Class 2 Material

colonization

the presence and growth of microorganisms within a host, but WITHOUT tissue invasion or damage

Infection

the invasion of a susceptible host by pathogens or microorganisms, RESULTING IN disease

infectious disease

communicable and transmissible from one person or source to another

what does HAIs stand for

Health Care — Associated Infections

HAIs (define)

• infections associated with healthcare delivery in any healthcare facility

• a localized or systemic condition resulting from an adverse reaction to an infectious agent or its toxin that was NOT present on admission

the two risk factors that are often forgetten about regarding assessment of infection risk

• travel

• occupation

the chain of infection

• infectious agent

• reservoir

• portal of exit

• mode of transmission

• portal of entry

• susceptible host

infectious agent

• within the chain of infection

• the microorganism that causes harmful infections

reservoir

• within the chain of infection

• where the germ lives and grows before it gets into your body

portal of exit: way out

• within the chain of infection

• germ finding a way out of reservoir to spread

mode of transmission

• within the chain of infection

• how it gets other people sick, air or contact

portal of entry: way in

• within the chain of infection

• germ finding a way into another person ex) open wounds

susceptible host

• within the chain of infection

• the person who is at risk of infection because they were unable to fight the infection

asepsis

the absence of pathogenic (disease-producing) microorganisms

medical asepsis

procedures used to reduce the number and transmission of disease-causing microorganisms after they leave the body—but do not necessarily eliminate them

universal precautions

• precaution

• purpose: to prevent transmission of bloodborne pathogens from exposure to blood and other potentially infectious materials

some examples of universal precautions

• Hepatits B and C (HBV & HCV)

• Human Immunodeficiency Virus (HIV)

what does universal precautions apply to

• semen

• vaginal secretions

• saliva

• any fluid contaminated with blood

what does universal precautions NOT apply to

• sputum

• feces

• sweat

• emesis

• urine

• nasal secretions

standard precautions

• precaution

• purpose: to prevent and control infection and its spread to ALL persons

which PPEs to wear for standard precaution

• gown

• gloves

• mask

types of isolations

• contact

• droplet

• airborne

examples of contact precautions

• MRSA

• VRE

• C. diff

examples of droplet precautions

• influenza

• meningitis

examples of airborne precautions

• tuberculosis

• SARS

contact precaution (define)

• precaution

• direct patient or environmental contact

droplet precaution (define)

• precaution

• respiratory transmission over short distances

airborne precaution

• precaution

• remains in the air, infective over time and distance

elements of personal hygiene

• bathing

• perineal and incontinence care

• hair care: brushing and shampooing

• oral hygiene: brushing and denture care

• shaving

• foot and nail care

factors influencing hygeiene practices

• social practices

• personal preferences

• body image

• socioeconomic status

• health beliefs and motivation

• cultural variables

• physical condition

what are the vital signs

• temperature

• pulse

• respiration

• blood pressure

• oxygen saturation

• pain

factors affecting body temperature

• age

• exercise

• hormonal level

• circadian rhythm

• environment

• temperature alterations

when is body temperature lowest

early morning

when is body temperature highest

late afternoon or early evening

PO

• oral

• wait 30 min after hot or cold intake

Ax

• axillary

• reads lowest of the sites

R

• rectal

• reads highest; several contraindications

TM

• tympanic

• ear, fast, and non-invasive

TA

• temporal

• forehead scan

which electronic thermometer is the blue probe(s)

oral or axillary

which electronic thermometer the red probe

rectal.

normal range oral for temperature (average adult)

37C or 98.6F

normal range rectal/tympanic for temperature (average adult)

37.5C or 99.5F

normal range axillary (average adult)

36.6C or 97.6

average temperature range for adult

36 to 38C or 96.8 to 100.4F

average temperature range for older adult oral

35 to 36.1C or 95 to 97F

pulse and heart rate definintion

the palpable bounding of blood flow in a peripheral artery — an INDIRECT indicator of circulatory status

when to use an apical instead of radial assessment

• when radial pulse is irregular, weak, or hard to palpate

• before giving cardiac medications such as digoxin

• count for a full minute, not a 30-second doubling

average pulse range for adult

60 to 100 bpm (eucardia)

tachycardia

• high pulse rate

• >100 bpm

bradycardia

• low pulse rate

• <60 bpm

what to assess for radial pulse

• rate

• rhythm

• strength/amplitude (force)

