N309 Foundations of Nursing test 1 UMMC SON

What Does Nursing Involve?

Thinking (most important)

Doing

Caring

What Is Clinical Judgment? Following the procedure is not clinical judgement!!!!!!!!

The National Council of State Boards of Nursing (NCSBN):

Integrate critical thinking and decision making

Apply nursing knowledge "to observe and assess presenting situations, prioritize concerns, and generate the best possible evidence-based solutions to deliver safe client care."

Utilize processes that promote safe client care. Nurses:

Recognize and interpret client problems

Prioritize a response

Take action

Evaluate outcomes

Modify actions as needed

4 Types of Nursing Knowledge

Theoretical: information, facts, principles, and evidence-based theories

- Includes: research findings/explanations of phenomena, pathophysiology of the disease process, medical treatment (e.g., dietary, medications, activity), surgical treatment and perioperative care, and client and family factors.

- Used to: describe clients, understand their health status, explain reasoning for choosing interventions, and predict client responses to interventions

Practical: knowing what to do and how to do it - an aspect of nursing expertise.

- Consists of: processes (decision making and/or nursing processes) and procedures (e.g., how to give an injection).

- Requires an understanding of the "how and why" of correctly performing nursing skills.

Self: Awareness of your own beliefs, values, and cultural and religious biases.

- Self-knowledge gained by: developing personal awareness, by reflecting (asking yourself), "Why did I do that?" or "How did I come to think that?"

Ethical:

- Consists of: information about moral principles and processes for making moral decisions.

- Helps fulfill ethical obligations to clients and colleagues.

6 functions of clinical judgement

Recognize cues

- What matter most?

Analyze cues

- What does it mean?

Proritize hypotheses

- What do I start?

Generate solutions

- What can I do?

Take action

- What will I do?

Evaluate outcomes

- Did it help?

Nursing process

Assessment

Analysis

Planning

Implementation

Evaluation

Remember tips: A Delicious PIE!

Layers of the NCSBN Clinical Judgment Model

Layer 0 — clinical decisions

Layer 1 — comprises the outcome (clinical judgment)

Layer 2 — form, refine hypotheses; evaluation

Layer 3 — contains the clinical judgment tasks (recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action, evaluate outcomes)

Layer 4 — context (individual and environmental factors)

Then nursing process

Which type of nursing knowledge requires an understanding of the pathophysiology of the disease process, medical treatment, and client and family factors?

Theoretical knowledge is understanding the "why" to gain a strong foundation for analysis and synthesis of data.

It consists of information, facts, principles, and evidence-based theories in nursing and related disciplines (e.g., physiology, psychology).

What Is Critical Thinking?

A combination of:

- The ability to question & desire to seek truth

- Recognize knowledge gaps/need for more info

- Openness to alternatives & thinking in different ways

- Ability to reflect: acknowledge and test previously held assumptions

Enables a person to see that there may be more than one correct answer

Helps the nurse know what is important about the client’s situation

Essential to the development of CJ (critical judgement)

What Are Critical-Thinking Skills?

Nurses:

gather information about the client, then

draw tentative conclusions about the meaning of the information to identify the client's problems, then

think of several different actions they might take to help solve or relieve the problem.

All leads to clinical reasoning

- Professional nursing requires strong clinical reasoning skills due to a ever-changing healthcare environment.

- Ineffective clinical reasoning skills result in failure of nurses to respond appropriately to deteriorating client conditions

Why Is Critical Thinking Important for Nurses?

Nurses are faced with complex situations.

Each client is unique.

- Age, culture, illness...

- Acknowledging this ensures holistic care is provided

Nursing is an applied discipline.

Nursing uses knowledge from other fields.

Nursing is fast-paced.

The scientific basis for client care changes constantly.

Critical thinking is linked to evidence-based practice.

What Are Critical-Thinking Skills?

Objectively organizing or grouping information in meaningful ways

Listening carefully; reading thoughtfully

Evaluating the credibility and usefulness of sources of information

Exploring the advantages, disadvantages, and consequences of each potential action

Analyzing/Interpreting information

Making inferences (tentative conclusions) about the meaning of the information

Visualizing potential solutions to a problem

What Are Critical-Thinking Attitudes?

