chapter 16, 17, and 37

the four most common multi drug-resistant organisms are

1: methicillin-resistant staphylococcus aureus MRSA, 2: vancomycin-resistant Enterococcus VRE 3: extended spectrum beta lactamase producing ESBL pneumonia Klebsiella pneumonia or E coli, and 4: clostridium difficle C diff

3. Wear a mask if working within 3 feet of the patient.

4. Transport the patient outside of the room only when necessary, and place a surgical mask on the patient if possible.

Contact precautions: After hand hygiene, do not touch possibly contaminated surfaces or items in the room.

4. Wear a gown when entering a room if there is a possibility of contact with infected surfaces or items, or if the patient is incontinent or has diarrhea, a colostomy, or wound drainage not contained by a dressing. Limit movement of the patient outside the room.

4. Susceptible people should not enter the room of a patient who has rubella (measles) or varicella (chickenpox). If they must enter, they should wear an N95 respirator.

5. Limit movement of the patient outside the room to essential purposes. Place a surgical mask on the patient if possible.

Check the surgical site when the patient returns to the unit. The dressing should be dry. If it is stained, outline the area with pen and note the time so that further bleeding can be assessed later.

Check the surgical site each hour for the first 4 hours, then every 2 hours if bleeding has not occurred. ains for patency when checking the wound, and empty and recompresss drainage devices as needed

pathogenic microorganisms must be destroyed or rendered harmless to remove this link from the chain.

disinfection and sterilization are methods used in the process of destroying all microorganisms, pathogens, or pathogenic products.

local anesthesia: Local anesthesia is used for minor procedures such as superficial tissue biopsies, surface cyst excision, insertion of a pacemaker, and insertion of vascular access devices.

does not need care in the postanesthesia care recovery unit

increased susceptibility of the

elderly to infection:

patients must be educated about the correct use and possible misuse of antimicrobial-killing or suppressing growth of microorganisms agents.

encourage each patinet to take the entire antimicroial prescription as odered by the health care provider.

some pathogenic microorganisms produce harmful toxins, and others release indotoxins.

endotoxins are responsible for the symptoms seen in botulism, tetanus, diptheria, and escherichia coli infection.

A total score of 9 or 10 usually indicates the patient is ready for transfer. Because patients are coming out of anesthesia through the various stages and are unstable, the

environment is kept as quiet as possible. Communication among the staff is kept to a minimum and is done in hushed tones.

Remain aware of your facility's policies and procedures regarding the care of a patient in protective

environment isolation, and follow them at all times

wound and evisceration extrusion of the viscera through the surgical incision may occur when the patient is coughing, particularly if the abdominal incision is not properly splinted.

evaluation: Evaluation is based on whether goals and expected outcomes have been met. Evaluative statements regarding previously stated general goals might be as follows:

Postoperative care: assessment data collection: Vital signs and careful assessment are performed every 15 minutes for the first hour, every 30 minutes for the next 2 hours, every hour for the next 4 hours, and then

every 4 hours until the patient is totally recovered from anesthesia and vital signs have returned to normal. Vital signs are taken more frequently if they are unstable according to nursing

characteristics that affect virulence are ability to 1. adhere to mucosal surfaces or cell walls, 2. penetrate mucous membranes, 3. multiply in the body, 4. screte harmful enzymes or toxins,5. resist phagocytosis-destruction of white blood cells, 6.bind with iron essential for bacterial growth.

four stage of infection process are incubation, prodrome, illness and convalescence.

Recommended Diagnostic Tests Before Surgery: Complete blood count (CBC), Urinalysis, Chest x-ray examination, Electrocardiogram over age 40, Pregnancy test for women of childbearing age, Electrolytes, blood glucose, liver function, and kidney

function tests, Prothrombin time (PT), activated partial thromboplastin time APTT , Blood type and crossmatch

Fungi: tiny, primitive organism of the plant kingdom that contain no chlorophyll. examples include yeasts and molds. fungi feel on living plants, animals, and decaying organic material.

fungi reproduce by means of spores. IN humans, fungal infections are called mycoses. fungal infections such as vaginal candidiasis may occur- yeast infection. example: candida albicans. disease manifestations: thrush vaginitis, meningitis, pneumonia

Reservoir- link two- are places where microorganisms are found. reseroirs can be infected wounds, human or animal waste, animals and insects, contaminated food and water, or a person with an infection such as bladder or lungs. Precautions to prevent the spread

good hand hygiene and sterile technique with out pathologic organism. example, it is used to insert an indwelling urinary catheter to help prevent the transfer of normal flora from the skin and mucous membranes in the the sterile bladder where it can cause infection.

N95 respirator masks must be approved by the National Institute for Occupational Safety and Health (NIOSH). They prevent passage of 95% of particulate matter. There are several styles of both regular and respirator masks. When removing masks,

handle only the elastic band or ties, and discard in a regular waste receptacle; do not leave them hanging around the neck or in a pocket. Change the mask any time it becomes moist.

All responsible adults are asked to complete advance directives when admitted to the hospital

if they do not already have such a document on file;

Surgical site identification: In 2003 a National Patient Safety Goal was instituted to "Eliminate wrong-site, wrong-patient, wrong-procedure surgery." A preoperative checklist verification process is used to ensure that appropriate medical records and

imaging studies are available. A process must also be implemented to mark the surgical site and involve the patient in the marking process. This should be done before preoperative medications are given so that the patient is alert to participate in this procedure. Before surgery commences,

Portal of exit transmission can be interrupted by indentifying and treating infected patients. isolation techniues and barrier precaution that

include the proper handling and disposal of secretions, urine and feces, and exudate can prevent pathogen transfer.

When droperidol plus fentanyl (Innovar) is given as a preoperative medication, narcotic pain medication

is reduced by half for the 8 hours after the preoperative medication, or the narcotic analgesic will gravely depress respirations.

Infection control surveillance: In most health care agencies an infection prevention and control practitioner, known as an infection preventionist (IP),

is responsible for ensuring that infection prevention and control measures are followed. When a patient is known to have an infection, the information is typically reported to the IP. the IP also assesses the facility for spread of infection.

Infection:

is the entry of an infectious agent, a microorganism-only visible with a micro scope-into the body that multiplies and causes tissue damage. careful hand hygiene is essential to prevent cross contamination.

Both age-groups are at risk for dehydration or overhydration Other types of patients who are at higher risk during and after surgery are those with bleeding disorders, cancer, heart disease, chronic respiratory disease, diabetes, liver disease, immune disorders, chronic

pain, upper respiratory tract infection, fever, or drug abuse issues (Table 37-1). These patients are subject to a variety of complications and should be carefully assessed during the postoperative period.

a "time-out" is called and the correct patient, correct site, and correct body

part are verified by the operating team via the chart orders, operative permit, and imaging studies.

Natural defenses. Protect intact skin and mucous membranes, promote a balanced diet and sufficient fluids, provide opportunity for adequate sleep and rest, and decrease stress as much as possible.

patient placement: Place a patient in need of Transmission-Based Precautions in a private room. If the patient is under Airborne Infection Isolation Precautions, a private room with negative airflow or a portable HEPA (high-efficiency particulate air) filter machine is essential.

Place an IV pole at the head of the bed. Connect oxygen and suction equipment if their need is anticipated. A thermometer, sphygmomanometer and stethoscope, and pulse oximeter should be close at hand on the

patient's return to the unit. If a PCA pump, sequential pneumatic compression devices, or a passive range-of-motion machine will be needed, see that they are obtained and ready.

Regional anethesia: It is often more economical than general anesthesia. Spinal or epidural blocks are frequently used for high-risk

patients undergoing pelvic or lower extremity surgery; epidural blocks are widely used in obstetric procedures.

