1104 Unit 1

Aerobic

bacteria require oxygen for survival and for multiplication sufficient to cause disease. Aerobic organisms cause more infections in humans than anaerobic organisms. An example of an aerobic organism is Staphylococcus aureus

Anaerobic

bacteria thrive where little or no free oxygen is available. Anaerobes typically cause infections deep within the pleural cavity, in a joint, or in a deep sinus tract. An example of an anaerobic organism is Bacteroides fragilis, an organism that is part of the normal flora of the human colon but can cause infection if displaced into the bloodstream or surrounding tissue following surgery or injury

Nonverbal Communication

erbal communication includes the five senses and everything that does not involve the spoken or written word. Nonverbal aspects of communication such as voice tone, eye contact, and body positioning are often as important as verbal messages (Dossey and Keegan, 2013). Thus nonverbal communication is unconsciously motivated and more accurately indicates a person's intended meaning than spoken words (Stuart, 2013). When there is incongruity between verbal and nonverbal communication, the receiver usually "hears" the nonverbal message as the true message.

Communication

establishes these caring healing relationships. All behavior communicates, and all communication influences behavior You become more competent in the nursing process as your communication skills develop. You learn to integrate communication skills throughout the nursing process as you collaborate with patients and health care team members to achieve goals (Box 24-1). Use communication skills to gather, analyze, and transmit information and accomplish the work of each step of the process. Assessment, diagnosis, planning, implementation, and evaluation all depend on effective communication among nurse, patient, family, and others on the health care team

Metacommunication

is a broad term that refers to all factors that influence communication. Awareness of influencing factors helps people better understand what is communicated (Arnold and Boggs, 2011). For example, a nurse observes a young patient holding his body rigidly, and his voice is sharp as he says, "Going to surgery is no big deal." The nurse replies, "You say having surgery doesn't bother you, but you look and sound tense. I'd like to hear more about how you're feeling." Awareness of the tone of the verbal response and the nonverbal behavior results in further exploration of the patient's feelings and concerns.

Sharing Empathy

is the ability to understand and accept another person's reality, accurately perceive feelings, and communicate this understanding to the other. This is a therapeutic communication technique that enables you to understand a patient's situation, feelings, and concern

Asepsis

is the absence of pathogenic (disease-producing) microorganisms. Aseptic technique refers to the practices/procedures that help reduce the risk for infection. The two types of aseptic technique are medical and surgical asepsis. Basic medical aseptic techniques break the chain of infection

Blood Pressure

is the force exerted on the walls of an artery by the pulsing blood under pressure from the heart. Blood flows throughout the circulatory system because of pressure changes. It moves from an area of high pressure to one of low pressure. Systemic or arterial BP, the BP in the system of arteries in the body, is a good indicator of cardiovascular health. The contraction of the heart forces the blood under high pressure into the aorta.

Infection

is the invasion of a susceptible host (e.g., human being)

Colonization

is the presence and growth of microorganisms within a host but without tissue invasion or damage

Evaporation

is the transfer of heat energy when a liquid is changed to a gas. The body continuously loses heat by evaporation. Approximately 600 to 900 mL a day evaporates from the skin and lungs, resulting in water and heat loss. By regulating perspiration or sweating, the body promotes additional evaporative heat loss. When body temperature rises, the anterior hypothalamus signals the sweat glands to release sweat through tiny ducts on the surface of the skin. Sweat evaporates, resulting in heat loss. During physical exercise over 80% of the heat produced is lost by evaporation

Conduction

is the transfer of heat from one object to another with direct contact. Solids, liquids, and gases conduct heat through contact. When the warm skin touches a cooler object, heat is lost. Conduction normally accounts for a small amount of heat loss. Applying an ice pack or bathing a patient with a cool cloth increases conductive heat loss. Applying several layers of clothing reduces conductive loss. The body gains heat by conduction when it makes contact with materials warmer than skin temperature (e.g., application of an aquathermia pad).

Radiation

is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. As much as 85% of the surface area of the human body radiates heat to the environment. Peripheral vasodilation increases blood flow from the internal organs to the skin to increase radiant heat loss. Peripheral vasoconstriction minimizes radiant heat loss. Radiation increases as the temperature difference between the objects increases. Radiation heat loss can be considerable during surgery when the patient's skin is exposed to a cool environment. However, if the environment is warmer than the skin, the body absorbs heat through radiation tient's position enhances radiation heat loss (e.g., standing exposes a greater radiating surface area, and lying in a fetal position minimizes heat radiation). Help promote heat loss through radiation by removing clothing or blankets. Covering the body with dark, closely woven clothing decreases the amount of heat lost from radiation.

Diaphoresis

is visible perspiration primarily occurring on the forehead and upper thorax, although you can see it in other places on the body. For each hour of exercise in hot conditions image to 2 L of body fluid can be lost in sweat (Rowland, 2011). Excessive evaporation causes skin scaling and itching and drying of the nares and pharynx. A lowered body temperature inhibits sweat gland secretion. People who have a congenital absence of sweat glands or a serious skin disease that impairs sweating are unable to tolerate warm temperatures because they cannot cool themselves adequately.

Active Listening

means being attentive to what a patient is saying both verbally and nonverbally. It facilitates patient communication. Inexperienced nurses sometimes feel the need to talk to prove that they know what they are doing or to decrease anxiety

Capnography (ETCO2)

measurement of exhaled carbon dioxide through exhalation, at the end of exhalation the ETCO2 measurement approximates the PaCo2 (normally 35-45 mm Hg in a health patient) In nonintubated patients ETCO2 can be obtained from special nasal cannula connected to monitor to detect carbon dioxide percentage at the end of the respiratory cycle. ETCO2 can also be used to detect respiratory and cardiac status

Fever (Pyrexia)

occurs because heat-loss mechanisms are unable to keep pace with excessive heat production, resulting in an abnormal rise in body temperature. A fever is usually not harmful if it stays below 39° C (102.2° F) in adults or below 40° C (104° F) in children. A single temperature reading does not always indicate a fever. In addition to physical signs and symptoms of infection, fever determination is based on several temperature readings at different times of the day compared with the usual value for that person at that time. The hypothalamus reacts to raise the set point, and the body responds by producing and conserving heat. Several hours pass before the body temperature reaches the new set point. During this period a person experiences chills, shivers, and feels cold, even though the body temperature is rising (Figure 30-3). The chill phase resolves when the new set point, a higher temperature, is achieved. During the next phase, the plateau, the chills subside, and the person feels warm and dry. If the new set point is "overshot" or the pyrogens are removed (e.g., destruction of bacteria by antibiotics), the third phase of a febrile episode occurs. The hypothalamus set point drops, initiating heat-loss responses. The skin becomes warm and flushed because of vasodilation. Diaphoresis assists in evaporative heat loss. When the fever "breaks," the patient becomes afebrile.

Heat Exhaustion

occurs when profuse diaphoresis results in excess water and electrolyte loss. Caused by environmental heat exposure, a patient exhibits signs and symptoms of deficient fluid volume (see Chapter 42). First aid includes transporting him or her to a cooler environment and restoring fluid and electrolyte balance.

Orthostatic Hypotension (postural hypotension)

occurs with normotensive person develops symptoms and a drop in systolic pressure by at least 20 mmHg or a drop in diastolic pressure by at least 10 mmHg within 3 minutes of standing or postural change of being upright when a healthy person changes position from laying to sitting to standing the peripheral blood vessels in the legs constrict when standing the lower extremity vessels constrict preventing blood pooling in the legs caused by gravity thus a normal individual does not feel any symptoms when standing. in contrast when patients have decreased blood volume their blood vessels are already constricted, when patient with decreased volume stand there is a significant drop in BP, with an increase in HR, to compensate with cardiac output patients with anemia dehydration, or experienced prolonged bedrest or excessive blood loss, are at risk for orthostatic hypotension some medications can cause orthstatic hypotension if misused Assess for orthostatic hypotension during measurements of vital signs by obtaining BP and pulse in sequence with the patient supine, sitting, and standing

Hematocrit

percentage of RBC in the blood, also determines blood viscosity (thickness) when hematocrit rises and blood flow slows, arterial BP increases

Reservoir

place where microorganisms survive, multiply, and await transfer to a susceptible host. Common reservoirs are humans and animals (hosts), insects, food, water, and organic matter on inanimate surfaces (fomites). Frequent reservoirs for HAIs include health care workers, especially their hands; patients; equipment; and the environment. Human reservoirs are divided into two types: those with acute or symptomatic disease and those who show no signs of disease but are carriers of it. Humans can transmit microorganisms in either case. Animals, food, water, insects, and inanimate objects can also be reservoirs for infectious organisms. To thrive organisms require a proper environment, including appropriate food, oxygen, water, temperature, pH, and light

Hypotension

present when systolic BP falls below 90 mmHg occurs because of dilation of the arteries in the vascular bed, loss of blood volume, or failure of the heart to pump properly Hypotension that is associated with pallor, skin mottling, clamminess, confusion, increased HR, decreased urine output, is life threatening and needs reported to physician immediately

Measurement of Arterial Oxygen Saturation

pulse oximeter permits indirect measurement of oxygen saturation LED light emits wave lengths that the oxygenated and deoxygenated hemoglobin molecules absorb differently a photodetector in the probe detects amount of oxygen bound to hemoglobin molecules, and the oximeter calculates the SpO2 (pulse saturation) SpO2 is a reliable estimate of SaO2 what SaO2 is over is over 70% a saturation of less than 90% is a clinical emergency gtq

Pyrogens

such as bacteria and viruses elevate body temperature. They act as antigens, triggering immune system responses

AIDET

technique developed by the Studer Group to enable health care workers to provide accurate and timely communication to patients and families while focusing on excellent patient service. It is a technique commonly used in hospitals today. The acronym stands for Acknowledge, Introduce, Duration, Explain, and Thank you.

Therapeutic Communication Techniques

techniques are specific responses that encourage the expression of feelings and ideas and convey acceptance and respect. These techniques apply in a variety of different situations. Although some of the techniques seem artificial at first, skill and comfort increase with practice. Tremendous satisfaction results from developing therapeutic relationships that achieve desired patient outcomes.

Perfusion

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

Ventilation

the movement of gases in and out of the lungs

Diffusion

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

Psychological Implications of Isolation

the overall experience of isolation is commonly viewed negatively (Barratt, 2010). Isolation imposes barriers to the expression of a patient's identity and normal interpersonal relationships and affects the delivery of quality care. When a patient requires isolation in a private room, a sense of loneliness sometimes develops because normal social relationships become disrupted. This situation can be psychologically harmful, especially for children.