Intellectual autonomy

Intellectual curiosity

Intellectual humility

Intellectual empathy

Fair-mindedness

Intellectual perseverance

Intellectual courage

A nurse who is newly employed at a hospital questions a standard of client care that does not seem to follow evidence-based practice. Which critical thinking attitude is the nurse demonstrating?

Intellectual autonomy

Critical thinkers are not afraid to question things. They do not proceed with a questionable action simply because "that's the way it's always been done."

What Is Full-Spectrum Nursing?

A unique blend of thinking, doing, and caring for the purpose of affecting good outcomes from a client situation

- Thinking

- Doing

- Caring

- These three are seen through the lens of each client's unique situation

Nursing knowledge - clinical reasoning - critical thinking - nursing process - clinical judgement

How Does the Model Work?

Thinking

- Critical thinking

- Theoretical knowledge

Doing

- Practical knowledge

- Nursing process

Caring

- Self-knowledge

- Ethical knowledge

Client situation

- Client data

- Client preferences

- Context

Breaking down the nursing process (know implementation)

Assessment

- Gathering data about the patient and their health status

Diagnosis

- Analyzing data to identify patterns to help draw conclusions about the patient’s health status

Planning

- Identifying goals and outcomes, choosing interventions, and creating a nursing care plan

Implementation

- Performing or delegating planned interventions. Steps of carrying out the plan

Evaluation

- Last step of the process. Involves making judgments about the patient's progress toward desired outcomes, the effectiveness of the care plan, and the quality of nursing care

Assessment

Systematic gathering of information

Must be accurate and complete

Reveals information to help formulate outcomes

Helps guide the choice of effective interventions and how to implement them best

Guidepost for reassessment in the evaluation step

Assessment (2)

Collecting data

- from the client's medical record, observation, interview with client/caregivers, medical history, physical assessment, diagnostic/lab reports, and from other interprofessional team members.

Using a systematic and ongoing process

- systematic allows you to stay organized and not miss important data; ongoing refers to the process being constantly changing as new information is revealed

Types of Assessment Data

Subjective: What the client tells the nurse

- Others can provide, but their accuracy may be questionable

Objective: What can be observed or measured

- Gathered through physical assessment and lab or diagnostic tests

- Can be measured or observed by the nurse or other HCP

Primary: Obtained directly from the client by what they state or what the nurse observes

- Can be subjective or objective

Secondary: Obtained secondhand through the medical record or another person

- "They told me their shoulder is very sore this morning."

Subjective or Objective?:

- Pt. states their pain level is a 10.

- Pt.'s blood pressure is 180/90.

- "My shoulder really, really hurts."

- Client grimaces when attempting to brush hair with left arm.

Types of Assessments

Comprehensive Assessment

Focused

What Is the Difference?

Medical assessments

- focus on disease and pathology.

Nursing assessments

- focus on the client's responses to illness will initiate changes in the plan of care.

Validating Data

Process of Validating

- Double checking data obtained

- Not all data needs validation

When Should the Nurse Validate Data?

- Subjective/objective data do not agree or make sense

- Client's statements differ at different times in the interview

- Data are far outside normal range

- Factors are present that interfere with accurate measurement

When gathering admission assessment data, the nurse obtains a weight of 200 pounds. The client states, "I've never weighed that much!" What should the nurse do?

Check the calibration and re-weigh the client.

It is important to FIRST validate data when there is a mismatch between what the client states as history and the data obtained. Validating data often includes ensuring that equipment is functioning properly first.

Guidelines for Documenting Data

Document as soon as possible.

Write neatly, legibly, and in black ink or record data.

Document electronically.

Use proper spelling and grammar.

Use acronyms sparingly.

Write the patient's own words, when possible.

Record only the most important patient words.

Use concrete, specific information.

Record cues, not inferences.

