exam 4.docx

Untitled Monday, October 9, 2023 10:44 AM   Asepsis & infection control Infection control nurse- nurses that concentrate in Gather and interpret data Reporting Infection Prevention Education Policies and Procedures Pathogens- microorganism with the ability to cause disease Bacteria Categ...

Untitled Monday, October 9, 2023 10:44 AM   Asepsis & infection control Infection control nurse- nurses that concentrate in Gather and interpret data Reporting Infection Prevention Education Policies and Procedures Pathogens- microorganism with the ability to cause disease Bacteria Categorize by the shape. Virus Smallest Antibiotics have no affect Fungi Parasite Needs a host to survive Healthcare Acquired Infections (HAI) Known as nosocomial infection They are acquire during hospital stay Can lead to deaths Preventable in most cases. #1 prevention is handwashing procedure Chain of infection 1. Infection Agent ( Pathogens) Bacteria, virus, fungi, parasite 2. Reservoir Humans, water, anything that is contaminated 3. portal of exit Fluids, sneezing, cuts, open wound, GI, Respiratory. 4. mode of transmission Airborne, droplet, vector, in/direct contact. 5. portal of entry Broken skin, respiratory tract, mucous membranes, CVC and tubes. 6. susceptible host Anyone, immunocompromise , children, elders. Factors affecting an organism that potential to produce disease Number of organisms Virulence ( type of virus) Competence of immune system( how strong is yours IS) It is stronger by vitamin C, diet, sleep, and contractability Length or extent of contact between person and microorganism Classification of infections Location Local or systemic Origin Primary or secondary Exogenous or endogenous Duration Acute, chronic, or latent. Stages of infection Incubation The stage of where organisms are growing and multiplying. Prodromal Most infectious and contagious and it shows early signs and symptoms of disease. Can cause low-grade fever and fatigue Illness Full stage illness with present of infection-specific signs and symptoms. Convalescent The beginning of the recovery stage from infection. Body defense The skin and mucous membranes are the first-line of defense also; Normal flora - found in the GI track. Skin, mucous membranes (1st defense) Nares, trachea, bronchi Eyes Mouth GI and GU tracts Inflammatory response is a protective mechanism that helps the body neutralize, control, or eliminate the offending agent and prepares the site for repair. Phagocytosis Complement cascade Inflammatory response Fever Immune response Specific immunity B cells T cells Factors that affect host susceptibility Skin and mucous membranes Normal Ph levels White blood cells Age, sex, ethnicity, hereditary factors Immunization Fatigue Climate etc Increases infection Risks Tobacco use, substance abuse, multiple sexual partners, medications, and medical procedures. Nursing Process: Assessment Risk factors, Age, nutrition, disease process, Appearance Local infection- located in one area in the body. Redness Swelling drainage Pain/ tenderness Decreases movement of affected area Systemic - within the whole body. Fever, fatigue, nausea, lymph nodes enlarge  lethargy, anorexia, fever, increased pulse and respiratory rate, and tenderness and enlargement of the lymph nodes. Lab Results White blood cells Normal range 5,00 to 10,000 / mm Leukocytosis- term for elevated white blood cell count Leukopenia- term for low white blood cells ( especially granulocytes) CRP ( C- REACTIVE PROTEIN) ESR or SED rate ( ERYTHROCYTE SEDIMENTATION RATE) Culture and sensitivity Procalcitonin Planning Remain free of S/S (signs and symptoms) of infection. Make sure the pt states the S/S of infection and when to call the physician. Implementation Nursing care based on breaking chain of infection Standard precautions Transmission precaution Transmission Precautions Contact precautions Anything that has a drainage, patient supplies, secretion, urine/feces Anything that can get to you. This is the most common form of transmission. ALWAYS MUST WEAR GLOVES AND GOWN Droplet precautions Anything that is spread through moist droplets Sneezing, coughing and talking Ed Airborne Precautions Anything that is spread through air TB, Varicella, SARS, Rubeola Wear N95 C-DIFF WASH HANDS NOT HANDSANITATION Reverse Isolation Protects vulnerable pts for infection Only one nurse and cannot take are of anyone with infection Aseptic Technique