310- Exam 2 (Hygiene, "Be Safe", Input and Output, Infection control, Mobility, Grief, loss, and Palliative care, Safety)

Hygiene

actions and practices that decrease the spread or transmission of pathogens, lessening occurrence of illness.

Purpose and parts of Integumentary system

Physical barrier to external environment, prevent pathogens from entering the body

-Skin, hair, nails, sebaceous glands, and sweat glands.

Skin

Largest organ in body, first line of defense against pathogens, serves as physical barrier, contains Langerhans cells.

Protect from environment and regulate skin temp.

The body’s defenses

-Skin, mucous membranes, teeth, nails

Mucous membranes

Act as barrier to pathogens.

Locations= nose, GI, urinary tract, mouth. Line passageways outside the body.

Teeth

Role in facial structure and speech, layers of _.

Nails

Protective properties of nails, importance of nail hygiene.

Epidermis

Protective outer layer

Dermis

Connective tissue, sweat glands, nervous tissue, blood and blood vessels.

2nd layer/ middle layer.

Hypodermis

Subcutaneous layer, adipose tissue, cushion and insulation. Separates dermis from underlying muscle and bone.

3rd layer.

Skin integrity

Skin is always at risk for breakdown, can occur rapidly.

-Regardless of defenses, regardless of age and mobility level, appropriate hygiene protects our skin. Nutritional status, amount of adipose tissue, and if patient is INC.

-Assess skin when; giving bath, turning, and on admission.

Health Care-Associated Infections (HAI’s)

Infection acquired during medical care. Threat to patients safety/health. Extend length of hospital stay.

-Annual cost $20 billion. Top 10 causes of death in U.S.

Hand Hygiene

Is key to HAI prevention. Effective _ is imperative. Disinfecting surfaces is also important. Determine when to use them and ensure proper technique.

-Handwashing- hands visably soiled, suspect diarrhea and c-diff.

-Alcohol-based hand gel- After soiled area and before going to clean area. Touching client and after/before entering room.

Health Promotion

Social constructs of health.

Social determinants of health -Many aspects of deviation from health are beyond our control. Where we were born, live, work. Health inequities.

-Ex= living in rural community, Living in an urban community.

Health Equity

the fair and just distribution of health resources, opportunities, and outcomes across all populations, regardless of their social, economic, or demographic characteristics. It aims to ensure that everyone has an equal chance to achieve their optimal health potential, without being disadvantaged by factors such as:

-Race, Ethnicity, Socioeconomic status, Gender, Sexual orientation, Disability, and Geographic location

Health promotion

Facilitate clients control. Promoting positive behavior changes. Empowerment of communities and individuals.

A whole person approach to _= consider mental, spiritual, emotional, physical aspects to health.

Developmental considerations that affect hygiene

-Newborns and infants- diaper rash(leave open to air), clean front to back (female), skin barriers, change more frequently.

-School age children/Teens= hormonal changes, starting menses

-Older adults= may refuse to bathe, risk of skin tear increased.

Physiological considerations that affect hygiene

Stroke, Bariatric considerations, dementia, amputation, visual impairment, spinal cord injury.

Stroke

Caused by head bleed or blockage. Varying effects from _. The effect of reduced mobility on hygiene.

Dressing a client with paralysis or weakness to one side. Determine if any assistive devices is needed for hygiene.

-Shower bench, long handled brush or sponge, and bench. Involve PT and OT.

Bariatric considerations

Increased BMI correlates with increased need for assistance. Excess skin creates large skin folds in abdomen, groin, under breasts, behind knees. Higher BMI can also lead to overheating, more perspiration.

Assessment should determine ability to perform hygiene tasks and signs of infection. Provided appropriate education. Check skin folds.

Visual impairment

Various types, determine assistive devices needed. Educate client and family on importance of hygiene. Foster independence- try and help them be as independent as possible.

Dementia

Condition that worsens with age. ADL’s become more challenging for clients. Ensure practices and approach to care is evidence-based and client-centered.

