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Summary FUNDAMENTALS IN NURSING
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Revised notes on fundamentals of nursing.
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FUNDAMENTALS IN NURSINGREVISED NOTES RATED A+.
UPDATED.
Asepsis
Asepsis is the state of being free from disease-causing contaminants (such as bacteria,
viruses, fungi, and parasites) or, preventing contact with microorganisms. The
term asepsis often refers to those practices used to promote or induce asepsis in an
operative field in surgery or medicine to prevent infection.
Medical asepsis
1. Includes all practices intended to confine a specific microorganism to a specific
area
2. Limits the number, growth, and transmission of microorganisms
3. Objects referred to as clean or dirty (soiled, contaminated)
Surgical asepsis
1. Sterile technique
2. Practices that keep an area or object free of all microorganisms
3. Practices that destroy all microorganisms and spores
4. Used for all procedures involving sterile areas of the body
Principles of Aseptic Technique Only sterile items are used
within sterile field.
1. Sterile objects become unsterile when touched by unsterile objects.
2. Sterile items that are out of vision or below the waist level of the nurse are
considered unsterile.
3. Sterile objects can become unsterile by prolong exposure to airborne
microorganisms.
4. Fluids flow in the direction of gravity.
5. Moisture that passes through a sterile object draws microorganism from unsterile
surfaces above or below to the surface by capillary reaction.
6. The edges of a sterile field are considered unsterile.
7. The skin cannot be sterilized and is unsterile.
8. Conscientiousness, alertness and honesty are essential qualities in maintaining
surgical asepsis
,Infection
Signs of Localized Infection
Localized swelling
Localized redness
Pain or tenderness with palpation or movement
Palpable heat in the infected area
Loss of function of the body part affected, depending on the site and
extent of involvement
Signs of Systemic Infection
Fever
Increased pulse and respiratory rate if the fever high
Malaise and loss of energy
Anorexia and, in some situations, nausea and vomiting
Enlargement and tenderness of lymph nodes that drain the area of infection
Factors Influencing Microorganism’s Capability to Produce Infection
Number of microorganism’s present
Virulence and potency of the microorganisms (pathogenicity)
Ability to enter the body
Susceptibility of the host
Ability to live in the host’s body
Anatomic and Physiologic Barriers Defend Against Infection
Intact skin and mucous membranes
Moist mucous membranes and cilia of the nasal passages
Alveolar macrophages
Tears
High acidity of the stomach
Resident flora of the large intestine
Peristalsis
Low pH of the vagina
Urine flow through the urethra
NANDA Diagnosis
Risk for Infection
State in which an individual is at increased risk for being invaded by
pathogenic microorganisms
Risks factors
Inadequate primary defenses
Inadequate secondary defenses
Related Diagnoses
, Potential Complication of Infection: Fever
Imbalanced Nutrition: Less than Body Requirement
Acute Pain
Impaired Social Interaction or Social Isolation
Anxiety
Interventions to Reduce Risk for Infection
Proper hand hygiene techniques
Environmental controls
Sterile technique when warranted
Identification and management of clients at risk
Chain of Infection
1. The chain of infection refers to those elements that must be present to cause an
infection from a microorganism
2. Basic to the principle of infection is to interrupt this chain so that an infection
from a microorganism does not occur in client
3. Infectious agent; microorganisms capable of causing infections are referred to as
an infectious agent or pathogen
4. Modes of transmission: the microorganism must have a means of transmission to
get from one location to another, called direct and indirect
5. Susceptible host describes a host (human or animal) not possessing enough
resistance against a particular pathogen to prevent disease or infection from
occurring when exposed to the pathogen; in humans this may occur if the person’s
resistance is low because of poor nutrition, lack of exercise of a coexisting illness
that weakens the host.
6. Portal of entry: the means of a pathogen entering a host: the means of entry can be
the same as one that is the portal of exit (gastrointestinal, respiratory,
genitourinary tract).
