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188 Cards in this Set
- Front
- Back
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Nurse's Role
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providing a biologically safe environment for the patients that the nurse cares for
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Infection
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invasion of body tissues by microorganisms and their proliferation in that area
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microorganism
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infectious agent
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Symptomatic or subclinical
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no clinical evidence of infection
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What represents the #1 cause of world wide death?
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Infectious Diseases, leading cause of death in USA
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WHO
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World Health Organization
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CDC
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principle health agency at national level
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DPH
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state and local agencies tracking epidemics, illnesses, and outbreaks
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Medical Asepsis
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includes all practices to confine a specific organism to a specific area, limiting number and growth and transmission
(objects are referred to clean and dirty) ex: taking an oral temp |
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Surgical Asepsis
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AKA sterile technique
practices that keep an area or object free or all microorganisms includes practices that destroy all microorganisms, spores **used for all procdures *sepsis = state of infection ex: preparing an IM for infection |
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Bacteria
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MOST COMMON, can be transported through air, water, food, soil, body tissues/fluids, and inanimate objects
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Viruses
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consist of nucleic acid and therefore must enter living thing to reproduce (HIV, herepes)
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Fungi
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yeasts and molds (candida)
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Parasites
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live on other organisms (ticks)
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Colonization
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-process by which strains of microorganisms become resident flora
- can grow and multiply but do not cause disease |
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Types of Infections
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Local
Systemic Acute Chronic |
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Systemic Infection
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microorganisms sperad and damage different parts of the body
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Local infection
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limited to the specific part of the body where the microorganisms remain
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acute infection
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appear suddenly and last a short time
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chronic infection
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- occur slowly, may last for months or years
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Local Infection Signs
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1. localized swelling
2. localized redness 3. pain or tenderness with palpation or movement 4. palpable heat in infected area 5. loss of function of the body part affected, depending on the site and extent of involvement |
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Systemic Infection Signs
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1. fever
2. increased pulse and respiratory rate if fever is high 3. tired(malaise) and loss of energy 4. anorexia and in some situations nausea and vomiting 5. enlargement and tenderness of lymph nodes that drain the area of infection |
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What are the stages of Infection?
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Incubation Period
Prodomal Stage Full Stage of Illness Convalescent Period |
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Incubation Period
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interval between pathogen invasion and appearance of infection, time varies
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Prodomal stage
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person most infectious, signs and symptoms present, but extremely vague (tired), hours to days, person is unaware they are contagious
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Full Stage Illness
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specific signs and symptoms, types of infection determines length of illness and severity, symptoms can be localized or systemic
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Convalescent Period
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recovery from illness, depends of severity of illness and co-morbiditites
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What is a nosocomial infection?
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infections associated with the delivery of health care services in health care facilities
- can develop during or after pt stay - can also be aquired by health care workers - 20,000 deaths per year -* most common ICU setting, urinary tract, respiratory tract |
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Iatrogenic Infection
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direct result of a diagnostic or therapeutic procedure EX: urinary catheterization
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Urinary Tract Organisms and Causes
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****most common, improper catheter
- Ecoli Enteroccocus species Psuedomonas aeruginosa Causes: improper cath technique, contamination of closed catheter system ** In Adequate Handwashing ** |
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Surgical Site Organisms and Causes
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Staphyloccocus aureus
Enterococcus species Pseudomonas aeruginosa Causes: **Inadequate handwashing, improper dressing technique |
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Bloodstream Organisms and Causes
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Coagulase-negative staphyllocci
Stephylococcus aureus Enterococcus species Cuase** Inadequate handwashins, improper IV fluid, tubing and site care technique |
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Pneumonia Organisms and Causes
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Staphylococcus aureus
Pseudominas aeruginosa Enterobacter species Causes** Inadequate hand washing, improper suctioning technique |
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Cost of Nosocomial Infection
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4.5 BILLION annually!