Blood Volume

the volume of blood circulating within vascular system effects BP most adults have circulating blood volume of 5000mL an increase in volume increases pressure against wall, and decrease of volume decreases pressure

Verbal communication

uses spoken or written words. Verbal language is a code that conveys specific meaning through a combination of words.

Arteriosclerosis

vessel walls loose elasticity and are replaced by fibrous tissue that cannot stretch well. reduced elasticity results in greater resistance to blood flow resulting when the left ventricle releases SV the vessels no longer yield to pressure, instead a given volume of blood is forced through the rigid arterial wall and systemic pressure rises. Making systolic pressure higher than diastolic pressure due to reduced elasticity

Communication Objectives

• Demonstrate qualities, behaviors, and communication techniques of professional communication while interacting with patients. • Identify opportunities to improve communication with patients while giving care. • Engage in effective communication techniques for older patients. • Offer alternative communication devices when appropriate to promote communication with patients who have impaired communication. • Implement nursing care measures for patients with special communication needs.

Focus on Older Adults

• Make sure the patient knows that you are talking. • Face the patient, be sure that your face/mouth is visible to him or her, and do not chew gum or talk while chewing. • Speak clearly but do not exaggerate lip movement or shout. • Speak a little more slowly but not excessively slow. • Check if patient uses hearing aids, glasses, or other adaptive equipment. • Choose a quiet, well-lit environment with minimal distractions. • Allow time for the patient to respond. Do not assume that patient is being uncooperative if he or she does not reply or takes a long time to reply. • Give the patient a chance to ask questions. • Keep communication short and to the point. Ask one question at a time

Guidelines for Measuring Vital Signs

• Measuring vital signs is your responsibility. You may delegate measurement of vital signs in selected situations (e.g., in stable patients). However, it is your responsibility to review vital sign data, interpret their significance, and critically think through decisions about interventions. • Assess equipment to ensure that it is working correctly and provides accurate findings. • Select equipment on the basis of the patient's condition and characteristics (e.g., do not use an adult-size BP cuff for a child). • Know the patient's usual range of vital signs. These values can differ from the acceptable range for that age or physical state. The patient's usual values serve as a baseline for comparison with later findings. Thus you are able to detect a change in condition over time. • Know your patient's medical history, therapies, and prescribed medications. Some illnesses or treatments cause predictable changes in vital signs. Some medications affect one or more vital signs. • Control or minimize environmental factors that affect vital signs. For example, assessing a patient's temperature in a warm, humid room may yield a value that is not a true indicator of his or her condition. • Use an organized, systematic approach when taking vital signs. Each procedure requires a step-by-step approach to ensure accuracy. • On the basis of a patient's condition, collaborate with health care providers to decide the frequency of vital sign assessment. In the hospital health care providers order a minimum frequency of vital sign measurements for each patient. Following surgery or treatment intervention you measure vital signs more frequently to detect complications. In a clinic or outpatient setting you take vital signs before the health care provider examines the patient and after any invasive procedures. As a patient's physical condition worsens, it is often necessary to monitor vital signs as often as every 5 to 10 minutes. The nurse is responsible for judging whether more frequent assessments are necessary (Box 30-2). • Use vital sign measurements to determine indications for medication administration. For example, give certain cardiac drugs only within a range of pulse or BP values. Administer antipyretics when temperature is elevated outside of the acceptable range for the patient. Know the acceptable ranges for your patients before administering medications. • Analyze the results of vital sign measurement on the basis of patient's condition and past medical history. • Verify and communicate significant changes in vital signs. Baseline measurements provide a starting point for identifying and accurately interpreting possible changes. When vital signs appear abnormal, have another nurse or health care provider repeat the measurement to verify readings. Inform the charge nurse or health care provider immediately, document findings in your patient's record, and report vital sign changes to nurses during hand-off communication (TJC, 2016) • Instruct the patient or family caregiver in vital sign assessment and the significance of findings

Implications for Patient-Centered Care

• Understand your own cultural values and biases. • Assess the patient's primary language and level of fluency in English. • Provide a professional interpreter for the patient and health care providers to communicate with one another. Do not use a family member as an interpreter. • Speak directly to the patient even if an interpreter is present. • Nodding or statements such as "OK" do not necessarily mean that the patient understands. • Provide written information in English and primary language. • Learn about other cultures, especially those commonly encountered in your work area. • Incorporate the patient's communication methods or need into plan of care.

Fire safety: Follow the acronym RACE.

(1) R escue patient from immediate injury by removing from area or shielding from fire to avoid burns. (2) A ctivate fire alarm immediately. Follow agency policy for alerting staff to respond. (In many situations perform Steps (1) and (2) simultaneously by using call system to alert staff while you help patients at risk.) (3) C ontain the fire by: (a) Closing all doors and windows. (b) Turning off oxygen and electrical equipment. (c) Placing wet towels along base of doors. (4) E vacuate patients: (a) Direct ambulatory patients to walk by themselves to a safe area. Know the fire exits and emergency evacuation route. (b) If patient is on life support, maintain respiratory status manually (Ambu bag) until you remove him or her from fire area. (c) Move bedridden patients by stretcher, bed, or wheelchair. (d) For patients who cannot walk or ambulate use these options: (i) Place on blanket and drag patient out of area of danger. (ii) Use two-person swing: Place patient in sitting position and have two staff members form a seat by clasping forearms together. Lift patient into "seat" and carry out of area of danger

White blood cell (WBC) count

5000-10,000/mm3 Increased in acute infection, decreased in certain viral or overwhelming infections This is the primary lab you need to know to testing in NURS 1871. What is a normal WBC?

Iron level

80-180 mcg/mL for men 60-160 mcg/ml for women Decreased in chronic infection

Factors Influencing Infection Control and Prevention: Nutrition

A patient's nutritional health directly influences susceptibility to infection. A reduction in the intake of protein and other nutrients such as carbohydrates and fats reduces body defenses against infection and impairs wound healing (see Chapter 48). Patients with illnesses or problems that increase protein requirements, such as extensive burns and febrile conditions, are at further risk. For example, patients who have undergone surgery require increased protein. A thorough diet history is necessary. Determine a patient's normal daily nutrient intake and whether preexisting problems such as nausea, impaired swallowing, or oral pain alter food intake. Confer with a dietitian to assist in calculating the calorie count of foods ingested

Oxygen Reservoir

Aerobic bacteria require oxygen for survival and for multiplication sufficient to cause disease. Aerobic organisms cause more infections in humans than anaerobic organisms. An example of an aerobic organism is Staphylococcus aureus. Anaerobic bacteria thrive where little or no free oxygen is available. Anaerobes typically cause infections deep within the pleural cavity, in a joint, or in a deep sinus tract. An example of an anaerobic organism is Bacteroides fragilis, an organism that is part of the normal flora of the human colon but can cause infection if displaced into the bloodstream or surrounding tissue following surgery or injury.

Factors Influencing Blood Pressure- Ethnicity

African Americans are at greater risk for hypertension, developing more severe hypertension at an earlier age and twice the risk for complications such as heart attack or stroke. Hypertension related deaths are higher among African Americans as well

Portal of Exit

After microorganisms find a site to grow and multiply, they need to find a portal of exit if they are to enter another host and cause disease. Portals of exit include sites such as blood, skin and mucous membranes, respiratory tract, genitourinary (GU) tract, gastrointestinal (GI) tract, and transplacental (mother to fetus). Some viruses such as Ebola virus are transmitted through direct contact with the blood or body fluids of a person who is sick with Ebola. However, droplets (e.g., splashes or sprays) of respiratory or other secretions from a person who is sick with Ebola could also be infectious. Therefore certain precautions (called standard, contact, and droplet precautions) are recommended for use in health care settings to prevent the transmission of the virus from patients who are sick with Ebola to health care personnel and other patients or family members

Factors that effecting Body Temperature

Age, Exercise, Hormone Level, Circadian Rhythm, Stress, Environment, Temperature Alteration,

Hyperthermia

An elevated body temperature related to the inability of the body to promote heat loss or reduce heat production is hyperthermia. Whereas fever is an upward shift in the set point, hyperthermia results from an overload of the thermoregulatory mechanisms of the body. Any disease or trauma to the hypothalamus impairs heat-loss mechanisms. Malignant hyperthermia is a hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs.

Pulse Deficit

An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a pulse deficit. To assess a pulse deficit you and a colleague assess radial and apical rates simultaneously and then compare rates. The difference between the apical and radial pulse rates is the pulse deficit. For example, an apical rate of 92 with a radial rate of 78 leaves a pulse deficit of 14 beats. Pulse deficits are often associated with abnormal rhythms.

Nature of Infection

An infection is the invasion of a susceptible host (e.g., human being) by pathogens or microorganisms, resulting in disease. It is important to know the difference between an infection and colonization

Dysrhythmia

An interval interrupted by an early or late beat or a missed beat indicates an abnormal rhythm or dysrhythmia. A dysrhythmia threatens the ability of the heart to provide adequate cardiac output, particularly if it occurs repetitively. You identify a dysrhythmia by palpating an interruption in successive pulse waves or auscultating an interruption between heart sounds. If a dysrhythmia is present, assess the regularity of its occurrence and auscultate the apical rate (see Chapter 31). Dysrhythmias are described as regularly irregular or irregularly irregular. Children often have a sinus dysrhythmia, which is an irregular heartbeat that speeds up with inspiration and slows with expiration. This is a normal finding that you can verify by having the child hold his or her breath; the HR usually becomes regular

Factors Influencing Blood Pressure- Stress

Anxiety, Fear, Pain, and Emotional Stress can result in Sympathetic stimulation which increases HR, cardiac output and vascular resistance The effect of sympathetic can increase BP as much as 30mm Hg

communicable disease

Any disease that can be transmitted from one person or animal to another by direct or indirect contact or by vectors

Hypoxemia

Arterial blood oxygen level less than 60 mm Hg; low oxygen level in the blood. If arterial oxygen levels fall, these receptors signal the brain to increase the rate and depth of ventilation. Hypoxemia helps to control ventilation in patients with chronic lung disease. Because low levels of arterial O2 provide the stimulus that allows a patient to breathe, administration of high oxygen levels is fatal for patients with chronic lung disease.

