SOSN - (102; Exam 1)
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Created by:
Muffy11 on July 14, 2010
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UPMC Shadyside School of Nursing
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61 terms
Terms | Definitions |
|---|---|
 Chain of Infection | must remain intact for infection to occur |
| Pathogen | infectious agent, to thrive, organism require a proper environment, food, oxygen and water supply, temperature, pH and light |
| Communicable | can be transmitted directly from one person to another |
| Potential for Disease | depends on: NUMBER of organisms, VIRULENCE, or ability to produce disease, ability to enter and survive in the host, SUSCEPTIBILITY of the host |
| Reservoir | pathogens can survive but may or may not produce disease, most common is the HUMAN BODY |
| Carriers | persons or animals contain the pathogen(s) but show no symptoms and can transfer it to others |
| Modes of Transmission | can be transmitted by more than one route, most common: HANDS OF HEALTH CARE WORKERS; ROUTES: contact, air, vehicles (catherters), vectors |
| Portal of Entry | usually where the bodies defenses are low, increase risk when any device is placed such as a catheter, can use the same routes as they use for exiting; Contributing Factors: high stress(#1), lack of rest, inadequate diet, seasonal changes, impaired skin integrity |
| Susceptibility | depends on the individual degree of resistance, the more virulent, the greater the likelihood of aquiring, overuse of antibiotics has lead to organism resistance |
| Localized | one area of the body |
| Systemic | throughout the body or blood (sepsis) |
| Supportive Therapy | nutrition and rest that bolsters defense against the infection process |
| Normal Flora | the body's normal and natural defense against infection |
| Inflammatory Response | portective reaction that neutralizes pathogens and repairs body cells, formation of inflammatory exudates for tissue repair |
| Immune System | comprised of seperate cells and molecules that help the body resist disease |
| Inflammation | cellular response to injury or infection, delivers fluid, blood products and nutrients to interstitial tissues, inlcudes swelling, redness, heat, pain, tenderlness or loss of function in the affected body part, may be triggered by physical & chemical agents as well as microorganisms |
| Nosocomial Infections | occur in healthcare setting; transmitted by healthcare workers; hospitals harbor high populations of virulent strains of microbes that may be resistant to antibiotics |
| Iatrogenic Infection | resulting from a diagnostic or therapeutic procedure (ex. UTI) |
| Exogenous Infection | arise from microbes EXTERNAL to the individual that do NOT exist as normal flora |
| Endogenous Infection | normal flora becomes altered and an overgrowith results (ex. E. Coli) |
| Client Susceptibility | may increase with:age, nutritional status, stress, medical therapy |
| Asepsis | absence of pathogenic microorganisms; medical asepsis - clean; surgical asepsis - sterile |
| Patient on Isolation Precautions | determine type of isolation, perform hand hygiene and prepare equipment to be take into room (mask, gown etc.); use disposable equipment when available and leave your personal contents out of the room |
| When Leaving Isolation | remove gloves first (most contaminated), then mask, gown, lastly eyewear; perform hand hygiene |
| Types of Precautions | airborne, droplets, contact |
| The Occupational Safety and Health Act of 1991 | establishes roules and regulations to protect employees from infectious hazards at work( UPMC follows OSHA regulations regarding bodily fluid exposures); guidlelines are incorporated into the policies and procedures and are part of regularly scheduled staff edu. programs |
| Bloodborne Pathogens | pathogenic microorganisms that are present in human blood and can cause disease in humans (ex. HIV, Hepatitis B, C, and D) |
| Universal Precautions | treat ALL human blood and other body substances AS IF THEY WERE INFECTIOUS for HIV, Hepatitis or other bloodborne pathogens |
| Assessment | first and most critical phase of nursing process, information obtained is used to determine persons level of health and all future decision with the patient (continues throughout the nursing process) |
| Health History | 4 sections: history of present health concern (what brought them in), PMH, FH, lifestyle and health practices |
| Physical Assessment | objective data collected during hands on assessment; enables the nurse to make judgements for: a. nursing diagnosis, b. collaborative problems, c. referrals, d. need for client teaching |
| 4 Types of Physical Assessment | 1. initial comprehensive assessment 2. ongoing or partial assessment (throughout the day) 3. focused or problem oriented assessment 4. emergency assessment |
| Gerontologic Considerations | STATE OF MIND; can they hear you?, can they understand and read writing? |