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LOS
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length of stay
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Chain of Infection
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1. Pathogenic Microorganism/Etilogic Agent
2. Resevoir 3. Means of Escape 4. Mode of Transmission 5. Means of Entry 6. Host suceptibility |
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Breaking the Chain: Etilogic agent
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- correctly cleaning, disinfecting, or sterilizing articles before use
- educating clients and support persons about appropriate methods to clean, disinfect, and sterilize |
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Breaking the Chain:
Resevior |
- changing dressing and bandages when soiled or wet
- appropriate skin and oral hygiene - disposing of damp, soiled linens appropriately -disposing of feces and urine in appropriate receptibles -ensuring that all fluid containers are covered or capped -emptying suction and drainage bottles at the end of -each shift or before dull or according to agency police |
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Breaking the Chain
Portal of Exit |
- avoiding talking, coughing, ot sneezing over open wounds or sterile fields
- covering the mouth and nose when coughing or sneezing |
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Breaking the Charin
Method of Transmission |
1. Direct Transmission
- immediate and direct transfer from person to person through hitting, kissing, touching, or sex EX- droplet (sneezing) 2. Indirect Transmission -2 methods - Vehicle-borne transmission - Vector-borne transmission 3. Air-borne Transmission |
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Vehicle -borne transmission
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vehicle in any substance that serves as intermediate means to transport and introduce infectious agent to susceptible host through suitable portal of entry
Fomites (inanimate objects) toys, water, food, etc |
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VEctor-borne Transmission
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animal or insect that serves as an intermediate means of transporting the infectious agent
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Airborne Transmission
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may involve droplets or dust
- droplet nuclei, residue of evaporated droplets emitted by an infected host can remain in the air for a long period of time material is transmitted by air to suitable portal of entry (usually respiratory) |
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Breaking the Chain
Method of Transmission |
- proper hand hygeine
instructing clients and support persons to perform hand hygeine before handling food wearing gloves when handling secretions, excretions, and if there is a danger of soiling clothing with body substances - place discarded soiled materials in moisture proof refuse bags -holding used bedpans steadily to prevent spillage -disposing of urine and feces in appropriate recepticles -initiating and implementing aseptic precautions -wearing masks and eye protection when in close contact with clients who have infections transmitted by droplets from the respiratory tract -wearing masks and eye protection when sprays of body fluid possible |
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Breaking the Chain:
Portal of Entry |
using sterile technique for invasive procedures, when exposing open wounds or handling dressings
-placing used disposable needles and syringes in puncture-resistant containers for disposal -providing all clients with own personal care items |
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What is a susceptible host?
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any perosn who is at risk for infection
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Compromised host
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person at increased risk....
(age (veryyoung/old) pt w/ chrnoic illness, chemo, immune def. |
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Breaking the Chain
Susceptible HOst |
- maintaning the integrit of the clients skin and mucous membranes
- ensuring that the client recieves a balanced diet - educating the public about the importance of immunization |
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PT has been diagnosed with gastrointestinal bacteria obtained from drinking contaminated water. In the chain of infection, what is the water?
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Resevoir
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Nonspecific Body Defenses
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Protect against all microorganisms regardless of prior exposure
- intact skin, dry skin, acidic skin, resident bacteria of skin |
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Specific Defenses
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are directed against identifiable bacteria, viruses, fungi, or other infectious agents
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Inflammatory Response
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adaptive mechanism that destroys, dilutes and prevents spread and contributes to healing
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5 Signs of Inflammation
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1. Pail
2. Swelling 3. Redness 4. Heat 5. Impaired function of body part |
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What are the 3 stages of inflammatory response?
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1. Vascular and cellular responses
2. Exudate production 3. Reparative Phase |
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Vascular and cellular responses
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- marked increase in blood supply called hyperemia
- leukocytes into interstitial space - normal WBC (4500-11,000) |
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EXUDATE PRODUCTION
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-serous, pertulent, sanguineous
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Reparative Phase
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-regeneration
- scar tissue (cicatrix) -granulation tissue (beefy red) |
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Specific Defenses
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- involves immunity system
-antigen is protein that induces a state of sensitivity or immunity |
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auto-antigen
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the antigen originates in the person's own body
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Immune system has two components...
