DUTIES OF SCRUB NURSE

Before an operation

Ensures that the circulating nurse has checked the equipment Ensures that the theater has been cleaned before the trolley is set Prepares the instruments and equipment needed in the operation Uses sterile technique for scrubbing, gowning and gloving Receives sterile equipment via circulating nurse using sterile technique Performs initial sponges, instruments and needle count, checks with circulating nurse

When surgeon arrives after scrubbing

Perform assisted gowning and gloving to the surgeon and assistant surgeon as soon as they enter the operation suite Assemble the drapes according to use. Start with towel, towel clips, draw sheet and then lap sheet. Then, assist in draping the patient aseptically according to routine procedure Place blade on the knife handle using needle holder, assemble suction tip and suction tube Bring mayo stand and back table near the draped patient after draping is completed Secure suction tube and cautery cord with towel clips or allis Prepares sutures and needles according to use

During an operation

Maintain sterility throughout the procedure Awareness of the patients safety Adhere to the policy regarding sponge/ instruments count/ surgical needles Arrange the instrument on the mayo table and on the back table

Before the Incision Begins

Provide 2 sponges on the operative site prior to incision Passes the 1st knife for the skin to the surgeon with blade facing downward and a hemostat to the assistant surgeon Hand the retractor to the assistant surgeon Watch the field/ procedure and anticipate the surgeons needs Pass the instrument in a decisive and positive manner Watch out for hand signals to ask for instruments and keep instrument as clean as possible by wiping instrument with moist sponge Always remove charred tissue from the cautery tip Notify circulating nurse if you need additional instruments as clear as possible Keep 2 sponges on the field Save and care for tissue specimen according to the hospital policy Remove excess instrument from the sterile field

Adhere and maintain sterile technique and watch for any breaks

End of Operation

Undertake count of sponges and instruments with circulating nurse Informs the surgeon of count result Clears away instrument and equipment After operation: helps to apply dressing Removes and siposes of drapes De-gown Prepares the patient for recovery room Completes documentation Hand patient over to recover room

DUTIES OF CIRCULATING NURSE

Before an operation

Checks all equipment for proper functioning such as cautery machine, suction machine, OR light and OR table Make sure theater is clean Arrange furniture according to use Place a clean sheet, arm board (arm strap) and a pillow on the OR table Provide a clean kick bucket and pail Collect necessary stock and equipment Turn on aircon unit Help scrub nurse with setting up the theater Assist with counts and records

During the Induction of Anesthesia

Turn on OR light Assist the anesthesiologist in positioning the patient Assist the patient in assuming the position for anesthesia Anticipate the anesthesiologists needs If spinal anesthesia is contemplated:

Place the patient in quasi fetal position and provide pillow Perform lumbar preparation aseptically Anticipate anesthesiologists needs After the patient is anesthetized

Reposition the patient per anesthesiologists instruction

Attached anesthesia screen and place the patients arm on the arm boards Apply restraints on the patient Expose the area for skin preparation Catheterize the patient as indicated by the anesthesiologist Perform skin preparation

During Operation

Remain in theater throughout operation Focus the OR light every now and then Connect diatherapy, suction, etc. Position kick buckets on the operating side Replenishes and records sponge/ sutures Ensure the theater door remain closed and patient s dignity is upheld Watch out for any break in aseptic technique

End of Operation

Assist with final sponge and instruments count Signs the theater register Ensures specimen are properly labeled and signed

After an Operation

Hands dressing to the scrub nurse Helps remove and dispose of drapes Helps to prepare the patient for the recovery room Assist the scrub nurse, taking the instrumentations to the service (washroom) Ensures that the theater is ready for the next case

ROLE OF SCRUB NURSE

1. Works directly with surgeon within the sterile field, passing instruments, sponges and other

items needed during the procedure

2. Members of the surgical team who prepares and preserves a sterile field in which the
operation

can take place

3. Responsible for the sponge counts, the blades and needles and instruments check

throughout the operation 4. Has a job requiring anticipation, quick reaction and conscientious observation as well as knowledge of anatomy and of operative procedures

ROLE OF THE PERIOPERATIVE NURSE

1. Creating and maintaining the sterile field is the responsibility of perioperative nurse

2. All members of surgical team must be knowledgeable of and adhere to aseptic technique principles 3. Perioperative nurse monitors the implementation of aseptic technique principle by all surgical team members and ensures that beaks in techniques are corrected.