7. Reservoir: the environment in which the microorganism lives to ensure survival;
it can be a person, animal, arthropod, plant, oil or a combination of these things;
reservoirs that support organism that are pathogenic to humans are inanimate
objects food and water, and other humans.
8. Portal of exit: the means in which the pathogen escapes from the reservoir and
can cause disease; there is usually a common escape route for each
type of microorganism; on humans, common escape routes are the
gastrointestinal, respiratory and the genitourinary tract.
, Asepsis and Infection Control
Breaking the Chain of Infection
Etiologic agent
Correctly cleaning, disinfecting or sterilizing articles before use
Educating clients and support persons about appropriate methods to clean,
disinfect, and sterilize article
Reservoir (source)
Changing dressings and bandages when soiled or wet
Appropriate skin and oral hygiene
Disposing of damp, soiled linens appropriately
Disposing of feces and urine in appropriate receptacles
Ensuring that all fluid containers are covered or capped
Emptying suction and drainage bottles at end of each shift or before full or
according to agency policy
Portal of exit
Avoiding talking, coughing, or sneezing over open wounds or sterile fields
Covering the mouth and nose when coughing or sneezing
Method of transmission
Proper hand hygiene
, Instructing clients and support persons to perform hand hygiene before handling
food, eating, after eliminating and after touching infectious material
Wearing gloves when handling secretions and excretions
Wearing gowns if there is danger of soiling clothing with body substances
Placing discarded soiled materials in moisture-proof refuse bags
Holding used bedpans steadily to prevent spillage
Disposing of urine and feces in appropriate receptacles
Initiating and implementing aseptic precautions for all clients
Wearing masks and eye protection when in close contact with clients who have
infections transmitted by droplets from the respiratory tract
Wearing masks and eye protection when sprays of body fluid are possible
Portal of entry
Using sterile technique for invasive procedures, when exposing open wounds or
handling dressings
Placing used disposable needles and syringes in puncture-resistant containers for
disposal
Providing all clients with own personal care items
Susceptible host
Maintaining the integrity of the client’s skin and mucous membranes
Ensuring that the client receives a balanced diet
Educating the public about the importance of immunizations
Modes of Transmission
1. Direct contact: describes the way in which microorganisms are transferred from
person to person through biting, touching, kissing, or sexual intercourse; droplet
spread is also a form of direct contact but can occur only if the source and the host
are within 3 feet from each other; transmission by droplet can occur when a
person coughs, sneezes, spits, or talks.
2. Indirect contact: can occur through fomites (inanimate objects or materials) or
through vectors (animal or insect, flying or crawling); the fomites or vectors act
as vehicle for transmission
3. Air: airborne transmission involves droplets or dust; droplet nuclei can remain in
the air for long periods and dust particles containing infectious agents can become
airborne infecting a susceptible host generally through the respiratory tract
Course of Infection
1. Incubation: the time between initial contact with an infectious agent until the first
signs of symptoms the incubation period varies from different pathogens;
microorganisms are growing and multiplying during this stage
2. Prodromal Stage: the time period from the onset of nonspecific symptoms to the
appearance of specific symptoms related to the causative pathogen symptoms
, range from being fatigued to having a low-grade fever with malaise; during this
phase it is still possible to transmit the pathogen to another host
3. Full Stage: manifestations of specific signs & symptoms of infectious agent;
referred to as the acute stage; during this stage, it may be possible to transmit the
infectious agent to another, depending on the virulence of the infectious agent
4. Convalescence: time period that the host takes to return to the pre-illness stage;
also called the recovery period; the host defense mechanisms have responded to
the infectious agent and the signs and symptoms of the disease disappear; the
host, however, is more vulnerable to other pathogens at this time; an appropriate
nursing diagnostic label related to this process would be Risk for Infection
Inflammation
The protective response of the tissues of the body to injury or infection; the
physiological reaction to injury or infection is the inflammatory response; it may
be acute or chronic
Body’s response
1. The “inflammatory response” begins with vasoconstriction that is followed by a
brief increase in vascular permeability; the blood vessels dilate allowing plasma
to escape into the injured tissue
2. WBCs (neutrophils, monocytes, and macrophages) migrate to the area of injury
and attack and ingest the invaders (phagocytosis); this process is responsible for
the signs of inflammation
3. Redness occurs when blood accumulates in the dilated capillaries; warmth occurs
as a result of the heat from the increased blood in the area, swelling occurs from
fluid accumulation; the pain occurs from pressure or injury to the local nerves.