Diagnosis

A clinical judgment about a client's experiences/responses to actual or potential health problems/life processes

- Analyze the data collected during the assessment phase

- Identify patterns and draw conclusions about the client's problems

- Purpose is to identify the client's health status

- May lead to a need to collect more data

- ANA Nursing Scope and Standards of Practice

Nursing diagnosis

Statement of client health that the nurse can identify, prevent, or treat independently

Stated based on the client's reactions to the disease process.

Responses can be:

- Biological

- Emotional

- Interpersonal

- Social

- Spiritual

- Problem or strength

Medical diagnosis

Describes a disease, illness, or injury

Help identify the pathology so appropriate treatment can be given

Nurses can not legally diagnose or treat medical problems

Health problem (or "collaborative problem")

Physiological complications of diseases, medical treatments, or diagnostic studies

Clients with certain diseases or treatments are at risk for developing the same complications.

Always a potential problem

Diagnostic Reasoning AKA "Clinical Judgement"

Use critical thinking to:

- Analyze and interpret data

- Draw conclusions about the client's health status

- Verify problems with the client

- Prioritize the problems

- Record the diagnostic statements

Analyzing & Interpreting Data

Compare data with expected standards/reference ranges

Identify significant data (cues)

Cluster cues

- a group of cues that are related to each other in some way. The cluster may suggest a health problem

Recognize patterns/trends

Identify data gaps and inconsistencies.

- As you cluster and think about relationships among the cues, you will identify the need for data that were not apparent before and also look for inconsistencies in the data

Draw Conclusions about Health Status

Can be strengths or problems

Make inferences.

- This is a critical-thinking skill. Recall that cues are facts (or data), whereas inferences are conclusions (judgments, interpretations) that are based on the data.

Identify problem etiologies.

- factors that are causing or contributing to the problem. Etiologies may be pathophysiological, treatment related, situational, social, spiritual, maturational, or environmental

Prioritizing Problems

Places problems in order of importance

- High priority = life threatening

- Medium priority = Not a direct threat to life, but may cause destructive physical or emotional changes

- Low priority = Requires minimal supportive nursing intervention

Does not mean that you must resolve one problem before attending to another

Determined by the theoretical framework you use

- Maslow's Hierarchy of Needs is commonly used to prioritize nursing problems

Which statement is a priority nursing diagnosis?

A. Impaired Verbal Communication related to Altered Central Nervous System

B. Fluid Volume Excess related to Compromised Regulatory Mechanism

C. Impaired Physical Mobility related to Discomfort

D. Activity Intolerance related to Generalized Weakness

B

Maslow's Hierarchy of Human Needs places survival needs as a priority. Fluid volume excess can lead to pulmonary edema, impaired gas exchange, and respiratory failure. Fluid volume excess is therefore life-threatening and would be a high priority when ranking problems according to problem urgency.

Planning

Realistic goals and effective nursing interventions

Should be able to measure/evaluate

Types of Planning

Initial

- Begins with first client contact

- Written after initial (comprehensive) assessment

Ongoing

- Occurs throughout the provision of care

- New information obtained and/or evaluating a client's responses to care may lead to modification of initial plan

Discharge

- Anticipating and planning for client's needs

- Planning for self-care and continuity of care after client leaves healthcare setting

- Begins with initial assessment

- Needed by all clients

- Requires collaboration

Why Is a Patient Care Plan Important?

The comprehensive patient care plan is the central source of information needed to

- Ensure care is complete

- Provide continuity of care

- Promote efficient use of nursing efforts

- Provide a guide for assessing and charting

- Meet requirements of accrediting agencies

- Establish goals (optimal status) & outcomes (observable criterion that will determine success or failure)

Process for Writing Individualized Nursing Care Plans

Make a problem list.

Decide which problems can be managed with a care plan.

Individualize the plan as needed (make it specific to the patient)

Reassess and revise the plan as needed.

Formulate goals/outcomes for improving or maintaining health status

Distinguish between short-term and long-term goals.

Make sure goals are "SMART" (specific, measurable, attainable, relevant, time-based)

Identify activities of daily living (ADLs) and basic care needs in the patient care summary.

