NURS 202 Chapter Notes - Chapter Unit 3-Unit 4: Muscle Atrophy, Shampoo, Peripheral Artery Disease
U3 infection control, mobility
Potter ch32,36,37,45
Factors Affecting
Safety
1. Psychosocial considerations,
2. basic needs,
3. physical hazards.
Infants/Toddlers
-Injuries, educate parents regarding safety.
-Poisoning due to curious and oral activity.
-Drowning.
School-Aged
Children
1. Increased activities;
2. prone to injury. Need for helmets.
Adolescents
Drugs and alcohol in situations of danger.
Risk-taking behaviors.
Young Adults
1. Lifestyle habits;
2. stress.
Older Adults
-Physiological changes (hearing vision).
-Falls are common and fatal (90%).
-Hip fractures are among the most serious fall-related injuries.
Healthcare
Associated
Infections
1. Infections found in acute care setting.
2. Someone acquires an infection because of being in the hospital.
Delirium
The sudden acute onset of confusion
Fall Prevention
-Check patients.
-Use brakes.
-Use shoes or rubber slippers.
-Keep items within reach.
Restraints
1. -Use as a last resort. May increase the severity from a fall.
2. -Actually increases nursing care.
3. -Use of a restraint must be clinically justified
Side Rails
Risk for entrapment.
Making Beds
1. Change linen as necessary (if soiled).
2. Raise bed to proper working height.
3. Work with another person.
4. Never shake linen (spread of microbes through air).
Positioning
Every 2 hours day and night. Lung expansion and prevents ulcers.
Fowlers
45-60. Lung expansion, nasogastric tube insertion. Use for when patient eats.
High Fowlers
90 degrees. Orthopneic.
Low Fowlers
30 degrees.
Prone
1. For patients with acute respiratory distress and acute lung injury.
2. Watch for hypertension and hyperextension.
Chain of Infection
All parts must be intact for an infection to occur:
1. Infectious agent,
2. reseroivr,
3. portal of exit,
4. mode of transmission,
5. portal of entry into hit,
6. susceptible host.
Reservoir
Bacteria love glucose (diabetics more prone to infection), moisture (key to infection). (When body
recognizes an organism, fever is induced). pH levels (gastric juice help fight microbes). Light.
Entry
Human being bladder, mouth. Must survive there.
Exit
Requires fluid to leave. Orphaces are portals of entry and exit. Breaks in skin/mucous membranes.
Modes of
Transmission
Reservoir to host. Contact, direct, indirect, droplet, airborne, vectors, vehicles.
Susceptibility
Smokers have less ability to fight infection. Chemotherapy (takes away good cells).
Infection Control
Proper cleaning.
Communicable
Disease
If an infection can be transmitted from one person to another.
Number of
Microbes
1. Must be enough to cause an infection.
2. Reduced amount is less likely to cause an infection.
Virulence
The ability or strength of the organism to take the host.
Newborns
Immune system still immature. Higher risk for infection as well as older adults.
Infection
Prevention
1. HH before and after you put gloves on.
2. Anytime you are in contact with body fluids.
3. After leaving pt room.
Personal
Protective
Equipment
Personal Protective Equipment
Host
Degree of resistance to a pathogen.
Resistance increased by immunizations and exposure to disease.
Serous Exudate
Clear water
Sanguineous
exudate
blood
Purulent exudate
puss
Serosanguinous
exudate
Clear with blood
Exogenous
Infection
From microorganisms external to the individual that do not exist as normal flora.
Endogenous
Infection
When some of the patient's flora becomes altered and overgrowth results.
Disinfection
Disinfection
Sterilization
The destruction of all microorganisms including spores.
Droplet
HH, mask, eyewear
contact
HH, gown, gloves
airborne
HH, N95 mask
P32 infection control
Acute
inflammatory
process
1.Sign: pain
-the swelling of inflamed tissues increases pressure on nerve endings, causing pain. Histamine also
stimulate nerve endings, adding to the pain response.
2.elevated WBC count is another indicator,
ESR
Normal ESR for women: 20mm/hr
If the value is abnormal, indicating the presence of an inflammatory process
Droplet precaution
-is instituted for known or suspected infections caused by microbes transmitted by droplets
produced by coughing
Ex: influenza, chickepox
Contact precaution
Ex: C. difficile infection
Airborne
precaution
Ex: measles; pulmonary tuberculosis, active tuberculosis
Surgical aseptic
technique
-be used during procedures that require intentional perforation of the pt’s skin, such as with the
insertion of intravenous catheter
Sterile asepsis
Before pouring the solution into the container, the nurse pours a small amount (1-2mL) into a
disposable cap or plastic-lined waste receptacle. The discarded solution cleans the lip of the bottle.
