VITAL SIGNS 2.

SURFACE TEMPERATURE

 BODY TEMPERATURE  Is the temperature of the skin, the

subcutaneous tissue, and fat.
 PULSE RATE
 Rises and falls in response to the
 RESPIRATORY RATE environment
 BLOOD PRESSURE
The signs reflect changes in function that Normal range of the body temperature is
otherwise might not be observed. between
Monitoring a patient’s vital signs should not be 36.2 to 37.2C
an automatic or routine procedure; it should be
THOUGHTFUL, SCIENTIFIC ASSESSMENT. Factors Affecting Body’s heat production

Should be evaluated with reference to the  Basal metabolic rate (BMR)

patient’s present and prior health status – are
- is the rate of energy utilization in the body
compared to the patient’s usual (if known) and
to maintain essential activities such as breathing
accepted normal standards.
 Muscle Activity
When and how often to assess a specific
patient’s vital signs are chiefly NURSING - including shivering can greatly increase
JUDGEMENTS, depending on the patient’s metabolic rate.
health.
 Thyroxine Output
Times to Assess Vital Signs:
-increased thyroxine output increases the
 On admission to a health care agency to rate of cellular metabolism throughout the body.
obtain baseline data This effect is called Chemical Thermogenesis, the
stimulation of heat production in the body through
 When a patient has a change in health
increased cellular metabolism.
status or reports symptoms
 Epinephrine, Norepinephrine and
 Before and after surgery or an invasive
Sympathetic stimulation
procedure
- these hormones immediately increases the
 Before and/or after the administration of a
rate of cellular metabolism in many body tissues.
medication that could affect the respiratory
or cardiovascular systems  Fever
 Before and after any nursing intervention - increases the cellular metabolic rate and
that could affect the vital signs thus increases the body’s temperature further.
BODY TEMPERATURE Factors affecting Heat Loss
 Reflects the balance between the heat  Radiation
produced and the heat lost from the body.
- is the transfer of heat from the surface of
 Measured in heat units called DEGREES one object to the surface of another without contact
between the two objects.
TWO KINDS OF BODY TEMPERATURE
 Conduction
1. CORE TEMPERATURE
- Is the transfer of heat from one
 Is the temperature of the deep tissues of the
molecule to a molecule of lower
body
temperature.
- Conductive transfer cannot take place without  Environment
contact between the molecules.
Alterations in Body Temperature
 Convection
 Pyrexia/Hyperthermia/Fever
- is the dispersion of heat by air currents.
- a body temperature above the usual range
 Vaporization
 Hyperpyrexia
- is the continuous evaporation of moisture
- very high fever
from the respiratory tract and from the mucosa of
the mouth and from the skin. This continuous and ** The patient who has a fever is referred to
unnoticed water loss is called insensible water as febrile; the one who does not is afrebrile.
loss, and the accompanying heat loss is called
insensible heat loss. Four common types of fever

