safety and asepsis and infection

safety

Freedom from danger, harm or risk

• Safety and security are basic human needs

Need to teach the client/family and communicate with them and

other members of the health care team to promote safety

identifying Your Client

Check name band

Check date of birth/medical record number

Ask client their name

This is essential when you first meet the client and each time you give

medications, provide a treatment, admit/discharge/transfer, etc.

Do NOT use a room number as a safety identifier

factors affecting safety

Age/developmental considerations (what concerns do we have with different age groups?)

• Lifestyle (occupation, social behavior, environment)

• Sensory perception

Mobility

• Cognitive awareness

• Ability to communicate

• Physical health state

Psychosocial health state

• Knowledge

• Environmental factors

• History of previous accidents/falls

assessing

recognize cues

• Nursing history

• Physical assessment

• Risk factor assessments

(ex. Morse Fall Scale, Hendrich Fall Risk Model)

• Assess the environment

What problems may a client have in terms of safety?

nursing judgment

formulate outcomes based on individual circumstances

The key is prevention!!!

implementing

Perform risk assessment

• Communication!!!!!!!!!!!

• Teaching!!!!!!!!!!!!!!!!

• What else?..............

evaluating outcomes

Was the client outcome (s) met?

How do we know?

What do we do if they were not met?

falls

Leading cause of accidents among older adults and cause frequent

hospital admissions

• Major health concern in older adults

• Cost, complications, death

• Many older adults have a fear of falling as it may threaten their

independence

risk factors for falls

• Advanced age

• Unfamiliar environment

• Impaired vision

• Confusion/disorientation

• Impaired gait/balance

• Orthostatic (postural) hypotension

Urinary frequency

• Medical history/chronic medical conditions

• Weakness

• Problems with transferring

• Medications

• History of falls

• Poor lighting

• Improper use of assistive devices

measures to prevent falls

• Screen for risk—use risk assessment tool

• Identify safety as at risk for falls, according to policy

• Orient/reorient to surroundings frequently

• Call bell in reach---TEACH!!!!!!!!!!!

• Prompt response to call lights

• Room near nurse’s station

\ Bed in lowest position

• Lock wheels

• Nonskid footwear

• Keep floor free of clutter and dry

• Hourly rounding!

• Teach………………………!!!!!

Adequate lighting

• Use or glasses, walkers, etc.

• Keep belongings within reach

• Teach to rise slowly to standing

• Sit with legs over the side of the bed for a few minutes before standing (dangling)

• If dizzy, teach to sit/low down

• Assist to the bathroom—if so, must stay an arm’s length from them

• Bedside commode

Measures to Prevent Falls
• Communicate with the staff
• Have family stay, if possible
• One on one observation (sitter)
• Electronic alarm system
• Remote safety observation system
• Provide a diversional activity
• CLIENT AND FAMILY TEACHING!!!!!....................

infection definitions

Infection - A disease state that results from the presence of pathogens

Pathogen - Microorganism that causes disease

Disease - A detectable alteration in normal tissue function

stages of infection

• Incubation Period: The time after a germ enters the body but before any symptoms start. The germ is multiplying, but you feel completely fine.

• Prodromal Stage: The early phase where you start feeling "under the weather." You experience vague symptoms like tiredness or a mild headache, and you are often highly contagious.

• Full Stage of Illness: The peak of the sickness where specific, severe symptoms appear (like a high fever, rash, or vomiting) as the body fights the infection.

• Convalescent Period: The recovery stage where the germs clear out, symptoms fade, and your body regains its strength.

Anatomic and physiologic barriers

These are the body's first line of defense. They try to prevent pathogens from entering the body in the first place.

Anatomic barriers

These are physical structures that protect the body.

Skin

• The skin is a major barrier against microorganisms.

• Intact skin prevents pathogens from entering.

• Example: A cut or open wound removes part of this protection.

Mucous membranes

• Found in areas such as the nose, mouth, respiratory tract, and digestive tract.

• They produce mucus, which can trap microorganisms.

Cilia

• Tiny hair-like structures in the respiratory tract.

• They move mucus and trapped particles toward the throat so they can be removed.

Physiologic barriers

These use body processes or chemicals to destroy or prevent microorganisms.

Tears

• Wash microorganisms away.

• Contain lysozyme, an enzyme that can damage certain bacteria.

