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170 Cards in this Set
- Front
- Back
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Chain of infection
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-infectious agent
-reservoir -portal of exit from reservoir -mode of transmission -portal of entry -susceptible host |
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infectious agents
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microorganisms
(bacteria, viruses, fungi, protozoa) |
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virulence
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ability to produce disease, ability to enter and survive in host, susceptibility of the host
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reservoir
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place where a pathogen can survive and may or may not multiply
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bacteria live
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in human body
-on skin -within cavities -fluids and discharges -may not always cause sickness |
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dirtiest part of body
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mouth
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proper environment factors for organism to survive and multiply
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-food
-oxygen -water -temperature -pH -light |
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portals of exit
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-skin and mucous membranes
-respiratory tract -urinary tract -GI tract (mouth, bacteria in digestion) -reproductive tract -blood |
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mode of transmission
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-contact (indirect, direct, droplet)
-air -contaminated items -vectors or insects |
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portal of entry
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-can enter the body through same route used for exiting
-obstruction of urinary catheter -mishandling of contaminated dressing or bandages |
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susceptible host
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-depends on the individuals degree of resistance
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resistance to infection factors
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-age (young, old)
-nutritional status -chronic illness -immunosuppressed individual |
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localized infection
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local symptoms such as pain and tenderness at the wound site
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systemic infection
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an infection that affects the entire site instead of a single organ or part (usually spread through blood or lymph)
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"septic"
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have systemic infection
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immunosuppressed individual
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-HIV/AIDS
-cancer -organ transplants -stress |
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stages of infection
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-incubation
-prodromal -illness -convalescence |
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incubation stage
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-interval between the entrance of pathogen into body and appearance of first symptoms
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prodromal stage
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interval from onset of nonspecific signs and symptoms to more specific symptoms
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illness stage
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interval when client manifest signs and symptoms specific to type of illness
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convalescence
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interval when acute symptoms of illness disappear
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defenses against infection
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-normal flora
-body system defense -immune response |
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inflammatory response
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-protective vascular and cellular reaction that neutralizes pathogens and repairs body cells
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inflammatory response (steps)
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-vascular and cellular response
-formation of inflammatory exudates -tissue repair -histamine release that adds to the pain |
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immune reponse
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-cell-mediated immunity
-humoral immunity -complement -interferon |
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cell-mediated immunity (immune response)
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T lymphocytes and B lymphocytes
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humoral immunity (immune response)
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synthesis of immunoglobulin or antibodies
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complement (immune response)
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enzyme activated when antigen and antibody bind
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interferon (immune response)
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protein substance synthesized in response to virus
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nosocomial infection
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infection acquired in the hospital setting
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latrogenic infection
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nosocomial infection resulting from a diagnostic or therapeutic procedure
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examples of latrogenic infections
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-bloodstream
-respiratory tract -surgical or traumatic wound -urinary tract |
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surgical asepsis
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-sterile technique include produce to elimate microorganisms, including pathogens and spores from an object or area
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what is considered contaminated in surgical asepsis
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object or area touched by any object not sterile
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sterile procedures performed at bedside
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-IV placement
-foley insertion -trach suctioning -reapplying sterile dressing |
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principles of surgical asepsis
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-a sterile object remains sterile object
-only sterile objects may be placed on a sterile field -a sterile object or field out of visual range or below the person's waist is contaminated -a sterile object or field becomes contaminated by prolonged exposure to air |
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principles of surgical asepsis
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-when a sterile surface comes in contact with a contaminated wet surface, the object or field is considered contaminated
-fluid flaws in direction of gravity -the edge of a sterile field or container are considered contaminated |
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medical asepsis
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a clean technique including procedures to reduce or prevent the spread of microorganisms
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examples of medical asepsis
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-handwashing
-using gloves in handling blood and body fluids |
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isolation precautions
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-single client room with negative pressure maintained
-door kept closed -minimum of 6 air exchanges/hour in existing facility and 12/hour in new facilities -possible use of UV light or HEPA air filtration system -use of face mask when entering the room -disposal of trash and waste in marked contaminated double bagged trash containers -degree of isolation applied as to mode of disease transmission |
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universal precautions
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-measures implemented to protect health care workers and patients from contamination and transmittal of HIV and Hepatitis
-use of protective equipment in hospital setting when exposure to blood or body fluid is possible -gloves used in blood drawing and IV starting -gloves in all suctioning or gastric lavage -mask included when rish of respiratory or gastric secretion may be forcefully expelled -cleaning of all lab specimens and bagging for safe transport |
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thermoregulation
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-balance between heat loss and heat produced
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thermoregulation is regulated by:
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-physiological and behavioral mechanisms
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ischemic
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no O2 in tissue
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why does a heart attack/cold fingers and toes hurt?