PRINCIPLES OF ASEPTIC TECHNIQUE

Only sterile items are used within sterile field. Sterile objects become unsterile when touched by unsterile objects. Sterile items that are out of vision or below the waist level of the nurse are considered unsterile. Sterile objects can become unsterile by prolong exposure to airborne microorganisms. Fluids flow in the direction of gravity. Moisture that passes through a sterile object draws microorganism from unsterile surfaces above or below to the surface by capillary reaction. The edges of a sterile field are considered unsterile. The skin cannot be sterilized and is unsterile. Conscientiousness, alertness and honesty are essential qualities in maintaining surgical asepsis

HISTORICAL EVOLUTION OF NURSING

I. Period of Intuitive Nursing/Medieval Period Nursing was untaught and instinctive. It was performed of compassion for others, out of the wish to help others. Nursing was a function that belonged to women. It was viewed as a natural nurturing job for women. She is expected to take good care of the children, the sick and the aged. No caregiving training is evident. It was based on experience and observation. Primitive men believed that illness was caused by the invasion of the victims body of evil spirits. They believed that the medicine man, Shaman or witch doctor had the power to heal by using white magic, hypnosis, charms, dances, incantation, purgatives, massage, fire, water and herbs as a mean of driving illness from the victim. Trephining drilling a hole in the skull with a rock or stone without anesthesia was a last resort to drive evil spirits from the body of the afflicted. II. Period of Apprentice Nursing/Middle Ages Care was done by crusaders, prisoners, religious orders Nursing care was performed without any formal education and by people who were directed by more experienced nurses (on the job training). This kind of nursing was developed by religious orders of the Christian Church. Nursing went down to the lowest level -wrath/anger of Protestantism confiscated properties of hospitals and schools connected with Roman Catholicism.

- Nurses fled their lives; soon there was shortage of people to care for the sick - Hundreds of Hospitals closed, there was no provision for the sick, no one to care for the sick - Nursing became the work of the least desirable of women prostitutes, alcoholics, prisoners Pastor Theodore Fliedner and his wife, frederika established the Kaiserswerth Institute for the training of Deaconesses (the 1st formal training school for nurses) in Germany. - This was where Florence Nightingale received her 3-month course of stude in nursing. III. Period of Educated Nursing/Nightingale Era 19th-20th century The development of nursing during this period was strongly influenced by: a.) trends resulting from wars Crimean, civil war b.) arousal of social consciousness c.) increased educational opportunities offered to women. Florence Nightingale was asked by Sir Sidney Herbert of the British War Department to recruit female nurses to provide care for the sick and injured in the Crimean War. In 1860, The Nightingale Training School of Nurses opened at St. Thomas Hospital in London. - The school served as a model for other training schools. Its graduates traveled to other countries to manage hospitals and institute nurse-training programs. - Nightingale focus vision of nursing Nightingale system was more on developing the profession within hospitals. Nurses should be taught in hospitals associated with medical schools and that the curriculum should include both theory and practice. - It was the 1st school of nursing that provided both theory-based knowledge and clinical skill building. Nursing evolved as an art and science Formal nursing education and nursing service begun FACTS ABOUT FLORENCE NIGHTINGALE Mother of modern nursing. Lady with the Lamp because of her achievements in improving the standards for the care of war casualties in the Crimean war. Born may 12, 1800 in Florence, Italy Raised in England in an atmosphere of culture and affluence Not contended with the social custom imposed upon her as a Victorian Lady, she developed her self-appointed goal: To change the profile of Nursing She compiled notes of her visits to hospitals and her observations of the sanitary facilities, social problems of the places she visited. Noted the need for preventive medicine and god nursing Advocated for care of those afflicted with diseases caused by lack of hygienic practices At age 31, she entered the Deaconesses School at Kaiserswerth inspite of her familys resistance to her ambitions. She became a nurse over the objections of society and her family. Worked as a superintendent for Gentlewomen Hospital, a charity hospital for ill governesses. Disapproved the restrictions on admission of patients and considered this unchristian and incompatible with health care Upgraded the practice of nursing and made nursing an honorable profession for women. Led nurses that took care of the wounded during the Crimean war

Put down her ideas in 2 published books: Notes on Nursing, What It Is ans What It Is Not and Notes on Hospitals. She revolutionized the publics perception of nursing (not the image of a doctors handmaiden) and the method for educating nurses. IV. Period of Contemporary Nursing/20th Century Licensure of nurses started Specialization of Hospital and diagnosis Training of Nurses in diploma program Development of baccalaureate and advance degree programs Scientific and technological development as well as social changes mark this period. a. Health is perceived as a fundamental human right b. Nursing involvement in community health c. Techological advances disposable supplies and equipments d. Expanded roles of nurses was developed e. WHO was established by the United Nations f. Aerospace Nursing was developed g. Use of atomic energies for medical diagnosis, treatment h. Computers were utilized-data collection, teaching, diagnosis, inventory, payrolls, record keeping, billing. i. Use of sophisticated equipment for diagnosis and therapy.