Perform hand hygiene well and often,

paying close attention to areas around and under the fingernails and between the fingers Place trash and used linens in impervious, or moisture and particle-proof, plastic bags

Patient identification is verified again by the circulating nurse. The patient is positioned with padding to prevent injury to nerves and to minimize pressure over bony prominences. Safety straps are secured around the patient.

personnel who will be entering the OR wear clean scrub outfits, hair covers, shoe covers, and sterile gowns and masks; they perform a surgical scrub before entering the room. Strict surgical asepsis is mandatory throughout the surgical area. The circulating nurse or scrub person and

Helminths: are parasitic worms or flukes bellonging to the animal kingdom.

pinworms mostly afftect children, and are most common. ex: ascaris lumbricoides-round worm, enterobius vermicularis-pinworm, taenia solium-pork tapeworm. diease manifestations: anemia, hydronephrosis.

protozoa: one-celled microscopic organisms belonging to the animal kingdom.

plasmodium species that causes malaria: entamoeba hystolytica, which causes amebic dystentery: and other strains capable of causing diarrhea. exapmle: diarrhea, colitis, malaria

Surgical consent: The surgeon is responsible for obtaining an informed surgical consent. The need for the procedure, a description of the procedure to be performed, its risks and benefits, and alternative treatments available and their

possible consequences must be explained to the patient in understandable terms, and the explanation not just the patient's signature should be witnessed by at least one health care professional. Any questions must be answered. The surgeon often explains the procedure with the nurse

NPO status: Food and fluids are restricted before surgery, and the patient is placed on NPO (nothing by mouth) status. A light meal such as toast and clear fluids may be allowed up to 6 hours before surgery and a heavier meal 8 hours before surgery

practice guideline in 1999 for preoperative fasting in healthy patients (American Society of Anesthesiologists, 2011. Clear liquids such as black coffee, tea, apple juice, or carbonated beverages may be consumed up to 2 hours before surgery in some elective cases.

Health care- associated infections: HAIs Infections transmitted to a person while receiving health care services are called health care-associated infections (HAIs). A health care worker can also contract an HAI e.g., head cold, flu, staphylococcal skin infection if appropriate

precautions are not used. The Centers for Disease Control and Prevention (CDC) estimate that HAIs in acute care hospitals cause yearly at least 2 million infections, contribute to at least 98,000 deaths, and cost as much as $31.5 billion to treat (Scott, 2009).

Emphasize to the patient that exercise is vital to prevent circulatory problems. Do not rub the legs to promote circulation. Such an action may disrupt a clot that has formed and cause an embolus clot that travels and lodges in a vessel to the lung, the heart, or the brain.

prevent infection: Aseptic technique must be used when caring for the postoperative patient. Good handwashing is the primary means of preventing infection

Give an estimate of how long the tube will remain in the stomach. Explain the function, care, and

probable duration of use of other expected tubes such as drains, IV line, oxygen delivery and monitoring devices, chest tube, and urinary catheter.

During the illness period, localized and systemic signs and symptoms appear. The individual may have fever, headache, and malaise. Other specific signs of infection may be detected, such as rash, swollen lymph nodes, leukocytosis (increased white blood cells),

purulent wound exudate, diarrhea, and vomiting. The severity of the symptoms and the duration of the illness depend on the virulence of the pathogen and the person's susceptibility to the microorganism. In this phase people perceive they are ill and may seek professional care.

reinfused. This procedure is acceptable to Jehovah's Witnesses as long as there is a continuously closed circuit for collection and reinfusion. • Hemodilution during surgery may be used, in which up to seven units of the patient's blood are

removed and replaced with crystalloids or colloids. The cells are usually reinfused later, again via a closed system. The replacement fluids decrease blood viscosity, increase blood flow in tissues, and help maintain oxygen transport and blood pressure.

portal of entry: link five: Pathogens can enter the body through the mucous membranes of the eyes, nose, mouth, trachea or skin. examples: breathing in droplets containing pathogens and contracting a virus through broken skin.

useing only sterile and clean items when caring for patients reduces entry. barrier percaustions, safe handeling of food and water, good personal hygiene, advoidance of high risk behaviors and protection from insect bites and stings can prevent entry of microorganism.

Preventing spread of MRSA:

wash hands frequently: use an alcohol based rub when soap and running whater are unavailable. keep cut and abrasions clean and covered with a bandage until healed. avoid sharing personal items shcu as razors, towels and make up. avoid contact with other peoples bandages or wounds.

final identification involves chemical testing of the bacteria by performing a culture. sensitivity test are then performed to determine which antiiotic is most effective againt the bacteria.

when culture results show that a drug resistant organism is responsible for an infection, extreme care must be taken to prevent the spread of the organism.

anohter example of a drug resistant organism is penicillin resistant streptococcus pneumonia,

which causes a form of pneumonia that can be difficult to treat.

Whenever an infection is suspected, take additional precautions to prevent the possible spread of microorganisms,

which if left untreated could lead to sepsis or even death.

Latex allergy: Exposure may cause redness, local inflammation, pruritus of the hands, and anaphylaxis.

who have food allergies to bananas, kiwis, or avocados; or who have a history of reactions to other latex-containing products are at risk for developing this allergy.

• Repeated injections or venipunctures for blood tests

• A compromised immune system from factors such as chemotherapy, HIV infection, or long-term steroid use

• Able to verbalize understanding of the procedure and the expectations of him in the postoperative period

• Able to maintain fluid and electrolyte balance throughout the perioperative period

• Always face the sterile field, even when moving to the other side.

• Allow sufficient space (at least 6 inches) between the body and the sterile field.

Using an Incentive Spirometer • Insert the mouthpiece, covering it completely with the lips. • Take a slow deep breath and hold it for at least 3 seconds. • Exhale slowly, keeping the lips puckered.

• Breathe normally for a few breaths. • Try to increase the inspired volume by at least 100 mL with each breath on the spirometer. .

• Once maximal volume is achieved, attempt to inspire this volume 10 times, resting a few breaths in between each attempt.

• Clean the mouthpiece of the spirometer when finished

Specific Ways to Prevent Health Care-Associated Infections (HAIs): • Perform hand hygiene before and after caring for the patient, before donning gloves, and after their removal.

• Cleanse hands and change gloves between procedures that involve contact with mucous membranes, the perineal area, feces, wound drainage, or other contaminated matter. • Help all patients on bed rest turn, deep breathe, and cough effectively at least every 2 hours.

• Never shake linen when removing it or placing it on the bed. • Change gloves and perform hand hygiene after handling contaminated items.

• Faucets should be turned on and off using a dry paper towel to protect the hands from recontamination.

Contact Precautions Use in addition to Standard Precautions for patients with known or suspected serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment. Examples of such illnesses include:

• Gastrointestinal, respiratory, skin, or wound infections or colonization with multidrug-resistant organisms • Enteric infections with a low infectious dose or prolonged environmental survival, including Clostridium difficile

• The use of lasers, electrocautery, argon beam coagulators, and harmonic scalpels, which cause blood to coagulate after tissue is cut, decreases blood loss.

• If the patient is anemic before surgery, epoetin alfa (Epogen, Procrit) is used along with vitamins B12 and C to stimulate red blood cell production.

Infection prevention and control involve the following: • Observing patients for signs of infection • Recognizing individuals at high risk for infection and implementing appropriate precautions

• Implementing procedures to contain microorganisms when an infection is suspected • Monitoring diagnostic reports related to infection

Nursing diagnosis: • Pain related to disruption of tissue • Risk for infection related to surgical wound • Impaired gas exchange related to the effect of anesthesia on the lungs

• Ineffective airway clearance related to inability to breathe deeply and cough without discomfort • Self-care deficit, bathing/hygiene, related to decreased mobility, tubes, and dressings

Patients at greatest risk for HAIs include those with: • Surgical incisions with or without drains • Artificial airways, including endotracheal tube or tracheostomy • Indwelling urinary catheters

• Intravenous (IV) lines, particularly central venous or arterial lines • Implanted prosthetic devices (such as heart valves; vascular grafts; or orthopedic joints, rods, and screws)

Droplet Precautions Use in addition to Standard Precautions for patients with known or suspected serious illnesses transmitted by large-particle droplets. Examples of such illnesses are:

• Invasive Haemophilus influenzae type b disease, including meningitis, pneumonia, and epiglottitis • Invasive Neisseria meningitidis disease, including meningitis, pneumonia, and sepsis

• Assess IV line sites for signs of infection at least once per shift and each time you access the ports. • Use aseptic technique when suctioning the airway. • Always cleanse from the urinary meatus toward the rectum (front to back).

• Keep urinary catheter drainage bag below the level of the bladder at ALL times (even when transferring or transporting a patient). • Clean residual urine off the catheter bag drainage tube after emptying the bag; do not let the tube touch the collection container or floor.

• Kidney function is decreased in the elderly, which makes them less tolerant of normal adult dosages of medications. Watch for medication toxicity.

• Meperidine may cause confusion if used continuously.

• Puncture wounds from contaminated needles or other sharps • Skin contact, allowing blood, body fluids, and other potentially infectious materials to enter through damaged or broken skin

• Mucous membrane contact, allowing infectious materials to enter through the mucous membranes of the eyes, mouth, and nose Actions that decrease the nurse's risk for infection include using good hand hygiene and other general medical aseptic

• Lungs clear to auscultation; respirations 18 • Pulse 82, BP 136/86, peripheral pulses present

• No signs of thrombophlebitis or infection Each nursing care plan is evaluated on whether the individual specific outcomes have been met. Further examples of evaluation are in the nursing care plan for this chapter.

general principles regarding Isolation: • Floors are contaminated. Anything dropped on the floor is contaminated and must be discarded or cleaned carefully before reuse.