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constricted blood vessels = less blood = less O2 to area
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mechanism of control in thermoregulation
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-neural and vascular control
-heat production |
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heat production
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-basal metabolic rate
-voluntary muscle activity -shivering -nonshivering thermogenesis |
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neural and vascular control
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-hypothalamus
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heat loss
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-conduction
-convection -evaporation -diaphoresis |
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diaphoresis
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sweating
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skin in temperature regulation
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-insulation
-vasoconstriction -temperature sensation |
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behavorial control of thermoregulation
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-degree of temperature extreme
-person's ability to sense feeling comfortable or uncomfortable -thought processes or emotions -person's mobility or ability to add or remove clothing |
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factors affecting body temperature
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-age
-exercise -hormone level -circadian rhythm -stress -environment -temperature alterations |
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temperature alterations
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-hyperpyrexia or fever
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pyrogens
febrile afebrile |
-things that cause fever
-with fever -without fever |
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fever
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-up to 102.2 F enhances body immune response
-increases body metabolic rate 7% for every degree F -increased oxygen consumption -increases heart rate and respiratory rate (adds to fatigue) |
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if down 1 degree in temp.
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up 7% metabolic rate
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hyperthemia
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an elevated body temperature related to the bodies inability to promote heat loss or reduce heat production
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heatstroke
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a prolonged exposure to the sun or high environmental temperature that overwhelms the bodies heat loss mechanism
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heat exhaustion
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occurs when profuse diaphoresis results in excessive water and electrolyte loss
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hypothermia
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caused by heat loss during prolonged exposure to cold overwhelming the body's ability to produce heat
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treatments of hyperthemia
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-administration of antipyretics as prescribed
-tepid water sponge bath -remove blankets and cool room -ice packs to axillea and groin -fans -cooling blankets |
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examples of antipyretics
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acetomenaphine (tylenol) and ibprofin
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if used ice bath
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it will shock patient resulting in no muscle function
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during a period of increased temperature
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-increase fluids and nutritional rate
-keep client dry after period of diaphoresis -assess oxygen needs and supply oxygen to keep oxygen saturation about 95% |
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Food and Drug Administration
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federal agency that enforces federal regulation regarding manufacturing, processing and distribution of food, drugs and cosmetics
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carbon monoxide
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colorless, odorless, poisonous gas produced by combustion of carbon or organic fuel, binds strongly to hemoglobin preventing the formation of oxyhemoglobin
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poisoning
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ingesting or absorption of toxic substance
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food poisioning
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food improperly prepared or handled allowing bacterial contamination
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human immunodefiency virus
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HIV
-pathogenic virus that spreads through blood and body fluids -virus that causes AIDS |
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Hepatitis C
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-pathogic virus that spreads through blood and body fluids
-may cuase severe liver damage |
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factors affecting safety
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-physical hazards
-transmission of pathogens -pollutions -risks at developmental stages -individual risk factors |
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inner city children are more at risk for:
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-upper respiratory diseases, asthma, allergies
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physical hazards
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-lighting
-obstacles -bathroom hazards -security |
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lighting
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adequate lighting reduces physical hazard by illuminating in which areas a client moves and works
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obstacles
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client tripping over or coming in contact with common household items
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bathroom hazards
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accidents such as falls, burns, and poisoning commonly occur in bathroom
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security
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fires, intruders, lead paint prior to 1978
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transmission of pathogen
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-careful hand washing home and hospital
-adequate disposal of human waste -rodent and insect control |
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pollution
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-air
-land -water -noise |
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risks at developmental stages
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-infant, toddlers and preschool - falls, poisonings, choking
-school age child - bicycles, no seatbelts -adolescent - drugs, alcohol, MVA -adult - least susceptible, MVA -older adult - falls, sensory alterations/responses |
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adolescents
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#1 least restrained group
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individual risk factors
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-lifestyle
-impaired mobility -sensory or communication impairment -lack of safety awareness |
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client-inherited accidents (seizures)
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a hyperexcitation and disorderly discharge of neurons in the brain leading to a sudden, violent, involuntary series of muscle contractions that may be paraoxysmal and episodic
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falls
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90% of hospital incidents are related to falls
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equipment related accidents
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electrical fire, electrocution, and injury due to faulty equipment
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procedure related accidents
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medication and fluid errors, improper application of external devices, and improper performance of procedures
-restraints |
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assessment of client at risk of injury
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-identify actual and potential threats to the client's safety
