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Concepts Ch 14 & 16
Concepts of nursing chapters 14 & 16
| Term | Definition |
|---|---|
| Microorganisms | Infections are caused by a variety of these |
| Microorganism | cannot be seen without a microscope but can be touched |
| Pathogens | microorganisms that cause infection in humans |
| Normal Flora | many microorganisms live in and on our bodies, performing needed functions to protect us from harmful pathogens and helping us break down and digest food. |
| Types of pathogens | Bacteria, Viruses, Protozoa, Fungi, or Helminths |
| Bacteria | one-celled microorganisms found virtually everywhere, including in the human body. It is only when they invade an area outside their normal location that problems result. Treated with antibiotics |
| Staphylococcus | the most common bacteria |
| Gram Stain | another step in identifying which coccus, bacillus, or spirillum is under the microscope involves using a dark purple stain |
| gram-positive organisms | those that appear either purple or blue |
| gram-negative organisms | those that appear pink or red |
| Vectors | a living organism that carries and transmits a disease-causing agent (pathogen) from one infected host to another |
| Multiple-drug-resistant organisms (MDROs) | are bacteria that have mutated in such a way that they are resistant to many of the antibiotics normally used to treat infections |
| Community- associated (CA-MRSA) | MRSA infections that occur outside the hospital and affects healthy people. |
| Viruses | are not made up of individual cells; rather, they are very tiny parasites that live within the cells of the host and reproduce there. They can be seen with microscopes, and treated with antiviral |
| Protozoa | single-celled animals that live in water. They can be ingested by humans through water or food, and when that occurs, protozoa cause intestinal illnesses. Treated with antiparasitic drugs |
| Fungi | may be made up of one or more cells. Not all fungi require a microscope to be seen. Although fungi are present in the environment, they cause illness when they enter the human body through cuts or cracks in the skin. Treated with antifungal medications |
| Helminths | a parasitic worm that can inhabit the digestive tract of humans. Can be treated with anthelmintic or antihelmintic |
| Chain of infection | An infectious agent(causative organism), A reservoir(place they grows), A portal of exit(how they leave the reservoir), A mode of transmission(how they was moved), A portal of entry(how they enter the new host), A susceptible host(whose body they entered) |
| Health-care-associated infection (HAI)/Nosocomial infections | is an infection that is required while the patient is being cared for in any health-care setting, including home health care and long-term care. |
| Primary Infection | Initial infection caused by one pathogen only |
| Secondary Infection | Caused by a second, different pathogen |
| Localized Infection | If a person has an infection in one area of the body |
| Systemic Infection | If the infection then spreads from the lungs to other organs and spread through the bloodstream |
| Septicemia | When microorganisms are present and multiplying in the blood. Condition is extremely serious requiring aggressive treatment with IV antibiotic. Infections may start as one type and then progress to another. |
| Primary Defenses | Include body systems, or portions of them, that block or trap invading pathogens |
| Skin | Intact skin protects the body from microbes that would cause disease in subcutaneous or deeper tissue. When breaks in the skin occur, such as cuts, scrapes, and burns, the resulting opening is a portal of entry for pathogens. |
| Mucous Membranes | These membranes produce sticky mucus that traps invading pathogens. In the respiratory tract, the mucus may be coughed up and expectorated or blown out of the nose, taking microorganisms with it. |
| Gastrointestinal System | The mouth provides entry into the gastrointestinal system and contains some bacteria. Saliva contains enzymes that help remove microorganisms from the teeth. Normal flora helps prevent invasion by pathogens. |
| Secondary Defenses | Occurs at the cellular level in reaction to toxins secreted by invading pathogens |
| Inflammatory Process | When injury occurs, white blood cells release histamine and other chemicals that cause blood vessels near the injury to dilate. This dilation results in redness & warmth in the area of injury. |
| Elevated Temperature | The body responds to invading pathogens by creating an hostile environment. The increase of body temperature to 101°F (38.3°C) or higher is too warm for most microorganisms to live & multiply. |
| Complement Cascade | When invading pathogens are detected in the body, complement is released. Complement is a group of specialized proteins that attack the pathogens by releasing chemicals that make their cell membranes rupture. |
| Tertiary Defenses | The third line of defense involves specialized white blood cells called lymphocytes that fight infection, either as B cells or T cells. When pathogens are found, the B and T cells signal phagocytes to destroy the invaders. |
| Factors that affect the body's defenses against infection | Age, chemical Exposure, Chronic Illness, Lack of exercise, Lack or rest, Increased stress, Nonintact skin, Poor nutrition |
| Preventing Infection | The most effective way to break the chain of infection is to use appropriate hand hygiene |