Regulation of Body Temperature  Intermittent Fever

 The hypothalamic integrator - the body temperature alternates at regular

intervals between periods of fever and periods of
- the center that controls the core normal temperatures.
temperature
 Remittent Fever
- is located in the preoptic area of the
hypothalamus. - a wide range of temperature fluctuations
occurs over the 2 hour period, all of which are
**When the sensors in the hypothalamus above normal.
detect heat, they send out signals intended to
reduce the temperature, that is, to decrease heat  Relapsing Fever
production and increase heat loss. In contrast, -short febrile periods of a few days are
when the cold sensors are stimulated, signals are interspersed with periods of 1 or 2 days of normal
sent out to increase heat production and decrease temperature.
heat loss.
 Constant Fever
- the body temperature fluctuates minimally
but always remains elevated.
**Fever Spike
- a temperature that rises to fever
level rapidly following a normal temperature and
then returns to normal within a few hours.
Clinical Manifestations of Fever
 Onset (Cold or Chill Phase)
1. Increased heart rate and respiratory
rate and depth
Factors Affecting Body Temperature
2. Shivering
 Age
3. Cold skin
 Diurnal variations (circadian rhythms)
4. Cyanotic nail beds
 Exercise
5. Complaints of feeling cold
 Hormones
6. Gooseflesh appearance of the skin
 Stress
 7. Cessation of sweating Hypothermia
 Course (Plateau Phase)  Is a core body temperature below the lower
limit of normal.
1. Absence of chills
Physiologic mechanisms of hypothermia
2. Skin feels warm
1. Excessive heat loss
3. Photosensitivity
2. Inadequate heat production to counteract
4. Glassy-eyed appearance
the heat loss
5. Increased pulse and respiratory rate
3. Impaired hypothalamic thermoregulation
6. Increased thirst
Clinical Manifestations of Hypothermia
7. Mild to severe dehydration
 Decreased body temperature, pulse, and
8. Drowsiness, restlessness, delirium or respirations
convulsions
 Severe shivering (initially)
9. Loss of appetite
 Feelings of cold and chills
10. Malaise, weakness, and aching
 Pale, cool, waxy skin
muscles
 Hypotension
 Defervescence (Fever Abatement/Flush
Phase)  Decreased urinary output
1. Flushed and warm skin  Lack of muscle coordination
2. Sweating  Disorientation
3. Decreased shivering  Drowsiness progressing to coma
4. Possible dehydration Nursing Interventions for patients with
Hypothermia
Nursing Interventions for patient with Fever
 Provide a warm environment
 Monitor vital signs
 Provide dry clothing
 Assess skin color and temperature
 Apply warm blankets
 Monitor WBCs count and other pertinent
laboratory records  Keep limbs close to body
 Remove excess clothes when the patient  Cover the patient’s scalp with a cap or
feels warm, but provide extra warmth when turban
the patient feels chilled
 Supply warm oral or intravenous fluids
 Measure intake and output
 Apply warming pads
 Reduced physical activity
Sites for Assessing Body Temperature
 Provide oral hygiene to keep the mucous
 Orally
membranes moist
- common way (3–5 min)
 Applied moist cold applications such as cold
compresses tepid sponge and ice bag to - The oral cavity temperature is considered
increase loss through conduction to be reliable when the thermometer is placed
posteriorly into the sublingual pocket. This
 Provide cool circulating air by using a fan to
increase heat loss through convection.
landmark is close to the sublingual artery, so this
site tracks changes in core body temperature.
Axillary (safe way)
Tympanic membrane
- Temperature is measured at the axilla by
placing the thermometer in the central position and - The tympanic thermometer senses reflected
adducting the arm close to the chest wall. infrared emissions from the tympanic
membrane through a probe placed in the
- is considered to be an unreliable site for external auditory canal. This method is
estimating core body temperature quick (<1 minute), minimally invasive and
easy to perform.

Temporal artery
- safe and non-invasive
- measured on the forehead

Types of Thermometers

Rectal (accurate reading)

- The most accurate method for measuring
Glass Thermometer
the core temperature, and should reduce 0.5 C° to
the actual reading  Body temperature were measured using
mercury-in-glass thermometers
 Can be hazardous due to exposure to
mercury, which is toxic to humans, and
broken glass should the thermometer crack
or break.
Electronic Thermometer
 The equipment consists of a battery-
operated portable electronic unit, a probe
Infrared Thermometers
that the nurse attaches to the unit, and a
probe cover, which is usually disposable.  Sense body heat in the form of infrared
energy given off by a heat source

Chemical disposable thermometer Temporal artery Thermometers

 Using liquid crystal dots or bars or heat-  Determine temperature using a scanning
sensitive tape or patches applied to the infrared thermometer that compares arterial
forehead change color to indicate temperature in the temporal artery of the
temperature. forehead to the temperature in the room and
calculates the heat balance to approximate
the core temperature of the blood in the
pulmonary artery.

Temperature-sensitive tape
 Applied to the skin, usually forehead or
abdomen Alterations in Thermoregulation

 The temperature digits on the tape respond

by changing color
 a. illness or trauma affecting temperature
regulation.
b. medication or vigorous activity.
 Altered body temperature (hyperthermia)
related to exposure to excessively hot
environment, increase metabolic rate, or
dehydration.
 Altered body temperature (hypothermia)
related exposure to excessively cool
environment, debilitating or trauma, or lack of
adequate clothing and shelter.
 Ineffective thermoregulation
related to decreased basal metabolism
secondary to aging, or trauma, or illness.
 Risk for imbalanced body temperature
at risk for failure to maintain body
temperature within normal range.
Pulse
 Pulse is a wave of blood created by
contraction of the left ventricle of the heart.
The heart is a pulsate pump and the blood
Conversion Formulas enters the arteries with each heartbeat,
 To convert from Fahrenheit to Celsius, causing pulse waves.
deduct 32 from the Fahrenheit, and then  Pulse assessment is the measurement of a
multiply by 5/9 pressure pulsation created when the heart
 C= (Fahrenheit temperature -32) × 5/9 contracts and ejects blood into the aorta.

