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44 Cards in this Set
- Front
- Back
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Chapter 31
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Asepsis
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Active Immunity
Specific defense |
Host PRODUCES antibodies in response to natural or artificial antigens
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Natural active immunity
vs Artificial active immunity |
Formation of antibodies in response to an active infection-lifetime immunity
vs Healthcare administered antigens-short term immunity |
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Passive immunity
Specific defense |
Host RECEIVES natural or artificial antibodies produced from another source
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Natural passive immunity
vs Artifical passive immunity |
Passing of antibodies from mother to child
vs Injection of antibodies from a host |
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Anatomic and Physiologic barriers against infection
Nonspecific defense |
Intact skin and mucous membranes
Moist mucous and cilia of the nasal passages Alveolar macrophages Tears Stomach acid Resident intestinal flora Peristalsis Low vagina pH Urine flow through the urethra |
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Signs of LOCALIZED infection
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Pain
Swelling Redness Heat Impaired function of the part |
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Signs of SYSTEMIC infection
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Fever
Increased pules Increase respirations Malaise Anorexia, nausea, vomiting Lymph node involvement |
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Bacteremia
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Cultured blood reveals microorganisms
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Septicemia
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When bacteremia results in a systemic infection
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Common manifestations of
Wound infection |
Pirulent drainage
Swelling Redness Heat |
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Common manifestations of
Urinary tract infection |
Cloudy urine
Frequency in urination Burning Chills/fever Confusion Hematuria |
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Common manifestations of
Respiratory infection |
Cough
Fever Colored sputum Rails Dimished lung sounds |
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Common manifestations of
Gastrointestinal infection |
Blood in feces
Pain Fever Vomiting Diarrhea |
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Common manifestations of
Blood stream infection |
Septicemia
Fever Chills Confusion |
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Confusion may be caused by decreased:
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Oxygen and sodium
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Nosocomial infections are
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Infections that are associated with the delivery of health care services in a health care facility
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Most common risk factors of nosocomial infections
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Iatrogenic infections
Compromised host Insufficient hand hygiene |
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Iatrogenic infections
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Infections that are the direct result of diagnostic or therapeutic procedures
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Risk factors for breaks in the skin and mucous membranes
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Meds such as steroids
Surgical intervention Diagnostic procedures Therapeutic procedures |
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Portals of entry are
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Invasive devices such as
Tubes IVs Catheters Surgical drains |
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Infection Risk factors related to
Stasis of body fluids |
Stagnant secretions-bandages
Tubes-not drained or back flowed Smoking-inhibits lung clearance Tumors Decreased fluid intake-decr. body flushing Immobility-slow GI, pooling of fluids Urinary tract obstruction |
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Infection risk factors related to
Stress |
Stress releases cortisol which increases serum glucose; providing a medium for bacterial growth
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Infection risk factors related to
Immune system dysfunction AIDS Cancer |
AIDS decreases immune system function
Cancer treatments destroy healthy cells and depress bone marrow function-WBC's |
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Infection risk factors related to
Drug therapy |
Steroids decrease the inflammatory response
Chemotherapy depresses bone marrow function and harms good cells Antimetabolites inhibit cell DNA production Antibiotics kill resident microflora and may result in antibiotic resistant strains |
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Superinfection
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Suppression of normal flora allows the proliferation of strains that would not grow and multiply in the body under normal conditions
C. Defficile |
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Factors influencing microorgnaism's capability to produce infection
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# of microorganisms present
Pathogenicity of the microorganism Ability to enter the body Susceptibility of the host Ability to live in the host's body |
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Urinary tract infection factors
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Contamination of the urethral area
Ascent of organisms Reduced urine flow Bacterial colonization Improper cath Contamination of closed drain Inadequate hand cleansing |
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Wound infection factors
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Local factors- cause of the wound
Treatment factors-dressing change, hand cleansing Host factors-compromised immunity |
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Respiratory infection factors
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Increased secretion production-pneumonia
Decreased chest wall movement Inhibited secretion clearance Depressed respiratory center Increased risk of microbial colonization Smoking, immobility, pain medications Improper suctioning, inadequate hand cleansing |
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Assessment for
Asepsis risk Septicemia risk Nursing History |
Assess:
Degree to which a client is at risk for developing an infection Client complaints suggesting an infection |
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Asepsis Risk
Interview |
Last immunizations, TB tests
Past infections and treatments Antibiotics, steroids, anti-inflamatories, cancer meds. Recent penetrating diagnostic procedures or therapies Past surgeries Eating habits Vitamins Stress Loss of energy, appetite, nausea, headache, specific signs of illness |
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Asepsis Risk
Physical |
Swelling, redness, tenderness, heat, loss of function, lymph nodes, drainage
Vital sings out of range Abnormal breath or bowel sounds |
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Asepsis Risk
Laboratory data |
Elevated leukocytes 4500-11000 normal
Increased differentials in WBC Elevated erythrocyte sedimintation Urine, blood, sputum, drainage culture results Therapeutic drug level monitoring Diagnostic imaging results |
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NANDA Diagnosis is
Risk for infection Includes risk factors for: |
Inadequate primary defenses
Inadequate secondary defenses |
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Inadequate primary defenses include
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Broken skin, traumatized tissue, decreased ciliary action, stasis of body fluids, change in pH of secretions, and altered peristalsis
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Inadequate secondary defenses include
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Leukopenia, immunosuppression, decreased hemoglobin, suppressed inflammatory response
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Diagnoses related to Risk for Infection include
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Potential complication of infection-fever
Imbalanced nutrition: less than body requirements-too ill to eat Acute pain-due to tissue damage Impaired social interaction or social isolation-isolation patients Anxiety-due to life changes, social interaction changes |
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Outcome Identification
Goal |
The client will demonstrate adequate knowledge to recognize and report signs of infection
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Outcome Identification
Criteria |
After a teaching session, the client lists four signs of infection
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Asepsis Interventions
To reduce risk of infection |
Proper Hand hygiene techniques
Environmental controls-asepsis and disinfecting Medical and Surgical sterile technique ID and management of clients at risk Supporting defenses of a susceptible host |
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The chain of infection goes like this:
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Etiologic agent-infective microorganism
Reservoir-source of microorganism Portal of exit from reservoir Method of transmission-direct, indirect, airborne Portal of entry to the susceptible host Susceptible host-any person at risk of infection |
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Standard Precautions
Are used for: Apply to: |
The care of all hospitalized persons
Apply to blood and all body fluids except sweat and nonintact skin and mucous membranes |
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Transmission based precautions are used for
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Known or suspected infections that are spread by airborne, droplet, or contact
Are always used in addition to standard precautions |