• Patients with communicable diseases should be grouped according to the epidemiology of transmission: • Anything that is brought into the isolation area must not be removed except in proper containers, which are then placed in an outside container labeled "Hazardous Materials—Biohazard."

Planning: Expected outcomes are written for the individual nursing diagnoses assigned to each patient. However, general goals for all preoperative patients are the same in that the patient will be:

• Prepared for surgery physically and emotionally • Able to demonstrate deep breathing, coughing, and leg exercises

• Using approved sanitation methods

• Properly handling and sterilizing or disposing of contaminated items and equipment

• The elderly patient should be taught needed information in short segments to prevent confusion and increase the patient's comprehension.

• Provide written reminders of the instructions to the patient.

• For diapered or incontinent patients: enterohemorrhagic Escherichia coli O157:H7, Shigella, hepatitis A, or rotavirus infection • Respiratory syncytial virus (RSV), parainfluenza virus, or enteroviral infections in infants and young children

• Skin infections that are highly contagious or that may occur on dry skin, including diphtheria (cutaneous), herpes simplex virus (neonatal or mucocutaneous), impetigo, major (noncontained) abscesses,

• Other serious bacterial respiratory tract infections spread by droplet transmission, including diphtheria (pharyngeal), Mycoplasma pneumonia, pertussis, and pneumonic plague

• Streptococcal (group A) pharyngitis, pneumonia, or scarlet fever in infants and young children • Serious viral infections spread by droplet transmission, including adenovirus, influenza, mumps, parvovirus B19, and rubella

• Take a deep breath through the nose and cough as you exhale with the mouth open but covered with a tissue. • If you cannot move secretions with your cough, use a forced exhalation cough.

• Take a deep breath through the nose and forcibly and quickly exhale, producing a huff-cough. • Repeat the process. • Repeat again, using three short "huffs" as you exhale to bring the secretions to the mouth where they can be expectorated.

• To reduce anxiety and promote a restful state • To decrease secretion of mucus and other body fluids

• To counteract nausea and reduce emesis • To enhance the effects of the anesthetic

The principles to observe when opening sterile packages are as follows: • Perform hand hygiene. • Open the sterile package away from the body.

• Touch only the outside of the wrapper. • Do not reach across a sterile field; go around the sterile field if necessary to reach the other side.

cellulitis, decubitus ulcers, pediculosis, scabies, staphylococcal furunculosis in infants and young children, and zoster (disseminated or in the immunocompromised host)

• Viral or hemorrhagic conjunctivitis • Viral or hemorrhagic infections (

Perform hand hygiene before gloving and immediately after removing the gloves because no glove is 100% protective.

Never reuse or wash gloves.

Reconstructive surgery, such as mammoplasty after a mastectomy, is done to restore appearance or function. Curative surgery alleviates (cures) a problem, as when a gallbladder that is full of stones, causing blockage or pain, is removed.

Patients at higher risk for surgical complicationa: The infant and the elderly person are at higher risk for complications of surgery because of either immature body systems or a decline in function of various body systems. Maintaining core body temperature is one concern for these patients.

Once the patient is eating again, he should have a bowel movement within 2 or 3 days. If one does not occur, an order for a suppository may be needed to stimulate a bowel movement.

Patients receiving narcotic analgesics may become constipated and require stool softeners or laxatives to produce normal bowel movements.

the mode of transmission can be interupted by effective hand hygiene, proper disinfection and sterlization medical equipment, use of aseptic free of microorganisms technnque in performing procedures and diagnostic test and use of standard precaustions to prevent contamination.

The current CDC recommendations are to sneeze or cough into the bended elbow rather than covering the mouth with the hands. this way the spread of the respiratory droplets is prevented and hands are not contaminated.

specific secretions, body fluids, tissues, or excretions that might be infective.

The different types of Transmission-Based Precautions may be used alone or in combination, but they are always used in addition to Standard Precautions.

Infecton prevention and control in the home: The patient at home has less exposure to HAIs, but can still be at risk.

The emphasis in the home environment is on containing pathogens and preventing transmission to health care personnel, caregivers, and others in the household.

To perform a sterile dressing change outside the operating room, use sterile gloves, a mask, and a sterile field. Talking during the dressing change is discouraged.

The four rules of surgical asepsis are as follows: 1. Know what is sterile. 2. Know what is not sterile. 3. Separate sterile from unsterile. 4. Remedy contamination immediately. The goal in surgical asepsis is to keep an area free of microorganisms.

chapter 17:

The infectious process has four stages: the incubation period, the prodromal period, the illness period, and the convalescent period.

Cilia, which line the respiratory tract, trap microorganisms and debris (dead tissue or foreign matter) and propel them up and out of the body with a wavelike action.

The intestinal system is a major portal of entry for pathogens, and the liver is an essential part of the body's defense system.Gastric secretions such as hydrochloric acid destroy ingested pathogens.

Cleanliness The idea of being "contaminated," "soiled," or "dirty" can make the patient feel at fault or inferior. The patient may blame himself.

The nurse can help overcome this with a warm, caring, and accepting attitude, and by avoiding displaying any irritation about the precautions or any evidence of distaste in dealing with the infection.

psychological aspects of isolation: The patient with Transmission-Based Isolation Precautions is at risk for both decreased self-esteem and sensory deprivation. Assessment for sensory deprivation needs to be ongoing.

The signs can include boredom, slowness of thought, disorganized thoughts, excessive sleeping during the day, anxiety, hallucinations, or panic attacks. Having visitors can be helpful in preventing sensory deprivation.

Intraoperative care: The patient is transported to a holding room where the circulating nurse verifies the patient's identification and that all preoperative orders have been accomplished

The surgical site is verified with the patient and marked, if not already done, before medications are given. Any ordered preoperative medications are administered. When the OR is ready, the patient is transferred to the

Some agencies use paper dishes and trays for a patient under

Transmission-Based Precautions, but this is not a CDC requirement. Box 17-2 presents other general principles.

Airway Lung sounds, depth and quality of air movement, respiratory rate. Auscultate lungs initially; respiratory rate q 15 min until fully aroused from anesthesia, then assess quality of respirations with vital signs

assessment. Oxygen saturation; oxygen delivery at rate ordered and patent system. Note per vital signs schedule and whenever in room. Check oxygen delivery system with initial assessment.

Teaching for postoperative exercises: Teaching the patient breathing, coughing, turning, and leg exercises is a high priority during the preoperative period. Venous return is often hampered during the surgical procedure because of the position

assumed on the operating table and pooling of blood in the lower extremities. The stasis (stoppage of flow) of blood places the patient at risk for thrombophlebitis (blood clot causing inflammation of a vessel). Specific leg exercises help prevent this complication

Speaking to the patient in advance via the intercom

can help ensure you will have everything necessary when you don your protective clothing and enter the room.

process of infection: the process by which an infection is spread from one person to another can be thought of as a continuous chain.

causative agent link one- is amy microorganism or biologic agent capable of causing disease. agents include: bacteria, viruses, protozoa, prions, rickettsia, fungi, and helminths.

techniques, wearing PPE, using needleless IV equipment and needles with guards, and avoiding carelessness in the clinical area. it is also recommended that health care workers be immunized if they do not have an active immunity to

certain diseases, including hepatitis B, influenza, mumps, measles, rubella, varicella (chickenpox), tetanus, diphtheria, pertussis, and meningococcal disease. In areas with high prevalence of pulmonary tuberculosis, yearly testing for tuberculosis is recommended for health care workers.

other infectious agents: mycoplasmas are very small organisms with out a cell. they cause infections of the respiratory or gential tract. mycoplasma pneumoniae is and example.

chlamydia, another type of organism affects the genitourinary and reproductive tracts. in countries where hygiene is poor, chlamydia trachomatis is responsible for trachoma, an eye disease that can cause blindness. In US this organism cause sexually transmitted infections.

Classification of bacteria according to their morphology shape places them into one of three main groups:

cocci-round, baccilli-rod shaped, and spirochetes-spiral. some grow in chains streptococci, some in pairs diplococci and some in clusters staphylococci.

shoe cover: Shoes are covered so that pathogens are not carried out of the room; the covers are removed when exiting the room in the same manner as the head cover.

delivery room or in the emergency department when dealing with trauma patients.

