Defense And Immunity (Exam 2) Flashcards
What is the Chain of Infection?
- The infectious agent
- The reservoir
- Portal if exit
- Means of transmission
- Portal of entry
- Susceptible host
What is the infectious agent?
This could be bacteria, virus or even parasites
What is the reservoir?
This is where the the infectious agent lives. This could be people, animals, soil etc
Portal of exit
Where the infectious agent escape from the reservoir.
Blood, tissue, respiratory tract
Mode of transmission
Could be through contact through touch
Droplets: sneeze and cough
Susceptible host
Babies
People who are hospitalized
The elderly
What factors affect a patient risk for infection? (7)
- Skin integrity: breakdown of the skin
- The pH level of the GI and GU tract
- Integrity and the number of the white blood cells (WBC): the patient should have enough white blood cells. It provides protection against infection
- Age, sex, race and heredity
- Immunizations
- Level of fatigue, stress level and health habits
- Invasive or indwelling medical devices: Foley catheter, tracheostomy
Who is more susceptible to infection?
Pregnant women
Women are more susceptible to UTI
Older adults
What does stress do to the immune system?
It decrease suppresses the immune system
What are health care associated infections (HAIs)?
This is when a patient acquires infection while their stay at the hospital
What is standard precautions
This is the regular precaution that is taken to avoid or prevent infection.
Includes following hand hygiene techniques
Wearing gloves
Name all of the transmission based precautions
Airborne, contact and droplet
Droplet precautions
Rubella, mumps,
Hand hygiene
Mask
Eyewear
Airborne precautions
TB, varicella, measles
Patient must be in area with negative air pressure
All doors and windows closed
Hand hygiene
N95 mask
Contact precautions
C-Diff, MRSA
Place the patient in a private room
Surgical asepsis
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
Medical asepsis
This is the clean technique
Reduces the spread and number of microorganisms
What are the signs and symptoms of infection
Redness
Swelling
Inflammation
Fever
Diarrhea
Cramps
Warmth
Pain
Weight loss
CLOSTRIDIODES DIFFICILE
Also known as C-Diff
Is caused by bacteria and commonly affects older adults
What population is more likely to be affected by c-diff
Older adults
Signs snd symptoms of c-diff
Watery diarrhea, fever, mild abdominal pain and cramping
What are some precautions of c-diff
Disinfect everything after you’re finished
Always wash hands!!!!!!!!
Sanitizing don’t work
Gown and cloves
Private room
Is c-diff precaution disinfection or sterilization
Disinfection
Name some functions of the skin
Protection
Temperature regulation
Psychosocial
Sensation
Absorption
Elimination
Vitamin d production
Immunolgic
What factors might affect skin integrity?
If the skin is unbroken or unbroken
Resistance of injury to the skin
Adequate circulation
Adequate nutrition
Factors affecting skin integrity for children
Skin is thinner and weaker
Skin and mucous membrane easy to break
Factors affecting skin integrity for adults older
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
Name some other factors that might affect skin integrity
Lifestyle
Body piercing
Dehydration or malnutrition
Reduced sensation
Diabetes
Bed rest
Casts
Medication
What are some implementations for older adults
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
Name the phases of wound healing
- Hemostasis
- Inflammatory phase
- Proliferation phase
- Maturation phase
Hemostasis
The initial stage where the blood clot is formed
Blood vessels constrict forming a blood clot
Inflammatory phase
Phagocyte engulf
Proliferation phase
Repair phase
New tissue is built to fill the wound space
Maturation phase
Wound is remodeled
Scar is formed
What are the local factors that affect the wound healing?
Pressure
Desiccation (dehydration)
Maceration (over hydration)
Trauma
Edema
Infection
Excessive blessing
Necrosis
Presence of biofilm
What is desiccation
This is dehydration
What is maceration
This is over hydration of the wound
Biofilm
This is when bacteria grow in clumps on the wound
What systemic factors affect wound healing?
Age
Circulation & oxygenation
Nutritional status
Medication and health Status
Immunosuppression
Incision
Cutting or sharp instrument
Contusion
Blunt instrument and the over lying skin remains intact
Injury to the underlying tissue
A bruise
Abrasion
Friction
Rubbing or scrapping epidermal layers of the skin
Like a scratch
Laceration
Tearing of the skin and tissue with blunt or irregular instruments
Usually happen with accidents
What are HAI
This is hospital acquired infection
How long does it take for symptoms of wound infection become apparent?
2-7 days after surgery
What are the signs and symptoms of infection
Prulent drainage
Increased drainage from the wound
Pain
Redness
Swelling
Increased body temperatures
White blood cell count increased
Discoloration of the wound
Delayed healing
What is a hemorrhage
This is dislodged clot from the wound site
How long does the hemorrhage take to occur
The first 48 hours
Dehiscence vs evisceration
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
Who are more at risk for evisceration
Obese, malnourished, smoke tobacco,use anticoagulants,etc
What are some intervention that reduce the risk of wound complications
- Encourage intake of fluids
- Good sources of protein
- Perform sound cleansing and irrigation
- Remove staples and sutures
- Administer med
- Document
What is a pressure injury
Caused by prolonged pressure of the skin
Who is usually affected by pressure injury
Those confined to bed
Sit in wheel chair long time
Factors and risk for pressure injury development
External pressure
Friction and shear: pulling and pushing
Immobility
Nutrition and hydration
Moisture: too much hydration
Mental status
Age: older patient
Shearing forces
Me layer of the skin slides over the other
What are the common sites development of pressure injury
Bony prominences: scapula, greater trochanter, etc
Stage 1 pressure ulcer
The skin is intact over the bony prominence
Nonblanchable redness
Stage 2 pressure injury
Partial thickness of loss of the dermis
Ruptured or intact blister
Dermis is exposed looks like a blister
Stage 3 pressure injury
Full thickness tissue loss
Slough and eschar may be seen
Maceration: the skin is too wet
Stage 4 pressure injury
Full thickness tissue loss with exposed/ palpable bone cartilage, ligament, tendon, fascia, or muscle
You can see the bone
Unstageable
Base of the ulcer is covered by slough and/ eschar. The eschar must be removed before it can be staged
Eschar must be debridement
Deep tissue injury
Purple or maroon localized area of discolored intact skin or blood blister due to the underlying tissue from pressure or shear
Braden scale
19-23: no risk
15-18: mild risk
13-14: moderate risk
10-12: high risk
Less than 9: very high risk
Nursing process: Assessment (ongoing)
History and physical
Skin assessment
Pin assessment: before and after
Common drains
Types of drains
Penrose (open)
Jackson Pratt (closed)
Hemovac (closed)
T tube (closed)
Wound assessment
Always do sight and smell
Color of wound tissue: red, yellow, and black
Red: healthy
Black: dead tissue that should be removed
Yellow or slough: purulent drainage or dead tissue that should be removed
Appearance of the wound. What should you be looking for?
Assess the length, width, depth, wound edges, tunneling , undermining , odor
What are the different kinds of drainage
Serous: clear
Sanguineous: bloody
Serosanguineous: pink. A mixture of serum and blood
Purulent: smelly rotten, sign of infection
Common nursing diagnosis
- Impaired skin integrity
- Risk for impaired skin integrity
- Impaired mobility
- Ineffective tissue perfusion
- Risk for infection
- Imbalanced nutrition
- Body image disturbance
- Hopelessness
- Pain
- Knowledge deficit
An example of smart outcome
Patient will remain afebrile, with the absence of redness imprudent drainage at the surgical site for the entire shift
Some nursing interventions for skin
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
Check pressure points for injury every?
30 minutes