 For example, convert 98.6 Fahrenheit to  Expressed in beats per minute

Celsius reading
 C= ( 98.6- 32) × 5/9 C=( 66.6) × 5/9 C = 37 Normal Values
Celsius degree.
 To convert from Celsius to Fahrenheit,
multiply the Celsius reading by the fraction
9/5 and then add 32 .
 F = (Celsius temperature x 9/5) + 32
 For example, convert 37 Celsius degree to
Fahrenheit reading
F = ( 37 × 9/5) + 32 F = ( 66.6) + 32 F = 98.6 ºF
 Compliance – of the arteries is their ability
Nursing Diagnosis to contract and expand.

 Potential altered body temperature  Cardiac Output – is the volume of blood

related to: pumped into the arteries by the heart and
 equals the result of stroke volume (SV)  Increasing age
times the heart rate (HR) per minute.
 People with thin body size
- For example, 65mL x 70 beats per
 Some Medications
minute = 4.55L per minute
 Thyroid gland disturbances
- When an adult is resting, the heart
pumps about 5L of blood each
minute.
 Peripheral pulse
- is a pulse located away from the heart
(foot or wrist)
 Apical pulse
-is a central pulse
- located at the apex of the heart
- point of maximal impulse (PMI)
Factors affecting the Pulse
 Pulse Volume – is a measurement of the
strength or amplitude of force exerted by the
ejected blood against the arterial wall with
each contraction.
- it is described as normal (full, easily
palpable)
- weak (thready and usually rapid)
- strong (bounding)

Factors Contribute to Increase Pulse Rate

 Pain
 Fever
 Stress, exercise
 Bleeding
 Decrease in blood pressure
 Some medications as (adrenalin,
aminophylline)
Factors May Slow the Pulse
 Rest
 cardiovascular, pulmonary, and renal
diseases.
 It is commonly assessed prior to
administering medications that effect heart
rate.
 The apical side is also used to assess the
pulse for newborns, infants, and children up
to 2-3 years old.
Apical –Radial Pulse
 An apical-radial pulse may need to be
assessed for clients with certain
cardiovascular disorders.
 Normally the apical and radial rates are
identical.
Pulse deficit
 Pulse deficit is the difference in the apical
pulse and the radial pulse. These should be
taken at the same time, which will require
that 2 people take the pulse. One with a
stethoscope and one at the wrist. Count for
1 full minute. Then subtract the radial from
the apical. This is the Pulse Deficit.
Respiration

Peripheral Pulse Assessment  Pulmonary ventilation (breathing ):

movement of air in and out of the lungs.
A peripheral pulse, usually the radial pulse, is
assessed by palpation for all individual except:  Inspiration (inhalation) is the act of
breathing in.
a. Newborns and children up to 2 or 3 years.
Apical pulse is assessed in these patients.  Expiration (exhalation ) is the act of
breathing out .
b. Very obese or elderly patients, whose radial
pulse may be difficult to palpate. Doppler  Normally described in breaths per minute
equipment may be used for these patients,
or the apical pulse is assessed.
c. Individual with heart disease, who require
apical pulse assessment.
d. Individuals in whom the circulation to a
specific body part must be assessed, e.g.
following leg surgery the pedal ( dorsalis
pedis) is assessed.
Apical Pulse Assessment
 Assessment of the apical pulse is indicator
for clients whose peripheral pulse is
irregular as well as for clients with known Normal Values
  Newborn – 30 – 80 Characteristics of Normal and Abnormal
Breathing Sounds
 1 year - 20 – 40
 5-8 yrs - 15 – 25
 10 yrs - 15 – 25
 Teen - adult - 12 – 20
Two types of breathing
 Costal (thoracic) breathing
- occurs when external intercostal muscles
and the other accessory muscles are used to move
the chest upward and outward.
 Diaphragmatic(abdominal) breathing
 Dyspnea - refers to difficulty in breathing as
- occurs when the diaphragm contracts and observed by labored or forced respirations
relaxes as observed by movement of the abdomen through the use of accessory muscles in the
chest and neck to breathe.
Factors Affecting Respiration
 Apnea - respirations cease for several
 Pain, anxiety, exercise
seconds. Persistent cessation is called
 Medications respiratory arrest.