Pneumonia in
older adult patient
-an infection in older adults may not demonstrate typical signs and symptoms. Atypical symptoms
such as confusion, incontinence, or agitation may be the only symptoms of an infectious illness
-an unexplained increased heart rate, confusion, or generalized fatigue may be the only symptoms
basophils
Lab values for basophils are normal with the patient who has an infection
Semicritical item
Ex: a vaginal speculum used for a pap smear
illness stage
Is the interval btw the entrance of pathogen into the body and the appearance of first symptoms
Prodromal stage
Is the interval from the onset of nonspecific signs and symptoms to more specific symptoms
Incubation period
Is the interval when the pt manifests signs and symptoms specific to the type of infection
convalescence
Is the interval when the acute symptoms of infection disappear and the body tries to replenish its
resources and return to a state of homeostasis
P36 safety
falls
-falls can occur as a result of intrinsic factors (eg illness, drug therapy, alcohol use) and extrinsic
environmental factors (eg tripping over doormats, small rugs on the stairs, wet spots on the floor,
clutter on bedside tables, closet shelves)
-intrinsic factors is difficulty to modify or eliminate
-extrinsic factors can be modified or eliminated
-the greatest indicator of risk for falls is a history of falls
restraint
-the use of restraints must be part of he pat’s medical treatment and must be ordered according to
provincial or territorial legislation and agency policy. In some settings, physicians and nurses may
order restraints
-restrains must be periodically removed, and the nurse must assess the pt to determine if the
restraints continue to be needed
-while the use of any restraint may be associated with serious complication, including pressure,
ulcers, constipation, pneumonia, urinary and fecal incontinence, and urinary retention. The most
critical concerns are contractures, nerve damage and circulatory impairment (ex: hands cool to
touch). This can result in permanent damage.
Wrist restraint
-maintains immobility of an extremity to prevent the patient from removing a therapeutic device, such
as an IV tube
Jacket restraint
-is often used to prevent a patient from getting up and falling
Elbow restraint
-is commonly used with infants and children to prevent elbow flexion, such as after an IV lines is in
place
Mummy restraint
-is used in the short term for a small child or infant for examination or treatment involving the head
and neck. Ex: used for a 1-year-old who is going to receive an IV line
Fire extinguishers
Type A-are used for ordinary combustibles such as wood, cloth, paper, plastic, ex: a garbage can
Type B- are used for flammable liquids ex: gasoline, grease, paint, anaesthetic gas
Type C- are used for electrical equipment
Safe driving tips
Ex: driving shorter distances and only during daylight hours, using side and rear-view mirrors
carefully, and looking toward the ‘blind spot’ before changing lanes
Unregulated care
provider (UCP)
UCP can apply the restraints under the nurse’s direction, but she can’t document, evaluate, or take
physician’s orders. The nurse is always responsible for assessment of pt’s safety needs
Hendrich II fall risk
model
>5: pt is at high risk for fall
Whims logo
P37 hygiene
For mouth care ex:
stomatitis
-normal saline rinses (about 30mL) on awaking in the morning, after each meal, and at bedtime
-the rinses can be increased to every two hours if necessary
Electric razor for
male pt
-Pt with (Thrombocytopenia: decreased platelets) prone to bleeding, they must use an electric razor
for shaving
-pt with pneumonia may use electric razor if no oxygen administered. If having oxygen administered,
should use razor blade because electric razor could create a spark and O2 is flammable
For administering
oral care
-The nurse should place a semi-comatose pt on the side (Sim’s positon) with head turned well toward
the dependent side to facilitate drainage of secretions from the mouth
-when teaching pt how to properly brush their teeth, teaching the pt to hold the toothbrush bristles at
a 45-degree angle to the gum line
Flat position
-is used for pt with vertebral injuries and in cervical traction, for sleeping pts, and for those who are
hypotensive
Fowler’s position
-is preferred while the pt eats and is used during nasogastric tube insertion. This position promotes
lung expansion
Semi-fowler’s
position
- promotes lung expansion and is used when pts receive gastric feedings to reduce regurgitation and
risk of aspiration
Trendelenburg’s
bed position
-is used for postural drainage
Dorsal recumbent
position
-provides easy access to the female genitalia, so nurses can perform female perineal care
Bag bath
-reduces the risk of infection
-use of the traditional washbasin may increase the risk of infection because if it is not cleaned and
dried completely after use, gram-negative bacteria may contaminate the washbasin.
Athlete’s foot
The condition can spread to other parts of the body, esp the hands, if it’s not managed well. It’s
contagious and frequently recurs
Head lice
-a repeat application of medicated shampoo to treat head lice is required 7-10 days later, to ensure
that surviving eggs are destroyed
P45 mobility and immobility
A wedge pillow
-is a triangular pillow made of heavy foam used to maintain the legs in adduction after total hip
replacement surgery
A foot boot
-maintains feet in dorsiflexion and prevent footdrop(=plantar flexion)
A footboard
-prevents footdrop by maintain the feet in dorsiflexion
A bed board
-is used to increase back support and alignment, eps with a soft mattress
A trochanter roll
-prevents external rotation of the hips (when the pt is in a supine position)
sandbags
Can be sued to shape body contours and immobilize an extremity
A trapeze bar
-used to assist the pt in mobility
-allows the pt to pull with the upper extremities to raise the trunk off the bed, to assist in transfer
from bed to wheelchair, or to perform upper arm exercises.
BMI
30-39.9 Grade II, severely obese
Document Summary
Disease: psychosocial considerations, basic needs, physical hazards. Hip fractures are among the most serious fall-related injuries. Infections found in acute care setting: someone acquires an infection because of being in the hospital. Use of a restraint must be clinically justified. Risk for entrapment: change linen as necessary (if soiled), raise bed to proper working height, work with another person, never shake linen (spread of microbes through air). 30 degrees: for patients with acute respiratory distress and acute lung injury, watch for hypertension and hyperextension. All parts must be intact for an infection to occur: Infectious agent, reseroivr: portal of exit, mode of transmission, portal of entry into hit, susceptible host. Bacteria love glucose (diabetics more prone to infection), moisture (key to infection). (when body recognizes an organism, fever is induced). ph levels (gastric juice help fight microbes). If an infection can be transmitted from one person to another.