NURSING AS A PROFESSION
Profession - is a calling that requires special knowledge, skill and preparation. An occupation that requires advanced knowledge and skills and that it grows out of societys needs for special services. Criteria of Profession: 1. To provide a needed service to the society. 2. To advance knowledge in its field. 3. To protect its members and make it possible to practice effectively. Characteristics of a Profession: 1. A basic profession requires an extended education of its members, as well as a basic liberal foundation. 2. A profession has a theoretical body of knowledge leading to defined skills, abilities and norms. 3. A profession provides a specific service. 4. Members of a profession have autonomy in decision-making and practice. 5. The profession has a code of ethics for practice. NURSING >is a disciplined involved in the delivery of health care to the society.

>is a helping profession >is service-oriented to maintain health and well-being of people. >is an art and a science. NURSE - originated from a Latin word NUTRIX, to nourish. Characteristics of Nursing: 1. Nursing is caring. 2. Nursing involves close personal contact with the recipient of care. 3. Nursing is concerned with services that take humans into account as physiological, psychological, and sociological organisms. 4. Nursing is committed to promoting individual, family, community, and national health goals in its best manner possible. 5. Nursing is committed to personalized services for all persons without regard to color, creed, social or economic status. 6. Nursing is committed to involvement in ethical, legal, and political issues in the delivery of health care. Personal Qualities of a Nurse:

1. Must have a Bachelor of Science degree in nursing.

2. Must be physically and mentally fit. 3. Must have a license to practice nursing in the country. A professional nurse therefore, is a person who has completed a basic nursing education program and is licensed in his country to practice professional nursing. Roles of a Professional

1. Caregiver/ Care provider

the traditional and most essential role functions as nurturer, comforter, provider mothering actions of the nurse provides direct care and promotes comfort of client activities involves knowledge and sensitivity to what matters and what is important to clients show concern for client welfare and acceptance of the client as a person

2. Teacher

provides information and helps the client to learn or acquire new knowledge and technical skills encourages compliance with prescribed therapy. promotes healthy lifestyles

interprets information to the client

3. Counselor

helps client to recognize and cope with stressful psychologic or social problems; to develop an improve interpersonal relationships and to promote personal growth provides emotional, intellectual to and psychologic support focuses on helping a client to develop new attitudes, feelings and behaviors rather than promoting intellectual growth. encourages the client to look at alternative behaviors recognize the choices and develop a sense of control.

4. Change agent

initiate changes or assist clients to make modifications in themselves or in the system of care.

5. Client advocate

involves concern for and actions in behalf of the client to bring about a change. promotes what is best for the client, ensuring that the clients needs are met and protecting the clients right. provides explanation in clients language and support clients decisions.

6. Manager

makes decisions, coordinates activities of others, allocate resource evaluate care and personnel plans, give direction, develop staff, monitors operations, give the rewards fairly and represents both staff and administrations as needed.

7. Researcher

participates in identifying significant researchable problems participates in scientific investigation and must be a consumer of research findings must be aware of the research process, language of research, a sensitive to issues related to protecting the rights of human subjects.

Expanded role as of the nurse 1 Clinical Specialists- is a nurse who has completed a masters degree in specialty and has considerable clinical expertise in that specialty. She provides expert care to individuals, participates in educating health care professionals and ancillary, acts as a clinical consultant and participates in research. 2. Nurse Practitioner- is a nurse who has completed either as certificate program or a masters degree in a specialty and is also certified by the appropriate specialty organization.

She is skilled at making nursing assessments, performing P. E., counseling, teaching and treating minor and self- limiting illness. 3. Nurse-midwife- a nurse who has completed a program in midwifery; provides prenatal and postnatal care and delivers babies to woman with uncomplicated pregnancies. 4. Nurse anesthetist- a nurse who completed the course of study in an anesthesia school and carries out pre-operative status of clients. 5. Nurse Educator- A nurse usually with advanced degree, who beaches in clinical or educational settings, teaches theoretical knowledge, clinical skills and conduct research. 6. Nurse Entrepreneur- a nurse who has an advanced degree, and manages health-related business. 7. Nurse administrator- a nurse who functions at various levels of management in health settings; responsible for the management and administration of resources and personnel involved in giving patient care. Fields and Opportunities in Nursing 1. Hospital/Institutional Nursing a nurse working in an institution with patients Example: rehabilitation, lying-in, etc. 2. Public Health Nursing/Community Health Nursing usually deals with families and communities. (no confinement, OPD only) Example: brgy. Health Center 3. Private Duty/special Duty Nurse privately hired 4. Industrial/Occupational Nursing a nurse working in factories, office, companies 5. Nursing Education nurses working in school, review center and in hospital as a CI. 6. Military Nurse nurses working in a military base. 7. Clinic Nurse nurses working in a private and public clinic. 8. Independent Nursing Practice private practice, BP monitoring, home service. - Independent Nurse Practitioner.