Saliva

• Helps wash microorganisms away.

• Contains substances that help fight microbes.

Stomach acid

• Very acidic environment that can destroy many microorganisms swallowed with food.

Urine

• Helps flush microorganisms out of the urinary tract.

Normal microbiota

• Helpful microorganisms normally living on the skin and in places like the intestines.

• They compete with harmful microorganisms for nutrients and space.

🧠 NCLEX tip:

If the question asks about the first line of defense, think:

Skin + mucous membranes + secretions + normal microbiota

Inflammatory response

If pathogens get past the first line of defense, the body can respond with inflammation.

Inflammation is part of the body's nonspecific/innate defense.

It doesn't need to recognize one specific pathogen first.

What happens?

Imagine you get a small cut.

1. Tissue is damaged

2. Chemical signals are released.

3. Blood vessels dilate (widen).

4. Blood flow to the area increases.

5. Blood vessels become more permeable.

6. White blood cells move toward the injured/infected area.

7. The cells attack pathogens and remove damaged tissue.

The classic signs of inflammation:

R — Redness
H — Heat
S — Swelling
P — Pain

Sometimes you'll also see loss of function.

Example:

You get a cut on your finger.

The area becomes:

• Red

• Warm

• Swollen

• Painful

That's the inflammatory response working to protect you.

immune response

The immune response is more specific.

Unlike the inflammatory response, the immune system can recognize specific foreign substances (antigens) and develop targeted defenses.

There are two major types of lymphocytes:

B cells 🅱

B cells are responsible for humoral immunity.

They can develop into plasma cells, which produce antibodies.

Antibodies attach to specific antigens and help the body neutralize or remove them.

Think:

B cells → antibodies

---

T cells 🅣

T cells are responsible for cell-mediated immunity.

Different T cells have different jobs.

For example:

• Helper T cells → help coordinate immune responses.

• Cytotoxic T cells → attack infected or abnormal cells.

• Memory T cells → help the body respond more quickly if the same antigen appears again.

Think:

T cells → target infected/abnormal cells and coordinate immunity

---

🧠 Innate vs. Adaptive Immunity

This is VERY important for NCLEX.

Innate defenses	Adaptive immunity
Nonspecific	Specific
Present from birth	Develops after exposure
Responds quickly	Usually takes longer during first exposure
Skin	B cells
Mucous membranes	T cells
Inflammation	Antibodies
Phagocytes	Immune memory

factors affecting risk of infection

• Age

• Heredity

• Stress

• Immunizations

Nutritional status

• General health status

• Current medical therapy

• Use of invasive or indwelling medical devices

• Integrity of skin and mucous membranes

• Number and integrity of white blood cells

• Improper practices by health care workers

assessment recognizing cues

Assessment (Recognizing Cues)

• Risk factors

• Complaints that suggest infection

• Physical assessment (swelling, redness, pain, tenderness, fever,

enlarged lymph nodes, malaise)

• Elevated WBC’s

• Lab specimens

• Immunizations

analyzing

Risk for infection

• Fever

• Impaired oral mucous membranes

• Pain

Social isolation

planning

Plan outcomes that prevent infection or interfere with the infection

cycle

implementing

Hand washing

• Provide hygiene

• Nutrition/fluids

• Rest/sleep

• Decrease stress

• Immunizations

• Proper disposal of

tissues, cover mouth,

etc.

• TEACHING!!!!!

• Clean equipment properly

• Use of PPE

• Follow isolation procedures, if

appropriate

• Maintain sterile technique,

when appropriate

Evaluating (Evaluating Outcomes)

• Were the outcomes achieved?

• Modify as necessary

isolation

Protective procedure designed to prevent the transmission of

specific microorganisms

precautions

Precaution	How it spreads	PPE	Examples
🟢 Airborne	Tiny particles in air	N95	TB, measles, varicella
🔵 Droplet	Respiratory droplets	Surgical mask	Flu, pertussis
🟠 Contact	Touch/contaminated surfaces	Gloves + gown	C. diff, some MRSA

Health Care Associated Infections

(HAIs)

Infections not noted to be present on admission

Invasive medical devices (ex. CAUTIs)

• Multidrug resistant organisms:

MRSA-methicillin resistant staph aureus

 VRE-vancomycin-resistant enterococcus

 clostridium difficile (C. diff)