gonorrhoeae
● hepa A virus
Role of Health Care Personnel and Health Agencies in
● hepa B virus
Infection Control
● Hepa c
● Mask and eye protection or face shield ● HIV
● Non-sterile gown ● herpes simplex
● Tuberculosis masks ● virus -type1
● Isolation precautions initiated when positive ● aspergillus organism
cultures from a draining wound are reported ● candida albicans
● Reinforce adherence to isolation. ● plasmodium
● Post signs indicating type of isolation. ● falciparum
● Provide necessary supplies.
● Place clients in a private room with adequate
Health Care Associated Infections(HAIs)
ventilation. ● are called nosocomial or health-care acquired
● Use disposable supplies and equipment. infections- results from the delivery of health
● Labeling of all articles leaving the room services in a health care facility. – due to
● Use of impermeable bags or double bagging invasive procedures, antibiotics administration,
● Client and family instruction the presence of multi-drug resistant organisms
● Alert to psychological discomfort and break in infection control and prevention.
● In the intensive care unit(ICU) uses of IV, urinary
catherter so meticulos hand hygiene partices is
● Blood-Borne Pathogen Exposure needed to prevent infection.
- OSHA requires that all health agencies
make available the hepatitis B vaccine Type of infections:
and vaccination series to all employees. ● Iatrogenic infection
● Exposure Control Plan - from a diagnostic or therapeutic
- Begins with standard precautions and procedure
moves to post exposure prophylaxis
 - ex. Bronchocopy,treatment with exhale. throat’,
broad-spectrum antibiotics. Disease meningitis
● HAIs spread when
- are also exogenous infection come from people are
microorganisms from outside the close to each
individuals like salmonella, clostridium other (usually
<3 feet) and
tetani , and aspergillus
inhale droplet
● endogenous infections
Indirect Contact with Skin Hand-hygi
- occurs when part of the patient’s flora
contact contaminated infections, ene,
becomes altered and an overgrowth surfaces, diarrhea sanitizing
results clothing, etc. disease infected
- ex. Staphylocci,enterococci,yeast,and surfaces
streptococci vector Bite from Lyme Vector
disease-carryi disease, control
Definition of Terms
ng ticks, fleas, Lacrosse
● Host: living animal or plant mosquitoes encephalitis
● Agent: something that produces or is capable vehicle Eat/drink Some Proper
of producing an effect, i.e. infection contaminated diarrhea hygiene
food/beverage disease, and
● Vector: an organism (as an insect) that
, transfuse hepatitis b/c sanitation,
transmits an agent from one organism or source
infected cook
to another
blood, food/boil
● Vehicle: inanimate object (food, water, etc) that formites water, etc.
can carry an agent from one organism to (bedding,
another infected
● Disease: impairment of normal functioning, tattoo needle)
manifested by signs and symptoms airborn Organism on Chicken pox, Respirator
● Infection: the state produced by the e dust particles tuberculosis, y
establishment of an infective agent in or on a or small smallpox, etiquette,
suitable host, host may or may not have signs or respiratory SARS, isolation
symptoms droplets that anthrax (if
● Carrier: individual harbors the agent but does may become (inhalational necessary)
not have symptoms. Person can infect others. aerosolized )
when people
● Reservoir: habitat (man, animal, etc.) in which
sneeze, cough,
the agent normally lives, grows, and multiplies
laugh, or
Mode of Transmission and Infection Control exhale

ROUTE EXAMPLE DISEASE Control

Measures Infection Prevention
Direct Kissing, sexual STD’s, skin Use of ● Education and Training
contact contact, infections, barrier
- Hygiene
skin-to-skin scabies (condom,
- Sanitation
contact clothing,
dressing) - Follow public health recommendations
Droplet Organism on Mumps, Respirator - food preparation, isolation and
s large pertussis y etiquette quarantine
respiratory (whooping ● Vaccination
droplets that cough), - Keep up to date
people common ● Medicine
sneeze, cough, cold, ‘strep - Prophylactic antibiotics – meningitis,
drip, or pertussis
L2: Applying sterile gloves via the open accidental 8. Promotes proper
contamination. fit over the
method
6. With the gloved fingers.
EQUIPMENT NEEDED dominant hand, 9. Contact is made
slip your fingers with two sterile
● Package of proper-sized sterile gloves under the cuff of gloves.
Implementation - action/rationale the other glove, 10. Frees the thumb
ACTION RATIONALE gloved thumb for the next step.
1. Wash hands. 1. Prevents abducted, 11. Contact is made
2. Read the transmission of making sure it with two sterile
manufacturer’s infection. does not touch gloves.
instructions on 2. Different any part on your 12. Removes glove
the package of manufacturers non-dominant without contact
sterile gloves; package gloves hand. Be careful with soiled
proceed as differently; the not to drag glove surfaces.
directed in instructions will or touch gloved 13. Exposes only the
removing the tell you how to dominant hand clean surface of
outer wrapper properly open to with ungloved the gloves.
from the avoid dominant hand. 14. Prevents the
package. contamination of 7. Gently slip the transfer of
3. Identify right the inner glove onto your microorganisms.
band left hand; wrapper; any non-dominant
glove dominant moisture on the hand, making
hand first. surface will sure the fingers
4. Grasp the 2-inch- contaminate the slip into the
(5-cm-) wide cuff gloves. proper spaces.
with the thumb 3. Dominant hand 8. With gloved
and first two should facilitate hands, interlock
fingers of the motor dexterity fingers to fit the
non-dominant during gloving. gloves onto each
hand, touching 4. Maintains finger. If the
only the cuff. sterility of the gloves are soiled,
5. Gently pull the outer surfaces of remove by
glove over the the sterile glove. turning inside out
dominant hand, 5. Prevents tearing as follows:
making sure the the glove 9. Slip gloved
thumb and material; guiding fingers of the
fingers fit into the fingers into dominant hand
the proper proper places under the cuff of
spaces of the facilitates the opposite
glove. Hold hands gloving. hand, or grasp
above the waist 6. Cuff protects the outer part of
while applying gloved fingers, the glove at the
glove. Once maintaining wrist if there is
dominant hand is sterility. no cuff.
gloved, keep 7. Constancy is 10. Pull the glove
hands visible and made with two down to the
above waist to sterile gloves. fingers, exposing
prevent the thumb.
 11. Slip the ● Client behavior incidents
uncovered thumb ● Therapeutic procedure incidents
into the opposite ● Equipment incidents
at the wrist, Safety and the Environment of Care
allowing only the
A safe environment is one in which each facility
glove-covered
follows specific safety processes and procedures derived
fingers of the
from national and state directives, TJC guidelines, and
hand to touch
best industry practices.
the soiled glove.
12. Pull the glove ● Each nurse is responsible for following the
down over the facility’s established safety guidelines.
dominant hand ● It is the nurse’s responsibility to report promptly
almost to the and to document a mishap.
fingertips, and Potential Occupational Hazards
slip the glove on
Numerous potential hazard exposures exist in
to the other
today’s health care workplace, placing health care
hand.
providers at unnecessary risk.
