Fundamentals Exam 1

invasion of a susceptible host by pathogens or microorganisms, resulting in disease

entry and multiplication of organisms result in disease

when a microorganism invades the host but does not cause an infection

infectious disease transmitted from one person to another

when pathogens multiply and cause clinical signs and symptoms

when clinical signs and symptoms are not present

*most important technique in preventing and controlling the transmission of infection*

Infectious Agent, Reservoir, Portal of Exit, Mode of Transmission, Portal Entry, Host

Direct, Indirect, Droplet, Airborne, Vehicles, Vector

Person to Person / Person to Source

Person to inanimate object

Coughing, Sneezing, Talking

Droplet nuclei or residue suspended in air or on dust particles

Food, Water, Drugs & Solutions, blood, fomites

External transfer, Internal transmission (parasitic), Mosquito, flea, tick, louse

having an impaired immune system

the ability to produce disease

requires oxygen for survival and for multiplication sufficient to cause disease

thrive where little or no free oxygen is available

Prevention of growth and reproduction of bacteria

destructive to bacteria

hand hygiene, sterilization, antibiotics/antimicrobials

Transmission-based precautions, sterilization or use of disposable supplies

dry intact dressings, hand hygiene, wear gloves if in contact with body fluids, cover nose and mouth when sneezing

hand hygiene, use of pesticides to eliminate vectors, adequate refrigeration

hand hygiene, wear gloves, wear masks and appropriate protective gear, proper disposal of needles and sharps

Immunizations & healthcare screenings

Incubation Period, Prodromal Stage, Illness Stage, Convalescence

the time interval between entrance of pathogen and appearance of first symptoms

the interval from the onset of of nonspecific signs and symptoms to more specific symptoms

interval when the patient manifests signs and symptoms specific to the type of infection

interval when acute symptoms of infection disappear (takes about one week for antibiotics to work)

Client experiences symptoms in a specific area

Affects the entire body, can be fatal if not treated or not detected

mask, face shield/protective eye equipment, gown & gloves

microorganisms, normal body fluid helps to resist infection by releasing antibacterial substances and inhibiting multiplication of pathogenic microorganisms

skin, saliva, intestines, oral mucosa

Normal Flora, Body Defense Mechanisms, Inflammation, Vascular and Cellular Responses, Inflammatory Exudate, Tissue Repain

the skin, mouth, eyes, respiratory tract, and vagina have natural defenses against infection

it delivers fluid, blood products, and nutrients to an injured area. the accumulation of fluid appears as localized swelling (fluid)

accumulation of fluid, dead tissues, and WBC's that form at the site of infection. something that leaves your body - serous, sanguineous, purulent

clear, like plasma

containing red blood cells

containing WBC's and bacteria

Occurs when tissue cells undergo an injury. damaged cells are replaced with healthy cells. *If inflammation in chronic, tissues will be replaced with granulation tissues, which is not as strong as strong as normal tissue and will leave a scar

Healthcare Acquired Infection - Results from delivery of health services in a healthcare facility - nosocomial

multiple illnesses, older adults, poorly nourished, lowered resistance to infection, critical illness, invasive treatment devices

number of health care employees with direct contact to the patient, types and numbers of invasive procedures, therapy received, length of hospitalization

surgical or traumatic wounds, urinary and respiratory tracts & bloodstream

from a diagnostic/therapeutic procedure

from microorganisms found outside the individual

Occurs when part of the client's flora becomes altered and an overgrowth occurs

age, nutritional status, stress, disease process, treatments or conditions that compromise the immune response

controlling pathogens, hand hygiene, "clean procedure", common on home/ECF/assisted living, standard precautions (CDC)

killing or eliminating pathogen, scrub (surgical), PPE sterile handling, common in hospital

sterile equipment may touch sterile equipment, sterile objects can only touch sterile field, when object it out of reach/vision or under the waist it is considered contaminated, if sterile equipment is wet it is then considered contaminated, fluid flows in direction of gravity, edges of sterile field are considered contaminated

a process that eliminates many or all microorganisms, with the exception of bacterial spores, from inanimate objects

the complete elimination or destruction of all microorganisms, including spores

hand washing, bathing, dressing changes, contaminated needles/sharps, bedside table clean, surgical wounds, preventing backwash of drains/tubes

separate personal care items, handling solid and liquid waste appropriately, wound cleaning, pt education, cough etiquette, isolation precautions, surgical asepsis

cover your mouth when coughing or sneezing, promptly dispose of used tissue, wear mask, practice hand hygiene, keep 3 feet between you and the person who is contaminated

wash hands, put on gown, mask, eye protection, gloves

gloves, eye protection, gown, mask, wash hands

psychological considerations (loneliness), environment (negative pressure), PPE equipment, specimen collection (clean), patient transport (pt must wear mask if airborne), linen (tie bag to prevent spread of infection)

