Core Concepts of Nursing: Module 2 Blueprint

Inflammation

an immune response to injury and illness, and aids the body in healing
- a normal response
- the foundation of many diagnoses

Signs and Symptoms of Inflammation

redness, swelling, heat, pain, loss of function

Pathophysiology of Infection

1. Cellular Damage or Perceived Damage
2. Release of Chemical Mediators
3a. Increased Blood Flow > Heat & Redness
3b. Increased Capillary Permeability > Swelling
3c. Attracts Immune Cells > Immune Cells clean up and promote inflammation > Exudate

R.I.C.E.

Rest the injured area for 48 hours
Ice for 20 minutes at a time, 4 to 8 times per day
Compress to help reduce swelling
Elevate the injured limb 6 to 10 inches above the heart

Exudate

fluid, such as pus, that leaks out of an infected wound

Types of Exudate

Serous: clear and watery
Sanguineous: red bloody
Serosanguinous: light pink
Purulent: opaque and milky

Different Medications for Inflammation

NSAIDs/Antipyretics, Corticosteroids, DMARDs, A/B Adrenergic agonists, B2 Agonists, and PPI

Stages of Inflammation

1. Vascular and Cellular Response
2. Exudate production
3. Reparative phase

Vascular and Cellular Response of Inflammation (Stage 1)

- increased blood flow (vasodilation) and blood supply (hyperemia) cause redness and heat
- increased vascular permeability and fluid/leukocytes cause swelling and edema
- stimulation of the nerve endings cause pain and loss of function

Reparative Phase of Inflammation (Stage 3)

regeneration of fibrous tissues (scar formation)

granulation occur

can take up to a year

regeneration

a replacement of destroyed cells with new or identical cells

Granulation

a replacement of destroyed cells with tissue, collagen, etc
- the healed wound will have a scar

"-itis"

inflammation

Mast Cells

leukocytes found in most of our tissues and body; primary source of cell derived mediators
EX: WBCs w/ histamine and heparin that release them

Function of Histamine in Inflammation

vasodilation (increased vascular permeability) (redness and heat)

Function of Heparin in Inflammation

prevents blood clotting

Receptors Involved in the Inflammatory Response

H1 and H4 receptors

H1 Receptors

primarily found on smooth muscle cells, on the endothelium, and in the CNS
- vasodilation, pain, itching, hives

H4 Receptors

located in peripheral WBCs and mast cells, are also involved in immune responses

Infiltration

non-harmful fluid leaking into the subcutaneous tissue
EX: NS

Extravasation

leak of a vesicant fluid into the intravascular space
- causes tissue damage
EX: a strong antibiotic

Phlebitis

inflammation of the vein or vessel due to injury or irritation
- streaky, red, palpable vein

Thrombophlebitis

inflammation of the vein due to a blood clot
- do NOT elevate or rub

Cellulitis

a bacterial infection of the vein that surrounds the tissue
- caused by an IV;warmcompress

5 Diagnostic Tests for Inflammation

- WBC
- ESR (erythrocytes/sedimentation rate)
- CRP (C reactive protein - liver + fat cells)
- CMP/BMP (renal + liver + albumin)

Independent Nursing Interventions for Inflammation

- Elevate with a pillow
- providing extra pillows
- alternate positions

Pathogens

disease causing agents (signs and symptoms of a disease depend on the pathogen)
Includes: bacteria, virus, parasites, fungi, and prions (not living)

Stages of Infection

Incubation
Prodromal
Illness
Convalescence

Incubation Stage of Infection

the interval between the pathogen entering the body and the presentation of the first non-specific symptom
EX: fatigue, drainage, cough

Prodromal Period of Infection

begins when the first non-specific symptom appears to when the specific symptoms appear
EX: loss of taste

Illness Stage of Infection

the interval when symptoms specific to the infection occur until the symptoms go away
- includes the period of illness and the period of decline (body starts to win!)

Convalescence Period of Infection

symptom disappear to complete recovery
- you can still have the virus in your body

Nonspecific Immunity

things our body already has to fight infection; no memory
Includes: skin, mucous, hair, and the inflammatory response

Specific Immunity

acquired or adaptive immunity that is specific to the causative agent; uses memory
Includes: antibody mediated response, requires past exposure to antigen, lymphocytes, and vaccines

Chain of Infection (6)

1. Infectious Agent
2. Reservoir
3. Portal of Exit
4. Mode of Transmission
5. Portal of Entry
6. Susceptible Host (older adults, immunocompromised, and risky behaviors)

Risk Factors of Infection

- poor hand/personal hygiene
- compromised immune system
- compromised defense
- nosocomial infections (hospital acquired)
- poor hygiene
- smoking/alcohol use
- crowded environments
- chronic illnesses (cancer, HIV, etc)
- internal (stress, lack of rest, etc)
- age

glucocorticoids

decrease immunity

antineoplastics

wipe out the immune system
- chemo

Signs of a Local Infection

redness, warmth, edema, pain, loss of function
- can become systemic

Systemic Infections

fever, tachycardia, tachypnea, hypotension, fatigue, anorexia, enlarged lymph nodes
EX: flu

bacteremia

bacteria in the blood
- normal labs

Septicemia

infection in the blood, which causes the body to mount an immune response that can be deadly
- signs and symptoms; altered vital signs
- systemic

