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Fundamentals (Nurs 113) > Defense And Immunity (Exam 2) > Flashcards

Defense And Immunity (Exam 2) Flashcards

1
Q

What is the Chain of Infection?

A
  1. The infectious agent
  2. The reservoir
  3. Portal if exit
  4. Means of transmission
  5. Portal of entry
  6. Susceptible host
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2
Q

What is the infectious agent?

A

This could be bacteria, virus or even parasites

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3
Q

What is the reservoir?

A

This is where the the infectious agent lives. This could be people, animals, soil etc

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4
Q

Portal of exit

A

Where the infectious agent escape from the reservoir.
Blood, tissue, respiratory tract

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5
Q

Mode of transmission

A

Could be through contact through touch
Droplets: sneeze and cough

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6
Q

Susceptible host

A

Babies
People who are hospitalized
The elderly

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7
Q

What factors affect a patient risk for infection? (7)

A
  1. Skin integrity: breakdown of the skin
  2. The pH level of the GI and GU tract
  3. Integrity and the number of the white blood cells (WBC): the patient should have enough white blood cells. It provides protection against infection
  4. Age, sex, race and heredity
  5. Immunizations
  6. Level of fatigue, stress level and health habits
  7. Invasive or indwelling medical devices: Foley catheter, tracheostomy
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8
Q

Who is more susceptible to infection?

A

Pregnant women
Women are more susceptible to UTI
Older adults

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9
Q

What does stress do to the immune system?

A

It decrease suppresses the immune system

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10
Q

What are health care associated infections (HAIs)?

A

This is when a patient acquires infection while their stay at the hospital

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11
Q

What is standard precautions

A

This is the regular precaution that is taken to avoid or prevent infection.
Includes following hand hygiene techniques
Wearing gloves

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12
Q

Name all of the transmission based precautions

A

Airborne, contact and droplet

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13
Q

Droplet precautions

A

Rubella, mumps,
Hand hygiene
Mask
Eyewear

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14
Q

Airborne precautions

A

TB, varicella, measles
Patient must be in area with negative air pressure
All doors and windows closed
Hand hygiene
N95 mask

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15
Q

Contact precautions

A

C-Diff, MRSA
Place the patient in a private room

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16
Q

Surgical asepsis

A

This is sterile
Unsterile means that the object is contaminated
Hold objects above the waist level
Never walk away or turn your back from the sterile fields
Eliminates all microorganisms

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17
Q

Medical asepsis

A

This is the clean technique
Reduces the spread and number of microorganisms

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18
Q

What are the signs and symptoms of infection

A

Redness
Swelling
Inflammation
Fever
Diarrhea
Cramps
Warmth
Pain
Weight loss

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19
Q

CLOSTRIDIODES DIFFICILE

A

Also known as C-Diff
Is caused by bacteria and commonly affects older adults

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20
Q

What population is more likely to be affected by c-diff

A

Older adults

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21
Q

Signs snd symptoms of c-diff

A

Watery diarrhea, fever, mild abdominal pain and cramping

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22
Q

What are some precautions of c-diff

A

Disinfect everything after you’re finished
Always wash hands!!!!!!!!
Sanitizing don’t work
Gown and cloves
Private room

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23
Q

Is c-diff precaution disinfection or sterilization

A

Disinfection

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24
Q

Name some functions of the skin

A

Protection
Temperature regulation
Psychosocial
Sensation
Absorption
Elimination
Vitamin d production
Immunolgic

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25
Q

What factors might affect skin integrity?

A

If the skin is unbroken or unbroken
Resistance of injury to the skin
Adequate circulation
Adequate nutrition

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26
Q

Factors affecting skin integrity for children

A

Skin is thinner and weaker
Skin and mucous membrane easy to break

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27
Q

Factors affecting skin integrity for adults older

A

Dry skin
Thin which makes is easier to damage
A decrease in elasticity
Have delayed time in healing
Sensation ti pain and pressure is reduced
Unevenly pigmented

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28
Q

Name some other factors that might affect skin integrity

A

Lifestyle
Body piercing
Dehydration or malnutrition
Reduced sensation
Diabetes
Bed rest
Casts
Medication

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29
Q

What are some implementations for older adults

A

Do not apply tape to the skin unless it is necessary
Check the skin frequently for signs if pressure injury
Padding to the bony prominences
Apply lotions and moisturizers where it is necessary
Encourage hydration to the patient
Do skin assessment
Eliminate use of harsh soaps
Check pressure points for redness every 30 minutes

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30
Q

Name the phases of wound healing

A
  1. Hemostasis
  2. Inflammatory phase
  3. Proliferation phase
  4. Maturation phase
31
Q

Hemostasis

A

The initial stage where the blood clot is formed
Blood vessels constrict forming a blood clot

32
Q

Inflammatory phase

A

Phagocyte engulf

33
Q

Proliferation phase

A

Repair phase
New tissue is built to fill the wound space

34
Q

Maturation phase

A

Wound is remodeled
Scar is formed

35
Q

What are the local factors that affect the wound healing?

