Health assessment and infection prevention/control

assessment

information, data, and facts about a patient, family or community that are used to identify patterns and health problems of your patient

subjective data

symptoms or feelings

things a person tells you about that you cannot observe through your senses;

objective data

direct measurements or findings resulting from observation of a patients behavior and clinical signs. This includes what you see, hear, and touch

nursing health history

Data collected about a patient's present level of wellness, changes in life patterns, sociocultural role, and mental and emotional reactions to illness.

supine

lying on the back

dorsal recumbent

lying on the back with knees up and feet flat on the table, best for abdominal assessment

lithotomy position

lying on back with legs raised and feet in stirrups

prone

lying face down

lateral recumbent

lying on the side. aids in detecting murmurs

inspection

deliberate observation of nonverbal expressions of emotional and mental status. Along with interacting with patients, assessing physical movements and structural components

palpitation

a physical examination method that uses the sense of touch to evaluate body tissues, organs, and overall health. touch can help you make judgements about expected and unexpected findings

percussion

tapping fingertips on skin to cause vibration in underlying tissues and organs which help determine density of tissue and identify organs or masses

Auscultation

listening to sounds within the body and observing any abnormalities

symmetry

compare both sides of body for symmetry, some degree of asymmetry is normal

general survey

physical appearance, body structure, mobility, behavior, emotional state

asepsis

Absence of disease-causing microorganisms.

Aerobic

bacteria that rely on oxygen to survive and multiply, causing disease

Anaerobic

bacteria that dont need oxygen and thrive, causing infection deep within plural cavity or joints

colonization

growth of microorganisms within a host but without tissue damage

disinfection

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

Health care-associated infections (HAIs)

An infection that is acquired in a hospital setting, formerly known as a nosocomial infection

personal protective equipment

Specialized clothing or equipment, worn by an employee for protection against infectious materials (as defined by OSHA).

Standard Precautions

A strict form of infection control that is based on the assumption that all blood and other body fluids are infectious.

"The 4 C's" interview

courtesy, comfort, connection, confirmation

why is confidentiality important when obtaining health history

It builds trust between patient and provider while also creating a private space for patient to explain what health changes are occuring

PQRST assessment

P - provokes (How did pain come about? What makes it better or worse?)

Q - quality of pain (dull, stabbing)

R - radiation/location (can you point to it? does anything else hurt?)

S - Severity (scale 0-10)

T - timing (when does it hurt, how long, do symptoms linger?)

components of nursing health history

biographical information, reason for seeking health care(patient's statement is not diagnostic, it is perception), patient expectations, present illness or health concerns, health history, family history, psychosocial history(stress coping, parent's support system), spiritual health, review of systems(subject data)

biographical information

Factual demographic data about the patient

-patient age, gender, address, insurance, occupation, working status, marital status

Chief concern or reason for seeking health care

the patients own words on why they are seeking healthcare which offers a place to focus and explore patients concern

Present illness/health concerns

- Collect essential & relevant data about a patients illness or sickness

- P / Q / R / S / T

past health history

a holistic view of a patients past healthcare experiences and current health habits, gather information, history, allergies, and lifestyle patterns

family history

information about immediate family and blood relatives. determine if patient is at risk for illnesses of genetic nature and identify areas of health promotion

Psychosocial History

information about a patients support system and weather a patient has experienced recent loss. This includes how they cope with grief

Spiritual Health

ask about a patients beliefs along with any rituals or practices that may impact their care while in a healthcare setting

review of systems

a collection of subjective information from patients about any health related issues in their body. During this assessment you will understand normal body functioning for the patient and understand any changes

Observation of Patient Behavior

Look for a patient's verbal and nonverbal behaviors to add depth to data and make better clinical judgements about a patients condition

areas of general appearance and behavior

gender and race, age, signs of distress, body type, posture, gait, body movements, hygiene and grooming, dress, body odor, affect and mood, speech, sign of patient abuse, substance abuse

during health history, the nurse realizes that the nurse and patient dont share a common language. Her son is present and offers to translate. What is the most appropriate actions to take and explain why

Politely decline, get translator because family members may include their own opinions reducing the accuracy of translated information from patient

What is chain of infection

infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host

When should soap and water be used instead of hand sanitizer

soap and water should be used if hands are visibly soiled or exposed to spore forming organisms (C.Diff)

how long should you wash your hands with soap and water to effectively remove germs

hand washing should be completed for 20 secs to effectively remove germs

six situations in which healthcare workers should perform hand hygiene

1. Before, after, between patient contact

2. Before putting on sterile gloves

3. After contact with body fluids or excretions

4. Hands are visibly dirty

5. After contact with surfaces/objects in patients room

6. After removing gloves

What areas of the hand are commonly missed during hand washing

fingertips, thumbs, wrists, and the area inbetween fingers

standard precautions

CDC precautions used in the care of all patients regardless of their diagnosis or possible infection status; this category combines universal and body substance precautions

what do you use for standard precautions

-depends on task being preformed

mainly gloves

-can be gown, gloves, or mask

what type of patient or disease do you use with standard precautions

all patients in all settings regardless of assumed infection status

are there any barriers or protection conditions for standard precautions

depends on task being preformed

What do you use for airborne precautions

N95 mask for TB

mask or respiratory protection device

What type of patient or disease do you use airborne precautions with

measels, chicken pox, disseminated herpes zoster, rubeola

are there any barriers or protection conditions for airborne precautions

negative airflow

what do you use for droplet precautions

surgical mask and hand hygiene

what type of patient or disease do you use with droplet precautions

influenza, group a streptococcus diptheria, pneumonic plague, rubella, mumps

are there any barriers or protection conditions for droplet precautions

private room

what do you use for contact precautions

gown and gloves

what type of patient or disease do you use with contact precautions

colonization or infection with multidrug-resistant organisms (VRE and MRSA) clostridium difficule, scabies

are there any barriers or protection conditions for contact precautions

private room

what do you use for protective environment

mask, gown, gloves

what type of patient or disease do you use with protective environment

allogenic hematopoietic stem cell transplants

are there any barriers or protection conditions for protective enviornment

positive airflow with greater than or equal to air exchanges, HEPA, filtration for incoming air