NSG 2000- Exam #2

Chain of infection

a chain of necessary pieces needed for an infection to occur and includes the following links:

1. infectious agent

2. reservoir

3. portal of exit

4. mode of transmission

5. portal of entry

6. susceptible host

Infectious agent

something that contains bacteria, fungi, virus, parasite, or prion

Reservior

the habitat of the infectious agent; a location where it can live, grow, and reproduce itself or replicate

Portal of exit

the means by which the infectious agent can leave the reservior

Modes of transmission

the moving of bacteria, viruses, fungi, parasites, and prions from place to place; these are contact, droplet, and airborne

Portal of entry

any body orifice, such as ears, nose, mouth, or even the skin, and provides a place for the infectious agent to replicate or for toxin to act; include invasive lines and devices

Susceptible host

required for the infectious agent to take hold and become a reservoir for infection; not everyone who is exposed to an infectious agent will get ill; some people never exhibit manifestations at all but can becomes colonized (temporarily or permanently) with the infectious agent

Virulent

how effective the infectious agent is at causing illness

Factors that increase host susceptibility

1. age

2. underlying disease

3. HIV/AIDS

4. malignancy

5. transplants

6. medications

7. surgical procedures

8. radiation therapy

9. indwelling devices

Direct contact transmission

occurs when microorganisms are directly moved from an infected person to another person, rather than through a contaminated object or person

Indirect contact transmission

occurs when microorganisms are directly moved from the infected person to another person with having a contaminated object or person between these two

Droplet transmission

occurs when droplets from the respiratory tract of a client travel through the air and into the mucosa of a host; include:

1. norovirus

2. rhinovirus

3. covid

4. influenza

5. pertussis

Airborne transmission

occurs when small particulates move into the airspace of another person; include:

1. tuberculosis

2. rubeola (measles)

3. varicella (chickenpox)

Vehicle transmission

transmission of infectious agents to various individuals through a common source, such as contaminated food or water

Vector-borne transmission

transmission of infectious agents through animals, such as an insect or a rodent

Nonspecific immunity

comprised of neutrophils and macrophages and their work at phagocytes

Phagocytes

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

Specific immunity

the work of antibodies (immunoglobins) and lymphocytes

Inflammatory response

natural defense of the body when injured, when foreign substances are present, or when infectious agents attack

Infectious triggers

1. viruses

2. bacteria

3. other microorganisms

Noninfectious triggers

1. physical: burns, frostbite, injury, foreign bodies, trauma, radiation

2. chemical: glucose, fatty acids, toxins, alcohol, irritants (e.g. fluoride, nickel)

3. biological: damaged cells

4. psychological: excitment

Manifestations of swelling

1. heat

2. redness

3. swelling

4. pain

5. loss of function (potentially)

Stages of infection

1. incubation

2. prodromal

3. acute illness

4. period of decline

5. period of convalescence

Incubation

first stage of infection in which the client might not feel ill or have visible manifestations

Prodromal

second stage of infection when client begins having initial manifestations as the infectious agent replicates

Acute illness

third stage of infection where manifestations of a specific infectious disease process are obvious; most severe stage

Period of decline

fourth stage of infection when manifestations begin to wane as the number of infectious disease decreases

Period of convalescence

fifth/last stage of the infection when the client returns to normal or a "new normal" state of health

Local infections

infections confined to one area of the body

Systemic infections

start as local infections and then transmit into the bloodstream to infect the entire body system

Antiseptic agents

1. alcohols

2. chlorhexidine

3. chlorine

4. chloroxylenol

5. hexachlorophene

6. iodine/iodophors

7. quaternary ammonium compounds

8. triclosan

Medical asepsis

cleaning technique practices that reduce the presence of disease-causing microorganisms on surfaces

Surgical asepsis

cleaning techniques that ensures the sterility of items that will come in contact with the client, through use of equipment such as sterile gloves, in order to prevent pathogen transfer to the client