13. With the
dominant hand ● Chemical and biological exposures
touching only the ● Physical exposures (lasers, ionizing radiation,
inside of the noise)
other glove, pull ● Psychosocial stressors (shift work, overtime,
the glove over threat of workplace violence)
the dominant ● Ergonomic stressors (lifting and moving clients)
hand so that only Routes of Exposure
the inside (clean
surface) is Methods by which chemical and biological substances
exposed. are assimilated into the body
14. Dispose of soiled ● Inhalation
gloves according ● Ingestion
to institutional ● Injection
policy and wash ● Skin contact
hands. ● Skin absorption
Exposure Prevention and Control

● Substitution
L3: Safety and Hygiene ● Engineering Controls
Excellent nursing care is safe for both the clients ● Administrative Controls
receiving the care, and the workers involved in the ● Personal Protective Equipment (PPE)
delivery of health care. Exposure Prevention and Control

Factors Affecting Client Safety Transmission-Based Precautions

● Age Standard Precautions and Transmission-Based

● Lifestyle Precautions
● Sensory and Perceptual Alterations
● Masks
● Mobility
● Respirators
● Emotional State
● Goggles
● Types of Incidents
● Private room with negative pressure ventilation
Types of Incidents
Hazardous Substances
 ● Corrosives ● Self-care management
● Carcinogens Physical Examination
● Teratogens
● Level of consciousness
● Target organ chemicals
● Range of motion or total immobilization of an
● Sensitizers
extremity
Potential Occupational Hazards
● Localized infection
Latex Allergy ● Systemic infection
● Secretions or exudate of skin or mucous
● Irritant contact dermatitis
membranes
● Allergic contact dermatitis
● Presence of crackles, rhonchi, or wheezes
● Immediate hypersensitivity
Diagnostic and Laboratory Data
- A systemic reaction also called type 1
IgE-mediated reaction Client in an Inpatient Setting
- Any dermatitis should be promptly reported to
● Fall and infection risk factors
Employee Health.
Client in the Home
- Barrier creams or special soaps are available.
- Strict guidelines on nail care and nail coverings ● Risk for falls, fires, electrical malfunctions,
should be implemented and followed suffocation, weapons, and household and
Work-Related Musculoskeletal Disorders (MSDs) medication poisonings
● OSHA mandatory standards
Nursing Diagnosis
● Prevention of work-related MSDs such as back Risk for Injury
injuries
Safety and Health Training ● Risk for Suffocation
● Risk for Poisoning
● Injury prevention training ● Risk for Trauma
● Upgraded as client and employee needs change ● Risk for Aspiration
Hygiene ● Risk for Disuse Syndrome
● Latex Allergy Response
● Hygiene is the science of health.
Risk for Infection Related to (RT)
● Promotes cleanliness, provides comfort and
relaxation, improves self-image, and promotes ● Inadequate primary defenses
healthy skin. ● Inadequate secondary defenses
● The skin and mucous membranes are the body’s ● Tissue destruction and increased environmental
first line of defense. exposure
● The type of hygienic care provided depends on ● Chronic diseases and malnutrition
the client’s ability, needs, and practices. Risk for Infection Related to
Factors Influencing Hygienic Practice
● Invasive procedures
● Body Image ● Pharmaceutical agents
● Social and Cultural Practices ● Trauma
● Personal Preferences ● Rupture of amniotic membranes
● Socioeconomic Status ● Insufficient knowledge to avoid exposure to
● Knowledge pathogens
Assessment to Identify At-Risk Clients Self-Care Deficit
Health History ● Bathing/hygiene
● Dressing/grooming
Data regarding client’s routine self-care and health
● Toileting
promotion needs
Other Nursing Diagnoses
● General health perception
● Imbalanced Nutrition
 ● Ineffective Protection ● Both the client and the nurse are at risk for
● Impaired Tissue Integrity injury.
● Impaired Oral Mucous Membranes ● Radiation injury can occur from overexposure or
● Impaired Skin Integrity exposure to untargeted tissues.
● Social Isolation ● General principles of radiation exposure and
● Risk for Loneliness protection are based on time, distance, and
● Ineffective Coping shielding.
● Impaired Physical Mobility Prevent poisoning.
● Hopelessness
● A poison is any substance that causes an
● Powerlessness
alteration in the client’s health when inhaled,
● Deficient Knowledge
injected, ingested, or absorbed by the body.
● Acute Pain
● Antidotes and treatments are available for some
● Anxiety
but not all types of poisonings.
● Fear
● Poison control center
Outcome Identification and Planning
● Client education
● Identification of actual or potential hazards Reduce Noise Pollution.
● Reduction of the risk of injury and infection
● Sensory overload can alter a client’s recovery by
● Client/caregiver education regarding safety
increasing anxiety, paranoia, hallucinations, and
measures and modification of an unsafe
depression.
environment
● Safety measures include maintaining a quiet
Implementation
environment, traffic control, and providing
● Raise Safety Awareness and Knowledge earplugs.
● Bed Safety Provide for Client Bathing Needs.
● Prevent Falls
● Cleaning Baths
- Apply restraints
● Shower
- Ensure adequate lighting
● Tub Bath
- Remove obstacles
● Self-Help Bath
Types of physical restraints:
● Complete Bed Bath
● Jacket ● Partial Bath
● Belt ● Therapeutic Bath
● Mitten or Hand - Requires a physician’s order.
● Elbow o Type of bath
● Limb or Extremity o Temperature of water
● Mummy o Body surface to be treated
Reduce Bathroom Hazards o Type of medicated solutions to
use
Prevent Fire
● Clean Bed Linen
● Common causes of fire ● Skin Care
● Fire prevention ● Offer Back Rubs
● Protection of clients during a fire - Stimulate circulation
● Institutional policies and procedures for fire - Relax muscles
containment and evacuation - Relieve muscle tension
Ensure safe operation of electrical equipment. - Skin assessment
● Foot and Nail Care
● Three-pronged electrical plug that is grounded
- Prevents infection.
● Warning labels on all equipment
- Prevents soft tissue trauma from
● Electrical shock
ingrown or jagged nails.
Reduce exposure to radiation.
 - Eliminates odor. ● an alteration of v/s signals a change in
● Clients with diabetes mellitus need special foot physiological function and the need for medical
and nail care. or nursing intervention
● Oral Care ● Clinically v/s is the bases for decision making
- Fluoride and problem solving.
- Flossing
- Brushing
Guideline in the measurements of V/S
- Oral care for the unconscious patient ● it is the nurse’s responsibility…delegation to
● Hair Care nursing attendant or student nurses only to
- Brushing and combing stable patient- but interpretation and
- Shampooing significance of the v/s be done by nurses.
- Shaving ● assess equipment’s to ensure that it is working
- Mustache and beard care correctly and provides accurate findings.
● Eye, Ear, and Nose Care ● select equipment’s on the basis of patient’s
- Contact Lenses condition and characteristics (use adult size bp
o Level of assistance required cuff adult patient)
o Hard and soft lenses ● Know usual range of v/s of patient.