Current standards regarding the time for the traditional scrub are based on the recommendations of the antiseptic agent manufacturer, and consequently the recommended time varies from one agency to another,

depending on the product used. A 2- to 4-minute scrub is average. A newer brushless technique, which may be done with or without water, uses an antimicrobial agent that is at least 60% alcohol.

This increased production or release of leukocytes is termed leukocytosis. phagocytes work to destroy or stop their invasion. The macrophages assist in body defense by removing cellular debris, engulfing and lymphocytic cells.

destroying bacteria and viruses, and removing metabolic waste products. Some phagocytes are called tissue macrophages; others, which are concerned with immunity, are the lymphocytic cells. Phagocytosis is part of the inflammatory response, another defense mechanism of the body.

The inflammatory response: The blood vessels dilate, bringing more blood to the damaged area, causing redness, warmth, and edema. Inflammation is a localized protective response brought on by injury or destruction of tissues. The basic purposes of the inflammatory response are to

(1) neutralize and destroy harmful agents, (2) limit their spread to other tissues in the body, and (3) prepare the damaged tissues for repair. During inflammation the chemicals histamine and serotonin are released.

Patients at high risk for infection are those who (1) are weakened by injury or severe illness; (2) have another chronic illness; (3) have a central venous catheter, IV cannula, indwelling drainage tube, or endotracheal tube for mechanical ventilation;

(4) are very young or very old; (5) have an open wound; (6) have a surgical incision; or (7) have a compromised immune system from chemotherapy or immunosuppression.

TERMINOLOGY FOR SURGICAL PROCEDURES: Lysis: removal or destruction of (lysis of adhesions: removal of adhesions) Anastomosis: joining of two parts, ducts, or blood vessels

-ectomy: cutting out or off colectomy: cutting out a part of the colon) -ostomy: furnishing with a mouth or an outlet colostomy: creating an outlet from the body for the colon -otomy: cutting into thoracotomy: cutting into the chest cavity)

-plasty: revision, molding, or repair of tissue mammoplasty: revision of the breast

-pexy: fixation, anchoring in place orchiopexy: fixation of an undescended testicle in the scrotum

Tranmission based precautions requirements: Airborne Infection Isolation Precautions Use in addition to Standard Precautions for patients with known or suspected serious illnesses transmitted by airborne droplet nuclei.

. Examples of such diseases are:• Measles (rubella) • Varicella (including disseminated zoster) • Pulmonary tuberculosis

standard percausions: Standard Precautions to facilitate breaking the chain of infection. These precautions protect both the nurse and the patient and are to be used for every patient contact; they include the use of hand hygiene and personal protective equipment (PPE)

. PPE includes gloves, gowns, masks, protective eyewear, shoe covering, and hair covering.

Airbornine infection isolation precautions: Use the Tier 1 precautions (Standard Precautions) as well as the following:

1. Place the patient in a private room that has negative air pressure: 6 to 12 air exchanges per hour and discharge of air to the outside or a filtration system for the room air.

droplet precautions: Use the Tier 1 precautions (Standard Precautions) as well as the following: 1. Place the patient in a private room.

2. If a private room is not available, place the patient with another patient who is infected with the same microorganism.

1 .Rinse the object with cold water to remove organic material. 2. Once all visible organic material has been removed, wash the object in hot, soapy water.

3. Use a stiff-bristled brush or abrasive to clean equipment with grooves and narrow spaces. Friction helps dislodge soil. 4. Rinse the object well with moderately hot water. 5. Dry the object; it is now considered clean, but not sterile

2. If a private room is not available, place the patient with another patient who is infected with the same microorganism. In select situations, approval from the local health department may be required (e.g., for pulmonary tuberculosis patient).

3. Wear a respiratory device (N95 respirator) when entering the room of a patient who is known to have or suspected of having primary tuberculosis.

mode of transfer link four: include: 1. direct persoanl contact with body excretions or drainage such as from an infected wound 2. indirect contact with contaminated inanimate object called fomites, such as needles, drinking and eating utensiles, dressings and hospital equipment

3. vectors such as fleas, ticks, mosquitoes, and other insects that harbor infectious agents and transmit infection to humans through bites and stings. 4. droplet infection or contamination by the aerosol route through sneezing and coughing. 5. spread of infection from one body to another.

assurance of sufficient privacy and protection of modesty to allay any fears she might have

; such issues and interventions must be conveyed to the OR.

An antiseptic is a chemical compound that is used on skin or tissue to inhibit the growth of or to eliminate microorganisms. Disinfectants and antiseptics have bactericidal or bacteriostatic properties.

A bactericidal solution destroys bacteria; a bacteriostatic solution prevents the growth and reproduction of some bacteria.

Disinfectants are solutions containing chemical compounds such as phenol, alcohol, or chlorine that kill or inactivate nearly all microorganisms. These chemicals can be caustic to the skin and are used only on inanimate objects.

A recommended disinfectant is chlorine bleach and water at a ratio of 1:10. Before disinfection, items must be thoroughly rinsed after cleaning because soap residue may react with the disinfectant, preventing its killing properties from working. An antiseptic is a chemical compound that is used on skin or tissue to inhibit the growth of or to eliminate microorganisms.

Rest and sedation: It is desirable for the patient to be as well rested as possible before surgery so the body is not compromised in meeting the stresses of anesthesia and the procedure.

A sedative is usually ordered for the night before surgery, but, if in the hospital, the patient often must ask for it.

Check the date before using a hospital-prepared sterile pack. Commercially prepared packs may also have expiration dates that need to be checked before use.

A sterile field is set up by using the inside of the wrapper on the sterile pack or by opening and draping a tabletop or instrument tray with sterile drapes and then placing the sterile items to be used on the field

Sharps Needles are not to be recapped before disposal

Never put your fingers inside the opening of the sharps container. Shake the container gently to settle the contents and make more room if necessary. Replace sharps containers when they are two-thirds full.

application of the nursing process: At the first encounter with the patient, assess for signs of infection that may require Transmission-Based Precautions. Assess wounds each shift for signs of infection. Monitor the patient's temperature.

Admission laboratory studies may also give indications of possible infection, such as an increased white blood cell count or a urinalysis that is positive for bacteria. If cultures were performed,

head cover: on the head if there is danger of contamination of the hair or if microorganisms resident in the hair might endanger the patient.

After use, remove the cap by slipping the fingers beneath the elastic and handling only the inner surface of the head cover to prevent hand

Skin Preparation: The patient may be asked to shower with a special antibacterial cleanser the night or morning before surgery to remove as many microorganisms from the skin as possible.

Although this is often done in the OR, it may be part of your job to clip hair or use a depilatory before the patient goes to surgery

Check the patient's identification bracelet against the chart for accuracy to avoid any error or mix-up of patients in the OR.

Attend to all items on the preoperative checklist that can be handled ahead of time early in the morning

Cleaning and disinfection: Pathogens can be killed or inactivated by disinfection, sterilization, or the use of sanitizing agents.

Appropriate cleaning removes and inhibits the growth of microorganisms. Always wear gloves when cleaning visibly soiled objects or performing wound care. Whether in the hospital, a long-term care facility, or a home setting, follow these steps to clean objects:

Asepsis and control of microorganisms: medical asepsis and surgical asepsis:

Asepsis is the practice of making the environment and objects free of microorganisms. Medical asepsis is referred to as clean technique because most, but not all, microorganisms are destroyed.

Always check the physician's order before giving anything by mouth in the immediate preoperative period

Ask the patient to empty the bladder, unless a catheter is in place, as you finish the preoperative checklist. Relaxation induced by medications and anesthesia causes the urge to urinate if the bladder is not empty.

Circulation Auscultate heart; check peripheral pulses and sensation, especially distal to surgical site.

Assess skin color. Initially, q 4 hr × 2, then with vital signs. If surgery was on an extremity, assess each time vital signs are measured.

Entry nurses note: 4/11/14 0740 prop checlist complete. surgical site and knee verified with patient and marked S. Crebs, LPN 0800 took via strecher. s crebs, LPN

Assist in transferring the patient to the stretcher when the transport person comes to take the patient to surgery. Compare the patient's identification bracelet name and numbers with the transport request sheet.

assessment data collection: The nursing history and assessment focus on possible factors that indicate the patient is at higher risk for complications from surgery

Besides checking for drug allergies, it is important to determine whether the patient has a latex allergy.

Personal protective equipment: Use clean disposable gloves for most general care, such as bathing, perineal care, IV site care, and most dressing changes.

CDC guidelines state that if full PPE is required, it is donned in the following order: gown, followed by the mask or respirator, then goggles or face shield, and finally gloves.

a spinal headache, but it is not necessary to stay totally flat for the first 12 hours because this has proven ineffective. If a headache develops, staying flat reduces the pain.