Communication Throughout the Nursing Process

Assessment • Verbal interviewing and history taking • Visual and intuitive observation of nonverbal behavior • Visual, tactile, and auditory data gathering during physical examination • Written medical records, diagnostic tests, and literature review Nursing Diagnosis • Intrapersonal analysis of assessment findings • Validation of health care needs and priorities via verbal discussion with patient • Documentation of nursing diagnosis Planning • Interpersonal or small-group health care team planning sessions • Interpersonal collaboration with patient and family to determine implementation methods • Written documentation of expected outcomes • Written or verbal referral to health care team members Implementation • Delegation and verbal discussion with health care team • Verbal, visual, auditory, and tactile health teaching activities • Provision of support via therapeutic communication techniques • Contact with other health resources • Written documentation of patient's progress in medical record Evaluation • Acquisition of verbal and nonverbal feedback • Comparison of actual and expected outcomes • Identification of factors affecting outcomes • Modification and update of care plan • Verbal and/or written explanation of care plan revisions to patient

Factors Influencing Blood Pressure- Age

BP changes from childhood to adulthood increasing and decreasing

Common Pathogens and Some Infections or Diseases They Produce

Bacteria Escherichia coli Colon Gastroenteritis, urinary tract infection Staphylococcus aureus Skin, hair, anterior nares, mouth Wound infection, pneumonia, food poisoning, cellulitis streptococcus (beta-hemolytic group A) organisms Oropharynx, skin, perianal area "Strep throat," rheumatic fever, scarlet fever, impetigo, wound infection Streptococcus (beta-hemolytic group B) organisms Adult genitalia Urinary tract infection, wound infection, postpartum sepsis, neonatal sepsis Mycobacterium tuberculosis Droplet nuclei from lungs, larynx Tuberculosis Neisseria gonorrhoeae GU tract, rectum, mouth Gonorrhea, pelvic inflammatory disease, infectious arthritis, conjunctivitis Rickettsia rickettsii Wood tick Rocky Mountain spotted fever Staphylococcus epidermidis Skin Wound infection, bacteremia Viruses Hepatitis A virus Feces Hepatitis A Hepatitis B virus Blood and certain body fluids, sexual contact Hepatitis B Hepatitis C virus Blood, certain body fluids, sexual contact Hepatitis C Herpes simplex virus (type 1) Lesions of mouth or skin, saliva, genitalia Cold sores, aseptic meningitis, sexually transmitted disease, herpetic whitlow Human immunodeficiency virus (HIV) Blood, semen, vaginal secretions via sexual contact Acquired immunodeficiency syndrome (AIDS) Fungi Aspergillus organisms Soil, dust, mouth, skin, colon, genital tract Aspergillosis, pneumonia, sepsis Candida albicans Mouth, skin, colon, genital tract Candidiasis, pneumonia, sepsis Protozoa Plasmodium falciparum Blood Malaria

Cardiac Output

Blood Pressure depends on cardiac output. When volume increases in blood vessel the pressure rises, increasing cardiac output Cardiac Output increases as a result of increased heart rate Greater Heart muscle contractility or an increase of blood volume Changes in heart rate occur faster than changes in heart muscle contractility or blood volume a rapid or significant increase in HR decreasing the filling time of the heart, as a result BP decreases

Factors Influencing Blood Pressure- Daily Variations

Blood Pressure varies throughout the day Lower BP during sleep between midnight and 3am Rising between 3am-6am Early morning surge after patient awakens Highest being during the day between 10am-6pm

Physiology of Arterial Blood Pressure

Blood pressure reflects the interrelationships of cardiac output, peripheral vascular resistance, blood volume, blood viscosity, and artery elasticity. Your knowledge of these hemodynamic variables helps in the assessment of BP alterations

Body Temperature

Body Temperature is the difference between the amount of heat produced by body process and the amount lost to the external environment Body Temperature = Heat Produced - Heat Lost

Physiological Control of Ventilation

Body regulates ventilation by using levels of O2, CO2, and hydrogen ion concentration (pH) in the arterial blood the MOST important factor in the control of ventilation is the level of CO2 in the arterial blood, and elevation of CO2 causes respiratory control center in the brain to increase rate and depth of breathing, increased ventilation effort removes excess CO2 (hypercarbia) by increasing exhalation People with chronic lung disease have ongoing hypercarbia, for these patients chemoreceptors in the carotid artery and aorta become sensitive to hypoxemia, if arterial levels fall these receptors signal brain to increase rate and depth of ventilation. Hypoxemia- low levels of arterial O2 hypoxemia helps control ventilation in patients with chronic lung disease because low levels of O2 provides stimulus that allows patient to breathe administration of high oxygen can be fatal for patients with chronic lung disease

Implementation

By identifying and assessing a patient's risk factors and implementing appropriate measures, you can effectively reduce the risk of infection It is very important to think about your patients situation once they leave your care. what risks in relation to infection will they have and what can you do to prevent any or further infection. what teaching and changes in their environment would be important

The Infectious Process

By understanding the chain of infection, you have knowledge that is vital in preventing infections. When the patient acquires an infection, observe for signs and symptoms of infection and take appropriate actions to prevent its spread. Infections follow a progressive course

Modes of Transmission

Contact Direct • Person-to-person (fecal, oral) physical contact between source and susceptible host (e.g., touching patient feces and then touching your inner mouth or consuming contaminated food) Indirect • Personal contact of susceptible host with contaminated inanimate object (e.g., needles or sharp objects, dressings, environment) Droplet • Large particles that travel up to 3 feet during coughing, sneezing, or talking and come in contact with susceptible host Airborne • Droplet nuclei or residue or evaporated droplets suspended in air during coughing or sneezing or carried on dust particles Vehicles • Contaminated items • Water • Drugs, solutions • Blood • Food (improperly handled, stored, or cooked; fresh or thawed meats) Vector • External mechanical transfer (flies) • Internal transmission such as parasitic conditions between vector and host such as: • Mosquito • Louse • Flea • Tick

Sites for Temperature

Core and surface body temperature can be measured at several sites. Intensive care units use the core temperatures of the pulmonary artery, esophagus, and urinary bladder. These measurements require the use of continuous invasive devices placed in body cavities or organs and continually display readings on an electronic monitor.

Sociocultural Factors

Culture influences thinking, feeling, behaving, and communicating. Be aware of the typical patterns of interaction that characterize various ethnic groups, but do not allow this information to bias your response. Know each patient individually (e.g., does he or she feel comfortable with eye contact or in sharing information with others). You will approach a patient very differently if he or she is open and willing to discuss private family matters versus others who are reluctant to reveal personal or family information to strangers Use of family members, children, or auxiliary personnel poses legal liabilities

Procedural Guidelines: Caring for a Patient on Isolation Precautions

Delegation Considerations The skill of caring for a patient on isolation precautions can be delegated to nursing assistive personnel (NAP). However, it is the nurse who assesses the patient's status and isolation indications. Instruct NAP about: • Reason patient is on isolation precautions. • Precautions about bringing equipment into the patient's room. • Special precautions regarding individual patient needs such as transportation to diagnostic tests. Equipment Personal protective equipment (PPE) determined by type of isolation—gloves, gowns, masks, protective eyewear, or face shield—that may be needed; supplies depend on procedures performed in room; sharps container; disposable blood pressure (BP) cuff. Steps 1. Assess isolation indications (e.g., patient's medical history for exposure, laboratory tests, and wound drainage). 2. Review laboratory test results to identify type of microorganism for which the patient is isolated and if patient is immunocompromised. 3. Review agency policies and precautions necessary for the specific isolation system and consider care measures you will perform while in patient's room. 4. Review nurses' notes or speak with colleagues regarding patient's emotional state and adjustment to isolation. 5. Determine if patient has latex allergy to avoid sensitivity or allergic reaction. 6. Perform hand hygiene and prepare all equipment that you need to take into patient's room. In some cases equipment remains in the room (stethoscope or BP cuff). Decide which isolation equipment is necessary before entering the patient's room. For example, decide if you need a gown and gloves for a patient in contact precautions or a special respirator mask for a patient on airborne precautions. 7. Prepare for entrance into isolation room: a. Apply cover gown, being sure that it covers all outer garments. Pull sleeves down to wrist. Tie securely at neck and waist

Diastolic Pressure

Diastolic Pressure is the minimal pressure exerted against arterial walls at all times Standard unit for measuring BP is millimeters of mercury (mm Hg) the measurement indicates the height to which BP raises a column of mercury

Eosinophils

Differential Count (Percentage of Each Type of White Blood Cell) 1%-4% Increased in parasitic infection

Basophils

Differential Count (Percentage of Each Type of White Blood Cell) 0.5%-1.5% Normal during infection

Monocytes

Differential Count (Percentage of Each Type of White Blood Cell) 2%-8% Increased in protozoan, rickettsial, and tuberculosis infections

Lymphocytes

Differential Count (Percentage of Each Type of White Blood Cell) 20%-40% Increased in chronic bacterial and viral infection, decreased in sepsis

Neutrophils

Differential Count (Percentage of Each Type of White Blood Cell) 55%-70% Increased in acute suppurative (pus-forming) infection, decreased in overwhelming bacterial infection (older adult)

Lower-Extremity Blood Pressure

Dressings, IV Catheters, Casts, or anteriovenous fistulas or shunts make the upper extremities inaccessible for BP management and would need to obtain from lower extremity comparing upper extremity BP with that of lower extremity BP is also necessary with patients with certain cardiac and BP abnormalities popletiel artery behind the knee is the site for auscultation with patient sitting in the prone position systolic artery in the leg is usually higher by 10-40 mmHg higher than brachial but dystolic should be the same

Complications with Fever

During a fever cellular metabolism increases, and oxygen consumption rises. Body metabolism increases 10% for every degree Celsius of temperature elevation. Heart and respiratory rates increase to meet the metabolic needs of the body for nutrients. The increased metabolism uses energy that produces additional heat. If a patient has a cardiac or respiratory problem, the stress of a fever is great. A prolonged fever weakens a patient by exhausting energy stores. Increased metabolism requires additional oxygen. If the body cannot meet the demand for additional oxygen, cellular hypoxia (inadequate oxygen) occurs. Myocardial hypoxia produces angina (chest pain). Cerebral hypoxia produces confusion. Interventions during a fever include oxygen therapy. When water loss through increased respiration and diaphoresis is excessive, the patient is at risk for fluid volume deficit. Dehydration is a serious problem for older adults and children with low body weight. Maintaining optimum fluid volume status is an important nursing action

Auscultation of BP

During the initial assessment obtain and record the BP in both arms. Normally there is a difference of 5 to 10 mm Hg between the arms. In subsequent assessments measure the BP in the arm with the higher pressure. Pressure differences greater than 10 mm Hg indicate vascular problems and are reported to the health care provider or nurse in charge. Ask the patient to state his or her usual BP.

Modes of Transmission

Each disease has a specific mode of transmission. Many times you are able to do little about the infectious agent or the susceptible host; but, by practicing infection prevention and control techniques such as hand hygiene, you interrupt the mode of transmission (Box 29-1). The same microorganism is sometimes transmitted by more than one route. For example, varicella zoster (chickenpox) is spread by the airborne route in droplet nuclei or by direct contact.