Asepsis- the prevention of infection or break the chain of infection. Medical Asepsis Decreasing of microorganisms Surgical Asepsis Sterile and no microorganisms Multidrug resistance organisms Medications for Infections Anti-infective agents Antibiotics ( look into these) Inhibits(stops) the growth of the bacteria Cephalosporin Can rupture tendons Antiviral agents Lessens symptoms Antifungal agents Antiprotozoal agents Anthelmintic Agents Nutrition Good nutrition can make us healthier Poor nutrition can cause illness Nutrition is the study of intake of food and how it nourish the body. Metabolism- the sum of all chemical reactions in an organism. The process by which converting food into energy. BMR- # of calories required for involuntary activities. Nutrients- are used for growth, development, activity. Etc. Most nutrients work better together than alone. There is two types of nutrients Macronutrients- supply energy an build tissue ( carbs, fats, protein) Micronutrients- required in much smaller amounts to regulate and control body process ( vitamins and minerals) Non-essential nutrients ex. Vitamin D and cholesterol. Six types of nutrients Carbohydrates Provide energy 45-65% of daily calories Whole grain bread, baked potatoes, brown rice, and other plant foods. Digestible carbs provide 4 cal/g of energy Molecular structure CHO Types Monosaccharides (1)- simple carb ( honey) Disaccharides (2)- simple barb ( table sugar) Polysaccharides ( multiple) complex carbs- (potatoes) It is important to know these to control our body energy and food intake Fiber- It is categorized as a carb Substance in plant foods that are undigestible Dissolves in water Barley, beans, broccoli, citrus fruits, oatmeal It helps with glucose stability, helps with diarrhea and constipation, Promotes weight loss and decrease cholesterol levels. Protein Required for formation of body structures Two types of proteins Complete Eggs, dairy, and meat. Contains sufficient amount of all essential amino acids to support growth. Incomplete proteins Lack one or more essential amino acids. Grains, vegetables Two can create a complete protein. Metabolic functions of protein Tissue-building and maintenance. Balance nitrogen and water Backup energy Support metabolic process, immune system. Facilitating acid-base, fluid, and electrolyte balance Formation of neurotransmitters, enzymes, antibodies, hormones, breast milk, mucus, histamine, and sperm Protein requirement 10-35% of total calories 3 main factors Tissue growth needs Quality of dietary protein Provides 4 cal/g of energy Lipids Dark meat, poultry skin, dairy foods, salmon, egg yolks. AMDR fat is 20-35% of total calories 10% or less total calories should come from saturated fat sources. High fat diet is linked with CVD, hypertension, and diabetes. Lipids provide 9 cal/g of energy and are densest form of stored energy. Types Triglycerides Phospholipids Sterols Fat- like substances found in animal products. They're non-essential. cholesterols Fat- like HDL Good cholesterol LDL Bad cholesterol Vitamins- Regulator nutrients from organic sources and are required for metabolic function. They do not give energy There is two types Water soluble B vitamins Usually are in green leafy vegetables and grains. Vitamin C - aid in tissue building, metabolic reaction, and boost immunity. Citrus fruits ( lemons), tomatoes, peppers, green vegetables and strawberries. Scurvy- severe deficiency of vitamin C. Fat soluble - can reach toxic levels. Vitamin A- vision health, tissue strength, growth and embryonic development. Dark yellow/orange fruits and veggies, butter, carrots, egg yolk etc. Vitamin D- assists in absorption of calcium and phosphorus and mineralization of bone. Sunlight synthesize vitamin D in skin. Eggs, cereals, milk, orange juice. Vitamin E- antioxidants that preserve lung and RBC membranes. Oils and nuts Vitamin K- assist in blood clotting and bone maintenance. Used as antidote for excessive anticoagulant Warfarin Dark green veggies, carrots, eggs. Minerals ( know safe ranges) Also known as macro-minerals. Sodium Na Maintains fluid volume Salt, processed foods Potassium K Muscle action Chicken, beef, broccoli, bananas, potatoes Calcium Ca- bones/teeth formation and bp Dairy, broccoli, kale. Magnesium Mg Smooth muscle relaxation. Green leafy veggies, nuts, chocolate Assessing high levels Potassium k high/ low Check heart abnormalities Sodium