- Hearing Aids ● get patients medical history; therapies and
o Types medication.
o Function ● control or minimize environmental factors that
o Storage affect v/s (eg. warm humid room yield not true
- Nose indicator of patients’ condition)
o Nasogastric tube care
Range of vital signs: Adults
Evaluation
Temp. pul RR BP Pulse Capnog
● Frequent reassessment of client health risks
se Oximie rphy
● Need for timely adjustments to plan of care and
tery (EtCH0
expected outcomes (Spo02 2)
)
L4: VITAL SIGNS Adul 36º- 60- 12 <120/ >95% Normal
t 38ºC 10 -2 <80 or :
● are signs of life aver or 0 0 mmH equal 25-45
● tools to determine or indicators of once health age (96.8º B/ b/ g mmHg
status -100.4º m m
● are obtained by health professionals; C) bp
- Temperature m
- Pulse Oral
- blood pressure /TYMP
- respiration ANIC
- oxygen saturation -37ºC
● are indicators of health status these measures (98.6
°F)
the effectiveness of circulation, respiratory,
Rectal:
neural and endocrine body function.
37.5ºC
● Pain – is a subjective symptom also called a 99.6ºF
vital sign AXILLA
● Usually provides the baseline data to determine RY:
patient’s health status 36.5ºc
● Provides data to determine diagnosis, (97.7º)
implement plan of intervention and evaluates
outcomes of care.
 ● How to convert Fahrenheit to Celsius: ● true fever is a result of alteration in the
hypothalamic set point as a result of pyrogens
C= (F-32) x5/9 like bacteria or virus.
Example:40ºC = (104ºF – 32) x5/9 ● It serves as antigens which needs triggering
immune response

WHEN DO YOU TAKE THE VITAL SIGNS?

● How to convert Celsius to Fahrenheit
● on admission to health facilities
F =(9/5xºC) + 32 ● assessing during a home visits
● hospital routine standard before during, after a
Example: 104ºF =(9/5X40ºC) +32
surgical procedure
FACTORS AFFECTING BODY TEMPERATURE ● before, during and after transfusion of blood
produces
1. AGE AS A FACTOR
● before, during, after administration of drugs or
● HEALTHY YOUNG ADULT – AVERAGE 37ºC
therapies affecting cardiovascular respiratory or
(98.6ºF)
temperature –control functions
● elderly - average core temp. ranges from
● when patients general condition change
35-36.1ºC (95to 97ºF) due to decreased in
● before, during, after nsg intervention is done,
immunity
like exercises or ambulation
2. CIRCADIAN RHYTHM
● body temp changes abt. 0.5 to 1ºc in 24 hrs. BODY TEMPERATURE (temp.)
● time of the day affects the body temp with the
SITES OF TEMP MEASUREMENTS IS A FACTOR THAT
lowest at 6am and highest at 4pm in healthy
DETERMINES THE TEMP.
person.
● Note consistent body site is used to allow you to ● ORAL
monitor patterns of your pts. body temp. .so ● RECTAL
select a more appropriate site. ● TYMPANIC MEMBRANE
3. EXERCISE ● TEMPORAL ARTERY
● muscle activity increases blood supply, ● AXILLARY
carbohydrates and fat breakdown ● ESOPHAGEAL
4. HORMONAL LEVEL ● PULMONARY ARTERY
● women experience greater fluctuation of temp. ● EVEN URINARY BLADDER
men during menstruation, because of the rise in
progesterone BODY TEMPERATURE (temp.) Physiology:
● when progesterone level is low the temp. is heat is produced by body processes - heat lost to the
lower than normal until ovulation- environment = body temperature or core temp.
● persist during ovulation because greater
progesterone enters the circulatory system, Core temperature- is the temperature of the deep
these predict a women’s fertile period tissues
5. STRESS ● relatively constant from 36 to 38ºC
● physical and emotional stress
● Environment – when in warm temperature; Body temperature
warm climate
● represents the balance between heat
FEVER OR PYREXIA production and heat loss (Marieb and Hoehn,
2010). If the rate of heat generated equates to
● fever usually is not harmful if it stays at 39ºc in the rate of heat lost, the core body temperature
adults and below 40ºc in children- it must be will be stable (Tortora and Derrickson, 2011)
several readings to confirm.
THERMOREGULATION
 ● it is the physiological and behavioral mechanism causes serious alteration in temperature
regulates between heat lost and heat produced. control.
● Temperature controls mechanism to promote
temp. regulation.
HEAT PRODUCTION
HOW DO BODY HEAT PRODUCED?
Neural and vascular control
● body heat is a byproduct of metabolism, which
● the hypothalamus located between the cerebral
is the chemical reaction of all body cells.
hemispheres of the brain controls the same way
- activities
as a thermostat works in the home.
as metabolism increases heat is produced
how do thermostat work in the home? As metabolism decreases less heat is
produced.
● a comfortable temp is the set point at which ● basal metabolism account for the heat
heating system operates, a drop is the production by the body at rest. Basal metabolic
environmental temperature activates the rate (BMR)
furnace, whereas a rise in the temp. Shuts the ● thyroid hormone affects BMR- when large
system down. amount of thyroid hormone are secreted BMR
HOW DO THERMOREGULATION WORKS? increase 100% above normal
● absence of thyroid hormone reduces the BMR
● same is true with the hypothalamus, when its by half, causing a decrease in heat production
senses minor body temp. changes the anterior ● muscle movement increases BMR by 50 times
hypothalamus controls heat loss, and the normal
posterior hypothalamus controls heat ● shivering an involuntary muscle response
production. increases heat production by 4-5times greater
● When nerve cells are heated in the anterior than normal
hypothalamus beyond the set point (PYREXIA ● nonshivering thermogenegis – occurs in
38ºc and above) impulses are sent out to neonates, because neonates cannot shiver since
reduce body temp. they have a limited amount of vascular brown
● so that results to mechanism of heat loss tissue, present at birth, is metabolized for heat
sweating, vasodilation(widening) of blood production
vessels and inhibition of heat production. The
body redistribute blood to surface vessels to HEAT LOSS
promote heat loss.
● exposure of the skin to the environment results
if the posterior hypothalamus senses that the body in constant heat loss by:
temp. is lower than the set point (HYPOTHERMIA-34- - Radiation
35ºC) - Conduction
- Convection
● the body initiates heat-conservation mechanism
- Evaporation
- resulting to vasoconstriction (narrowing) of the
● exposure of the skin to the environment results
blood vessels reduces flow to the skin and
in constant heat loss by:
extremities.
- Radiation - transfer of heat from one
● a compensatory heat production stimulated
surface to the surface of another
through voluntary muscle contraction and
without direct contact. because the skin
muscle shivering
radiates heat to the environment about
when vasoconstriction is ineffective in preventing more 85%
heat loss shivering begins. ● exposure of the skin to the environment results
in constant heat loss by:
● Trauma or disease to the hypothalamus or the
- conduction –transfer of heat from one
spinal cord, carrying hypothalamic messages,
object to another with direct contact.
 when a warm skin touches a cooler - pay particular attention to issues of
objects heat is lost. ex. warm pads or privacy.
aquathrmia pad
Nursing care plan: HYPERTHERMIA RELATED TO
- convection- transfer of heat away by air
INFECTIOUS PROCESS
movements ex. A fan. A rate of heat loss
increases when a moistened skin in ● S- “I’m not feeling well in this past few days” I
contact with slightly moving air. had on and off fever for 2 days now.” as
- evaporation – transfer of heat energy verbalized by patient.
when liquid is change into gas. ● o- warm and dry to touch
- Body losses600-900ml of liquid by skin, - flushed face
lung by perspiration, - BP 114/62mmhg.