Consider a toileting schedule if there are signs of incontinence. Change soiled clothing. Affects family members seeing clients not keep up with hygiene.

Spinal cord injuries

Difficulty with ability to feel hot or cold. Risk for pressure injuries, various assistive devices. Nurse should assist and educate as appropriate.

Amputations

Assistive or safety equipment, prevent injury. Decrease effort required for hygiene. Assess residual limb.

The nurse delegates needed hygiene care of alert elderly client who had a stroke. Which interventions would be appropriate for assistive personnel to perform during a bath?

Providing special skin care, and providing range-of-motion exercises to extremities.

A nurse is preparing to provided hygiene care to client’s face. In what order should the nurse cleanse the clients face?

Eyes

Forehead

Cheeks

Nose

Ears

Neck

Oral care

Look at teeth, touge and mucous membrane. Helps prevent infection. Consider challenges your client might face.

-Impaired mobility and vision impairment.

Denture care- find out what patient prefers.

A nurse is performing oral care for an unconscious client. Which is the first action the nurse should take?

Turn the client’s head to the side.

Nail care

Per facility policy. Clean thoroughly under the nails. Keep nails short and free of sharp edges. Consider risk factors for your client.

-If diabetic or blood thinners.

Perineal care

Typically part of bath, prevents odor and infection. Provide privacy during care. Promote independence.

Always cleanse area front to back for females, Cleanse from meatus outward.

-Catheter care is provided daily= assess for excoriation, drainage, odors, lesions. Proper catheter care technique.

Foot care

Should be performed during daily bathing, completely dry feet after cleansing, apply lotion to dry skin, provide toenail care per facility policy.

Special considerations- check water temp, never go barefoot, trim toenails straight across.

What is the proper position for an unresponsive client during oral care to prevent aspiration?

Semi-fowler’s position with head to side and Sims’ position.

Workplace Bullying

Growing concern among nurses in health care settings.

Bullying

repetitive harassment, harm, social isolation, and belittlement of an individual by one or a group of persons.

Workplace violence

Act or threat of physical violence, harassment, intimidation, or other disruptive behavior that occurs at worksite. Can range from verbal abuse to physical violence.

Types of workplace violence (WPV)

Type 1- Criminal intent, robbery

Type 2- customer/client. client violence with healthcare staff.

Type 3- worker-on-worker

Type 4- Personal relationship, domestic situations.

Why don’t people report violent events

Pressure or fear from administration about tarnishing the reputation of facility. Stigma associated with being a victim.

Fear of intimidation or retaliation by employer. Lack of knowledge by staff about how to report.

Contributing factors/Medical conditions to WPV

Culture differences, upbringing, habitat and environment, age and gender, Impairment and disabilities, frustration, fear, in custody.

Multiple sclerosis, alzheimers, parkinson’s, huntington’s disease, traumatic brain injury. Hypoxia, meds, mental illness.

Keep yourself safe

Be aware of your; own voice (avoid loud voices), Listening skills (use empathetic listening skills), and non-verbal cues (Avoid arms crossed, hands behind your back).

PLAN-IDENTIFY-ACT

Plan yourself mentally.

Identify any nonverbal or signs of aggression for individual prior to entering room.

Take action. DO NOT FREEZE.

Safest place in room

Always have exit route. Stay between the individual and door.

Balance

understanding proper body mechanics and supportive stance.

Movement

move while maintaining balance but in shuffling movement. Avoid tripping or falling. Do not freeze.

Center

your inner strength.

De-Escalation Tips

1. Respect personal space. Maintain 2 arm lengths away. If individual tells you to get out of way then do so.

2. Be appropriate and professional. Use clam, non-threatening body language, nothing in pockets.

3. Establish verbal contact. Only one person interacting with individual at time.

4. First person who makes contact designated to de-escalate individual

5. Introduce self who is upset to assure them support, be polite, keep them safe.

6. Orient person to where and what to expect, ask for their name.

7. Speak clearly, short, sweet. Debrief individual and staff.

8. Set clear and reasonable goals.

9. Establish boundaries in respectful manner.

10. Acknowledging persons wants and feelings

11. Free information can help examiner identify

12. Agree or Agree to Disagree. Remove audience

13. Medication rule- calm them can participate own care.

Emergency Response

Threat is identified. An employee activates control alert leadership role.

