Nurs 100 Week 1 Pt 1
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Questions and Answers

How do Hispanic groups typically express pain?

  • By remaining silent and stoic
  • Through expressive behaviors such as moaning and crying (correct)
  • Using indirect descriptions of symptoms
  • By seeking immediate medical attention

    • What is a common belief about pain among Asian cultures?

  • Pain is a symptom of a greater illness and should be openly discussed
  • Pain should be treated with prayer only
  • Pain is a matter of family honor and is endured silently (correct)
  • Pain must be immediately addressed with invasive procedures

    • In what way do American Indian cultures typically perceive pain?

  • As something to be feared and avoided
  • As an experience to endure without seeking help (correct)
  • As a symptom that requires immediate medical attention
  • As a problem best solved with community support

    • How do Arab individuals generally respond to pain?

    <p>They control and promptly treat pain while describing it in terms of hot and cold</p> Signup and view all the answers

    What is a concern for older adults in some cultural groups regarding pain medication?

    <p>They fear addiction to pain medication and may avoid it</p> Signup and view all the answers

    What does pain threshold refer to?

    <p>The point at which pain is perceived</p> Signup and view all the answers

    Which of the following symptoms is associated with acute pain?

    <p>Increased heart rate</p> Signup and view all the answers

    Chronic pain is typically characterized by which of the following symptoms?

    <p>Irritability and depression</p> Signup and view all the answers

    What does the 'R' in the OLDCARTS mnemonic stand for?

    <p>Relieving/provoking factors</p> Signup and view all the answers

    Which pain rating scale is particularly useful for children?

    <p>Visual scale</p> Signup and view all the answers

    What is a key feature of patient-controlled analgesia (PCA) pumps?

    <p>The client pushes the pain button only</p> Signup and view all the answers

    Which of the following is NOT a non-analgesic medication used for pain management?

    <p>Opioids</p> Signup and view all the answers

    Which nursing consideration is essential when managing pain medication?

    <p>Managing constipation</p> Signup and view all the answers

    Which of the following locations can be used to assess heart rate?

    <p>Carotid</p> Signup and view all the answers

    What is defined as tachycardia?

    <p>A heart rate above 100 bpm</p> Signup and view all the answers

    Which factor is NOT associated with bradycardia?

    <p>Epinephrine use</p> Signup and view all the answers

    What is the normal range for respiration rate in adults?

    <p>12-20 breaths per minute</p> Signup and view all the answers

    Which of the following is NOT a complication associated with tachycardia?

    <p>Hypotension due to dehydration</p> Signup and view all the answers

    What influences the respiration rate according to age?

    <p>Respiration rate decreases with age</p> Signup and view all the answers

    Which of the following medications is known to increase respiration rate?

    <p>Bronchodilators</p> Signup and view all the answers

    What does a pulse deficit measure?

    <p>The difference between the apical rate and radial rate</p> Signup and view all the answers

    What is the primary respiratory drive in patients with COPD?

    <p>Low oxygen levels</p> Signup and view all the answers

    Which condition is least likely to cause bradycardia?

    <p>Anemia</p> Signup and view all the answers

    What type of exudate is characterized by containing leukocytes and bacteria, and has a greenish-yellowish odor?

    <p>Purulent</p> Signup and view all the answers

    Which symptom is commonly associated with systemic infections?

    <p>Fever</p> Signup and view all the answers

    What is a common change in the immune response of older adults regarding infections?

    <p>Weakened immune response</p> Signup and view all the answers

    What is a likely consequence of reduced gastric acid production in older adults?

    <p>Slower healing process</p> Signup and view all the answers

    Which of the following is NOT a stage of the local inflammatory response?

    <p>Fever</p> Signup and view all the answers

    Which factor does NOT affect the body's response to infection?

    <p>Physical exercise routine</p> Signup and view all the answers

    What is a common laboratory indicator of infection in blood tests?

    <p>WBC count greater than 10,000/µL</p> Signup and view all the answers

    Which of the following is a symptom that may indicate a systemic infection?

    <p>Diarrhea</p> Signup and view all the answers

    What defines virulence in a pathogen?

