Exam 2 Study Guide

immunity

body’s ability to resist disease

defense

body protect against invasions and prevents development of infection by attacking antigens or pathogens

homeostasis

damaged cells are digested and removed

cell types stay uniform and unchanged

surveillance

mutations arise and recognized as foreign cells

these foreign cells are destroyed

innate immunity

present at birth

active natural immunity

natural contact with antigen through direct infection

ex: chicken pox

active artificial immunity

immunization with antigen

ex: vaccines for chicken pox

passive natural immunity

transplacental and colostrum transfer from mother to baby

ex: mom’s Ig passed to baby

passive artificial immunity

injection of serum with antibodies from 1 person to another person without antibodies

ex: injection of HepB Ig to a person

nurse responsibilities for safe medical administration

adhere to professional standards

apply steps of the nursing process to safely administer medication

questions orders that are not clear

has up to an hour before and after to administer medications that are routine or daily meds

medication reconciliation

comparing patient’s medication order to all the medications that the patient has been taking

why: to reduce/avoid risk of unintended changes, duplications, or other med errors

when: admission, routine visits, transitions of care

how: bring meds, bring list of meds, review EHR

steps of medication reconciliation

develop list of current meds

develop list of medications to be prescribed

compare medications from both lists

make decisions based on the comparison

communicate new list to patient and caregivers

requirements for medication order

patient’s name, dob, mrn

date and time the order was written

name of med

dose of med

route of administration

frequency of administration

indication

physician name, signature, identifier

routine order

2/day

continued until physician discontinues order or until number of days or doses have occurred

prn order

only when patient needs it

one-time/on-call order

only once at a specified time

before sx or diagnostic procedure

stat order

immediately and only once

given within 30 minutes

emergency situations

now order

needed quickly but not as immediately as stat order and only once

given within 60 minutes

nurse responsibilities for understanding medication orders

read entire order

know purpose

know how it works

know typical dosage range

know routes of administration

know what must be monitored

know side effects and black box warnings

clarify unclear order with physician before administration

before administering medication

assess orientation and consciousness

assess GI function/motility

assess ability to swallow for PO meds

assess venous access for IV meds

review vital signs and lab results

first step of medication safety

prevention of medication errors

prevent inappropriate medication use or client harm

rights of medication

right client

right medication

right dosage

right route

right time

right reason

right assessment data

right response

right documentation

right to education

right to refuse

right response

reevaluate pt to make sure meds are doing their intended effect

right documentation

includes what med is for, what results are expected, what are the side effects

1st check

nurse finds the medication in drawer and compares to MAR

2nd check

after medication is retrieved from drawer, medication is compared again with MAR; look for dosage and expiration date

3rd check

check medication with MAR at patient’s bedside prior to giving medication

risk factors for medication errors

lack of pharmacological knowledge

too many patients assigned

fatigue

distractions while preparing or administering medications

prevention for medication errors

self study medication

advocate for safe staffing ratios

follow safe habits and routines

examples of promoting patient safety

follow 11 rights

evaluate medications for polypharmacy

perform 3 checks

ID patients with 2 identifiers

question unclear orders

report errors and near-misses

what to do when there is a medication error

immediately assess client and take action to offset adverse effects**

notify health care team

document and file incident report

possible reaction to medication

common side effects

adverse drug effects (not common)

allergic reactions → anaphylactic shock

toxicity

what to do when there is an allergic reaction

immediate discontinuation

call physician

document as allergy

medical interventions: epinephrine, airway management, O2, IV access, steroids, antihistamines

patient education prior to medication administration

provide info on medication: name, why is it prescribed, side effects or adverse effects, what time to take, duration, how it is administered, demonstration

is it food? can it be crushed?