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Antibody mediate defenses
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Active Immunity
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host produces antibodies in response to natural antigens (infectious microorganisms or vaccines)
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Natural Active Immunity
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antibodies are fomed in presence of active infection in the body (duration life long)
"got chicken pox" |
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Artifical active immunity
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antigens administered tos timulate antibody formation(lasts many years) reinforced by booster
ex. vaccinations |
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Passive Immunity
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(aquired) host recieves natural or articial antibodies f=produed from another source
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natural passive immunity
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mom to baby
antibodies transferred naturally from an immune mother to baby through the placenta or in colostrum lasts about 6 months to a year |
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Artificial passive immunity
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occurs when immune serum (antibody) from an animal or another human is injected (lasts 2-3 weeks)
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Cell Mediated Defenses
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aka cellular immunity
occurs through the T-cell system cell mediated immunity is lost with disease such as HIV individual is defenseless against most viral, bacterial and fungal infections |
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life span considerations
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* normal aging predisposes to infection
*nutrition/protein intake = poor * diabetes increases risk of infection and delays healing * immune system reacts slower * confusions and disorientation * normal inflammatory response is delayed |
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Age Related Pulmonary Changes
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-decreased cough reflex, elastic, recoil of lungs, activity of cilia
- abnormal swallowing reflexes -place pt in sitting position to eat and drink -encourage fluid intake, coughing, turning, and deep breathing |
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Age Related Urinary Tract Changes
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- incomplete emptying of bladder
-decreased sphincter control - enlarged prostate -pelvic floor relaxation -reduced renal blood flow -encourage voiding at regular intervals -forcue fluids, meds for prostate - change incotinence pads freq/good peri care -***** for UTI, void after sex |
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Age Related Skin Changes
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- loss of elasticity
- increased dryness - thinning of epidermis -slowing of cell replacement - force fluids - good daily hygiene - apply lotion to skin as needed assess for break in skin integrity, rashes or changes in skin |
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The Nursing Process
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developed by Lydia Hall
1. Assessment 2. Diagnosis 3. Goals 4. Implement 5. Evaluation (((ADPIE))) |
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Nursing Process
Assesment |
-systematically collecting data
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Nursing Process
Diagnosis |
identify actual and potential problems
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Nursing Process
Goals |
Develop an individualized plan
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Nursing Process
Implement |
execute plan
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Nursing Process
Evaluation |
Evaluation
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Physical Assessment
Localized Infection |
localized swelling
localized redness pain/tenderness on palpation or movement palpable heat at site loss of function of body part |
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Physical Assessment
Systemic Infection |
fever
increased pulse malaise and loss of energy anorexia (nausea and vomiting) lymph node enlargement/involvement |
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Hand Washing
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CDC says 20 seconds with antimicrobial foam washing under a stream of water
nails short no jewelery but wedding band check hands for breaks in skin |
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Universal Precautions
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technique to be used with all clients to decrease risk of transmitting unidentified pathogen
- interfere with the spread of blood borne pathogens (HIV) |
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HICPAC Isolation Precautions 1996
Standard Precautions |
used in care of all hospitalized pts regardless of diagnosis or possible infection status
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Standard Precaution
Universal Precautions Tier 1 |
- wash hands after handling body secretions, gloves or - clean gloves, not sterile
-mask, face shield with risk of splashing of bodily fluids -respiratory hygiene/cough etiquette -wear non-sterile gown to protect clothing against bodily fluids -handle linen appropriately -handle equipment appropriately, dispose of it properly |
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Transmission Based Precautions
Tier 2 |
- used in addition to standard precautions
- used to prevent spread of infection by airborne, droplet, or contact - place pt in private room with neg pressure - wear special mask if pt has TB (N95) - susceptible people should not enter - wear mask within 3 ft of pt - gloves as with std. - gown as needed |
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Airborne
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measeles, varicella, TB
- need N95 mask |
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Droplet
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-within 3 feet
-diphtheria, mycoplasma pneumonia, pertusiss, mumps, scarlet fever |
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Contact
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gastrointestinal, respiratory skin or wound infection
**MRSA respresents 40% of staph infections and are resistant to penicillin |
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Vancomycin
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last line of defense to these organisms and increasingly strains are becoming resistant
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The pt abdominal dressing is described as having a moderate amount of serosanguineous drainage and a very foul odor. In planning the dressing change, it is most important for the nurse to...
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Wash her hands before and after the dressing change
**handwashing is the single most effective method in preventing the spread of microorganisms** |
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What is PPE?