Planning Client Goals/Outcomes

Goals/Outcomes: Changes in client health status you hope to achieve

Goals for a wellness diagnoses:

- Demonstrate health maintenance OR

- Achieve an even higher level of health

Any goals or outcomes should be:

- Client-centered

- Singular

- Observable

- Measurable (help you evaluate progress)

- Time-limited (long or short term, hours or weeks?)

- Mutually agreeable

- Reasonable

Nurse-Initiated (independent) interventions

Actions initiated by nurse that do not require direction or an order from another health care professional

Use evidence and scientific rationale

Base actions on identified problems and health are needs

Performs or delegates within scope of practice

Remains accountable for these internvetions

Ex: After completing the Braden Scale, the nurse determines that their client is at high risk for skin breakdown. Staff begins repositioning the client Q 2 hrs to prevent skin breakdown.

Provider-initiated (dependent) interventions

Actions that require an order from a physician or other health are professional

Initiate after a provider's prescription/order (written, verbal, standing) or per facility protocol

EX: Blood administration procedures, fluid restrictions, O2 administration

Identify the client outcome/goal that is written correctly.

A. The client's urine output will be adequate by the end of the shift.

B. The client's pneumonia will be resolved as evidenced by clear breath sounds bilaterally by discharge.

C. The client will ambulate 20 feet in the hallway using a walker by evening shift tomorrow.

D. The client will drink more fluids than they did yesterday by 7:00 p.m. today.

C

This statement meets all of the criteria for a correctly written client outcome. "Adequate" is not measurable; clear breath sounds only would not be evidence of the resolution of pneumonia, and this is the medical diagnosis; "more fluids than yesterday" is vague and unclear.

Safe, Effective Nursing Care: Thinking, Doing, Caring

Provide goal-directed, client-centered care.

- Establish mutual goals with client.

- Show respect for client values, religious beliefs, needs, and preferences.

- Implement interventions to promote client comfort.

Validate evidence-based research to incorporate in practice.

- Incorporate evidence-based findings into client care.

Provide safe, quality client care.

- Design a "Thinking, Caring, Doing" framework that incorporates a holistic approach to client care.

Think Like a Nurse

For the following nursing diagnoses, write one intervention to address the problem and one intervention for the etiology of the problem.

- Airway Clearance Impairment (related to thick secretions and decreased chest expansion secondary to dehydration and pain)

- Bathing, Dressing, Feeding, Toileting Deficit (related to fatigue secondary to heart failure)

Implementing the Plan

Nurse performs or delegates planned interventions (carry out the care plan)

- Cognitive, interpersonal, psychomotor

Ends when the nurse documents the nursing actions

Overlaps with all parts of the Nursing process

Check your knowledge and abilities

Organize

Prepare the patient

Five Rights of Delegation

- right task, right circumstance, right person, right direction/communication, right supervision/evaluation

Documentation

The final step of implementation

Records the nursing activities and the client's response

- Better?

- Worse?

- The same?

Evaluation

The final step of the nursing process

Related to every other step

Planned, ongoing, systematic

What are we evaluating?

- Client's progress toward goals (outcomes):

- Observable or measurable changes in the patient's health status that result from the care given

- Effectiveness of the care plan (process)

- Quality of nursing care

Frequency and Time of Evaluation

Ongoing

- Performed while implementing, immediately after an intervention, and at each patient contact.

Intermittent

- Performed at specified times

Terminal

- At the time of discharge

The clients status determines if the evaluation is ongoing, intermittent, or terminal

How Do I Evaluate Client Progress?

Review outcomes.

Collect reassessment data.

Judge goal achievement.

Record the evaluative statement.

Evaluate collaborative problems.

Evaluating and Revising the Care Plan

Relate outcome to interventions.

Draw conclusions about problem status.

Revise the care plan.

Relationship Between Nursing Process Steps

Steps are used to help the nurse develop and execute the client's overall plan of care

Even though there are steps, it is not a linear process

One step does not rigidly follow another

Cyclical process that follows a logical progression

Nurses go back and forward between steps

Knowing Why: Hygiene & Self-care

Hygiene: Activities involved in maintaining personal cleanliness and grooming.

Activities of daily living (ADLs): Bathing, showering, washing hair, brushing teeth, etc.

