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67 Cards in this Set
- Front
- Back
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Explain concept of medical asepsis |
Includes all practices intended to confine a specific microorganism to a specific area, limiting number, growth, and transmission of microorganisms. |
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Asepsis |
Freedom from disease-causing microorganisms |
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In medical asepsis, objects are referred to as what? |
Clean, meaning the absence of almost all microorganisms OR Dirty (soiled, contaminated) which means likely to have microorganisms, some of which may be capable of causing infection. |
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Explain the concept of surgical asepsis |
Also referred to as sterile technique, it refers to practices that keep an area or object free of all microorganisms |
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Surgical asepsis includes practices that....? |
Destroy all microorganisms and spores (microscopic dormant structures formed by some pathogens that are very hardy and often survive common cleaning techniques). |
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Surgical asepsis is used for? |
All procedures involving sterile areas of the body |
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What are signs of a localized infection? |
Limited to a specific part of the body Localized swelling & redness Pain or tenderness with palpation or movement Palpable heat in infected area Loss of function of the body part affected, depending on the site and extent of infection |
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What are signs of a systemic infection? |
If the infection has spread to different parts of the body Fever Increased pulse & respiratory rate if fever is high Malaise (feeling of sickness) & loss of energy Anorexia, & in some situations, nausea & vomiting Enlargement & tenderness of lymph nodes that drain the area |
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Signs of Infection |
With lab data=elevated WBC count High WBC=Bacterial infection Low WBC=Viral Infection Increase in certain specific WBC types Elevated ESR |
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Nosocomial Infections |
Infections that originate in the hospital Microorganisms that cause nosocomial infections can originate from the clients themselves (endogenous) or from the hospital (exogenous) |
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Iatrogenic Infections |
Are the direct result of diagnostic or therapeutic procedures such as catheters or central IV's Not all nosocomial infections are iatrogenic and not all nosocomial infections preventable |
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Risks for Nosocomial Infections |
Compromised host Hands of personnel are common vehicle for spread of microorgs Insufficient hand hygiene Most infections appear to endogenous |
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Factors influencing microorganism's capability to produce an infection |
An infection is the growth of microorgs in body tissue where they are not usually found Factors are number of microorgs present Infections depend of their virulence (degree of pathogenicity) & pathogenicity (ability to produce disease). "True" pathogen causes disease in a healthy person. Ability to enter the body Susceptibility of the host Ability to live in the host's body |
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Anatomic & physiologic barriers that defend against microorgs |
Intact skin & mucous membranes=1st line of defense (is effective unless skin becomes broken) Moist mucous membranes & cilia of the nasal passages which traps microorgs & dust High acidity of stomach prevents growth Resident flora prevents establishment of microorgs Peristalsis |
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Relevant Nursing Diagnoses for risks for infection |
Inadequate primary defenses such as broken skin, traumatized tissue, decreased ciliary action, change in pH, or altered peristalsis Inadequate secondary defense such as leukopenia, immunosuppression, decreased hemoglobin, or suppressed inflammatory response |
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Contributing factors for clients at risk for infections |
Candidates who have or are at risk for infections are prime candidates for other problems Potential complication of infection: fever Imbalanced nutrition: less than body requirements if patient is too ill to eat Acute pain Social Isolation if patient has to be separated Anxiety |
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Interventions to reduce risks for infections |
Correctly cleaning, disinfecting Educate patients about proper clean methods Hand hygiene Disposing of soiled linen, feces, and change dressings when soiled Avoid coughing over open wounds and cover mouth/nose when sneezing |
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Category-specific isolation precautions uses seven categories |
Strict isolation, contact isolation, respiratory isolation, TB isolation, enteric precautions, drainage/secretions precautions, and bloody/body fluid precautions. |
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Disease-specific isolation precautions |
Delineate use of private rooms w/ special ventilation, having patient share a room w/ other patients infected w/ same org, & gowning to prevent gross soilage of clothes for specific infectious diseases |
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Universal Precautions |
Treats all human blood & certain bodily fluids as if they were KNOWN to be infected w/ bloodborne pathogen Outdated and is precursor to standard precautions |
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Standard Precautions |