 Trauma  Orthopnea - respiratory condition in which

a person must sit or stand in order to
 Infection breathe deeply or comfortably.
 Respiratory and cardiovascular disease Assessment of respiration
 Alteration in fluids, electrolytes, acid- base  Depth - by assessing the degree of
balances. excursion or movement in the chest wall;
Assessing Respirations shallow, deep or normal.

 Inspection  Rhythm

 Listening with stethoscope  Rate - the nurse observes a full inspiration

& expiration when counting.
 Monitoring arterial blood gas results
Sites of breathing measurement
 Using a pulse oximeter.
 Normal breathing is slightly observable,
Control of Breathing effortless, quiet, automatic, and regular.
 Respiration is controlled by:  Another method the nurse can use to
assess breathing is to place the back of the
1. Respiratory center in the medulla oblongata
hand next to the client’s nose and mouth to
and the pons of the brain
feel the expired air.
2. Chemoreceptors located centrally in the
medulla in peripherally in the carotid and
Important Note
aortic bodies. These centers and receptors
Nurse must not tell the patient that he or
respond to changes in the concentration of
she will assess his respiration because the
oxygen ( O2), carbon dioxide ( Co 2), and
patient can control his breathing so that will
hydrogen ( H+) levels in the arterial blood.
give a wrong assessment.
  Hand hygiene is therefore the most important
measure to avoid the transmission of harmful
germs and prevent health care-associated
infections.

Medical hand washing

 HAND WASHING (or handwashing), also

known as hand hygiene, is the act of cleaning
hands for the purpose of removing soil, dirt, and
microorganisms
 MEDICAL HAND HYGIENE refers to hygiene
practices related to medical procedures.
Fundamentals of Nursing  Hand washing before administering medicine or
medical care can prevent or minimize the spread
(Hand hygiene, Asepsis and Concept of Infection.) of disease.
 The main medical purpose of washing hands is
to cleanse the hands of pathogens (like bacteria
Health care hand washing or viruses) and chemicals which can cause harm
 In the healthcare setting, handwashing is often or disease.
cited as the primary weapon in the infection  This is especially important for people who
control arsenal. handle food or work in the medical field, but
 The purpose of handwashing in the healthcare also important practice for the general public.
setting is microbial reduction in an effort to
decrease the risk of nosocomial infections. Types of hand hygiene
 Prevention and control of infectious activities
are designed to limit the spread of infection and  MEDICAL HAND WASHING with plain soap
provide a safe environment for all patients, is mechanical removal of soil and transient
regardless of the setting. bacteria (for 20-30 sec.)
 In light of the emergence of antibiotic resistant  HAND ANTISEPSIS is removal & destroy of
organisms, effective infection control measures, transient flora using anti-microbial soap or
such as handwashing, are essential to alcohol-based hand rub (for 60 sec.)
prevention.  SURGICAL HAND SCRUB: removal or
destruction of transient flora and reduction of
resident flora using anti-microbial soap or
What is hand washing? alcohol-based detergent with effective rubbing
 According to the World Health Organization (for least 2-3 min)
(WHO)
 Thousands of people die every day around the When to do hand washing
world from infections acquired while receiving
health care. 1. Before & after an aseptic technique or invasive
procedure.
 Hands are the main pathways of germ
transmission during health care. 2. Before & after contact with a patient or caring of
a wound or IV line.
3. After contact with body fluids & excreta removal.  Rinse hands thoroughly under running water.
 Dry hands properly with a disposable towel.
4. After handling of contaminated equipment or
laundry  Drying is equally as important as washing –
bacteria thrive in moisture.
5. Before the administration of medicines
6. After cleaning of spillage.
7. After using the toilet. Five common types of faucet controls
8. Before having meals.  Hand-operated handles
9. At the beginning and end of duty.  Knee levers.
 Foot pedals.
10. Gloves cannot substitute hand washing which
 Elbow controls: move these with the elbows
must be done before putting on gloves and after
instead of the hands.
their removal.
 Infrared control: motion in front of the sensor
causes water to start and stop flowing
automatically.
Who should perform medical/surgical hand
hygiene?
7 steps to wash your hands properly
Any health-care worker, caregiver or person
involved in direct or indirect patient care needs to
be concerned about hand hygiene and should be
able to perform it correctly and at the right time.
(Nurses, Doctors, Midwives, Attendant)