ETHICO-MORAL ASPECTS IN NURSING

Ethos - comes from Greek work w/c means character/culture - Branch of Philosophy w/c determines right and wrong Moral - personal/private interpretation from what is good and bad. Ethical Principles:
1. Autonomy the right/freedom to decide (the patient has the right to refuse despite the

explanation of the nurse) Example: surgery, or any procedure 2. Nonmaleficence the duty not to harm/cause harm or inflict harm to others (harm maybe physical, financial or social) 3. Beneficence- for the goodness and welfare of the clients 4. Justice equality/fairness in terms of resources/personnel 5. Veracity - the act of truthfulness 6. Fidelity faithfulness/loyalty to clients Moral Principles: 1. Golden Rule 2. The principle of Totality The whole is greater than its parts 3. Epikia There is always an exemption to the rule 4. One who acts through as agent is herself responsible (instrument to the crime) 5. No one is obliged to betray herself You cannot betray yourself 6. The end does not justify the means 7. Defects of nature maybe corrected 8. If one is willing to cooperate in the act, no justice is done to him 9. A little more or a little less does not change the substance of an act. 10. No one is held to impossible Law - rule of conduct commanding what is right and what is wrong. Derived from an AngloSaxon term that means that which is laid down or fixed Court -body/agency in government wherein the administration of justice is delegated. Plaintiff complainant or person who files the case (accuser) Defendant accused/respondent or person who is the subject of complaint Witness individual held upon to testify in reference to a case either for the accused or against the accused. Written orders of court 1. Writ legal notes from the court A. Subpoena 1. Subpoena Testificandum a writ/notice to an individual/ordering him to appear in court at a specific time and date as witness.

2. Subpoena Duces Tecum- notice given to a witness to appear in court to testify including all important documents Summon notice to a defendant/accused ordering him to appear in court to answer the complaint against him Warrant of Arrest - court order to arrest or detain a person Search warrant - court order to search for properties. Private/Civil Law - body of law that deals with relationships among private individuals Public law - body of law that deals with relationship between individuals and the State/government and government agencies. Laws for the welfare of the general public. Private/Civil Law : 1. Contract law involves the enforcement of agreements among private individuals or the payment of compensation for failure to fulfill the agreements Ex. Nurse and client nurse and insurance Nurse and employer client and health agency - an agreement between 2 or more competent person to do or not to do some lawful act. - it maybe written or oral= both equally binding Types of Contract: 1. Expressed when 2 parties discuss and agree orally or in writing the terms and conditions during the creation of the contract. Example: nurse will work at a hospital for only a stated length of time (6 months),under stated conditions (as volunteer, straight AM shift, with food/transportation allowance) 2. Implied one that has not been explicitly agreed to by the parties, but that the law considers to exist. Example: Nurse newly employed in a hospital is expected to be competent and to follow hospital policies and procedures even though these expectations were not written or discussed. Likewise: the hospital is expected to provide the necessary supplies, equipment needed to provide competent, quality nursing care. Feature/Characteristics/Elements of a lawful contract:

1. Promise or agreement between 2 or more persons for the performance of an action or restraint from certain actions. 2. Mutual understanding of the terms and meaning of the contract by all. 3. A lawful purpose activity must be legal 4. Compensation in the form of something of value-monetary Persons who may not enter into a contract: minor, insane, deaf, mute and ignorant 1. Tort law is a civil wrong committed against a person or a persons property. - person/persons responsible for the tort are sued for DAMAGES - Is based on : ACT OF COMMISSION something that was done incorrectly or ACT OF OMMISION something that should have been done but was not. Classification of Tort 1. Unintetional a. Negligence misconduct or practice that is below the standard expected of ordinary, reasonable and prudent person - failure to do something due to lack of foresight or prudence - failure of an individual to provide care that a reasonable person would ordinarily use in a similar circumstance. - An act of omission or commission wherein a nurse fails to act in accordance with the standard of care. Doctrines of Negligence: 1. Res ipsa loquitor the thing speaks for itself the injury is enough proof of negligence 2. Respondeat Superior let the master answer command responsibility 3. Force majuere unforeseen event, irresistible force b. malpractice stepping beyond ones authority 6 elements of nursing malpractice:

