Foundations of Nursing Exam #1 Infection and Control

Results when a pathogen invades tissues and begins growing within a host

What is an infection?

Presence and growth of microorganisms within a host without tissue invasion or damage

What is colonization?

* Chain of Infection

\-----------------------
* Infectious Agent
* Reservoir (food, oxygen, water, temperature, pH, and light
* Portal of Exit (skin and mucous membranes, respiratory tract, urinary tract, gastrointestinal tract, reproductive tract, blood
* Modes of transmission (contact, droplet, airborne
* Port of Entry
* Susceptible Host

What is the chain of infection?

* Defenses against infection
* Normal Floras (exists in our gut)
* Body system defenses (our skin to help keep pathogens out)
* Inflammation
* Vascular and Cellular responses
* Inflammatory exudate
* Tissue repair

What are some of the defenses our body uses against infectious processes?

Infections that occur in a clinical setting due to:

* Invasive procedures (surgical procedures)
* antibiotic administration
* Multi-drug-resistant organisms (MDROs)
* Breaks in infection prevention and control activities

What are Health-Care Associated Infections? (HAIs)

* Age
* Sex
* Nutritional Status
* Stress
* Disease Process

What are contributing factors influencing infection prevention and control

* Through the patient eyes
* Past Experiences
* Knowledge of infection
* Risk factors
* Clinical appearance (do they appear tired?, do they have dry skin which might lead to an entry in for bacteria
* Status of defense mechanisms
* Medical Therapy
* Travel History
* Laboratory data

What is the Nursing Process with assessing a patient with an infection?

A term used to describe an infection that can be transmitted directly from one person to another

What is a Communicable Disease?

* Risk for Infections
* Impaired Nutritional Status: Deficient Food Intake
* Impaired Oral Mucus Membrane
* Social Isolation
* Impaired Tissue Integrity

What are some Nursing Diagnoses for Infection?

* Common goals of care often include:
* Preventing further exposure to infectious organisms
* Controlling or reducing extent of infection
* Maintaining resistance to infection
* Verbalizing understanding of infection prevention and control

\
* Setting Priorities

\- Establish priorities for each diagnosis and for related goals of care (ABCs Maslow Hierarchy of needs)

\
* Teamwork and Collboration

- Collaborate with patients and interprofessional team

What are some common goals and outcomes in preventing infection and prevention

* Nutrition
* Hygiene
* Immunzation
* Adequate rest and exercise

What are some ways nurses try to promote health during the implementation process

* Eliminate the infectious organisms
* Support the patient’s defenses

What are some ways nurses can promote health in a acute care setting

* Control or elimination of infectious agent
* Cleaning
* Disinfection and sterilization
* Protection of the susceptible host
* Control and elimination of reservoir of infection
* Control portal of exit/entry (cough etiquette)
* Control of transmission (hand hygiene)

What is medical asepsis?

* Airborne (chicken-pox), Droplet (flu), Contact, Protective Environment

What are some examples of transmission-based precautions

Gowns, masks, eye protection, gloves (REMEMBER GMEG)

G- Gown

M- Mask

E- Eyewear

G- Gloves

What are some common PPE (Personal Protective Equipment) that nurses use to prevent infection?

* Loneliness
* Anxiety and Depression

What are some psychological implications of isolation?

* Isolation Environment
* Specimen collection
* Bagging trash or linen
* Transporting patients

What are some isolation precautions nurses must implement during the nursing process?

1. Before touching the patient
2. Before clean/aseptic procedure
3. After body fluid exposure risk
4. After touching a patient
5. After touching patient surroundings

What are the 5 moments for hand hygiene?

* See through patient’s eyes
* Have the patients expectations been met
* Patient outcomes
* Measure the success of the infection control techniques
* Compare the patient actual response with expected outcomes
* If goals are not achieved, determine what steps must be taken

What the nurses goals of evaluation during the nursing process

* Gloves (GEGM)
* Eye Protection
* Gown
* Mask

What is the correct order of removing PPE?