Preparation

 Keep nails short - most bacteria on the hands

come from beneath the nails.
 Do not wear nail varnish or false nails.
 Do not wear ridged/stoned rings
 Remove all jewelleries such as rings, and
bracelets
 Remove wrist watches and roll up or remove
long sleeved clothing

Sequence 
 Wet hands under running water Step 1 - Wet your hands and apply enough soap
 Dispense soap/antiseptic (5mls approx) into a (coin size).
cupped hand  Step 2 - Rub your palms together.
 Hand wash for 10-15 seconds vigorously and  Step 3 - Rub the back of each hand.
thoroughly without adding more water.  Step 4 - Rub both your hands while interlocking
your fingers.
 Step 5 - Rub the back of your fingers.  Localized swelling
 Step 5 - Rub the tips of your fingers.  Localized redness
 Step 6 - Rub your thumbs and the ends of your  Pain or tenderness with palpation or movement
wrists  Palpable heat in the infected area
 Step 7 - Rinse both hands properly with water  Loss of function of the body part affected,
(Lower than the elbow) depending on the site and extent of involvement

Things to remember Signs of Systemic Infection

 Hand Sanitisers are good tools to keep your  Fever
hands clean, but they should not replace soap  Increased pulse and respiratory rate if the fever
and water. high
 Sanitisers should be used only after hand  Malaise and loss of energy
washing.  Anorexia and, in some situations, nausea and
 Excess use of sanitisers can cause dry and vomiting
chapped hands due to their high alcohol content.  Enlargement and tenderness of lymph nodes that
 For younger Children, during hand wash sing a drain the area of infection
song that lasts 30 seconds to reinforce the habit
of cleaning their hands properly such as two
happy birthday song. Signs of Infection

 Laboratory data
Asepsis  Elevated WBC (white blood cell) count
 Increase in specific WBC types
Medical asepsis  Elevated ESR (Erythrocyte Sedimentation
 Includes all practices intended to confine a Rate) -blood test that detects/monitors
specific microorganism to a specific area inflammation of the body
 Limits the number, growth, and transmission of  Cultures of urine, blood, sputum, or other
microorganisms drainage
 Objects referred to as clean or dirty (soiled,
contaminated) Risks for Nosocomial Infections

 Diagnostic or therapeutic procedures

Surgical asepsis  Iatrogenic infections
 Sterile technique  Compromised host- a pt. with acquired or
 Practices that keep an area or object free of all congenital immunologic deficiency at increased
microorganisms risk for infectious disease complications
 Practices that destroy all microorganisms and  Insufficient hand hygiene
spores
 Used for all procedures involving sterile areas of Factors Influencing Microorganism’s Capability to
the body Produce Infection

 Number of microorganisms present

Signs of Localized Infection  Virulence and potency of the microorganisms
(pathogenicity)
 Ability to enter the body  Occurs when immune serum (antibody)
 Susceptibility of the host from an animal or another human is injected
 Ability to live in the host’s body  Lasts 2 to 3 weeks
 Virulence- the ability of an agent of infection to
produce disease NANDA Diagnosis

 Risk for Infection

Anatomic and Physiologic Barriers Defend Against  State in which an individual is at increased
Infection risk for being invaded by pathogenic
 Intact skin and mucous membranes microorganisms
 Moist mucous membranes and cilia of the nasal  Risks factors
passages  Inadequate primary defenses
 Alveolar macrophages  Inadequate secondary defenses
 Tears
 High acidity of the stomach Related Diagnoses
 Resident flora of the large intestine
 Potential Complication of Infection: Fever
 Peristalsis
 Imbalanced Nutrition: Less than Body
 Low pH of the vagina
Requirement
 Urine flow through the urethra
 Acute Pain
 Impaired Social Interaction or Social Isolation
Active Immunity  Anxiety
 Host produces antibodies in response to natural
antigens or artificial antigens
 Natural active immunity
 Antibodies are formed in presence of active
infection in the body Interventions to Reduce Risk for Infection
 Duration lifelong
 Proper hand hygiene techniques
 Artificial active immunity
 Environmental controls
 Antigens administered to stimulate antibody
formation  Sterile technique when warranted
 Lasts for many years  Identification and management of clients at risk
 Reinforced by booster

