Nursing Process: Asepsis and Infection Control #2 Flashcards
Body Defenses against infection
Nonspecific Defenses
Specific Defenses
Antibody Mediated Defenses
Cell Mediated Defenses
Nonspecific Defenses: Anatomic and Physiologic Barriers
Nasal Passages
Lungs
Phagocytes
Oral Cavity
Saliva
Eye (by Tears)
Gi Tract (High acidity)
Large intestine (Resident flora)
Vagina (pH level of 3.5 - 4.5)
Urethra (Urine)
is a local and
nonspecific defensive response of the
tissues to an injurious or infectious
agent.
Inflammation
What are the non specific defences
-Anatomic and Physiologic Barriers
-Inflammatory Response
Injurious agents can be categorized as
Physical agents
Chemical agents
Microorganisms
an agent that includes mechanical objects causing
trauma to tissues, excessive heat or cold, and
radiation
Physical agents
an agent that includes external irritants (e.g.,
strong acids, alkalis, poisons, and irritating gases)
and internal irritants (substances manufactured
within the body such as excessive hydrochloric acid
in the stomach)
Chemical agents
a agent that includes broad groups of bacteria, viruses, fungi, and parasites
Microorganisms
is produced, consisting
of fluid that escaped from the
blood vessels, dead phagocytic
cells, and dead tissue cells and
products that they release.
Exudate
What works together to form an interlacing network to wall off the area and prevent spread of injurious agent
Fibrinogen and Platelets
Suffix that describes inflammatory proces
itis
involves the repair of injured
tissues by regeneration or
replacement with fibrous
tissue (scar) formation
Reparative
Phase
is the
replacement of destroyed
tissue cells by cells that are
identical or similar in
structure and function.
Regeneration
What system does specific defense of the body involve
Immune system
is a substance that induces a state of sensitivity or immune responsiveness
antigen
if the proteins originate in an individual’s own body the antigen is called what?
Autoantigen
2 components of immune response
Anti Body mediated defenses
Cell mediated defenses
defend primarily against the extracellular
phases of bacterial and viral infections.
Antibody Mediated Defenses
Also called Immunoglobulins, and are a part of the body’s plasma proteins
Antibodies
These defenses reside ultimately in the B lymphocytes and are mediated by antibodies produced by B cells
Humoral immunity
where does Humoral immunity reside?
In B Lymphocytes
What mediates the Humoral Immunity
antibodies produced by B cells
2 major types of immunity
Active and Passive immunity
5 classes of immunoglobulin designated by letters
IgM, IgG, IgA, IgD, IgE
what immunoglobulin indicates current infection
IgM
what immunoglobulin
anti body indicated past infection and subsequent immunity
IgG antibodies
the host receives natural
(e.g., from a nursing mother) or artificial (e.g.,
from an injection of immune serum) antibodies
produced by another source
acquired immunity
Types of immunity and their definition
Active - antibodies produced by the body in response to an antigen (long duration)
Passive (acquired) - antibodies produced by another source, animal or human (short duration)
What are the Natural and Artificial antibodies of active immunity
Natural - antibodies formed in the presence of infection (lifelong duration)
Artificial - Antigens are administered to stimulate antibody production (many year duration and must be reinforced by booster)
What are the Natural and Artificial antibodies of passive immunity
Natural - Antibodies are transferred from an immune mother to her baby through the placenta or colostrum (6 to 1 year duration)
Artificial - Immune serum from an animal or human is injected (2-3 Weeks duration)
occur through the T-cell system. On
exposure to an antigen, the lymphoid tissues
release large numbers of activated T cells into
the lymph system.
cell-mediated defenses, or cellular
immunity
3 main groups of T cells
Helper T Cells
Cytotoxic T Cells
Suppressor T Cells
T cells that help in the functions
of the immune system;
Helper T Cells
T cells that attack and kill
microorganisms and sometimes the
body’s own cells
Cytotoxic T Cells
T cells that can suppress the
functions of the helper T cells and the Cytotoxic T Cells
Suppressor T cells
Factors increasing susceptibility to infection
Age
Heredity
Level of Stress
Nutritional Status
Current Medical Therapy
Pre Existing Disease process
Types of Exudate
Serous - Clear, Thin, Watery fluid
Serosanguineous - Thin, Watery, with light red or pink hue
Sanguineous - Bright Red, Fresh blood
Purulent - Thick, Opaque, Odorous build up from infection
Signs of systemic infection include
the following:
-Fever
-Increased pulse and respiratory rate if the fever is high
- Malaise and loss of energy
- Anorexia and, in some situations, nausea and vomiting
- Enlargement and tenderness of
lymph nodes that drain the area of infection
To identify clients at risk, the nurse:
- reviews the client’s chart
- collect data regarding the factors influencing the development of infection like:
- existing disease process
- history of recurrent infections
- current medications
- therapeutic measures
- current emotional stressors
- nutritional status
- history of immunizations
Laboratory data that may indicate the presence of an infection
include the following:
- Elevated leukocyte
- Elevated erythrocyte
- Urine, blood, sputum, or other drainage cultures that indicate presence of pathogenic microorganism
- Elevated Serum Lactate
normal WBC count
4500 - 11, 000>mL3
Diagnosing : What are the actual and potential problem
Risk of Infection
Altered comfort
Ineffective Coping
Patients with infections are at risk of
complications. This diagnosis emphasizes the potential for
infection and the need for preventive measures.
Risk for Infection
Infections often lead to discomfort and pain.
This diagnosis focuses on comfort measures and symptom
management
Altered Comfort
Dealing with an infection can be emotionally
challenging. This diagnosis addresses the patient’s coping
abilities
Ineffective Coping
Major Goals in planning
- Maintain or restore defenses
- Avoid the spread of infectious organisms
- Reduce or alleviate problems associated with infection
Health Teaching Plan for the Client and Family
- ENVIRONMENTAL MANAGEMENT
- Teach the client and family members the signs and symptoms of infection, and
when to contact a healthcare provider. - Teach the client and family members how to avoid infections
- Suggest techniques for safe food preservation and preparation
-INFECTION PREVENTION
- Remind to avoid coughing, sneezing, or breathing
directly on others.
- Inform of the importance of maintaining sufficient fluid
intake to promote urine production and output.
- Emphasize the need for proper immunizations of all
family members.
- Discuss hand soaps and effective disinfectants.
- Promote nail care
Implementing: Preventing Healthcare - Associated Infections
Hand Hygiene
is a chemical preparation used on skin or
tissue.
antiseptic
is a chemical preparation, such as phenol or
iodine compounds, used on inanimate objects
antiseptic
preparation destroys
bacteria
Bactericidal
preparation prevents
the growth and
reproduction of
some bacteria
Bacteriostatic
is a process that destroys all
microorganisms, including spores and
viruses.
Sterilization
Four commonly used methods of
sterilization
moist heat, gas, boiling
water, and radiation
, steam under
pressure is used because it attains
temperatures higher than the boiling
point
Moist Heat (use of autoclave)
destroys
microorganisms by interfering
with their metabolic processes.
Ethylene oxide
It is also effective against
spores.
Its advantages are good penetration
and effectiveness for heat-sensitive
items.
Its major disadvantage is its
toxicity to humans
Gas
This is the most practical and
inexpensive method for sterilizing
in the home.
The main disadvantage is that spores
and some viruses are not killed by
this method.
Boiling Water
Both ionizing (such as alpha, beta, and xrays) and nonionizing (ultraviolet light)
radiation are used for disinfection
and sterilization.
Radiation