| Standard Precautions | a group of safety measures performed to prevent the transmission of pathogens found in the blood and body fluids. This includes performing hand hygiene, wearing appropriate protective equipment if exposure is possible, and using cough etiquette. |
| Transmission-based precautions | used to prevent the spread of known infection to patients or health-care staff. They are used when a patient has a communicable illness that can be spread through contact, through respiratory droplets, or through the air. |
| Medical Asepsis | refers to practices performed to prevent the spread of infection. It is also sometimes described as using “clean technique.” |
| Surgical Asepsis | refers to maintaining a sterile environment |
| Sterile Technique | Performing procedures in such a way that no pathogens will enter the patients body when you insert tubes or give injections |
| Airborne Transmission | Occurs when infectious particles are so small and lightweight that they can float in the air and be spread through air currents |
| Airborne Infection Isolation Rooms | special rooms that have a lower pressure gradient than the hallway |
| Negative Pressure Rooms | Are designed to prevent microorganisms from floating from the patients room into the hallway |
| Droplet Transmission | can be transmitted from the respiratory system of one person to another through the small droplets that occur when a person coughs, sneezes, or talks. Another person could then inhale or swallow the droplets and contract the illness. |
| Direct Contact | The most common path of microorganism transmission. This means that the microorganism spreads from one person directly to another, usually on the hands. |
| Indirect Contact | occurs when microorganisms leave one person and contaminate an object such as a blood pressure cuff that is then used on another patient. The second patient becomes ill because of contact with the same microorganism. |
| Immobility | Occurs as a result of a lack of activity and movement, which may occur when a person is ill and less active than usual. |
| Muscle Atrophy | When a patient is unable to move about, they can suffer from muscle atrophy, which means the muscle decreases in size, tone, and strength as a result of disuse. |
| Contractures | Shortening and tightening of the muscle because of disuse. |
| Osteoporosis | A conditioned that occurs because of loss of bone minerals; it leads to an increased risk of skeletal fractures. Immobility increases the risk of osteoporosis because a lack of activity and weight-bearing results in a loss of calcium form the bones |
| Supine Position | Correct body alignment |
| Dorsiflexion | The patients ankles should be flexed approximately 90 degrees so that the toes point toward the ceiling. |
| Range-Of-Motion | Are a series of activities designed to move each joint through all of its natural actions |
| Trochanter Roll | A rolled towel or cylindrical device placed snuggly against the lateral aspect of the patients thigh to prevent the leg from rotating outward. |
| Footdrop Boots | A splint like padded device that supports the foot in proper plantar flexion and suspends the heel over a small pocket of air, thereby reducing the risk of pressure injuries and footdrop. |
| Active Range-Of-Motion | Exercises are performed by the patient without physical nursing assistance. The nurse may remind or encourage the patient to perform the exercises, but the patient is able to move all extremities independently. |
| Passive Range-Of-Motion | Exercises are done with the nurse performing the exercise of the patients joints while providing proper support to the patients extremity. Indicated when a patient is too weak to move their own extremities or when one or more extremities are paralyzed. |
| Venous Stasis | Pooling of blood in the veins of the lower legs |
| Deep Vein Thrombosis (DVT) | A clot that develops in the deep veins of the legs |
| Embolus | Any stationary clot or clot fragment may dislodge and enter the circulation. Also known as a traveling blood clot |
| Pulmonary embolus (PE) | When the embolus becomes lodged so that it blocks blood flow to a portion of a vital organ, oxygen and nutrients are prevented from reaching the tissue, resulting in the death of the affected cells. This one occurs in the lungs. |
| Myocardial Infarction (MI)/ Heart Attack | Once the embolus becomes lodged so that it blocks blood flow to a portion of a vital organ, oxygen and nutrients are prevented from reaching the tissue, resulting in the death of the affected cells. This one occurs in the heart |
| Cerebrovascular Accident (CVA)/ Stroke | Once the embolus becomes lodged so that it blocks blood flow to a portion of a vital organ, oxygen and nutrients are prevented from reaching the tissue, resulting in the death of the affected cells. This one occurs in the brain |
| Orthostatic Hypotension/ Postural Hypotension | A decrease in blood pressure that occurs when a patient changes from a reclining or flat position to an upright position, such as sitting or standing |
| Syncope | Fainting |
| Antiembolism Stockings | Close-fitting elastic stockings that usually cover the whole leg |
| Sequential Compression Devices (SCDs) | Air-filled sleeves that are wrapped around the patients lower legs and connect to a pump that inflates and deflates each area of the sleeve in a sequence designed to move blood in the legs toward the heart |
| Effects of Immobility on the Respiratory System | When the patient is unable to move about and take deep breaths, the result is a decrease in lung expansion and respiratory muscle weakness. Pneumonia and pulmonary emboli are adverse respiratory conditions that can occur in immobilized patients. |