Sterilization

cleaning instruments so that all microorganisms, including bacterial spores are eradicated

Sterile field

created to assure that the smallest number of microorganisms possible are present; used for procedures where surgical asepsis is indicated

Disinfection

cleans instruments so that almost all microorganisms are eradicated but not all; high level and low level

Standard precautions (universal precautions)

infection prevention practices that apply to all clients, whether or not they are known to have an infectious agent

Contact precautions

precautions used when a client has an infectious agent that can be transmitted by direct or indirect contact with body secretions; requires a minimum of gown and gloves prior to client interactions; patient must be in private room or cohort with same organism

Droplet precautions

precautions used when a client has an infectious agent that can be transmitted by large particles over close distance; requires donning a mask when entering the client room or coming into close contact with a client; patient must be in private room or cohort

Airborne precautions

precautions used when a client has an infectious agent that can be transmitted through the air and should don an N95 mask or a high-level respirator when entering the room of a client; patient must be in private negative air pressure room and cannot cohort!

Airborne infection isolation room

AIIR room; single-client rooms built with special air handling and ventilation to provide a negative pressure; also, a negative pressure room; 6-12 exchanges via HEPA filter per hour

Protective isolation

isolation used during approximately the first 100 days after the transplant; specific engineering and hospital designs that decrease the risk of environmental fungi to the client who had HSCT

Health care-associated infections (HAIs)

infections that are acquired in a health care facility; often preventable; increase length of stay, cost, and mortality; major ones include:

1. central line-associated blood stream infections (CLABSIs)

2. catheter-associated urinary tract infections (CAUTIs)

3. surgical-site infections (SSIs)

4. ventilator-assisted pneumonias (VAPs)

Infection control bundles

guidelines for practice that are bundles together to prevent HAIs such as CAUTIs, CLABSIs, VAPs, and SSIs; "care bundles"

Multidrug-resistant organisms (MDROs)

bacteria that are resistant to one or more classes of existing antimicrobials

Enhanced barrier precautions

nursing home staff must wear gown and gloves to prevent transfer of organisms to themselves or their clothing when engaging in certain client care activities

Closed-glove technique

technique to don sterile gloves using surgical asepsis after the individual has performed a surgical hand scrub and donned a sterile gown; hands are kept inside the sterile gown until gloves are donned

Open-glove technique

technique to don sterile gloves using surgical asepsis; gloves are touched directly with the hands

Abdomen

xiphoid process to the pubic symphysis; divided into 4 quadrants

RUQ

contains the:

1. liver

2. pancreas

3. gallbladder

4. ascending colon

5. some of the kidneys

LUQ

contains the:

1. stomach

2. spleen

3. pancreas

4. transverse colon

5. intestines

LLQ

contains the:

1. small and large intestines

2. left reproductive organs

RLQ

contains the:

1. appendix

2. intestines

3. right reproductive organs

Midlines

contains the:

1. bladder

2. uterus

Liver, pancreas, gallbladder, ascending colon, and kidneys

organs of the RUQ

Stomach, spleen, pancreas, transverse colon, kidneys, and intestines

organs of the LUQ

Small and large intestines and reproductive organs

organs of the LLQ

Appendix, intestines and reproductive organs

organs of the RLQ

Bladder and uterus

organs in the midline

Referred pain

symptoms do not always occur in the quadrant of the organ of pathology

Inspection, auscultation, percussion, palpation

order of assessment for abdominal

Tips for abdominal assessments

1. warm up hands

2. have patient empty bladder

3. lay supine or side

4. place pillow under hand and knees

5. identify and assess tender areas last

Hinderances to abdominal examinations

1. clothing

2. surgical incisions and wounds

3. self-consciousness

4. ticklishness

5. cold hands

Peristalsis

bowl/digestion movements

Striae

stretch marks

Cullen sign

ecchymosis; bruising around umbilicus; sign of bleeding in the peritoneal cavity or parancitis

