FUNDA MIDTERMS SUMMER

• Microorganisms


  Exist everywhere: in water, in soil, and on body surfaces such as the skin, intestinal tract, and other areas open to the outside (e.g., mouth, upper respiratory tract, vagina, and lower urinary tract)
• Asepsis


  Freedom from disease-causing microorganisms
• Sepsis


  Condition in which acute organ dysfunction occurs secondary to infection
• Communicable Disease


  An illness caused by an infectious agent or its toxins that occurs through the direct or indirect transmission of the infectious agent or its products from an infected individual or vectors
• Virulence


  Severity or harmfulness of a disease
• Infection


  Implantation and successful replication of an organism in the tissue of the host resulting in signs and symptoms
• Infectious Agent


  Microorganisms or etiologic agent
• Pathogenicity


  Ability of an organism to produce a disease
• Pathogens

  • True pathogen - infectious agent that causes disease in virtually any susceptible host
  • Opportunistic pathogen - potentially infectious agents that rarely cause disease in individuals with healthy immune systems
• Bacteremia


  When a culture of the individual's blood reveals microorganisms
• Septicemia


  When bacteremia results in systemic infection
• Colonization


  When microorganisms are present but not causing disease
• Local infection


  Limited to the specific part of the body
• Systemic infection

  The spread of infection to different parts of the body
• Acute Infection


  Generally appear suddenly or last a short time
• Chronic infection


  May occur slowly, over a very long period, and may last months or years
• Medical asepsis


  Practices intended to confine / reduce microorganism
• Surgical asepsis


  Practices that keep an area or object free of all microorganisms
• Major categories of microorganisms

  • Bacteria
  • Virus
  • Fungi
  • Parasites
• Nosocomial and health-associated infections


  • CLABSI - Central IV Line-Associated Bloodstream Infection
  • CAUTI - Catheter-Associated Urinary Tract Infection
  • SSI - Surgical Site Infections
  • VAP - Ventilator-Associated Pneumonia
• Five (5) moments of handwashing

  • Before touching a patient
  • Before clean/aseptic procedure
  • After body fluid exposure risk
  • After touching a patient
  • After touching patient surroundings
• Nursing Process

  A framework for providing quality nursing care, a frame for critical thinking, a systematic, rational method of planning and providing individualized nursing care
• The nursing process was originated by Lydia Hall in 1955
• Purposes of the nursing process

  • Identify a client's health status
  • Identify actual or potential healthcare problems or needs
  • Establish plans to meet the identified needs
  • Deliver specific nursing interventions to meet those needs
• Characteristics of the nursing process

  • Cyclic and dynamic
  • Client centered
  • Adaptation of problem solving and systems theory
  • Decision making
  • Interpersonal and collaborative
  • Universal applicability
  • Critical thinking
  • Clinical reasoning
• Steps of the nursing process (ADPIE)

  • Assessment
  • Diagnosis
  • Planning
  • Implementing/intervention
  • Evaluating
• Historical perspectives on the nursing process

  • Lydia Hall (1955) - "Nursing Process"
  • Fry (1953) - 1st used the term "nursing diagnosis"
  • Johnson (1959), Orlando (1961), Weidenbach (1963) - Assessment, Planning, Evaluation
  • Yura & Walsh (1967) - Assessment, Planning, Implementation, Evaluation
  • NANDA (1974) - Assessing, Diagnosing, Planning, Implementing, Evaluation
• Steps of the nursing process (ADPIE)

  • Assessment - Collect, Organize, Validate, Document
  • Diagnosis - Analyze collected data, Identify problems, risks, strengths, Formulate diagnostic statements
  • Planning - Prioritize problem/diagnoses, Formulate the goal/desired outcome, Select nursing intervention, Write nursing intervention (NCP)
  • Intervention/implement - Reassess, Assistance, Implement Nursing Intervention, Delegated care (supervise), Document
  • Evaluating - Judge, Collected Data And Compare With Outcome, Relate Nursing Action To Goals, Draw Conclusion, Continue, Modify, Terminate Care Plan
• Assessment


  First step of the Nursing Process, Systematic and continuous gathering of information or collection of data
• Types of assessment sources

  • Primary source - Client
  • Secondary source - Family, physical exam, nursing history, team members, lab reports, diagnostic tests
• Types of assessment data

  • Subjective - From the client/as verbalized (symptoms)
  • Objective - Observable data/measured data (signs and symptoms)
  • Constant - Info that does not change overtime
  • Variable - Data can change frequently or quickly
• Types of assessment

  • Initial assessment - Performed within specified time after admission
  • Problem-focused assessment - Ongoing process integrated with nursing care
  • Emergency assessment - During any physiologic or psychologic crisis
  • Time-lapsed reassessment - Several months after initial assessment
  • Comprehensive assessment - Performed upon admission
  • Focused assessment - Focused on particular need/health care problem
  • Ongoing assessment - Systematic monitoring & observation related to specific problems
• Sources of data

  • Client records - Information documented by various healthcare professionals
  • Health care professionals
  • Literature
• Components of nursing health history/database

  • Biographic data - Client's name, age, sex, marital status, occupation, religious affiliation
  • Chief complaint/reason for visit
  • History of present illness
  • Past history of illness
  • Family history of illness
  • Lifestyle - Personal habits, diet, sleep/rest, ADLs, recreation/hobbies
  • Social data - Family relationship, ethnic affiliation, education, occupation, economic status, home and neighborhood conditions
  • Psychologic data - Major stressors, usual coping patterns, communication style
  • Patterns of healthcare
  • Review of systems
• Data collection methods


  • Observing - Using the senses
  • Interviewing - Planned communication with patient
  • Examining - Uses IPPA
• Nursing Diagnosis

  Second step of the Nursing Process, Interpret and analyze clustered data, Clinical judgement about the client's response to actual and potential health problems of life processes
• Nursing diagnosis


  Statement of how the client is responding to an actual or potential problem that requires nursing intervention
• Differences between nursing diagnosis and medical diagnosis

  • Nursing diagnosis - Within the scope of nursing practice, Describe the human response to an illness or health problem, Identify responses to health and illness, Can change from day to day
  • Medical diagnosis - Within the scope of medical practice, Refers to the disease process, Focuses on curing pathology, Stays the same as long as the disease is present
• Status of nursing diagnoses

  • Actual nursing diagnoses - Problem-based
  • Health promotion diagnosis - Patient's preparedness to implement behaviors to improve health
  • Risk nursing diagnosis - Problem does not exist yet but risk factors indicate a problem is likely to develop
  • Syndrome diagnosis - Several similar diagnoses
  • Wellness diagnosis - State of being healthy that may be enhanced by deliberate health promoting activities
• Components of a nursing diagnosis (PES)

  • Problem and its definition - Describe the patient's health status and health problem
  • Etiology - Factors contributing to or probable causes of the responses
  • Signs and Symptoms (defining characteristics) - Cluster of signs and symptoms that indicate the presence of a particular diagnostic label