    <p>The ability to invade and harm a host</p> Signup and view all the answers

    Which of the following is NOT a type of pathogen?

    <p>Allergens</p> Signup and view all the answers

    During which stage of infection do specific symptoms first appear?

    <p>Illness Stage</p> Signup and view all the answers

    What is a common reservoir for pathogens?

    <p>Food</p> Signup and view all the answers

    Which mode of transmission involves transferring pathogens through an insect?

    <p>Vector-borne transmission</p> Signup and view all the answers

    Individuals who are immunocompromised are considered which part of the infection process?

    <p>Susceptible Hosts</p> Signup and view all the answers

    Which option describes an incorrect portal of exit for pathogens?

    <p>Intravenous fluids</p> Signup and view all the answers

    What is NOT considered a risk factor for infection?

    <p>Regular exercise</p> Signup and view all the answers

    What element of culture primarily involves the understanding of language and non-verbal cues?

    <p>Communication</p> Signup and view all the answers

    Which nursing practice focuses on recognizing external signs of diversity?

    <p>Cultural awareness</p> Signup and view all the answers

    Which medication should be used with caution due to the risk of liver damage when combined with anticoagulants?

    <p>Acetaminophen</p> Signup and view all the answers

    What should a nurse do if a patient experiences respiratory depression due to opioids?

    <p>Call for immediate resuscitation measures</p> Signup and view all the answers

    Which term describes the respect and consideration shown towards individuals from diverse backgrounds in nursing?

    <p>Cultural sensitivity</p> Signup and view all the answers

    Personal space perceptions fall under which element of culture?

    <p>Space</p> Signup and view all the answers

    What is a non-pharmacological approach to pain management?

    <p>Heat/cold therapy</p> Signup and view all the answers

    Which approach is important for addressing health disparities in nursing care?

    <p>Understanding and respecting diverse beliefs</p> Signup and view all the answers

    What is cultural competency primarily focused on?

    <p>Understanding and responding to diverse cultural needs</p> Signup and view all the answers

    Which principle is important for cultural competency?

    <p>Being open-minded and nonjudgmental</p> Signup and view all the answers

    How do Black or African Americans typically attribute illness?

    <p>To disharmony due to food choices or bad luck</p> Signup and view all the answers

    What is a common belief about pain in Hispanic or Mexican American cultures?

    <p>Pain is considered a consequence of immoral behavior</p> Signup and view all the answers

    According to cultural beliefs, how do White or European men typically express their pain?

    <p>By displaying stoicism</p> Signup and view all the answers

    What is a significant influence on a person's perception and expression of pain?

    <p>Cultural background</p> Signup and view all the answers

    Why might individuals from White or European backgrounds prefer non-narcotic medications?

    <p>To avoid addiction to pain medication</p> Signup and view all the answers

    Which statement reflects a common misconception about pain among some cultures?

    <p>Pain can have spiritual significance</p> Signup and view all the answers

    Which temperature measurement method is typically considered the least invasive?

    <p>Temporal</p> Signup and view all the answers

    What is the normal temperature range for newborns?

    <p>97.7-99.7°F</p> Signup and view all the answers

    What is hyperthermia defined as?

    <p>Abnormally high temperature above 104°F</p> Signup and view all the answers

    Which nursing intervention is appropriate for managing hypothermia?

    <p>Use heated humidified oxygen</p> Signup and view all the answers

    Which factor can lead to a temporary rise in body temperature?

    <p>Hormonal changes</p> Signup and view all the answers

    What must be done prior to taking a patient's oral temperature after they have eaten?

    <p>Wait 20-30 minutes</p> Signup and view all the answers

    Which is a normal pulse range for adults?

    <p>60-100 BPM</p> Signup and view all the answers

    What action should be taken if a thermometer for temporal temperature readings is soiled?

    <p>Wipe with alcohol</p> Signup and view all the answers

    Which symptom may indicate an irregular heart rate?

    <p>Unequal peripheral pulses</p> Signup and view all the answers

    What can affect the accuracy of tympanic temperature readings?