Assessment, Diagnosis, Plan, Implementation, Evaluation

review past diseases, travel history, immunizations/vaccines, status of defense mechanisms, pt susceptibility, medications/therapy, clinical appearance, signs and symptoms of infection, Lab tests (CBC & WBC)

pus forming, bacteria

chronic bacteria or viral infection

protozoan, TB infection

parasitic infection

normal during infection, anaphylaxis

risk for infection, imbalanced nutrition (less than body requirements), impaired oral mucous membranes, risk for impaired skin integrity, social isolation, impaired tissue integrity, readiness for enhanced immunization status

Goals and outcomes: preventing exposure to infectious organism, controlling/reducing extent of infection, maintain resistance to infection, explain infection prevention and control techniques

establish priorities for each diagnoses and for related goals of care

remember to plan care and include other disciplines as necessary

*Health promotion - prevention is key*

Consider: medical/surgical asepsis, control of infectious agents, control reservoirs, control portals of entry, control transmission, hand hygiene, isolation precautions

treating an infectious process includes eliminating the infectious organisms and supporting the patients defenses

absence of pathogenic (disease producing) microorganisms

practices/procedures that assist in reducing the risk for infection

*AKA clean technique* includes procedures for reducing the number of organisms present and preventing the transfer of organisms

*AKA Sterile Technique* prevents contamination of an open wound, serves to isolate the operative area from the unsterile environment, and maintains a sterile field for surgery

see through the patients eyes, patient outcomes, exposure issues

measure the success of the infection control techniques, compare pts response to expected outcomes, if goals are not achieved - create new steps to complete goals

pts and healthcare workers are at risk for acquiring, infection from accidental needle sticks - report immediately, follow-up for risk of acquiring infection begins with patient testing

prepare foods at high enough temp, use care with cutting boards/utensils, keep food refrigerated, wash raw fruits and vegetables, use pasteurized milk and fruit juices, wash hands after bathroom/before cooking, use individual care items, cough/sneeze into inner arm (not hands)

Can be defined as the inability to engage in activity - NANDA International

Impaired Physical Mobility as a limitation in independent, purposeful physical movement of the body or one or more of its extremities

the kind and amount of exercise or activity a person is able to perform

Physiological Factors, Emotional Factors, Developmental Factors, Pregnancy

congenital defects (acquired), disorders of bones/joints/muscles, CNS damage, MS trauma

Can be defined as using alignment, posture, and balance in a purposeful and coordinated effort during activity

1. Assess the situation carefully before acting

2. Use the large muscle groups whenever possible

3. Work at appropriate height

4. Use mechanical lifts or assistance as indicated

Any doubt, ask for assistance, if you're working with someone - always communicate... 1 2 3 lift

decreased number of falls/injuries, increased comfort for pt, decrease skin tears, decrease anxiety, decrease risk of injury to nurse, easiest for full-lift patients

great base of support = more stable body, face direction of work, use less energy if body is balanced, pelvic tilt, less energy to keep object moving, reducing friction = less energy required, hold object close to body, use strong leg muscles when pushing/pulling, smooth and continuous movements, rhythmic movements at normal speed = less energy

adjust height of work area, correct alignment, widen base of support, pelvic tilt, center of gravity, objects close to body, push/pull/roll item instead of lifting, face direction of movement, avoid twisting/stretching/reaching, use arms and legs for power, smooth motions, reduce friction, bend knees/hips

No body system is immune to effects of immobility - influenced by the client's general health status and developmental status

decreased metabolic rate, altered metabolism of carbohydrates/fats/proteins, fluid/electrolyte/calcium imbalances, decreased appetite and slowing of peristalsis, calcium resorption (release of calcium into circulation, leads to hypercalcium with increase chance of renal calculi), negative nitrogen balance

fluid/electrolyte imbalances, bone demineralization, alters exchange of nutrients, altered GI fuctioning

constipation, nausea/vomiting, indigestion, decreased appetite

Assessment: Anthropometric measurements, fluid intake and output measurements, lab tests

Interventions: high-protein/calorie diet, supplemental vitamin C, vitamin B complex, TPN/Enteral Feedings

-Decreases lung expansion, promotes retained secretions, impairs gas exchange, atelectasis (collapse of aveoli), hypostatic pneumonia

Assessment: assess respiratory status, assess breath sounds, check O2 saturations

Interventions: Incentive Spirometer (q1-2h when awake), TCDB (q1-2h when awake)

