Clinical Reasoning and Infection Control Unit 1 NR224

Clinical Reasoning and Infection Control

Clinical Judgement

• Evaluation:

  • Implementation

  • Assessment

  • Evaluate Outcomes

  • Recognize Cues

  • Take Action

• Clinical Decision Making:

  • Analyze Cues

  • Generate Solutions

  • Prioritize Hypotheses

• Planning:

  • Diagnosis

Concept Mapping

• Definition:

  • Visual representation of clinical reasoning and judgment, enabling the recognition of relationships between data and seeing the whole person.

• Characteristics:

  • Less linear than the nursing process.

• Steps Involved:

  • Collect and analyze information.

  • Identify the main health concern to focus on.

  • Place sub-concepts.

  • Identify connections, similarities, and cross-links.

  • Review the concept map.

  • Revise the concept map as new information is discovered.

SOAP Note

• Definition:

  • A standardized format for organizing nursing documentation.

• Components:

  • Subjective Data:

  • Information shared by the patient or family; cannot be verified by the nurse.

  • Objective Data:

  • Information assessed and verified by the nurse utilizing their senses.

  • Assessment:

  • The nurse's hypothesis or evaluation based on data cues.

  • Plan:

  • Intended actions to support the patient's health.

EMR vs EHR

• Electronic Medical Record (EMR):

  • Documentation of a single encounter between an individual and a healthcare professional.

• Electronic Health Record (EHR):

  • A longitudinal record of an individual’s encounters with multiple health professionals, providing a comprehensive account of total health history.

• Importance of Accuracy:

  • The accuracy of the EHR depends on health professionals using the same informatics system.

• Efficiency of Electronic Information Transfer:

  • Facilitates efficient sharing of health information with patient consent.

Documentation and Informatics

• General Guidelines:

  • Begin each entry with date and time.

  • Record all data factually and objectively.

  • Include observations of patient behavior and actions of other professionals.

  • Provide complete descriptions of assessments and care without generalizations.

  • Quote the patient’s words, especially when expressing emotions or thoughts of self-harm.

  • Document consultations clarifying prescribed interventions.

  • Only document personal observations or actions.

  • Document care as it is provided, not at the end of the shift for increased accuracy.

  • If a late entry is necessary, document the time charting was completed and the time care was provided.

Standards of Documentation

• Error Correction:

  • Correct errors when discovered; procedures may vary by software.

  • End each entry with signature and role (e.g., C. Simpson, RN).

  • Use correct medical terminology and spelling.

  • Grammar and punctuation are not crucial, but clarity is essential.

  • Be aware of surroundings while documenting; protect patient confidentiality.

  • Avoid leaving screens active when away from computers.

Handwriting and Written Documentation

• Error Handling:

  • Draw a single line through any error, write "error," initial, and date.

  • Record corrected information with a notation such as “Correction to entry of date/time.”

  • Chart line by line without blanks; if a line is skipped, cross it out to prevent out-of-order entries.

  • Use legible handwriting in black ink or as required by facility standards.

  • Avoid using erasable ink or felt-tip pens.

Fax and Email Communication

• Fax Protocol:

  • Place fax machines in secure areas; limit access to designated personnel.

  • Use encryption for fax transmissions to protect confidential information.

  • Confirm fax number accuracy and use cover sheets for clarity.

  • Use speed-dial features to eliminate dialing errors; log fax transmissions not completed electronically.

• Email Protocol:

  • Confirm email addresses before sending.

  • Request email confirmation of information received.

  • Always encrypt email communications.

Documenting Communication with Providers and Unique Events

• Telephone Documentation:

  • Document every phone call made to a healthcare provider.

• Verbal Orders (VOs):

  • Generally discouraged except in urgent situations.

• Incident Reports:

  • Define an incident as any event inconsistent with routine patient care or standard procedures.

Practice Questions Example

• Scenario:

  • A nurse notices a medication dosage higher than normal; actions to take include:

  • Consult the charge nurse about communication issues.

  • Hold the dose and confer with ordering provider immediately.

  • Assess patient knowledge on routine dosage.

  • Do not wait until the end of shift to check dosage.

Nursing Process

• Steps Involved:

  • Assessment

  • Identifying risk factors

  • A clinical appearance

  • Assessing status of defense mechanisms

  • Analyzing medical therapy

  • Reviewing travel history

  • Utilizing laboratory data

Infection Prevention and Control

• Exposure to Infectious Agents:

  • Understanding the incubation stages and types of infectious diseases including:

  • Illness

  • Convalescence

  • Prodromal phase

Exudate Types

• Definition:

  • Exudate is a type of fluid secreted by an open wound in response to tissue damage.

• Common Types of Exudate:

  • Serous: Clear, thin, and watery fluid.

  • Serosanguineous: Thin and watery with a light red or pink hue.

  • Sanguineous: Bright red, fresh blood, may be hemorrhagic.

  • Purulent: Thick, opaque, and odoriferous, indicating infection.

Nursing Diagnoses for Infection

• Example Diagnoses:

  • Risk for Infection

  • Impaired Nutritional Status: Deficient Food Intake

  • Impaired Oral Mucous Membrane

  • Social Isolation

  • Impaired Tissue Integrity

Planning and Outcomes Identification

• Examples of Patient Outcomes:

  • Patient demonstrates proper hand hygiene prior to discharge.

