Nursing Study Guide/Care of Immuno-Lymphatic Needs

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Nurse using reverse barrier to prevent contaminating infant with face mask

Temperature assessment

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See thermoregulation explained Temperature may be taken by following route

  • tympanic - most common method where device available.
  • oral - most common in developing countries.
  • rectal - rarely used. one centigrade higher than oral reflects the same core temperature.
  • axillary - note always one centigrade lower than oral temperature.
  • spectroscopic - common for neonatal nurses only.

Factors influencing temperature include

  • Maturity - the elderly have a lower metabolic rate and lower body temperature.
  • Gender - females tend to have lower body temperature and monthly cyclic variation.

The client record should include a chart for graphical representation of the temperature and other vital signs, intake and output, and weight. Special attention must be given to the entry blocks indicating hospital day, postoperative day, date, and hour blocks. Also note the units (eg. Farenheit or Celsius) according to the space allowed on the chart. A row on a chart marked one degree and divided into five has 0.2 degree gradients. Normal range for temperature is 36.5 to 37.5 centigrades.

  • Check your agency for charting rules. eg. Always use black biro. A solid dot for temperature and an open dot for pulse. These symbols are placed between the columns and rows of dots and joined by a straight line (temperature symbol to temperature symbol, etc.).
  • If the route of determining temperature is other than oral, it should be indicated by (R) for rectal and (A) for axillary.
  • The number of respirations are written in digits in the space for "Respiration Record."
  • Vital signs measurement can be grouped to avoid disturbing client.
  • Frequency. Generally four hourly temperature will indicate previously unforeseen problems in medical clients. Temperature is generally noted hourly at most frequent, with the exception of blood transfusion when a rise can indicate early intolerance of the transfused fluid. Psychiatric clients have their temperature routinely monitored once per week on admission and monthly in chronic settings.
  • Note whether thermoregulation support is under way - Air Warmer, Blood heater, Ice Pack, Cryotherapy.

Barrier versus Reverse Barrier

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Clients with highly contagious diseases need barriers to prevent contamination of other clients and nurses. The usual meaning of BARRIER NURSING is to isolate an infectious condition. On the other hand, the barriers can be placed to protect the weaker defenses in a client who is immuno-compromised, this is referred to as reverse barrier nursing. A nurse who wears a face mask to protect an infant is using a reverse barrier.

Infection Control

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Nurses should follow the precautions specified by each employer appropriate for the facility and condition. Conditions are usually classified according to the means of transmission, such as droplet, blood-borne or contact. Nursing measures will include

  • Hand hygiene (eg. between clients as the bare minimum)
  • warning system, such as a coloured card fixed to the client's door which stipulates the measures required to prevent cross-contamination.
  • Personal protective equipment such as mask, gown, gloves
  • Having separate linen disposal and garbage disposal
  • separate meal trays or disposable food packaging
  • negative pressure rooms, where air from the hospital corridor may circulate into the room before air conditioning ventilates the air safely outside the building.
  • requesting the room be cleaned appropriately
  • using a surgical conscience and being honest about all and any possible contamination, even where this has consequences such as consuming time and physical resources.

Sterile versus clean

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Nursing specialists who work in operating theatres and similar areas use sterile equipment, but they themselves can never be effectively sterile. One needs to clarify levels of disinfection, from clean, disinfected to sterile and work with a knowledge of what is appropriate for a given task, role or piece of equipment.

Client teaching

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Health education may help to raise awareness of issues impacting lymphatic wellness. Nurses can help to combat illness at the bedside by providing target populations (eg clients and their families) with information about diseases, risks and preventative techniques.

  • Handwashing
  • Signs of illness suggesting a contagious condition
  • Use condoms to prevent sexually transmitted disease
  • Encourage clients to use the entire course of medication in collaboration with other health professionals to prevent the development of resistant strains of microbes
  • Food safety following a cold chain and handling regulations
  • Refer to a scientific evidence base to support vaccination
  • Be aware of common events and advise clients on managing inflammatory conditions and excessive Immunoglobulin E through avoidance of allergens and supplementary anti-histamines in collaboration with other health professions (eg. pharmacist)

Lymphatic drainage

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Early after an injury, a certain degree of swelling is inevitable. Histamine and bradykinins released by mast cells in damaged tissue make the capillaries leaky in the affected area. From 48 hours after an injury, nurses with massage training may help to alleviate swelling and augment immune function with massage toward the heart. Lymphatic vessels contribute fluid to the intravascular space. Nurses need to be aware that massage in overdose is capable of rhabdomyolisis (muscle catabolism) and skin trauma. Massage alone should not be used to treat underlying edema.