Fundamentals Exam 2: Infection, Immobility, Oxygenation, and Integumentary

Infection Risk Factors

Age, weight, heredity, chronic illness, stress, current medical therapy, pre-existing disease, and nutrition

-Opportunistic infections

Infection Lifespan Considerations

Children: majority of infections caused by viruses

-Newborns have underdeveloped immune system therefore may not be able to respond to infections

-6 months-5 years have higher risk for febrile seizures

-Adolescents at higher risk for STI's

Older adults: changes take place in the skin, respiratory tract, GI system, kidneys, and immune system

-adequate nutrition (protein) needed to build up and maintain immune system

-Diabetes= higher risk for infection

-Normal inflammatory response delayed causing atypical responses to infection (confusion, agitation, disorientation, incontinence, falls, etc.)

Common Assessments/Findings Associated With Infection

1. History/Interview: preexisting or current conditions, history of recurrent infections, medications, emotional stressors, nutritional status, immunization status, and health practices

2. Physical assessment: s/s vary according to the site of the infection

3. Findings:

Common nursing interventions for a client with an infection

-Antibiotic usage for bacterial infections

-Promote optimal sleep

-Promote adequate nutrition

-Provide adequate hydration

Healthcare Associated Infection (Nosocomial)

Acquired within a hospital setting

CLABSI-central line associated blood stream infection

CAUTI-catheter assosciated urinary tract infection

SSI- surgical site infection

VAP or VAE-venetilator associated pnuemonia, ventilator associated event

Effects of Immobility

-Neurological: depression, anxiety, forgetfulness, and confusion

-Cardiovascular: postural hypotension, cardiac muscle atrophy, orthostatic intolerance, and DVT

-Respiratory: respiratory tract infections, atelectasis, and PE

-Hematologic: anemia

-Metabolic: glucose intolerance

-Musculoskeletal: osteoporosis, muscle atrophy, weakness, and contractures

-Renal: calculi

-Gastrointestinal: constipation and fecal impaction

-Skin: pressure ulcers

Assessment of a client with mobility problems

Risks

-History of exercise habits/recent changes

-Physical examination: body alignment, gait, appearance/movement of joints, muscle mass/strength, physical energy, and problems related to immobility

Lifespan Considerations Related to Immobility

Older adults

-Decreased speed, strength, resistance to fatigue, reaction time, and coordination (decreased nerve conduction)

-Increased activity intolerance

-Fall risks

-Body responses return to normal more slowly (ex: increased HR takes longer to return to normal)

Common Nursing Interventions for a Client with a Immobility Problem

-Promote body alignment

-ROM exercises

-Ambulation

-Positioning

-Body mechanics

-Use of assistive devices

Factors Influencing the Development of Oxygenation Problems

Age

Environment

Lifestyle

Health status

Medications

Stress

Assessment of a Client with Oxygenation Problems

1. History: age, smoking, duration of breathlessness, severity, presence/absence of other symptoms, past medical history, & family history

2. Examination: basic observations, BMI, peak expiratory flow rate, chest auscultation, heart sounds, & leg edema

3. Investigations: full blood count, urea/electrolytes, NT-pro-BNT, peak flow diary, post-bronchodilator spirometry, chest x-ray, ECG, & CT

Oxygenation Diagnostic Tests

Full blood count

Urea & electrolytes

NT-pro-BNT

Peak flow diary

Post-bronchodilator spirometry

Chest X-ray

Electrocardiogram (ECG)

Computed tomography pulmonary angiogram (CT)

Common Nursing Interventions for a Client with an Oxygenation Problem

-Encourage wellness and prevention

-Increase fluid intake

-Encourage ambulation and frequent position changes

-Teach deep breathing and coughing techniques

-Pace activities to conserve energy

-Eat more frequent and smaller meals

-Avoid extreme hot or cold temperatures

-Teach actions and side effects of inhalers, drugs, and treatments

Oxygenation Lifespan Considerations

Infants:

-Higher respiration rates (Around 30 breaths per minute)

-Rely mostly on diaphragmatic movement for breathing due to rib cage structure

Children:

-Around 25 breaths per minute, then 12-18 by late adolescence

-Risk for airway obstruction

-Viral respiratory infections common (usually not serious)

Older adults:

-Increased risk for acute respiratory disease

-Pnemonia may not be present with usual fever symptoms, but may have atypical symptoms such as confusion, weakness, loss of appetite, and increased HR/respirations

Assessment of a Client with Integumentary Problem(s)

-Ability to move around

-Personal/family history

-Nutritional/fluid intake

-Continent status

-Medications

-Allergies

-Exposure to chemicals/plants/sun

-Soaps/detergents

-Recent travel

OLDCARTS

Integumentary Data Collection Tools

Inspection & Palpation

Integumentary Lifespan Considerations

-Thinning of epidermis

-Decreased elasticity

-Increased incidence of wrinkles

-Blood vessels of dermis are more fragile

-Subcutaneous tissue thins (sagging skin)

-Dry

-Delayed healing

Common Nursing Interventions for a Client with an Integumentary Problem

-Prevent sun exposure

-Nutritional support

-Adequate fluids (avoid alcohol)

-Keep skin clean & dry (but moisturized)

-Sleep/rest

-Repositioning/offloading

Inflammation vs. Infection

Inflammation can occur without infection: redness, swelling, etc.