These activities promote comfort, improve self-image and decrease infection and disease.

Encourage as much independence as possible!

Knowing Why: Factors Influencing Hygiene Practices (for homeless, environment is the biggest risk for hygiene)

Personal preferences

Culture

Religion/ Spirituality

Economic status/ Living environment

Age

Knowledge level

Knowing Why: Health Status & Self-care Ability

Pain

- Limited mobility, drowsiness from medication

Limited mobility

- Joint, muscle problems, injury, weakness, fatigue, surgery, bed-rest

Sensory deficits

- Visual or hearing impairment

Cognitive impairment

- Stroke, dementia, psychosis, delirium, traumatic brain injury (TBI)

Emotional or mental health disturbances

- Lack of energy, lack of motivation

Knowing How: Hygiene Care (2)

Assess the client's ability to perform ADLs and their need for assistance (observe head to toe)

Self-care deficit: Occurs when a person is unable to perform consistent and effective self-care

Personalize interventions:

- Pain medication prior to ADLs

- Allow sufficient time

- Provide care in small segments

Knowing How: Hygiene Care (3)

Hourly rounds (check patient every hour):

- 4Ps

- Pain

- Positioning

- Potty

- Possessions

- Improves patient safety!

H.S. (hour of sleep)

Knowing How: Hygiene Care

Toileting aids

- Bedpan and urinal

- Fracture pan

- Bedside commode

- Incontinence pads

Skills videos: Bowel elimination

- Placing a bedpan

- Removing a bedpan

Knowing Why: Care of the Skin

Review: 5 main functions of the skin

- Protection

- Sensation

- Regulation

- Secretion/ excretion

- Vitamin D formation

Knowing Why: Care of the Skin (2)

Impaired skin integrity: Impaired ability to maintain the epidermis or dermis

Anything that interferes with the hydration, circulation, and nutrition of the skin creates a risk to skin integrity.

- Dampness: Excessive perspiration, incontinence of urine and/or stool

- Maceration (在水里泡太久)

- Dehydration: Fluid loss or insufficient fluid intake

- Nutritional status: Very thin or very obese

- Insufficient circulation: Immobility, vascular disease, and inadequate nutritional status compromise circulation

- Skin diseases

- Jaundice

- Lifestyle and personal choices (protein is key for skin integrity)

Knowing How: Care of the Skin (3)

Bathing

Types of baths:

- Assist: Nurse or UAP assists the patient with areas that are difficult to reach

- Complete: Nurse or UAP completes the entire bath without assistance from the patient

- Partial: Only the areas that cause odor or discomfort

- Bed bath

Safety:

- Water temperature

- Prevent falls

- Patient tolerance

Move from clean to dirty!

- Face first

- Perineal area & buttocks last

Knowing How: Care of the Skin (4)

Prepackaged bathing products:

- Pre-moistened, disposable washcloths

- Decrease the risk of infection compared to soap/water baths

Chlorhexidine gluconate (CHG) wipes (eg: surgical and IV patients):

- Strong antimicrobial

- No rinse, air dry

- Avoid eyes and ear canals

- Safe for perineal area

Knowing How: Care of the Skin (5)

Perineal care:

- Promotes comfort, prevents odor, skin excoriation, and infection

Completed at least once a shift in ALL patients with an indwelling urinary catheter

- Sitz bath: Soaks the patient's perineal area

- Encourage independence!

Uncircumcised male:

- The foreskin must be retracted to adequately clean the head of the penis.

- The foreskin must always be replaced to prevent in injury

Knowing How: Care of the Skin (6)

Special considerations:

- Dementia

- Morbid obesity

- Older adults

- Goal: Prevent drying of and injury to the skin

Skills videos: Facilitating hygiene

- Bathing: Providing a complete bed bath using a prepackaged bathing product

- Providing perineal care

Knowing How: Care of the Nails & Ears

Nails

- Clients with diabetes or circulatory problems should file, as cutting increases the risk for injury to the surrounding tissues

- File the nails straight across

Ears

- Teach patients to avoid using rigid objects to clear their ears.