Sharing Feelings

Emotions are subjective feelings that result from one's thoughts and perceptions When you care for patients, be aware of your own emotions because feelings are difficult to hide

Assessment of Diffusion and Perfusion

Evaluate the respiratory process of diffusion and perfusion by measuring oxygen saturation of the blood. blood flow through the pulmonary capillaries delivers red blood cells for oxygen attachment. After oxygen diffuses from alveoli into pulmonary blood, most of the oxygen attaches to hemoglobin molecules in red blood cells. RBC carry oxygenated hemoglobin molecules through left side of heart and out to peripheral capillaries, where oxygen detaches, depending on needs of the tissue percent of hemoglobin that is bound with oxygen in the arteries is percent of saturation on hemoglobin (SaO2) usually between 95%-100% and is effected by factors that interfere with ventilation, perfusion, diffusion. Saturation of Venous Blood (SvO2) is lower because tissues have removed some of the hemoglobin molecules, usually 70%, factors that interfere with or increase or tissue oxygen demand affect normal value

Factors Influencing Character of Respirations

Exercise • Exercise increases rate and depth to meet the need of the body for additional oxygen and to rid the body of CO2. Acute Pain • Pain alters rate and rhythm of respirations; breathing becomes shallow. • Patient inhibits or splints chest wall movement when pain is in area of chest or abdomen. Anxiety • Anxiety increases respiration rate and depth as a result of sympathetic stimulation. Smoking • Chronic smoking changes pulmonary airways, resulting in increased rate of respirations at rest when not smoking. Body Position • A straight, erect posture promotes full chest expansion. • A stooped or slumped position impairs ventilatory movement. • Lying flat prevents full chest expansion. Medications • Opioid analgesics, general anesthetics, and sedative hypnotics depress rate and depth. • Amphetamines and cocaine sometimes increase rate and depth. • Bronchodilators slow rate by causing airway dilation. Neurological Injury • Injury to brainstem impairs respiratory center and inhibits respiratory rate and rhythm. Hemoglobin Function • Decreased hemoglobin levels (anemia) reduce oxygen-carrying capacity of the blood, which increases respiratory rate. • Increased altitude lowers amount of saturated hemoglobin, which increases respiratory rate and depth. • Abnormal blood cell function (e.g., sickle cell disease) reduces ability of hemoglobin to carry oxygen, which increases respiratory rate and depth.

Focusing

Focusing involves centering a conversation on key elements or concepts of a message. If conversation is vague or rambling or patients begin to repeat themselves, focusing is a useful technique. Do not use focusing if it interrupts patients while they are discussing important issues. Rather use it to guide the direction of conversation to important areas: "We've talked a lot about your medications; now let's look more closely at the trouble you're having in taking them on time."

Planning

Goals and Outcomes. The patient's care plan is based on each nursing diagnosis and related factor (see the Nursing Care Plan). Develop a plan that sets realistic outcomes so interventions are purposeful, direct, and measurable. For example, when you care for a patient with broken skin and obesity, the nursing diagnosis of Risk for Infection would require you to implement skin and wound care measures to promote healing. The expected outcome of "absence of drainage" sets a target for measuring the patient's improvement. Common goals of care applicable to patients with infection often include the following: •Preventing further exposure to infectious organisms • Controlling or reducing the extent of infection • Maintaining resistance to infection • Verbalizing understanding of infection prevention and control techniques (e.g., hand hygiene) Preventing further exposure to infectious organisms • Controlling or reducing the extent of infection • Maintaining resistance to infection • Verbalizing understanding of infection prevention and control techniques (e.g., hand hygiene)

Behavioral Control and Temperature Regulation

Healthy individuals are able to maintain comfortable body temperature when exposed to temperature extremes. The ability of a person to control body temperature depends on (1) the degree of temperature extreme, (2) the person's ability to sense feeling comfortable or uncomfortable, (3) thought processes or emotions, and (4) the person's mobility or ability to remove or add clothes. Individuals are unable to control body temperature if any of these abilities is lost. For example, infants are able to sense uncomfortable warm conditions but need help to change their environment. Older adults sometimes need help to detect cold environments and minimize heat loss. Illnesses, a decreased level of consciousness, or impaired thought processes result in an inability to recognize the need to change behavior for temperature control. When temperatures become extremely hot or cold, health-promoting behaviors such as removing or adding clothing have a limited effect on controlling temperature.

Heat Production

Heat Production occurs during rest, voluntary movements, involuntary shivering, and nonshivering thermogenisis

Heatstroke

Heat depresses hypothalamic function. Prolonged exposure to the sun or a high environmental temperature overwhelms the heat-loss mechanisms of the body. These conditions cause heatstroke, defined as a body temperature of 40° C (104° F) or more (Goforth and Kazman, 2015). Heatstroke is a dangerous heat emergency with a high mortality rate. Patients at risk include the very young or very old and those who have cardiovascular disease, hypothyroidism, diabetes, or alcoholism. Also at risk are those who take medications that decrease the ability of the body to lose heat (e.g., phenothiazines, anticholinergics, diuretics, amphetamines, and beta-adrenergic receptor antagonists) and those who exercise or work strenuously (e.g., athletes, construction workers, and farmers). Signs and symptoms of heatstroke include giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, and even incontinence. Vital signs reveal a body temperature sometimes as high as 45° C (113° F), with an increase in heart rate (HR) and lowering of BP. The most important sign of heatstroke is hot, dry skin. Victims of heatstroke do not sweat because of severe electrolyte loss and hypothalamic malfunction. If the condition progresses, a patient with heatstroke becomes unconscious, with fixed, nonreactive pupils. Permanent neurological damage occurs unless cooling measures are rapidly started

Hypothermia

Heat loss during prolonged exposure to cold overwhelms the ability of the body to produce heat, causing hypothermia. Hypothermia is classified by core temperature measurements (Table 30-1). It is sometimes unintentional such as falling through the ice of a frozen lake. Occasionally hypothermia is intentionally induced during surgical or emergency procedures to reduce metabolic demand and the need of the body for oxygen

Skin in Temperature Regulation

Heat transfers from the blood, through vessel walls, to the surface of the skin and is lost to the environment through the heat-loss mechanisms. The core temperature of the body remains within safe limits. The degree of vasoconstriction determines the amount of blood flow and heat loss to the skin. If the core temperature is too high, the hypothalamus inhibits vasoconstriction. As a result, blood vessels dilate, and more blood reaches the surface of the skin. On a hot, humid day the blood vessels in the hands are dilated and easily visible. In contrast, if the core temperature becomes too low, the hypothalamus initiates vasoconstriction, and blood flow to the skin lessens to conserve heat.

Heat Stroke

Heatstroke is an emergency situation. First aid treatment includes moving the patient to a cooler environment; removing excess body clothing; placing cool, wet towels over the skin; and using oscillating fans to increase convective heat loss. Emergency medical treatment includes intravenous (IV) fluids, irrigating the stomach and lower bowel with cool solutions, and hypothermia blankets.

Respiration

Human survival depends on the ability of oxygen (O2) to reach body cells and carbon dioxide (CO2) to be removed from the cells. Respiration is the mechanism the body uses to exchange gases between the atmosphere and the blood and the blood and the cells. Respiration involves ventilation, diffusion, perfusion. Analyzing respiratory efficiency requires integrating assessment data from all three processes. Asses ventilation rate by determining respiratory rate, depth, rhythm, and ETCO2 (end tidal carbon dioxide value)

Localized Infection

If an infection is localized (e.g., a wound infection), a patient usually experiences localized symptoms such as pain, tenderness, warmth, and redness at the wound site. Use standard precautions, appropriate PPE, and hand hygiene when assessing the woun

Communicable Disease

If an infectious disease can be transmitted directly from one person to another, it is termed a

asymptomatic

If clinical signs and symptoms are not present

Asymptomatic

If clinical signs and symptoms are not present, the illness is termed

symptomatic

If the pathogens multiply and cause clinical signs and symptoms

Symptomatic

If the pathogens multiply and cause clinical signs and symptoms, the infection is

Course of Infection by Stage

Incubation Period Interval between entrance of pathogen into body and appearance of first symptoms (e.g., chickenpox, 14 to 16 days after exposure; common cold, 1 to 2 days; influenza, 1 to 4 days; measles, 10 to 12 days; mumps, 16 to 18 days; Ebola 2 to 21 days (CDC, 2015b). Prodromal Stage Interval from onset of nonspecific signs and symptoms (malaise, low-grade fever, fatigue) to more specific symptoms. (During this time microorganisms grow and multiply, and patient may be capable of spreading disease to others.) For example, herpes simplex begins with itching and tingling at the site before the lesion appears. Illness Stage Interval when patient manifests signs and symptoms specific to type of infection. For example, strep throat is manifested by sore throat, pain, and swelling; mumps is manifested by high fever, parotid and salivary gland swelling. Convalescence Interval when acute symptoms of infection disappear. (Length of recovery depends on severity of infection and patient's host resistance; recovery may take several days to months.)

Auscultatory Gap

Indirect measurement of BP by palpation is useful for patients whose arterial pulsations are too weak to create sounds. Severe blood loss and decreased heart contractility are examples of conditions that result in BPs too low to auscultate accurately. In these cases you can assess the systolic BP by palpation (Box 30-9). The diastolic BP is difficult to determine by palpation. When using the palpation technique, record the systolic value and how you measured it (e.g., RA 90/-, palpated, supine)

Palpation

Indirect measurement of BP by palpation is useful for patients whose arterial pulsations are too weak to create sounds. Severe blood loss and decreased heart contractility are examples of conditions that result in BPs too low to auscultate accurately. In these cases you can assess the systolic BP by palpation (Box 30-9). The diastolic BP is difficult to determine by palpation. When using the palpation technique, record the systolic value and how you measured it (e.g., RA 90/-, palpated, supine)

Systemic Infection

Infection that affects the entire body instead of just a single organ or part is systemic and can become fatal if undetected and untreated.

Subjective Data

Information gathered from patient statements; the patient's feelings and perceptions. Not verifiable by another except by inference.

