NUR 118 - Lect. #1 Body Defense / Infect. Process Flashcards
NUR 118 - Define Infection
Invasion of pathogens in the body
NUR 118 - Factors that increase risk of infection
- Age
- Stress
- Poor diet
- Medications (steroids)
- immune deficiency disease (cancer)
- Travel
- Substance abuse
- Skin breakdown
- Invasive surgeries
- Living/work environment
NUR 118 - Factors that decrease risk of infection/Support host defenses
Proper nutrition, hygiene, rest (reduce stress), exercise, immunization,
NUR 118 - What are Healthcare Associated Infections (HAIs) vs Nosocomial infections?
HAIs - Infections that patients contract in any healthcare setting
Nosocomial - Hospital acquired infection
- Ex: Urinary catheters, not removed or poorly managed; CENTRAL LINES - IMPROPER MANAGEMENT THAT LEADS TO A BLOODSTREAM INFECTION
NUR 118 - Name and define the six links in order
1) Infectious Agent - the source; pathogens
2) Reservoir - Where pathogens live and multiply
3) Portal of EXIT - How the pathogen “exits”; ex: Coughing, sneezing, IV lines
- skin to skin, skin to surface, blood
4) Mode of Transmission - Contact, direct (airborne, droplet contact), or indirect (w/ a fomite: contaminated equipment, vectors, water)
5) Portal of Entry - Normal body openings: Eyes, mouth, vagina, nose
Abnormal body openings: Wounds, scrapes, IVs, incisions
6) Susceptible Host - Person with inadequate defense; ex: elderly, young, immunocompromised
NUR 118 - Name and define the stages of infection in order
- Incubation – Time of infection/entry
- Prodromal – Vague signs & symptoms
- Illness – Obvious signs & symptoms; can end in death if not treated
- (Pathogenic) Decline – Number of pathogens decline; signs & symptoms
- Convalescence – Tissue repair; return to health; # of microorganisms reach zero
NUR 118 - Classifications of Infections - Location
Local – Occurs in a specific region of the body
- location determines signs & symptoms
Ex: skin, bladder, lung
Systemic – When pathogens invade the blood or lymph and spread through the body
- Starts as a local infection
Sepsis – Systemic infection spread via blood
–> Blood poisoning, tissue damage, shock, death
NUR 118 - Classification of Infection by Duration
Acute - Rapid onset of short duration
Ex: common cold
Chronic: slow development, long duration
Ex: Hepatitis B and C, long COVID
Latent – Infection present with NO discernible symptoms
Ex: HIV/AIDS, Tuberculosis, shingles
What is the function of the Primary (Immune) Body Defenses?
List examples
Function: Prevent organisms from entering body
- Normal Flora
- Skin (intact, healthy = prevents pathogen entry)
- Eyes: Lysozymes in tears
- Mouth: Lysozymes in saliva
- GastroIntestinal (GI): Acidity, bile, vomiting
- GenitoUrinary (GU): Mucus membrane, vaginal acidity & lysozymes in urine
What are Endogenous vs Exogenous infections?
Endogenous - Infection caused from inside the patient, when the patient’s normal flora is altered
Exogenous - Infection caused from a source outside the patient
What is the function of Secondary Body Defense?
List examples
Function: Protective biochemical processes that fight pathogen that enter, chemically activated when pathogens get past primary
Phagocytosis - Special WBC attack&kill pathogens (WBC count > 10,000; normal count 4,500-10,000)
Complement Cascade - Chemicals attack pathogen, histamine released = triggers inflammation
Inflammation - Histamine released from damaged cells, blood vessels dilate (assess: redness, warm to touch, edema, pain)
Fever - Rise in core body temp = increases metabolism, inhibits pathogens
What is the function of Tertiary body defense?
List examples
Function: Body builds immune memory
Natural active - after becoming ill with infection; body makes its own antibodies to protect from pathogens
Natural Passive - Antibodies from someone else/one body to another; ex: placenta, breast milk
Artificial active - Immune response from artificial exposure from vaccines; Body makes antibodies to block illness development
Artificial Passive - Serum/injection from another person or animal with antibodies; ex: rabies, botulism
What is Medical Asepsis?