* Hand Hygiene and Clean Gloves

What are examples of standard precaution techniques?

* When a healthcare provider knows that the patient has some sort of pathogen through the contact route of transmission (i.e C Diff, MRSA, RSV, Lice, Scabies)
* IF A PATIENT HAS C DIFF YOU MUST WASH YOUR HANDS WITH SOAP AND WATER
* Must had a gown and gloves

What are contact precautions/PPE used against it

* Any sort of respiratory droplets
* Must have a gown, gloves, and surgical mask if we are making contact within 3 feet of the patient
* Droplet precautions are typically directed towards patients with (influenza, pertussis, group A step, rubella, and bacterial meningtitis

What are droplet precautions?

* Conditions that are spread through aerosolized particles (BIG ONE: Tuberculosis, measles, chicken-pox (variella)
* MUST use a Gown, Gloves, N95 Respirator

What are airborne precautions?

Washing hands with Soap and Water

How would a nurse properly perform hand hygiene after caring for a patient with C.Diff?

• Posion

• Falls

• Fire

• Immunzations

• Disasters

• Transmission of Pathogens

• Motor Vehicle Accidents

  • Car seat use, elderly

• Physical Hazards

  • Often results in physical or psychological injury or death

• Temperature

  • Extremes post safety risks to vulnerable populations

• Nutrition

  • Requires knowledge about healthy food and food safety

• Environmental Safety

  • A safe environment protects the staff to function optimally

• Basic Human Needs

  • Sufficient oxygen, nutrition, and optimum temperature, influence a person’s safety

  • Oxygen

    • Supplemental poses fire risk

What are some contributing factors when it comes to ensuring patient safety and quality?

• Patient’s developmental level

• Mobility, Sensory, and Cognitive Status

• Lifestyle choices

• Knowledge of common safety pre-cautions

What are factors influencing patient safety?

• Lifestyle

• Impaired mobility

• Sensory or communication impairment

• Economic Resources

• Lack of Safety Awareness

What are Individual Risk Factors to Patient’s Safety?

• Medical Errors

• TJC and CMC “Speak up Campaign”

• National Quality Forum Mission

  • Serious reportable event (SREs)

• Environmental Risks

• Chemical Exposure

What are some risks in Healthcare Agencies?

• Falls

• Patient-inherent accidents

• Procedure-related accidents

• Equipment-related accidents

• Workplace safety

What are some specific risks to a patient’s safety within the health care environment?

• Successful critical thinking requires a synthesis of knowledge, experience, critical thinking attitudes, and intellectual and professional standards

• Critical thinking allows nurses to anticipate the needs of particular patients and make conclusions about available data

• On-going process

What is required from a nurse to have successful critical thinking skills

• Self-Actualization (desire to become the most that one can be)

• Self-Esteem (respect, self-esteem, status, recognition, strength, freedom)

• Love and Belonging

  (friendship, intimacy, family, sense of connection)

• Safety and Security

  (personal security, employment, resources, health, property)

• Physiological Needs

  (Air, water, food, shelter, sleep, clothing, reproduction)

What is Maslow’s hierarchy of needs?

• Environmental Interventions

  • Basic needs

  • Fall safety in the home

• General Protective Measures

  • Lighting

  • Changing the environment

What are some Environmental Interventions and General Preventive Measures

• Fall prevention

  • Follow fall protocols

  • Patient-centered care

  • Assistive Aids

• Restraints

  • Physical

  • Chemical

  • Ongoing Assessment

  • Objectives

What are some examples of acute and restorative care

• Fires

• Electrical hazards

• Seizures

• Disasters

• Preventing Workplace Violence

What are some examples of Acute Care Safety procedures?

 Nurses must make accurate and appropriate
clinical decisions or judgments.
 Clinical judgment
 Observed outcome of critical thinking and decision
making
 Clinical decision making
 Separates professional nurses from technicians or
other assistive personnel (AP)

What is the purpose of the Clinical Judgment Model (CJM)

1. Assessment-

2. Diagnosis

3. Planning

4. Implementation

5. Evaluation

What is the correct order of the Nursing Process?