Objective Data

Information that can be observed by others; free of feelings, perceptions, prejudices

Mechanics of Breathing

Inspiration is an active process During inspiration respiratory center in the brain sends signal along the phrenic nerve causing diaphragm to contract during normal relaxed breath a patient will inhale 500mL of air this is referred to as Tidal Volume Expiration is a passive process Sighing interrupts the normal rate and depth of ventilation. The sigh is a prolonged deep breath and is a protective physiological mechanism for expanding small airways and alveoli not ventilated during normal breath

Factors Affecting Determination of SpO2 (pulse oxygen saturation)

Interference with Light Transmission • Outside light sources interfere with ability of oximeter to process reflected light. • Carbon monoxide (caused by smoke inhalation or poisoning) artificially elevates SpO2 by absorbing light similar to oxygen. • Patient motion interferes with ability of oximeter to process reflected light. • Jaundice interferes with ability of oximeter to process reflected light. • Intravascular dyes (methylene blue) absorb light similar to deoxyhemoglobin and artificially lower saturation. • Black or brown nail polish or metal studs in nails and thickened nails can interfere with light absorption and the ability of the oximeter to process reflected light (Chan et al., 2013). • Dark skin pigment sometimes results in signal loss or overestimation of saturation. Interference with Arterial Pulsations • Peripheral vascular disease (atherosclerosis) reduces pulse volume. • Hypothermia at assessment site decreases peripheral blood flow. • Pharmacological vasoconstrictors (e.g., epinephrine) decrease peripheral pulse volume. • Low cardiac output and hypotension decrease blood flow to peripheral arteries. • Peripheral edema obscures arterial pulsation. • Tight probe records venous pulsations in finger that compete with arterial pulsations

Nursing Interventions for Patients with Fever

Interventions (Unless Contraindicated) • Obtain blood cultures (before beginning antibiotics) if ordered. Obtain blood specimens to coincide with temperature spikes when the antigen-producing organism is most prevalent. • Minimize heat production: reduce frequency of activities that increase oxygen demand such as excessive turning and ambulation; allow rest periods; limit physical activity. • Maximize heat loss: reduce external covering on patient's body without causing shivering; keep patient, clothing, and bed linen dry. • Satisfy requirements for increased metabolic rate: provide supplemental oxygen therapy as ordered to improve oxygen delivery to body cells; provide measures to stimulate appetite and offer well-balanced meals; provide fluids (at least 8-to-10 8-oz glasses for patients with normal cardiac and renal function) to replace fluids lost through insensible water loss and sweating. • Promote patient comfort: encourage oral hygiene because oral mucous membranes dry easily from dehydration; control temperature of the environment without inducing shivering; apply damp cloth to patient's forehead. • Identify onset and duration of febrile episode phases: examine previous temperature measurements for trends. • Initiate health teaching as indicated. • Control environmental temperature to 21° to 27° C (70° to 80° F).

Sharing Humor

It is a coping strategy that can reduce anxiety and promote positive feelings Patients use humor to release tension, cope with fear related to pain and suffering, communicate a fear or need, or cope with an uncomfortable or embarrassing situation

Isolation and Isolation Precautions

It is paramount that the RN follow isolation precautions as indicated by the policy. Failure to do so puts your patient and yourself at risk.

Nursing Diagnosis

Keep in mind as you utilize the nursing Dx for your patient. determine if it is an actual problem or a risk.potential problem. if the patient is in the hospital you can almost guarantee that they are at risk for infection During assessment gather objective data such as inspection of an open incision or a reduced caloric intake record and subjective data such as a patient's complaint of tenderness over a surgical wound site. Review the data carefully, looking for clusters of defining characteristics or risk factors that create a pattern. This pattern suggests a specific nursing diagnosis (Box 29-6). The following are examples of nursing diagnoses that often apply to patients with infection: • Risk for Infection • Imbalanced Nutrition: Less Than Body Requirements • Impaired Oral Mucous Membrane • Risk for Impaired Skin Integrity • Social Isolation • Impaired Tissue Integrity

Nursing Process and Respiratory Vital Signs

Measurement of respiratory rate, pattern, and depth, along with SpO2, assesses ventilation, diffusion, and perfusion. You also conduct other assessments to measure respiratory status (see Chapter 31). Use assessment data to determine the nature of a patient's problem. Respiratory assessment data are defining characteristics of many nursing diagnoses, including the following: • Activity Intolerance • Ineffective Airway Clearance • Anxiety • Ineffective Breathing Pattern • Impaired Gas Exchange • Acute Pain • Ineffective Peripheral Tissue Perfusion • Dysfunctional Ventilatory Weaning Response The nursing care plan includes interventions based on the nursing diagnosis identified and the related factors. For example, the defining characteristics of tachycardia, changes in depth of respirations, dyspnea, and a decline in CO2 level lead to a diagnosis of Impaired Gas Exchange. Related factors could include alveolar capillary membrane changes from infection or a ventilator-perfusion imbalance. You select interventions on the basis of the related factor. After intervening, evaluate patient outcomes by assessing the respiratory rate, ventilatory depth, rhythm, and SpO2.

Temperature Reservoir

Microorganisms can live only in certain temperature ranges. Each species of bacteria has a specific temperature at which it grows best. The ideal temperature for most human pathogens is 20° to 43° C (68° to 109° F). For example, Legionella pneumophila grows best in water at 25° to 42° C (77° to 108° F). Cold temperatures tend to prevent growth and reproduction of bacteria (bacteriostasis). A temperature or chemical that destroys bacteria is bactericidal

Pathogens

Microorganisms capable of producing disease

pathogens

Microorganisms capable of producing disease

Infectious Agent

Microorganisms include bacteria, viruses, fungi, and protozoa (Table 29-1). Microorganisms on the skin are either resident or transient flora. Resident organisms (normal flora) are permanent residents of the skin and within the body, where they survive and multiply without causing illness (CDC, 2008a; WHO, 2009). The potential for microorganisms or parasites to cause disease depends on the number of microorganisms present; their virulence, or ability to produce disease; their ability to enter and survive in a host; and the susceptibility of the host. Resident skin microorganisms are not virulent. However, these skin microorganisms can cause serious infection when surgery or other invasive procedures allow them to enter deep tissues or when a patient is severely immunocompromised (has an impaired immune system).

Food Reservoir

Microorganisms require nourishment. Some such as Clostridium perfringens, the microbe that causes gas gangrene, thrive on organic matter. Others such as Escherichia coli consume undigested foodstuff in the bowel. Carbon dioxide and inorganic material such as soil provide nourishment for other organisms

Light.

Microorganisms thrive in dark environments such as those under dressings and within body cavities

Water Reservoir

Most organisms require water or moisture for survival. For example, a frequent place for microorganisms is the moist drainage from a surgical wound. Some bacteria assume a form, called a spore, which is resistant to drying, and can live on inanimate surfaces for long periods of time. A common spore-forming bacterium is C. difficile, an organism that causes antibiotic-induced diarrhea

Factors Influencing Infection Prevention and Control

Multiple factors influence a patient's susceptibility to infection. It is important to understand how each of these factors alone or in combination increases this risk. When more than one factor is present, a patient's susceptibility often increases, which affects length of stay, recovery time, and/or overall level of health following an illness. Understanding these factors helps to assess and care for a patient who has an infection or is at risk for one.

Cultures and Gram stain of wound, sputum, and throat

No WBCs on Gram stain, possible normal flora Presence of infectious microorganism growth and WBCs on Gram stain

Cultures of urine and blood

Normally sterile, without microorganism growth Presence of infectious microorganism growth

Portal of Exit: Urinary Tract

Normally urine is sterile. However, when a patient has a urinary tract infection (UTI), microorganisms exit during urination

Sharing Observations

Nurses make observations by commenting on how the other person looks, sounds, or acts. Stating observations often helps a patient communicate without the need for extensive questioning, focusing, or clarification. This technique helps start a conversation with quiet or withdrawn persons. Do not state observations that will embarrass or anger a patient such as telling someone, "You look a mess!" Even if you make such an observation with humor, the patient can become resentful. Sharing observations differs from making assumptions, which means drawing unnecessary conclusions about the other person without validating them

Sharing Hope

Nurses recognize that hope is essential for healing and learn to communicate a "sense of possibility" to others. Appropriate encouragement and positive feedback are important in fostering hope and self-confidence and for helping people achieve their potential and reach their goals

Hypertension

Often asymptomatic Prehypertension is diagnosed after two or more readings on two subsequent visits is between 120-139 mmHg Systolic and 80-89mmHg diastolic Hypertension is defined as diastolic over 90mmHg and systolic greater than 140 mmHg

Portal of Exit: Reproductive Tract

Organisms such as Neisseria gonorrhea and HIV exit through a man's urethral meatus or a woman's vaginal canal during sexual contact

Risks for Infection-Focus on Older Adults

PREVENTION! PREVENTION! PREVENTION!!! Risks for Infection • An age-related functional deterioration in immune system function, termed immune senescence, increases the susceptibility of the body to infection and slows overall immune response (Larbi et al., 2013). • Older adults are less capable of producing lymphocytes to combat challenges to the immune system. When antibodies are produced, the duration of their response is shorter, and fewer cells are produced (Roach, 2014). • Risks associated with the development of infections or HAIs in older patients include poor nutrition, unintentional weight loss, lack of exercise, poor social support, and low serum albumin levels (Meiner, 2014). • Flu and pneumonia vaccinations are recommended for the older-adult population to reduce their risk for infectious diseases. • Teach older adults and their families how to reduce the risk for infections by using proper hand hygiene practices.

Paraphrasing

Paraphrasing is restating another's message more briefly using one's own words. Through paraphrasing you send feedback that lets a patient know that he or she is actively involved in the search for understanding. Accurate paraphrasing requires practice. If the meaning of a message is changed or distorted through paraphrasing, communication becomes ineffective. For example, a patient says, "I've been overweight all my life and never had any problems. I can't understand why I need to be on a diet." Paraphrasing this statement by saying, "You don't care if you're overweight," is incorrect. It is more accurate to say, "You're not convinced that you need a diet because you've stayed healthy."

Portal of Exit: Respiratory Tract

Pathogens that infect the respiratory tract such as the influenza virus are released from the body when an infected person sneezes or cough

Communicating with Patients Who Have Special Needs

Patients Who Cannot Speak Clearly (Aphasia, Dysarthria, Muteness) • Listen attentively, be patient, and do not interrupt. • Ask simple questions that require "yes" or "no" answers. • Allow time for understanding and response. • Use visual cues (e.g., words, pictures, and objects) when possible. • Allow only one person to speak at a time. • Encourage patient to converse. • Let patient know if you have not understood him or her. • Collaborate with speech therapist as needed. • Use communication aids: letter boards, flash cards, computer-generated speech program), Patients Who Are Cognitively Impaired • Use simple sentences and avoid long explanations. • Ask one question at a time. • Allow time for patient to respond. • Be an attentive listener. • Include family and friends in conversations, especially in subjects known to patient. • Use picture or gestures that mimic the action desired. Patients Who Are Hearing Impaired • Check for hearing aids and glasses. • Reduce environmental noise. • Get patient's attention before speaking. • Face patient with mouth visible. • Do not chew gum. • Speak at normal volume—do not shout. • Rephrase rather than repeat if misunderstood. • Provide a sign-language interpreter if indicated. Patients Who Are Visually Impaired • Check for use of glasses or contact lenses. • Identify yourself when you enter room and notify patient when you leave room. • Speak in a normal tone of voice. • Do not rely on gestures or nonverbal communication. • Use indirect lighting, avoiding glare. • Use at least 14-point print. Patients Who Are Unresponsive • Call patient by name during interactions. • Communicate both verbally and by touch. • Speak to patient as though he or she can hear. • Explain all procedures and sensations. • Provide orientation to person, place, and time. • Avoid talking about patient to others in his or her presence. Patients Who Do Not Speak English • Speak to patient in normal tone of voice. • Establish method for patient to ask for assistance (call light or bell). • Provide a professional interpreter as needed. • Avoid using family members, especially children, as interpreters. • Use communication board, pictures, or cards. • Translate words from native language into English list for patient to make basic requests. • Have dictionary (e.g., English/Spanish) available if patient can read.