Medical Asepsis

the use of precise practices to reduce the number, growth, and spread of micro-organisms
- the "clean technique"
EX: washing your hands, starting and IV/NG tube, giving vaccinations

Surgical Asepsis

the use of precise practices to eliminate all micro-organisms
- the "sterile technique"
EX: surgery, inserting a catheter, sterile dressing changes

When do you NOT use alcohol based products to perform hand hygiene?

when your hands are visibly soiled, or after dealing with C. diff

Standard Precautions

precautions used in the care of all patients regardless of their diagnosis or possible infection status
- all bodily fluids (except sweat), open wounds, and mucous membranes
- Hand Hygiene + Gloves

Airborne Precautions

- negative pressure private room (air sucked in, filtered out)
- N95 mask prior to entering the room
- face shield if splash/spray
- client wears a surgical mask when leaving room
For: TB, measles, varicella, chicken pox
- microbes are smaller so they travel far (mainly respiratory)

Droplet Precautions

- private room or with same
- surgical mask
- client wears mask when leaving the room
For: Flu, whooping cough, mumps
- microbes are larger so they do not travel as far

Contact Precautions

practices used to prevent spread of disease by direct or indirect contact
-private room or with same
- gloves + gowns
For: C. diff and MRSA

Neutropenic Precautions

Isolation procedures to protect an immunocompromised patient (low WBC) from infections
- positive pressure private room (air from hallway does not come inside)
- patient wears mask outside room
- no live plants, or fresh fruits/veggies
- fully cooked food
- nurse wears mask inside the room

Levels of Consciousness

Full consciousness
Confusion
Disorientation
Obtunded (SHAKE)
Stupor (PAIN)
Coma (decorticate vs decerebrate)

Decorticate

flexion into body (core)
- patient is likely to die

Decerebrate

extension away from body, pronation of arms/legs

GCS Checks

1. eye opening spontaneously
2. verbal response
3. motor response

Seizure Precautions

- all side rails up; padded
- have suction and oxygen available
- pillow to protect head
- privacy provided as soon as possible
- bed locked and in lowest position
- loose clothes
- side-lying position

Cranial Nerve 1

Olfactory (smell)
- sensory

Have the patient close eye, occlude one nostril and identify the sent offered, do other side

Cranial Nerve 2

Optic (vision)
- sensory

Distance test using Snellen chart (20 feet), Rosenbaum for near sided check (14 in). Test each eye then both together

Cranial Nerve 3 (III)

Oculomotor (eye movement, pupil constriction)
- motor

PERLA check and eye lid findings

Cranial Nerve 4 (IV)

Trochlear (vertical eye movement)
- motor

Pupillary response to accommodation (changing focus from near to far)

Cranial Nerve 5 (V)

Trigeminal (facial sensation, chewing)
- sensory AND motor

Ask patient to clench and release the jaw while palpating over the muscles

Ask patient to close eyes and run a cotton all on the cheek

Cranial Nerve 6 (VI)

Abducens (lateral eye movement)
- motor

Cranial Nerve 7 (VII)

Facial (taste - salt/sweet, facial movements)
- sensory AND motor

Ask patient to smile, frown, puff cheeks, raise eyebrows

Cranial Nerve 8 (VIII)

Vestibulocochlear/Auditory (hearing and balance)
- sensory

Whisper Test

Cranial Nerve 9 (IX)

Glossopharyngeal (taste - sour/bitter, swallowing, gag reflex)
- sensory AND motor

Gag reflex response

Cranial Nerve 10 (X)

Vagus (gag reflex, swallowing, speech)
- sensory AND motor

With a penlight and tongue depressor, ask patient to say ahh.

Cranial Nerve 11 (XI)

Spinal Accessory (shoulder shrugging, head-turning)
- motor

Cranial Nerve 12 (XII)

Hypoglossal (tongue movement)
- motor

Ask patient to stick tongue out and check to see if it protrudes midline

Intracranial Regulation Assessments

- LOC
- Pupillary Response
- Oculomotor Response
- Motor Response
- Breathing

Intracranial Regulation Diagnostic Tests

- X rays and images to look at structures
- Therapeutic drug levels
- Serum lab values

Independent Nursing Interventions to Assess Intracranial Regulation

- Vital signs
- PERRLA
- LOC
- monitoring I&O
- reducing environmental stimuli
- positioning
- protecting airway
- seizure precautions

Collaborative Interventions to Assess Intracranial Regulation

- monitor airway
- monitor blood gases (ABCs)
- administer medications
- nutrition

External Stimuli

1. Visual
2. Auditory
3. Olfactory
4. Tactile
5. Gustatory (taste)

Internal Stimuli

1. Gustatory (taste)
2. Kinesthetic (awareness of position/movement)
3. Stereognosis (identifying a 3D object w/o sight)
4. Visceral

Motor Tests

1. Romberg Test: balance (feet together, arms at side, eyes closed)
2. Heel-to-Toe Walk: balance
3. Gait (walking should be smooth/steady)
4. Deep Tendon Reflexes (reflex hammer)