Critical thinking
 The ability to think in a systematic and logical manner
with openness to question and reflect on the
reasoning process.
 The aim of critical thinking is the ability to focus on the
important issues in any clinical situation and make
decisions that produce desired patient outcomes

What is Critical Thinking?

• influences patients’ comfort, safety, and well-being

• A variety of personal, social, financial and cultural factors influence hygiene practices

• Use communication skills

• When providing hygiene, integrate other nursing activities, including patient assessment and interventions

• Always ensure privacy, convey, respect, and foster a patient’s independence, safety, and comfort

How does personal hygiene play a role in patient/nursing care?

During a bath

When is the best time to assess a patient’s skin or integumentary system?

The skin

• Epidermis- Top layer of the skin, helps by preventing entrance of micro-organisms

What organ is classified as the largest organ in the body?

Tape scraping, or stripping, using dry razors, tape removal, or improper turning or positioning techniques

What are some possible actions that could potential damage or weaken the epidermis?

• The skin

  • Sensory organ

  • Temperature Regulation

  • Excretion and Secretion purposes (oils may sometimes harbor microorganisms

• The feet, hands, and nails

  • Requires special attention

  • Influences the ability for the patient to perform hygiene (if they can’t bear weight, they can’t ambulate)

  • Inadequate nutrition and disease can change the the shape and thickness of our nails or cause curvature

• The oral cavity- Teeth (HUGE AREA RISK FOR INFECTION)

• Increased risk for gingivitis (inflammation of the gums.

• Medication, exposure to radiation, dehydration, and mouth breathing may impair salivary secretion

  • May cause Xerostomia- Dry mouth

• The Hair

• The way our hair grows is a indication of a patient’s health status (i.e an individual who has cancer may begin to see the lost or thinning of the hair)

• Hormonal changes, stress, nutrition, aging

The eyes, ears, and nose - Don’t get soap in the eyes

• Eyes have their own mechanisms to clean itself (i.e tears)

• Cerebrum that we excrete in our ears help trap foreign bodies

Scientific Knowledge Base

• Social Practices

• Personal Preferences

• Body image

• Socioeconomic status

• Health benefits and motivation

• Cultural Variables

• Development Stages

  • Skin

  • Feet and Nails

  • The mouth

  • Hair

  • Eyes, ear, and nose

• Physical Condition

Describe factors that influence personal hygiene practices.

Teeth/dentition

What is classified as a huge area of infection for patients?

• Integrate nursing knowledge

• Consider developmental and cultural influences

• Think creatively

• Be non-judgemental and confident

• Draw on your own experiences

• Rely on professional standards

Discuss how to apply critical thinking when providing hygiene.

o Use correct handwashing techniques before and after entering the room.
o Wear gloves and gown when changing the client's brief.
o Change gloves between procedures.
o Hand hygiene with antimicrobial soap and water after removing gloves

A healthcare student is assigned to a client who is on isolation precautions and needs
assistance with hygiene and elimination. The client is 47 years old, diagnosed with
clostridium difficile (C.Diff.) and wears an adult brief due to incontinence of stool.
The client has requested assistance with bathing and changing their brief.

o Perform hand hygiene using antimicrobial soap and water due to C.Diff.
diagnosis.
o Wear appropriate personal protective equipment (PPE) as outline by the
facility.
o Maintain hygiene practice to decrease the risk of spreading infections to
visitors

What infection prevention education should be shared with
the client and their family?

o The client may feel neglected due to the limited interaction with others.
This may cause mixed emotions from the client, for example, feeling
lonely, depressed, or angry. It is important to provide optimal, holistic care
and continue to assess client's physical, psychosocial, and emotional well-
being

The client is on isolation precautions, how may this impact the client?