Passive Immunity

 Host receives natural or artificial antibodies

produced from another source
 Natural passive immunity
 Antibodies transferred naturally from an
immune mother to baby through the placenta
or in colostrums
 Lasts 6 months to 1 year
 Artificial passive immunity
 The Chain of Infection  Covering the mouth and nose when
coughing or sneezing

 Method of transmission
 Proper hand hygiene
 Instructing clients and support persons to
perform hand hygiene before handling food,
eating, after eliminating and after touching
infectious material
 Wearing gloves when handling secretions
and excretions
 Wearing gowns if there is danger of soiling
clothing with body substances
 Placing discarded soiled materials in
moisture-proof refuse bags
 Holding used bedpans steadily to prevent
spillage
Breaking the Chain of Infection  Disposing of urine and feces in appropriate
receptacles
 Etiologic agent (microorganisms)
 Initiating and implementing aseptic
 Correctly cleaning, disinfecting or sterilizing
precautions for all clients
articles before use
 Wearing masks and eye protection when in
 Educating clients and support persons about
close contact with clients who have
appropriate methods to clean, disinfect, and
infections transmitted by droplets from the
sterilize article
respiratory tract
 Wearing masks and eye protection when
 Reservoir (source) sprays of body fluid are possible
 Changing dressings and bandages when
soiled or wet
 Portal of entry (to the susceptible host)
 Appropriate skin and oral hygiene
 Using sterile technique for invasive
 Disposing of damp, soiled linens
procedures, when exposing open wounds or
appropriately
handling dressings
 Disposing of feces and urine in appropriate
 Placing used disposable needles and
receptacles
syringes in puncture-resistant containers for
 Ensuring that all fluid containers are covered
disposal
or capped
 Providing all clients with own personal care
 Emptying suction and drainage bottles at
items
end of each shift or before full or according
to agency policy
 Susceptible host
 Maintaining the integrity of the client’s skin
 Portal of exit (from the reservoir) and mucous membranes
 Avoiding talking, coughing, or sneezing  Ensuring that the client receives a balanced
over open wounds or sterile fields diet
  Educating the public about the importance Standard Precautions
of immunizations
 Used in the care of all hospitalized persons
regardless of their diagnosis or possible
Category-specific Isolation Precautions infection status
 Apply to
 Strict isolation
 Blood
 Contact isolation
 All body fluids, secretions, and excretions
 Respiratory isolation
except sweat (whether or not blood is
 Tuberculosis isolation present or visible)
 Enteric precautions  Nonintact skin and mucous membranes
 Drainage/secretions precautions  Combine the major features of UP and BSI
 Blood/body fluid precautions

Transmission-based Precautions
Disease-specific Isolation Precautions
 Used in addition to standard precautions
 Delineate practices for control of specific  For known or suspected infections that are
diseases spread in one of three ways:
 Use of private rooms with special ventilation  Airborne
 Cohorting clients infected with the same  Droplet
organism  Contact
 Gowning to prevent gross soilage of clothes  May be used alone or in combination but always
in addition to standard precautions
Universal Precautions (UP) Handwashing and Gloving

 Used with all clients

 Decrease the risk of transmitting unidentified
pathogens
 Obstruct the spread of bloodborne pathogens
(hepatitis B and C viruses and HIV)
 Used in conjunction with disease-specific or
category-specific precautions

Body Substance Isolation (BSI)

 Employs generic infection control precautions

for all clients
 Body substances include:
 Blood Donning and Removing PPE:
 Urine
Gowns Mask
 Feces
 Wound drainage
 Oral secretions
 Any other body product or tissue
  Identification and documentation of the source
individual when feasible and legal
Donning and Removing PPE:
 Testing of the source for hepatitis B, C and
HIV when feasible and consent is given
 Making results of the test available to the
source individual’s health care provider
 Testing of blood exposed nurse (with consent)
for hepatitis B, C, and HIV – please check
these to match style used in book – fairly
certain it should be caped antibodies
 Postexposure prophylaxis if medically
indicated
Establishing and Maintaining a Sterile Field:  Medical and psychologic counseling

