Foundations Exam 1 Flashcards
infection
invasion of a susceptible host by pathogens or microorganisms, resulting in disease
colonization
occurs when microorganism invades host but does not cause infection
patients in healthcare settings are at increased risk for acquiring infection because…
lower resistance to pathogens, increased exposure, invasive procedures, resistance
symptomatic
infection accompanied by clinical symptoms
asymptomatic
infection without clinical signs/symptoms
most important technique used in preventing and controlling the transmission of infection
hand hygiene
the CDC now recommends what as an alternative to hand washing?
alcohol-based waterless antiseptics (unless hands are visibly soiled)
Explain the chain of infection.
Host > Infectious agent > Reservoir > Portal of exit > mode of transmission > portal of entry > repeat.
Susceptibility to an infectious agent depends on…
An individual’s degree of resistance to pathogens
Reservoir
A place where microorganisms survive, multiply, and await transfer to a susceptible host
Exit portal
a source of exit from the reservoir
examples of exit portals
skin wounds, respiratory tract, urinary tract, blood, GI tract
immunocompromised
having an impaired immune system
virulence
the ability to produce disease
aerobic bacteria
require oxygen for survival and for enough multiplication to cause disease
anaerobic bacteria
thrive on little or no free oxygen
bacteriostasis
prevention of growth and reproduction of bacteria
bactericidal
destructive to bacteria
Four stages of the infectious process
incubation period, prodromal stage, illness stage, convalescence stage
incubation period
time between pathogen entry and first symptoms. patient contagious, but don’t know it (dangerous stage).
prodromal stage
time from development of nonspecific signs and symptoms to development of more specific signs and symptoms
illness stage
time when patient manifests signs and symptoms specific to the type of infection
convalescence
time when acute symptoms disappear
what precautions do you take when an infection becomes localized?
standard precautions, PPE, and hand hygiene to prevent spread to other body areas
what does PPE consist of?
gown, mask, goggle, gloves
Explain difference between localized and systemic infection.
Localized affects one body area, systemic affects entire body and can be fatal if undetected/untreated
normal flora
microorganisms that reside in the body
where are normal flora located?
skin, saliva, oral mucosa, intestinal walls
body organ defense mechanisms
A number of body organ systems have unique defenses against infection. For example, the airways are lined with moist mucous membranes and cilia, which rhythmically beat to move mucus or cellular debris up to the pharynx to be expelled through swallowing
how do normal flora help the body resist infections?
it helps by releasing antibacterial substances and inhibiting multiplication of pathogenic microorganism
body defenses against infection
normal flora, body system defenses, inflammation
inflammatory response
protective cellular and vascular reaction that helps neutralize pathogens and repair body cells
how does inflammation help the cells in response to injury or infection?
it delivers fluid, blood products (i.e. platelets, WBCs), and nutrients to injured areas. neutralizes and eliminates pathogens or dead (necrotic) tissues and establishes a means of repairing body cells and tissues
the accumulation of fluid appears as…
edema (localized swelling)
signs and symptoms of infection
usually include fever, leukocytosis, malaise, anorexia, nausea, vomiting, and lymph node enlargement
leukocytosis
increase in circulating WBCs in response to WBCs leaving the blood stream.
phagocytosis
the process of destroying and absorbing bacteria
inflammatory exudate
the accumulation of fluid, dead cells, and WBCs that forms at the site of infection
what carries inflammatory exudate away (usually)?
lymph system
serous exudate (color)
yellowish clear color
serosanguinous exudate (color)
pink, thinner consistency than sanguinous
sanguinous exudate (color)
red, bloody, thicker than serosanguinouso
purulent exudate (describe)
thick, white-yellow-green-tan colors, odorous. contains WBCs and bacteria
if inflammation is chronic, normal tissue will be replaced by what?
granulation tissue, which is not as strong and may leave a scar
signs of inflammation?
redness, heat, swelling, sometimes pain.
signs of inflammation and localized infection are…
identical
HAIs (healthcare associated/acquired infections)
result from the delivery of healthcare in a healthcare setting. occur as the result of invasive procedures, antibiotic administration, the presence of multidrug-resistant organisms, and breaks in infection prevention and control activities
What increases risk for HAIs?
