foundations 2 exam 1

Infection

The invasion and multiplication of pathogenic organisms in the body

chain of infection

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

infectious agent

The pathogen that can cause infection, such as bacteria, viruses, fungi, or parasites

reservoir

The place where a pathogen lives, grows, and reproduces; can include people, healthcare workers, visitors, equipment, surfaces, laundry, and the environment

portal of exit

The way a pathogen leaves its reservoir; examples include respiratory secretions, GI contents, blood, wounds, skin lesions, and mucous membranes

mode of transmission

How a pathogen moves from its reservoir to another host; includes contact, droplet, airborne, and other transmission routes

portal of entry

The way a pathogen enters a new host; examples include the respiratory tract, GI tract, wounds, breaks in skin, and mucous membranes

susceptible host

A person who is vulnerable to infection because their defenses are weakened or compromised

how to break the chain of infection

Hand hygiene is the number one measure; other measures include appropriate PPE, cleaning the environment, sterile technique when appropriate, safe sharps disposal, and protecting skin integrity

incubation stage

The period from when the pathogen enters the body until symptoms first begin; can range from hours to months

prodromal stage

The early stage of infection characterized by vague, nonspecific symptoms such as fatigue, decreased appetite, or low-grade fever

illness stage

The stage when specific signs and symptoms of the infection become apparent

convalescence stage

The recovery stage when the body eliminates the infection and symptoms decrease

localized infection

An infection contained in one area, often causing localized redness, swelling, warmth, pain, or altered function

systemic infection

An infection that has spread throughout the body and may cause changes such as fever, increased pulse, increased respiratory rate, fatigue, nausea, vomiting, or confusion

healthcare-associated infection (HAI)

An infection that develops in association with healthcare, such as an infection that begins after a patient enters the hospital

community-acquired infection

An infection that was acquired outside the healthcare setting and is present when the patient seeks healthcare

primary infection

The initial infection or first infection that occurs

secondary infection

An additional infection that develops because the patient is already compromised by another infection or condition

primary defense

The body's external defenses, especially intact skin and mucous membranes, that help prevent pathogens from entering

secondary defense

The immune response that attacks pathogens after they enter the body, including white blood cells

tertiary defense

Developed immunity from previous exposure, involving antibodies and memory cells that help the body respond when the pathogen is encountered again

activities that promote immune function and infection prevention

Good nutrition, maintaining skin integrity, avoiding smoking, immunization, hand hygiene, and appropriate infection-control practices

risk factors for infection

Chronic conditions such as diabetes, COPD, or heart disease; very young or older age; immunosuppression; organ transplantation; surgery or invasive procedures; poor nutrition; and breaks in skin integrity

standard precautions

Precautions used with every patient; PPE is selected based on the care being provided and potential exposure to blood or body fluids

contact precautions

typically include gown and gloves and usually a private room when appropriate

droplet precautions

Additional precautions for droplet transmission; typically include a surgical mask and usually a private room when appropriate

airborne precautions

transmission of very small particles that can remain suspended in air; use an N95 respirator or other appropriate respirator and appropriate room controls

medical asepsis

Clean technique used to reduce the number and spread of microorganisms

sterile technique

surgical asepsis used to eliminate microorganisms from a field or prevent contamination; may involve sterile gloves, sterile drapes, and sterile instruments or supplies

multidrug-resistant pathogens

Pathogens resistant to multiple medications are a special healthcare concern because treatment becomes more difficult and infection-control measures become especially important

four basic levels of communication

Intrapersonal, interpersonal, group, and public

intrapersonal communication

Communication occurring within oneself, such as internal thoughts or self-talk

interpersonal communication

Communication between individuals, such as a nurse communicating one-on-one with a patient

group communication

Communication involving three or more people, such as a patient, nurse, and family members

public communication

Communication directed toward a larger audience, such as giving a presentation

communication process

Message, sender, channel or method of transmission, receiver, and feedback

message

The information or meaning the sender wants to communicate

sender

The person who initiates and sends the message

channel

The method used to transmit the message, such as speaking, writing, texting, or another communication method

receiver

The person who receives and interprets the message

feedback

The receiver's response that confirms whether the message was received and understood

teach-back

A communication method in which the nurse teaches information and then asks the patient to explain it back to confirm understanding

verbal communication

Communication through spoken words, including factors such as tone, pitch, and pace

nonverbal communication

Communication through body language, gestures, facial expressions, posture, and other behaviors

written communication

Communication through written information such as patient charts and electronic messages

factors influencing communication

Language, culture, environment, stress, sensory deficits, disabilities, developmental level, personal experiences, and other individual factors

assertive communication

Direct, clear, and respectful communication that appropriately expresses needs or concerns

passive communication

Communication in which a person suppresses or avoids expressing their needs, feelings, or concerns

aggressive communication

Communication that dominates, intimidates, or disregards the needs of others

passive-aggressive communication

Indirect communication in which hostility or disagreement is expressed indirectly

collaborative professional communication

Clear, respectful communication that promotes teamwork, shared goals, patient involvement, and coordination among healthcare professionals

conflict resolution

The process of addressing disagreement directly, using respectful communication, active listening, acknowledgment of feelings, brainstorming solutions, shared goals, compromise, agreement, and follow-up