Infection: invasion of pathogens into body tissues (body fights back causing inflammatory response)

Local vs. Systemic

L: localized swelling, erythema, heat, edema, limited ROM, and pain/tenderness

S: malaise (loss of energy), anorexia (loss of appetite), enlarged/tender lymph nodes, and fever ^ TPR

Acute vs. Chronic

A: sudden onset, rapid progression and often seen with severe symptoms (appear suddenly, last short time)

C: delayed onset (occurs slowly, can last long time)

Superinfection

Secondary infection that occurs when normal microbial flora of the body are disturbed during antibiotic therapy.

typically you get a second infection when taking an antibiotic, broad spectrum antibiotic, more than 1 antibiotic and it kills too much good flora too resulting in, things like yeast infection, thrush, c diff etc

Susceptible vs. Compromised

S: any individual at risk for developing an infection (age, weight, chronic illness, stress, and nutrition)

C: increased risk for 1 or more reasons making them more likely to develop and infection (opportunistic)

Virulence

Microorganisms vary in ability to cause disease

Pathogenicity

Ability to cause disease- pathogen = microorganism that causes disease

Urosepsis

Sepsis caused by infection in the urinary tract

Chain of Infection

1. etiologic agent (microorganisms)

2. reservoir

3. portal of exit

4. method of transmission

5. portal of entry

6. susceptible host

Laboratory Data for Infections

ESR ('sed rate' of RBC's)

WBC's

Culture/sensitivity

Elevated serum lactate

Antibiotic Resistance

Caused my misuse of antibiotics and genetic mutations

Prevalent resistant organisms: Staph aureus, C. diff, and Pseudomonas

Factors affecting mobility

Growth and development

Nutrition

Personal values

External factors

Prescribed limitations

Orthopnea

Shortness of breath

Hypoxemia

Low oxygen in the blood

Hypoxia

Low oxygen in the body (tissues)

Hypovolemia

Decrease in fluid volume (blood or water)

Incision

Open wounds (deep or shallow)

-Done by a sharp instrument

Contusion

Closed wound- skin appears ecchymotic (bruised) because of damaged blood vessels

-Blow from a blunt instrument

Abrasion

Open wound

-Surface scrape (either intentional or unintentional)

Puncture

Open wound

-Small hole in skin and sometimes underlying tissue (either intentional or unintentional)

Laceration

Open wound- edges often jagged

-Tissues torn apart often from accidents

Penetrating wound

Open wound

-Penetration of skin and underlying tissues, usually unintentional

Friction/Shearing

F: force acting parallel to skin surface

S: combination of friction and pressure

Slough

Semi-liquid necrotic tissue

-'Yellow wounds'

Eschar

Necrotic tissue

-'Black wounds'

Ischemia

Deficiency of blood supply caused by obstruction of circulation to the body part

Erythema

-Blanchable and Non-blanchable

-Skin redness associated with a variety of rashes/other conditions

Exudate

Purulent drainage

Dehiscence

Partial or total rupture of a sutured wound

-Usually abdominal wound

Evisceration

Protrusion of internal organs through an incision

Iatrogenic infections

directly from diagnostic or therapeutic procedures

nosomical infections

those infections that originate while in the hospital setting.

develop during the hospital stay or manifest after discharge,

ex-pregnant women delivers baby and goes home and has covid. she probably contracted it at the hospital. Or patient develops Cdiff during hospital stay due to contracting it.

oppurtunistic infections

all these organisms live in our day to day life the dirt, in our bodys but can become infections when someone is susceptible or immuno compromised.

What as a nurse will you do to break the chain of infection

infections agent-rapid accurate identification of organisms

Reservoirs-employee health, environmental sanitation, disinfection/sterilizations

portal of exit-proper attire, handwashing, control of excretions and secretions, trash and waste disposal.

means of transmission- food handling, air flow control, sterilization, handwashing

portal of entry, aseptic technique, catheter care, wound care

susceptible host-recognition of high risk patients, treatment of underlying diseases.

Labs to be draw when assessing if a patient has an infection

Erythrocyte sedimentation rate(ESR)- this number is elevated in presence of inflammatory process

WBCs- if elevated body is working to fight infection normal(4500-11,000) also concerning if they're low because then they don't have

Culture and sensitivity- identifying infectious agent and the sensitivity is finding the antibiotic that will destroy it

Elevated serum lactate- very worried about sepsis

C-Reactive Protein (CRP)-a lab result that tells us the body is initiating a inflammatory response

CRP and ESR- alone do not tell us an infection is happening

misuse of antibiotics(not finishing prescription)

genetic mutations

resistant organisms that are prevalent

staph aureus (MRSA)

Pseudonomas

C.diff