Immune Response
1. The immune response involves specific reactions in the body to antigens or
foreign material
2. This specific response is the body’s attempt to protect itself, the body protects
itself by activating 2 types of lymphocytes, the T-lymphocytes and B-
lymphocytes
3. Cell mediated immunity: T-lymphocytes are responsible for cellular immunity
When fungi , protozoa, bacteria and some viruses activate T-lymphocytes,
they enter the circulation from lymph tissue and seek out the antigen
Once the antigen is found they produce proteins (lymphokines) that increase
the migration of phagocytes to the area and keep them there to kill the antigen
After the antigen is gone, the lymphokines disappear
Some T-lymphocytes remain and keep a memory of the antigen and are
reactivated if the antigen appears again.
4. Humoral response: the ability of the body to develop a specific antibody to a
specific antigen (antigen-antibody response)
, B-lymphocytes provide humoral immunity by producing antibodies that
convey specific resistance to many bacterial and viral infections
Active immunity is produced when the immune system is activated either
naturally or artificially.
3.
Natural immunity involves acquisition of immunity through developing
the disease
4.
Active immunity can also be produced through vaccination by
introducing into the body a weakened or killed antigen (artificially
acquired immunity)
5.
Passive immunity does not require a host to develop antibodies, rather it
is transferred to the individual, passive immunity occurs when a mother
passes antibodies to a newborn or when a person is given antibodies from
an animal or person who has had the disease in the form of immune
globulins; this type of immunity only offers temporary protection from
the antigen.
Types of Immunity
Active Immunity
Host produces antibodies in response to natural antigens or artificial antigens
Natural active immunity
Antibodies are formed in presence of active infection in the body
Duration lifelong
Artificial active immunity
Antigens administered to stimulate antibody formation
Lasts for many years
Reinforced by booster
Passive Immunity
Host receives natural or artificial antibodies produced from another source
Natural passive immunity
Antibodies transferred naturally from an immune mother to baby through the
placenta or in colostrum’s
Lasts 6 months to 1 year
Artificial passive immunity
Occurs when immune serum (antibody) from an animal or another human is
injected
Lasts 2 to 3 weeks
,Nosocomial Infection
1. Nosocomial Infections: are those that are acquired as a result of a healthcare
delivery system
2. Iatrogenic infection: these nosocomial infections are directly related to the client’s
treatment or diagnostic procedures; an example of an iatrogenic infection would
be a bacterial infection that results from an intravascular line or Pseudomonas
aeruginosa pneumonia as a result of respiratory suctioning
3. Exogenous Infection: are a result of the healthcare facility environment or
personnel; an example would be an upper respiratory infection resulting from
contact with a caregiver who has an upper respiratory infection
4. Endogenous Infection: can occur from clients themselves or as a reactivation of a
previous dormant organism such as tuberculosis; an example of endogenous
infection would be a yeast infection arising in a woman receiving antibiotic
therapy; the yeast organisms are always present in the vagina, but with the
elimination of the normal bacterial flora, the yeast flourish.
Risks for Nosocomial Infections
Diagnostic or therapeutic procedures
Iatrogenic infections
Compromised host
Insufficient hand hygiene
Factors Increasing Susceptibility to Infection
1. Age: young infants & older adults are at greater risk of infection
because of reduced defense mechanisms
Young infants have reduced defenses related to immature immune systems
In elderly people, physiological changes occur in the body that make them
more susceptible to infectious disease; some of these changes are:
3.
