Nursing Theory

Exam 1

Contact Transmission

Direct contact

indirect contact

direct contact

Microorganisms moved directly from one infected person to another without a contaminated object or intermediary in between

indirect contact

microorganimis are transfered from one infected person to another via an intermediate contaminated object or person.

droplet transmission

airborne droplets carrying microorgansimis are originated from the respiratory tract of an infected person and travel through the air into the mucosal surfaces of a host

airborne transmission

micro organisms carried on small particulates move into the airspace of another person

portal of entry

mucouse membrane

respiratory system

digestive system

broken skin

susceptible host

immune deficiency

diabetes

burns

surgery

age

immune system competence

nonspecific immunity

specific immunity

humoral immunity

cell mediated immunity

inflammatory response

nonspecific immunity

involves neutrophils and macrophages, which recruited during inflammotiry response to ingest and destroy microorganisms

specific immunity

Mediated by lymphocytes and antibodies (immunoglobulins), which specifically bind to antigens like bacteria and recruit complement proteins and white blood cells for destruction.

hummoral immunity

process where the body produces specialized anitbodies in response to the presence of a foreign anitgen

cell mediated immunity

involves an increase in lymphocytes that recognize, react with, and destroy harmful cells

inflammotry response

Pattern receptors on cell surfaces recognize harmful stimuli, triggering the activation of inflammatory pathways, the release of inflammatory markers, and the recruitment of inflammatory cells

development competence

Immune strength varies over the lifespan. By late childhood, the immune system becomes competent enough to protect against common infections, whereas older adults experience the opposite, increasing their vulnerability.

infectious agents

bacteria

fungi

parasites

prions

viruses

bacteria

serve as a primary example of a foregin antigen that triggers the bosies humoral immune response

fungi

categorized as disease caseing microorganisms within the chain of infection

parasites

listed among the infectious agents capable of establishing an infection in a suceptible host

prions

grouped alongside bacteria, fungi, and parasites as infectious agents

viruses

Not specifically listed in the chain of infection.

viral pathogens are addresed in the context of prevention through immunizations

bacteria

single celled prokaryotic organisms that can reproduce independently outside or inside a host and are commonly treated with antibacterial medications

viruses

Genetic material (DNA/RNA) enclosed in a protein coat that cannot replicate on its own and must invade a living host cell to multiply

fungi

eukaryotic organisms (yeasts/molds) that feed on organic matter and can cause localized or systemic fungal infections

parasites

organsims (protozoa/helminths) that live on or inside a host organism, relying on the host for nutrients at the host’s expense

portals of exit

respiratory tract

gastrointetinal tract

genitourinary tract

skin and breaks in the skin

blood and tissue

secretions and excretions

progression of symptoms across stages

prodromal stage

acute illness stage

decline stage

prodromal stage

symptoms first begin to appear

acute illness stage

symptoms become more obvious and may be more severe

decline stage

symptoms go away

clinical symptoms

fever

fatigue

cough

sputum

pain

dyspnea

local infection

One specific area of the body. ex. folicultis, green nail syndrome, sever necrotizing infections

labroatroy indicators

Laboratory data, including elevated leukocytes, provide objective evidence of infection

medical asepsis (clean technique)

elimination and absence of disease causing micro organisms

key practices for MA

effective hand hygiene, maintaining good personal hygiene, properly disposing of soiled articles, applying appropraite cleansing and disinfecting techniques

goal of MA

aim to decrease the spread or transmission of pathogens, thereby lessening occurece of illness

types of hand hygeine

standard hand washing with soap and water, using alcohol-based hand sanitizers, using antiseptic handwashing or hand rub

surgical asepsis (sterile technique)

advanced form of hand cleansing and emphasize performinhg hand hygeine prior to any clean asepctic procedure

personal protective equipment (PPE)

highlighted as an essential component of infection control and standard precautions

standard precaution of ppe

infection prevention practices are applied to all clients, regardless of whether an infectious agent is known to be present

moments for hand hygeine

before touching a patient

before a clean or aseptic procedure

after body fluid exposure risk

after touching a patient

after touching patient surroundings

ventilator associated pneumonia (VAP)

respiratory tract infections occurring in acute and long term care settings which carry high rates of multidrug resistance

catheter related urinary tract infections

infections of the urinary tract associated with catheter placement, where biofilm formation on the catheter presents significant management challlenges

bloodstream infection

systemic bloodstream infections that can take progressive course, carry a high case fatality rate, adn lead to severe complications like sepsis

skin and soft tissue infections

burn wound infections

loclaized primary infecitons

sever necrotizing infections

burn wound infections

often exhibit high resistance rates

loclaized primary infections

follicultis

green nail syndrome

interdigital infections

enviornmental and article management

demonstrating proper disposal of soiled articles and executing effective cleansing ad disinfecting techniques

senses involved in sensory reception

visiual

auditory

olfactory

gustatory

tactile

stereognosis

kinesthetic and visceral

proprioception

visual

perception through sight

auditory

perception through sound waves and hearing

olfactory

perception through odors and smell

gustatory

perception through physical contact and touch

stereognosis

ability to percieve and recognize the solidiity, size, and shape of objects through touch (cant see it)

kinesthetic and visceral

internal sensing mechanisms that serve as basic internal orienting systems providing awareness of interanl organ sensations and body movement

proprioception

spatial awareness of body posture, movement, and position

condiotions recquired to recieve data

stimulus

receptor

nervous pathway to brain

functioning brain

stimulus

enviornmental factor capable of initiating a response

receptor

specialized cell or organ that recieves the stimulus and converts it into a nerve impulse

nervous pathway to brain

Iintact neural tract that condicts the nerve impulese from the receptor site to the central nervous system

functioning brain

healthy brain capable of receiving, processing, and translating incoming impulses

reticular activating system (RAS)