Turn, Cough, Deep Breath

increases cardiac workload, causes orthostatic hypotension, increases risk from thrombus formation

Monitor vital signs, orthostatic vital signs, monitor for edema and signs and symptoms of DVT

avoid sudden changes in position (HOB, dangle, standing), mobilize client/activity schedule, dangle client, discourage use of valsalva maneuver (exhale rather than hold breath when moving), assess for DVT risk, initiate DVT prophylaxis, TED hose/SCD's

Reduce DVT risk, leg/foot/ankle exercises, fluids, position changes, meds, SCD's/TED hose, *DO NOT MASSAGE LEGS*

Urinary stasis, renal calculi, increased risk for UTI

Assessment: I&O's, Signs and symptoms of UTI

Intervention: Encourage fluids, record I&O's

Abdominal/perineal muscles can weaken, in supine position - rectal filling is slowed, client may fail to respond to urge when immobile - intestines absorb more water - dehydration can worsen the problem, client may develop impaction

Significant risk for pressure ulcer

1.Conduct a pressure ulcer admission risk assessment for all patients

2. Reassess skin daily

3. Manage Moisture

4. Optimize Nutrition

5. Optimize Hydration

6. Minimize pressure - turn and reposition at least every 2 hours

hostility/fear/anxiety, confusion, powerless with decreased self-esteem, altered coping, sleep-wake alterations, depression

Decrease muscle strength/tone, contractures and joint pain, lack of coordination, altered gait, activity intolerance, may lead to permanent or temporary impairment or permanent disability

Reduced muscle mass/strength, disuse atrophy, puts clients at risk for falls

Intervention: maintain strength muscles must contract, without contractions muscle strength may decrease by 5% per day

Impaired calcium metabolism, bone resorption (leads to osteoporosis), joint abnormalities (joint contracture - foot drop)

Intervention: Mobilize patient, without stress of weight bearing activity *bone demineralize*

Supported Fowler's, Othopneic, Sims', Prone, Knee-Chest, Lithotomy, Trendelenburg

Head of bed raised approximately 45-60 degrees

Sitting up in bed at 90 degree angle, sometimes resting forward supported by pillow on overbed table

Lying on side with knee and thigh drawn upward toward chest

Horizontal position when lying face down

Patient kneels; weight of body supported by knees and chest, with abdomen raised, head turned to one side, and arms flexed

Lying supine with hips and knees flexed and thighs abducted and rotated externally

Head low and body and legs elevated on an incline

moving a joint or extremity toward the midline of the body

Moving a joint or extremity away from the midline of the body

Turning a joint or extremity toward the body's midline

Turning a joint or extremity away from the body's midline

Decreasing the angle between two bones

Straightening a joint

Moving a joint past normal extension

turning the body or body part to face upwards

turning the body or body part to face downwards

moving a body part in widening circles

turning feet inward - toes toward midline

turning feet outward - toes away from midline

touching the thumb to each finger

Range of Motion - any body action involving the muscles and joints in natural directional movements

performed by PT or by nurse/NCT, indicated for patients confined to bed for long periods, performed passively by nurse or actively by patient, 2 hours per 24 hour period, perform exercise 3 times a day - twice a day

stop movement if client complains of pain or if there is resistance

Assessment: anthropometric measurements, ROM measurements

Intervention: active/passive ROM, individualized/progressive exercise program, participation in self-care, use of footboard or foot splint

Activity intolerance, impaired physical mobility/walking/gas exchange/skin integrity/urinary elimination/bowel elimination, ineffective breathing pattern/airway clearance/individual coping/ social isolation, Risk for injury/falls, sedentary lifestyle

Temp, pulse, respirations, BP, O2 & pain

monitor a pts condition, identify problems, evaluate response to intervention

homeostatic mechanisms

Nurse must be able to : measure VS correctly, know equipment & patient, be organized/use systematic approach, delegate measurement appropriately, analyze/interpret trends, begin interventions appropriately, communicate/document findings correctly

36-38 C (96.8^F - 100.4^F)

37 C (98.6 F)

37 C (98.6F)

37.5 C (99.5F)

60-100 BPM

12-20 Breaths per Min

<120/<80 (119/79)

30 to 50 mmHG

95%-100%

Thermoregulatory center - regulates body temperature

Heat Gained = Heat Lost

Heat produced - Heat Lost = Body temp

oral, axillary, rectal, tempanic membrane, temporal artery, esophageal, pulmonary artery & bladder temp

core & surface

temp of deep tissues, remains constant unless exposed to severe extremes in environmental temps, more reliable indicator of body temp

may vary a great deal in response to the environment

age, exercise, hormonal level, circadian rhythm, environment, temp alterations

*Fever* >39C or 102.2^F