• Body temp. of 40 C (104 F)
• Hot and dry skin
• Confusion
• Delirium
• Nausea
• Muscle Cramps

• Vasodilation of blood vessels
• Inhibition of heat production
• Body redistributes blood to surface vessels to promote heat loss

• Vasoconstriction reduces blood flow to skin/extremities
• Compensatory heat production stimulated through voluntary muscle contractions and muscle shivering

• 36-38 degrees celcius (98.6-100.4)
• Pulse 60-100 bpm
• Respirations 12-20 per min
• BP <120/<80

Oral/tympanic 37 C

Rectal 37.5 C

Axillary 36.5 C

• dehydrated
• anemic
• experienced prolonged bed rest
• recent blood loss

Assess during measurements of vital signs by obtaining BP and pulse with patient in supine, sitting, and standing position

Obtain 1-3 minutes after patient changes position

120-139 or 80-89

• Explain measures to prevent body temp alterations
• Instruct on risk factors for hypthermia, forstbite, and heat stroke
• Demonstrate self-assessment of HR using carotid
• Instruct on normal BP and risk factors for hypertension
• Demonstrate to patient's family caregiver on how to obtain BP

• Result from the delivery of health services in a health care facility 
• Improperly performing hand hygiene increases patient risk

Urinary Tract

Surgical/Traumatic Wounds

Respiratory Tract

Bloodstream

Private Room

Negative-pressure airflow

Mask or respiratory protection device

N95 respirator

Private room or cohort patients

Mask or respirator required

Private room or cohort patients

Gloves

Gowns

Private Room

Positive airflow for incoming air

Mask to be worn by patient when out of room

1. A sterile object remains sterile only when touched by another sterile object
2. Only sterile objects may be placed on sterile field
3. Sterile object or field out of the range of vision or an object held below a person's waist is contaminated
4. A sterile object/field becomes contaminated by prolonged exposure to air
5. When sterile surface becomes in contact with a wet surface --> contaminated
6. Fluid flows in the direction of gravity
7. The edges of a sterile field are considered to be contaminated

Infection occurs in the presence of all the following:

• Infectious agent/pathogen
• A reservoir or source for pathogen growth
• Portal of Exit
• Mode of transmission
• Portal of Entry
• Susceptible host

Incubation period

Prodromal stage

Illness stage

Convalescence

• Interval from onset of nonspecific signs/symptoms to more specific symptoms 
• During this time, microorganisms grow and multiply and patient may be capable of spreading disease

Hep A-C reserviors

Hep A: Feces

Hep B & C: Certain body fluids and sexual contact

Iatrogenic Infections

• Hand hygiene
• No fake nails/tips
• Wear gloves
• Wear PPE when there is a possibility of contact with blood/fluids
• Use sharps container
• Respiratory hygiene/cough etiquette

• Patient is subject to sensory deprivation because of the restricted environment
• Loneliness
• Disruption of normal social relationships
• Patients feel unclean, rejected, lonely, guilty
• Depression, anxiety, and less satisfaction with care

• Scaling of scalp accompanied by itching
• Causes embaressment and if enters eyes, conjunctivitis can develop
• Shampoo regularly with medicated shampoo

• Small grey/brown parasites that burrow into skin and suck blood
• Transmit seveal diseases to people
• Using blunt tweezers, grasp tick as close to the head as possible and pull upward

• Lice; parasites that resides on scalp attacked to ends of hair; bites may be observed at hairline and behind ears
• Difficult to remove and can spread if not treated; cannot fly or jump and carried by animals
• Use medicated shampoo

• Body lice; parasites tend to cling to clothing where they lay eggs
• Patient itches constantly; scratches on skin become infected
• Bathe or shower thoroughly and after skin is dried medicated lotion applied

• Crabs; grey/white with red legs
• Spreads through bed linen, clothing, or sexual contact
• Shave hair off infected area

• Occurs in all races; hair becomes brittle/broken
• Alters patient's appearance
• Stop haircare practices (curlers, hair picks, tight braiding)

• Head of bed raised to 45 degrees or more; semi-sitting position
• While patient is eating
• Promotes lung expansion and eases difficult breathing

• Head of bed raised to 30 degrees
• Promotes lung expansion
• Used when patients recieve gastric feedings

• Entire bed frame tilted with head of bed down
• Facilitates venous return in patients with poor peripheral perfusion

• Entire bed frame tilted with foot of bed down
• Used infrequently
• Promotes gastric emptying

• Used for patients with vertebral injuries and in cervical traction
• Used for patients who are hypotensive
• Patients usually prefer for sleeping

• Uncircumcised males
• Patients with urinary catheters
• Recovering from rectal/genital surgery
• Recovering from childbirth
• Women having menstrual period

• Not inflammed and no damage 
• Wash with clean washcloth moistened with water
• clean from inner to outter canthus

• Observe for presence of accumulated earwax or drainage, and local inflammation
• Clean with end of moistened washcloth rotated gently into the ear canal

• Inspect for inflammation, discharge, lesions, edema, and deformity
• Mucosa is pink and clear and has little or no discharge
• Use wet washcloth or cotton-tipped applicator mositened with water or saline

• Apply clean gloves and place towel under patient's head and basin under chin
• Remove dentures if present
• Clean chewing and inner tooth surfaces first
• Clean outter tooth surfaces
• Swab roof of mouth, gums, and inside cheeks
• Apply water-soluble jelly to lips

• Need to pay special attention because they often have no gag reflex
• One nurse does actual cleaning while another removes secretions with suction equipment

• Bias or prejudice does not enter into a decision
• Look at situation objectively and consider all view points to understand the situation completely before making a decision

• Challenge the ways others think and look for rational and logical answers to problems
• When nurses ask questions and look for evidence behind clinical problems, they are thinking independently

• A guideline or principle for rational thought 
• Applied when using the nursing process
• When you consider a patient problem, apply intellectual standards such as preciseness, accuracy, and consistency to make sure all clinical decions are sound