Funds test

asepsis

absence of microorganisms

goals of asepsis

prevent infection and spread of disease

medical asepsis

• clean technique

• REDUCES spread of microorganisms

• hand hygiene before/after patient care

• don’t touch dirty with clean

• keep environment clean

surgical asepsis

• sterile technique

• ELIMINATES ALL microorganisms and spores

• used for surgery, catheters, IV lines, wound care

• keep sterile field in sight

• anything below wasted = contaminated

• moisture contaminates sterile field

infectious agent

• bacteria, viruses, fungi

• microorganism causing the disease

reservoir

• where organism lives, grows, multiplies

• humans, animals, environment

portal of exit

• path by which the pathogen leaves the reservoir

• blood, respiratory (cough/sneeze), secretions, urine

mode of transmission

• how pathogen moves to new host

• contact, droplet, airborne

portal of entry

• opening where pathogen enters new host

• broken skin, mucous membrane (mouth/eyes/nose)

susceptible host

• person at risk/vulnerable of infection

• elderly, immunocompromised, chronic illness

types of microorganisms

bacteria, viruses, fungi, parasites

healthcare-associated infections (HAIs)

• infection acquired in healthcare setting

• prevention is a major nursing responsibility

examples of HAIs

• CAUTI (urinary)

• CLABSI (bloodstream)

• surgical site infection

standard precautions

• hand hygiene (most important)

• gloves when touching body fluids

• masks/eye protection if splash risk

• safe injection practices

• proper cleaning of equipment

contact precaution

• MRSA, C DIFF

• gloves, gown

• private room preferred

droplet precaution

• INFLUENZA, PNEUMONIA

• surgical mask

• maintain 3-6 feet distance

airborne precaution

• TB, MEASLES, VARICELLA

• N95 respirator

• negative pressure room required

hand hygiene

• soap and water (visible soiled, c diff)

• alcohol based sanitizer (most other cases)

donning

gown, mask/respirator, goggles/face shield, gloves

doffing

gloves, goggles/face shield, gown, mask

nursing responsibilities

• follow infection control protocols

• educate patients and families

• monitor signs of infection (fever, redness, swelling, drainage)

• report changes promptly

chain of infection

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

assess (assessment of hygiene needs)

• ability to perform self-care

• skin integrity

• oral cavity conditions

• hair/scalp

• nails/feet

• sensory deficits

risks (assessment of hygiene needs)

safety during hygiene care (falls, medical conditions, wounds)

identify (assessment of hygiene needs)

needs for assistance/adaptive devices

purpose of bathing

• cleansing skin

• promotes circulation

• increase comfort

• reduce odor

• assess skin

types of bathing

• complete bed bath

• partial bath

• tub bath

• shower

• therapeutic bath

nursing considerations in bathing

• privacy/dignity

• water temp

• infection control

• fall prevention

• skin assessment during bathing

importance of oral hygiene

• prevent infection

• maintain comfort

• promote nutrition/hydration

oral care procedures

• routine oral care

• denture care

• care for unconscious patients

• care for patients receiving oxygen therapy

assessment findings in oral hygiene

• dry mucous membranes

• lesions/bleeding gums

• halitosis (bad breath)

• thrush (yeast infection)

hair care

• shampooing

• brushing/combing

• preventing tangles/scalp issues

nail care

• cleaning/trimming nails

• infection prevention

• special precautions for diabetic patients

food care

• inspect for circulation and skin issues

• proper footwear

• diabetic foot care teaching

perineal care

• front-to-back cleansing

• privacy/dignity

• gloves and standard precautions

• incontinence (loss of bladder control), postpartum care, indwelling catheter care, surgery patients

purpose of vital signs and pain

• indicators of physiologic status

• baseline data collection

• monitoring changes in conditions

pain

• 5th vital

• subjective/assessment

• scale

• pharmacologic vs not

oxygen vital signs

• 95-100%

• accuracy factors (<skin pigmentation, nail polish, circulation, hemoglobin)