-determine impact of the underlying illness on the client's safety -identify the presence of risks for the client's developmental stage |
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nursing diagnosis for client at risk of injury
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-risk for injury to impaired mobility
-risk for injury related to barriers in the home environment |
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-planning for client at risk of injury
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-select nursing interventions to promote safety according to the client's developmental and health care needs
-consult with occupation and physical therapists for assistive devices -select interventions that will improve the safety of the client's environment |
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evaluation for client at risk of injury
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-reassess the client for the presence of physical, social, environmental, or developmental risk
-determine if changes in the client's care resulted in increased threats to safety -ask if client's expectations are met |
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sensory alteration
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-visual
-auditory -tactile -olfactory -gustatory -kinesthetic -sterognosis |
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stereognosis
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recognize size, shape and texture of object
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kinesthetic
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awareness of position and movement of body
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gustatory
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taste
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tactile
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touch
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sensory deficit
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a deficit in the normal function of sensory reception and perception
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sensory deprivation
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a person experiences inadequate quality or quantity of meaningful stimuli
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sensory overload
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a person receives multiple sensory stimuli and cannot perceptively disregard or selectively ignore some stimuli
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factors increasing risk of sensory alteration
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-environmental factors
-changes in sensory input |
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changes in sensory input
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-isolation
-immobility -physical injury -aging -physical disability |
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assessment of patient with sensory alteration
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-client health promotion practices
-history regarding extent of risk for and existing sensory deficits -review of potential factors that may affect the client's sensory function -extent of lifestyle and self-care alterations -determining the client's expectations regarding sensory alteration |
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planning of patient with sensory alteration
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-select strategies to assist the client in remaining functional in the home
-adapt therapies depending on whether sensory deficit is short or long term -involve family in helping the client adjust to limitations -refer to appropriate health care professional and community agency |
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evaluation of patient with sensory alteration
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-reassess signs and symptoms of sensory alteration
-determine the client's ability to remain functional within the home or health care environment -ask client to demonstrate or explain newly learn self-care skills -ask client if expectations are met |
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Benner definition of caring
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persons, events, projects and things that matter to people; being connected, reveals what is stressful and the available options for coping
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caring is
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the essential requisite of coping
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focus of Benner's theory
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to help people in their unique situations cope with the stress of illness
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behaviors clients value in healthcare providers
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-treating each client as a unique person
-closely monitoring client's status -showing interest in the client as a person |
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caring in nursing practice
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-presence
-comforting -listening -knowing the client -spiritual caring -family care |
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unconditional positive regard
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acceptance and respect for the client that is not dependent on the client's behaviors
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role
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a set of behaviors, attitudes, beliefs, principles and values that are expected of a person in a given social position of status in a group
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role conflict
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occurs when a person has incompatible expectations for behavior within a role or between 2 or more roles, or when a role is incongruent with the person's beliefs and values
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example of role conflict
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husband of dying wife, go to work to pay mortgage or be support force for wife
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role strain
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when a person feels unable to accomplish the tasks required for a role, results in frustration, tension and overload
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example of role strain
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having too many chapters to read for a class
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social isolation
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experience of aloneness, viewed as a negative or threatened state, seen as being imposed by others
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social support increases
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health
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impaired social interaction
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state in which a person engages in social exchange but finds it to be poor in quantity or quality
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learned helplessness
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a phenomenon which influences the quality and effectiveness of social interaction, perception that further efforts would be useless based on the failure of previous efforts
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learned helplessness is seen in
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frail elderly, battered, disabled
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relocation stress syndrome
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physiologic and psychosocial disturbances caused by transferring a person from one environment to another
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example of relocation stress syndrome
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patient had surgery and is moved to rehab, move to different state or country
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relocation stress syndrome is common in
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nursing homes
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factors affecting roles and relationships
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-developmental
-cultural/religious -socioeconomic -physiological -psychological |
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social isolation assessment
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assess client's appearance (grooming, dress, eye contact, posture, handicaps, mannerisms, gait), memory, manner of speech, communication
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examples of questions to ask a socially isolated patient
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-have you taken on any new roles or have any roles changed for you?