First tier in isolation guidelines All health care pro use SP when providing care to all patients rather than the suspected presence or absence of infectious orgs determining use of clean gloves, gowns, masks, and & eye protection |
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Transmission based precautions |
Includes Airborne precautions, Droplet precautions, & contact precautions |
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Bloodborne Pathogen Exposure |
Report incident immediately Complete injury report Seek appropriate evaluation & follow up Identification & documentation of the source individual Testing of the source for Hep B, C, & HIV Testing of blood exposed nurse Postexposure prophylaxis if medically indicated |
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Describe hygienic care that nurses provide to clients |
Early morning care=when patients wake up & consists of washing face, oral care, & urinal Morning care=after patients eat & consists of shower, perineal care, oral, nail, & hair care Hours of sleep or PM care=before patients retire for the night & consists of washing, urinal, oral care As needed (prn) care=as the patient requires |
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Factors influencing personal hygiene |
Culture Religion=ceremonial washings Environment=finances such as homelessness Developmental level=children Health & energy Personal preference=showers over baths |
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Purposes of Bathing |
Remove transient microorgs, body secretions, & dead skin cells Stimulate circulation & promotes healing, bringing nourishment to skin Produce a sense of well being Promote relaxation & comfort Prevent or eliminate unpleasant body odors |
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Types of Cleansing Baths Complete bed bath |
Nurse washes entire body of a dependent client in bed |
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Types of Cleansing Baths Self-help bed bath |
Patients confined to bed are able to bathe themselves with help from the nurse for washing the back and perhaps the feet |
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Types of Cleansing Baths Partial Bath |
Only the parts of the patient's body that might cause discomfort, or odor, are washed (face, hands, axillae, perineal area, & back). |
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Types of Cleansing Baths Bag Bath |
Bath is commercially prepared product that contains 10-12 presoaked disposable washcloths that contain norinse cleanser solution. Package is warmed in a microwave & each area of body is cleaned w/ a different cloth & air dried so the emollient in the solution remains on skin |
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Types of Cleansing Baths Towel Bath |
Bath similar to bag bath but w/ regular towels. Useful for clients who are bedridden/dementia. Client covered, kept warm throughout bathing process by bath blanket |
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Types of Cleansing Baths Tub Bath |
Amount of assistance nurse offers depends on abilities of patient |
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Therapeutic Baths |
Given for physical effects, such as to soothe irritated skin or treat an area. Generally taken in a tub on third or one half full |
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Nursing Process for skin Assessment |
Assessment includes patient's skin care practices, self care abilities, & past or current skin problems, and physical assessment of skin(includes inspection & palpation) |
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Nursing Process for skin Diagnosing |
Bathing Self care deficit Dressing self care deficit Toileting self care deficit *Feeding self care deficit *Risk for impaired skin integrity *Impaired Skin integrity |
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Nursing Process for skin Planning |
Nurse and patient set outcomes for each nursing diagnosis. Nurse then performs nursing interventions and activities to achieve the patient outcomes. |
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Nursing Process for skin Implementation |
Nurse applies general guidelines for skin care while providing one of the various types of baths available |
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Nursing Process for skin Evaluation |
Nurse judges whether desired outcomes have been achieved |
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Nursing process for feet Assessing |
Assessment of patients feet includes a nursing health history, physical assessment of the feet, & identifying patients at risk for foot problems |
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Nursing process for feet Assessing & Nursing History |
Nurse determines the patients history of normal nail and foot care practices, type of footwear worn, self care abilities, presence of risk factors for foot problems, any foot discomfort, & any perceived problems w/ foot mobility |
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Nursing process for feet Diagnosing |
Bathing Self care deficit Risk for impaired skin integrity Risk for infection Deficient Knowledge |
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Nursing process for feet Planning |
Identifying nursing interventions that will help patient maintain, restore healthy foot care practices & establishing desired outcome for each patient. Interventions=teaching patient about correct nail/foot care |
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Bed making |
When turning client to side while making an occupied bed, raise the side rail nearest to client Raise the side rails Place bed in low position when leaving client Put items used by client in easy reach w/ call light Provide smooth, wrinkle free bed to avoid skin breakdown |