- Never use cotton tip applicators

- Hearing aids: Never place in water

Knowing Why: Oral Care

Oral hygiene:

Removes food particles and secretions

A clean mouth promotes a better appetite

Reduces the incidence of healthcare-acquired pneumonia in older adults and critically ill patients

Risk factors for oral problems:

Anything that prevents regular oral hygiene

- Lack of money or dental insurance

- Poor nutrition or eating habits

- Medications

- Medical treatments

- Conditions causing dry-mouth

- Compromised self-care abilities

- Age

Knowing How: Oral Care

Denture care

- Remove at bedtime

- Remove dentures from the mouth and clean at least once a day, preferably after each meal

- Use regular toothpaste or special denture-cleaning solutions

- Hot water can damage dentures

- Store dentures in a denture cup when not in use

Knowing How: Oral Care (2)

Critically ill: Keeping the teeth clean is a simple and effective way to reduce the risk of pneumonia (VAP)

- Brush the teeth twice a day

- Use a soft toothbrush

- Moisturize oral mucosa and lips every 2-4 hours

- Position the patient side-lying with the head turned to the side

- Perform oral suctioning when fluid accumulates in the mouth

- Never use petroleum-based jelly (Vasoline) for clients receiving oxygen therapy

- Always use a tongue blade, never use your fingers to hold the mouth open

Knowing How: Oral Care (3)

Oral suction: Use to prevent oral and nasal secretions from entering the lower airway

- Yankauer: Rigid device for suctioning the oral cavity

- Suction pressure: 100-150 mm Hg (Adults)

Skills videos: Facilitating hygiene

- Denture care

- Oral care for an unconscious patient

Knowing How: Eye care

Comatose or critically ill patients need frequent eye care, every 2-4 hours

Lubrication is required to protect the eyes from corneal abrasions and drying

- Saline or artificial tears

Protective eye shields should be used to keep the eyes closed

Always clean the eyes from the inner to the outer canthus

Knowing How: Shaving

Safety first: If the patient has a bleeding disorder or is taking anticoagulant medication, they should always use an electric razor.

Knowing How: Delegating Hygiene Care

The RN is always responsible for assessing the client

Before delegating hygiene care to an unlicensed assistive personnel (UAP) consider:

- The patient's limitations and restrictions and amount of assistance necessary

- Use of assistive devices

- Safety precautions

Knowing How: Well-being & the Environment

Environmental safety scan:

- Side rails up when indicated (if your patient is mentally or physically capable, you should not raise 4 side rails up! It is considered a restriction.)

- Bed in low position with wheels locked

- Call device within reach

- Uncluttered walking space

Environmental comfort measures:

- Room temperature

- Clean linens

- Overbed table clean and uncluttered

- Unpleasant odors

- Limit noise

Knowing How: Well-being & the Environment (2)

Linens

- Sheets

- Drawsheet

- Incontinence pads

Skills video: Facilitating hygiene

- Making an occupied bed

What is an infection?

Invasion of and multiplication in the body by a pathogen (disease-causing microorganism)

Chain of infection

Starts out from germs (also known as agent or pathogen)

- bacteria

- viruses

- parasites

Where germs live (reservoir)

- people

- animals/pets (dogs, cats, reptiles)

- wild animals

- food

- soil

- water

How germs get out (portal or exit)

- mouth (vomit, saliva, fluid, breast milk)

- cuts in the skin (blood)

- during diapering and toileting stool

Germs get around (made of transmission)

- contact (hands, toys, sand)

- droplets (when you speak, sneeze or cough)

How germs get in (portal of entry)

- mouth (mucous membrane)

- cuts in the skin

- eyes

- surgical incision; IV;

Next sick person (suseptible host)

- babies

- children

- elderly

- people with a weakened immune system

- unimmunized people

- anyone

If we want to stop the infection, the only way is to the break the chain!

Infectious Agent Additional Information

Normal flora: Live in the intestine, aid in digestion, synthesize vitamin K and release several other vitamins. Normal flora limit the growth of harmful bacteria by competing for available nutrients. May become a pathogen if they enter into regions of the body they do not normally inhabit.