HANDS!, elderly, multiple illnesses, poor nourishment, low resistance to infection, invasive procedures, medical therapies, long hospitalizations, and increased contact with HC personnel.
ways to prevent HAIs
Meticulous hand hygiene practices, use of chlorhexidine washes, and other advances in intensive care unit (ICU) infection prevention
HAIs and cost
HAIs sig. increase costs. Insurance won’t cover cost of treating certain HAIs like UTIs with Foley catheters (hospital responsible for infection, so responsible for $ for tx)
biggest risk factor for HAIs
contact with hc personnel hands
major sites for HAI infections
traumatic or surgical wounds, respiratory and urinary tracts
asepsis
absence of pathogenic microorganisms
aseptic technique
practices/procedures that help reduce the risk for infection
medical asepsis
aka clean technique. includes procedures for reducing number of organisms present and preventing transfer of organisms
surgical asepsis
aka sterile technique. isolates the operative area from unsterile environment to prevent contamination of open wounds or maintain sterile field for surgery.
when do you use soap and water versus hand sani/chlorohexidine?
soap and water when hands are visibly soiled or patient has c.diff.
when do you wash hands?
when enter/exit room or before/after patient contact, after removing gloves, after using restroom, before eating, throughout day, no artificial nails or nail polish.
standard precautions
prevent and control the spread of infection; apply to all blood, body fluids, non intact skin, and mucous membranes. use generic barrier techniques for all patients.
hand hygiene
instant alcohol hand sanitizer when providing patient care, washing hands when soiled, performing surgical scrub.
hand washing
washing hands with soap and water for 15-20 sec, rinsing under stream of water
when to wear gloves
when touching body fluids, membranes
when to wear gowns
isolation, incontinence, risk for splashing/coughing fluids
when to wear mask
isolation (droplet), risk for splashing/coughing fluids
when to wear eye protection
risk for splashing/coughing fluids
disinfection versus sterilization
disinfection: eliminates many or all microorganisms from inanimate objects (except bacterial spores)
sterilization: elimination or destruction of all microorganisms including bacterial spores
cough etiquette
cover nose/mouth with tissue–promptly dispose of it. place surgical mask on pt if they can tolerate it. hand hygiene when in contact with resp. infection pts. separate >3ft with resp. infection pts. cough into gloved hands unless soiled, then cough into elbow away from pt.
if cough over sterile field
not sterile anymore
isolation
separation and restriction of movement of patients with contagious infections/diseases
implications of isolation (for patient and staff)
psychological implications: loneliness isolation environment (neg. pressure rooms, etc), PPE, specimen collection, bagging trash/linen, patient must wear mask for transport (transport limited to essentials)
types of isolation
airborne, droplet, contact, protective
airborne precautions
protect against:
droplet precautions
protect against: bigger droplet (>5 microns) transmitted infections within 3-6 ft. of pt.
require: private room, surgical mask, dedicated equipment
contact isolation
protects against: direct contact-transmitted infections
requires: gloves/gowns, special disposal of trash/linen (biohazard), dedicated equipment
protective isolation
protects: immunocompromised pts. from outside infections
requires: + airflow room, no fresh/dried flowers or fruit, respiratory mask, gown, gloves
PPE proper sequence for donning and doffing
donning: gown, mask, goggles, gloves
doffing: gloves, goggles, gown, mask
who monitors infection rates?