risk from needle stick injuries

exposure to bloodborne pathogens (HIV, HepB/C)

common injuries regarding needles

recapping needles

mishandling IV lines/needles

needles left at bedside

inflammatory response

sequential reaction to cell injury

neutralizes/dilutes inflammatory agent

removes necrotic materials

establishes environment for healing and repair

does not always occur when there is an infection

types of defenses

anatomical/chemical barriers

inflammatory response

immune system

first line of defense

anatomical/chemical barriers

skin: physical barrier with acidic pH to discourage growth

mucous membranes

hair

sweat: with oil gland secretions to kill bacteria

saliva: washes microbes from teeth and mm of the mouth

tears: wash away irritant microbes and kills bacteria with lysozyme

gastric juice: acidic enough to kill microbes

urine: wash microbes from urethra

vaginal secretions

second line of defense

inflammation response

phagocytosis

macrophages and neutrophils

occurs in response to injury

localized, immediate, nonspecific

appropriate level of response

beneficial: vasodilation to bring 3rd line of defense

third line of defense

specific immune response

B cells, T cells, natural killer cells, antibodies

ways normal defenses of the body are interrupted

antibiotics, invasive procedures, introducing devices

causes of inflammation

physical: trauma, laceration, burn

chemical: bites or allergic response

microbes: bacteria

phases of inflammation

vascular response (blood vessels)

cellular response (WBC)

formation of exudate (neutrophils + fluids)

healing (regenerate/repair)

vascular phase (after injury occurs)

vasoconstriction to stop blood flow after injury and release kinins, histamines, prostaglandins

vasodilation and increased blood flow —> redness

increase capillary pressure and permeability to allow things to enter/exit

fluid exudate (from inside cells) leak into capillaries to tissue —> edema

cellular phase

chemotaxis initiates 3rd line of defense and WBC come

neutrophils and monocytes migrate to site of injury

macrophages signal immune response

other cells released: eosinophils (allergy), lymphocytes (develop immunity), and basophils (histamine and heparin)

major events in inflammatory response

macrophages and mast cells release chemical signals → widen capillaries → increase permeability

fluid, proteins, clotting elements move to site to begin clotting

chemokines attract more phagocytic cells and come to site

neutrophils and macrophages phagocytose pathogens and debris → tissue heals

formation of exudate

fluid leaks from capillaries into tissue space

contains serous fluid, cells, and chemical mediators

types: catarrhal (runny nose), fibrinous (adhesions in sx drain tubing), hemorrhagic (bleed after sx), purulent (boil), serosanguinous (sx drain fluid), or serous (blisters)

can be white, yellow, green

NO ODOR = NO INFECTION

healing phase

minor injuries: return to normal, cells are replaced, tissues regenerated

major injuries: infection or granuloma formation, repair occurs with replacement of destroyed tissue → scar tissue, cover/seal/shrink of wound

primary: margins brought together (initial, granulation, maturation)

secondary: wounds have exudate and wider margins with extensive tissue loss

tertiary: delayed suturing, 2 layers of granulation are sutured together

signs of inflammation

redness

swelling

heat

pain

loss of function

lab tests to diagnose inflammation

CRP (C reactive protein)

ESR (erythrocyte sedimentation rate)

WBC (white blood cells)

CRP

<1 mg/dl → no inflammation

>1 mg/dl → INFLAMMATION

nonspecific tests identifies presence of inflammation

ESR

<20 mm/hr → no inflammation

>20 mm/hr → INFLAMMATION

WBC results

5k-10k mm³ → no inflammation

>10k mm³ → INFLAMMATION *does not always mean infection

<5k mm³ → body if vulnerable to infection

RICE

rest - affected area/dont overuse

ice - cause vasoconstriction, localized, 20 min off/on

compress - prevents spread of inflammation

elevate - decrease blood flow

immune system components

bone marrow, lymph system, thymus gland, accessory glands

acquired immunity

produced by immune response

lymphocytes

WBC to remember and recognize previous invaders

B cells and T cells

B cells

produce antibodies and attach to specific antigens causing body to recognize and quickly destroy the antigen

T cells

attack antigens directly and release cytokines to control immune response

geriatric immune function

decline in function causing them to be at risk

deceased T cell and B cell functions

increased auto antibody attack on normal tissue

nursing process: immunity

assessment: history, pain medication, lifestyle, other factors

other: neoplastic/autoimmune disease, chronic illness, sx

interventions to improve immune status

assist people in identifying coping strategies following stressful events

education about effects of stress

encourage vitamin/mineral supplementation

discourage megadosing → can lead to toxicity

encourage exercise plan

administer vaccines recommended by PCP

stress importance of early influenza vaccination

immunization process

pathogen injected into body

antibodies respond to pathogen and remember that pathogen

vaccines with weakened/inactive parts of pathogen trigger immune response

vaccine screening

fever? feel sick? any serious reactions to vaccines? allergy to eggs? experience GBS?