1. duty the nurse must have a relationship with the client that involves providing care and following an acceotable standard of care. 2. breach of duty the standard of care expected in a situation was not observed by the nurse -is the failure to act as a reasonable, prudent nurse under the circumstances -something was done that should not have been done or nothing was done when it should have been done 3. foreseeability a link must exist between the nurses act and the injury suffered 4. causation it must be proved that the harm occurred as a direct result of the nurses failure to follow the standard of care and the nurse should or could have known that the failure to follow the standard of care could result in such harm. 5. harm/injury physical, financial, emotional as a result of the breach of duty to the client Example: physical injury, medical cost/expenses, loss of wages, pain and suffering 6. damages amount of money in payment of damage/harm/injury II. Intentional Tort Unintentional tort do not require intent bur do require the element of HARM Intentional tort the act was done on PURPOSE or with INTENT - No harm/injury/damage is needed to be liable - No expert witnesses are needed 1. Assault an attempt or threat to touch another person unjustifiably

Ex.: A person who threatens someone with a club or closed fist. Nurse threatens a client with an injection after refusing to take the meds orally. 1. Battery willful touching of a person, persons clothes or something the person is carrying that may or may not cause harm but the touching was done without permission, without consent, is embarrassing or causes injury. Example: a nurse threatens the patient with injection if the patient refuses his medsorally. If the nurse gave the injection without clients consent, the nurse would be committing battery even if the client benefits from the nurses action. 1. False Imprisonment unjustifiable detention of a person without legal warrant to confine the person - occurs when clients are made to wrongful believe that they cannot leave the place Example: Telling a client no to leave the hospital until bill is paid Use of physical or chemical restraints False Imprisonment Forceful Restraint=Battery 1. Invasion Of Privacy intrusion into the clients private domain -right to be left alone Types of Invasion the client must be protected from: a. use of clients name for profit without consent using ones name, photograph for advertisements of HC agency or provider without clients permission b. Unreasonable intrusion observation or taking of photograph of the client for whatever purpose without clients consent. c. Public disclosure of private facts private information is given to others who have no legitimate need for that. d. Putting a person in a false/bad light publishing information that is normally considered offensive but which is not true. 1. Defamation communication that is false or made with a careless disregard for the truth and results in injury to the reputation of a person Types:

a. Libel defamation by means of print, writing or picture Example: writing in the chart/nurses notes that doctor A is incompetent because he didnt respond immediately to a call a. Slander defamation by the spoken word stating unprivileged (not legally protected) or false word by which a reputation is damaged Example: Nurse A telling a client that nurse B is incompetent - person defamed may bring the lawsuit - the material (nurses notes) must be communicated to a 3rd party in order that the persons reputation maybe harmed Public Law: 1. Criminal Law deals with actions or offenses against the safety and welfare of the public. a. b. c. d. e. f. homicide self-defense arson- burning or property theft stealing sexual harassment active euthanasia illegal possession of controlled drugs

Homicide killing of any person without criminal intent may be done as self-defense Arson willful burning of property Theft act of stealing

VITAL SIGNS1
These are indices of health, or signposts in determining clients condition. This is also known as cardinal signs and it includes body temperature, pulse, respirations, and blood pressure. These signs have to be looked at in total, to monitor the functions of the body. Different considerations in Taking Vital signs 1) The frequency of taking TPR and BP depends upon the condition of the client and the policy of the institution.

2) The procedure should be explained to the client before taking his TPR and BP. 3) Obtain baseline data. 1. BODY TEMPERATURE Factors that Affect Body Temperature 1. Age The infant is greatly influenced by the temperature of the environment and must be protected from extreme changes. Childrens temperature continue to be more labile than those of adults until puberty. Elderly people are at risk of hypothermia for variety of reasons. Such as lack of central heating, inadequate diet, loss of subcutaneous fat, lack of activity, and reduced thermoregulatory efficiency. 2. Diurnal variations (circadian rhythms) This refers to the sleep wake rhythm of the body, a pattern that varies slightly from person to person. Body temperature normally changes throughout the day, varying as much as 1.0C between the early morning and the late afternoon. 3. Exercise Hard work or strenuous exercise can increase body temperature. 4. Hormones Women usually experience more hormone fluctuations than men do. Progesterone secretion at the time of ovulation raises body temperature above basal temperature. 5. Stress Stimulation of the SNS can increase the production of epinephrine and norepinephrine, thereby increasing metabolic activity and heat production. 6. Environment Extremes in environmental temperatures can affect a persons temperature regulatory systems. Common Sites for Measuring BT 1. Oral