- DIAPHORESIS- a visible perspiration - radial pulse 128bpm
primarily occurring on the forehead, - RR 26bpm
upper thorax - during exercises. - temp. 39.2 ºc
The oral cavity temperature Nursing care plan: HYPERTHERMIA
● is considered to be reliable when the ● A- Hyperthermia related to infectious process
thermometer is placed posteriorly into the ● P- temp. decrease from 39.2 to at least 38ºC
sublingual pocket (Hamilton and Price, 2007). with in next 4 hrs.
● This landmark is close to the sublingual artery, - to lower body temp from 39.2 to at
so this site tracks changes in core body least 38.5 after tepid sponge bath
temperature (Dougherty and Lister, 2011). - maintain fluid and electrolyte balance.
Tympanic temperature ● E-temp-37.8ºC
- improve rest and sleep pattern and
● The tympanic thermometer senses reflected increase energy level
infrared emissions from the tympanic
membrane through a probe placed in the ASSESSING PULSE
external auditory canal.
● This method is quick (<1 minute), minimally ● PULSE – is a palpable bounding flow, it is the
invasive and easy to perform. It has been indicator of circulatory and cardiovascular
reported to estimate rapid fluctuations in core health and the response of the body to other
temperature accurately because the tympanic system imbalances
membrane is close to the hypothalamus PHYSIOLOGY AND REGULATION
(Stanhope, 2006).
● electronic impulses originating from the
Axillary temperature sinoatrial(SA) node travels through heart muscle
● Temperature is measured at the axilla by placing to stimulate cardiac contractions
the thermometer in the central position and ● about 60-70 ml of blood enters the aorta with
adducting the arm close to the chest wall. each ventricular contraction
● (STROKE VOLUME) with each stoke vol. ejection,
Rectal temperature the walls of the aorta distend, creating a pulse
wave that travels rapidly to the distal end of the
● the most accurate method for measuring the
arteries.
core temperature (Lefrant et al, 2003).
● the vol. of blood pumped by the heart during 1
● However, obtaining this is more time consuming
minute is the cardiac output- the product of HR
than other methods and might be considered
and the stroke vol.(SV) of the ventricle
unfavourable for some patients (Dzarr et al,
● in adults 5000ml of blood is pump per min.
2009).
 ● Ex. If a person’s HR is 70 beats/min and the - diffusion the movement of oxygen and
stroke vol. is 70 ml. the cardiac output is CO2 between the alveoli and the red
4900ml. (70bpm. Times 70mlp/b. blood cell (determine by oxygen
● if HR drops to 60b/m and the stroke vol. rise to saturation)
85ml/b,the cardiac output increase to 5100mlor - perfusion distribution of red blood cells
5.1 liter per min.(60b/m x 85ml/beat. to and from the pulmonary capillaries
● BRAINSTEM - respiratory center. – regulates
CHARACTERISTIC S OF PULSE
the involuntary control of respiration.
● rate: ● RR – is normal rate in adult is 12to 20 beat per
- Infant – 120-160b/m minutes
- toddlers - 90-140b/m ● Body regulates ventilation using level of co2, o2
- preschoolers- 80-110 and hydrogen ion concentration (pH) in the
- school-age- 75-100b/m arterial blood.
- adolescents 60- 100b/m ● the elevation in the co2 level causes the
- adults- 60-90b/m respiratory control system to increase the rate
depth of breathing
ABNORMALITY OF PULSE RATE ● the increased ventilatory effort removes excess
● tachycardia- abnormal elevated HR. above co2(HYPERCARBIA) by increasing exhalation.
100b/m ● hypoxemia low level of arterial o2
● bradycardia- slow rate below 60b/m ● MECHANISM - During relax inspiration the
● dysrhythmia - interval interrupted by an early respiratory center sends impulses along the
or late beats or missed beat indicate an phrenic nerve, causing the diaphragm to
abnormal rhythm contract so abdominal organs move downward
and forward, increasing and allow to move air
Nursing Process and Pulse Determination into the lung
● pulse assessment determines a general state of ● normal relaxed breath - inhales 500 ml of air.
cardiovascular health and the response of the ● Eupnea- Normal respiration that is quiet,
body to other system imbalances: rhythmic and effortless
● tachycardia, bradycardia and dysthymias’ – are ● Tachypnea- Rapid respirations above 20
the defining characteristics breaths/minute in an adult
- activity intolerance ● Bradypnea- Slow breathing, less than 12
- anxiety breaths/minute in an adult
- fear ● Hyperventilation- Deep rapid respiration
- decreased cardiac output ● Carbon Dioxide is excessively exhaled- =
- ineffective peripheral tissue perfusion Respiratory Alkalosis
- Impaired gas exchange ● Hypoventilation- Slow, shallow respiration
- deficient/excess fluid volume ● Carbon Dioxide is excessively retained=
Respiratory Acidosis
RESPIRATION ● Dyspnea= Difficult and labored breathing
● Orthopnea= Ability to breath only in upright
● human survival depends on the ability of
position
oxygen(O2) to reach body cells and carbon
● Apnea= Absence of respirations
dioxide (CO2) to be removed from cells.
● a mechanism of the body to exchange gases Normal range of RR
bet. atmospheres and the blood and the cells.
● involves 3 processes ● NEWBORN- 30-60breaths /minutes.
- ventilation movement of gases in and ● INFANTS 6months- 30-50 breaths /min.
out of the lungs (Determined by RR) ● TODDLERS- (2y/o) - 25-32b/min
● child - 20- 30
● adolescent- 16-20b/min
 ● adults – 12-20b/m. - carbon monoxide caused by smoke
- patient motion
FACTORS AFFECTING RESPIRATORY RATE(RR) ● INTERFERENCE WITH ARTERIAL PULSATION
● Exercise – Increases RR - Peripheral vascular disease
● Stress – Increases RR - low cardiac output
● Environment - peripheral edema which obscured
- Increased Temperature of the arterial pulsation
environment decreases RR
- Decreased Temperature, Increases RR
BLOOD PRESSURE
● Altitude – Increases RR ● the force exerted on the walls of an artery by
● Medications – E.g. Narcotics Decreases RR\ the pulsing blood under pressure from the
heart.
Assessment of diffusion and perfusion
● It moves from an area of high pressure to one of
● assessing the respiratory process of diffusion low pressure.
–and perfusion by measuring the oxygen ● the arterial BP – is an indicator of good health
saturation of the blood. ● Contraction of the heart -> forces the blood into
● Blood -> flow thru the pulmonary capillaries the aorta. The peak of maximum pressure is the
delivers RBC for oxygen attachment, after systolic pressure -> when the ventricle relaxes
oxygen diffuses from the alveoli into the the blood remaining in the arteries exerts a
pulmonary blood most of the oxygen attach to minimum pressure or the diastolic pressure.
the hemoglobin molecules in the RBC. ● the standard unit for BP is millimeters of
● and this become oxygenated, RBC carry the mercury((mmHg)
oxygenated hemoglobin molecules through the ● use of
left side of the heart and out to the peripheral - Stethoscope
capillaries where the oxygen detached based on - Sphygmo-manometer
the need of the tissues.