blood pressure vital signs

• avg 120/80

• hypertension 130/80

• hypotension 90/60

pulse/respirations vital signs

• avg 60-100 beats per min

• radial artery

temperature vital signs

• avg 98.6

• oral, rectal, auxiliary, tympanic, temporal

spirituality

• personal experience

• meaning/purpose

• individualized

• may exist without religion

religion

• organized system

• shared beliefs/practices

• structured rituals

• often include spirituality

spiritual health

• sense of peace

• hopefulness

• ability to forgive

• positive relationships

• purpose in life

• acceptance during illness/crisis

factors affecting spiritual health

• developmental: age, maturity

• cultural/family: religious tradition, family belief, community support

• situational: illness, grief/loss, chronic disease, trauma

signs/symptoms (spiritual distress)

• hopelessness

• anger toward God/higher power

• withdrawal

• anxiety/fear

• questioning meaning of illness

• refusing spiritual practice

risk factors (spiritual distress)

• terminal illness

• loss of independence

• isolation

• chronic pain

spiritual nursing interventions

• facilitate spiritual practices

• provide privacy for pray/meditation

• contact chaplain/spiritual advisor

cultural considerations (spirituality)

• prayer ritual

• dietary restrictions

• end of life practices

• sacred objects

• decision making roles

spiritual care at end of life

• meaning/closure

• forgiveness

• family connection

• religious rituals

• quiet environment

• facilitate clergy visits

• respect final wishes

interprofessional collaboration

• team members: chaplains, social workers, hospice/palliative care, mental health professionals

• collaboration improves: coping, emotional support, holistic outcomes

complementary care

• used alongside conventional medicine

• yoga, meditation, guided imagery

alternative care

• used instead of conventional medicine

• chiropractor, herbal medicine, acupuncture

integrated medicine

combines evidence-based CAM with traditional healthcare

biologically-based CAM

• herbal products/probiotics

• vitamin/supplements

• special diets

mind-body therapies of CAM

• meditation

• yoga

• spiritual healing/prayer

• biofeedback

• hypnosis

manipulative and body-based of CAM

• chiropractic care

• massage therapy

• acupuncture/acupressure

• reflexology

garlic

• lowers cholesterol/bp

• concern: bleeding risk

gingko biloba

• memory

• concern: bleeding risk

st johns wort

• helps with depression

• concern: drug interactions

echinacea

• immune support

• concern: allergic reactions

ginseng

• energy

• concern: hypertension, insomnia

ginger

• helps with nausea

• concern: bleeding risk

safety concerns of CAM

• lack of FDA regulations for supplements

• variability in product quality/purity

• drug-herb interactions

• adverse effects/toxicity

• delayed medical treatment

• misleading health claims

nursing responsibilities in CAM

• assess CAM use during patient history

• monitor for interactions/adverse effects

• respect cultural/personal beliefs

• document CAM therapies used

CAM in specific populations

• older adults: poly-pharmacy concerns, increased sensitivity to supplements

• pediatrics: safety/dosing concerns

• pregnancy: many herbs are contradicted

• chronic illness: pain management, anxiety/stress reduction, cancer symptoms management

cultural humility

lifelong self-reflection/openness to learning

components of culture

• language

• religion/spirituality

• family structure

• gender roles

• dietary practices

• health beliefs

• traditions/rituals

cultural influences on health

• perception of illness

• pain response

• medication adherence

• acceptance of treatments

• end of life decisions

health disparities

• differences in healthcare outcomes among populations

• limited healthcare access, language barriers, poverty, discrimination, lack of insurance, low health literacy

• nursing role: advocacy, education, equal access to care

cultural assessment

• preferred language

• dietary needs

• healthcare beliefs

• religious practices

• family roles

• traditional healing practices

effective communication strategies

• use plain language/avoid medical jargon

• speak slowly/clearly

• observe nonverbal communication

• use certified interpreters