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Personal Protective Equipment
* gloves- protect hands of nurse *gowns- clean or disposable impervious *facemasks- worn to reduce the risk of transmission of organisms by droplet contact, by airborne routes and by splattering of body substances *eye shield- protective eyewear, goggles, glasses, or face shields and masks |
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Putting on PPE
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1. Gown
2. Mask 3. Eyewear 4. Gloves |
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Removing PPE
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1. Gloves
2. Eyewear 3. Gown 4. Mask |
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Disposal of Soiled Equipment and Supplies
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bag all items that have been contaminated, likely to have been contaminated with pus blood body fluids or feces
-may need to double bag (bag all linen and handle as little as possible) |
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Disposal of Lab Specimens
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use specimen bags, label appropriately
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Disposal of Dishes
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no special precautions, may use disposable
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Disposal of BP equipment
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no special precautions unless becomes contaminated, many facilities have disposable cuff
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Disposal of Thermometers
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no special precautions with disposable covers
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How to transport pt on precautions?
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Cover wounds
airborne- pt wears mask notify receiving department chat in plastic bag gloves and gown follow agency policy |
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Psychosocial needs of PT on precautions
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- sensory deprivation
-feelings of inferiority - risk for low self of steam |
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Bloodborne Pathogen Exposure
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report the incident exposure
complete injury report seek appropriate evaluation and follow-up |
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The client is a chronic carrier of infection. To prevent the spread of the infection to other clients of health care providers, the nurse emphasizes interventions that do which of the following?
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block portal of exit from reservoir
** this will succeed in preventing the infection of other people** |
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The most effective nursing action for controlling the spread of infection includes which of the following?
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thorough hand washing
** hands are the most obvious of transmission ** |
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When caring for single client during one shift, it is appropriate for the nurse to reuse which of the following PPE?
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goggles
** unless overly contaminated, goggles may be used** |
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After evaluating pt chart, the nurse concludes a 65 year old clients immunizations are current. What evidence supports this conclusion?
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1. Receives a flu shot every year
2. only persons at risk need to receive HEP B vaccine 3. only persons at risk need hep a vaccine |
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The nurse is exiting the isolation room. Considering infection control protocols which would be first action the nurse would take?
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Dispose of equipment inside of room
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Which of the following is a transmission based precaution?
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droplet
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For an infection to occur siz links or steps must be present...which of these is not a link?
Infectious agent Reservoir Portal of Entry Droplet transmission |
Droplet transmission
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Which of the client statements indicates a client who is at risk for infection?
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"i had by last dose of chemo" chemo- immune system comp.
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Immunity that is obtained as a result of experiencing an illness is known as
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Active Natural Immunity
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Which of the following groups of people are most susceptible to infection?
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new born infants
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A client with a wound infection is placed on contact precaution based on a wound culture. When should the nurse caring for the patient don gloves?
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- upon entering the pt room
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A nurse enters a pt room at the beg of the shift. The nurse looks around the room for potential sources for infection. Which of the following pose a potential risk for infection...
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- clients abdominal dressing has 3 diff areas of moist drainage saturating the dressing and soiling the pt gown
- an opened package of gauze sponges is present on window sill - tubing of clients IV fluids is not labeled with the date of the last tubing change |
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Signs of infection would include all of the following except
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Elevated WBC
(would be elevated if infection in present) |
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The nurse is caring for a pt on transmission based precautions. Which of the following is true of transmission based precautions?
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Transmission based precautions are used with all patients
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When caring for a client with AIDS related cancer the nurse should always use which of the following protective measures
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standard precautions
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An individual who is more likely to acquire an infection is...
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Susceptible host
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The pt is positive for c-diff, the nurse should institute which of the following?
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contact precautions
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When brushing a pt hair the nurse notices white oval particles attached to the hair behind the ears. The nurse should ***** the pt further for signs of...
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Pediculous
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The nurse is concerned about the pt ability to withstand exposure to pathogens. Which blood component should the nurse monitor?
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neutriphils- the most numerous leukocytes are a primary defense against infection
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The primary reason that a nurse should avoid glue on artificial nails is because
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harbor organisms
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The client is a chronic carrier of infection. To prevent the spread of infection to other clients or health care provides, the nurse emphasizes interventions that do which of the following?
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block the portal of exit from reservoir...
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Which is the most effective nursing action for controlling the spread of infection?
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thorough hand hygiene
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The nurse determines that a field remains sterile if which of the following conditions exist?
