Comprehensive Nursing Care & Infection Control: Key Concepts and Practices

Personalized Nursing Care

Patient-centered care that views the patient as a whole (physical, emotional, cultural, spiritual).

Autonomy

Independence in making nursing decisions.

Accountability

Responsibility for nursing actions.

Advocate

Nurse protects patient rights and choices.

QSEN

Competencies for nursing (safety, patient-centered care, teamwork, evidence-based practice, informatics, quality improvement).

Health Belief Model

Patient's beliefs about health influence care decisions.

Health Promotion Model

Focuses on engaging in wellness behaviors.

Holistic Health Model

Considers physical, emotional, spiritual, cultural needs.

Maslow's Hierarchy

Needs ranked from basic survival → self-actualization.

Primary Prevention

Prevent disease before it starts (vaccines, education).

Secondary Prevention

Detect/limit disease early (screenings).

Tertiary Prevention

Prevent complications/disability in chronic illness.

Subjective Data

Patient-reported info (pain, symptoms).

Objective Data

Nurse-observed/measured info (vitals, labs).

Social Determinants of Health (SDoH)

External factors (income, education, housing, access to care).

TeamSTEPPS

Teamwork system for patient safety.

SBAR

Communication tool → Situation, Background, Assessment, Recommendation.

Call-Out

Informing all team members at once in emergencies.

Check-Back

Closed-loop communication to confirm accuracy.

Fall

Unintentional change in position to ground/surface.

Intrinsic Factors

Patient-related fall risks (age, illness).

Extrinsic Factors

Environment-related fall risks (spills, cords).

Restraint

Device/measure restricting movement (last resort, requires order).

Physical Restraint Complications

Incontinence, pneumonia, pressure ulcers.

Hygiene

Practices that promote cleanliness (skin, mouth, nails, perineum).

Infection Control

Preventing spread of pathogens.

PPE Order (Donning)

Gown → Mask → Goggles → Gloves.

PPE Order (Doffing)

Gloves → Goggles → Gown → Mask.

Standard Precautions

Basic infection prevention for all patients.

Contact Precautions

Gown and gloves (e.g., MRSA, C. diff).

Droplet Precautions

Mask and eye protection (e.g., flu).

Airborne Precautions

N95 mask, negative-pressure room (e.g., TB).

HAI

Healthcare-Associated Infection.

Nursing Diagnosis

RN's judgment of patient response to health problem.

Actual Diagnosis

Problem exists now (3-part statement).

Risk Diagnosis

Problem may develop (2-part statement).

Range of Motion (ROM)

Degree of joint movement.

Exercise Pattern

Usual activity/exercise routine.

Activity Tolerance

Amount of activity safely tolerated.

Immobility

Inability to move normally → causes systemic complications.

DVT (Deep Vein Thrombosis)

Blood clot in deep vein, usually legs.

PE (Pulmonary Embolism)

Clot travels to lungs.

SCDs (Sequential Compression Devices)

Prevent blood clots by squeezing legs.

Active ROM

Patient moves joints independently.

Active-Assisted ROM

Patient + nurse share movement.

Passive ROM

Nurse moves joints for patient.

Pressure Injury

Localized skin/tissue damage from pressure.

Shear

Sliding of skin over bone causing tissue damage.

Friction

Rubbing of skin against surfaces.

Stage 1 Pressure Injury

Non-blanchable redness.

Stage 2 Pressure Injury

Partial skin loss, blister.

Stage 3 Pressure Injury

Full-thickness loss, fat visible.

Stage 4 Pressure Injury

Full-thickness loss, bone/muscle visible.

Unstageable Pressure Injury

Covered by slough/eschar.

Deep Tissue Pressure Injury

Purple/maroon discoloration, blood blister.

Primary Intention Healing

Edges closed, sutures/staples, minimal scarring.

Secondary Intention Healing

Open wound, heals bottom-up, big scar.

Tertiary Intention Healing

Delayed closure after infection risk resolves.

Drainage - Serous

Clear, watery.

Drainage - Sanguineous

Bright red, bloody.

Drainage - Serosanguineous

Pink, watery (blood + serous).

Drainage - Purulent

Thick, yellow/green, foul odor → infection.

Drainage - Fibrinous

Sticky, with fibrin strands, chronic wounds.

Granulation Tissue

Red, moist new tissue in healing wounds.

Slough

Yellow/white dead tissue.

Eschar

Black/brown dead tissue, hard/leathery.

Exudate

Fluid from wound.

Tunneling

Channel that extends into wound tissue.

Undermining

Wound edges separate from tissue underneath.

Heat Therapy

Increases blood flow, relaxes muscles (≤20 min).

Cold Therapy

Reduces swelling/pain (10-15 min).