PARTS OF STETOSCOPE
● the % of hemoglobin that bound with O2 in the
arteries is the % of saturation of ● earpiece
hemoglobin(SaO2) ● 2binaurals
● normal SaO2- is between 95-100% ● tubing
● the pulse oximeter permits the indirect ● chest piece – bell & the diaphragm
measurements of oxygen saturation, it detects
the amount of O2 bound to hemoglobin
Physiology of Arterial Blood Pressure
molecules, the oximeter calculates the pulse ● the BP—reflects the interrelationship of
saturation (SpO2) 1. Cardiac output
● SpO2 – is a reliable estimate of SaO2. A 2. Peripheral vascular resistance
saturation of less than 90% is an 3. blood volume
emergency(WHO,2011) 4. blood viscosity
● sites for measuring 5. artery elasticity
- photo detector is in the oximeter probe. ● CARDIAC OUTPUT
selecting appropriate probe is - more blood is pumped against arterial
important to reduce measurement walls, causing the BP to rise
error. - cardiac output increases as a result of
● Earlobe- greater accuracy an increase in HR, greater heart muscle
● Forehead quicker than finger probes contractility or an increase in blood
factors that affect determination of SpO2 volume
● PERIPHERAL RESISTANCE
● SpO2(pulse oxygen saturation) - BP depend on peripheral vascular
- outside light resistance
 - the resistance to blood flow determined prehypertension 120-139 80-89
by the tone of vascular musculature and
diameter of blood vessels
stage 1 > 140 >90
- the smaller the lumen of a vessel, the
greater is the peripheral vascular
Stage 2 > 160 > 90
resistance to blood flow
- As resistance rises, arterial BP rises.
classification of BP – for 18y/o and older
- as vessels dilates the resistance falls, BP
falls.
● BLOOD VOLUME
- volume of blood circulating with in the
HYPOTENSION
vascular system affect BP. ● reason why HYPOTENSION occurs
- Adult have a circulating volume of ● dilation of the arteries in the vascular bed
5000ml. ● loss of substantial amount of circulating blood
o rapid uncontrolled infusion of IV volume –like in hemorrhage
fluids elevates BP. ● in myocardial infarction where there is failure of
o in case of hemorrhage and heart muscle to pump blood
dehydration BP – falls ● when BP- systolic falls to 90 mmHg or below
● VISCOSITY: ● low BP is an abnormal findings associated with
- the thickness of blood affects the ease illness.
with which blood flow through small
vessels, the hematocrit or % of RBC in FACTORS INFLUENCING BLOOD PRESSURE
the blood determines blood viscosity. ● age
● ELASTICITY: ● STRESS
- Normally the walls of the artery are ● ETHNICITY- genetics and environmental factors
elastic and is distensible ● gender – males tend to have higher BP
- arterial dispensability prevents wide ● daily variation - time, activity at am, pm,at night
fluctuations in BP. but in case of ● medication
arteriosclerosis the vessels lose its ● activity and weight
elasticity and are replace with fibrous ● smoking
tissue that cannot stretch well. ● Systolic Pressure= Pressure of the blood as a
result of contraction of the ventricles
Average optimal blood pressure
- Normal: 100 – 140 mmHg 
● age BP in mmHg ● Diastolic Pressure= Pressure when the
● newborn- 6.6 lb 40(mean) ventricles are at rest
● 1 month 85/54 - Normal: 60 – 90 mmHg
● 1 ylo 95/65 ● 1905 Korotkoff, a Russian surgeon first
● 6y/o 105/65 described the sounds heard over an arterial
● 10-13y/o 110/65 distal to the BP cuff - onset of the sound
● 14-17ylo 119/75 corresponds to the systolic pressure.
● 18ylo and older < 120/<80 ● The 4th korotkoff sound becomes muffled and
low pitched as the cuff is further inflated at this
CATEGORY SYSTOLIC point the cuff pressure has fallen below the
mmHg diastolic pressure within the vessel wall;
mmHg - This sound is the diastolic pressure in
infants and children.
normal < 120 < 80 ● the fifth korotkoff sound marks the
disappearance of sound in adolescents and
adults corresponds to the diastolic pressure.
L3-4: ASSISTING WITH HYGIENE & ● ASSIST WITH ELIMINATION
● CLEAN INCONTINENT PERSONS
ASSISTING WITH GROOMING
● ASSIST WITH WASHING FACE AND HANDS
PERSONAL CARE INCLUDES: ● PROVIDE ORAL HYGIENE AND PUT IN DENTURES
● ASSIST WITH DRESSING AND HAIR CARE
● BATHING ● POSITION THE PERSON FOR BREAKFAST
● BRUSHING THE TEETH ● BEGIN MAKING BEDS
● COMBING THE HAIR
● DRESSING MORNING CARE (GIVEN AFTER BREAKFAST)
● SHAVING ● ASSIST WITH ELIMINATION
● APPLYING MAKEUP ● CLEAN INCONTINENT PERSONS
PATIENTS SHOULD BE ENCOURAGED TO DO AS MUCH ● ASSIST WITH ORAL HYGIENE
FOR THEMSELVES AS POSSIBLE ● ASSIST WITH BATHING (SHOWER, TUB, PARTIAL)
● ASSIST WITH PERINEAL CARE
WHY IS CLEANLINESS IMPORTANT? ● ASSIST WITH DRESSING
● CLEANLINESS IS NEEDED FOR COMFORT, SAFETY, ● ASSIST WITH GROOMING (COMB HAIR, SHAVE,
AND HEALTH APPLY MAKEUP)
● CLEANLINESS MAINTAINS THE HEALTH OF THE ● ASSIST WITH ACTIVITIES – ROM, AMBULATION
SKIN AND MUCOUS MEMBRANES ● MAKE BEDS AND STRAIGHTEN THE CLIENT’S
● CLEANLINESS PREVENTS BODY AND BREATH UNIT
ODORS, PROMOTES RELAXATION, AND AFTERNOON CARE (GIVEN AFTER LUNCH)
INCREASES CIRCULATION
● ASSIST WITH ELIMINATION
CULTURE AND PERSONAL CHOICE ● CLEAN INCONTINENT PERSONS
● SOME PEOPLE PREFER SHOWERS, OTHERS ● ASSIST WITH WASHING FACE AND HANDS
PREFER TUB BATHS ● ASSIST WITH ORAL HYGIENE
● SOME PEOPLE BATHE IN THE MORNING, SOME ● ASSIST WITH GROOMING – CHANGING
BATHE AT BEDTIME CLOTHING, HAIR CARE
● BATHING FREQUENCY VARIES AMONG ● ASSIST WITH ACTIVITIES – ROM, AMBULATION
INDIVIDUALS OR CULTURES ● STRAIGHTEN THE BED LINENS AND THE
● SOME PEOPLE CANNOT AFFORD SOAP, CLIENT’S UNIT
DEODORANT, SHAMPOO, TOOTHPASTE, OR EVENING CARE (PM CARE, HS CARE)
OTHER HYGIENE PRODUCTS
● PROTECT THE PATIENT’S PRIVACY DURING GIVEN AT BEDTIME (HOUR OF SLEEP)
HYGIENE AND PERSONAL CARE PROCEDURES
● ASSIST WITH ELIMINATION
● THE NEED FOR CLEANLINESS AND SKIN CARE IS
● CLEAN INCONTINENT PERSONS
AFFECTED BY:
● ASSIST WITH WASHING FACE AND HANDS
- PERSPIRATION
● ASSIST WITH ORAL HYGIENE (REMOVE
- VOMITING
DENTURES)
- URINARY AND BOWEL ELIMINATION
● ASSIST WITH NIGHTCLOTHES
- DRAINAGE FROM WOUNDS OR BODY
● GIVE BACKRUB
OPENINGS
● POSITION RESIDENT AND STRAIGHTEN LINEN
- ACTIVITY
● STRAIGHTEN CLIENT’S UNIT
DAILY CARE ROUTINES (EARLY MORNING, CARE
ORAL HYGIENE
AM CARE)
MOUTH CARE KEEPS THE MOUTH AND TEETH CLEAN –
GIVEN BEFORE BREAKFAST WHEN THE CLIENT FIRST
WAKES UP ● PREVENTS MOUTH ODORS
● PREVENTS INFECTIONS
 ● INCREASES COMFORT ● THE MOUTH OF AN UNCONSCIOUS PERSON
● MAKES FOOD TASTE BETTER MAY HANG OPEN CAUSING THE MOUTH AND
● PREVENTS CAVITIES MUCOUS MEMBRANES TO DRY OUT. OR
● ORAL SECRETIONS MAY ACCUMULATE IN THE
MUST BE DONE FOR:
MOUTH DUE TO THE PERSON’S INABILITY TO
● WEAK PERSONS COUGH OR CLEAR THE THROAT.