    <p>Presence of earwax</p> Signup and view all the answers

    What is considered hypotension in terms of blood pressure readings?

    <p>Diastolic less than 60 mmHg and systolic less than 80 mmHg</p> Signup and view all the answers

    When should vital signs be assessed?

    <p>Before and after activities with increased risk</p> Signup and view all the answers

    What does the systolic blood pressure represent?

    <p>Pressure when ventricles contract</p> Signup and view all the answers

    What indicates an active infection or inflammatory process based on erythrocyte sedimentation rate (ESR)?

    <p>An ESR over 20 mm/hr</p> Signup and view all the answers

    Which of the following is a method to prevent urinary stasis and maintain hydration?

    <p>Encouraging sufficient fluid intake</p> Signup and view all the answers

    Which statement regarding blood pressure measurement is true?

    <p>Rest for at least 5 minutes before measurement</p> Signup and view all the answers

    What is the normal range for blood pressure?

    <p>80/60 to 120/80</p> Signup and view all the answers

    When should the protective equipment (PPE) be changed according to isolation guidelines?

    <p>After contact with each client</p> Signup and view all the answers

    Which of the following factors can affect blood pressure?

    <p>Caffeine consumption</p> Signup and view all the answers

    Which common infection occurs in healthcare settings most frequently?

    <p>Urinary tract infections caused by <em>Escherichia coli</em></p> Signup and view all the answers

    What does the pulse pressure indicate?

    <p>The difference between systolic and diastolic readings</p> Signup and view all the answers

    What is the correct definition of healthcare-associated infections (HAIs)?

    <p>Infections that occur while receiving care in a healthcare setting</p> Signup and view all the answers

    Which of the following best describes aseptic technique in nursing care?

    <p>Minimizing exposure to microorganisms</p> Signup and view all the answers

    How does exercise typically affect blood pressure?

    <p>It lowers blood pressure over time</p> Signup and view all the answers

    How does the temperature generally differ when measured orally compared to axillary?

    <p>Oral temperature is higher by approximately 0.9°F</p> Signup and view all the answers

    What is essential before and after patient care to maintain infection control?

    <p>Frequent and effective hand hygiene</p> Signup and view all the answers

    Which group is noted for a higher incidence of hypertension?

    <p>African Americans</p> Signup and view all the answers

    What role does good oral hygiene play in infection control?

    <p>It decreases protein in the oral cavity</p> Signup and view all the answers

    What is the most effective way to prevent healthcare-associated infections (HAIs)?

    <p>Frequent and effective hand hygiene</p> Signup and view all the answers

    Which of the following actions is part of pulmonary hygiene for immobile clients?

    <p>Performing pulmonary hygiene every 2 hours or as prescribed</p> Signup and view all the answers

    Study Notes

    Vital Signs

    • Vital signs are measurements of the body's most basic functions: temperature, pulse, respiration/oxygen saturation, blood pressure, and pain.
    • Vital signs are assessed on admission, with changes in patient condition, before and after surgery or procedures, before and after activities that increase risk, and before administering medications affecting cardiovascular and respiratory function.

    Blood Pressure

    • Reflects the force of blood against artery walls during contraction (systole) and relaxation (diastole).
    • Systolic BP: Maximum pressure during ventricular contraction.
    • Diastolic BP: Minimum pressure during ventricular relaxation.
    • Normal range: 80/60 to 120/80 mmHg.
    • Determinants of BP: Cardiac output and systemic vascular resistance.
    • Hypotension: BP below normal range (diastolic < 60 mmHg, systolic < 80 mmHg).
    • Hypertension: BP above normal range (systolic > 120 mmHg, diastolic > 80 mmHg).
    • Pulse pressure: Difference between systolic and diastolic readings.
    • Orthostatic hypotension: BP drops significantly when changing positions (lying to sitting to standing).

    Nursing Considerations for Blood Pressure

    • Infants have lower BP than older children, and older adults have slightly higher BP due to decreased arterial elasticity.
    • Stress, medications (e.g., opiates, oral contraceptives, alcohol, antidepressants), and exercise can affect BP.
    • Males generally have higher BP than females.
    • African Americans may have a higher incidence of hypertension.
    • Obesity and family history are risk factors for hypertension.