Coming in contact with: nonintact skin, mucous membrane, secretions, excretions, or blood

A nurse should use clean gloves when?

Assessment-

Diagnosis

Planning or outcome identification

Implementation

Evaluation

What is the mnemonic ADPIE

• Demographics

• Social Determinants of Health

• Health Disparites

• Physical

• Functional

• Psychosocial

• Emotional

• Cognitive

• Sexual

• Cultural

• Age-related

• Environmental

• Spiritual/Transpersonal

• Economic

What are some information the nurse will collect from a patient when conducting an assessment

• Focuses on the patient’s response to health problems

• Collecting Data

• Identifying Cues and making inferences

• Validating Data

• Clustering related data and identifying data

• Reporting and recording data

What is the main purpose of conducting the Assessment Portion of the Nursing Process?

• Identifying how the patient reacts to actual or potential health and life processes

• Identify the factors that contribute or cause health problems (etiology)

• Identify resources or strengths the patient can rely on to prevent or resolve problems

What is the main purpose of conducting the Diagnosis Portion of the Nursing Process?

1. Create a list of suspended problems (diagnosis)

2. Ruling out Similar problems and diagnosis

3. Naming actual and potential problems

4. Determining risk factors

5. Identifying resources, strengths, and areas for health promotion

How do we develop a diagnosis?

• Establish priorities

• Identify expected outcomes

• Select evidence-based nursing interventions

• Communicate the plan of care

What is the main purpose of outcome identification and planning

Identify and select nursing-initiated interventions

• Desired patient outcomes

• Characteristics of the nursing diagnosis

• Acceptability of the patient

• Capability of the patient

• Research base for the intervention

• Carry out the plan

• Continue data collection

• Document the care

What is the purpose of Implementation in the Nursing process?

• Identify expected patient outcomes

• Collect Data

• Interpret and Summarize your findings

• Document your judgement

• Terminate, continue or modify plan of care

What is the purpose of Evaluation in the Nursing Process

• Support soft tissues of the body

• Protects crucial components of the body

• Furnishes surfaces for the attachment of muscles, tendons, and ligaments

• Provides storage areas for minerals and fat

• Produces blood cells

What is the main function of the Skeletal System?

• Cardiovascular

  • Increased efficiency of our heart

  • Decreased heart rate and blood pressure

  • Increased blood flow to all body parts

  • Improved Venous Return

  • Increased circulating fibrolysin (substance that breaks up small clots)

• Respiratory

  • Improved Alveolar ventilation

  • Decreased work of breathing

  • Improved diaphragmatic excursion

• Gastrointestinal

  • Increased appetite

  • Increased Intestinal Tone

• Urinary

  • Increased blood flow to the kidneys

  • Increased efficiency of acid-base balance

  • Efficiency in excreting body waste

• Musculoskeletal

  • Increased muscle efficiency and flexibility

  • Increased efficiency and of nerve impulse transmission

  • Reduced bone loss

  • Increased Coordination

• Intregumentary

  • Improved Tone, Color, Tugor

  • Improved Skin Circulation

How does exercise effect our body systems?

• Developmental considerations

• Physical Health

• Mental Health

• Lifestyle

• Attitude and Values

• Fatigue and Stress

• External Factors

What are some psychological benefits of exercise for a patient?

• General ease of movement and gait

• Alignment

• Joint Structure and Function

• Muscle mass, tone, and strength

• Endurance

Describe the use of safe patient handling techniques during transfers and ambulation.

Gait Belt

• Stand-assist and repositioning aids

• Lateral-assist devices

• Friction-reducing sheets

• Mechanical lateral-assist devices

• Transfer chairs

• Powered stand-assist

Sedentary and immobile patient

Equipment and and Assistive Devices

• Low or Semi Fowlers: 30 degrees

• Fowlers: 45-60 degrees

• High Fowlers: 90 degrees

• Supine position= 0

What are fowlers positions?