● CONFUSED PERSONS ● THESE CONDITIONS MAY LEAD TO DISCOMFORT
● PEOPLE THAT CANNOT USE THEIR ARMS AND THE GROWTH OF PATHOGENS.
● ALWAYS WEAR GLOVES WHEN PERFORMING
INCLUDES: ORAL HYGIENE.
● BRUSHING THE TEETH, GUMS, AND TONGUE ● POSITION THE COMATOSE PATIENT ON HIS SIDE
● FLOSSING THE TEETH (REMOVES PLAQUE AND TO PREVENT ASPIRATION.
TARTAR) ● PLACE A TOWEL UNDER THE PATIENT’S HEAD
● RINSING THE MOUTH WITH MOUTHWASH TO CATCH SECRETIONS.
● BRUSH THE TEETH IN AN UP AND DOWN ● USE A PADDED TONGUE BLADE TO OPEN THE
MOTION, BRUSHING ALL SURFACES OF THE PERSON’S MOUTH.
TEETH ● A SPONGY PIECE OF FOAM ON A STICK – CALLED
● CLEANING DENTURES IS ALSO A PART OF ORAL A TOOTHETTE IS USED TO CLEAN THE MOUTH
HYGIENE OF A COMATOSE PATIENT. MAKE SURE THE
SPONGE IS TIGHT ON THE STICK.
OBSERVATIONS ● CHECK THE CARE PLAN FOR WHAT CLEANING
● DRY, CRACKED, SWOLLEN, OR BLISTERED LIPS AGENT TO USE, USUALLY DILUTED
● UNPLEASANT MOUTH ODORS MOUTHWASH.
● LOOSE, BROKEN OR DECAYED TEETH ● MAY ALSO USE A LARGE, PREPACKAGED
● SWELLING, REDNESS, SORES, BLEEDING, OR COTTON SWAB CALLED A LEMON & GLYCERIN
WHITE PATCHES IN THE MOUTH OR ON THE SWAB
TONGUE ● BE SURE TO USE ONLY A SMALL AMOUNT OF
● BLEEDING, SWELLING, OR REDNESS OF THE FLUID TO PREVENT ASPIRATION
GUMS ● ALWAYS ASSUME THE UNCONSCIOUS PERSON
● LOOSE, CHIPPED, OR BROKEN DENTURES CAN HEAR YOU. ALWAYS EXPLAIN WHAT YOU
● PATIENT COMPLAINTS ARE DOING.
● SOME PATIENTS WILL BE ABLE TO PERFORM DENTURE CARE
ORAL HYGIENE INDEPENDENTLY.
● OTHERS MAY NEED YOU TO ASSIST WITH ORAL ● DENTURES SHOULD BE CLEANED AS OFTEN AS
HYGIENE NATURAL TEETH.
● SOME MAY NEED YOU TO PROVIDE THE CARE ● DENTURES ARE SLIPPERY WHEN WET. THEY
FOR THEM CAN EASILY BREAK IF DROPPED ONTO A HARD
● ORAL HYGIENE IS INCLUDED IN OUR ADL’S SURFACE.
● IT SHOULD BE PROVIDED IN THE MORNING, ● DENTURES ARE EXPENSIVE AND ARE THE
AFTER MEALS, AND AT BEDTIME. RESIDENT’S PERSONAL PROPERTY. LOSING OR
DAMAGING DENTURES IS NEGLIGENT
ORAL HYGIENE IS GIVEN EVERY TWO HOURS FOR THE: CONDUCT.
● COMATOSE PATIENT ● CARRY THE DENTURES BACK AND FORTH FROM
● PATIENT WITH A NASOGASTRIC TUBE THE SINK IN AN EMESIS BASIN LINED WITH A
● PATIENT RECEIVING OXYGEN PAPER TOWEL.
● USE A GAUZE PAD TO GRASP THE UPPER
PROVIDING ORAL CARE FOR THE COMATOSE PATIENT DENTURE AND USING YOUR THUMB GENTLY
BREAK THE SUCTION HOLDING THE DENTURE IN
PLACE.
 ● CLEAN THE DENTURES IN A BASIN OR SINK ● HELPS PREVENT SKIN PROBLEMS
LINED WITH PAPER TOWELS OR A WASHCLOTH. ● PROVIDES EXERCISE
● FILL THE BASIN OR SINK PART WAY WITH COOL
WATER
FOUR MAIN TYPES OF BATHS
● USE COOL WATER TO CLEAN THE DENTURES. ● COMPLETE BED BATH
(HOT WATER WILL CAUSE THEM TO WARP) ● PARTIAL BED BATH
● STORE THE DENTURES IN COOL WATER IN THE ● TUB BATH
PERSON’S DENTURE CUP ● SHOWER
● CHECK THE LINEN WHEN STRIPPING THE BED
OR THE MEAL TRAY BEFORE RETURNING IT FOR RULES FOR BATHING
WAYWARD DENTURES.
● ASK THE NURSE OR CHECK THE CARE PLAN TO
BACKRUBS DETERMINE WHAT TYPE OF BATH THE PERSON
SHOULD HAVE.
● BACKRUBS ARE USED TO STIMULATE THE ● ENCOURAGE THE PATIENT TO DO AS MUCH OF
PATIENT’S CIRCULATION, PREVENT SKIN THE BATH AS HE CAN.
BREAKDOWN, AND SOOTHE AND REFRESH THE ● OFFER THE BEDPAN OR URINAL BEFORE YOU
PATIENT. BEGIN THE PROCEDURE.