This is the most accessible and convenient. However, because of the mercury in glass thermometer, this is contraindicated for children under 6 years and clients who are confused or who have convulsive disorder. 2. Rectal This is considered the most accurate. However, it is inconvenient and more unpleasant for client. It is contraindicated for clients who are undergoing rectal surgery or have diarrhea or diseases of the rectum. 3. Axillary This is the safest and most noninvasive. It is the preferred site for measuring temperature in newborns because there was no possibility of rectal perforation. 4. Tympanic membrane This is readily accessible and reflects the core temperature. The tympanic has an abundant arterial blood supply, primarily from branches of the external carotid artery. The noninvasive infrared thermometers are now used for this purpose. Nursing Interventions for Clients with fever (Fund. Of Nursing, Kozier, et al.)
1. Monitor vital signs.

2. Assess skin color and temperature. 3. Monitor white blood cell count, hematocrit value, and other pertinent laboratory records. 4. Remove excess blankets when the client feels warm, but provide extra warmth when the client feels chilled. 5. Provide adequate food and fluids to meet the increased metabolic demands and prevent dehydration, if health permits. Clients who sweat profusely can become dehydrated. 6. Measure intake and output. 7. Maintain prescribed intravenous fluids. 8. Reduce physical activity to limit heat producing, especially the flush stage. 9. Administer antipyretics as ordered. 10. Provide oral hygiene to keep the mucous membranes moist. They can become dry and cracked because of excessive fluid loss. 11. Provide a tepid sponge bath to increase heat loss through conduction. 12. Provide dry clothing and bed linens to increase heat loss through conduction. 2. Pulse This is a wave of blood created by contraction of the left ventricle of the heart. The heart is a pulsating pump, and the blood enters the arteries with each heartbeat, causing pressure pulses or pulse waves. Generally, the pulse wave represents the stroke volume and the compliance of the arteries.

Stroke volume is the amount of blood that enters the arteries with each contraction in a healthy adult. Compliance of the arteries is their ability to contract and expand. When a persons arteries lose their distensibility, greater pressure is required to pump the blood into the arteries. Peripheral pulse is the pulse located in the periphery of the body, for example in the foot, hand and neck. Apical pulse is a central pulse. It is located at the apex of the heart. Factors Affecting Pulse Rate 1. Age As age increases, the pulse rate gradually decreases. 2. Sex After puberty, the average males pulse rate is slightly lower than the females. 3. Exercise Pulse rate normally increases with activity. 4. Fever The pulse rate increases in response to the lowered blood pressure that results from peripheral vasodilation associated with elevated body temperature, and because of the increased metabolic rate. 5. Medications Some medications decrease the pulse rate, and others increase it. 6. Hemorrhage Loss of blood from the vascular system normally increases pulse rate. 7. Stress In response to stress, sympathetic nervous stimulation increases the overall activity of the heart. Stress increases the rate as well as the force of the heartbeat. 8. Position changes When a person assumes a sitting or standing position, blood usually pools in dependent vessels of the venous system. Pooling results in a transient decrease in the venous blood return to

the heart and a subsequent reduction in blood pressure reduction in blood pressure and increase in the heart rate.

Characteristics of Normal Pulse 1. Rate This is the number of pulse beats per minute (70 80 beats/min in the adult). An excessively fast heart rate (100 beats/min) is referred to as tachycardia. A heart rate in the adult of 60 beats/minute or less is called bradycardia. 2. Pulse rhythm This is the pattern of the beats and the intervals between the beats. Equal time elapses between beats of a normal pulse. A pulse with an irregular rhythm is referred to as a dysrhythmia or arrhythmia. It may consist of random, irregular beats or a predictable pattern of irregular beats. 3. Pulse volume This is also called the pulse strength or amplitude. It refers to the force of blood with each beat. It can range from absent to bounding. A normal pulse can be felt with moderate pressure of the fingers and can be obliterated with greater pressure. A forceful or full blood volume that is obliterated only with difficulty is called a full or bounding pulse. A pulse that is readily obliterated with pressure from the fingers is referred to as weak, feeble, or thready. A pulse volume is usually measured on a scale 0 to 3. Pulse Sites
1. Temporal, where the temporal artery passes over the temporal bone of the head. The site is

superior and lateral to the eye.

2. Carotid, at the side of the neck below the lobe of the ear, where the carotid artery runs

between the trachea and the sternocleidomastoid muscle.