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Sterile items are 2 inches from the edge of the field
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The client is unresponsive and requires total care. Prior to providing oral care, the nurse should ***** for what?
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gag reflex
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The client is in surgery and will be returning to his bed via a stretcher. The nurse plans ahead by making which type of bed and lacing the bed in what position?
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A surgical bed in high position
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The nurse observed the UAP perform perineal care for a client. Which of the following indicates that further teaching is required
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Does not retract foreskin
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The nurse is discussing foot care with a client who was recently diagnosed with diabetes. Which of the following statements indicated a need for further teaching?
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I enjoy walking barefoot around the house
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The client experiencing labored, shortness of breath has a respiratory rate of 28. The bed is currently in a flat position. The best nursing intervention includes puttting the bed in which of the following positions?
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Fowler's
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hygiene
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observance of health rules as they relate to self care activities
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What is self care?
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ability to perform primary functions in areas of bathing, feeding, toileting, and dressing without help from others
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Early morning care
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urinal or bedpan
washing face and hands oral care |
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Morning Care
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usually after breakfast
eliminations bath or shower peri care back massage oral nail and hair care bed making |
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HS or PM care (hours of sleep)
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elimination
washing face and hands oral care back massage |
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PRN (as needed)
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more frequent bathing
changes of clothes |
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Cleansing Bath
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keep skin free of secretions, microorganisms, perspiration and debris
- complete bed bath -self help bath - partial bath - towel or bag bath - tub bath - shower-stand or sit |
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Therapeutic Bath
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soothe skin irritation or promote healing
- sitz bath (maternity) - warm water bath - cool water bath - soaks |
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Levels of Self- Care
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Level 0- independent in self-care activities
Level 1- uses equipment or devices to perform self-care activities independently Level 2- requires assistance or supervision from another to complete self care activities Level 3- requires assistance or supervision from another and use of devices/ equipment Level 4- completely dependent on another to perform self-care activities |
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Assessment of Self Care Activities
Subjective Data |
Normal Pattern Identification
- How do you manage bathing? Risk identification - Describe any factors that interfere with your ability to bathe or complete ADLS Dysfunction Identification - familiarity with signs indicating inability to perform self care |
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Assessment of Self care Activities
Objective Data |
Validate information obtained during interview and look for evidence of inability for self care, use of mechanical aids etc
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Abnormal Findings of the Skin
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Abrasion- top layer of skin scraped off
Excessive dryness Ammonia dermatitis Acne Erythema- pressure Hirtutism- excessive hair |
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Abnormal Findings on Feet
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excessive dryness
areas of inflammation or swelling plantar works cool skin temp in one or both feet swelling and pitting edema |
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Foot/Nail care
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wash and dry WELL
change socks daily inspect foot daily using mirror do not walk barefoot NO bathroom surgery (doing things yourself) |
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Nail Care
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filing is preferred over cutting
diabetic pts must have nails cut by podiatrist |
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Abnormal findings of the nails
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spoon nails
excessive thickness or clubbing beaus lines discolored or attached etc |
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Oral Care
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assesment or oral cavity, mucosa, detentition, gums, pocketing of food
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Abnormal Findings of Mouth
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halitosis- bad breathe
glossitis- inflammation gingivitis- infected gums periodontal disease- gum disease dental caries- cavities sordes- food/material inside of mouth |
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Abnormal Findings of the Hair
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dandruff
hair loss ticks pediculosis (head lice) |
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Shaving
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electric ONLY is on anticoagulants
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Eye care
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inner cathus to outer canthus, new area of cloth with each wipe
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Abnormal Findings of Eye
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loss of hair, scaling, flaky eyebrows
crusting flaking swelling jaundiced sclera unequal pupils |
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Ear Care
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inspect external canal
clean auricles with a wash cloth covered finger no qtips |
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Abnormal Findings of Ears
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-asymmetrical, excessively red or tender auricles
-lesions, flaky, scaly - normal voice tones not hears |
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Abnormal FIndings of Nose
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asymmetrical
discharge localized redness/tenderness/lesions |
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Perineal Care
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- genital care performed by nurse if pt cant do it
embarrassement factor is huge WOMEN: cleanse upper inner thighs, labia majora, and folds between labia majora and minora and cleanse butt MEN: cleanse upper inner thighs, penis, scrotum, retract forskin briefly and cleanse buttocks |
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Flo's Big Six
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1. Clean body bed and room
2. quiet 3. light 4. fresh air 5. warmth 6. nutrition |
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Bedmaking 101
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change linen on basis of need not routine
linens that are soiled wet or stained need to be changed put bed at workable height to avoid back strain place the bedside table over bed within reach |
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Unoccupied Bed
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level in low position if returning to bed after being up
(closed vs open bed) |
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Occupied Bed
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When turning the client to the side while making an occupied bed, raise the side rail nearest the client
- to ensure continued safet of the client after making occupied bed (raise side rails, place the bed in the low position, put items used by client within reach, attach the signal cord) |
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Surgical bed
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linen open to the side
leave the bed in high position if returning by stretcher |
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Which is the first assessment the nurse should make when planning to meet the hygiene needs of a pt?