| Hypostatic Pneumonia | A type of lung infection that occurs when a patient is immobile |
| Atelectasis | The collapse of lung tissue affecting part or all of lung, can occur because of the inability of the lung to fully expand |
| Hypoxemia | When the alveoli collapse, oxygen and carbon dioxide exchange is impaired, resulting in lowered oxygen in the blood |
| Turning | Turn the patient from side to side at least every 2 hours and make him or her comfortable. This stimulates circulation to help prevent blood clots and prevent stasis of fluids in the lungs. |
| Deep Breathing | Instruct the patient to take a long, slow, deep breath; hold it for 3 seconds; and then exhale slowly. This should be repeated at least five times. This serves to expand the lungs and increase gas exchange. |
| Coughing | Instruct the patient to inhale using long, slow, deep breaths. Hold for 3 seconds and then cough forcefully on the third or fourth expiration. Repeat at least five times. This also helps to prevent stasis of fluid in the lungs. |
| Effects of Immobility on the Gastrointestinal System | The major effect is the lack of peristalsis, or natural movement of the intestines. Without activity, the smooth muscle of the intestines is less active. This results in constipation, flatulence, distention, indigestion and lack of appetite. |
| Effects of Immobility on the Urinary System | The patient who is lying in bed is at risk for a urinary tract infection because urine can pool in the renal pelvis of the kidney. Normally when a person is upright, urine moves from the renal pelvis into the ureters and then to the bladder. |
| Effects of Immobility on the Integumentary System | When a patient is immobile and consistent pressure is applied to the same area of the body, the blood flow to that area is reduced or is stopped entirely. When this occurs, the skin and underlying tissue die. |
| Pressure injury/Skin Breakdown/Decubitus Ulcer | The skin and underlying tissue die. The area may be red at first, but the skin will continue to deteriorate if the circulation to the area does not improve. Shearing of the skin will further destroy the integument. |
| Shearing | Occurs when the skin layer is pulled across muscle and bone in one direction while the skin slides over another surface, such as a bed sheet, in the opposite direction |
| Effects of Immobility on the Neurological System | When a patient is immobile, several neurological complications may result. The patient may become less mentally alert, and their vision may be less clear. Balance and coordination will decrease as immobility persists. |
| Compression Neuropathy | In addition, if the patient is not turned and positioned appropriately, nerves may be compressed between the bones and the firm surface of the bed, resulting in impaired nerve function called compression neuropathy. |
| Footdrop | Most common site for compression neuropathy in the lower extremities is the peroneal nerve at the fibular head. Compression of this nerve can result in footdrop, which causes the foot to point in the downward position of plantar flexion. |
| Psychological Effects of Immobility | Psychological effects of immobility will differ with each individual. Depression, anxiety, hostility, and fear are common adverse effects. Restricted mobility affects the patient’s self-image, independence, and ability to meet their own needs. |
| Position of Function | Means placing the extremities in alignment to maintain the potential for their use and movement. Positioning for function will help prevent undue pressure on nerves and help prevent discomfort, pain, and nerve damage. |
| Supine Position | Description: Lying on the back with arms at sides Purpose: For physical examination, resting in bed, undergoing anesthesia |
| Dorsal Recumbent | Description: Lying on the back with arms at sides, legs apart, knees bent, and feet flat on the bed Purpose: For physical examination of abdomen and genitalia, perineal care, examination during labor |
| Trendelenburg's | Description: Lying on back with arms at sides, bed positioned so that foot is higher than the head Purpose: During some abdominal surgeries to shift abdominal contents upward |
| Reverse Trendelenburg's | Description: Lying on back with arms at sides, bed positioned so that head is higher than foot but with no flexion at waist Purpose: After certain angiography procedures, allows head of bed to be elevated without causing pressure on the femoral artery |
| Lateral | Description: Lying on the left or right side, supported behind back and between knees and ankles with pillows. Purpose: For patient comfort, to promote lung & cardiac function. To relieve pressure on bony prominences of the coccyx and sacrum |
| Left Semi-Prone | Description: Lying on left side in semi-prone position with right leg flexed and drawn up toward the chest; left arm is positioned along the patient’s back Purpose: For rectal examinations and for administering enemas |
| Right Semi-Prone | Description: Lying on right side in semi-prone position with left leg flexed; right arm is positioned along the patient’s back Purpose: To relieve pressure on bony prominences of coccyx and sacrum |
| Fowler's | Description: Semi-sitting position with various degrees of head elevation with knees slightly elevated Purposes vary based on elevation |
| Low Fowler's | Description: Head of bed elevated 30 degrees Purpose: To prevent aspiration during tube feeding |