I statements

A communication strategy used to express concerns directly and respectfully without blaming another person

active listening

Fully focusing on the speaker, showing attention, acknowledging what is said, and seeking understanding

confidentiality in communication

Sharing patient information only with people who have a legitimate need to know and protecting patient information from unauthorized disclosure

informed consent communication

Explaining information thoroughly so the patient can make an informed decision, while recognizing the patient's right to refuse

professional boundaries

Maintaining appropriate limits in professional relationships and protecting patient information and privacy

communication and cultural differences

Avoid assumptions or stereotypes; recognize that communication practices and values can differ between people and ask rather than assume

qualified interpreter

An appropriate interpreter used when a patient has limited ability to communicate in the language used for healthcare; do not rely automatically on family members for important medical communication

communication with impaired hearing

Face the patient, communicate clearly, use appropriate assistive devices when available, and avoid making assumptions about the patient's hearing ability

communication with impaired speech

Allow adequate time, listen carefully, use appropriate assistive devices, and focus on understanding the patient's intended message

communication with impaired cognition

Use clear, simple communication appropriate to the patient's cognitive ability and assess understanding

therapeutic relationship phases

Preinteraction, orientation, working, and termination

preinteraction phase

The nurse prepares for the relationship by reviewing available information and examining personal thoughts or biases before meeting the patient

orientation phase

The nurse and patient meet, establish rapport, clarify roles and expectations, identify the patient's concerns, and establish the relationship

working phase

The nurse and patient work toward identified goals through therapeutic communication, interventions, problem solving, and evaluation

termination phase

The therapeutic relationship ends when goals are met or care is transferred; the nurse and patient review progress and prepare for separation

motivational interviewing

A collaborative communication approach that helps patients explore their own reasons for change rather than having the nurse simply tell them what to do

emotional intelligence

The ability to recognize, understand, manage, and appropriately respond to one's own emotions and the emotions of others

clinical judgment

The process of making decisions about patient care by recognizing relevant information, interpreting it, determining priorities, taking appropriate action, and evaluating outcomes

clinical reasoning

The cognitive process of analyzing patient information and determining what the information means in the clinical situation

critical thinking

A disciplined intellectual process of reasoning, analyzing data, evaluating information, questioning assumptions, and using evidence to guide decisions

clinical reasoning vs clinical judgment vs critical thinking

Critical thinking provides the broader reasoning process; clinical reasoning applies that reasoning to a clinical situation; clinical judgment is the decision made about what should be done for the patient

Tanner clinical judgment model

Noticing, interpreting, responding, and reflecting

Tanner: noticing

Recognizing and grasping relevant information or cues from the patient situation

Tanner: interpreting

Making sense of collected information, identifying patterns, and determining possible problems

Tanner: responding

Determining and carrying out actions or interventions based on the interpretation of the patient's situation

Tanner: reflecting

Evaluating whether actions were effective and identifying areas for improvement and future clinical learning

NCSBN clinical judgment model

Recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action, and evaluate outcomes

recognize cues

Identify relevant and important information from assessment findings

analyze cues

Determine what the collected findings mean and how they relate to one another

prioritize hypotheses

Determine which possible explanation or problem is most important to address first

generate solutions

Determine possible interventions or actions that could address the patient's needs

take action

Implement the appropriate intervention

evaluate outcomes

Determine whether the intervention produced the expected result and whether the plan needs to continue or change

nursing process

Assessment, diagnosis, planning, implementation, and evaluation

assessment

Collecting information about the patient's current physical, psychological, social, cultural, and health status

assessment cannot be delegated

The RN is responsible for performing the nursing assessment and determining what information is clinically important

subjective data

Data reported by the patient, such as pain, nausea, dizziness, or how the patient says they feel

objective data

Data that can be observed or measured by the nurse, such as vital signs, wound drainage, appearance, or behavior

primary data source

The patient, when the patient can provide information directly

secondary data source

Information obtained from sources other than the patient, such as family, healthcare providers, medical records, or other available sources

nursing diagnosis

A statement addressing the patient's response to a health condition and guiding nursing interventions

medical diagnosis

The provider's identification of the disease or pathology affecting the patient

collaborative problem

A patient problem that requires nursing and medical or interdisciplinary management because complications may require interventions from multiple healthcare professionals

planning

The phase in which the nurse establishes priorities, identifies measurable goals or outcomes, and selects interventions to address identified problems

Maslow's hierarchy for prioritization

Basic physiologic needs are prioritized first, followed by safety, love and belonging, self-esteem, and higher-level needs

ABCs for prioritization

Airway, breathing, and circulation; immediate threats to these basic functions receive high priority

implementation

Carrying out the planned nursing interventions and actions for the patient