    Measuring Accurate Blood Pressure

    • Client preparation includes resting for 5 minutes and avoiding nicotine and caffeine for 30 minutes beforehand.
    • Sit in a chair with feet flat and arm supported at heart level.
    • Estimation: Palpate radial pulse to estimate BP. Inflate cuff until pulse disappears.
    • Auscultation: Use stethoscope and appropriately sized cuff. Inflate 30 mmHg above estimated pressure and slowly deflate.
    • Multiple readings: Take at least two readings 2 minutes apart. If readings differ by 5 mmHg, repeat.
    • Avoid: Measuring BP in an arm with an IV, mastectomy, arteriovenous shunt, or fistula.

    Temperature

    • Measurement of heat balance between production and loss.
    • Normal range: 96.5°F to 99.5°F.
    • Sites: Skin, mouth, axilla (armpit).
    • Difference: Oral temperature is typically 0.9°F higher than axillary temperature.

    Temperature Measurement

    • Temporal, Tympanic, and Rectal: These measurements are core temperatures.
    • Rectal readings are 0.9°F higher than oral and tympanic.

    Factors Affecting Temperature

    • Age/Developmental Stage: Newborns lose heat rapidly, older adults lose heat more easily due to fat loss.
    • Hormonal Changes: Temperature rises slightly during ovulation and menstruation.
    • Activity, Exercise, and Dehydration: Can lead to hyperthermia.
    • Illness and Injury: Can cause a fever in response to infection.

    Nursing Considerations for Temperature

    • Equipment: Electronic thermometers (disposable, rectal, temporal, oral, tympanic).
    • Cleaning: Clean reusable thermometers with each use.
    • Placement: Place thermometers correctly and wait for readings. Discard disposable thermometers after use.
    • Oral Readings: Wait 20-30 minutes for accurate reading after eating.

    Temporal Temperature Checks

    • Cleaning: Wipe the lens with alcohol.
    • Placement: Hold the probe flat against the forehead over the temporal artery and drag toward the ear or lift and place behind the earlobe.
    • Reading: Release the scan button for the reading.

    Temperature Complications

    Hyperthermia

    • Definition: Abnormally high temperature above 104°F due to thermoregulation failure.
    • Nursing Interventions: Obtain cultures, administer antibiotics, provide fluids and rest, use cooling blankets, give antipyretics (avoid aspirin in children due to Reye's Syndrome), maintain environmental temperature at 70-80°F.

    Hypothermia

    • Definition: Body temperature less than 95°F.
    • Nursing Interventions: Maintain warm environment, use heated humidified oxygen, use warming blankets or warmed IV/oral fluids, keep the head covered, continuous cardiac monitoring, have emergency resuscitation equipment on standby.

    Pulse/Heart Rate

    • Measurement of heart rate and rhythm, reflecting blood flow.
    • Provides information about circulatory status.
    • Normal Range: 60-100 beats per minute (BPM). (Newborns have higher ranges that vary with age)
    • Rate: Number of heartbeats per minute.
    • Rhythm: Regularity of heart impulses. Irregularities can indicate an irregular heart rate.
    • Strength: Volume of blood ejected with each contraction (graded 0-4).
    • Equality: Peripheral pulses should be symmetrical. Inequality can suggest a thrombus or aortic dissection.

    Nursing Considerations for Pulse/Heart Rate

    • Equipment: Device for counting seconds and a stethoscope.

    Dysrhythmia:

    • Irregular heart rhythm with an irregular radial pulse.
    • Pulse deficit: Difference between apical rate and radial rate (count simultaneously)

    Complications:

    Tachycardia

    • Heart rate above 100 bpm or above expected.
    • Factors: Exercise, fever, heat exposure, medications, position changes, acute pain, anemia, hypoxemia, hypovolemia, shock, heart failure, hemorrhage.
    • Nursing interventions: Monitor for pain, anxiety, low cardiac output, medication side effects, and protect patients from injury.