Encourage the patient to drink a lot of fluids, including those containing caffeine. The fluids and caffeine raise the vascular pressure at the spinal puncture site and help seal the hole.

Turning, coughing, and deep breathing, plus ambulation, assist in preventing pneumonia (inflammation and consolidation of the lung with exudate) from retained secretions and lack of movement.

Complications of surgery: A major nursing responsibility is continuous monitoring for signs of the various complications that may occur as a result of surgery. summarizes postoperative complications and nursing actions to prevent them. Dehiscence (separation of the layers of the surgical

One of the greatest fears of the elderly person facing surgery is a loss of independence. It is important to stress the measures that will be taken to return the patient to independence after surgery.

Cultural beliefs and values regarding surgery must be taken into consideration. If the patient does not speak the same language as the surgical team, an interpreter should be enlisted to assist with communication. If a female patient's culture has strict rules for female attire, she needs

Respiratory function: Impaired cough mechanism and impaired function of cilia decrease ability to expel foreign substances and mucus from the lungs, predisposing the person to respiratory tract infection. Decreased macrophage activity in the lungs

Decreased macrophage activity in the lungs. Discourage smoking. Encourage deep breathing and intake of fluid to keep lung secretions thinned.

Postoperatively, you will be asked to deep breathe and cough to open the lungs and clear secretions. Sit up away from the mattress when you do these exercises. The exercises should be performed every 2 hours during waking hours.

Deep Breathing • Take a deep breath in through the nose, hold for a few seconds, and slowly exhale. • Repeat twice more. Forced Exhalation Coughing Splint the abdominal or chest incision and:

For deep breathing and coughing, it is preferable for the patient to sit up with the back away from the mattress or chair. This allows for full lung expansion. The surgical incision should be splinted with a pillow

Deep breathing and coughing should be performed every 2 hours for 72 hours after general anesthesia. The surgeon may order use of an incentive spirometer. Instruct the patient in its use and supervise until the patient has mastered the technique. Help the same-day surgery patient devise a

If a wedding band is to be worn to surgery, tape it to the finger without restricting circulation.

Dentures are removed, placed in a labeled cup, and kept in a designated place according to hospital policy

disposal of sharps:

Disposable sharp instruments, referred to as "sharps," are placed directly into a special puncture-resistant sharps biohazard container immediately after use

contaminated waste:

Dispose of items contaminated with infectious material in sealed, impermeable plastic bags marked "Hazardous Waste" or "Biohazard." This includes soiled dressings, used sanitary pads, suction drainage containers, and any other item that has been in contact with body fluids

Measures to help prevent latex sensitivity include using gloves in appropriate situations and not for routine tasks in which a blood, body fluid, or microorganism contact exposure is unlikely. Gloves are removed directly over a trash receptacle without "snapping" them off.

Do not use petroleum-based lotions under latex gloves because they attract latex proteins from the

General anesthesia: General anesthesia is induced by the administration of an inhalant gas or an intravenous (IV) medication.

During general anesthesia the patient is in a deep sleep state with muscle relaxation and is not aware of anything going on in the operating room. Quiet must be maintained while the patient is in stage 2 because noise may excite the patient, resulting in instability of vital signs.

Preoperative procedures: divided into four phases: preoperative, intraoperative, postanesthesia immediate care, and postoperative care.

During the preoperative phase, nonanemic patients may donate their own blood 2 to 4 weeks before surgery to be banked in case of postoperative autologous (related to self) transfusion need.

Explain that asking for the pain medication before the pain becomes severe makes it easier to control the pain level. The patient will be much more comfortable if pain medication is administered regularly for the first 48 hours after surgery.

Effectiveness of medication delivered by the PCA pump must be assessed and the physician consulted if pain is not being well controlled with use of the pump.

Isolation is a means of preventing contact between a patient and others to prevent the spread of infection.

Emphasis is placed on containing microorganisms and preventing their spread.

Other areas to evaluate are whether the patient's valuables were safely returned after surgery, and whether dentures, glasses, or hearing aids were found and reinserted. If any of these items was misplaced, then procedures need to be changed.

Expected outcomes written for individual nursing diagnoses must also be addressed during evaluation

elimination: If the patient is having colon surgery, enemas may be ordered to be given until clear. The patient may be on a special soft or liquid diet for 3 days before surgery to decrease the content of the bowel

Expected tubes and equipment: If a nasogastric tube will be inserted during surgery for postoperative use, explain its purpose, its care, and what it will feel like to the patient.

Implementation: Teach a patient with an infection about the disease process, modes of transmission, and precautions necessary to prevent spread of the infection (Nursing Care Plan 17-1).

Explain Standard and Transmission-Based Precautions to any visitors.

ENHANCEMENTS TO SURGICAL TECHNIQUE: LASER: Laser (Light Amplification by the Stimulated Emission of Radiation) surgery is common and is often combined with microscopic, endoscopic, and robotic-enhanced procedures.

Fiberoptic surgery: Fiberoptics allows the use of endoscopes with high-resolution video cameras passed through a very small incision for an ever-increasing variety of surgical procedures.

nursing diagnosis: Expected outcomes include "No HAI is evident." When using Transmission-Based Precautions that require putting on personal protective equipment (PPE), you must prepare before each entry into the patient's room.

For example, will you need more linen? Are all the dressing supplies in the room? Does the patient need pain medication? Are routine medications due at this time? Is there drinking water in the room?

check the reports to see if any microorganism has been identified. Frequent voiding of small amounts, pain on urination, or a decrease in overall urine output may also indicate infection.

Frequent voiding of small amounts, pain on urination, or a decrease in overall urine output may also indicate infection.

• Teach patients and families the importance of hand hygiene. Stress that hands must be cleansed before caring for the patient and after care is finished.

Gloves are needed in addition to hand hygiene for tasks such as tracheal suctioning and tracheostomy care, dressing changes and wound or drain care, tube feedings, and cleansing of personal areas of the body.

Fever is a natural defense mechanism. Therefore a fever should not be treated right away unless it is dangerously high.

In many instances it is not desirable to lower the body temperature to normal. Rest and increased fluids are the correct treatment for the first few days.

Hand hygene: Hand hygiene is one of the most effective ways to reduce the number of microorganisms on the hands,

Health care workers must perform hand hygiene before and after giving care to a patient. In 2002 the CDC concluded from research that alcohol hand rubs can be more effective than handwashing in ridding the hands of microorganisms

Promote respiratory function: Atelectasis collapse of alveoli in the lungs assess the rate and depth of breathing, and encourage the patient to deep breathe and cough every 2 hours. This is essential to prevent pneumonia and relieve atelectasis.

Hypostatic pneumonia occurs when lack of movement or of position change causes stasis of secretions, which become a breeding ground for bacteria. Coughing may be contraindicated for patients who have had hernia repair or eye, ear, or brain surgery. Check the physician's orders.

Pain control: Many surgeons order a patient-controlled analgesia (PCA) pump for their patients postoperatively. Patients should receive instruction about the pump and how to operate it before surgery.

If patients will be receiving injections for pain control, explain that this type of medication is ordered on an as-needed basis every 3 to 4 hours and that they must ask for it.

All patients should be asked during a health assessment whether they have had a tetanus immunization within the past 10 years.

If they have not, seek an order for the immunization as long as the patient is healthy enough to receive it. Tetanus can be deadly

transporting patient: Avoid transporting the isolation patient unless absolutely necessary.

If transporting is unavoidable, give the patient a standard mask to wear while out of the room.

Influenza immunization is recommended yearly for all health care workers and anyone over 6 months of age.

Immune function Both immediate and delayed immune responses are decreased or altered. Protect from exposure to pathogens.

Use Standard Precautions for each contact with every patient, regardless of whether infection is known to be present.

Implement Transmission-Based Precautions based on the individual patient's infection status.

Infection Prevention and Control for the Nurse OSHA regulations protect health care workers from occupational exposure to blood-borne pathogens in the workplace.

In Canada the Canadian Centre for Occupational Health and Safety addresses worker safety. These two agencies have determined that the three main modes of occupational exposure to blood-borne pathogens are as follows:

Grieving related to impending loss of a body function or body part Deficient knowledge related to preoperative and postoperative routines Sleep deprivation related to stress or unfamiliar environment

Ineffective coping related to lack of problem-solving skills or adequate support Ineffective role performance related to inability to care for children during hospitalization

Drop used syringes and other sharps into the container designated for sharps disposal, and then activate the lever that drops the sharp into the container.

