Urinary Elimination Study Guide PDF

# 2nd Test - Urinary Elimination ## Urinary Elimination Elimination falls under physiological needs in Maslow's. This is the last step in the removal and elimination of excess water and by-products of body metabolism. Adequate elimination depends on the coordinated function of the: - Kidneys -...

# 2nd Test - Urinary Elimination ## Urinary Elimination Elimination falls under physiological needs in Maslow's. This is the last step in the removal and elimination of excess water and by-products of body metabolism. Adequate elimination depends on the coordinated function of the: - Kidneys - The kidneys filter waste products of metabolism from the blood and the ureters transport urine from the kidneys to the bladder and then the bladder holds urine until the volume in the bladder triggers a sensation of urge, indicating the need to pass urine. - Ureters - Remove waste products from the blood - Bladder - Urethra ## Micturition Micturition is the act of urinating and occurs when the brain triggers the bladder to empty, the bladder contracts, the urinary sphincter relaxes, and urine leaves the body through the urethra. This is a complex interaction among the bladder, urinary sphincter, and central nervous system. ## Nephrons The kidneys play a big role in the elimination of urine. Nephrons are the main functioning unit of the kidneys and function by doing the following: - Play a major role in the regulation of fluid and electrolyte balance Each one of the nephrons contains a cluster of capillaries called the **glomerulus**. You can suspect injury to the glomerulus when proteinuria (protein) or hematuria (blood) is found in the urine. The glomerulus functions in doing the following: - Filtering water, glucose, amino acids, urea, uric acid, creatinine, and major electrolytes. The kidneys will hold 300-500 mL of urine. ## Bladder Control & Function Internal and external sphincters help control the bladder. The external urethral sphincter is made up of striated muscles and contributes to voluntary control over the flow of urine. The kidneys have other essential functions other than just eliminating body wastes including: - They produce erythropoietin which stimulates red blood cell production and maturation in bone marrow. - The kidneys play a vital role in blood pressure control via the renin-angiotensin system. - The kidneys produce a hormone that converts vitamin D into its active form. A ureter is attached to each kidney pelvis and carries urinary waste to the bladder. The bladder is a hollow, distensible, muscular organ that holds urine. The bladder has 2 parts: - Trigone- a fixed base - Detrusor- a distensible body Urethra is where the urine travels from the bladder. From the urethra the urine passes to the outside of the body through the urethral meatus. The urethra passes through a thick layer of skeletal muscles called the pelvic floor muscles, which stabilize the urethra and contribute to urinary continence. The female urethra is shorter than the male urethra which puts females more at risk for urinary tract infections (UTI). - Female urethra- 3 to 4 cm (1-1½ inches) long - Male urethra- 18 to 20 cm (7-8 inches) long. Urination, micturition, and voiding are all terms that describe the process of bladder emptying. ## Common Urinary Elimination Problems The most common problems involve the inability to store urine or fully empty the bladder. These problems can result from: - Irritable or overactive bladder - Obstruction of urine flow - Impaired bladder contractility - Issues that impair innervation to the bladder that result in sensory or motor dysfunction Urinary retention is the inability to empty the bladder partially or completely. **ACUTE** or **RAPID**-onset retention stretches the bladder which causes feelings of pressure, discomfort/pain, tenderness over the symphysis pubis, restlessness, and sometimes diaphoresis. Patients with retentions may have: - No urine output over several hours - In some cases they can experience frequency, urgency, small-volume voiding, or incontinence. **Post Void residual (PVR)** is the amount of urine left in the bladder after voiding and is measured with either ultrasonography or straight catheterization. Incontinence caused by urinary retention is called: **overflow incontinence** or **incontinence associated with chronic retention of urine**. ## Urinary Incontinence | DEFINITION for transient incontinence | CHARACTERISTICS | SELECTED NURSING INTERVENTIONS | |---------------------------------------|-----------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------| | Incontinence caused by medical conditions that in many cases are treatable and reversible | Reversible causes include: delirium and/or acute confusion, inflammation, medications, excessive urine