    Bradycardia

    • Heart rate below expected or below 60 bpm.
    • Factors: Long-term physical fitness, hypothermia, medications, position changes, chronic severe pain, hypothyroidism, relaxation.
    • Nursing interventions: Monitor for manifestations of low cardiac output, medication side effects, and protect patients from injury.

    Respiration (RR)

    • The body's mechanism for oxygen and carbon dioxide exchange between the atmosphere and blood/cells.
    • Normal range: 12-20 breaths per minute (BPM).
    • Chemoreceptors in the carotid arteries and aorta monitor blood carbon dioxide levels.
    • Ventilation: Exchange of oxygen and carbon dioxide in the lungs (inspiration and expiration).
    • Diffusion: Exchange of oxygen and carbon dioxide between alveoli and red blood cells.
    • Perfusion: Flow of red blood cells to and from pulmonary capillaries (measured by pulse oximetry).
    • Observe chest wall movement for rate, depth, and rhythm during measurement.

    Factors Affecting RR

    • Age: Respiration rate decreases with age.
    • Gender: Males and children often have diaphragmatic breathing; females have thoracic breathing.
    • Pain: Pain increases respiration.
    • Anxiety: Anxiety increases respiration rate.
    • Medications: Opioids, sedatives, and bronchodilators can affect breathing rate.
    • Anemia and high altitudes: Increase the depth and rate of respiration to compensate.

    Pain

    • Subjective experience
    • Pain threshold: Point at which pain is perceived.
    • Pain tolerance: Length of time or intensity of pain endured before responding.
    • Phantom pain: Pain without tissue involvement.

    Acute Pain

    • Symptoms: Rapid respiration, increased heart rate (HR), increased blood pressure (BP), diaphoresis, grimacing, guarding, flushing, pallor, sweating.
    • May last hours to days.
    • Usually has a known cause (e.g., surgery, injury).

    Chronic Pain

    • Symptoms: Withdrawal, depression, low self-esteem, flat affect, irritability, anxiety.
    • Months to years.
    • Can be disabling, affecting living, socialization, and mood.
    • Pain is a stressor to the body, taking energy to manage.
    • Often associated with depression and fatigue.

    Pain Assessment and Documentation

    • Use OLDCARTS mnemonic to ask clients about pain:
      • Onset
      • Location/Radiating
      • Duration
      • Characteristics
      • Agggravating factors
      • Relieving/provoking
      • Treatment
      • Severity

    Pain Rating Scales

    • Numbered scale
    • Visual scale (e.g., Wong-Baker faces)
    • Color scale (e.g., with descriptions)
    • Pieces of pain scale (e.g., poker chips)
    • Behavioral pain scale (e.g., FLACC)

    Pain Management/Treatment

    • Includes pharmacological and non-pharmacological approaches for comfort.

    Pharmacological Approaches

    • Analgesic medications (opioids): Oral, transdermal patches, IV analgesics, patient-controlled analgesia (PCA pump).

    Non-Analgesic Medications

    • Antidepressants
    • Chemotherapeutic agents and immunosuppressants
    • Anticonvulsants
    • Muscle relaxants
    • Marijuana

    Nursing Considerations for Pain Management

    • Constipation (related to opioids)

    Cultural Considerations in Nursing

    • Culture: Shared beliefs, values, and practices within a community (includes economic factors, religion, worldview).
    • Elements of Culture Affecting Health: Communication, space, time orientation, social organization, biological variations, environmental control.
    • Nursing Cultural Considerations: Cultural awareness (recognizing external signs of diversity), cultural sensitivity (demonstrating respectful and considerate attitudes).
    • Addressing Health Disparities: Nurses encounter diverse patients and need to understand and respect beliefs to provide effective care.

    Pain Management Medications

    • Opioids: Slow peristalsis (increase oral fluids, stool softeners may help), report allergic reactions immediately and discontinue medication, respiratory depression can occur (resuscitate immediately, use Naloxone [Narcan] to reverse).
    • Acetaminophen and NSAIDs: Educate patients about risks of liver damage or bleeding, particularly for older patients (use with caution in conjunction with anticoagulants).