3. Apical, at the apex of the heart. 4. Brachial, at the inner aspect of the biceps muscle of the arm (especially in infants) or

medially in the antecubital space (elbow crease).

5. Radial, where the radial artery runs along the radial bone, on the thumb site of the inner

aspect of the wrist.

6. Femoral, where the femoral artery passes alongside the inguinal ligament. 7. Popliteal, where the popliteal artery passes behind the knee. This point is difficult to find,

but it can be palpated if the client flexes the knee slightly. 8. Poserior tibial, on the medial surface of the ankle where the posterior tibial artery passes behind the medial malleolus.

9. Pedal (dorsalis pedis), where the dorsalis pedis artery passes over the bones of the foot.

This artery can be palpated by feeling the dorsum of the foot on the imaginary line drawn from the middle of the ankle to the space between the big and second toes. 3. RESPIRATION Assessing Respirations Resting respirations should be assessed when the client is at rest because exercise affects respirations, and increase their rate and depth as well. Respiration may also need to be assessed after exercise to identify the clients tolerance to activity. Before assessing a clients respirations, a nurse should be aware of: The clients normal breathing pattern. The influence of the clients health problems on respirations. Any medications or therapies that might affect respirations. The relationship of the clients respirations to cardiovascular function. Characteristics of Normal Respiration 1. Respiratory rate This is described in breaths per minute. A healthy adult normally takes between 15 and 20 breaths per minute. Breathing that is normal in rate is eupnea. Abnormally slow respirations are referred to as bradypnea, and abnormally fast respirations are called tachypnea or polypnea. 2. Depth This can be established by watching the movement of the chest. It is generally described as normal, deep, or shallow. 3. Respiratory rhythm or pattern This refers to the regularity of the expirations and the inspirations. Normally, respirations are evenly spaced. Respiratory rhythm can be described as regular or irregular. 4. Respiratory quality or character This refers to those aspects of breathing that are different from normal, effortless breathing. It includes:
a. Amount of effort a client must exert to breathe. Usually, breathing does not require

noticeable effort.

b. The sound of breathing. Normal breathing is silent, but a number of abnormal sounds such

as a wheeze are obvious to the nurses ear. 4. BLOOD PRESSURE This is the force exerted by the blood against a vessel wall. Arterial blood pressure is a measure of the pressure exerted by the blood as it flows through the arties. There are two blood pressure measures:
1. Systolic pressure. This is the pressure of the blood because of contraction of the ventricles,

which is the height of the blood wave.

2. Diastolic pressure. This is the pressure when the ventricles are at rest. It is the lower

pressure present at all times within the arteries. Pulse pressure is the difference between the diastolic and systolic pressures. Blood pressure is measured in millimeters of mercury (mm Hg) and recorded as a fraction. The systolic pressure is written over the diastolic pressure. The average blood pressure of a healthy adult is 120/80 mm Hg. A number of conditions are reflected by changes in blood pressure. The most common is hypertension, an abnormally high blood pressure. Hypotension is an abnormally low blood pressure below 100min Hg systolic. Physiology of Arterial Blood Pressure 1) Pumping action of the heart Cardiac output is the volume of blood pumped into the arteries by the heart. When the pumping action of the heart is weak, less blood is pumped into arteries, and the blood pressure decreases. When the hearts pumping action is strong and the volume of blood pumped into the circulation increases, the blood pressure increases. Cardiac output increases with fever and exercise. 2) Peripheral Vascular Resistance This can increase blood pressure. The diastolic pressure is especially affected. The following are factors that create resistance in the arterial system: a. Size of the arterioles and capillaries. This determines in great part the peripheral resistance to the blood in the body pressure, whereas decreased vasoconstriction lowers the blood pressure.

b. Compliance of the arteries. The arteries contain smooth muscles that permit them to contract, thus decreasing their compliance (distensibility). The major factor reducing arterial compliance is pathologic change affecting the arterial walls. The elastic and muscular tissues of the arteries are replaced with fibrous tissues. The

condition, most common in middle-aged and elderly adults, is known as arteriosclerosis. c. Viscosity of the blood.