Altered immune function (specifically, decreased phagocytosis by the
neutrophils and by the macrophages)
4.
Decreased bladder muscle tone resulting in urinary retention
5.
Diminished cough reflex, loss of elastic recoil by the lungs leading to
inability to evacuate normal secretions
6.
Gastrointestinal changes resulting in decreased swallowing ability and
delayed gastric emptying.
,2. Heredity: some people have a genetic predisposition or susceptibility to some
infectious diseases
3. Cultural practices: healthcare beliefs and practices, as well as nutritional and
hygiene practices, can influence a person’s susceptibility to infectious diseases
4. Nutrition: inadequate nutrition can make a person more susceptible to infectious
diseases; nutritional practices that do not supply the body with the basic
components necessary to synthesized proteins affect the way the body’s immune
system can respond to pathogens
5. Stress: stressors, both physical and emotional, affect the body’s ability to protect
against invading pathogens; stressors affect the body by elevating blood cortisone
levels; if elevation of serum cortisone is prolonged, it decreases the anti-
inflammatory response and depletes energy stores, thus increasing the
risk of infection
6. Rest, exercise and personal health habits: altered rest and exercise patterns
decrease the body’s protective, mechanisms and may cause physical stress to the
body resulting in an increased risk of infection; personal health habits such as
poor nutrition and unhealthy lifestyle habits increase the risk of infectious over
time by altering the body’s response to pathogens
7. Inadequate defenses: any physiological abnormality or lifestyle habit can
influence normal defense mechanisms in the body, making the client more
susceptible to infection; the immune system functions throughout the body and
depends on the following:
Intact skin and mucous membranes
Adequate blood cell production and differentiation
A functional lymphatic system and spleen
An ability to differentiate foreign tissue and pathogens from normal body
tissue and flora; in autoimmune disease, the body has a problem with
recognizing its own tissue and cells; people with autoimmune disease are at
increased risk of infection related to their immune system deficiencies.
8. Environmental: an environment that exposes individuals to an increased
number of toxins or pathogens also increases the risk of infection; pathogens
grow well in warm moist areas with oxygen (aerobic) or without oxygen
(anaerobic) depending on the microorganism, an environment that increases
exposure to toxic substances also increases risk
9. Immunization history: inadequately immunized people have an increased
risk of infection specifically for those diseases for which vaccines have been
developed.
10. Medications and medical therapies: examples of therapies and medications that
increase clients risk for infection includes radiation treatment, anti-neo-plastic
drugs, anti-inflammatory drugs and surgery
, Diagnostic Tests Used to Screen for Infection
1. Signs and symptoms related to infections are associated with the area infected; for
instance, symptoms of a local infection on the skin or mucous membranes are
localized swelling, redness, pain and warmth
2. Symptoms related to systemic infections include fever, increased pulse &
respirations, lethargy, anorexia, and enlarged lymph nodes
3. Certain diagnostic tests are ordered to confirm the presence of an infection.
Category-specific Isolation Precautions
Strict isolation
Contact isolation
Respiratory isolation
Tuberculosis isolation
Enteric precautions
Drainage/secretions precautions
Blood/body fluid precautions
Disease-specific Isolation Precautions
Delineate practices for control of specific diseases
Use of private rooms with special ventilation
Cohorting clients infected with the same organism
Gowning to prevent gross soilage of clothes
Universal Precautions (UP)
Used with all clients
Decrease the risk of transmitting unidentified pathogens
Obstruct the spread of blood borne pathogens (hepatitis B and C viruses and HIV)
Used in conjunction with disease-specific or category-specific precautions
Body Substance Isolation (BSI)
Employs generic infection control precautions for all clients
Body substances include:
Blood
Urine
Feces
Wound drainage
Oral secretions
Any other body product or tissue
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