inflammation vs immunity

inflammation is precursor to infection → not always an infection if there is inflammation

immunity is a defense mechanism

influenza

type A (humans and animals): most dangerous

type B/C: humans only

droplet and inhalation transmission

pathophysiology of influenza

virus targets upper respiratory tract and causes inflammation of tree and trachea

risk factors of influenza

age

immunocompromised (cancer/HIV)

rest or sleep dysfunction

stress

envrionment

signs and symptoms of influenza

chills (due to fever)

fever

cough, sore throat

runny nose, watery yes

congestion, sneezing,

body aches

loss of appetite

fatigue

treatment of influenza

nurse focus on symptom relief

supportive therapy: rest, hydration, analgesic, antipyretic

symptom management should happen with 24-48 hours → tamiflu, relenza

other meds: zanamivir (inhaler), oseltamivir (oral), peramivir (IV), baloxavir marboxil (oral)

vaccination considerations for influenza

GBS, allergies, current illness

2 weeks to build immunity

chain of infection

agent: bacteria, virus, parasite, fungi
*consider its virulence

reservoir: where germ lives
on people, water, soil, food, things

portal of exit: how germs get out

mode of transmission: how germs get around
direct, indirect, airborne, droplet

portal of entry: how germs get in

susceptible host: the next sick person
microbe must survive new host’s defenses

break agent

accurately identify microbe and start medication to treat it

break reservoir

compliance with employee health, environmental sanitation, disinfect, sterilize

break portal of exit

wear proper PPE, hand wash, control excretions and secretions, dispose trash and waste properly

break means of transmission

isolate, proper food handling, air flow control, sterilization, handwash

break portal of entry

aseptic technique, proper catheter care, proper wound care

break susceptible host

treat underlying disease, recognize high risk patients

susceptible host

host must be susceptible to microbe

factors: age, stress, nutrition, chemotherapy/radiation, steroids, immunosuppressants, present disease, sx procedure

geriatric risk factors to infection

deficient immune system

malnourished

likely to harbor resistant microbes due to being hospitalized, living in nursing home, and exposed to many antibiotics

most commonly found infection-causing agent in healthcare settings

bacteria

moments for hand hygiene

before touching a patient

before clean/aseptic procedures

after body fluid exposure risk

after touching a patient

after touching patient surroundings

type of hand hygiene when interacting with C. diff patient

wash hands

standard precaution

used in care of all hospitalized patients regardless of diagnosis or infection status

caution: blood, body secretions/fluids, non intact skin, mucous membranes

consider: respiratory hygiene, cough etiquette, safe injection practices, directions to use a mask

wear: gloves, gown, mask

contact precaution

used for patients with a resistant organism after health care team is notified by lab, infection control, or physician

ex: VRE, MRSA, RSV, C. diff

wear: gloves, gown, mask

droplet precaution

used for patients with diseases that can spread via large droplets (>5 µm) in the air, talking, sneezing, coughing

droplets travel less than 3 ft

ex: influenza, meningitis, pertussis, covid, scarlet fever

wear: mask, goggles/face shield

airborne precautions

used for patients with diseases that can spread via small evaporated droplets (<5 µm) in the air for long periods of time

ex: TB, varicella, rubeola, SARS, avian flu

wear: N95 maski

isolation precaution implementation

assess, evaluate information, make clinical judgement

patient can be placed in iso without order

PPE sequence

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

doff: glove and gown, goggles/face shield, mask/respirator

precaution for patient that needs vital signs taken

standard

precaution for patient with influenza

droplet

precaution for patient with MRSA

contact

precaution for patient with TB

airborne

precaution for patient with broken bone

standard

precaution for patient with C. diff

contact/contact +

medical asepsis

clean technique

reduce microbes

hand wash, use standard precautions, provide personal hygiene, clean equipment regularly

surgical asepsis

sterile technique

destroy microbes

care for sx wounds, catheter insertion, invasive procedures, sx

sterile field

field is area free from microbes

field remains away and in front of body

field remains above the waist

never cross the field

never turn back on field

one inch around field in contaminated

field must be on flat, dry surface