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Nociceptive Pain |
Experienced when an intact, properly functioning nervous system sends signals that tissues are damaged, requiring attention & proper care. Ex: a broken bone alerts person to avoid further damage until its healed |
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Neuropathic Pain |
Associated with damaged or malfunctioning nerves due to an illness, injury (phantom limb, spinal cord injury pain), or undetermined reasons. Typically chronic w/ tingling, dull, aching, burning, & "electric shock" |
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Nociception's four processes |
Transduction, Transmission, Perception, Modulation |
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Nociception Transduction & pain interventions |
Harmful stimuli trigger release of biochemical mediators such prostaglandins which sensitize nociceptors. Pain meds can work during this phase by blocking production of prostaglandin (aspirin or ibuprofen) or by decreasing movement of ions across cell membranes Topical analgesic capsaicin=depletes substance P |
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Nociception Transmission & pain interventions |
1st stage=pain impulses travel from peripheral nerves fibers to spinal cord. Substance P=neurotransmitter, enhancing movement of impulses across nerve synapse from primary neuron to 2nd order neuron in dorsal horn of spinal cord. 2nd stage=transmission of pain signal thru ascending pathway, spinal cord~brain (pain control takes place here by opioids=block release of neurotransmitters=substance P=stops pain @ spinal level. Capsaicin depletes 3rd stage=transmission of info to brain where pain perception occurs |
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Nociception Perception & pain interventions |
When client becomes aware of pain |
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Nociception Modulation & pain interventions |
"Descending system" Neurons in brain send signals back down to dorsal horn of spinal cord. These fibers release substances such endogenous opioids which inhibit painful ascending impulses=often short lived as they are reabsorbed into nerves. Tricyclic antidepressants can relieve pain by blocking reuptake (reabsorption) of norepinephrine, making them available to fight pain |
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Gate Control Theory |
Small-diameter (A-delta or C) peripheral nerve fibers carry signals of painful stimuli to dorsal horn, where these signals are modified when exposed to substantia gelatinosa (milieu in CNS). Ion channels on pre & post synaptic membranes serve as gates, when open, permit positively charged ions to rush into 2nd order neuron, sparking an electrical impulse & sending pain signals to thalamus. Nurses use this model to stop nociceptor firing, apply topical therapies (heat, cold) & address client mood |
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Tolerance |
Occurs when client's opioid dose, over time, leads to a decreased sensitivity of the drug's analegesic effect |
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Pseudoaddiction |
Condition that results from the dertreatment of pain where client may become so focused on obtaining meds for pain relief that they become angry and demanding, may "clock-watch", & may seem "drug seeking"
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Addiction |
Chronic, relapsing, treatable disease influenced by genetic, pshychosocial, and environmental factors. |
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Factors that can affect a person's perception of pain |
Ethnic background & cultural heritage Age & developmental stage of a client Environment & support people Previous Pain Experiences Meaning of Pain |
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Barriers to effect pain management |
Failure to assess pain Underestimation of pain Failure to accept client's report of pain Failure to act on client's report of pain Concerns about addiction |
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Nursing diagnoses for pain |
Acute pain Chronic pain |
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Pharmacologic pain control interventiongs |
Opioids Nonopioids Conanalgesic drugs |
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WHO 3 step ladder for cancer pain |
Mild pain 1-3=nonopioids Moderate 4-6=opioid for moderate pain or combo of opioid & nonopioids Severe 7-10=opioid for severe pain |
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Actions of drugs on body |
half life |
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Factors Affecting Med action |
Developmental factors Gender=distribution of body fat/fluid, hormone Cultural, ethnic, & genetic factors Diet Environment Psychological factors Illness/disease Time of administration |
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Routes of med administration |
Oral Sublingual Buccal Parenteral Topical |
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Types of med orders |
State order=given immediately & only once Single order=med given once @ specified time Standing order=carried out indefinitely PRN=permits nurse to give med when client requires |
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Essential parts of med order |
Full name of client Date and time order is written Name of drug to be administered Dosage of drug Frequency of administration Route of admin Signature of person writing order |
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6 rights |
Right meds Right person Right time Right amount Right route Right documentation |
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Adult SQ injection needle and gauge size? |
24-26 gauge & 3/8-5/8 needle |
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IM injection |
Longer needle 1-11/2 w/ a gauge of 20-22 |