Assess edema, lungs, turgor. Magnesium Abnormalities Hypotension, seizures, High levels- seizure, low - will cause too much relaxation. High levels cause high bp and low Calcium 8.6- Can cause deposits in blood vessels. Trace minerals Iodine- helps sysnthesis of thyroxine aka thyroid hormone Iron- oxygen distribution Vitamin C increases absorption of iron Fluoride- bonds with calcium and accumulates in bone and teeth. Zinc- improves function and wound healing. Chromium- potentiates the effects of insulin. Water- Intake must be approximate to output. Minimum daily is 1500 ml Males 3.7l females 2.7 Intracellular- within the cell Extracellular- outside the cell Fluid loss Sensible loss- can be measured. Urination, defecation, wounds. Insensible- unable to be measured. Food labels Based on 2,000 calorie diet It is regulated by FDA. Nutritional Assessment Medications that increase metabolism Epinephrine, levothyroxine, ephedrine sulfate. Illness with increase Basal metabolic rate. BMI- body mass index. Indicates total body bat stores. Obesity greater than or equal to 30 BMI Can cause disease such as diabetes. Lack of exercise, unhealthy diet, and medical conditions. Waist circumference It is measured with measuring tape, snugly around the waist at level of umbilicus. Abdominal fat is a reliable indicator risk for disease. 40'' or more for men and 35" for women. Factors that affect nutrition Cultural practice Financial issues Appetite Food preference Environmental factors Disease and illness Medications age Factors for inadequate nutrition Biophysical factors Disease, age, genetics Psychological factors Mental illness Excessive stress Socioeconomic factors Poverty Substance abuse Special diet Food preference Lab Data Albumin - reads protein 3/5- 5.5 g/dl ***Pre- albumin 23-43 mg/ dL Nitrogen Balance- the difference between intake and urinary excretion of nitrogen. -1 to +1 t Positive means the body is holding, negative is too much excretion. Blood glucose 70-90 without diabetes Hemoglobin A1c- sugar levels stuck to hemoglobin Less than 5.7 (<) Hemoglobin- 12-18 g/ dL Hematocrit - red blood cells level 40-50% PT education Balance energy intake Establish exercise routine Consume a min. of 5 servings per day of fiber rich fruits and veggies. Limit sugar and starchy food Less salt Clear liquid diet Anything that is clear and avoid red or purple drinks. Fluid liquid diet Watery food that are clear liquids too Pureed diet Pure diet. Dysphagia diet The trouble to swallow. Elimination Hematuria- blood within elimination ( urine or stool)\ Anuria - unable to urinate Oliguria- low urine output Polyuria- Excessive urination Nocturia- night urination Pyuria- Pus in the urine Factors that affecting urinary elimination Developmental considerations Kids will be incontinent. Elders Pregnancy causes frequent urination. Diet Poor nutrition/ excessive. Drug abuse ( Alcohol) Immobility Ability to urinate Catheterization can cause tissue tone. Psychosocial factors Pain Surgical procedures Medications Pathologic conditions. Assessing of urinary function Assess data about voiding ( urinating) patterns, habits, and history of problems. Physical assessment Kidneys Ask for pain with the area of location. Urinary bladder Pain, palpate, and Urethra orifice Check for redness, tenderness, or discharge Skin Check for discharge, redness, or tenderness, and integrity. Urine Check for color, smell, lab cultures. Bedpan Fracture bedpans are no more than 30 degrees I and O Anything that is less than 30 mL/hr for more than 2hrs is a concern. Urinary retention S/SX of bladder distention Suprapubic discomfort, diaphoresis and restlessness. Use bladder scanner Anything more than 200 mL is considered abnormal. Urinary incontinence. Enuresis- bed wetting Risk factors are Females, pregnancy, vaginal birth, chronic diseases and diabetes. Confusion, dementia, immobility, etc. Physiological changes of aging, obesity, and medications. Complications of urinary incontinence Skin breakdown Keep skin clean and dry Assess any skin breakdown Apply protective barrier creams Bladder-retaining program Social isolation Assist with measures to conceal urinary leaking Offer emotional support. Nursing preventions Establish toileting schedule Monitor I and O and decrease fluid in night time Use external catheters ( non-invasive) Provide perineal care. Patient Education Maintain Regular bowel movements Try to empty