Gray turner

ecchymosis in the flank; sign of bleeding in the peritoneal cavity or parancitis

Gravid

the shape of a pregnant woman's abdomen

Scaphoid

a concave shaped abdomen; seen in adolescents, young adults, and thin adults

Rounded

a curved abdomen; common in young children or adults with poor muscle tone; normal if symmetrical; can be a sign of malnourishment because fluid leaks into peritoneal cavity due to low protein

Distended

bloating; can be present in one or more quadrants; indictive of chromes disease or celiac's disease

Protuberant

a bulging abdomen, due to obesity; pendulous abdomen

5-35

normal amount of bowl sounds heard per minute

Borborygmi

loud growling sounds from increased GI motility for various reasons; often no stethoscope is needed to hear them

Absent bowel sounds

no bowl sounds after 5 minutes

Hypoactive bowel sounds

more than 15-30 seconds to hear bowl sounds; at least 1 every 5 minutes

Hyperactive bowel sounds

very frequent bowel sounds; about every 5 seconds

Bruit

swooshing sounds made by turbulent blood moving through narrowed arteries; indictive of hypotension, constricted/narrowing/stenosis arteries, or ruptured arteries

Shifting dullness

caused by ascites/fluid in the abdomen; heard when patient is sitting up: tympany of top of abdomen, dullness inferiorly; heard when patient is laying on left side: tympany on right side, dullness of left side

Peritonitis, acute cholecystitis, appendicitis

if abdomen remains hard after patient relaxes, that could be indicative of _______, _______, _______

McBurney point

point in the RLQ that is associated with appendicitis

Cerebrum

part of the brain responsible for a person's mental status

Cerebral cortex

part of the brain responsible for "higher" mental functions such as perception and behavior

Frontal lobe

part of the brain responsible for short term memory, expression of emotion, decision-making, problem-solving, and concentration and includes broca's area; not fully developed until late 20s

Parietal lobe

part of the brain responsible for receiving and processing sensory data

Temporal lobe

part of the brain responsible for sounds and long term memory

Limbi system

part of the brain responsible for survival behaviors and emotions

Survival behaviors

mating, aggression, fear, and affection

Emotions

anger, love, hostility, and envy

Reticular activating system (RAS)

neurons in the brain responsible for awareness and arousal; when disrupted, it can lead to altered mental status such as delirium or confusion

Nursing history for neurological assessment

1. present illness

a. change in behavior

b. anxiety

c. depression

2. past medical history

a. neurological disorders

b. psychiatric disorders

3. medication use

4. family history

Neurological disorders

1. epilepsy

2. ADHD

3. stokes

4. trauma

5. neuro surgeries

6. bells palsy

Psychiatric disorders

1. bipolar

2. depression

3. eating disorders

4. schizophrenia

5. anxiety disorders

Neurological medications

1. anti-depressant

2. anti-psychiatric

3. elicit drug use

4. nervous system stimulants

Neurological family history

1. psychiatric disorders

2. mental illness

3. Alzheimer's disease

4. learning disorders

5. intellectual disabilities

a. asperger's

b. autism

Mini-mental exam

a mental examination where an individual can score up to 31; a score of <21 warrants further evaluation

Glasgow coma scale

a scale that measures consciousness; can be measured over a period of time; can score 3 (comatose)- 15 (A+O)

Components of a mental exam

1. level of consciousness

a. alert

b. oriented

i. person

ii. place

iii. time

iv. situation

2. behavior and appearance

a. mood

b. hygiene

c. body language

3. language

a. normal vs. aphasia

4. memory

a. recent (short term)

b. remote (long term)

c. delirium

d. dementia

Sensory/receptive aphasia

when a person cannot understand what is being said/written to them

Motor/expressive aphasia

when a person cannot speak/express what they're saying; "word salad"