Joint Commission, CDC, Center for Medicare reimbursement
What does patient safety in healthcare settings do?
reduces incidence of illness/injury, prevents extended LOS, improves functional status, increases patients sense of well-being
a safe environment
meets patients physical, psychosocial needs; applies to all places pts receive care, includes pt and provider well-being, reduces risk of injury and transmission of pathogens, maintains sanitation, reduces pollution
largest safety issue for patients
medication errors
sentinel events
unexpected occurrence involving death or serious physical injury (loss of limb/functions)
nurse’s role in patient safety
assessing factors, maintain safe environment, provide patient teaching
factors influencing patient safety
age, lifestyle, occupation (exposure), social behavior (risk taking), environment (safety, exposures)
greatest age group @ risk of home accidents that result in severe injury
children
risks for school aged children
@ risk at home, school, and traveling to/from school
risks to adolescents safety
car accidents, suicide, drug/alcohol abuse
adult safety risks
mostly lifestyle (drinking, drugs, exercise, diet, work stress/env, domestic violence, car accidents
elderly safety risks
falls, car accidents, elder abuse, sensorimotor changes, fire
major cause of injury for those >64 years…
falls
risk factors for falls
age, hx of falls, impaired balance, altered gait/posture, weakness, medication, walking aids, orthostatic hypotension, slow run time, unfamiliar environment
how do you perform a controlled fall?
stand feet apart for support base, extend one leg and let patient slide against it to floor (“break fall” with leg), bend knees and lower patient to floor as they fall
types of restraints
physical (wrist ties, vests) and chemical (alters behavior)
negative outcomes of restraints
lowers cognitive ability, skin breakdown, contractures, incontinence, depression, delirium, anxiety, aspiration, breathing difficulties
where do you tie restraints?
to bed frame, NOT RAILS. always use quick release knot
cardiac effects of immobility
increased workload @ heart, orthostatic hypotension, venous stasis, thrombus formation (clotting)
respiratory effects of immobility
decreased respiration rate and depth, impaired gas exchange, pooling of secretions
musculoskeletal effects of immobility
atrophy, weakness, disuse osteoporosis (increased bone reabsorption), joint contractures
metabolic effects of immobility
negative nitrogen balance (impedes wound healing), electrolyte/fluid imbalances, altered nutrients/gas exchange
GI effects of immobility
constipation, decreased appetite
GUT effects of immobility
urinary stasis, urinary retention, bladder infections, kidney stones, incontinence
skin effects of immobility
decubitus ulcers (pressure ulcer)
psychosocial effects of immobility
isolation, depression, negative effects on mood/behavior
when not to use gait belts
in patients with abdominal or thoracic incisions
how often do you change pt positions
q2h
how do you maintain functional positions for paralyzed/unconscious patients
use rolls under hands (towels, etc)
how do you prevent foot drop?
use foot supports to keep at 90 deg angle
safe patient transfer practices
elevate or lower bed to appropriate height, LOCK WHEELS, avoid friction on pt skin, smooth motions (yours and pts), use mechanical devices or other personnel when needed
moving patients…body mechanics?
DONT USE BACK OR TWIST
purpose of bathing patient
clean and assess skin, stimulate circulation, improve self-image, reduce body odors, promote range of motion
risk factors for skin impairment
immobility, reduced sensation (Can’t feel pain), nutrition & hydration, excretions/secretions, vascular insufficiency, external devices, altered cognition
guidelines for bathing
privacy, safety, warmth, independence
types of baths
complete bed baths, partial bed baths, tub or shower
assessment points for oral hygiene
frequency, amount of assistance required
brushing teeth: precautions for aspiration
positioning (lateral with head turned to side), use suction equipment, never put hand in mouth
denture care
clean as often as natural teeth, personal property–careful!, remove before bed, store in labelled container with cleaner, when cleaning use washcloth in sink to prevent dropping/breaking.
concept map
visual plan of care, diagram of pt problems, links important ideas together
why make concept map?