- Transient Flora- Normal microbes you acquire by coming in contact with objects or another person.

- Resident Flora- Permanent inhabitants of the skin. They live and multiply harmlessly deep in the skin layers.

Transient flora can be eliminated by hand washing! But not resident flora!

Eg: candida (yeast); staphcocus aureus (skin); UTI (e. coli)

Reservoir Additional Information

Most pathogens thrive in a warm, dark, moist environment. Need nutrients and certain pH range to live and multiply.

-aerobic: must have oxygen

-anaerobic: do not require oxygen and may die when exposed to O2

Some people are carriers- they can defend themselves from active disease but harbor a pathogen within their bodies.

Many surfaces in healthcare settings serve as nonliving reservoirs- soiled briefs/diapers, wound dressings, sinks, counters, toilets, bedpans, call lights, bedside tables, bed rails, linens, etc.

Modes of Transmission Continued

Droplet:

- Pathogen travels in droplets expelled as an infected person exhales, coughs, sneezes, or talks.

- Oral care and suctioning

Airborne:

- Pathogen travels via air conditioning, sweeping

- Measles, tuberculosis, fungal infections

Classifications of Infections

Location

Local

Systemic

- Bacteremia (bacteria in the bloodstream)

- septicemia (bacteria, virus, or fungi in the bloodstream), especially for immune compromise patients

Duration

- Acute (short-lived; eg: cold, urine infection)

- Chronic (weeks to years; eg: diabetes;)

- Latent (dormant; eg: TB, HIV, herpes)

Source

- Exogenous (occur in the healthcare environment)

- Endogenous (pathogens arise from body's normal flora; treatment triggered infections; yeast infection from antibiotic treatment;)

Order

- Primary

- Secondary (has to follow a primary infection; especially for immune compromise patients)

Healthcare-Associated Infections (HAIs)

An infection associated with any type of healthcare setting.

Leading complication of hospital care (top 10 cause of death in U.S.).

Aggravate existing illness & lengthen hospital stay/recovery time.

Inpatients undergo invasive procedures (eg: IV, chest tube) which can be a source for microbes to enter the body.

Types of HAIs

Central line–associated bloodstream infection (CLABSI)

Surgical site infection (SSI)

Catheter-associated urinary tract infection (CAUTI)

Methicillin-resistant Staphylococcus aureus (MRSA)

Ventilator-associated pneumonia (VAP)

Multidrug-resistant organisms (MDROs)

C difficile infection (CDI) and hospitalization

Stages of Infection

Incubation (can be days or years)

Prodrome/Prodromal (1 -2 days after the first symptoms, fatigue and muscle pain, upset stomach)

Illness (infectious agents multiply at high level, fever, obvious symptoms)

Decline (patient begins to respond to the infection)

Convalescence (gradual recovery of health and strength after illness or injury)

How your body defends against infection or invasion of pathogens

Primary Defense

-Skin

-Normal Flora

-Respiratory Tree

-Eyes

-Mouth

-GI Tract

-GU Tract & Anus

Secondary Defense

-Phagocytosis

-Complement Cascade

-Inflammation

-Fever

Tertiary Defense

-Active Immunity

-Passive Immunity

-Specific Immunity

Assessment Cues - Physical Assessment

General Appearance

- Fatigue

- Diaphoresis (sweating)

- Do they appear well-nourished?

- Dry mucous membranes?

Skin

- Skin turgor

- pain, redness, swelling, warmth, and purulent drainage

- presence or absence of rashes, skin breaks, or reddened areas

*patients with poor peripheral circulation may have discolored skin rather than signs of inflammation with infection !!!

Physical Assessment Continued

Lymph Nodes

- Swollen and tender

Temperature & Pulse

- Both may be elevated

Diagnostic Testing - common tests used to identify the presence of or risk for infection

White Blood Cell Count

Blood Cultures

Throat or Wound Cultures

Disease Titers

C-Reactive Protein (CRP)

Erythrocyte Sedimentation Rate (ESR or SED Rate)

Take time for bacteria to grow, so they check 24, 48, 72 hours for growth!!!