    Cultural Competency and Pain Management Beliefs Across Cultures

    • Cultural competency: Proficiency in understanding and responding to diverse individuals.
    • Key Principles: Be open-minded, acknowledge differences, assess client beliefs, understand nonverbal cues, utilize qualified interpreters.
    • Dominant Cultural Practices (examples): Indigenous Americans (harmony with nature), Asian and Pacific Islander (physical and spiritual harmony), Black or African American (disharmony due to food choices or luck), Hispanic or Latino (reward for good behavior or luck), White or European (contamination, hereditary, psychosomatic, or supernatural).

    Cultural Considerations Regarding Pain

    • A person's cultural background influences pain perception and expression.
    • Cultures may view pain as natural, honorable, or a consequence of immoral behavior.
    • Cultures may value stoicism and discourage expressing pain openly.

    Cultural Beliefs Affecting Pain Perception and Treatment (examples)

    • White (European): Men often display stoicism, may fear addiction to medication.
    • Hispanic/Mexican American: May believe pain is "God's will", expression may be perceived as weakness.

    Cultural Perspectives on Pain

    • Highlight variations in how different cultural groups perceive and express pain.
    • Examples:
      • Hispanic groups (expressive, may favor injections),
      • Black (African American, African native) (pain is seen as a symptom),
      • Asian (stoicism, may view pain as a matter of family honor),
      • Native American (endure pain),
      • Arab (pain is to be controlled and treated promptly).

    Infection Prevention and Control

    • An infection occurs when a pathogen is present and intact, leading to a chain of events.
    • A nurse uses infection control practices to break the chain and stop the spread.

    Types of Pathogens or Agents

    • Bacteria: Examples include Staphylococcus aureus, Escherichia coli, and Mycobacterium tuberculosis.
    • Viruses: Examples include HIV, hepatitis, herpes zoster, and herpes simplex virus (HSV).

    Pathogens

    • Fungi: Candida albicans and Aspergillus
    • Prions: Creutzfeldt-Jakob disease
    • Parasites:
      • Protozoa (malaria and toxoplasmosis)
      • Helminths (flatworms, roundworms, and flukes)

    Virulence

    • Ability of a pathogen to invade and harm a host.

    Infection Process (Chain of Infection)

    • Causative Agent: Organisms that cause infection (bacteria, viruses, fungi, prions, parasites).
    • Reservoir: Humans, animals, food, organic matter on inanimate surfaces, water, soil, and insects.
    • Portal of Exit: The means by which the pathogen leaves the host (respiratory, gastrointestinal, genitourinary tracts, skin/mucous membranes, blood/body fluids, transplacental).
    • Mode of Transmission: How the pathogen moves from one host to another (contact, indirect contact, fecal-oral, droplet, airborne, vector-borne).
    • Portal of Entry: Path of entry into a new host (often the same as the portal of exit).
    • Susceptible Host: Individuals with compromised defense mechanisms (e.g., immunocompromised, breaks in skin).

    Stages of Infection

    • Incubation Stage: Interval between pathogen entry and first symptoms.
    • Prodromal Stage: Interval with general symptoms before more specific symptoms.
    • Illness Stage: Interval with specific findings of an infection.
    • Convalescence Stage: Interval when symptoms disappear. Recovery can take days to months.

    Clients at High Risk for Infection

    • Inadequate hand hygiene (client and caregivers)
    • Compromised health/defenses (immunocompromised)
    • Indwelling devices
    • Breaks in the skin
    • Poor oxygenation

    Types of Exudates

    • Serous: Clear
    • Sanguineous: Contains red blood cells
    • Serosanguinous: Mixture of serous and sanguineous
    • Purulent: Contains leukocytes and bacteria; has a greenish-yellowish odor

    Systemic Infection

    • Affects the entire body through the circulatory system.
    • Symptoms:
      • Fever
      • Chills
      • Sweating
      • Increased heart rate
      • Increased respiratory rate
      • Malaise
      • Fatigue
      • Anorexia
      • Nausea
      • Vomiting
      • Abdominal cramping
      • Diarrhea