Employee involved in situation initiates approaches to de-escalate the disruptive behavior.

Responders to Control Alert

Take direction from person serving as leader. Attempt verbal de-escalation as appropriate. Escort patients/visitors away to safe area.

Use a control hold if; Trained to do so, directed to do so and imminent danger.

Active shooter

3 priority actions;

-Run= run away from assailant if possible

-Hide= if people cannot run then they should hide in secure environment

-Fight= running or hiding is not an option then fight for your life against assailant.

Importance of Monitoring I and O

Body cells to function and eliminate waste products water is essential. Humans can survive for weeks without food but only a few days without water or other fluids.

Water comprised about 60% of adult body weight.

Adults should consume 2-3 L of water daily from food and beverages. Adult’s average output daily is 2,300 to 2,600 ml/day.

Purpose of I and O Calculations

Ensure accurate record keeping. Prevent circulatory overload, prevent dehydration. Aids in analyzing tends in fluid status.

Contributes to accurate assessment record.

Included for intake

Any fluid is taken IN the body through mouth, IV, or tube.

-Oral fluids, IV fluids, flushes, tube feedings, fluid irrigations, medications, and blood products.

Included for output

Any fluids that LEAVE the body. It can be via various routes as well.

-Urine output, emesis, liquid stool, wound draining, suction. Not included but needs to be considered is insensible loss.

About 600 ml a day.

When to monitor I and O

-Undergo surgery

-Receiving IV therapy, parenteral or enteral feedings.

-Has fluid and electrolyte imbalances

-Nasogastric(NG) tubes

-Connected to drainage

-Patients with burns, hemorrhage, vomiting, diarrhea and edema.

-Patient diagnosis of kidney, liver, or heart disease.

Measuring I and O

Should recorded in milliliters (NOT ounce). Frequency of record; hourly, every 8 to 12 hour shift depending on institution’s policy and patients condition.

Per providers order.

Documentation of Intake

Verify where to document; oral, IV, enteral, parental

Time and route

Document in ml.

Intake of Ice

Liquids consumed by mouth includes any liquid that is liquid at room temp. Ice melts at one half the volume.

8 oz of ice chips only record 4 oz (120 ml).

Calorie counting

Dietitian will calculate and document total calories consumed in medical record.

Patient teaching

Is important to involve patients in I and O monitoring. We also need to include family members and visitors.

What is being monitored and why. If patient is on fluid restriction, educate the plan.

Infectious Agent

agent is something that contains bacteria, fungi, virus, parasite, or prion.

Reservoir

habitat of infectious agent and is where it lives, grows, and reproduces itself or replicates.

Portal of Entry

can be any body orifice (ears, nose, mouth) or can even be through the skin, and it provides a place for the infectious agent to replicate or for toxin to act

Portal of Exit

means by which the infectious agent can leave reservoir

Susceptible host

required for infectious agent to take hold and become a reservoir for infection. Not everyone who is exposed to an infectious agent gets sick.

Contact transmission

occurs when microorganisms move from an infected person to another person.

Droplet transmission

Occurs when airborne droplets from respiratory tract of client travel through air and into mucosa of host.

Airborne transmission

occurs when small particulates move into airspace of another person.

Direct contact

transmission occurs when microorganisms are directly moved from infected person to another person without having a contaminated object or person between the two.

Indirect contact

transmission occurs when microorganisms are moved from infected person to another person with a contaminated object or person between the two.

Nonspecific immunity

refers to neutrophils and macrophages and their work as phagocytes.

Phagocytes eat and destroy microorganisms, thereby helping to protect the body from harm.