| General Survey | first step in a head to toe assessment, assess with eyes not by touching the patient, assess nutritional, emotional and skin status; provides validity of subjective data, level of conciousness (alert and oriented), body and posture movements |
| Vital Signs | completed to determine patients usual health and serves as a baseline for future comparisons, provides data that reflects several body systems' status; includes: pulse (2nd), blood pressure (4th), respirations (3rd), tempurature (1st), pain (5th vital sign); |
| Temperature | core body temp: between 36.6 and 37.7 C or 96 and 99 F; elderly about 1F lower temp, runs lowest in morning and highest in evening taken at various anatomical sites: 1. oral (blue probe) - mouth, 2. timpanic - ear, 3. Axilla (least reliable) - armpit, 4. rectal (red probe) - rectum (most reliable); hypothermia = less than 96F, hyperthermia = more than 100F; afebrile = no fever wnl, febrile = has fever |
| Pulse | many areas to check: radial (underside of the wrist), brachial (anticubital fossa), pedal (top of foot), femoral (groin); normal: 60-100 bpm, tachycardia - above 100 bpm, bradycardia - below 60 bpm; amplitude quantified as: 1+ - thready or weak, 2+ - normal, 3+ - bounding |
| Respirations | rate and character of breathing, watching the rise and fall of the chest wall (1 resp.); characteristics: 1. rate 2. rhythm 3. depth; 95%-100% on pulse oximetry |
| Blood Pressure | pressure exerted on walls of arteries, high point is reached during systole (ventricles contracted) and low point reached with diastole (ventricles relaxed); factors that impact BP: cardiac output, distensibility of the arteries, blood volume, velocity and viscocity |
| Blood Pressure Variances | usually due to external influences such as: time of day, caffiene or nicotine, exercise, emotions, pain, temperature, size of cuff - too small = false high pressure, too large = false low pressure |
| Pulse Pressure | the difference between the systolic and diastolic pressure; reflects the volume of blood ejected with each heartbeat |
| Blood Pressure With Body Position | BP increases with standing, BP decreases when lying down; Orthostatic BP - body doesnt respond to change in positions (determines if pt. has orthostatic hypotension which increases risk for falling), more than a 10 mm Hg drop in systolic or diastolic pressure and an increase in heart rate of 20 beats per minute |
| Fowlers | best position to asses for symmetry, laying down, head of bed at 45 degree angle |
| Auscultation | requires use of a stethoscope to assess movement of blood, bowel and air and is classified according to intensity, pitch, duration and quality of sound |
| Documenting Data | forms the database for the entire nursing process for you and for other members of the health care team; take credit for your work, if it wasn't charted - it didn't happen |
| Pallor | loss of color dcreased blood supply, anemia, flu etc. (deoxygenation) |
| Cyanosis | bluing of certain parts of body due to poor circulation; peripheral - vasal constriction, central - cardiac or respiratroy(lips blue, oral mucosa blue) |
| Acanthosis Nigricans | causes velvety, light-brown-to-black markings on the neck, under the arms or in the groin areas and is most often associated with obesity but sometimes with insulin assisted diabetes |
| Skin Turgor | assessing the mobility of skin (ability to grab skin), inelasticity is a normal part of aging; tenting - grabbing of the skin, normal: returns under 30 seconds; if it stays tented then patient is dehydrated |
| Edema | pitting, 2mm = springs back up, 8mm = stays for long period of time; bilateral - usually a systemic problem, unilateral - acute reason |
| Copper Coloring of Hair | vitamin deficiency |
| Alopecia | describes hair loss in smal round areas on the scalp |
| Nail Problems | bule lining - distinct lines laterally across fingernails, spoon nails - nails become concave more than convex (is an iron deficiency), clubbing - enlarging of the fingertips usually due to chronic respiratory disases and happens bilaterally |
| Pressure Ulcers | stage I - skin red and not broken, stage II - skin is broken, resembles blister or erosion, stage III - crater, involves epidermis, dermis and subcutaneous tissue, stage IV - includes all with bone and surrounding tissue (HOB should never be higher than 30 degrees, pt should be turned every 2 hrs.) Risk factors: incontinence, never rub a reddened area, destroys tissues |
| Macule | flat, non palpable with possible irregular borders (freckles, petechiae, vitiligo) |
| Papule | elevated, palpable and solid (usually smaller in size) (ex. wart) |
| Nodule/Tumor | elevated, solid, mass more into the dermis (bigger than macule) (ex. lipoma, poorly absorbed injection) |
| Vesicle | elevated, mass, contains serous (clear) fluid (herpes, poison ivy, blisters) |
| Wheal | elevated mass, no fluid, irregular borders, size and color not always the same (hives) |
| Pustule | elevated mass, contains pus inside the vesicle (acne, impetigo) |
| Cyst | semisolid mass, encapsulated fluid |
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