Puncture/Laceration

 Encourage bleeding
 Wash/clean the area with soap and water
 Initiate first aid and seek treatment if indicated
 Mucous membrane exposure (eyes, nose,
mouth)
 Flush with saline or water flush for 5 to 10
minutes

Postexposure Protocol (PEP) for HIV

 Start treatment as soon as possible preferably

within hours after exposure
 For “high-risk” exposure (high blood volume
Managing Equipment Used for Isolation Clients and source with a high HIV titer), three drug
treatment is recommended
 Many supplied for single use only  For “increased risk” exposure (high blood
 Disposed of after use volume or source with high HIV titer), three-
 Agencies have specific policies and procedures drug treatment is recommended
for handling soiled reusable equipment  For “low risk” exposure (neither high blood
 Nurses need to become familiar with these volume nor source with a high HIV titer), two-
practices drug treatment is considered
 Drug prophylaxis continues for 4 weeks
Bloodborne Pathogen Exposure  Drug regimens vary and new drugs and
regimens continuously being developed
 Report the incident immediately  HIV antibody tests should be done shortly after
 Complete injury report exposure (baseline), and 6 weeks, 3 months, and
 Seek appropriate evaluation and follow-up 6 months afterward
 Postexposure Protocol (PEP) for Hepatitis B items with contaminated gloves. Keep your
hands away from your face.
 Anti-HBs testing 1 to 2 months after last
 Remove gloves right after use. Wash hands- and
vaccine dose
put-on clean gloves between patients. Don’t
 HBIG and/or hepatitis B vaccine within 1 to 7
reuse disposable glove
days following exposure for nonimmune
workers
Parts of a Glove

Postexposure Protocol (PEP) for Hepatitis C 1.Palmar Surface 4. Cuff 

 Anti-HCV and ALT at baseline and 4 to 6 2. Dorsal Surface 5. Wrist

months after exposure
3. Finger Holes
Types of gloving technique
Donning and removing sterile gloves
(gloving technique)
Closed glove technique-in

Gloving The closed-glove technique, the scrub person's

hands remain inside the sleeves and should not
 Placing of gloves on the hands. During physical  touch the cuffs
examination and invasive procedures, such as ph
lebotomy or surgery, done to 
protect both caregiver and patient from transmiss
ible diseases.
 The procedure of donning sterile rubber gloves, i
n such a way as to preserve asepsis of the both Open-glove technique,
the patient and the care providers, before each
The scrub person's hands slide all the way
sterile procedure.
through the sleeves out beyond the cuffs.
 Health care gloves is a type of protective barrier
 Proper GLOVING TECHNIQUES is also a best
way to prevent cross contamination to occur
Donning sterile gloves
 Following the standard precaution
 Gloves are worn to complete the sterile dress in
order that the one who wears them may handle Open method of glove technique
sterile equipment
 Get the right-hand gloves with the left hand by
holding it at the edge of everted cuff. Step back
When to use?
from the sterile field.
 Wear gloves whenever contact is possible with  Explore the finger holes before inserting the
blood or other potentially infectious materials. whole hand completely. Leave the everted cuff
This includes any body fluids and substances, asis.
broken skin, or mucous membranes.  Slip the gloved right hand under the fold of the
 Wear gloves when touching any item that may everted cuff. Insert the left hand by exploring
be contaminated. Don't touch uncontaminated the fingerholes before inserting the whole hand
completely. Leave the folded cuff.
 Make a pleat at the cuff of the gown and secure  In serving, get the right glove with the left and
this is place with your right thumb. the left-hand glove with the right hand.
 Slip the four fingers of the right hand under the  Always keep gloved hands at waist level or
fold of the glove and pull it up over the pleated above.
cuff of the sleeves. Fix the glove firmly.  Keep gloved hands away from your mask.
 Repeat for the right hand