  • Patient identifies signs and symptoms of wound infection.

  • Patient is afebrile upon discharge.

  • Wound edges are approximated at discharge.

Hand Hygiene Practices

• Technique:

  • Wash hands for at least 20 seconds; longer durations remove more pathogens.

  • Wet hands under clean, running water, avoiding standing water.

  • Dry hands with a clean towel or air dry.

  • While washing, have fingers pointed down and move from fingers to wrists; rinse with fingers down to prevent recontamination.

When to Perform Hand Hygiene

• Situations Requiring Hand Hygiene:

  • Before touching a patient.

  • After exposure to body fluids or risk of contamination.

  • Before clean or aseptic procedure.

  • After touching a patient and their surroundings.

Hand Sanitizer Use

• Definition:

  • Antiseptic hand sanitizer can substitute soap and water when hands are not soiled.

• Usage Guidelines:

  • Soap and water are preferred for soiled hands or exposure to infectious agents.

  • Effective hand sanitizer must contain at least 60% alcohol.

  • Proper application includes rubbing hands for about 20 seconds.

Chain of Infection

• Components:

  • Susceptible Host:

  • Includes the elderly, infants, and immunocompromised individuals.

  • Portal of Entry:

  • Mouth, nose, eyes, or open wounds.

  • Pathogen:

  • Categories include bacteria, viruses, fungi, and parasites.

  • Reservoir:

  • Locations include people, animals, soil, food, and water.

  • Mode of Transmission:

  • Direct and indirect contact, droplets, vectors.

  • Portal of Exit:

  • Through coughing, sneezing, and bodily secretions.

Breaking the Chain of Infection

• Strategies Include:

  • Killing or decontaminating infectious agents.

  • Protecting susceptible individuals.

  • Covering breaks in the skin.

  • Personal hygiene practices.

  • Handwashing and wound cleaning.

  • Control secretions and drain.

  • Isolation precautions.

Nosocomial Infections

• Definition:

  • Also known as healthcare-associated infections (HAIs) which occur due to care received in a healthcare facility, often during invasive procedures.

Defenses Against Infection

• Intrinsic Defenses:

  • Saliva and tears contain antibacterial enzymes.

  • Skin acts as a barrier.

  • Protective “good” bacteria in gastrointestinal and urogenital tracts.

  • Cilia in the nasopharynx remove particles; mucous traps particles for expulsion.

  • Gastric secretions are acidic, helping neutralize pathogens.

Occupational Exposure Protocol

• Steps Following Exposure Incident:

  • Stay calm and manage sharp disposal.

  • Wash needlesticks or cuts.

  • Flush splashes to body parts with water.

  • Report incident and seek medical treatment promptly.

Medical Asepsis

• Definition:

  • Techniques and procedures that reduce the number of microorganisms to prevent disease spread.

• Core Practices:

  • Handwashing

  • Cleaning environment

  • Using appropriate personal protective equipment (PPE)

  • Disinfecting surfaces

  • Using antiseptics

Surgical Asepsis

• Definition:

  • Combination of practices to ensure the absence of all microorganisms, both pathogenic and non-pathogenic.

• Application:

  • Used in operating rooms, burn units, and some bedside procedures like catheter insertions.

• Key Practices Include:

  • Meticulous handwashing, using a sterile field, sterile instruments, and sterile gloves.

Principles of Sterility

• Principle 1:

  • All objects in a sterile field must be sterile.

• Principle 2:

  • Sterile fields must remain visible at all times.

• Principle 3:

  • Care must be taken to avoid contamination when adding supplies to a sterile field.

• Principle 4:

  • Sterile objects can become non-sterile through prolonged exposure to air or being held below waist level.

• Principle 5:

  • A one-inch border of the sterile drape is considered non-sterile.

Personal Protective Equipment (PPE)

• Masks:

  • Surgical masks protect against large droplets; respirators protect against smaller particles and require fit-testing.

• Gloves:

  • Protect caregiver's hands from contamination.

  • Types include latex, vinyl, or nitrile (consider patient allergies).

• Gowns:

  • Protect caregiver’s clothing and skin from contamination with body fluids.

Sequence for Putting on PPE

1. Gown: Cover torso and secure.

2. Mask: Secure snugly to face and perform fit check.

3. Goggles or Face Shield: Adjust to fit securely.

Sequence for Removing PPE

1. Remove Gloves: Discard properly to avoid contamination.

2. Goggles or Face Shield: Handle by head band.

3. Gown: Touch inside only, dispose properly.

4. Mask: Grasp ties to remove without touching the front.

5. Perform hand hygiene between steps and after all PPE removal.

Isolation Precautions

• Airborne Precautions:

  • Used for diseases like TB, requiring private rooms and N95 masks.

• Droplet Precautions:

  • For mumps, pneumonia, requiring masks within 3 feet of the patient.

• Contact Precautions:

  • For MRSA, C-diff, requiring gloves and gowns.

• Protective Environment Precautions:

  • For immunocompromised individuals, requiring HEPA filtration in rooms.

Evaluation in Infection Control

• Patient Outcomes Evaluated:

  • Risks for infection minimized, absence of infection signs, assessments of wound healing.

  • Compare actual patient responses versus expected outcomes; adjust interventions if goals are unmet.