completely bladder with each void. Avoid alcohol and coffee. Therapeutic procedures. Intermitted urinary catheterization Catheters that are removed as soon as used. External Catheters Alternative to indwelling catheter in incontinent clients PUREWICK are external female and male catheters. It is connected to low pressure suction ( 40mmHG) Recline, lying on side, or while seated. They are changed 8-12 hr or soiled Care of Indwelling catheter. Leave system closed as much possible. Do not allow bag or tubing to touch the floor. Always keep bag below bladder. Keep catheter and tubing free of kinks Attach to bedframe and never to siderail Symptoms of cystitis/ UTI Dark/ cloudy urine Blood in urine Pain and burning while peeing Always wipe front to back Drink at least 8 to 10 oz a day Hygiene Elimination Diagnostics and medications. Fecal Occult blood( guaiac) test It is given to test Stool for culture, parasites, ova, and blood. Stool Collection Void first so urine is not in stool sample Avoid tissue in specimen container. Avoid any soap, detergent etc. Medications Docusate sodium ( colace) - lubricating laxative It is use for constipations, prophylaxis for pt who shouldn't strain ( after surgery etc) Contraindications Allergy, ABD disorders ( appendicitis, fecal impaction, obstructions) Adverse effect Diarrhea, mild cramping, laxative dependence with long term or excessive use. Nursing consideration Determine whether pt has adequate fluid intake, exercise and diet. PT teaching Teach dietary sources, fiber, Stop drug and notify prescriber if severe cramping occurs. Do not use more than 7 days. Or abd pain, nausea, or vomiting is present Magnesium citrate ( citrate of magnesia) osmotic laxative Indications- it is used for short-term relief of constipation, prevent straining, GI procedures. Adverse effect- diarrhea, nausea, abdominal cramping, fluid and electrolyte (F&E) disturbances with daily use, laxative dependence. Nursing consideration Adequate fluid intake, exercise, and diet Electrolyte levels Caution with sodium restrictions. Administering Edema Always lay on the left side with right leg flexed forward. Insert tube 3-4 in and 2-3 in for child Raise bag 12-18 in above anus Medications to stop peristalsis Ioperamide ( Imodium) antidiarrheal Indications-Short term relief of diarrhea Adverse effects- Lab tests Blood urea nitrogen ( BUN) - 6-24 mg/dL Creatine - 0.7 -1.3 mg/dL for men and 0.6 to 1.1 mg/dL for women GFR (glomerular filtration rate 60 or higher in normal Below 60 may mean CKD 15 or lower may mean kidney failure. Nursing consideration for diuretics Assess pt for sulfa allergies Monitor bp, weight, I and O, and serum electrolyte levels. Monitor Blood glucose levels In can cause hyperglycemia Follow BUN and creatine levels. Administer in the morning. Medications for stimulation for urine Bethanechol ( Urecholine) It is use to treat urinary retention Adverse effects- urinary urgency, abdominal discomfort, salivation, nausea, vomiting, diaphoresis, flushing, bradycardia Nursing considerations Monitor patient for orthostatic hypotension. Watch closely for adverse reactions that may indicate drug toxicity Pt teaching Tell patient to take drug on an empty stomach and at regular intervals. Inform patient that drug is usually effective 30 to 90 minutes after use. Oxybutynin chloride ( Ditropan XL) urinary antispasmodic Treat overactive bladder Adverse effect Drowsiness, dizziness, blurred vision, tachycardia, dry mouth, nausea, urinary hesitancy, decreased sweating. Nursing consideration Ask for anticholinergic effects Monitor episodes of incontinence and postvoid residual and ask clients about a history of glaucoma Patient teaching Report dysuria, palpitations, and constipation. Warn patient to avoid hazardous activities, such as operating machinery or driving, until CNS effects of drug are known. Avoid alcohol. Caution patient that using drug during very hot weather may cause fever or heatstroke because it suppresses sweating LOOK AT PAGE 26 ON CC Oxygenation delivery Oxygenation therapy- Administration of oxygen greater than 21% to treat/prevent hypoxemia and hypoxia The fraction of inspired oxygen ( Fio2) is the percentage of oxygen the client receives. SpO2 must be maintain within 95-100% It is lower in COPD pts. Oxygen toxicity- Use the lowest oxygen concentration to prevent toxic Source of oxygen No not transfer pt if it its less than 500.