Both neutrophils and macrophages are released during the inflammatory response.

Specific immunity

refers to work of antibodies (immunoglobulins) and lymphocytes. Antibodies bind to infectious agents and call to the white blood cells and complement to destroy them.

Incubation stage

an infection enters host and begins to multiply.

Prodromal stage

the client begins having symptoms

Acute illness stage

Manifestations of specific infectious disease process are obvious and may become severe

Decline stage

Manifestations begin to wane as degree of infectious disease decreases.

Convalescence stage

the client returns to normal or “new normal” state of health

Systemic infection

start as local infections and then spread to bloodstream to infect the entire body.

Local infection

confined to one area of body. Can be treated with topical antibiotics and oral antibiotics.

Medical asepsis

(clean technique) term used to define the elimination of and absence of disease-causing microorganisms.

Standard precautions

used to describe infection prevention practices applied to all clients, whether or not they are known to have an infectious agent.

Four major Health care-associated infections (HAIs)

-Central line-associated bloodstream infections (CLABSIs)

-Catheter-associated urinary tract infection (CAUTIs)

-Surgical site infections (SSIs)

-Ventilator-assisted pneumonias (VAP’s)

Mobility

Another way to say motion or movement. Bodies designed for motion and require muscles, skeleton, and nerves to function in unison.

Nursing goal is assist in preserving, maintaining, and restoring as much mobility and function as possible.

Ability to walk from place to place independently is ambulation.

Body Mechanics

combination effort of musculoskeletal and nervous system. Maintain posture, alignment, gravity, and balance in daily life.

3 Important Principles= Posture, Balance, and Coordinated movements

Balance and alignment

Center of gravity is center point of weight for object or body. Wide base by spreading feet shoulder-width apart and flexing knees improves stability and balance.

Body alignment= posture.

Gravity and Friction

Moving a patient to reduce friction; have patient cross arms over chest and use draw sheet. Prevent fracture or shearing or tearing of skin.

Always ask for assistance to move patient. Use proper body mechanics to prevent injury to you and patient.

Muscular system

Comprised of muscles that provided motor power or force for movement.

More than 600 muscles in human body. Accounts for half person’s weight. Contract across joint and creates force to pull against skeleton.

-Help with heat production that helps move/breakdown food regulate blood flow.

Muscouloskeletal

referring to muscle and skeleton. Important for proper body mechanics, and posture.

The four properties of a muscle (CEEE)

Contractibility- ability to shorten(contract) and then relax

Excitability- muscle fibers can receive and respond to nerve or hormonal stimulation.

Extensibility- ability to stretch(extend), occurs simultaneously as other muscle contact

Elasticity- ability to bounce back or recoil to original state after being contracted or extended.

Smooth muscle

Located in blood vessels and visceral organs and function involuntarily

Cardiac muscle

only located in heart and function involuntarily

Skeletal muscle

attached to skeleton by tendons and function voluntarily

Skeletal system

Support(solid, stable framework)

Protect(protect internal organs, brain, spinal cord, heart and lungs)

Produce(red bone marrow, red blood cells, wbc, platelets, macrophages) Storage(calcium, phosphorus, iron, and lipids)

Movement(bones work with muscular attachment to create motion)

206 bones, made of hard connective tissue layers provide rigid structure and shape human body. weight-bearing organ of body. Protect and support internal organs and muscles store important minerals. Provide body shape but cannot move on own.

Remodeling

once bones have matured, undergo process where old bone is constantly being replaced with new bone.

-Osteoprosis occurs from prolonged bedrest, have to build bone strengh back.

Cartilage

firm, flexible connective tissue in many areas like ears, nose, larynx, ribs, intervertebral discs, knees and ankles.

Flexion

bed, reduce angle between bones

Extension

straighten limb.

Abduction

away from baseline/midline

Adduction

bring closer to midline, toward body

Pronation

turning to face down, dumping food.

Supination

turning to face up, scoping ice cream

Circumduction

circular motion