Nursing Interventions

Goals of infection prevention & control:

- Protect patients from infection

- Meet professional standards/guidelines

- Protect yourself and others from diseases

- Reduce severity of illness and complications resulting from infection

Broad interventions to prevent infection for those at risk

Use aseptic technique to reduce exposure to pathogens (keep everything clean)

Maintain skin integrity

Support natural defenses against infection

Promote healthy diet, activity, sleep, and lifestyle

Reduce stress

Provide supportive measures to decrease the length of time that invasive devices are needed

WASH YOUR HANDS !!!

Special Considerations for Preventing Infection

Patients at risk for pneumonia (dysphagia, COPD)

- coughing and deep breathing

Patients on mechanical ventilators (ICU setting)

- Meticulous (细致的) oral care

Elderly patients

- Encourage immunizations (Pneumococcal, Influenza, Shingles)

Levels of Asepsis

Surgical Asepsis (Sterile Technique)

- Removal of ALL pathogens

- Sterile touches sterile; unsterile touches unsterile

- Use of sterile gloves and sterile supplies

Modified Sterile Technique

- Using nonsterile gloves with sterile supplies

Medical Asepsis (Clean Technique) such as home

- Hand hygiene, environmental cleanliness, standard precautions

Difference of medical asepsis and surgical asepsis

Medical asepsis

- reduces number of pathogens

- preferred to as "clean technique"

- used in administration of medications enemas (灌肠), tube feedings, daily hygiene

Hand Washing is Number 1!!!

Surgical asepsis

- eliminates all pathogens

- preferred to as "sterile technique"

- used in dressing changes, catheterizations, surgical procedures

Personal Protective Equipment

Gloves

Gown

Eye Protection/goggles

Facemask (surgical, N95, etc.) or face shield

Hair Cover (optional)

Shoe Covers (optional)

*Must be donned (put it on) and doffed (take it off) in a particular order to reduce the risk of transmission*

Standard Precautions (if no more information about bacteria, then fluid also belongs to standard precautions, eg: vaginal discharge after birth)

What are they?

- Handwashing

- Use of gloves, gown, eye protection, face shield depending on expected exposure

- Safe injection practices (wipe when inject with needle)

- Respiratory hygiene/cough etiquette

When are they used?

- All patients

- All healthcare settings

- Regardless of suspected or confirmed presence of infection

Contact Precautions

What are they?

Standard Precautions plus…

Gown

Gloves

When are they used?

For organisms spread by direct contact with the patient or their environment.

Organisms: VRE, MRSA, any multidrug-resistant

Droplet Precautions

What are they?

Standard and Contact Precautions plus…

- Facemask and/or face shield

When are they used?

For pathogens spread through close respiratory or mucous membrane contact with respiratory secretions

Pathogens that do not remain infections over long distances.

Organisms: Influenza, RSV, Covid*

Airborne Precautions

What are they?

Standard and droplet precautions plus…

- N95 facemask

- Negative Pressure Room

When are they used?

For pathogens that are very small and remain infectious over long distances when suspended in the air and are easily transmitted through air currents (fanning linens, ventilating systems, etc.)

Organisms: Tuberculosis (TB), fungal infections, Covid*

Protective Isolation or Reverse Isolation

For patient who are severely immunocompromised

Private room

Restrict visitors and unnecessary personnel

Sanitizing patient's equipment and supplies

Follow standard precautions and consider donning a mask, gown, and gloves for patient contact

The patient may chose to wear a mask when leaving their hospital room or when others enter their room

(eg: cancer, AIDs, TB)

Caring for the patient on isolation precautions

May experience negative effects of isolation

Reduced contact, stigma, anxiety, depression

Use therapeutic communication when having contact with the patient

Reassure that you are going to take care of them

Explain what the PPE is and why personnel must wear it

Treat them how you would want to be treated

Control of Potentially Contaminated Equipment/Supplies

Disposable BP cuffs

Leave BP machine in the room during infection if possible

Sanitize equipment that cannot stay in the room after use (Sani wipes or Bleach wipes)

Disposable stethoscope

Do not reuse disposable masks