Providing Information

Patients have a right to know about their health status and what is happening in their environment. Providing relevant information tells other people what they need or want to know so they are able to make decisions, experience less anxiety, and feel safe and secure. It is also an integral aspect of health teaching

Health Care-Associated Infections

Patients in health care settings, especially hospitals and long-term care facilities, have an increased risk of acquiring infections. Health care-associated infections (HAIs) result from the delivery of health services in a health care facility. They occur as the result of invasive procedures, antibiotic administration, the presence of multidrug-resistant organisms (MDROs)

Factors Influencing Infection Control and Prevention: Disease Process

Patients with diseases of the immune system are at particular risk for infection. Leukemia, acquired immunodeficiency syndrome (AIDS), lymphoma, and aplastic anemia are conditions that compromise a host by weakening defenses against infectious organisms. For example, patients with leukemia are unable to produce enough WBCs to ward off infection. Patients with HIV are often unable to ward off simple infections and are prone to opportunistic infections. Patients with chronic diseases such as diabetes mellitus and multiple sclerosis are also more susceptible to infection because of general debilitation and nutritional impairment. Diseases that impair body system defenses such as emphysema and bronchitis (which impair ciliary action and thicken mucus), cancer (which alters the immune response), and peripheral vascular disease (which reduces blood flow to injured tissues) increase susceptibility to infection. Patients with burns have a high susceptibility to infection because of the damage to skin surfaces. The greater the depth and extent of the burns, the higher is the risk for infection. 8. Enter patient's room. Arrange supplies and equipment. (If equipment will be removed from room for reuse, place on clean paper towel.) 9. Explain purpose of isolation and necessary precautions to patient and family. Offer opportunity to ask questions. Discuss types of activities patient may wish to try to stay occupied. Assess for evidence of emotional problems that can occur from isolation. 10. Assess vital signs (see Chapter 30). a. If patient is infected or colonized with a resistant organism (e.g., VRE, MRSA, or C. diff), equipment remains in room. This includes stethoscope and BP cuff. b. If stethoscope is to be reused, clean diaphragm or bell with alcohol. Set aside on clean surface. c. Use individual electronic or disposable thermometer. CLINICAL DECISION: If disposable thermometer indicates a fever, assess for other signs/symptoms. Confirm fever using an alternative thermometer. Do not use electronic thermometer if patient is suspected or confirmed to have Clostridium difficile (Cohen et al., 2010) 11. Administer medications (see Chapter 32). a. Give oral medication in wrapper or cup. b. Dispose of wrapper or cup in plastic-lined receptacle. c. Wear gloves when administering an injection. d. Discard safety needle and syringe or uncapped needle into sharps container. e. Place reusable syringe (e.g., Carpujet) on a clean towel for eventual removal and disinfection. f. If you are not wearing gloves and hands come into contact with contaminated article or body fluids, perform hand hygiene as soon as possible. 12. Administer hygiene, encouraging patient to discuss questions or concerns about isolation. Provide informal teaching at this time. a. Avoid allowing gown to become wet. Carry wash basin out away from gown; avoid leaning against any wet surface. b. Remove linen from bed; avoid contact with gown. Place in linen bag according to agency policy. c. Provide clean bed linen and a set of towels. d. Change gloves and perform hand hygiene if they become solid and further care is necessary. 13. Collect specimens. a. Place specimen containers on clean paper towel in patient's bathroom. Follow procedure for collecting specimen of body fluids. b. Transfer specimen to container without soiling outside of container. Place container in plastic bag and place label on outside of bag or per agency policy. Label specimen in front of patient (TJC, 2016). c. Perform hand hygiene and reglove if additional procedures are needed. d. Check label on specimen for accuracy (warning labels are often used, depending on agency policy). Send to laboratory. Label containers with a biohazard label 14. Dispose of linen and trash bags as they become full. a. Use sturdy, moisture-resistant single bags to contain soiled articles. Use double bag if outside of bag is contaminated. b. Tie bags securely at top in knot 15. Remove all reusable equipment. Clean any contaminated surfaces (see health care facility or agency policy). 16. Resupply room as needed. Have a staff member outside isolation room hand you new supplies. 17. Explain to patient when you plan to return to room. Ask whether patient requires any personal care items, books, or magazines. 18. Leave isolation room. The order for removing PPE depends on what was needed for the type of isolation. The sequence listed is based on full PPE being required. a. Remove gloves. Remove one glove by grasping cuff and pulling glove inside out over hand. With ungloved hand tuck finger inside cuff of remaining glove and pull it off, inside out b. Remove eyewear/face shield or goggles. c. Untie waist and neck strings of gown. Allow gown to fall from shoulders. Remove hands from sleeves without touching outside of gown. Hold gown inside at shoulder seams and fold inside out. Discard in laundry bag if fabric or in trash can if gown is disposable. d. Remove mask: If mask loops over your ears, remove from ears and pull away from face. For a tie-on mask, untie top mask strings; hold strings; untie bottom strings, pull mask away from face, and drop it into trash receptacle. Do not touch outer surface of mask e. Perform hand hygiene. f. Leave room and close door if necessary. (Make sure that door is closed if patient is on airborne precautions.) g. Dispose of all contaminated supplies and equipment in a manner that prevents spread of microorganisms to other people (see health care facility or agency policy).

Systolic Pressure

Peak of maximum pressure when ejection occurs

Challenging Communication Situations

People who are silent, withdrawn, and have difficulty expressing feelings or needs • People who are sad and depressed • People who require assistance with visual or speech disabilities (special needs) • People who are angry or confrontational and cannot listen to explanations • People who are uncooperative and resent being asked to help others • People who are talkative or lonely and want someone to be with them all the time • People who are demanding and expect others to meet their requests • People who are frightened, anxious, and having difficulty coping • People who are confused and disoriented • People who speak and/or understand little English • People who are flirtatious or sexually inappropriate You will encounter all of these situations within your career

colonization

Presence and multiplication of microorganisms without tissue invasion or damage.

Convection

Process by which, in a fluid being heated, the warmer part of the mass will rise and the cooler portions will sink.

Elements of Professional Communication

Professional appearance, demeanor, and behavior are important in establishing trustworthiness and competence. A professional is expected to be clean, neat, well groomed, conservatively dressed, and odor free. Visible tattoos and piercings may not be considered acceptable in some professional settings. Professional behavior reflects warmth, friendliness, confidence, and competence. Professionals speak in a clear, well-modulated voice; use good grammar; listen to others; help and support colleagues; and communicate effectively. Being on time, organized, well prepared, and equipped for the responsibilities of the nursing role also communicate professionalism.

Factors Influencing Communication

Psychophysiological Context (Internal Factors Affecting Communication) • Physiological status (e.g., pain, hunger, nausea, weakness, dyspnea) • Emotional status (e.g., anxiety, anger, hopelessness, euphoria) • Growth and development status (e.g., age, developmental tasks) • Unmet needs (e.g., safety/security, love/belonging) • Attitudes, values, and beliefs (e.g., meaning of illness experience) • Perceptions and personality (e.g., optimist/pessimist, introvert/extrovert) • Self-concept and self-esteem (e.g., positive or negative) Relational Context (Nature of the Relationship Among Participants) • Social, helping, or working relationship • Level of trust among participants • Level of caring expressed • Level of self-disclosure among participants •Shared history of participants • Balance of power and control Situational Context (Reason for Communication) • Information exchange • Goal achievement • Problem resolution • Expression of feelings Environmental Context (Physical Surroundings in Which Communication Occurs) • Privacy level • Noise level • Comfort and safety level • Distraction level Cultural Context (Sociocultural Elements That Affect an Interaction) • Educational level of participants • Language and self-expression patterns • Customs and expectation

Nursing Process and Pulse Determination

Pulse assessment determines the general state of cardiovascular health and the response of the body to other system imbalances. Tachycardia, bradycardia, and dysrhythmias are defining characteristics of many nursing diagnoses, including the following: • Activity Intolerance • Anxiety • Decreased Cardiac Output • Deficient/Excess Fluid Volume • Impaired Gas Exchange • Acute Pain • Ineffective Peripheral Tissue Perfusion The nursing care plan includes interventions based on the nursing diagnosis identified and the related factors. For example, the defining characteristics of an abnormal HR, exertional dyspnea, and a patient's verbal report of fatigue lead to a diagnosis of Activity Intolerance. When the related factor is inactivity following a prolonged illness, interventions focus on increasing the patient's daily exercise routine. Once the plan is implemented, evaluate patient outcomes, including assessment of his or her pulse.

Assessing the Risk of Infection in Adults

Risk Factor: Chronic disease Causes: COPD, heart failure, diabetes Outcome: Pneumonia, skin breakdown, venous stasis ulcers Risk Factor: Lifestyle Causes: high-risk behaviors, Exposure to communicable/infectious diseases, use of IV drugs and other drugs/substances Outcome: STIs, HIV, HBV, HCV, opportunistic infections, viral infections, yeast infections, liver failure Risk Factor: Occupation Causes: Health care worker; miner, unemployed, homeless Outcome: Exposure to blood and body fluids increase risk of infection; black lung disease, pneumonia, TB, poor nutritional intake; lack of access to medical care; stress Risk Factor: Diagnostic procedures Causes: Invasive radiology, transplant Outcome: Multiple IV lines, immunosuppressive drugs Risk Factor: Heredity Causes: Sickle cell disease, diabetes Outcome: Anemia, delayed healing Risk Factor: Travel history Causes: West Nile virus, SARS, avian flu, Hantavirus Outcome: Meningitis, acute respiratory distress Risk Factor: Trauma Causes: Fractures, internal bleeding Outcome: Sepsis, secondary infection Risk: Nutrition Causes: Obesity, anorexia Outcome: Impaired immune response

Nursing Knowledge Base

Serious infections are ongoing challenges to clinicians, and they create feelings of anxiety, frustration, loneliness, and anger in patients and/or their families (Nesher et al., 2014). These feelings worsen when patients are isolated to prevent transmission of a microorganism to other patients or health care staff. Isolation disrupts normal social relationships with visitors and caregivers. Patient safety is usually an additional risk for the patient on isolation precautions (Monsees, 2014). For example, an older patient with a chronic illness is more at risk for a HAI. When family members fear the possibility of developing the infection, they may avoid contact with the patient. Some patients perceive the simple procedures of proper hand hygiene and gown and glove use as evidence of rejection. Help patients and families reduce some of these feelings by discussing the disease process; explaining isolation procedures; and maintaining a friendly, understanding manner. When establishing a plan of care, it is important to know how a patient reacts to an infection or infectious disease. The challenge is to 449identify and support behaviors that maintain human health or prevent infection. I seldom highlight an entire paragraph, but this one contain information that you can focus on for infection control and prevention. It is a priority in nursing care.