output, mobility impairment from any cause, fecal impaction, depression, acute urinary retention | With new-onset or increased incontinence, look for reversible causes. Notify health care provider of any suspected reversible causes. | | DEFINITION for functional incontinence | CHARACTERISTICS | SELECTED NURSING INTERVENTIONS | | Loss of continence because of causes outside the urinary tract. Usually related to functional deficits such as altered mobility and manual dexterity, cognitive impairment, poor motivation, or environmental barriers. | Toilet access restricted by: sensory impairments, cognitive impairments, altered mobility, altered manual dexterity, environmental barriers | Adequate lighting in bathroom, individualized toileting program designed for the degree of cognitive impairment, mobility aides, toilet area cleared to allow access for a walker or wheelchair, elastic-waist pants without buttons or zippers, nurse call system always within reach, use of incontinence containment with toileting | | DEFINITION of overflow incontinence | CHARACTERISTICS | SELECTED NURSING INTERVENTIONS | | Involuntary loss of urine caused by an overdistended bladder often related to bladder outlet obstruction or poor bladder emptying because of weak or absent bladder contractions | Distended bladder palpation, high post void residual, frequency, involuntary leakage of small volumes of urine, nocturia | Interventions individualized related to the severity of the urinary retention, ability of bladder to contract, and existing kidney damage. Mild retention with some bladder function including: timed voiding, double voiding, and monitor postvoid residual per health care provider's direction, intermittent catheterization. Severe retention, no bladder function: intermittent and indwelling catheterization | | DEFINITION of stress incontinence | CHARACTERISTICS | SELECTED NURSING INTERVENTIONS | | Involuntary leakage of small volumes of urine associated with increased intraabdominal pressure related to either urethral hypermobility or an incompetent urinary sphincter. Result of weakness or injury to the urinary sphincter or pelvic floor muscles. Underlying result: urethra cannot stay closed as pressure increases in the bladder because of increased abdominal pressure | Small-volume loss of urine with coughing, laughing, exercise, walking, getting up from a chair. Usually does not leak urine at night when sleeping | As directed by the health care provider, instruct patient in pelvic muscle exercises. | | DEFINITION of urge incontinence | CHARACTERISTICS | SELECTED NURSING INTERVENTIONS | | Involuntary passage of urine often associated with strong sense of urgency related to an overactive bladder caused by neurological problems, bladder inflammation, or bladder outlet obstruction. In many cases bladder overactivity is idiopathic; cause is not known. Caused by involuntary contractions of the bladder associated with an urge to void that causes leakage of urine. | May experience one or all of the following symptoms: urgency, frequency, nocturia, difficulty or inability to hold urine once the urge to void occurs, leaks on the way to the bathroom, leaks larger volumes of urine sometimes enough to wet outer clothing, dribbles small amounts on the way to the bathroom, strong urge/leaks when one hears water running; washes hands; or drinks fluids. | Ask patient about symptoms of a UTI. Avoid bladder irritants. As directed by the health care provider, instruct patient in pelvic muscle exercises, in urge-inhibition exercises, and/or in bladder training. If ordered by the health care provider, monitor patient symptoms and for the presence of side effects of antimuscarinic medications. | | DEFINITION of reflex incontinence | CHARACTERISTICS | SELECTED NURSING Interventions | | Involuntary loss of urine occurring at somewhat predictable intervals when patient reaches specific bladder volume related to spinal cord damage between C1 and S2. | Diminished or absent awareness of bladder filling and the urge to void. Leakage of urine without awareness. May not completely empty the bladder because of dyssynergia of the urinary sphincter- inappropriate contraction of the sphincter when the bladder contracts, causing obstruction to urine flow. **CAUTION:** at risk for developing autonomic dysreflexia, a life-threatening condition that causes severe elevation of blood pressure and pulse rate and diaphoresis | Follow the prescribed schedule for emptying the bladder either through voiding or by intermittent catheterization. Supply urine-containment products: condom catheter, undergarments, pads, briefs. Monitor for signs and symptoms of urinary retention and UTI. Monitor for autonomic dysreflexia— a medical emergency requiring immediate intervention; notify health care provider immediately | Urinary incontinence (UI) is defined as the “complaint of any involuntary loss of urine". ## Urinary Tract Infections Urinary tract infections are the 5th most common type of healthcare – associated infection, virtually caused by instrumentation of the urinary tract. **Escherichia coli** is the most common cause of a UTI. **Escherichia coli** is a bacteria that is commonly found in the colon. The risks for a UTI can include: - Presence of an indwelling catheter - Any instrumentation of the urinary tract - Urinary retention - Urinary and fecal incontinence - Poor hygiene practices UTI's are characterized by location: upper tract is the kidney and the lower tract is the bladder and urethra. Bacteria in the urine does not always mean that there is a UTI. In the absence of symptoms, the presence of bacteria in the urine as found on a urine culture is called **asymptomatic bacteriuria** and is not considered an infection and should not be treated with antibiotics. Symptomatic infection of the bladder can lead to a serious upper UTI known as, **pyelonephritis**, and life-threatening bloodstream infection (bacteremia or urosepsis) and should be treated with antibiotics. Symptoms of a lower UTI (bladder) can include: - Burning or pain with urination (dysuria) - characterized by urgency, frequency, incontinence, or suprapubic tenderness - Irritation of the bladder (cystitis) - Foul-smelling cloudy urine When an older adult develops infections like a UTI that can often have nonspecific symptoms such as: - Delirium - Confusion - Fatigue - Loss of appetite - Decline in function - Mental status changes - Incontinence - Falls - Subnormal temperature **Catheter-associated urinary tract infection (CAUTI)** risk factors are: presence of an indwelling catheter and the duration of its use. Urinary diversions are necessary for some patients that have had their bladder removed due to some medical reasons. This process is done by surgical procedures that divert urine to the outside of the body through an opening in the abdominal wall called a stoma. They are constructed from a section of intestine to create a storage reservoir or conduit for urine. There 2 types of continent urinary diversions: - Continent urinary reservoir - Created from a distal part of the ileum and proximal part of the colon. - Orthotopic neobladder - Uses an ileal pouch to replace the bladder A ureterostomy (ileal conduit) is a permanent incontinent urinary diversion. The patient has no sensation or control over the continuous flow of urine through the ileal conduit, requiring the effluent (drainage) to be collected in a pouch. **Nephrostomy tubes** are small tubes that are tunneled through the skin into the renal pelvis. These tubes are placed to drain the renal pelvis when the ureter is obstructed. ## Bowel Elimination The mouth mechanically and chemically breaks down nutrients into usable size and form. - The teeth chew food, breaking it down into size suitable for swallowing. - Saliva, produced by the salivary glands in the mouth, dilutes and softens the food in the mouth for easier swallowing. As food enters the upper esophagus, it passes through the upper esophageal sphincter, a circular muscle that prevents air from entering the esophagus and food from refluxing into the throat. - The bolus of food travels down the esophagus with the aid of peristalsis, which is a contraction that propels food through the length of the Gl tract. - The food moves down the esophagus and reaches the cardiac sphincter, which lies between the esophagus and upper end of the stomach. - The sphincter prevents reflux of stomach contents back into the esophagus. The **stomach** performs 3 tasks: storage of swallowed food and liquid, mixing of food with digestive juices into a substance called chyme, and regulated emptying of its contents into the small intestine. The **stomach** produces and secretes hydrochloric acid (HCI), mucus, the enzyme pepsin, and intrinsic factor. Pepsin and HCl help to digest protein. Mucus protects the stomach mucosa from acidity and enzyme activity. Intrinsic factor is essential in the absorption of vitamin B12. Movement within the small intestine, occurring by peristalsis, facilitates both digestion and absorption. Chyme comes into the small intestine as a liquid material and mixes with digestive enzymes. Resorption in the small intestine is so efficient that by the time the fluid reaches the end of the small intestine it is a thick liquid with some semi solid particles. The **small intestine** is divided into three sections: the duodenum, the jejunum, and the ileum. - The duodenum is approximately 20 to 28 cm (8 to 11 inches) long and continues to process fluid from the stomach. - The jejunum is approximately 2.5 m (8 feet) long and absorbs carbohydrates and proteins. - The