NSG 2000: Exam 2

Neurological, Infection Prevention, Precautions, Immunizations & Vaccinations

Cerebrum

Part of brain responsible for person’s mental status

Cerebral cortex

Part of brain responsible for perception and behavior

Frontal lobe

Part of brain responsible for short term memory, concentration, emotional expression, decision-making and problem-solving

Parietal lobe

Part of brain responsible for sensory data

Temporal lobe

Part of brain responsible for long term memory and sounds

Limbic System

Part of brain responsible for survival behaviors and emotions

Reticular activating system (RAS)

Part of brain responsible for awareness and arousal

Mini-mental State Exam (MMSE)

Exam to assess neurological function:

• Can score up to 31

• A score of 21 or less warrant further evaluation → reveals cognitive dysfunction

Glasgow Coma Scale

Scale used to assess neurological function:

• 15 is the best score and 3 is the worst

Level of conscious, behavior, appearance, language, memory

Components of mental exam:

• _____ __ _________

  • A&O

• ________ and _________

  • Mood, hygiene, body language

• ________

  • normal or aphasia: sensory and motor

• ______

  • Recent, remote, delirium, dementia

Other: knowledge, abstract thinking, association, judgment [know these definitions]

Alert and Oriented: person, place, time, situation

Exam what components for level of consciousness (LOC)?

Mood, hygiene, body language

Exam what components for behavior and appearance

normal or aphasia

Examining for what components of language

Sensory (receptive) aphasia

Cannot understand written or verbal speech. Hear words but no comprehension.

Motor (expressive) aphasia

Understands written or verbal speech but cannot write or speak appropriately. Cannot say what they want to say.

Recent memory

Short term

• Name unrelated objective; recall 3 words or series of numbers (keep it simple)

Remote memory

Long term

• Recall mother’s maiden name; an event in history; birthday

Delirium

• Acute (immediate, usually a cause, comes back)

• Sudden-short development

• Medical condition link (e.g. concussion, trauma)

• Impairs consciousness

• Potentially reversible

• Perform GCS

Dementia

• Chronic (slow, not coming back)

• Insidious-progressive

• Structural brain disease

• Impairs judgment, memory, thought patterns

I. olfactory (sensory)
II. optic (sensory)
III. oculomotor (motor)
IV. trochlear (motor)
V. trigeminal (sensory and motor)
VI. abducens (motor)
VII. facial (sensory and motor)
VIII. auditory (sensory)
IX. glossopharyngeal (sensory and motor)
X. vagus (sensory and motor)
XI. spinal accessory (motor)
XII. hypoglossal (motor)

Cranial Nerves

I

Cranial Nerve function(s): olfactory, smell

II, III, IV, VI

Cranial Nerve function(s): eye movement and visual acuity

VII, IX

Cranial Nerve function(s): taste

VIII

Cranial Nerve function(s): hearing

X

Cranial Nerve function(s): parasympathetic innervation, vagal response

XII

Cranial Nerve function(s): hypoglossal movement of the tongue

pain, temperature, position, vibration, touch

Sensory function is

coordination, balance, Romberg, stereognosis, graphesthesia, proprioception

Motor function tests

Coordination

Cerebral cortex. Perception. Maintains balance and posture.

A balance test but with eyes closed

Romberg test

identify objects eyes closed

Stereognosis test

identify written words in palm

Graphesthesia test

Proprioception

Making adjustments to environment. Perception of body in space with eyes closed

deep tendon reflexes and cutaneous reflexes

Categories of normal reflexes

peripheral spinal nerve function

Deep tendon reflexes (DTRs) tests for?

0 no response, 1 sluggish, 2 active and normal, 3 brisk and hyperactive, 4 more brisk and clonus (spastic)

Deep Tendon Reflexes grading scale:

Recognition, activation (911), release (news, awareness), recruitment

Steps of inflammatory response

Injury, infection, irritation

3 triggers of the inflammatory response

localized or systemic

Infection can be

5-10 Kelvin

Normal white blood count

15-2000 Kelvin

When having infection/respiratory response WBC count is?