Never allow your fingers to enter the container. Never recap needles that have been used on a patient.

Two types of asepsis are practiced within health care agencies. The first, medical asepsis, is the practice of reducing the number of organisms present or reducing the risk for transmission of organisms.

It prevents reinfection of the patient and the spread of infection from person to person. It involves cleanliness and is accomplished by protecting items in the environment from contamination and by disinfecting items that have been contaminated.

For cleansing items in the home, boiling in water is the easiest method. Items should be boiled for a minimum of 15 minutes.

Items that cannot be boiled or disinfected by running them through the dishwasher's "sanitize" cycle can be exposed to direct sunlight for several hours. The heat and ultraviolet rays kill many exposed microorganisms.

Immediate preoperative care: Dress the patient in a clean hospital gown, without underwear, for the OR. Hair is covered with a surgical paper cap. Long hair should be dressed so that it will tangle minimally; all hairpins and barrettes must be removed.

Jewelry is removed and, along with money and credit cards, is given to a significant other to keep or is secured in a valuables envelope and placed under lock and key.

Handle contaminated linens in a like manner unless all linen in the facility is treated as a contaminated biohazard. Gather soiled linens carefully and bag at the site of use.

Keep used linens away from your uniform. Do not put them on the floor or chair because microorganisms from the patient can be spread this way. Place them directly into the linen hamper.

Linens Soiled linen is handled as little as possible. Roll it up and place it inside the linen hamper in the patient's room.

Never carry unbagged soiled linens in the hallway, since it increases the risk of contaminating the surrounding environment. When the bag is two-thirds full, tie it closed and send it to the laundry according to agency policy. Double bagging is not necessary.

Promote gastrointestinal function: Eating is not allowed until bowel sounds have returned after surgery and general anesthesia because of the risk of development ofparalytic ileus failure of forward movement of bowel contents.

Listen for bowel sounds at least once per shift. When eating is resumed, clear liquids are usually ordered, followed by full liquids, then a regular diet if the preceding diets have been tolerated. After spinal anesthesia, the patient may be allowed to eat right away.

immune response: is the third line of defense against pathogenic organisms..

Microorganisms and other substances that do not belong in the body, such as pollen, are recognized as foreign invaders and trigger an immune response (the body's reaction to substances interpreted as nonself)

sterilization: Sterilization is the best method of eliminating microorganisms from equipment and supplies. There are five methods of sterilization: steam under pressure (moist heat), dry heat, ethylene oxide, liquid chemicals, and hydrogen peroxide gas plasma.

Moist heat is most often used by applying steam under pressure in a device called an autoclave. Ethylene oxide gas is effective against microorganisms and spores. It is used for heat-sensitive items and where good penetration is essential.

Evaluation: Evaluation is accomplished by determining whether the expected outcomes and goals have been met. If the patient is properly prepared for surgery, is kept

NPO, is reasonably calm, and is knowledgeable about the procedure and what is expected of him, then the general goals have been met.

Specimen Preparation and Transportation Before collecting body fluid or other potentially infectious material, verify the physician's order and fill out the correct laboratory requisition form.

Next, label the specimen container with the patient's name and medical record number. Place the label on the container itself, not the lid, since once the lid is removed in the laboratory, the specimen would be unlabeled.

promote comfort: If respirations are within normal limits and there is no contraindication to doing so, medicate promptly with the ordered analgesic.

Occasionally continuous hiccups occur after surgery, making the patient quite uncomfortable. Having the patient breathe into a paper bag often relieves the hiccups, but persistent hiccups require more vigorous treatment prescribed by the physician.

The immune system response is specific to the type of invader. Unique antigens on the surface of individual cells aid the immune system in distinguishing self from nonself (invaders) so it can destroy foreign material (antigens).

Once exposed to a microorganism, the body produces antibodies against that invader. In this way, naturally acquired immunity occurs.

Rest and activity: The patient needs to sleep after surgery. Keep the room quiet and group nursing activities to avoid waking the patient more than necessary. Every 2 hours the patient must do leg exercises and change position.

Orders for ambulation may begin 8 hours after surgery. After a few minutes, slowly help the patient stand. Have the patient walk around the room using a gait belt, or for at least a few steps

chapter 37 care of the surgical patient: A procedure may be elective (voluntary), such as when a hernia repair is scheduled a week away. Emergency surgery is often necessary in trauma cases in which serious consequences will occur if surgery is not done immediately.

Palliative surgery (to relieve pain or complications) is performed to make a patient more comfortable. Diagnostic surgery, such as a biopsy of a mass, is done to provide data for a diagnosis of the problem.

Hand hygiene: Hand hygiene is the most important action in preventing the transmission of infection (see Chapter 16). Perform hand hygiene before and after contact with a patient, wound care, or any invasive procedure.

Perform hand hygiene before donning gloves and after removing them. Even tasks like interviewing the patient requires that hand hygiene be performed before leaving the room, whether you touched the patient or not.

Mask: Apply a regular surgical face mask before entering the room if there is a chance that you will be in contact with airborne pathogens larger than 5 microns (e.g., influenza or meningitis) or splashed body fluids, such as when a patient is coughing or you are performing suctioning.

Place the mask over the nose and mouth and secure it in place by an elastic band or ties (Figure 16-5). Wear an N95 respirator mask when entering an area where airborne microorganisms less than 5 microns in size (e.g., Mycobacterium tuberculosis [TB]) are known to be present.

• Risk for injury related to sedation, decreased level of consciousness, or excessive blood loss

Planning: • Maintain patent airway and adequate respiratory exchange. • Maintain adequate tissue perfusion. • Promote comfort and rest. • Promote wound healing.• Prevent complications

Do not wear jewelry when you are providing patient care because microorganisms become lodged in the settings of stones, in the grooves of rings, and on the skin beneath the jewelry. Fingernails should be kept clean and short (no more than ¼ inch past the fingertips),

Polish, if allowed, should not be chipped because it can harbor bacteria. No artificial nails, extenders, silk nail wraps or tips, gels, or nail jewelry should be worn. Proper hand care includes prevention of hangnails and skin abrasions, which provide a point of entry for bacteria.

OR technician prepare the instruments and sterile supplies A study found that warming the patient before an operation can reduce the risk of surgical wound infection by 57%. Two different warming systems were used in the study

Postanesthesia immediate care: The period immediately after surgery with general anesthesia or after a major procedure performed with spinal anesthesia is a critical time and requires constant observation by specially trained nurses.

Check the chart to make certain that everything ordered has been done and make a final entry in the nurse's notes

Preoperative Medications Most preoperative medications are given intravenously in the surgical holding area rather than on the nursing unit. Preoperative medications are given for the following reasons:

Preparation for surgery is begun before admission

Preparation for surgery is begun before admission.

Artificially acquired passive immunity is provided by injection with antibodies derived from the infected blood of people or animals.

Serum immune globulin is often used for this purpose and is given to people who have been exposed to hepatitis A virus or mumps and who have not been previously immunized.

These chemicals act on the walls of the capillaries, causing them to be more permeable so that water, proteins, and defensive cells can pass out of the blood and into the fluid surrounding the damaged cells.

Purulent drainage called pus, caused by the debris that sometimes results from the inflammation process, may accumulate at the site. Leukocytosis is then triggered and draws phagocytes to the damaged tissue to begin their work.

Trash Place disposable soiled equipment and supplies inside the plastic bag lining the waste receptacle in the patient's room

Red bags marked with a biohazard symbol are for biohazardous waste only.

The body's second line of defense helps destroy pathogens that escape the first line of defense. This includes the mechanisms of fever, leukocytosis, phagocytosis, inflammation, and the action of interferon (biologic response modifier that affects cellular growth).

The body automatically raises its temperature in response to infection. A fever can slow the growth of many pathogens until other body defenses can be mobilized

Implementation: Maintaining an open airway is a priority measure. The patient must be positioned on the side or with the head turned to the side to prevent aspiration, if not contraindicated, until fully recovered, alert, and with the swallowing reflex intact.

Side rails are kept raised for safety until patients are fully recovered from anesthesia. A feeling of "pins and needles" in the legs is common. The patient is prone to hypotension until all effects of the spinal anesthesia are gone. Monitor the patient for

PainUse a pain scale and observation of nonverbal behaviors. Initially and with vital signs; assess at least q 2 hr.

Skin Pressure areas over bony prominences. Initially and q 2 hr.

Fluid status and hydration: IV site and flow rate; I & O; skin turgor; oral membranes. Check IV initially and when in room; I & O each shift; skin turgor and oral membranes initially and each shi

Surgical site: Check for bleeding; mark drainage on dressing; check wound drainage in containers. Initially and q 1 hr × 4; then with vital signs.