“Clean Technique”
Practices & Procedures that REDUCE number of microorganisms to decrease spread of infection
- Microorganisms exist everywhere except sterile objects
Best method = handwashing
What is Surgical Asepsis?
“Sterile Technique”
Practices/Procedures to eliminate ALL microorganisms & spores
Sterilization of equipment required
What are the principles of surgical asepsis?
- Sterile object remains sterile only when touched by another sterile object
- Only sterile objects can be placed on sterile field
- Sterile object/field out of range of vision, held above head or below waist is contaminated
- Sterile object/field is contaminated from prolonged exposure to air
- When sterile surface/field comes in contact with wet, contaminated surface, the sterile object/field is contaminated by capillary action
- Fluid flows in the direction of gravity
- Edges of sterile field/container are contaminated. 1 inch around sterile field.
What is standard precauations?
- What applies to every patient in all settings
- Utilize PPE (Personal protective equipment)
- Assume all blood, body fluids, secretions, opens skin & mucus membranes may contain pathogens
- Respiratory hygiene + cough etiquette
- Gloves for contact with fluids/opening
- Gown and goggles for splashing
Define Contact precautions: Patient placement/transport, PPE, diseases
Placement/transport: Private room/cohort, limit patient transport
PPE: gloves and gown
Diseases:
Clostridium Difficile (C-Diff)
Methicillin resistant staphylococcus aureus (MRSA)
Vancomycin Resistant Enterococcus (VRE)
Extended Spectrum beta-lactamase (ESBL)
Define droplet precautions: Particle size, pt placement/transport, PPE, Diseases
- Larger/heavier particles, >5 microns, travels 3-6 feet
Patient placement/transport: Private room/cohort, wear surgical mask on transport
PPE: surgical mask
Diseases: IMMMPS
Influenza (flu)
Mumps
Meningitis
(German) Measles
Pertussis (whooping cough)
Streptococcus (Strep throat)
Define airborne precautions: Particle, pt placement/transport, PPE, diseases
- Small aerosolized particles, travel over 6 feet
PPE: Fitted N95 respirator mask
Placement/Transport: Private, negative air pressure room, 6-12 gas exchanges per hour; only transport pt if necessary, pt wear surgical mask
Diseases: MTV-C-SARS
Measles (Rubeola)
Tuberculosis
Varicella (Chicken Pox OR Herpes Zoster = Shingles)
COVID
SARS
Why and how is protective isolation used?
Why: For immunocompromised pts to protect from organisms
How:
-No fresh fruits/veggies, plants/flowers, standing water
-PPE for staff/visitors: hand hygiene, gloves, gowns, mask
-Patient specific equipment or clean equipment
How do nurses contribute to asepsis?
-Hand hygiene
-Standard precautions
-Implement Transmission/isolation precautions (contact, droplet, airborne, reverse)
- Proper PPE
-Medical/surgical asepsis principles
Nursing interventions that promote wellness and support host defenses
(Think general, easy interventions)
Hand hygiene
Med + Surg Asepsis
Precautions and PPE
Monitor VS q4h (every 4 hours)
Reduce stress
Maintain skin integrity - Turn/position q2h, keep dry
Nursing Assesment ADPIE: A
- Take a history & perform physical assessment
History: information r/t (related to) risk for infection, exposure to pathogens, interact with sick person, travel outside country, unprotected sex, current meds
- Source can be: patient, family, medical record
Physical assessment:
General appearance - Fatigue, chills, well nourished
Skin - Turgor (elasticity), intact/breaks, signs of local infections
Palpation - Swollen lymph nodes, skin (dry/moist & hot/cold)
V/S - Temp >100.4, Heart rate >100
Labs - WBC > 10,000 , culture (urine, blood, throat, wound), ESR (Erythrocyte sedimentation rate) - detects inflammation
What stage of infection occurs from the time of infection to possible symptoms & can infect others?
Incubation
A duration classification of infection that develops slowly and can last for weeks, months to years?
Chronic
Nurse is assessing a client for a systemic response to an inflammatory process. For which response should the nurse monitor the client?
Fever
Leukocytosis (Increased WBC count)