organize data, visualize links/connections between issues, establish priorities, analyze, enable holistic view
critical thinking
ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process used to ensure safe nursing practice and quality care
nursing process
assessment, diagnosis, planning, implementation, evaluation (cyclical)
center of care map
patient (age, c/c, mdx/surgical procedure, identifying info, allergies, code status)
assessment: 2 steps
- collection of data
2. interpretation and validation of data
assessment
deliberate and systematic collection of information
how to cluster assessment data
patterns, i.e. Gordon’s Functional Health Patterns (11 common patterns of behavior that contribute to health)
SBAR stands for…
situation, background, assessment, recommendations
Gordon’s functional health patterns (11)
self-perception, role-relationship, sexuality-reproduction, coping-stress tolerance, value-belief, health perception-health management, nutritional-metabolic, elimination, activity-exercise, sleep-rest, cognitive-perceptual
care map boxes include
functional health pattern(s), problem/ndx, supporting data
diagnosis phase
interpret and validate data, analyze data, organize in to patterns, name them/ndx, prioritize, connect the dots
nursing diagnosis (definition)
statements that describe a patient’s actual or potential human response to life processes that nurses are qualified and competent to treat
NOT MED DX
parts of a ndx
problem (human response) and etiology (related to) and mdx (secondary to–don’t have to have this necessarily)
nursing dxs describe…
deviations from health, presence of risk, enhanced personal growth
guidelines for writing ndxs
legally advisable terms, no value judgements, not circular (two parts mean same thing), etiology must be stated in terms that are changeable/fixable
When prioritizing, what is generally most important?
ABCs
planning
set priorities, identify outcomes, select interventions, write nursing orders, set evaluation criteria
goals vs outcomes
goals = broad, outcomes = specific and MEASURABLE
format for goals/outcomes
the patient will (goal) by (time frame) as evidenced by (outcome)
components of an outcome statement
behavior, measurement, condition, time
skin layers
(superficial) epidermis > junction > dermis (deeper)
functions of skin
barrier/protection, sensory input for pain/touch/temp, synthesizes vitamin D, triggers healing response w/ injury
basal layer of epidermis
stem cells divide and migrate to surface (constant cellular turnover)
vascularity of skin layers
epidermis = avascular dermis = vascular (collagen, nerves, too)
pathogenesis of pressure ulcers
pressure intensity, tissue ischemia, blanching, pressure duration, skin breakdown, tissue tolerance
risk factors for pressure ulcer development
impaired sensory perception, impaired mobility, altered LOC, shear, friction, moisture
shear
force exerted parallel to skin (gravity + resistance)
friction
two surfaces sliding across one another
stage 1 pressure ulcer
intact skin with nonblanchable redness
stage 2 pressure ulcer
partial-thickness tissue loss involving the epidermis, dermis, or both
stage 3 pressure ulcer
full tissue thickness loss with fat visible (involves subcutaneous tissues)
stage 4 pressure ulcer
full-thickness tissue loss with bone, muscle, or tendon visible
purple
deep tissue injury, can’t classify
red area, but blanch-able
pre-ulcer area, @ risk area, move pt off pressure area to relieve.
wound classification
by thickness (partial or full)
wound color classifications:
black: eschar, necrotic tissue
white/yellow/tan: slough, required MD to remove
red: granulation tissue (new vessels, indicative of healing)
mixed-color: more than one of the above
primary intention
wound healing with approximated edges (surgical incision, closed for healing)
secondary intention
open edges and heals from the inside out. takes longer to heal. edges not together. scars.
wound repair
partial thickness: inflammation, epithelial proliferation, migration to surface/ reestablishment
full thickness: hemostasis (clotting), inflammatory, proliferation, maturation
complications of wound healing
hemorrhage, hematoma, infection, dehiscence, evisceration
osteomyelitis
when bone becomes infected. requires 6 mo. of abx to treat.
most common HAIs
wound infections
dehiscence
wound comes back open
evisceration
organs protrude through wound
how to predict pressure ulcers?