Using Silence

Silence is particularly useful when people are confronted with decisions that require much thought. For example, it helps a patient gain the necessary confidence to share the decision to refuse medical treatment. It also allows the nurse to pay particular attention to nonverbal messages such as worried expressions or loss of eye contact. Remaining silent demonstrates patience and a willingness to wait for a response when the other person is unable to reply quickly. Silence is especially therapeutic during times of profound sadness or grief

Natural Defense Mechanisms Against Infection

Skin Intact multilayered surface (first line of defense against infection) Provides barrier to microorganisms and antibacterial activity Cuts, abrasions, puncture wounds, areas of maceration Shedding of outer layer of skin cells Removes organisms that adhere to outer layers of skin Failure to bathe regularly, improper handwashing technique Sebum Contains fatty acid that kills some bacteria Excessive bathing Mouth Intact multilayered mucosa Provides mechanical barrier to microorganisms Lacerations, trauma, extracted teeth Saliva Washes away particles containing microorganisms Contains microbial inhibitors (e.g., lysozyme) Poor oral hygiene, dehydration Eye Tearing and blinking Provides mechanisms to reduce entry (blinking) or help wash away (tearing) particles containing pathogens, thus reducing dose of organisms Injury, exposure—splash/splatter of blood or other potentially infectious material into eye Respiratory Tract Cilia lining upper airway, coated by mucus Traps inhaled microbes and sweeps them outward in mucus to be expectorated or swallowed Smoking, high concentration of oxygen and carbon dioxide, decreased humidity, cold air Macrophages Engulf and destroy microorganisms that reach alveoli of lung Smoking Urinary Tract Flushing action of urine flow Washes away microorganisms on lining of bladder and urethra Obstruction to normal flow by urinary catheter placement, obstruction from growth or tumor, delayed micturition Intact multilayered epithelium Provides barrier to microorganisms Introduction of urinary catheter, continual movement of catheter in urethra can facilitate migration of organisms to bladder Gastrointestinal Tract Acidity of gastric secretions Prevents retention of bacterial contents Administration of antacids Rapid peristalsis in small intestine Delayed motility resulting from impaction of fecal contents in large bowel or mechanical obstruction by masses Vagina At puberty normal flora causing vaginal secretions to achieve low pH Inhibit growth of many microorganisms Antibiotics and oral contraceptives disrupting normal flora

Factors Influencing Blood Pressure- Medications

Some medications directly and indirectly effect BP Always check medications before BP assessment to factor these effects Meds that lower BP- antihypertensive, diuretic, other cardiac meds, opiod analgesics Meds that increase BP- Vasoconstrictors and excessive IV fluid intake

Susceptible Host

Susceptibility to an infectious agent depends on an individual's degree of resistance to pathogens. Although everyone is constantly in contact with large numbers of microorganisms, an infection does not develop until an individual becomes susceptible to the strength and numbers of the microorganisms. A person's natural defenses against infection and certain risk factors (e.g., age, nutritional status, presence of chronic disease, trauma, and smoking) affect susceptibility (resistance) (Roach, 2014). Organisms such as S. aureus with resistance to key antibiotics are becoming more common in all health care settings, but especially acute care. The increased resistance is associated with the frequent and sometimes inappropriate use of antibiotics over the years in all settings (i.e., acute care, ambulatory care, clinics, and long-term care)

Patterns of Fever

Sustained: A constant body temperature continuously above 38° C (100.4° F) that has little fluctuation Intermittent: Fever spikes interspersed with usual temperature levels (Temperature returns to acceptable value at least once in 24 hours.) Remittent: Fever spikes and falls without a return to acceptable temperature levels. Relapsing: Periods of febrile episodes and periods with acceptable temperature values (Febrile episodes and periods of normothermia are often longer than 24 hours.)

SBAR (Acronym for Situation, Background, Assessment, and Recommendation)

System of structured communication used to share information about a patient's condition Example: S (Situation): Patient verbalized preoperative fears. Nurse noted muscle tension and loud, agitated voice. B (Background): Patient fearful of surgery because of past experiences with anesthesia and pain. A (Assessment): BP: 160/84, T: 98.6°F; P: 86; R: 18. O2 Saturation: 96%. Skin warm and dry to touch. Respirations even and nonlabored. R (Recommendation): Encourage patient to discuss preoperative fears. Assess pain level at least every 4 hours after surgery. Provide nonpharmacological pain-management techniques and administer medication as needed. Can be used for a variety of purposes - handing off care - reporting urgent concerns - can be written or verbal

SOLER

S—Sit facing the patient. This posture conveys the message that you are there to listen and are interested in what the patient is saying. O—Open position (i.e., keep arms and legs uncrossed). This position suggests that you are "open" to what the patient says. A "closed" position such as crossing arms conveys a defensive attitude, possibly provoking a similar response in the patient. L—Lean toward the patient. This position conveys that you are involved and interested in the interaction. E—Eye contact—Establish and maintain intermittent eye contact to convey your involvement in and willingness to listen to what the patient is saying. Absence of eye contact or shifting the eyes gives the message that you are not interested in what the patient is saying. R—Relax. It is important to communicate a sense of being relaxed and comfortable with the patient. Restlessness communicates a lack of interest and a feeling of discomfort to the patient

Factors Effecting Vital Signs in Older Adults

Temperature • The temperature of older adults is at the lower end of the normal temperature range, 36° to 36.8° C (96.8° to 98.3° F) orally and 36.6° to 37.2° C (98° to 99° F) rectally. Therefore temperatures considered within normal range sometimes reflect a fever in an older adult. In an older adult fever is present when a single oral temperature is over 37.8° C (100° F); repeated oral temperatures are over 37.2° C (99° F); rectal temperatures are over 37.5° C (99.5° F); or temperature has increased more than 1° C (2° F) over baseline. • Older adults are very sensitive to slight changes in environmental temperature because their thermoregulatory systems are not as efficient. • A decrease in sweat gland reactivity in the older adult results in a higher threshold for sweating at high temperatures, which leads to hyperthermia and heatstroke. • Be especially attentive to subtle temperature changes and other manifestations of fever in this population such as tachypnea, anorexia, falls, delirium, and overall functional decline. • Older adults without teeth or with poor muscle control may be unable to close their mouths tightly to obtain accurate oral temperature readings. Pulse Rate • If it is difficult to palpate the pulse of an obese older adult, a Doppler device provides a more accurate reading. • Pedal pulses are often difficult to palpate in older adults. • The older adult has a decreased heart rate at rest. • It takes longer for the heart rate to rise in the older adult to meet sudden increased demands that result from stress, illness, or excitement. Once elevated, the pulse rate takes longer to return to normal resting rate. • Heart sounds are sometimes muffled or difficult to hear in older adults because of an increase in air space in the lungs. Blood Pressure • Older adults who have lost upper arm mass, especially the frail elderly, require special attention to selection of a smaller size blood pressure cuff. • Older adults sometimes have an increase in systolic pressure related to decreased vessel elasticity, whereas the diastolic pressure remains the same, resulting in a wider pulse pressure. • Instruct older adults to change position slowly and wait after each change to avoid postural hypotension and prevent injuries. • Skin of older adults is more fragile and susceptible to cuff pressure during frequent measurements. More frequent assessment of skin under the cuff or rotating blood pressure sites is recommended. Respirations • Aging causes ossification of costal cartilage and downward slant of ribs, resulting in a more rigid rib cage, which reduces chest wall expansion. Kyphosis and scoliosis that occur in older adults also restrict chest expansion and decrease tidal volume. • Older adults depend more on accessory abdominal muscles during respiration than on weaker thoracic muscles. • The respiratory system matures by the time a person reaches 20 years of age and begins to decline in healthy people after the age of 25. Despite this decline older adults are able to breathe effortlessly as long as they are healthy. However, sudden events that require an increased demand for oxygen (e.g., exercise, stress, illness) create shortness of breath in the older adult. • Identifying an acceptable pulse oximeter probe site is difficult with older adults because of the likelihood of peripheral vascular disease, decreased cardiac output, cold-induced vasoconstriction, and anemia.

Acceptable Vital Signs for Adults

Temperature Range Average temperature range: 36° to 38° C (96.8° to 100.4° F) Average oral/tympanic: 37° C (98.6° F) Average rectal: 37.5° C (99.5° F) Axillary: 36.5° C (97.7° F) Pulse 60 to 100 beats/min, strong and regular Pulse Oximetry (SpO2) Normal: SpO2 ≥95% Respirations Adult: 12 to 20 breaths/min, deep and regular Blood Pressure Systolic <120 mm Hg Diastolic <80 mm Hg Pulse pressure: 30 to 50 mm Hg Capnography (EtCO2) Normal: 35-45 mm Hg

Vital Signs

Temperature, pulse, respirations, and blood pressure

Peripheral Resistance

The BP depends on peripheral vascular resistance Blood circulates through a network of arteries, arterioles, capillaries, venules, and veins arteries and arterioles are surrounded by smooth muscle that contracts or relaxes to change the size of the lumen the size of arterioles and arteries changes to adjust blood flow to needs of tissue

Examples of Sites for and Causes of Health Care-Associated Infections

The RN need to be aware of the risks and speak with unlicensed personnel (PCA's) so that prevention is a team effort. Improperly performing hand hygiene increases patient risk for all types of health care-associated infections. Urinary Tract • Unsterile insertion of urinary catheter • Improper positioning of the drainage tubing • Open drainage system • Catheter and tube becoming disconnected • Drainage bag port touching contaminated surface • Improper specimen collection technique • Obstructing or interfering with urinary drainage • Urine in catheter or drainage tube being allowed to reenter bladder (reflux) • Repeated catheter irrigations • Improper perineal hygiene Surgical or Traumatic Wounds • Improper skin preparation before surgery (e.g., shaving versus clipping hair; not performing a preoperative bath or shower) • Failure to clean skin surface properly • Failure to use aseptic technique during operative procedures and dressing changes • Use of contaminated antiseptic solutions Respiratory Tract • Contaminated respiratory therapy equipment • Failure to use aseptic technique while suctioning airway • Improper disposal of secretions Bloodstream • Contamination of intravenous (IV) fluids by tubing • Insertion of drug additives to IV fluid • Addition of connecting tube or stopcocks to IV system • Improper care of needle insertion site • Contaminated needles or catheters • Failure to change IV access at first sign of infection or at recommended intervals • Improper technique during administration of multiple blood products • Improper care of peritoneal or hemodialysis shunts • Improperly accessing an IV port