    Localized Infection

    • Affects a specific area or organ.
    • Stages of inflammatory response:
      1. Redness (from blood vessel dilation)
      2. Warmth (palpation)
      3. Edema
      4. Pain/tenderness
      5. Loss of function of the affected body part

    Older Adults and Infection

    • Slower Response to Antibiotics
    • Weakened Immune Response
    • Subcutaneous Tissue Loss
    • Reduced Vascularity
    • Delayed Wound Healing
    • Reduced Cough and Gag Reflexes
    • Chronic Illnesses
    • Gastric Acid Production Decreased
    • Reduced Mobility
    • Bowel/Bladder Incontinence
    • Dementia
    • Increased Incidence of Invasive Devices (e.g., urinary catheters, feeding tubes)

    Factors Affecting Infection Response

    • Impaired Circulation
    • Chronic Disease (diabetes mellitus, adrenal or renal failure, hepatic failure, chronic lung disease)
    • Poor Personal Hygiene & Nutrition
    • Smoking or Alcohol Use
    • Stress
    • Overcrowding
    • IV Drug Use & Needle Sharing
    • Unprotected Sex
    • Exposure to Diseases Endemic to Different Regions/Countries
    • Poor Sanitation
    • Mosquito-borne diseases
    • Parasitic diseases

    Laboratory Tests for Infection

    • Elevated White Blood Cells (WBCs): A WBC count greater than 10,000/µL (leukocytosis) is a sign of infection.
    • Increased WBCs on differential (left shift) = increase in neutrophils
    • Elevated erythrocyte sedimentation rate (ESR) over 20 mm/hr: indicates an active infection or inflammatory process.

    Nursing Care Considerations for Infection Control

    • Hand Hygiene: Frequent and effective hand hygiene before and after care is essential.
    • Immunizations: Educate patients about necessary immunizations and where to obtain them, targeting children, older adults, those with chronic diseases, and immunocompromised individuals.
    • Oral Hygiene: Educate patients on good oral hygiene. Good oral hygiene decreases the protein in the oral cavity (attracting microorganisms), thereby decreasing microorganism growth.
    • Fluid Intake: Encourage sufficient fluid intake to prevent urinary stasis and maintain hydration. Adequate fluid intake prevents microorganism growth and keeps skin from breaking down.
    • Pulmonary Hygiene (for immobile clients): Every 2 hours, or as prescribed, perform pulmonary hygiene (turning, coughing, deep breathing, incentive spirometry) to avoid stasis of pulmonary excretions, stimulate ciliary movement, and clear lungs.
    • Aseptic Technique and PPE: Use aseptic technique and proper personal protective equipment (gloves, masks, gowns, goggles) for all clients to prevent unnecessary exposure to microorganisms.
    • Respiratory Hygiene/Cough Etiquette: Teach and practice respiratory hygiene/cough etiquette for all patients and visitors to minimize contamination, especially in waiting areas. This includes covering the mouth and nose when coughing/sneezing, using tissues promptly, and maintaining distance.

    Healthcare-Associated Infections (HAIs)

    • Definition: HAIs are infections that occur while receiving care in a healthcare setting. They can emerge from exogenous (outside) or endogenous (inside) sources.
    • Common Sites: Common sites include the urinary tract (often caused by Escherichia coli, Staphylococcus aureus, and enterococci), surgical wounds, the respiratory tract, and the bloodstream.
    • Iatrogenic Infections: Some HAIs can be iatrogenic meaning they result from a diagnostic or therapeutic procedure.
    • Prevention: Frequent and effective hand hygiene is the best way to prevent HAIs.

    Isolation Guidelines

    • Purpose: Isolation guidelines include hand hygiene and barrier precautions to minimize the transmission of infectious organisms.
    • Application: Precautionary measures apply to all clients, regardless of diagnosis, and are applied whenever contact with a potentially infectious material is anticipated.
    • PPE Changes: Protective equipment should be changed after contact with each client, and between procedures with the same client if substantial blood or body fluids exposure is anticipated.

    Standard Precautions

    • Standard precautions are a general approach to patient care. They focus on minimizing contamination risks.

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