Braden scale assessment
how to prevent pressure ulcers?
turn patient, risk assessment, thorough skin assessments, nutrition, hygiene, specialty beds/equipment
reimbursement related to pressure ulcers
CMS won’t reimburse for care related to Stage 3 or 4 pressure ulcers obtained in care facilities
most common sites for pressure ulcers/breakdown
bony prominences, areas that get most pressure
prevention of pressure ulcers
mobility, predictive measures (braden scale, ID risk), nutrition, hydration/fluids/weight, pain
what to chart about wound?
location, size, shape, type (partial/full), color, drainage & exudate characteristics, if has drain, type of closure, etc.
wound assessment includes…
predictive measures, mobility level, major risk areas/ pressure points, nutritional status, fluids, setting (Emergency v. stable), appearance, character of drainage, presence of drains, type of closure, palpation findings (temp, texture, etc.), cultures/labs
ndx related to impaired skin integrity/wounds
risk for infection, impaired nutrition, actor/chronic pain, impaired mobility, impaired skin integrity (or @ risk for), etc.
first aid for wounds includes…
hemostasis (control bleeding), clean, protect
purpose of wound dressings…
protect from microorganisms, aid in clotting, promotes healing (absorb drainage), derides wound (healing), supports wound site, insulates wound, keeps moist
types of wound dressings…
gauze, transparent film, hydrocolloid, hydrogel, foam, composite
packing wound is what type of therapy?
negative pressure therapy (pulls wound edges closer together)
way to clean contaminated sites…
from least to most contaminated (i.e. center of wound towards the edges) in circular motion. when irrigating, let flow from least to most contaminated areas.
what helps with drainage evacuation of wounds?
hemovac (accordion) or woundvacs (sponge). Helps remove and collect drainage.
when to use heat vs. ice
ice: usually for acute problems (not surgery though bc increases blood flow)
heat: for chronic problems
sitz bath
container that goes in toilet with warm/cold water depending. Often for hernia patients. facilitates cleaning of wounds in perineal area.
safety with wound care
positioning to prevent ulcers, falling off bed; plastic bag within reach for dressing disposal, extra gloves in case soiled, use PPE with irrigation, if using elastic bandage, check SCTM/CSMs below bandage.
ECF
extracellular fluid. 1/3 body fluid. made up of intravascular (plasma), interstitial fluid, and transcellular fluid (sec by epithelial cells-pleural spaces).
ICF
intracellular fluid. 2/3 body fluid.
cations in body fluids
K+, Na+, Mg 2+, Ca 2+
anions in body fluids
Cl-, HCO3-
osmolality
particles of solute per kg of water. used to measure fluid concentration.
effective concentration is determined by…
particles that cannot easily cross the cell membrane
isotonic
same tonicity as normal blood
hypotonic
more dilute than normal blood
hypertonic
more concentrated than normal blood
cells in hypotonic, hypertonic solutions do what?
hypotonic = swell hypertonic = shrink
osmosis
movement of fluids between extracellular and intracellular
filtration
movement of fluids between vascular and interstitial
osmotic pressure
pressure solutes exert in bloodstream
oncotic pressure
pressure albumin exerts
hydrostatic pressure
pressure water exerts. responsible for keeping vessels open, filtration.
average fluid intake for an adult/day
2300 ml
fluid homeostasis controlled @
hypothalamus
3 components of fluid homeostasis
fluid intake/absorption, distribution, and excretion
fluid output occurs @
skin, lungs, GI tract, kidneys
ADH functions
retain water, constrict blood vessels, increase BP
RAAS
detect low BP > kidneys release renin > stimulates release of angiotensin I (lung) > converted to angiotensin II (vasoconstrictor) > stimulates adrenal cortex to release aldosterone > stimulates reabsorption of water and sodium @ kidneys > inc. BP
osmoreceptor-mediated thirst
detect osmolality increase (more solutes concentrated in blood) and stimulates you to drink
baroreceptor-mediated thirst
detects low BP and stimulates you to drink
ANP
atrial natiuretic peptide. when excess fluid, cells @ atria stretch, release ANP which inhibits ADH and counters the effects of aldosterone (increases loss of sodium and water @ urine). Weak hormone.
ECV deficit
present when there is too little isotonic fluid in the extracellular compartment.