The Reticular Activating System (RAS) regulates sensory stimuli and arousal, helping the body achieve optimal sensory arousal.

conscious states

make up conditoins where a person retains varying levels of awareness, alertness, and responsiveness to their environment

classifications of conscious state

include normal consciousness, delirium, dementia, confusion, somnolence, minimally conscious states, and locked-in syndrome

care considerations of concious states

When communicating with a conscious client who is confused, nursing interventions emphasize frequent face-to-face interaction, speaking calmly and directly, offering explanations for care, and reorienting the patient to time, place, and person

unconcious states

Unconscious states represent conditions characterized by an absence of normal awareness or environmental responsiveness

classifications of unconscious state

include being asleep, stupor, coma, and a vegetative state

care considerations of unconcious state

A critical clinical distinction for unconscious clients is that hearing is the last sense that is lost. Caregivers should always assume the unconscious patient can hear what is being said, speak in a normal tone of voice, communicate before touching the client, and maintain a low level of environmental noise

comprehensive sesnory assessment

evaluates how client receives, processes and responds to environmental and internal stimuli.

stimulation

Assessing whether the environment provides sufficient, meaningful, or excessive sensory input regarding quality, quantity, and intensity

reception

Assessing the integrity and functioning of sensory receptors responsible for collecting stimul

transmission - perception - reaction

Assessing whether the neural pathways and brain are functioning properly to transmit, process, translate, and react appropriately to sensory input

signs and symptoms of sensory alterations

Evaluating for clinical manifestations of sensory deprivation (decreased or monotonous input) or sensory overload(excessive stimuli beyond processing capacity). This includes screening for perceptual, cognitive, and emotional disturbances

vission and heaing assessments

Performing direct screenings to identify visual impairments or hearing deficits, as well as evaluating the function or fit of supportive devices like hearing aids

ability to perform self care

Assessing how sensory deficits or alterations affect the client’s independent performance of daily self-care activities

developmental considerations

Lifespan-specific changes in sensory acuity and processing capabilities

stress and illness

Acute health conditions or severe stress that alter sensory thresholds

medications

Evaluating pharmacological agents that may alter sensory reception, perception, or cognitive arousal

personality, lifestyle, and culture

Understanding daily living patterns, personal preferences, and cultural influences on sensory perception and communication

announcing presence and departure

acknowledge your presence in the client’s room upon

Clearly indicate when you are leaving the room so the client is aware of your departure

effective communication and touch

Speak in a normal tone of voice (there is no need to raise your voice unless a hearing impairment is also present)

Explain the reason for touching the client before doing so to prevent startling them

enviornmental safety and orientation

Ensure the call light is kept within easy reach at all times

Orient the client to environmental sounds and the specific arrangement of room furnishings

Keep walkways and pathways clear of clutter and obstacles to prevent falls

Mobility Assistance

Assist the client with ambulation to maintain safety during movement

intiial orientation and environment

Orient the client to your presence before speaking

Decrease background noises before starting a conversation

positioning and assistive devices

Check the client’s hearing aids to confirm they are inserted and functioning properly

Position yourself so that light is on your face to allow the client to see your face and lip movements clearly

Direct Communication Practices

Talk directly to the client while facing him or her

Avoid chewing gum, covering your mouth, or turning away when speaking

alternative communication methods

Use pantomime or sign language as appropriate

Write down any ideas that cannot be conveyed in another manner

face to face interaction

Use frequent face-to-face contact to communicate the social process

calm and direct speech

speak calmly, simply, and directly to the client

enviornmental and person reorientation

Orient and reorient the client to the environment, as well as specifically to time, place, and person

offer explanation

Provide clear explanations for any care being delivered

encourage independence

Communicate that the client is expected to perform self-care activities

reinforce reality

Reinforce reality if the client experiences delusions

focus on strength

Emphasize the client's strengths rather than their weaknesses

conversations around unconscious patient

Healthcare workers must be extremely cautious about what is spoken in the client's presence, as hearing is the last sense that is lost

assume auditory reception and use normal tone

Always assume that the client can hear you and communicate with them using a normal tone of voice

speak prior to physical contact

Always speak to the client before touching them to explain or announce physical interaction

regulate enviornmental noise

Maintain a calm atmosphere by keeping environmental noises at a low level

assesment aproach for skin

Skin assessment combines a focused nursing history with direct physical inspection and palpation using appropriate assessment skills^[1]. The nurse evaluates general appearance, skin color, temperature, skin integrity, and presence of tenderness or lesions

possible findings and clinical concerns of skin

color alteration

skin integrity and deep folds

breaks in skin integrity

infectious and inflammatory conditions

color alterations

Inspection may reveal cyanosis (bluish discoloration) or pallor (paleness)