ileum is approximately 3.7 m (12 feet) long and absorbs water, fats, and bile salts. The duodenum and jejunum absorb most nutrients and electrolytes in the small intestine. The ileum absorbs certain vitamins, iron, and bile salts. Digestive enzymes and bile enter the small intestine from the pancreas and the liver to further break down nutrients into a form usable by the body. The digestive process is greatly altered when **small intestine** function is impaired. Conditions such as inflammation, infection, surgical resection, or obstruction disrupt peristalsis, reduce absorption, or block the passage of fluid, resulting in electrolyte and nutrient deficiencies. The lower Gl tract is called the large intestine or colon because it is larger in diameter than the small intestine. However, its length, 1.5 to 1.8 m (5 to 6 feet), is much shorter. The large intestine is divided into the cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum. The **large intestine** is the primary organ of bowel elimination. Digestive fluid enters the large intestine by waves of peristalsis through the ileocecal valve. The muscular tissue of the colon allows it to accommodate and eliminate large quantities of waste and gas (flatus). The colon has three functions: - Absorption - Secretion - Elimination The colon absorbs a large volume of water (up to 1.5L) and significant amounts of sodium and chloride daily. The amount of water absorbed depends on the speed at which colonic contents move. Normally the fecal matter becomes a soft, formed solid or semisolid mass. If peristalsis is abnormally fast, there is less time for water to be absorbed, and the stool will be watery. If peristaltic contractions slow down, water continues to be absorbed, and hard mass of stool forms, resulting in constipation. Peristaltic contractions move contents through the colon. Mass peristalsis pushes undigested food toward the rectum. These mass movements occur only 3 or 4 times daily, with the strongest during the hour after mealtime. The **rectum** is the final part of the large intestine. Normally the rectum is empty of fecal matter until just before defecation. It contains vertical and transverse folds of tissue that help to control expulsion of fecal contents during defecation. Each fold contains veins that can become distended from pressure during straining. This distention results in hemorrhoid formation. The body expels feces and flatus from the rectum through the anus. Contraction and relaxation of the internal and external sphincters, which are innervated by sympathetic and parasympathetic nerves, aid in the control of defecation. The anal canal contains a rich supply of sensory nerves that allow people to tell when there is solid, liquid, or gas that needs to be expelled and aids in maintaining continence. The physiological factors essential to bowel function and defecation include normal Gl tract function, sensory awareness of rectal distention and rectal contents, voluntary sphincter control, and adequate rectal capacity and compliance. Normal defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out. Defecation is usually painless, resulting in the passage of soft, formed stool. Straining while having a bowel movement indicates that the patient may need changes in diet or fluid intake or that there is an underlying disorder in GI function. ## Bowel Elimination Factors - **Age** - Infants have a smaller stomach capacity, less secretion of digestive enzymes, and more rapid intestinal peristalsis. - Ability to control defecation does not occur until 2 to 3 years of age. - Adolescents experience rapid growth and increased metabolic rate. There is also rapid growth of the large intestine and increased secretion of gastric acids to digest food fibers and act as a bactericide against swallowed organisms. - Older adults may have decreased chewing ability. Partially chewed food is not digested as easily. - Peristalsis declines, and esophageal emptying slows. This impairs absorption by the intestinal mucosa. Muscle tone in the perineal floor and anal sphincter weakens, which sometimes causes difficulty in controlling defecation. - **Diet** - Regular daily food intake helps maintain a regular pattern of peristalsis in the colon. - Fiber in the diet provides the bulk in the fecal material. Bulk-forming foods such as whole grains, fresh fruits, and vegetables help remove the fats and waste products from the body with more efficiency. ## Other Factors Affecting Bowel Elimination - **Fluid intake** - Although individual fluid needs vary with the person, a fluid intake of 3.7 L per day for men and 2.7 L per day for women is recommended. - You can meet some fluid needs by drinking fluids, but you also ingest fluid when you eat some foods, such as fruit and vegetables. - **Physical