A

Pressure
Desiccation (dehydration)
Maceration (over hydration)
Trauma
Edema
Infection
Excessive blessing
Necrosis
Presence of biofilm

36
Q

What is desiccation

A

This is dehydration

37
Q

What is maceration

A

This is over hydration of the wound

38
Q

Biofilm

A

This is when bacteria grow in clumps on the wound

39
Q

What systemic factors affect wound healing?

A

Age
Circulation & oxygenation
Nutritional status
Medication and health Status
Immunosuppression

40
Q

Incision

A

Cutting or sharp instrument

41
Q

Contusion

A

Blunt instrument and the over lying skin remains intact
Injury to the underlying tissue
A bruise

42
Q

Abrasion

A

Friction
Rubbing or scrapping epidermal layers of the skin
Like a scratch

43
Q

Laceration

A

Tearing of the skin and tissue with blunt or irregular instruments
Usually happen with accidents

44
Q

What are HAI

A

This is hospital acquired infection

45
Q

How long does it take for symptoms of wound infection become apparent?

A

2-7 days after surgery

46
Q

What are the signs and symptoms of infection

A

Prulent drainage
Increased drainage from the wound
Pain
Redness
Swelling
Increased body temperatures
White blood cell count increased
Discoloration of the wound
Delayed healing

47
Q

What is a hemorrhage

A

This is dislodged clot from the wound site

48
Q

How long does the hemorrhage take to occur

A

The first 48 hours

49
Q

Dehiscence vs evisceration

A

Dehiscence is the partial or total separation of a wound layers as a result of excessive stress on the wound that are not healed

Evisceration is when the abdominal wound completely separate with protrusion of the viscera through the incision area

50
Q

Who are more at risk for evisceration

A

Obese, malnourished, smoke tobacco,use anticoagulants,etc

51
Q

What are some intervention that reduce the risk of wound complications

A
  1. Encourage intake of fluids
  2. Good sources of protein
  3. Perform sound cleansing and irrigation
  4. Remove staples and sutures
  5. Administer med
  6. Document
52
Q

What is a pressure injury

A

Caused by prolonged pressure of the skin

53
Q

Who is usually affected by pressure injury

A

Those confined to bed
Sit in wheel chair long time

54
Q

Factors and risk for pressure injury development

A

External pressure
Friction and shear: pulling and pushing
Immobility
Nutrition and hydration
Moisture: too much hydration
Mental status
Age: older patient

55
Q

Shearing forces

A

Me layer of the skin slides over the other

56
Q

What are the common sites development of pressure injury

A

Bony prominences: scapula, greater trochanter, etc

57
Q

Stage 1 pressure ulcer

A

The skin is intact over the bony prominence
Nonblanchable redness

58
Q

Stage 2 pressure injury

A

Partial thickness of loss of the dermis
Ruptured or intact blister
Dermis is exposed looks like a blister

59
Q

Stage 3 pressure injury

A

Full thickness tissue loss
Slough and eschar may be seen
Maceration: the skin is too wet

60
Q

Stage 4 pressure injury

A

Full thickness tissue loss with exposed/ palpable bone cartilage, ligament, tendon, fascia, or muscle
You can see the bone

61
Q

Unstageable

A

Base of the ulcer is covered by slough and/ eschar. The eschar must be removed before it can be staged
Eschar must be debridement

62
Q

Deep tissue injury

A

Purple or maroon localized area of discolored intact skin or blood blister due to the underlying tissue from pressure or shear

63
Q

Braden scale

A

19-23: no risk
15-18: mild risk
13-14: moderate risk
10-12: high risk
Less than 9: very high risk

64
Q

Nursing process: Assessment (ongoing)

A

History and physical
Skin assessment
Pin assessment: before and after
Common drains

65
Q

Types of drains

A

Penrose (open)
Jackson Pratt (closed)
Hemovac (closed)
T tube (closed)

66
Q

Wound assessment

A

Always do sight and smell

67
Q

Color of wound tissue: red, yellow, and black

A

Red: healthy
Black: dead tissue that should be removed
Yellow or slough: purulent drainage or dead tissue that should be removed

68
Q

Appearance of the wound. What should you be looking for?

A

Assess the length, width, depth, wound edges, tunneling , undermining , odor

69
Q

What are the different kinds of drainage

A

Serous: clear
Sanguineous: bloody
Serosanguineous: pink. A mixture of serum and blood
Purulent: smelly rotten, sign of infection

70
Q

Common nursing diagnosis

A
  1. Impaired skin integrity
  2. Risk for impaired skin integrity
  3. Impaired mobility
  4. Ineffective tissue perfusion
  5. Risk for infection
  6. Imbalanced nutrition
  7. Body image disturbance
  8. Hopelessness
  9. Pain
  10. Knowledge deficit
71
Q

An example of smart outcome

A

Patient will remain afebrile, with the absence of redness imprudent drainage at the surgical site for the entire shift

72
Q

Some nursing interventions for skin

A

Maintaining aseptic technique
Teach the patient about signs and symptoms of an infection
Proper hand hygiene
Monitor for Signs and symptoms of infection
Monitor temperature every 4 hr
Reposition patient for every 2 hr
Use padded devices at pressure point
Consult with wound care specialists
Document
Assess for pain
Administer medication
ROM

73
Q

Check pressure points for injury every?

A

30 minutes

Fundamentals (Nurs 113) (11 decks)

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