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20 Cards in this Set

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Nursing Interventions that break the chain of Infection - Etiologic (microorganism)
make sure articles are correctly cleaned,disinfected or sterilized before use. Educate client on same.
Nursing Interventions that break the chain of Infection - Reservoir (source)
Change dressings and bandages when they are soiled or wet.
Assist clients to carry out appropriate skin and oral hygiene.
Dispose of damp, soiled linens appropriately.
Dispose of feces and urine in appropriate receptacles.
Ensure containers are covered.
Empty suction and drainage bottles.
Nursing Interventions that break the chain of Infection - Portal of exit from the reservoir
Avoid talking, coughing, or sneezing over open wounds or sterile fields.
Nursing Interventions that break the chain of Infection - Method of Transmission
Hand hygiene.
Wear gloves.
Wear gowns.
Discard soiled material in proper receptacle.
Hold bedpans steady to avoid spillage.
Initiate and implement aseptic precautions for all clients.
Wear masks and eye protections when needed.
Nursing Interventions that break the chain of Infection - portal of entry to the susceptible host
Use sterile technique for:
invasive procedures and exposing open wounds or handling dressings.
Dispose of needles and sharps properly.
provide clients with their own personal care items.
Nursing Interventions that break the chain of Infection - Susceptible Host
Maintain the integrity of clients skin and mucous membranes.
Ensure proper diet.
Body Defense against infection -
Nonspecific Defenses
Include anatomic and physiologic barriers and the inflammatory response.
Protect the person against all MOs regardless to prior exposure.
Body Defense against infection - Specific Repsonse
Involves the immune system.
Includes Antibody-Mediated defenses (active and passive immunity) and Cell-Mediated Immunity (T-cell system)
Inflammatory Response
Five Signs:
pain, swelling, redness, heat, impaired function of the part, if severe enough.
Nosocomial infections
associated with the delivery of health care services in a health care facility
Factors that increase susceptibility to infection
Age, heredity, level of stress, nutritional status, current medical therapy, and preexisting disease process.
Nursing Management -
Check for signs and symptoms of an infection. Localized swelling and redness, pain or tenderness to touch and movement, heat in affected area, loss of function, fever, increased pulse and resp rate, malaise, anorexia.
Labs - elevated WBC
Nursing management -
Risk for infection.
Associated diagnosis:
Potential complication of infection:fever.
Imbalanced nutrition: Less than body requirements.
Acute pain
Impaired Social Interaction or Social Isolation
Nursing management -
Major goals:
Maintain or restore defenses
Avoid the spread of infectious organisms.
Reduce or alleviate problems associated with the infection.
Nursing management -
If infection cannot be prevented, than the goal is to prevent the infection between persons and treat the existing infection
Standard Precautions
these precautions are used in the car of all hospitalized persons regardless of their diagnosis or possible infection status. Applies to blood, all body fluids, secretions, and excretions except sweat, nonintact skin and mucous membranes
Transmission based precautions
used in addition to standard precautions for clients with known or suspected infections that are spread in one of three ways: airborne, droplet or contact.
Airborne Precautions
Ex. TB
Private room or with someone with same MO.
Wear resp device.
Limit movement outside room. Mask on client during transport.
Droplet precaution
Private room or with someone with same MO.
Wear mask if within 3 ft.
Limit movement outside room. Client to wear mask during transport.
Contact Precautions
Private room or with someone with same MO.
Change gloves after contact with infectious material.
Cleans hands immediately after removing gloves.
Wear gown and remove before leaving room.