activity** - Physical activity promotes peristalsis, whereas immobilization slows it. - **Psychological factors** - During emotional stress, the digestive process is accelerated, and peristalsis is increased. - **Personal habits** - Personal elimination habits influence bowel function. Most people benefit from being able to use their own toilet facilities at a time that is most effective and convenient for them. - **Positions during defecation** - Squatting is the normal position during defecation. For patients that are immobilized in a bed, the nurse can raise the head of the bed to a more normal sitting position on a bedpan, enhancing the ability to defecate. - **Pain** - Normally defecation is painless. However, in some instances defecation can be painful and the patient often suppresses the urge to defecate to avoid pain, contributing to the development of constipation. - **Pregnancy** - As pregnancy advances, the size of the fetus increases, and pressure is exerted on the rectum. A temporary obstruction created by the fetus impairs passage of feces. - Slowing of peristalsis during the 3rd trimester often leads to constipation. Pregnant women strain frequently during defecation or delivery resulting in the formation of hemorrhoids. - **Surgery and anesthesia** - General anesthetic agents used during surgery cause temporary cessation of peristalsis. - Inhaled anesthetic agents block parasympathetic impulses to the intestinal musculature. - Patients who receive a local or regional anesthetic are less at risk for elimination alterations because this type of anesthetic generally affects bowel activity minimally or not at all. - **Medications** - Many medications prescribed for acute and chronic conditions have secondary effects on a patient's bowel elimination patterns. - Opioids slow peristalsis and contractions, often resulting in constipation. - Antibiotics decrease intestinal bacterial flora, often resulting in diarrhea. - Patients should avoid overuse or regular use of a stimulant laxative because the intestine can become dependent on it. - **Diagnostic tests** - Diagnostic examinations involving visualization of Gl structures often require a prescribed bowel preparation to ensure that the bowel is empty. - Following the diagnostic procedure, changes in elimination such as increased gas or loose stool often occurs until the patient resumes normal eating patterns, since the cannot eat or drink several hours before the examination. ## Common Bowel Elimination Problems - **Constipation** - Signs of constipation include infrequent bowel movements (fewer that 3 per week) and hard, dry stools that are difficult to pass. - Causes: irregular bowel habits, chronic illnesses, low-fiber diet high in animal fat and low fluid intake, stress, physical inactivity, medications, changes in life or routine, neurological conditions that block nerve impulses to the colon, and chronic bowel dysfunction. - **Impaction** - Fecal impaction results when a patient has unrelieved constipation and is unable to expel the hardened feces retained in the rectum. - **Diarrhea** - Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. - It is associated with disorders affecting digestion, absorption, and secretion in the Gl tract. - Excess loss of colonic fluid results in dehydration. - Signs of dehydration in adults: thirst, less frequent urination than usual, dark-colored urine, dry skin, fatigue, dizziness, and light-headedness. - Signs of dehydration in infants and young children: dry mouth and tongue, no tear when crying, no wet diapers for 3 hours or more, sunken eyes or cheeks or soft spot in the skull, high fever, and listlessness or irritability. - **Incontinence** - Fecal incontinence is the ability to control the passage of feces and gas from the anus. - **Flatulence** - As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends. - This is a common cause of abdominal fullness, pain, and cramping. - Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus). - **Hemorrhoids** - Hemorrhoids are dilated, engorged veins in the lining of the rectum. - They are either external or internal. - Increased venous pressure from straining at defecation, pregnancy, heart failure, and chronic liver disease frequently cause hemorrhoids. ## Bowel Diversions - Certain diseases or surgical altercations make the normal passage of intestinal contents throughout the small and large intestine difficult or inadvisable. - When these conditions are present, a temporary or permanent opening (stoma) is created surgically by bringing part of the intestine out through the abdominal wall. - These surgical openings are called an ileostomy or colostomy, depending on the location used to create the stoma. - The location of the ostomy determines the consistency of the stool. - The ileoanal