The Health Insurance Portability and Accountability Act of 1996 (HIPAA)

The Security Rule of HIPAA (1996) provides standards for the protection of electronic health information. Numerous nursing and medical professional organizations have developed guidelines and strategies for safe computer charting

pH

The acidity of an environment determines the viability of microorganisms. Most microorganisms prefer an environment within a pH range of 5.0 to 7.0. Bacteria in particular thrive in urine with an alkaline pH

Portal of Exit: Blood

The blood is normally a sterile body fluid; however, in the case of communicable diseases such as HBV, HCV, or HIV, it becomes a reservoir for pathogens. Organisms exit from wounds, venipuncture sites, hematemesis, and bloody stoo

Factors Influencing Infection Control and Prevention: Stress

The body responds to emotional or physical stress by the general adaptation syndrome (see Chapter 38). During the alarm stage the basal metabolic rate increases as the body uses energy stores. Adrenocorticotropic hormone increases serum glucose levels and decreases unnecessary antiinflammatory responses through the release of cortisone. If stress continues or becomes intense, elevated cortisone levels result in decreased resistance to infection. Continued stress leads to exhaustion, which causes depletion in energy stores, and the body has no resistance to invading organisms. The same conditions that increase nutritional requirements such as surgery or trauma also increase physiological stress.

Pulse Pressure

The difference between systolic and diastolic pressure ex. PP 120/80 is 40

Portal of Exit: GI Tract

The mouth is one of the most bacterially contaminated sites of the human body, but most of the organisms are normal floras. Organisms that are normal floras in one person can be pathogens in another. For example, organisms exit when a person expectorates saliva. In addition, gastrointestinal portals of exit include emesis, bowel elimination, drainage of bile via surgical wounds, or drainage tubes.

Chain of Infection

The presence of a pathogen does not mean that an infection will occur. Infection occurs in a cycle that depends on the presence of all of the following elements: • An infectious agent or pathogen • A reservoir or source for pathogen growth • A port of exit from the reservoir • A mode of transmission • A port of entry to a host • A susceptible host Infection can develop if this chain remains uninterrupted (Figure 29-1). Preventing infections involves breaking the chain of infection

Chain of Infection

The presence of a pathogen does not mean that an infection will occur. Infection occurs in a cycle that depends on the presence of all of the following elements: • An infectious agent or pathogen • A reservoir or source for pathogen growth • A port of exit from the reservoir • A mode of transmission • A port of entry to a host • A susceptible host Infection can develop if this chain remains uninterrupted (Figure 29-1). Preventing infections involves breaking the chain of infection.

Hypothermia

The priority treatment for hypothermia is to prevent a further decrease in body temperature. Removing wet clothes, replacing them with dry ones, and wrapping patients in blankets are key nursing interventions. In emergencies away from a health care setting, have the patient lie under blankets next to a warm person. A conscious patient benefits from drinking hot liquids such as soup and avoiding alcohol and caffeinated fluids. It is also helpful to keep the head covered, place the patient near a fire or in a warm room, or place heating pads next to areas of the body (head and neck) that lose heat the quickest.

Pulse

The pulse is the palpable bounding of blood flow in a peripheral artery. Blood flows through the body in a continuous circuit. The pulse is an indirect indicator of circulatory status.

Portal of Exit- Skin and Mucous Membranes

The skin is considered a portal of exit because any break in the integrity of the skin and mucous membranes allows pathogens to exit the body. This may be exhibited by the presence of purulent drainage

Cardiac Output

The volume of blood pumped by the heart during 1 minute. the product of HR and the SV of the ventricle. In an adult the heart normally pumps 5000 mL of blood per minute. A change in HR or SV does not always change the output of the heart or the amount of blood in the arteries. For example, if a person's HR is 70 beats/min and the SV is 70 mL, the cardiac output is 4900 mL/min (70 beats/min × 70 mL/beat). If the HR drops to 60 beats/min and the SV rises to 85 mL/beat, the cardiac output increases to 5100 mL or 5.1 L/min (60 beats/min × 85 mL/beat). Mechanical, neural, and chemical factors regulate the strength of ventricular contraction and its SV. But when these factors are unable to alter SV, a change in HR causes a change in cardiac output, which affects BP. As HR increases, there is less time for the ventricular chambers of the heart to fill. As HR increases without a change in SV, BP decreases. As HR slows, filling time is increased, and BP increases. The inability of BP to respond to increases or decreases in HR indicates a possible health problem. Report this to the health care provider. An abnormally slow, rapid, or irregular pulse alters cardiac output. Assess the ability of the heart to meet the demands of body tissue for nutrients by palpating a peripheral pulse or using a stethoscope to listen to heart sounds (apical rate).

Infectious Agent

This first paragraph is important. Utilize the table below if to apply to patient in clinical who have had labs completed to determine the type of organism growing. In NURS 1871 we not test you on specific organisms Microorganisms include bacteria, viruses, fungi, and protozoa (Table 29-1). Microorganisms on the skin are either resident or transient flora. Resident organisms (normal flora) are permanent residents of the skin and within the body, where they survive and multiply without causing illness (CDC, 2008a; WHO, 2009). The potential for microorganisms or parasites to cause disease depends on the number of microorganisms present; their virulence, or ability to produce disease; their ability to enter and survive in a host; and the susceptibility of the host. Resident skin microorganisms are not virulent. However, these skin microorganisms can cause serious infection when surgery or other invasive procedures allow them to enter deep tissues or when a patient is severely immunocompromised (has an impaired immune system)

Validation

This is a technique that nurses use to recognize and acknowledge a patient's thoughts, feelings, and needs. Patients and families know they are being heard and taken seriously when the caregiver addresses their issues (Harvey and Ahmann, 2014). For example, a nurse validates the patient's stated comments by asking, "Tell me if I understand your concerns regarding your surgery. You're worried that you will not be able to return to your usual way of life." This type of statement enables a nurse to convey empathy and interest in the patient's thoughts, feelings, and perceptions

Factors Influencing Infection Control: Age

Throughout life a person's susceptibility to infection changes. For example, an infant has immature defenses against infection. Born with only the antibodies provided by the mother, the infant's immune system is incapable of producing the necessary immunoglobulins and WBCs to adequately fight some infections. However, breastfed infants often have greater immunity than bottle-fed infants because they receive their mother's antibodies through the breast milk. As the child grows the immune system matures; but the child is still susceptible to organisms that cause the common cold; intestinal infections; and infectious diseases such as mumps, measles, and chickenpox (if not vaccinated). The young or middle-age adult has refined defenses against infection. Viruses are the most common cause of communicable illness in young or middle-age adults. Since 2000 there has been a major effort to vaccinate all children against all infectious diseases for which vaccines are available. Vaccine-preventable disease levels are at or near record lows (CDC, 2011a). Defenses against infection change with aging (Larbi et al., 2013). The immune response, particularly cell-mediated immunity, declines. Older adults also undergo alterations in the structure and function of the skin, urinary tract, and lungs. For example, the skin loses its turgor, and the epithelium thins. As a result it is easier to tear or abrade the skin, which increases the potential for invasion by pathogens. In addition, older adults who are hospitalized or reside in an assisted-living or residential care facility are at risk for airborne infections. Ensuring that health care workers are vaccinated against influenza reduces the transmission of this illness in older adults

Clarifying

To check whether you understand a message accurately, restate an unclear or ambiguous message to clarify the sender's meaning. In addition, ask the other person to rephrase it, explain further, or give an example of what the person means. Without clarification you may make invalid assumptions and miss valuable information. Despite efforts at paraphrasing, sometimes you do not understand a patient's message. Let the patient know if this is the case: "I'm not sure I understand what you mean by 'sicker than usual.' What is different now?"

Using Touch

Touch is one of the most potent and personal forms of communication

Erythrocyte sedimentation rate

Up to 15 mm/hr for men and 20 mm/hr for women Elevated in presence of inflammatory process

Nursing Process

Utilize the nursing process to apply the infectious process to a patient you have cared for. It could be an actual infection or a way in which you planned to prevent infection from occurring. Read the entire section related to nursing process and infection. This is information thta can be utilized on many patients Assessment During the assessment process thoroughly assess each patient and critically analyze findings to ensure that you make patient-centered clinical decisions required for safe nursing care. Determine how the patient feels about the illness or risk for infection. Assess his or her defense mechanisms, susceptibility, and knowledge of how infections are transmitted (Table 29-3). Conduct a review of systems and travel history with the patient and family to reveal any risks for exposure to a communicable disease. Immunization and vaccination history is also very useful. It is important to be thorough in assessing a patient's clinical condition. A medication history is necessary to identify medications that increase a patient's susceptibility to infection. An analysis of laboratory findings provides information about a patient's defense against infection. The early recognition of infection or risk factors helps you make the correct nursing diagnosis and establish a treatment plan.

Antipyretics

are medications that reduce fever. Acetaminophen and nonsteroidal antiinflammatory drugs such as ibuprofen, salicylates, and indomethacin reduce fever by increasing heat loss. Although not used to treat fever, corticosteroids reduce heat production by interfering with the hypothalamic response. It is important to remember that steroids mask signs and symptoms of infection by suppressing the immune system. Therefore patients who are prescribed steroids need to be monitored closely, especially if they are at risk for infection.

Inflammation

assessment of inflammation is priority to determine the extent of the infectious process The cellular response of the body to injury, infection, or irritation is termed inflammation. Inflammation is a protective vascular reaction that delivers fluid, blood products, and nutrients to an area of injury. The process neutralizes and eliminates pathogens or dead (necrotic) tissues and establishes a means of repairing body cells and tissues. Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of function in the affected body part. When inflammation becomes systemic, other signs and symptoms develop, including fever, increased white blood cells (WBCs), malaise, anorexia, nausea, vomiting, lymph node enlargement, or organ failure. Physical agents, chemical agents, or microorganisms trigger the inflammatory response. Mechanical trauma, temperature extremes, and radiation are examples of physical agents. Chemical agents include external and internal irritants such as harsh poisons or gastric acid. Sometimes microorganisms also trigger this response. After tissues are injured, a series of well-coordinated events occurs. The inflammatory response includes vascular and cellular responses, formation of inflammatory exudates (fluid and cells that are discharged from cells or blood vessels [e.g., pus or serum]), and tissue repair