Sensory Tests

1. Pain (sharp vs dull)
2. Vibration (where they feel the vibrating tuning fork)
3. Temperature (warm/cold test tubes)
4. Light touch (cotton ball)

Neurological Alterations with Aging

1. short term memory decline
2. decreased visual acuity with near objects (presbyopia)
3. hearing loss
4. decreased sense of taste and smell

Musculoskeletal Alterations with Aging

1. loss in bone mass and height (osteoporosis)
2. kyphosis (spine curvature; humpback)
3. loss of subcutaneous fat

Assessing the Eye and Vision

Cranial Nerves: 3, 4, and 6
- PERRLA
- the 6 Cardinal Gazes (follow finger w/ eyes)

Assessing Visual Acuity

Cranial Nerve 2
- Snellen Chart: tests for myopia; stands 20 ft from chart
- Rosenbaum eye chart: tests for presbyopia; 14 in from chart)
- Ishihara Test: color blindness (identify shaded shapes)

Expected Ear Assessment Findings

1. a small amount of ear wax
2. pull auricle up and back for adults

3.down and back for children
4. tympanic membrane should be pearly grey with light reflex and intact
- fluid = ear infection

Hearing Tests

Cranial Nerve 8
1. Whisper Test
2. Weber Test (tuning fork on head)
3. Rinne Test (tuning fork on mastoid bone, then by ear)

When testing taste and smell....

...have the client close their eyes

Thermoregulation

a physiological regulation of the human body-the balance of heat production and heat loss to maintain the body temp
- neurological and cardiovascular

hypothalamus

located between the cerebral hemispheres, and controls the body's temperature like a thermostat
- anterior: heat dissipation
- posterior: heat production

Concepts related to Thermoregulation

-Fluid and electrolyte imbalance
-Comfort
-Infection
-Inflammation
-Growth and development through the lifespan

Hyperthermia

more heat produced than lost; high body temperature (>100.4)
- fever not harmful until >102.2
- hypotension, tachypnea, tachycardia, thirst, headache

Hydration

Ice packs = groin, armpits, neck

Hypothermia

more heat lost than produced; low body temperature (<95)
- classified by measuring core temp
- confusion, shivering, slurred speech, bradycardia, and temp decreases BP does too

Warm infants slowly

Transmission Based Precautions

are used when the route of transmission can’t be stopped by the use of standard precautions alone. Sometimes more than one precaution may need to be used

What can nurses do to break the chain of infection?

1. Handwashing

2. Environmental Cleaning

3. Wear PPE

4. Antibiotics (when needed)

5. Contain Contaminated Waste

illness management

-Identify the body system and the effects the infection has on that body system

- Observe the manor of the presentation

- Identify causative agent and treat accordingly

Laboratory Test: Infections

1. WBC count

2. WBC differential

3. Cultures

4. Serological testing

5. Antibiotic peak and trough levels

6. Radiology

7. Lumbar puncture

8. Ultrasound

9. Urinalysis

WBC Count

Provides clues about the infecting organism and the body’s immune response to it (>10,000)

Number one indication of infection because your body is fighting something off

WBC Differential

Assess number of circulating neutrophils. Increase indicates infections, while decrease indicates a problem in the bone marrow. Immature neutrophils indicate an acute infection

Cultures

used to identify probable microorganisms by their characteristics. After culture, microorganism is tested with different antibiotics to determine which one is most effective (sensitivity testing), and it takes 24-28 hours.

Serological testing

Indirect way of identifying infection by looking at our antibodies (hep b, HIV)

Antibiotic peak and trough level

Measuring the blood levels of the prescribed medication. Making sure that it reaches it therapeutic range, and a range high enough to kill the microorganism

Complications from Surgical Procedures

-Wrong person surgery

-Right person, wrong site

- Right person, wrong surgery

Personal Hygiene Measures

Respiratory hygiene, keep hair short/pulled back, keep nails short/clean; NO GAIL GELS/ACRYLIC NAILS, Remove jewelry from hands and wrists

Physical Environment Measures

-Don’t place items on floor,

-Don’t shake linens/keep soiled linens away from clothing

-Clean from LEAST SOILED TO MOST SOILED

-Use plastic bags for moist/soiled items per protocol

-Place all laboratory specimens in biohazard containers or bags for transport

Maintaining Sterile Field

Avoid cough/sneeze, talk directly over sterile field

-Only sterile items may be in a sterile field

-Outer wrapping and 1 inch edges (border) of packaging are not sterile

-Tough “sterile to sterile” only (Sterile gloves to tough sterile supplies)

-Items below the waist or above the chest are not sterile

-Any nonsterile item touching a sterile field contaminates the sterile field, no matter how short the contact

-Do not reach across sterile field

-Do not turn your back on sterile field

-Hold items to add to a sterile field at a minimum of 6 inches above the field

-Any sterile, non-waterproof wrapper that comes in contact with moisture becomes non-sterile (by wicking action)

-Inspect all packages: dry, intact, not expired

WHEN IN DOUBT THROW IT OUT