-how well do you get along at work? -what are your friends like? -describe at ime when you were recently mad at your s.o.? -tell me about your important relationships. -who is the decision-maker in your family? -how do you spend your free time? -have you been able to work and do all ADLs? |
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LTG for altered role performance
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client will resume original role functioning in 3 months
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STGs for altered role performance
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-state 3 realistic expectations for the given role in 2 weeks
-assume certain behaviors in a newly modified role in 4 weeks |
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intervention tips for all relationship diagnoses
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-establish trust
-mutual goal-setting |
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intervention tips to improve role performance
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-clarify role
-develop resources -referral to job retraining -teaching -practice redefined roles |
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intervention tips to address social isolation
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-explore feelings
-enhance self-care -promote involvement with family and friends -encourage use of support groups -use pets therapeutically |
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intervention tips to enhance social interactions
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-ego building
-identify strengths and weaknesses -use role-playing -teach communication techniques -encourage use of support groups -increase social contacts |
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intervention tips to address relocation stress syndrome
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-reframe perceptions
-maintain the familiar -prevent relocation stress |
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comunication
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exchange of information, feelings and ideas between people
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communication skills are enhanced by
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good critical thinking
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critical thinkers can
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-interpret message received
-analyze content -make inferences -evaluate their effect -explain rationale for techniques used -examine own personal communication skills |
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levels of communication
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-intrapersonal
-interpersonal -transpersonal -small group -public |
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elements of communication process
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-referent
-sender and receiver -messages -channels -feedback -interpersonal variables -environment |
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verbal
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spoken or written
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nonverbal
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message transmission through body language without using words
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symbolic
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the verbal and nonverbal symbolism used to convey meaning (art and music)
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nurse-client helping relationship
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-takes skill and care to create
-built on the client's trust in the nurse -high expectation of confidentiality -the nurse establishes, directs and is responsible for interaction -client's needs take priority over nurse's needs |
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nurse-client helping relationship
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"therapeutic relationship"
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elements of professional communication
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-appearance
-demeanor -behavior -courtesy -use of names -privacy and confidentiality -trustworthiness -autonomy and responsibility -assertiveness |
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positive attitude of the nurse
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-caring
-empathy -honesty -factual -objectivity -competence -client-focused |
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negative attitude of the nurse
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-business-like
-sympathy -false promises -no knowledge base -biased -imcompetent -self focused |
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therapeutic communication techniques
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-active listening
-sharing observations, empathy, hope, humor, feelings -using touch, silence -asking relevant questions -providing information -paraphrasing -clarifying -focusing -summarizing -self disclosing -confronting |
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empathy
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-see things from client's perspective
-objective -be in other person's shoes -goal is help through therapeutic relationship |
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sympathy
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-feeling sorry for others
-subjective -without taking on client's feelings -goal is to decrease own personal distress |
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attentive listening
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-other person is center of your attention
-leads to understanding the message -use attending skills -focus on understand other person -maintain eye contact -place yourself at same level -sit when speaking to client -allow time for others to speak -respond frequently with general leads |
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intimate space
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12-18 inches, may feel invaded
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personal space
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18 inches - 4 feet, allows quiet talk, comfortable for most people
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social distance
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4-12 feet, formal, too far for personal matters
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public distance
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>12 feet, public speaking
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communication with special needs clients
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-verbal impairment
-hearing impairment -cognitive impairment -unresponsiveness -non-English speaking -infants, children, adolescents, elderly |
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diagnoses for impaired clients
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-impaired verbal communication
-disturbed sensory perception -risk for injury -risk for falls |
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self-concept
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-set of attitudes and beliefs about physical self and psychological self
-guides our actions, motivations, expectations and goals |
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how self-concept develops
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-reactions of others to one's body
-personality structure -relationships with self and others -prior/new experiences -expectations baout the self |
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4 components of self-concept
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1. self-esteem
2. personal identity 3. role performance 4. body image |
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self-esteem
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how much positive regard a person has of himself based on how he perceives that others view him, as well as his own view of self
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self-esteem
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-forms early in life and is based on relationships
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men base self-esteem on life on
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accomplishments
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women base self-esteem on life on
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relationships
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personal identity
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what about a person's personality that makes them unique
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components of personal identity
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-emotional images
-cognitive images -perceptual images |
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emotional images
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feelings about self that are familiar and normal
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cognitive images
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thinking about oneself
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perceptual images
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take sensory data and translate into mental pictures of reality
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role performance
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includes all roles a person assumes of is given, including thoughts and feelings associated with the role
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body image
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person's perception of his/her body, tied close to other 3 concepts, changes with time, very important in our culture
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