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determine the pt preferences about hygiene practices
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Which is the best when providing oral care to unconscious pt?
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packaged glycerin swabs
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The most important reason why the nurse washes a pts extremities from distal to proximal is to..?
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stimulate venous return
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A client has been diagnosed with tinea pedis. Which of the following statements indicates a need for further teaching in regard to this diagnosis?
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" ill be sure to remove my flipflops when i use the school shower"
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A pt is incontinent or urine of stool. For which pt response should the nurse be most concerned?
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Impaired Skin Integrity
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The nurse is giving the pt a bed bath. Which nursing action is most important?
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Lower the side rail on the working side of the bed
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The Nurse covers the pt with a cotton blanket during th bath. This is done to prevent heat loss during...
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convection
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cognitive awareness
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ability to perceive environmental stimuli and respond appropriately
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sensory perceptual alterations
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sensory perception of environmental stimuli is critical to safety
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emotional state
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extreme emotional states can alter the ability to perceive environmental hazards
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IOM reports that .....
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44,000 to 98,000 die each year d/t medical errors in hospital
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bioterrorism
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3 categories
Category A- high priority agents that pose a risk to national security Category B- 2nd highest priority agents that are fairly easy to take apart and results in moderate morbidity and low mortality Category C- third highest priority agents including "emerging pathogens" that can be engineered |
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FEMA
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Federal Emergency Management Agency
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4 Phases of Disaster Planning
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1. Preparedness- planning and preps required to handle emergency
2. mitigation- steps and activities related to preventing future emergencies or minimizing their effects 3. Response- actual activation of the emergency plan when the need arises 4.Recovery- actions needed to restore normal operations |
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FIRE SAFETY
(RACE) |
R- rescue- protect, evacuate pts who are in immediate danger
A-alarm- report fire C- contain the fire E- extinguish the fire |
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Orthostatic Hypotension
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decrease in BP as you move positions
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restraints
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purpose is to protect the pt from harming him/herself and others
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physical restraint
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any manual or physical/mechanical device, material or equipment attached to the pt body that cannot be removed easily which restrict the pt movements
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chemical restraint
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medication such as neuroleptics, anxiolytics, sedatives, and psychotropic agents used to control socially disruptive behavior
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2 Standards of Restraint Use
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1. acute medical-surgical care standard
2. behavior management standard |
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acute medical-surgical care standard
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- nurse can apply restraint
- up to 12 hr allowed for obtaining MD order -oder must be renewed daily |
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behavior management standard
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nurse may apply, but MD must see client within an hour
- written order required, good for 4 hours -if secluded, continual audio and visual over site |
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alternative to restraints
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- nurse "buddies"
- use pillows/pads -quiet area -determine cause -rocking chairs -keep bed at low position |
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applying restraints
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consent, orderm reson to pt/fam, least restrictive, pad bony parts, quick release knot, tie to bed frame, provide emotional support, check every 30 min, after removal, dont leave, release every 2-4 hours
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Which action takes priority when feeding a pt with dysphagia?
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check mouth for emptying between bites
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Which is the most important intervention to help prevent falls from physical hazards in the hospital?
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ensuring adequate lighting
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After pts are protected from danger and the fire is reported, the nurse should immediately
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close doors and windows
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Which is the best type of restraint to use on a pt who is trying to pull out his urinary retention catheter?
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mitt restraint
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The most serious risk for the pt with dysphagia is?
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Aspiration
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