• equality

what to document for rhythm for radial pulse

regular or irregular

what to document for strength/aimplitude for radial pulse

0 = absent

1+ = thready or weak

2+ = normal

3+ = bounding

what to document for equality for radial pulse

even or same on all peripheries

where is the apical pulse located

5th ICS, midclavicular line (MCL)

ventilation

the movement of gases in and out of the lungs

diffusion

the movement of oxygen and carbon dioxide between the alveoli and red blood cells

perfusion

the distribution of red blood cells to and from the pulmonary capillaries

what is respiration regulated by

CO2 levels NOT O2

inspiration (respiration)

• diaphragm contracts and moves down

• active

expiration (respiration)

• diaphragm relaxes; elastic recoil does the work

• passive

respiration normal range for adults

12 to 20 breaths per minute

tachypnea

• respiratory rate too high

• >20 per min

bradypnea

• respiratory rate too low

• <12 per min

asssesments for respiration

• rate

• depth

• rhythm

• effort

what to document for assessing depth for respiration

• full/normal/even

• shallow

what to document for assessing rhythm for respiration

• regular

• irregular

what to document for assessing effort for respiration

• early/relaxed

• hard to breath

dyspneic

hard to breathe

factors affecting respiration

• exercise

• acute pain

• anxiety smoking

• body position

• medications

• neurological injury

• hemoglobin function

the 5 interrelated factors that reflects BP

• cardiac output

• peripheral resistance

• blood volume

• viscosity

• elasticity

what happens to blood pressure when volume increases

blood pressure increases

what happens to blood pressure when volume decreases

blood pressure decreases

what happens to blood pressure and resistance when vessels harden/ are narrow?

blood pressure and resistance increases

what happens to blood pressure and cardiac output when oxygen demand increases?

blood pressure and cardiac output increases

factors that influence blood pressure

• age

• stress

• ethnicity

• gender

• daily variation

• medications

• activity and weight

• smoking

normal range for blood pressure in adult

120/80 mmHg

• systolic: <120

• diastolic: <80

hypotension range

systolic: <90

diastolic: <60

elevated range

systolic: >=120-129

diastolic: <80

hypertension stage 1 range

systolic: 130-139

diastolic: 80-89

hypertension stage 2 range

systolic: >= 140

diastolic: >= 90

what happens to the BP reading when cuff is too small?

falsely HIGH reading

what happens to the BP reading when cuff is too large?

falsely low reading

palpation technique for measuring BP

feel the radial or brachial pulse while you inflate the cuff. the point where the pulse disappears is YOUR estimated systolic

auscultation technique for measuring BP

listen over the brachial artery with stethoscope while you deflate. the first Korotkoff sound is systolic, the last is diastolic

Korotkoff Sounds

• sharp thump (systolic)

• blowing or whooshing sound (auscultatory gap may appear)

• a crisp, intense tapping

• a softer blowing sound that fades

• silence (diastolic)

range that the ausculatory gap covers

30 to 40 mmHg

what does the ausculatory gab effect?

• underestimates systolic

• overestimates diastolic

how to avoid the ausculatory gap

palpate the systolic first, then inflate 30 mmHg ABOVE that number so the readings are clearer

site precautions and documentation with BP

• hemodialysis patients with a shunt

• patients who have had a mastectomy or lymphectomy

• patients with vascular access, (central venous or PICC lines)

• sites disruptions": wounds, irritations, rashes, swelling, injury

other sides to take BP

• brachial

• radial

• popliteal

• dorsals pedis or posterior tibial

what oxygen saturation (SaO2) evaluate

diffusion and perfusion

normal range of SaO2

93 to 100%

what to asses for SaO2

• value

• flow rate

• delivery device

factors affecting oxygen saturation measurement

• interference with light transmission

• interference with arterial pulsation