ECV excess
too much isotonic fluid in extracellular compartment
osmolality imbalances
hypernatremia (too much salt) and hyponatremia (too little salt)
s/s hypernatremia
cognitive dysfunction as brain cells shrivel
s/s hypernatremia
cognitive dysfunction as brain cells swell. cerebral edema. Increase ICP. Dysfunction and damage.
clinical dehydration
ECV deficit and hypernatremia at the same time (loss of extracellular fluid and too much salt/body fluids too concentrated).
common causes of dehydration
fluid loss, fever, not enough fluid intake
plasma vs cell concentrations of K+, Ca2+, Mg2+, and phosphate
higher concentrations in the cell, lower concentrations in plasma. need different concentrations to polarize/depolarize for nerve function.
electrolyte output via…
sweat, urine, feces (normal) or vomiting, draining, fistulas
fluid volume deficit causes
hemorrhage, vomiting, diarrhea, burns, diuretics, fever, impaired thirst
clinical manifestations of fluid volume deficits
weight loss, thirst, orthostatic changes in BP/pulse, weak/rapid pulse, decreased urine output, dry membranes, tenting @ skin.
fluid volume deficit tx/interventions
diet therapy, oral rehydration therapy, IV therapy, electrolyte replacement
causes of fluid volume excess
CHF, renal failure, inc. sodium intake, IV therapy, corticosteroids
clinical manifestations of excess fluid volume
inc. BP, bounding pulse, venous distension, pulmonary edema (SOB, crackles)
tx excess fluid volume
diuretics (if no renal failure), dec./restrict sodium intake, I/O mgmt, weight
hypokalemia
not enough potassium. cells don’t polarize/depolarize well (excitability), nerve stimuli don’t work as well
hypokalemia causes
diuretics, shift into cells, digitalis (med), water intoxication, steroids, diarrhea, vomiting
hypokalemia s/s
Peak Q waves, alkalosis, shallow respirations, confusion, weakness, arrhythmias, lethargy, dec. interstitial motility, thready pulse
hypokalemia tx/intv.
encourage potassium-rich foods, K+ replacement, stop diuretics, monitor labs, treat underlying cause
hyperkalemia
too much K+ causes increased excitability of cells
hyperkalemia causes
too much K+ intake, renal failure, shift of K+ out of cell, K+ sparing diuretics
hyperkalemia s/s
peak T waves, cramps, weakness, paralysis, drowsiness, dec. BP, EKG changes, abdominal cramping, diarrhea, oliguria (v. concentrated urine)
hyperkalemia tx/intv.
need to restore balance, stop K+ administration, increase K+ excretion (Lasix, Kayexalate), infuse glucose and insulin, monitor cardiac function
hyponatremia
too little salt
hyponatremia causes
excessive sweating, wound drainage, NPO, CHF, low salt diet, renal disease, diuretics
hyponatremia s/s
skeletal muscle weakness, personality changes, shallow respirations, cardiac changes, explosive diarrhea, inc. urine output
hyponatremia tx/interv.
IV therapy saline (2-3% if severe), mannitol (osmotic diuretic), increase sodium intake, restrict fluid intake
hypernatremia
too much salt
hypernatremia causes
too much intake, diarrhea, dehydration, fever, hyperventilation, renal failure
hypernatremia s/s
muscle twitches, contractions, poor deep tendon reflexes, pulmonary edema, low cardiac output/pulse/BP, dry/flaky skin, edema, low urine output
hypernatremia tx/interv.
administer IV fluids (NSS or NaCl) and diet therapy (ensure water intake)
hypocalcemia s/s
muscle spasms/twitches (chvostek & trousseau’s signs), resp failure/tetany, diarrhea,
hypercalcemia s/s
disorientation, constipation, inc cardiac (HR, BP, bounding), inc. urine output
how do you monitor acid-base balance?
arterial blood gasses
normal blood pH
7.35-7.45
acid base imbalances include…
respiratory and metabolic acidosis/alkalosis
blood transfusion reactions
allergic (itching, swelling, rash/hives), febrile (fever, chills, anxiety), hemolytic (tachycardia, dec. BP, headache, chills, fever)
what to do with blood reaction?
STOP.
intervention for acid-base and electrolyte imbalances…
ABGs, support medical therapies to reduce imbalance, patient safety.