The Four Stages of Anesthesia Stage I: The stage of analgesia. Begins with the administration of the anesthetic agent and ends when the patient becomes unconscious incapable of responding to sensory stimuli. Hearing is amplified at the end of this stage.

Stage II: The excitement phase. Muscles become tense, but swallowing and vomiting reflexes are still present. Breathing may become irregular or the breath may be held. The environment should be kept quiet during this period.

Stage III: Surgical anesthesia state. Begins with the onset of regular breathing again. Vital functions are depressed, eyes are fixed, and reflexes are lost or temporarily depressed. The surgical procedure is begun during this stage.

Stage IV: Complete respiratory depression. Spontaneous respirations are absent. The patient is maintained by the anesthesia machine, which supplies oxygen and a set rate of breaths.

Artificially acquired immunity is achieved through injection of vaccines or immunizing substances that contain dead or inactive microorganisms or their toxins. The vaccine prompts the body to produce antibodies.

Vaccinations against polio, measles, hepatitis B, influenza, tetanus, and diphtheria provide this type of immunity.

Urinary tract: Prostatic hypertrophy, cystocele, rectocele, and degeneration of nerves to bladder cause urine stasis in bladder as a result of incomplete emptying.

Stasis predisposes to urinary tract infection Encourage intake of sufficient fluid to keep urine dilute

Surgical asepsis is the practice of preparing and handling materials in a way that prevents the patient's exposure to living microorganisms.

Surgical asepsis is referred to as sterile technique. It involves sterilization of all instruments and inanimate equipment, as well as use of sterile supplies and sterile technique, for procedures that invade the body and for wound care.

Passive acquired immunity occurs when a person is given an antitoxin or antiserum that contains antibodies or antitoxins that have been developed in another person.

Tetanus antitoxin is an example of a substance that provides passive immunity. It protects a person from the current invasion of microorganisms but does not provide lasting immunity.

Teach the patient to perform correct hand hygiene and to dispose of paper towels and facial tissues in an appropriate container. Instruct other family members to also perform hand hygiene frequently.

The bathroom should be cleaned daily with standard household cleaning agent or a 1:10 solution of chlorine bleach and water. Dishes should be washed on the hot (or sanitize) cycle of the dishwasher or soaked in scalding hot water after washing and allowed to air dry.

Opening Sterile Packs and Packages and Setting Up a Sterile Field Many sterile supplies are prepared commercially and are disposable, or one-time use, items.

The package, set, or kit provides all the items commonly required in a variety of nursing procedures, such as catheterization, suture removal, dressing change, and irrigation. Individually wrapped items can be obtained to supplement the packs as needed.

The patient is positioned to prevent aspiration and promote lung expansion. The patient is kept warm by covering with warmed blankets and is reassured that the surgery is over.

The patient remains in the PACU until the vital signs are stable and he is awake and able to respond to stimuli. A form of the Aldrete scoring system may be used to determine readiness for transfer. Activity, respiration, circulation, consciousness, and skin color are each given a score of 1 to 3.

The incubation period begins when the organism firsts enters the body and lasts until the onset of symptoms.

The prodromal period is the short time from the onset of vague, nonspecific symptoms to the beginning of specific symptoms of infection. The patient may be irritable and experience fatigue, malaise (not feeling "right"), and elevated temperature.

Robotic surgry: More surgeons are using remote-controlled robots to perform surgeries. Robotics is seen as a key to less invasive, less traumatic surgeries in the future.

The robot is operated from a nearby computer while the surgeon views magnified three-dimensional images of the surgical field on the computer's screen.

Implementaion: Preoperatively, divide your time between preparing the patient for surgery and teaching about what will happen and how to assist in the recovery period.

The same-day surgery patient receives teaching from the physician's office nurse or a surgical intake nurse.

surgical scurb: ) is more lengthy and vigorous than normal handwashing. Its purpose is to remove as many microorganisms as possible without damaging the skin of the hands.

The scrub begins at the tips of the fingers, working up the hands, and ends 2 inches above the elbows. Some agencies allow the use of the counted-stroke method of scrubbing rather than by-the-clock timing

present, answers questions, and then asks the nurse to obtain the patient's signature on the form. If the patient does not understand the procedure or has further questions for the surgeon, refer the matter back to the surgeon

The signature of the patient or the responsible party is witnessed by another party, often a staff member. The consent form must show the procedure to be performed and the risks involved, must include the time and date, and must be signed in ink. A witnessed "X" is acceptable

Procedural moderate sedation anesthesia: conscious sedation, and depression of the autonomic nervous system.

The technique can be used for any surgery or procedure that can be done with local anesthesia and is being used more and more frequently. The patient is monitored closely for blood pressure changes, oxygen saturation levels, and heart activity.

Signs of complications are complaints of shortness of breath; pain on inspiration; and extreme fatigue, which is related to hypoxemia.

The use of an incentive spirometer is especially helpful to prevent atelectasis and hypoventilation.

The convalescent (recovery) period begins when the symptoms begin to subside and extends until the patient has returned to a normal state of health. This can take days to weeks, depending on the microorganism and the person's overall state of health.

This can take days to weeks, depending on the microorganism and the person's overall state of health.

schedule for doing the exercises. Show the patient how to turn in bed by flexing the legs to relax the abdominal muscles, grabbing on to the side rail, and slowly turning to the side.

This maneuver is also used for getting up out of bed. The patient is also instructed in what to expect before, during, and after surgery.

Naturally acquired passive immunity occurs when the fetus receives antibodies from the mother through placental blood before birth..

This type of immunity is also acquired by the breastfeeding infant. It is temporary and typically lasts only until the infant's own immune system matures enough to function properly.

Gastrointestinal: Auscultate bowel sounds; assess abdomen; check NG drainage color, character, amount. Initially, then q 8 hr. Check drainage whenever in room.

TubesCheck for patency and function of each. Initially; then with vital signs after 1 hr. Kidney function. Assess urine output from Foley catheter; must void within 8 hr if no Foley in place. Initially and q 1 hr × 4; then if >30 mL/hr, q 4 hr.

This period lasts a few hours to a few days. Microorganisms are most likely to be spread during this highly infectious stage.

Typically, precautions against spreading the infection are not taken because people do not realize that they are ill until the more specific symptoms of infection appear

Radiation:

Ultraviolet light can be used for disinfection. Ionizing radiation is used to sterilize drugs, foods, and other items that would be damaged by heat. Irradiation is now being used on select fruits, vegetables, and meats as a way to ensure a safer food supply in the United States.

Mental status Level of consciousness and orientation. Initially and then with full vital signs.

Vital signs:Temperature, BP, pulse, and respirations. Check temperature initially then q 8 hr once stable. Check vital signs q 15 min × 1 hr; q 30 min × 2 hr; q 1 hr × 4; q 4 hr × 24-48 hr; or per agency protocol.

gloves:

Wear disposable gloves for Standard Precautions when there is a chance of contact with blood or body fluids, mucous membranes, nonintact skin, or secretions or excretions.

Although Standard Precautions and Transmission-Based Precautions can seem overwhelming at first, the concepts are actually relatively simple. For example, never touch with bare hands anything that contains fluids from a body surface or cavity.

Wear gloves for all contact with body fluids of any sort, including blood, saliva, urine, and feces. The only time gloves are not worn is for contact with intact skin or unsoiled articles.

Many hospitals and health care agencies provide alcohol hand rubs for personnel to use when hands are not visibly contaminated

When hands are visibly soiled, the CDC recommends wetting the hands; adding soap; performing at least 15 seconds of vigorous rubbing (friction) to aid in spreading the soap over the hands, fingers, and wrists; rinsing the hands under warm running water; and drying the hands thoroughly.

The sequence for removing PPE is gloves, followed by face shield or goggles, then the gown, and finally the mask or respirator. Always perform hand hygiene after removing gloves or any combination of PPE.

When the patient has known or suspected airborne infections such as pulmonary tuberculosis, you must wear a special particulate filter mask called an N95. Use the same type of mask when caring for patients with known or suspected rubeola or varicella unless you are immune to these diseases.

Other Equipment Clean reusable equipment if it is visibly soiled, and then send it to the central processing department to be disinfected. A stethoscope and blood pressure cuff are issued to the isolation patient, and only these are used within the isolation room.

When the patient is discharged, return these items to central processing for disinfection. No special treatment is necessary for dishes.

those retaining the stain are gram positive, and those losing the stain and taking up the counterstain are gram negative. Many gram negative bacteria are more dangerous than gram positive bacteria because they product an endotoxin that can cause hemorhagic shock

and severe diarrhea and can alter resistance to other bacterial infecion.