• Tripod/4 prong: Poor Balance

• Half Circle: minimal balance

• Straight handles:

  • If mild balance needed

  • Easier to hold with hand weakness

• Axillary Crutches: Short term use

  • Be cautious to avoid axillary nerve injury

  • Walkers: Full Support

Mechanical Aids to Walking:

Walker and Canes

• Take home message:

• Support foot in correct anatomical position

• Heel Support

What are the protective positioning for drop foot?

• Holds hand in functional assessment position

• Prevents claw-hand deformities

What are the protective positioning for Hand Rolls

• Skin

  • Epidermis

    • Top Layer

  • Dermis

    • Inner layer of collagen

  • Dermal- epidermal junction

    • Separates dermis and epidermis

What are the different layers of the skin?

• Pressure Injuries

• Pressure Ulcer, decubitus ulcer, or bed sore,

• Pathogensis

• Pressure Intensity

• Tissue ischemia

• Blanching

• Pressure Duration

• Tissue Tolerance

Scientific Knowledge Base (2 of 9)

• Impaired sensory perception

• Impaired mobility

• Alteration in LOC

• Shear Friction

• Moisture

What are the risk factors for pressure ulcer development?

Stage 1: Non-Blanchable erythema of intact skin

Stage 2: Partial-Thickness skin loss with exposed dermis

Stage 3:Full Thickness skin loss

Stage 4: Pressure Injury: Full thickness skin and tissue loss

What are the classifications of pressure injuries?

• Either covered with slough (yellowish) or may be covered with eschar which is dark, usually dark brown to black, very thick and hard layer to cover.

How can unstagable wounds be identified?

• Granulation Tissue

• Slough

• Eschar

• Exudate

What are some key components in identifying deep-tissue injuries

When the wound begins to heal from the the inside out

What is Secondary Intention?

Wound healing when you get scar tissue to form

• i.e surgical wound

What is Primary Intention?

Inflammatory Response, epithelial proliferation, and migration re-establishment of the epidermal layers

What is the Wound Repair Process for Partial thickness wounds?

Hemostasis- The even leveling of our tissues going back to normal,

inflammatory- WBC and phagocytes begin to attack and prevent any wound infection,

proliferation- The tissue begins to start growing and regenerating

maturation- Forms into the dermis and epidermal layers

What is the wound repair process for full-thickness wounds?

• Hemmorhage

• Infection

• Dehiscense

• Evisceration

What are some complications of wound healing?

• Turning our patients frequently

• offloading the pressure

• making sure we keep our patients clean and dry

How do we prevent pressure injuries?

the motion of a limb or appendage away from the midline of the body

What is Abduction?

a movement towards the midline

What is Adduction?

the movement of the limb, hand, or fingers in a circular pattern, using the sequential combination of flexion, adduction, extension, and abduction motions.

What is Circumduction?

Flexion refers to a movement that decreases the angle between two body parts.

What is Flexion

a straightening movement that increases the angle between body parts.

What is Extension?

excessive movement of a joint in one direction (straightening)

What is the muscle movement Hyperextension

the movement that occurs when your foot and shin approximate closer together

What is the muscle movement Dorsiflexion?

the movement of the foot in a downward motion away from the body

What is the muscle movement Plantarflexion?

rotation towards the center of the body.

What is Internal Rotation?

Rotation away from the body

What is External Rotation

When your palm or forearm faces up

What is Supination Position?

When your palm or forearm faces down

What is Pronation position?

When your toes point inwards

What is Inversion?

When your toes point outwards from the center of your body

What is Exersion?

Left/Right

What 2 halves are divided in the sagittal plane?

Up/down

What 2 halves are divided into the transverse plane?

Anterior/Posterior

What 2 halves are divided into the frontal/coronal

45 - 60 degrees

What is Semi-Fowler’s position?

• Bed position

  • Bed is angled 45-60 degrees

What is Fowler’s Position?

Supine Position

During male perineal care the patient should be in what position?

Red Wristband

What does a Red Wristband on a Patient indicate?