Localized infection

Only affects one area of body.
Symptoms: swelling, redness, tenderness, loss of function

Systemic infection

Affects entire body.
Symptoms: fever, increased leukocytosis, malaise, anorexia, N&V, lymph enlargement organ failure

1. incubation period

2. prodromal stage

3. acute illness stage

4. period of decline

5. period of convalescence

Course of infection

Incubation period

the time the pathogen enters the body until the appearance of signs and symptoms

Prodromal stage

onset of nonspecific to more specific signs and symptoms; contagious

Acute illness stage

symptoms of infection apparent; when infection is considered severe

Period of decline

signs and symptoms begin to disappear

Period of convalescence

return to state of health

Virulence

Degree of risk of causing someone to get sick. The higher the count the sicker you become

Pathogen, reservoir, animate or inanimate, Portal of exit, Mode of transmission, direct or indirect, portal of entry, susceptible host, elderly, babies, immunocompromised

Chain of infection:

• ________: normal flora in the wrong location can cause infection

• ________

  • ______ or ______

• Portal of ____

• Mode of ________

  • ______ or _______

• Portal of ____

• _______ host

  • (more likely) _____, ____, and ____________

GOAL: “break” the chain and it will slow the spread of infectious disease.

standard, contact, droplet, airborne, and protective

Precaution categories

Standard precautions

What precaution:

Applied to all patients.

• hand hygiene, gloves/PPE, room, sharps & equipment, respiratory/cough hygiene

direct or indirect, gloves and gown, private room or cohort

Contact precautions

• _____ or _______

• _____ and ______ (minimum PPE)

• _______ ____ or ______

Contact diseases

scabies, staph aureus, hepatitis, C. diff, MRSA, VRE, ESBLs, Herpes zoster or shingles, covid

6-10 feet, humidity and temp, mask, employee and patient, Face shield or goggles, private or cohort

Droplet precautions

• __-__ feet

• _____ and ____ impact spread (cold prevents)

• ____

  • ______ and ______ for transport

• ____ _____ or _____ (dependent on circumstance)

• _____ or ____ (room, 3 ft separation)

Droplet diseases

• influenza

• pertussis (whooping cough)

• mumps and measles

• adenovirus

• norovirus

• rhinovirus (common cold)

• mycoplasma pneumonia

• covid

long, small, hours, negative, N95, private

Airborne precautions:

• travel ___ distance

• ___ particles stay for ____

• ______ air pressure (AIIR, hallway to room; 6-12 exchanges with HEPA filter)

• ____ for client to transport

• _______ room

Airborne diseases

• TB

• smallpox

• chickenpox (varicella)

• Measles (rubeola)

• disseminated herpes zoster

• covid (other droplet diseases become airborne with aerosolizing procedures)

Private room ONLY

positive, transplants, plants

Protective precautions

• _____ airflow (AIIR: room to hallway with 12 exchanges an hour with HEPA filter)

• _______ (e.g. stem cell, kidney)

• No ____

gown, mask, goggles, gloves

Putting on PPE sequence

gloves, goggles, gown, mask

Doffing PPE sequence

preventable, increase, increases, death

Hospital-associated infection (HAI) characteristics:

• often ________

• _____ LOS

• _____ expense

• Increases potential for _____

catheter-associated urinary tract infection, surgical site infection, central line associated bloodstream infection, ventilator assisted pneumonias

Most common HAIs

• CAUTI

• SSI

• CLABSI

• VAP

Common multi drug-resistant organisms (MRDOs)

• MRSA

• VRE

• VRSA

• VISA

• ESBLs

• MDRSP

enhanced barrier precautions—long term care

one

Airborne is always ___ patient(s) to one room

Medical asepsis

Cleaning technique practices that reduce the presence of disease-causing microorganisms on surfaces.

e.g.) CHG baths, hand hygiene, cleaning your equipment (anything shared), etc.