pouch anastomosis is a surgical procedure for patients who need to have a colectomy for treatment of ulcerative colitis or familial adenoma polyposis (FAP). ## Bristol Stool Chart | Type | Description | |---|---| | 1 | Separate hard lumps, like nuts. Hard to pass | | 2 | Sausage-shaped but lumpy | | 3 | Like sausage but with cracks on the surface | | 4 | Like sausage or snake, smooth and soft | | 5 | Soft blobs with clear-cut edges. Passed easily | | 6 | Fluffy pieces with ragged edges, a mushy stool | | 7 | Watery, no solid pieces. Entirely liquid. | ## Infection An infection results when a pathogen invades tissues and begins growing within a host. Colonization is the presence and growth of microorganisms within a host but without tissue invasion or damage. Disease or infection results only if the pathogens multiply and alter normal tissue function. Communicable disease is when an infectious disease can be transmitted directly from one person to another. If the pathogens multiply and cause clinical signs and symptoms, it is symptomatic. If clinical signs and symptoms are not present, the illness is termed asymptomatic. ## Factors Affecting Infection - Humans' susceptibility - Drug resistance - Human tendency to avoid vaccination - Drug immunosuppression The effects of infectious disease are constantly evolving; an infection that is considered a national or global threat one year could be eliminated the next. - **Epidemic**: spread of some kind of pathogen in a specific area (just in 1 state or the United States). - **Pandemic**: spread of a pathogen globally. It can start in one area and travel to different regions. The Joint Commission (TJC) views HALs as a patient safety issue. Patients in all health care setting are at risk of acquiring infection because of lower resistance to PATHOGENS - Pathogens increased exposure to pathogens which may be resistant to antibodies; and INVASIVE procedure. Health care workers protect themselves (via applying knowledge of the infectious process and using appropriate personal protective equipment (PPE)) from contact with: - Infectious material - Sharps injury - Exposure to communicable diseases Increases in multidrug- resistant organisms (MDROs), HAls, and concern about diseases such as: - COVID-19 (SARS-CoV-2) - hepatitis B virus (HBV) - hepatitis C virus (HCV) - human immunodeficiency virus (HIV) infection - tuberculosis (TB) ## Chain of Infection Elements 1. **An infectious agent or pathogen** - These are the microorganisms (or microbes) with the ability to cause infection. The greater its ability to grow and multiply, enter tissue, and cause disease, the greater the possibility that the microbe will cause infection. - Bacteria, viruses, fungi, and protozoa. 2. **Reservoir** - This is where microorganisms survive, multiply, and await transfer to a susceptible host. - Common reservoirs are humans, animals, insects, food, water, and organic matter on inanimate surfaces (fomites). - Store food properly, good personal hygiene, keeping surfaces properly cleaned. 3. **A port of exit from the reservoir** - A place of exit providing a way for the microorganism to leave the reservoir. - Portals of exit include blood, skin and mucous membranes, respiratory tract, genitourinary (GU) tract, gastrointestinal (GI) tract, and transplacental (mother to fetus). Droplets can also be a way that it is transferred. - Wash hands, wear correct PPE, drink purified water, dispose of contaminated items, sometimes making the infected patient wear a mask. 4. **Mode of transmission** - The way in which the organism moves or is carried from one place to another. - Direct and indirect contact, droplet contact, airborne contact, vehicles, and vector. - Practicing necessary infection prevention and control techniques, wash hands, wear gloves, clean wounds, isolation precautions, sterilize and disinfect equipment and areas. 5. **A port of entry to a host** - An opening allowing the microorganism to enter the host. - Organisms enter the body the same way they leave. - Ingest clean air, wear mask, hygiene, clean catheters, using aseptic technique and PPE. 6. **A susceptible host** - The human body has natural defenses to prevent pathogens entering via the portals of entry described above, but some people get sick anyway. People who are susceptible hosts lack the immunity to overcome invasion by microorganisms. - The susceptibility to an infectious agent depends on an individual's degree of resistance to pathogens. This is when a protective environment is used and making sure the hygiene of the susceptible host is good. - Individuals that are susceptible hosts are elders and infants, those who are not vaccinated, immunocompromised, steroid medications. - You can help keep the susceptible host safe by educating them on precautions, protecting