3) Blood volume. When the blood volume decreases, the blood pressure decreases because of decreased fluid in the arteries. Conversely, when the volume increase, the blood pressure increases because of the greater fluid volume within the circulatory system. 4) Blood viscosity. This is a physical property that results from friction of molecules in a fluid. The blood pressure is higher when the blood is highly viscous, that is, when the proportion of RBCs to the blood plasma is high. This ratio is referred to as the hematocrit is more than 60 to 65% Factors Affecting Blood Pressure 1.) Age. Newborn have a mean systolic pressure of 78mmHg. The pressure rises with age. The pressure rises with age, reaching a peak at the onset of puberty, and then tends to decline somewhat. 2.) Exercise. Physical activity increase both the cardiac output and hence the blood pressure. Thus, a rest of 20 to 30 minutes is indicated before the blood pressure can be readily assessed. 3.) Stress. Stimulation of the sympathetic nervous system increase cardiac output and vasoconstriction of the arterioles, thus increasing the blood pressure. 4.) Race. African American males over 35 years have higher blood pressure than European American males of the same age. 5.) Obesity. Pressure is generally higher in some overweight and obese people than in people of normal weight. 6.) Sex. After puberty, females usually have lower blood pressures than males of the same age; this difference is thought to be due to hormonal variations. After menopause, women generally have higher blood pressures than before. 7.) Medications. Many medications may increase or decrease the blood pressure; nurses should be aware of the specific medications a client is receiving and consider their possible impact when interpreting blood pressure readings. 8.) Diurnal variations. Pressure is usually lowest early in the morning, when the metabolic rate is lowest, then rises throughout the day and peaks in the late afternoon or early evening.

9.) Disease process. Any conditions affecting the cardiac output, viscosity, and or compliance of the arteries have a direct effect on the blood pressure. Common Errors in Blood Pressure Assessment

Error Effect Bladder cuff too narrow Erroneously high Bladder cuff too wide Erroneously high Arm unsupported Erroneously high Insufficient rest before the assessment Erroneously high repeating assessment too quickly Erroneously high Cuff wrapped too loosely or Erroneously high unevenly Erroneously low systolic and high Deflating cuff too quickly diastolic reading Deflating cuff too slowly Erroneously high diastolic reading Failure to use the same arm Inconsistent measurements consistently Arm above level of the heart Erroneously low Assessing immediately after a meal or Erroneously high while client smokes Failure to identify auscultatory gap Erroneously low systolic pressure and pressure erroneously low diastolic

Auscultatory gap is the temporary disappearance of sounds normally haerd over the brachial artery when the cuff pressure is high and the reappearance of the sounds at a lower level.

VITAL SIGNS2
Provide excellent clues to the physiological functioning of the body. Alteration in body fxn are reflected in the body temp, pulse, respirations and blood pressure. These data provide part of the baseline info from which plan of care is developed.

Any change from normal is considered to be an indication of the persons state of health. Also called Cardinal Signs. Heat producing & Heat losing Mechanisms Heat production: most body heat is produced by the oxidation of foods, the rate at which it is produced is called METABOLIC RATE. Heat Loss: Radiation Conduction Convection Evaporation Pre optic area of the HYPOTHALAMUS Temperature regulator; thermostat Receives input from temp receptors in the skin & mucous membranes (peripheral thermoreceptors) & internal structures (central thermoreceptors) * if blood temp increases, neurons of the pre optic area fire nerve if it decreases. Heat Promoting Centers VASOCONSTRICTION = Less blood flow from the internal organs to the skin = less heat transfer from the internal organs to the skin = increases internal body temp SYMPATHETIC STIMULATION = stimulation of sympathetic nerves leading to the adrenal medulla = secretes epinephrine & norepinephrine = Increases cellular metabolism = increases heat production SKELETAL MUSCLES = stimulation of part of the brain that increases muscle tone (stretch reflex + contraction of muscles = SHIVERING) = heat production

THYROXINE = increases metabolism = increase in body temp Body Temperature Abnormalities FEVER/hyperthermia/hyperpyrexia - An abnormally high temp mainly results from infection from bacteria (& their toxins) & viruses. (stimulates prostaglandin secretion) Other causes: heart attacks, tumors, tissue destruction by x ray, surgery or trauma & rxns to vaccines. HEAT CRAMPS AND HEAT EXHAUSTION - Due to fluid & electrolyte loss HEAT STROKE HYPOTHERMIA The THERMOMETER A glass clinical thermometer is most commonly used to measure body temperature. It has 2 parts: BULB contains mercury which expands when exposed to heat & rise in the stem STEM is calibrated in degrees of Celcius or Fahrenheit Sites for Obtaining Body Temperature ORAL most common site (3 or 7 to 10minutes) C.I. : unconscious, irrational, seizure prone patients and infants & young children, those who breath through their mouth or for those with diseases/sugery of their mouth or nose. RECTAL most accurate, used when obtaining an oral temp is contraindicated (2 to 3 minutes) C.I. : rectal surgery, diarrhea, other diseases of the rectum, certain heart diseases. AXILLARY used when both oral & rectal are not accessible. Commonly used site (10minutes or more)