Gowning
Closed method
 All members of the sterile surgical scrub team
 With your right hands inside the gown’s sleeves, are required to perform a surgical hand scrub
lift the glove by the cuff. and don sterile gown and gloves before touching
 Put thumb down or your upturned left palm, sterile equipment or the sterile field.
fingers of glove pointed toward your elbow.  The correct performance of these procedures
 At this time, move your left hand so that your helps to protect a patient from infection by
fingers are halfway down the cuff of your gown. preventing pathogenic (disease producing)
Do not let them protrude from our gown cuff or micro-organisms on the hands, arms and clothes
touch the end of the cuff. of “sterile” team members from coming into
 With your right hand still inside the sleeve, take contact with a patients wound during an
hold of the folded cuff of the left glove and pull operation.
it out and over the left hand and well over the  The resulting infection from micro-organisms
cuff of the left sleeve. introduced into a wound during surgery could
 Take the right hand, still inside the sleeve, and prove fatal to the patient.
grasp the left glove and gown cuff at the wrist  Gowning is also a asepsis technique
and pull glove unto the hand.  A form of protective barrier to protect the
 Proceed to the right hand the same way healthcare provider and the patient from
acquiring microorganism that could cause cross
contamination
Removing the gloves:

 With the gloved right hand, remove the left

Point to remember
glove by holding it at its outer surface and pull
off. (This is the glove-to-glove technique).  Surgical gowns are folded with the inside facing
 To remove the right glove, insert your thumb or the scrub person.
three fingers between the skin and the glove and  This method of folding facilitates picking up
pull off. and donning the gown without touching the
 (This is the skin-to-skin technique) outside surface.
 If the scrub person touches the outside of the
gown whilst donning it, the gown must be
Points to remember in gloving:
considered to be contaminated. If this occurs
 Take care not to contaminate the outside surface discard the gown.
of the glove  The scrub person’s hands and arms are
 In serving the gloves, the nurse must have a contaminated if they are allowed to fall below
wide base of support by putting her foot apart. waist level or to touch the body therefore hands
 Always serve the right-hand glove first. and arms should be kept above the waist and
 away from the body at an angle of about 20 to hands are only in contact with the inside surface
30 degrees above the elbows. of the gown.
 After donning the surgical gown, the only parts  The circulating person then prepares to secure
of the gown that are considered sterile are the the gown, the neck and back may be secured
sleeves (except for the axillary area) and the with a Velcro tab or ties. The circulating person
front from waist level to a few inches below the then ties the gown at waist level at the back.
neck opening.  This technique prevents the contaminated
 If the gown is touched or brushed by an un- surfaces at the back of the gown from coming
sterile object the gown is then considered into contact with the front of the gown.
contaminated.
 The contaminated gown must be removed using
the proper technique and then a new sterile
gown should be donned
Gowning Procedure
(Steps in performing gowning technique)

 1. With one hand, pick up the entire folded

gown from the wrapper by grasping the gown
through all layers, being careful to touch only
the inside top layer which is exposed.
 Step back from the trolley / shelf.
 2. Hold the gown in the manner shown in Figure
near the gown's neck and allow it to unfold
being careful that it does not touch either the
body or other un-sterile objects.
 Grasp the inside shoulder seams and open the
gown with the armholes facing
 3. Slide arms part way into the sleeves of the Gowning and Gloving
gown keeping hands at shoulder level away
from the body  Take the sterile gown and gently shake it out,
taking care not to let anything else touch it
 4. Slide arms further into the gown sleeves and
when the fingertips are level with the proximal  Open it up and place your hands into the sleeves
edge of the cuff, grasp the inside seam at the keep your hands inside the sleeves
cuff hem using thumb and index finger. Be  Ask an assistant to help pull it up over your
careful that no part of the hand protrudes from shoulders and fasten it up at the back
the sleeve cuff  Take the right-hand glove and place it, palm
 5. The circulating person should assist at this down, fingers facing your body
point to position the gown over the shoulders by  Grasp the bottom of the cuff with the thumb and
grasping the inside surface of the gown at the index finger of your right hand, still inside the
shoulder seams. sleeve grasp the top of the cuff with your left
 They can then adjust the gown over the scrub hand (also inside the sleeve) and pull the glove
person’s shoulders. The circulating person’s around and over your right hand
 Pull gently on the sleeve of the gown to help
move your hands into the gloves and straighten
 out the fingers the sleeves of the gown should
remain over most of your palm
 Repeat this technique for the left hand
 It is advised to rest your hands on your front as
you move around to ensure you remain sterile
 Make sure you do not touch any non-sterile
equipment as you move to the operating area