● USE LOTION TO PREVENT FRICTION. ● COLLECT ALL THE EQUIPMENT NECESSARY
● WARM THE LOTION UNDER WARM, RUNNING BEFORE BEGINNING THE PROCEDURE.
WATER. ● PROTECT THE PERSON’S PRIVACY. CLOSE
● STROKE UPWARD USING LONG, FIRM STROKES DOORS, CURTAINS, AND KEEP THE PERSON
THEN RETURN WITHOUT LIFTING YOUR HANDS COVERED WITH A BATH BLANKET.
FROM THE BACK. ● KEEP THE WATER AT A SAFE TEMPERATURE.
● USE CIRCULAR MOTIONS TO MASSAGE THE ● USE GOOD BODY MECHANICS
BONY AREAS OF THE BACK. ● USE STANDARD PRECAUTIONS AS NEEDED
● SOME PATIENTS ARE NOT ALLOWED TO HAVE ● PROTECT THE PERSON FROM FALLING
BACK RUBS! ● WASH FROM THE CLEANEST AREA TO THE
● CHECK WITH THE NURSE AND THE CARE PLAN DIRTIEST AREA
● IF WHEN APPLYING LOTION, YOU NOTICE ● RINSE ALL AREAS THROUGHLY
REDDENED AREAS OF SKIN--- ● PAT SKIN DRY. DO NOT RUB THE SKIN
● MASSAGE AROUND THE AREA BUT NOT OVER ● DRY UNDER BREASTS, BETWEEN SKIN FOLDS,
THE REDDENED AREA AND BETWEEN TOES
● BATHE SKIN WHENEVER URINE OR FECES IS
RESTORATIVE SKIN CARE
PRESENT
WHEN GIVING A BATH YOU CAN EXAMINE THE ● MAKE A MITT WITH THE WASHCLOTH
PATIENT’S ENTIRE BODY. - WASH THE EYES FIRST. FROM THE
INSIDE CORNER TO THE OUTSIDE,
OBSERVE AND REPORT SKIN THAT IS:
USING A DIFFERENT AREA OF THE
● PALE, DARK, OR REDDENED IN COLOR. CLOTH FOR EACH EYE.
● ROUGH OR CHAPPED IN TEXTURE. - AFTER WASHING THE FACE, NECK, AND
● DRY OR FLAKING, LACKING IN MOISTURE. EARS, REMOVE THE GOWN AND WASH
● INJURED (BLISTERS, BRUISES, OR LACERATIONS) THE ARMS, ONE AT A TIME.
● SORE (PRESSURE SORES OR INFECTIONS) - PLACE THE TOWEL OVER THE PATIENT’S
CHEST. LIFT THE CORNER AS YOU WASH
BENEFITS OF BATHING THE CHEST. REPEAT FOR THE ABDOMEN.
● REMOVES PERSPIRATION, DIRT, AND GERMS - WASH THE BACK AND THE BUTTOCKS. A
● REFRESHES PATIENTS AND MAKES THEM MORE BACKRUB MAY BE GIVEN AT THIS TIME.
COMFORTABLE - WASH AND DRY ONE LEG AT A TIME.
● STIMULATES CIRCULATION
 - CHANGE THE WATER AT THIS TIME IF - A BATH SHOULD LAST NO LONGER
YOU HAVE NOT ALREADY NEEDED TO THAN 20 MINUTES.
DO SO. - PLACE A TOWEL ON THE BOTTOM OF
THE TUB TO PREVENT SLIPPING.
COMPLETE BED BATH - ADJUST THE WATER TEMPERATURE TO
● A COMPLETE BED BATH IS GIVEN TO PATIENTS 105°
WHO ARE NOT ABLE TO BATHE THEMSELVES. - DRAIN THE TUB BEFORE THE PERSON
● INVOLVES WASHING THE PERSON’S ENTIRE GETS OUT.
BODY IN BED. - CLEAN THE TUB BEFORE AND ATER USE.
● PERSONS WHO ARE:
SHOWER
- UNCONSCIOUS
- PARALYZED A RESIDENT WILL BE PLACED ON A SHOWER CHAIR TO
- IN A CAST OR TRACTION RECEIVE A SHOWER
- WEAK FROM ILLNESS OR SURGERY
● NEVER LEAVE THE PATIENT ALONE ON THE
PROCEDURE FOR BED BATHING SHOWER CHAIR OR IN THE SHOWER ROOM.
● ADJUST THE WATER TEMPERATURE BEFORE
● PLACE EVERYTHING YOU NEED ON THE YOU PLACE THE PERSON IN THE SHOWER.
OVERBED TABLE BEFORE BEGINNING THE BATH. ● CLEAN THE SHOWER BEFORE AND AFTER USE.
● RAISE THE BED TO A COMFORTABLE HEIGHT ● GLOVES MAY BE WORN WHILE BATHING A
AND RAISE THE RAIL ON THE FAR SIDE OF THE PATIENT IF DESIRED.
BED. ● NEVER LEAVE THE PATIENT ALONE ON THE
● WASH ONLY ONE PART OF THE BODY AT A TIME. SHOWER CHAIR OR IN THE SHOWER ROOM.
WASH, RINSE, AND DRY EACH PART AND THEN ● ADJUST THE WATER TEMPERATURE BEFORE
COVER IT WITH THE BATH BLANKET. YOU PLACE THE PERSON IN THE SHOWER.
● CHANGE THE WATER IN THE BASIN WHENEVER ● CLEAN THE SHOWER BEFORE AND AFTER USE.
IT BECOMES SOAPY, DIRTY, OR COOL. ● GLOVES MAY BE WORN WHILE BATHING A
● KEEP THE SOAP IN THE SOAP DISH BETWEEN PATIENT IF DESIRED.
LATHERINGS.
● WASH FROM THE CLEANEST TO THE DIRTEST SPECIALTY BATH
AREAS.
● A WHIRLPOOL BATH HELPS TO STIMULATE
PARTIAL BATH CIRCULATION AND RELAX MUSCLES
● A PORTABLE TUB CAN BE USED FOR COMATOSE
● INVOLVES WASHING THE AREAS OF THE BODY PATIENTS
THAT CAUSE DISCOMFORT AND ODOR OR NEED
DAILY CLEANING. PERINEAL CARE
● THE AREAS THAT ARE WASHED IN A PARTIAL
● INVOLVES THE CLEANING OF THE GENITAL AND
BATH ARE THE FACE, HANDS, AXILLAE, BACK,
ANAL AREAS OF THE BODY
AND PERINEAL AREA. OR
● THE PERINEAL AREA IS WARM, DARK, AND
● A PARTIAL BATH MAY REFER TO BATHING THE
MOIST AND SO PROVIDES AN IDEAL
AREAS THAT THE PATIENT CAN NOT REACH
ENVIRONMENT FOR MICROORGANISMS TO
WHEN HE IS BATHING HIMSELF IN BED.
GROW.
TUB BATH ● THE AREAS ARE CLEANED AT LEAST ONCE DAILY
TO PREVENT INFECTION AND ODORS AND TO
● BECAUSE OF SAFETY CONCERNS TUB BATHS ARE
PROVIDE COMFORT.
NOT FREQUENTLY GIVEN IN MOST NURSING
● PERI-CARE SHOULD BE PROVIDED AFTER EACH
HOMES.
INCONTINENT EPISODE.
