ICN definition
Promotion of health, prevention of illness, and collaborative care
ANA definition
Social policy statement
Blended Competencies
Cognitive, technical, interpersonal, ethical (legal)
QSEN Competencies
Patient-centered care, teamwork and collaboration, quality improvement, safety, evidence-based practice, informatics
Nursing aims
Promote health, prevent illness, restore health, facilitate coping disability or death
Nursing Practice Acts
define the legal scope of nursing practice and create a state board of nursing to make and enforce rules and regulations
Nursing Process Essentials
Assessing, diagnosing, planning, implementing, and evaluating
Signs of burnout
Compassion fatigue, burnout, and secondary traumatic stress
Vital Signs Method to Combat Burnout
BP - Be Present T - tracking P - practicing health and wellness behaviors R - refueling
Guidelines for Nursing practice
Standards of nursing practice, nurse practice acts and licensure, nursing process
Infectious agents
Bacteria, fungi, viruses
Reservoir
Natural habitat of an organism Food, soil, water and surfaces
Means of transmission
Direct contact, indirect contact, airborne contact
Portal of entry
Point at which organisms enter a new host
Examples of portal of entry
GI, GU, surface of skin, blood, and inhalation
Susceptible host
Must overcome resistance mounted by host's defenses
Bacteria
Most significant and most prevalent in hospital settings
Virus
Smallest of all microorganisms
Fungi
Plant-like organisms present in air, soil, and water
Factors affecting organism's potential to produce disease
number of organisms, virulence, immune capabilities, length of contact between person and organism
Possible reservoirs for microorganisms
other people, animals, soil, food, water, milk, and inanimate objects
Common portals of exit
respiratory, GI, GU, breaks in skin, blood, tissue
Stages of infection
Incubation, prodromal stage, full stage of illness, convalescent period
Incubation period
Organisms grow and multiply
Prodromal stage
Person is most infectious, vague and nonspecific signs of disease
Full stage of illness
Prescence of specific signs and symptoms of disease
Convalescent period
Recovery from infection
Factors affecting host susceptibility
Age, sex, race, hereditary factors, normal pH levels, etc.
Cardinal signs of acute infection
Redness, swelling, heat, pain, loss of function
Normal WBC count
5,000 to 10,000 mm3
WHO Hand Hygiene, how many moments are there?
5 moments
Moment 1
Prior to touching patient
Moment 2
Before a clean or aseptic procedure
Moment 3
After a body fluid exposure risk
Moment 4
After touching a patient
Moment 5
After touching patient surroundings
Bacterial flora locations
Transient and resident
Transient flora
Attached loosely to skin and removed with relative ease
Resident flora
Found in creases in skin, requires friction with brush to remove
Categories of Hospital-Acquired Infections
Catheter-associated urinary infection (CAUTI), surgical site infection (SSI), central line associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP)
What determines the body's defense against infection
Body's normal flora, inflammatory response, and immune response
List of PPE equipment used
Gloves, gowns, masks, protective eyewear
Aseptic technique
Activities performed to break the chain of infection
Categories of aseptic technique
Medical asepsis and surgical asepsis
Medical asepsis
Clean technique - soap and water are adequate
Surgical asepsis
Sterile technique - scrubbing sponge, sterile gloves, 2 min hand washing, etc.
Factors to consider when examining skin
Cleanliness, color, temperature, turgor, moisture, sensation, vascularity, and evidence of lesions
Assessment of oral cavity
Examine lips, buccal mucosa, color and surface of gums, teeth, tongue, hard and soft palates, oropharynx
Hygiene deficit categories for patients
Feeding, bathing, hygiene, dressing and grooming, and toileting
Times of care provided
Early morning care, morning care (AM care), afternoon care (PM care), hours of sleep care (HS care), as needed care (PRN care)
Physical assessment of teeth
Denture fit or loose teeth
Physical assessment of cheeks
Edema or swelling, dry mucosa
Physical assessment of tongue
Color and symmetry, texture, movement, lesions
Assessment of hard and soft palate
Discolorations, patches, lesions, and petechiae
Assessment of oropharynx
Tonsil swelling and uvula movement
Assessment of lips
dry or chapped, discoloration, peeling
Oral problems to assess for
Dental carries, periodontal disease, etc.
Assessment of eyes
Position, alignment, general appearance, redness, swelling, and discharge
Assessment of ears
Cerumen build up, dryness, crust, hearing aid placement
Assessment of nose
nostril patency, dryness, or bleeding
Assessment of hair
Texture, cleanliness, oiliness, dandruff, hair loss, texture, hair removal practices, infestations (lice), lesions on scalp, inflammation or redness
Assessment of feet and nails
Asses nails for color and shape, intactness, and cleanliness, tenderness Assess feet for lesions or breaks in skin, turgor, color, temperature, and integrity
Ensuring bedside safety steps
Bed in lowest position, position is safe for patient, bed controls are functioning, call light is functioning and within reach, side rails are raised if needed, wheels are locked
Vital Signs (abbreviated)
T, P, R, BP
What is the 5th vital sign?
Pain
Normal oral temperature (C and F)
36 to 38.2 C or 98.6 to 100.4 F
Normal pulse rate
60 to 100 bpm
Normal respirations
12 to 20 breaths per min
Normal blood pressure
120/80 mmHg Systolic - 100 to 140 Diastolic - 60 to 90
When to assess VS
On admission, institutional policies, change in condition, loss of consciousness, after surgical procedure, after ambulation, before administering cardiac medications
Factors affecting VS
Diagnosis, co-morbities, types of treatments received, patient's level of activity
Types of fever
Intermittent, remittent, sustained or continuous, relapsing or recurrent
Intermittent fever
Temp returns to normal at least once every 24 hours
Remittent fever
Temp does not return to normal and fluctuates a few degrees up and down
Sustained or continuous fever
Temp remains above normal with minimal variations
Relapsing or recurrent fever
Temp returns to normal for one or more days with one or more episodes of fever, as long as several days each
In what areas could body temperature be taken?
Rectal, oral, tympanic, axillary, and temporal
What area is the most accurate for temperature?
Rectal
When should you not use a rectal temp on a patient?
If the patient has neutropenia or thrombocytopenia
Normal rectal temp (C and F)
37.1 to 38.1 C or 99.5 F
Normal axillary temp
35.9 to 36.9 C
Normal tympanic temp
36.8 to 37.8 C
Normal temporal temp
37.1 to 38.1 C
Ways heat can be transferred out of body
Radiation, convection, evaporation, and conduction
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