the high risk patients, good hygiene, using dedicated equipment. ***Infection can develop if this chain remains uninterrupted*** The presence of a pathogen does not mean that an infection will occur. Preventing infections involves patients' self- care activities or nurses' actions that will break the chain of infection. Frequent reservoirs for HAI's include: health care workers and their hands, patients, equipment, and the environment. - **Human reservoirs** are divided into 2 types: - Acute or symptomatic disease - Those who show no signs of disease but are carriers of it. ## Infection Control By understanding the chain of infection, you have knowledge that is vital in preventing infections. ### Course of Infection by Stage - **Incubation period**: interval between entrance of pathogen into body and appearance of first symptoms. - **Prodromal stage**: interval from onset of nonspecific signs and symptoms to more specific symptoms. - During this time microorganisms grow and multiply, and patients may be capable of spreading disease to others. - **Illness stage**: interval when patient manifests signs and symptoms specific to type of infection. - **Convalescence**: interval when acute symptoms of infection disappear. - Length of recovery depends on severity of infection and patient's host resistance; recovery may take several days to months. If an infection is localized, a patient usually experiences localized symptoms such as pain, tenderness, warmth, and redness at the wound site. An infection that affects the entire body instead of just a single organ or part is systemic and can become fatal if undetected and untreated. ## Nurse's Role in Infection Control The nurse is responsible for: - Implementing infection control practices - Properly administering antibiotics - Monitoring the response to drug therapy - Using proper hand hygiene - Following Standard Precautions - Using Isolation Precautions when necessary Supportive therapy includes providing adequate nutrition and rest to bolster defenses of the body against the infectious process. ## Fighting Infection The body has natural defenses that protect against infection. If any of these body defenses fail, an infection usually occurs and leads to a serious health problem. The natural defenses include: - **Normal flora**: the body normally contains microorganisms that reside on the surface and deep layers of skin, in the saliva and oral mucosa, and in the GI and GU tracts. - Normal floras do not usually cause disease when residing in their usual area of the body but instead participate in maintaining health. - **Body system defenses**: a number of body organ systems have unique defenses against infection. - Each organ system has defense mechanisms physiologically suited to its specific structure and function. - **Inflammation**: this is a protective vascular reaction that delivers fluid, blood products, and nutrients to an area of injury. - The process neutralizes and eliminates pathogens or dead (necrotic) tissues and establishes a means of repairing body cells and tissues. - Vascular and cellular responses- acute inflammation is an immediate response to cellular injury. - Tissue repair- when there is injury to tissues cells, healing involves the defensive, reconstructive, and maturity stage. Patients in health care settings, especially hospitals and long-term care facilities, have an increased risk of acquiring infections. - **Health care-associated infections (HAIs)**- result from the delivery of health services in a health care agency. - They occur as the result of invasive procedures, antibiotic administration, the presence of multidrug-resistant organisms (MDROs), and breaks in infection prevention and control activities. - The # of health care employees having direct contact with a patient, the type and # of invasive procedures, the therapy received, and the length of hospitalization further influence the risk of infection. - Major sites for HAls include surgical or traumatic wounds, urinary and respiratory tracts, and the bloodstream. ## Risk Factors for Infection in Older Adults - **An age related functional deterioration in immune system function**, termed immune senescence, increases the susceptibility of the body to infection and slows overall immune response. - **Older adults are less capable of producing lymphocytes** to combat challenges to the immune system. When antibodies are produced, the duration of their response is shorter, and fewer cells are produced. - **Risks associated with the development of infections or HIAs in older patients** include poor nutrition and unintentional weight loss, lack of exercise, poor social support, and low serum albumin levels. - **Flu and pneumonia vaccination are recommended for older adults** to reduce their risk for infectious