Infection Prevention and control: Infection prevention and control rely on medical and surgical asepsis, Standard Precautions, and Transmission-Based Precautions to prevent or control the spread of microorganisms. The strict use of aseptic technique when performing

all diagnostic and therapeutic procedures involving catheters, IV therapy, endotracheal and tracheostomy tubes, drainage tubes, and wound care reduces the incidence of HAIs.

Jehovah's Witnesses refuse a blood transfusion because it is prohibited by their religion. In years past, many surgeries could not be performed on these individuals because the chance of death was too great. New bloodless medicine strategies have

allowed many surgeries to safely occur that were denied before. • Autologous transfusion (transfusion of one's own blood) is one method, using a cell-saver gathering system for blood lost during surgery or in the 2 days after surgery. These cells are washed and then

(unless a closed system is used); for performing wound irrigations;

and for performing or assisting with procedures in which blood or other body fluids might splatter (e.g., the insertion of a central venous line).

The home health nurse must teach patients and families about the importance of hand hygiene; how to dispose of contaminated medical supplies;

and methods for cleaning the home environment, including how to dispose of dirty supplies in a safe manner

Listen to the patient's feelings. Make positive comments on grooming and activity efforts. Try to engage the patient in meaningful conversation by asking about interests or hobbies. Make visitors feel welcome, and help them understand that the patient

benefits greatly from their presence. Addressing self-esteem needs is important for complete recovery, regardless of patient age.

Medical asepsis is referred to as clean technique because most,

but not all, microorganisms are destroyed.

protective environment: When a patient is significantly immunocompromised, such as a bone marrow transplant recipient,

it is important to protect him from exposure to potential pathogens. Place the patient in a special isolation room with its own ventilation system.

The nurse should learn about the patient's interests and provide appropriate activities. These can include playing games, reading books, doing puzzles or crafts, making telephone calls,

listening to music, using a laptop computer, and watching TV or a DVD. Sensory deprivation may occur if visitors are intimidated by the isolation precautions.

Preioperative nursing: Perioperative nursing refers to care of the patient from the time of the decision to have surgery through recovery from the procedure. Learning the terminology for surgical procedures will help in identifying what the surgeon is going to do (Box 37-2). surgry

may be performed as a same-day or outpatient procedure or an inpatient procedure in a hospital or surgery center. Minor surgery is often performed in a physician's office. Patients having same-day surgery are admitted early in the morning and discharged in the afternoon.

Current standards consist of two tiers developed by the Healthcare Infection Control Practices Advisory Committee (HICPAC) of the CDC. Tier 1 is Standard Precautions, and Tier 2 is Transmission-Based Precautions. Standard Precautions delineate

methods for avoiding direct contact with all body secretions except sweat, whether or not visible blood is present. This includes the mucous membranes and all nonintact skin. Transmission-Based Precautions (see Box 17-1) are based on interrupting the mode of transmission by identifying the

Rickettsia- parasites- small round or rod shaped microorganisms that are transmitted by the bites of lice, ticks, fleas, and mites that act as vectors.

multiply only in host cells. example include rocky moutain spotted fever and typhus, and Q fever

Microorganisma capable of causing disease are called pathogens. nonpathogenic organisms that are prevalent on and in the body are called normal flora.

normal floras prevent more harmful microorganism from colonizing and multiplying in the body. they do this by occupting receptor sites on cells, monopolizing the nutrients, and secreting substances that are toxic to other microorganisms.

prions: are protein particles that lack nucleic acids and are not inactivated by usual methods for destroying bacteria or viruses. they do not trigger an immune response, but can case degenerative neurologic disease.....mad co...creutzfeldt-jakob. viruses: are composed of particles of

nucleic acids either dna or rna with a protein coat and sometimes a membranous envelope. viruses can grow and replicate only with in a living cell. there survival depends on the host. plays a role in alzheimer disease, parkinson and other amyotropich lateral sclerosis ADL.

Nursing diagnosis: Nursing Diagnosis Nursing diagnoses in the preoperative stage include actual and potential problems identified by your data collection and the registered

nurse (RN) assessment. Examples of common nursing diagnoses are as follows: Anxiety related to the surgical experience and outcome Fear related to risk for death, effects of impending surgery, or loss of control due to anesthesia

Protective eyewear: Wear protective eyewear to prevent fluid from entering the eye area and coming in contact with the mucosa or surface of the eye through splattering or aerosolization. Eyewear may be in the form of goggles, a face shield,

or glasses with side and top pieces. Protective eyewear may be disposable or durable. If durable, the eyewear should be disinfected after each use. Wear eyewear for performing oral, nasotracheal, or endotracheal suctioning

Gown: Wear a clean barrier gown that is impermeable to water and other fluids when there is a chance of being splashed with blood, body fluid, or other potentially infectious materials,

or when these fluids may be aerosolized. Remove the gown after use, being careful not to contaminate the skin or clothing.

body defenses against infection: Intact skin serves a first line of defense against harmful environmental agents. skin functions as a protective barier. sebaceous glands excrete sweat, lactic acid, and fatty acids to limit microbial growth.

secretions from the mucous membranes lining the respiratory, gastrointestinal, and reproductive tracts contain an abundance of the enzyme lysozyme, which is bactericidal

preparation of the patient unit: While patients are in surgery, prepare the patient unit for their return. Make the bed with fresh linen, including a drawsheet placed at shoulder height. Place an underpad at the hip area. Fan-fold the top covers to the far

side of the bed or to the bottom of the bed. Have the bed in a raised position at the height of the stretcher that will return the patient, and arrange furniture so that the stretcher can be pulled up alongside the bed. Gather an emesis basin, tissues, a frequent vital signs sheet or postoperative

• You should monitor your own level of resistance to infection and report to the unit director or charge nurse any skin lesion,

sore throat, or other evidence of infection you may have. (You may be reassigned to protect yourself and the patient.)

Surgical Asepsis Surgical asepsis is another method used to prevent infection. Surgical asepsis is practiced in the operating room, obstetric areas, and special diagnostic areas and for procedures

such as administering injections, changing wound dressings, performing urinary catheterization, and administering IV therapy. In the operating room, strict surgical asepsis is practiced, and head coverings, sterile gowns, masks, and gloves are worn.

susceptible host- link six-a human host may be susceptible by virtue of age, state of health, or broken skin. measures used to prevent exposure to infectious agents and to improve a person's health by teaching good health and hygiene habits.

susceptible host can be protected by using aseptic techniques, barrier precautions, and protective isolation. Proper nutrition and a healthy lifestyle. increase resistance to infection.

physical examination: The referring physician, the surgeon, or a surgical resident takes a medical history, performs a physical examination, and orders necessary tests (Box 37-4). This may be done in the physician's office. The dictated report must be in

the record before the patient goes to surgery. The patient should be in the best possible physical condition, unless it is an emergency procedure. Most surgeons postpone surgery if the patient's hemoglobin level is too low.

Portal of exit-link three: route by which a pathogen leaves the body of its host: example of a portal of exit is the gastrointestinal tract, through which the feces may transport the typhoid bacillus from an infected person.

the respiratory tract is a portal of exit when microorganisms, such as those causing measles, mumps, pulmonay tuberculosis, and influenza, are released with coughing and sneezing. the skin and mucous membranes can also serve as a prtal of exit when an open or draining wound exists.

• Discard used dressings, tissues, wound-cleaning supplies, and any other item contaminated with body fluids into a plastic bag,

then seal the bag before placing it in the household trash for pickup.

susceptibility of the elderly: many factors can place the elderly person at higher risk of infection: poor nutrition, inadequate hygiene, impaired mobility, chronic illness, and physiologic changes all increase the risk of disease

they are hospitalized more frequently than younger people for problems caused by a chronic illness or for treatment after a fall. places them at greater risk for health care associated infection.

Bacteria are single cell microorganisms lacking a nucleus that reproduce from every few minutes up to several weeks. bacteria are classified according to their need for oxygen, their shape, and their gram staining properties aerobic bacteria need oxygen

to grow and thrive. anaerobic bacteria grow only when oxygen is not present. gram staining is performed to help in classifying the bacterias outer cell surface. this identification process also helps determine the most effective method to use in eliminating the microorganism.

if the patient cannot sign with a signature. If emergency surgery is needed and the patient is not conscious or able to give consent, immediate family is contacted. Telephone permission may be given as long as there are

two witnesses on extension lines. If no family can be found, the opinion of a second surgeon regarding the need for surgery is sought, and then the surgery may take place.