| Semi-Fowler's | Description: Head of bed elevated 45 degrees Purpose: To comfortably watch television or converse with visitors. After abdominal surgeries to relieve tension on incision. To assist patients who have difficulty breathing. |
| High Fowler's | Description: Head of bed elevated 90 degrees Purpose: To eat and drink without risk of choking To assist patients who have difficulty breathing |
| Orthopneic | Description: Sitting upright with head of bed elevated 90 degrees or on the side of the bed with feet flat on the floor; patient leaning slightly forward with arms raised and elbows flexed, supported on an overbed table. |
| Orthopneic purpose | Purpose: To assist patients in severe respiratory distress by allowing chest to expand to maximum capacity for moving air in and out of the lungs |
| Prone Position | Description: Lying on stomach with head turned to the side Purpose: To improve oxygenation in patients with acute respiratory distress To relieve pressure on the back, coccyx, and hips |
| Lithotomy | Description: Lying on back with knees flexed above the hips and legs supported in stirrups Purpose: For vaginal examinations, delivery of neonate, pelvic and gynecological surgery and procedures |
| Pillow Positioning Device Purpose | Used to keep the head in proper alignment with the spine and reduce excessive pressure on nerves caused by stretching of the neck. Used to relieve pressure on the lumbar spine and increase comfort. |
| Pillow Positioning Device Cont. | Used to reduce rotation of the spine & maintain proper spinal alignment. Placement: Under the head & shoulders when in a supine position. Under the knees in a supine position. Between the knees & ankles in a lateral position. |
| Arm Board | Purpose: Used to prevent flexion of a joint, such as when an IV catheter is near the joint Placement: Wrist or elbow |
| Blanket Roll | Purpose: Used to support the back or soles of the feet Placement: Place blanket roll firmly at the patients back or at the soles of the feet |
| Hand Roll | Purpose: Used to maintain a position of function of the hand and fingers of a patient with decreased movement of the hand and fingers Placement: In the palm of the hand |
| Foot Splint | Purpose: Used to maintain a position of function of the feet in relation to the legs of a patient with decreased movement and strength of the lower extremities Placement: Against the soles of the feet |
| Stirrups | Purpose: Positioning for vaginal surgery, pelvic examination, or delivery of infant Placement: Place feet in the stirrups to position the lower legs and feet in a lithotomy or dorsal recumbent position |
| Trochanter Roll | Purpose: Used to prevent rotation of the legs Placement: At the lateral side of the hip and thigh |
| Trapeze Bar | a triangular device suspended above the patient on an overbed frame, allows the patient to lift some or all of their weight off of the bed, which is helpful when moving the patient up in bed or turning the patient |
| Logroll | When a patient has undergone spinal surgery or has a spinal injury, it is necessary to turn their body as one unit. The patient is turned in the same way a log would be rolled. Three nursing are required to correctly logroll a patient. |
| Logroll Safety | It is very important that all three staff members turn the patient at the same time. Failure to do so can cause damage to the patient’s spine, which could potentially result in paralysis. |
| Transferring Patients | It is very important that you know the correct way to transfer, or move patients from one place to another, in a way that is safe both for you and for the patient. |
| Gait Belt | This device is placed around the patient’s waist during transfers or ambulation. It provides a place for you to grasp the patient without holding onto clothing that could tear or come loose if the patient loses his or her balance. |
| Slide Sheets | Are nylon friction-reducing devices made of thin webbed nylon sheets slightly smaller than the surface of the hospital bed. A slide sheet is placed beneath the patient, allowing the patient to move easily from the bed to a stretcher or up in the bed |
| Slide Boards/Transfer Boards | Are another method used to transfer a patient from the bed to a stretcher or a stretcher to the bed. A slide board is a hard, thin, flat plastic board that can be used with a draw sheet or plastic trash bag to help reduce friction |
| Sit-to-Stand | Useful when transferring a patient who is in need of assistance, such as those who are weak, older, or recovering from surgery. These devices may be used to transfer the patient from the bed to the chair, the bedside commode, or the bathroom. |
| Lifts | Sling-type, battery-operated patient lifts are used for the non-weight-bearing patient. The patient is rolled to the side, and a sling constructed of a thin webbed material is positioned beneath them according to the manufacturer’s recommendations. |
| Manual Transfer | If you must transfer a patient without an assistive device (called a manual transfer), you must use proper body mechanics. |
| Proper Body Mechanics | Proper body mechanics includes using a wide base of support and standing close to the object being moved, keeping your back straight, and avoiding twisting your torso. Use your thigh muscles instead of the muscles in your back. |
| Assisting With Ambulation | Patients needing assistance with ambulation should move from the supine position to the standing position in stages to avoid possible dizziness, orthostatic hypotension, and syncopal episodes. |
Created by:
makiyas
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