diseases.. - **Teach older adults and their families how to reduce the risk for infections** by using proper hand hygiene. HIAs are either exogenous or endogenous. - **Exogenous infection**: comes from microorganisms found outside the individual. - These microorganisms do not exist as normal floras. - **Endogenous infection**: occurs when part of the patient's flora becomes altered and an overgrowth occurs. **Iatrogenic infections** are a type of HAl caused by invasive diagnostic or therapeutic procedures. Body substances such as feces, urine, and wound drainage contain potentially infectious microorganisms. ## Factors Influencing Infection Prevention and Control - **Age** - Infants have immature defenses against infection. However, breastfed infants often have greater immunity than bottle-fed infants because they receive their mothers antibodies through the breast milk. - The young or middle-aged adult has refined defenses against infection. Viruses are the most common cause of communicable illness in young or middle-aged adults. - Older adults also undergo alterations in the structure and function of the skin, urinary tract, and lungs. - **Sex** - Besides genetic factors, these differences can be explained through the greatly divergent and changing levels of sex steroid hormones and their interplay with the immune system. Estrogen promotes (but androgens suppress) immune responses during infections and after vaccination. They also increase the risk for autoimmune diseases. - **Nutritional status** - A reduction in the intake of protein and other nutrients such as carbohydrates and fats reduces body defenses against infection and impairs wound healing. - **Stress** - The body responds to emotional or physical stress by the general adaptation syndrome. - During the alarm stage the basal metabolic rate increases as the body uses energy stores. Adrenocorticotropic hormone increases serum glucose levels and decreases unnecessary anti-inflammatory responses through the release of cortisone. - **Disease process** - Patients with diseases of the immune system are at particular risk for infection. ## Nursing Assessment for Infection - **Risk factors** - Tell me what vaccinations you have received in the last 5 years. - Describe for me any illnesses or diseases that you have and those for which you receive treatment. - Describe what you normally eat during a day. - **Possible existing infections** - Do you have or feel as if you have a fever? - Do you have any cuts or wounds with drainage? - Do you have any pain/burning during urination? - Do you have a cough? Is there any sputum? - **Recent travel history** - Have you traveled outside the United States in the past 6 months? - Are you a resident of or have you traveled within the past 21 days to a country where an Ebola outbreak is occurring? - Were any of the people you visited or traveled with ill? - **Medication history** - List for me the medications you are currently taking. - Describe for me the doses of each medication you are supposed to take daily. - Describe any over-the-counter medications or herbals that you are currently taking. - **Stressors** - Tell me about any major lifestyle change occurring, such as the loss of employment or place of residence, divorce, or disability. ## Labratory Tests for Infection - Laboratory value - White blood cell (WBC) count - Normal (adult) values- 5000-10,000/mm3 - Indication of infection- increased in acute infection, decreased in certain viral or overwhelming infections - Erythrocyte sedimentation rate - Normal (adult) values- up to 15 mm/hr for men and 20 mm/hr for women. - Indication of infection- elevated in presence of inflammatory process - Iron level - Normal (adult) values: 80-100 mcg/mL for men 60-160 mcg/mL for women - Indication of infection- decreased in chronic infection. - Cultures of urine and blood - Normal (adult) values- normally sterile, without microorganism growth. - Indication of infection- presence of infectious microorganism growth. - Cultures and gram stain of wound, sputum, and throat - Normal (adult) values- no WBC's on gram stain, possible normal flora. - Indication of infection- presence of infectious microorganism growth and WBCs on Gram stain - **Differential Count** (percentage of each type of white blood cell) - **Neutrophils** - Normal (adult) levels: 55-70% - Indication of infection: increased in acute suppurative (pus-forming) infection, decreased in overwhelming bacterial infection (older adult) - **Lymphocytes** - Normal adult levels: 20-40% - Indication of infection: increased in chronic bacterial and viral infection, decreased in sepsis. - **Monocytes** - Normal adult levels: 2-8% - Indication of infection: increased in protozoan, rickettsial, and tuberculosis infections - **Eosinophils** - Normal adult levels