● SAFETY MEASURES:
● USE STANDARD PRECAUTIONS.
- NEVER LEAVE A PATIENT ALONE IN THE
● MAY HAVE TO USE THE TERM PRIVATE AREA
TUB.
 FEMALE PERI-CARE ● PATIENTS SHOULD BE ASKED HOW THEY
WOULD LIKE THEIR HAIR STYLED.
● ALWAYS CLEANSE FROM THE URINARY MEATUS
TOWARD THE ANUS. (CLEAN TO DIRTY)
● DO NOT CHANGE A PATIENT’S HAIRSTYLE
● MAY HAVE A PREPACKAGED KIT OR USE WET WITHOUT PERMISSION.
WASHCLOTHS. ● NEVER CUT A PATIENT’S HAIR.
● USE A DIFFERENT PART OF THE WASHCLOTH ● MAKE SURE THE STYLE IS
FOR EACH STROKE AGE-APPROPRIATE.
● TO CLEAN THE ANAL AREA, CLEANSE FROM THE
VAGINA TOWARD THE ANUS (CLEAN TO DIRTY)
SHAMPOOING THE HAIR

MALE PERI-CARE ● THE HAIR IS USUALLY SHAMPOOED DURING

THE RESIDENT’S SHOWER
● START AT THE URINARY MEATUS AND USE - PUT A WASHCLOTH OVER THE
CIRCULAR MOTIONS AS YOU WIPE DOWNWARD PATIENT’S EYES
TO THE BASE
- RETURN MEDICATED SHAMPOO TO
● RETRACT THE FORESKIN IF THE PATIENT IS
THE NURSE
UNCIRCUMCISED
● RETURN THE FORESKIN TO ITS NATURAL
- TIP THE PERSON’S HEAD BACK TO
POSITION WHEN YOU ARE FINISHED PREVENT THE SHAMPOO FROM
RUNNING IN THE EYES
SKIN AND SCALP CONDITIONS ● A SHAMPOO TRAY CAN BE USED TO
● ALOPECIA – HAIR LOSS SHAMPOO THE HAIR OF A BEDBOUND
- MAY RESULT FROM HEREDITY PATIENT
- HAIR MAY THIN WITH AGING SHAVING THE PATIENT
- MAY BE RESULT OF CANCER
TREATMENTS ● ALWAYS WEAR GLOVES.
● HIRSUTISM – EXCESSIVE BODY HAIR ● PLACE A TOWEL ON THE PATIENT’S CHEST
- CAN OCCUR IN MEN, WOMEN, OR ● APPLY SHAVING CREAM TO THE FACE
CHILDREN ● SHAVE IN THE DIRECTION OF HAIR GROWTH
- MAY RESULT FROM HEREDITY OR ● HOLD THE SKIN TAUT WITH YOUR OTHER
HORMONE IMBALANCE HAND
● DANDRUFF – EXCESSIVE AMOUNT OF DRY, ● RINSE THE RAZOR FREQUENTLY
WHITE FLAKES FROM THE SCALP ● WASH THE FACE WHEN FINISHED
- PEDICULOSIS – INFESTATION OF LICE. CARING FOR MUSTACHES AND BEARDS
- CAPITUS – INFESTATION OF THE
SCALP ● DAILY WASHING AND COMBING ARE
- PUBIS – INFESTATION OF PUBIC HAIR NEEDED
- CORPORIS – INFESTATION OF BODY ● NEVER TRIM OR SHAVE A BEARD OR
HAIR MUSTACHE WITHOUT THE PERSON’S
● SCABIES – SMALL MITES BURROW UNDER CONSENT
THE SKIN AND LAYS EGGS. SHAVING LEGS AND UNDERARMS
HAIR CARE ● PRACTICE VARIES AMONG CULTURES
● PEOPLE FEEL BETTER ABOUT THEMSELVES ● USUALLY SHAVED AFTER BATHING
WHEN THEIR HAIR IS COMBED AND LOOKS ● WEAR GLOVES AND FOLLOW STANDARD
ATTRACTIVE. PRECAUTIONS
 ● UNDERARMS – SHAVE IN DIRECTION OF ● IN A NURSING HOME RESIDENTS ARE
HAIR GROWTH REQUIRED BY THE STATE TO BE DRESSED IN
● LEGS – START AT ANKLE AND SHAVE UP THE STREET CLOTHES DURING THE DAY
LEG ● IF THE RESIDENT CAN NOT ASSIST, IT IS
● APPLY DIRECT PRESSURE TO CUTS EASIER AND SAFER TO DRESS THE RESIDENT
WHILE SHE IS STILL IN BED.
NAIL CARE
GUIDELINES FOR DRESSING AND UNDRESSING
● SOAKING THE HANDS HELPS TO SOFTEN
THE NAILS BEFORE TRIMMING. ● PROVIDE FOR PRIVACY. DO NOT EXPOSE THE
● SOAK FINGERNAILS FOR 5 TO 10 MINUTES PERSON.
● ALWAYS USE A NAIL CLIPPER- NEVER ● ENCOURAGE THE PERSON TO DO AS MUCH
SCISSORS AS POSSIBLE.
● FILE ROUGH NAILS WITH AN EMERY BOARD ● ALLOW THE PERSON TO CHOOSE WHAT TO
● DO NOT TRIM TOENAILS!! ONLY AN RN OR WEAR.
DR. CAN TRIM TOENAILS. ● REMOVE CLOTHING FROM THE STRONG OR
GOOD SIDE FIRST.
EXAMINE THE FEET FOR: ● PUT CLOTHING ON THE WEAK SIDE FIRST.
● INGROWN NAILS - TOS – TAKE OFF STRONG
● HANG NAILS - POW – PUT ON WEAK
● BROKEN OR TORN NAILS ● A PERSON MAY HAVE TO BE TURNED FROM
● BLISTERS, RASH, OR REDDENED AREA SIDE TO SIDE AS YOU PUT ON OR REMOVE
● CALLUSES AND CORNS THEIR PANTS.
● SKIN BREAKS AND OTHER INJURIES. CHECK DRESSING THE PATIENT WITH AN IV
BETWEEN THE TOES FOR CRACKS AND
SORES. ● THE GOWN IS FIRST REMOVED FROM THE
● COMPLAINTS OF PAIN OR ITCHING GOOD ARM.
● IT IS THEN SLIPPED OVER THE IV SITE AND
LET THE NURSE KNOW IF THE PATIENT’S TOENAILS TUBING TO THE BAG.
NEED TRIMMING. ● THE BAG IS PASSED THROUGH THE SLEEVE.
SOAKING THE FEET ● THE CLEAN GOWN IS PASSED OVER THE IV
BAG.
● SOAK FEET FOR 15 TO 20 MINUTES
● CHECK WITH RN FOR WATER
TEMPERATURE.
● AFTER SOAKING, APPLY LOTION TO THE
FEET. DO NOT APPLY BETWEEN THE TOES.
● MAKE SURE YOU DRY THROUGHLY
BETWEEN THE TOES
● FOLLOW STANDARD PRECAUTIONS
ASSISTING WITH DRESSING
● IN A HOSPITAL PATIENTS WEAR HOSPITAL
GOWNS OR THEIR NIGHTCLOTHES