Surgical asepsis

Cleaning techniques that ensures the sterility of items that will come in contact with the client, through use of equipment such as sterile gloves, in order to prevent pathogen transfer to the client

100% no organisms

Sterilization

All microorganisms, including spores, are eradicated.

Processes: steam and then dry heat, ethylene oxide gas, chemicals

Disinfection

Cleans instruments so microorganisms are eradicated but does not remove spores. Otherwise use single use equipment.

• High-level: only a few spores remain

• Low-level: most bacteria destroyed but some spores, viruses, & fungi remain

active, passive, herd

Types of Immunity (3)

produce antibodies, natural, vaccine-induced, weeks, long-lasting

active immunity:

• Disease causes immune system to ______ ________

  • ____

  • ____-_____

• develops after ____

• ___-____

given, newborn via mother, immune globulin, immediate, short-lived

Passive immunity:

• _____ antibodies

  • ______ via ______

  • _____ ______

• protection is ________

• ___-____

Large, lowers

Herd:

• _____ percentage of population is protected against a certain disease

• ______ amount of virus transmission

parenteral: intramuscular or subcutaneous

Vaccine Routes

fever, soreness, swelling, redness, behavioral changes

Mild side effects of vaccine

cool compress 24 hours then warm or cold prn

What do you do with redness at injection site?

date of administration, manufacturer and lot number, name, address, title of person administering, site and route

Maintain vaccine record:

• ____ of _______

• _______ and ____ _______

• ____

• ______

• _____ of ______ _______

• ____ and _____ of administration

File report and notify local health department

Report adverse events how?

Titer

blood sample to document concentration of antibodies

immunity (positive)

Titer adequate levels meaning

no immunity (negative)

Titer inadequate levels

hep B, mumps, measles, rubella, varicella

Common titer tests

previous, egg, attenuated, live, fever

Anaphylactic reaction from:

• ______ vaccine

• Components in vaccine:

  • ___ allergy (or gelatin for live?)

  • _______ or _____

• Administer with caution to those with moderate or severe acute illness, with or without ______

deficient immune systems, sensitivity to gelatin, pregnant

Live virus not given to:

• Severely ______ _______ ______

• Severe _______ __ ______

• ______ women

Administer with caution: moderate or sever acute illness, with or without fever

correct needle size and length, appropriate site

Minimize vaccine reaction

Secure and maintain airway, antihistamine or epinephrine

Mild anaphylactic reaction

establish airway, CPR, elevate, epinephrine, fluids, vasopressors, vital signs, urine output

moderate to severe anaphylactic reaction:

• ______ _____

• ____

• _____ HOB

• Administer: _______, _____, _____ per orders

• Monitor _____ ____ and _____ _____

Vaccine Adverse Event Reporting System

VAERS

• Established in 1990.

• Managed by CDC and FDA.

• Accept & analyze reports of adverse events after vaccination. Anyone can report.

• Healthcare personnel are required to report.

65+ year olds (older adults)

what age has decreased response to vaccinations?

autonomy, beneficence, justice, non-maleficence, utilitarianism

main principles in nursing code of ethics

RUQ

Part of abdomen that contains the:

liver, pancreas, gallbladder, ascending colon, some of the kidneys

LUQ

Part of abdomen that contains the:

stomach, spleen, pancreas, transverse colon, intestines

LLQ

Part of the abdomen that contains the:

small + large intestine and left reproductive organs

RLQ

Part of the abdomen that contains the:

appendix, intestines, and right reproductive organs

Midlines

Area of abdomen that contains the bladder and uterus

Hypoactive

Bowel sounds that are more than 15-30 seconds to hear but at least one every 5 minutes.

Cullen sign

Ecchymosis; bruising around umbilicus

sign of bleeding in the peritoneal cavity or parancitis

Gray turner

Ecchymosis in the flank

Sign of bleeding in the peritoneal cavity or parancitis

Gravid

The shape of a pregnant woman’s abdomen