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- Some microbes are harmful and can cause infections. They are called pathogens. Non-pathogens are microbes that do not usually cause an infection.
- There are five types of microbes: Bacteria are one-celled organisms that multiply rapidly. Fungi are plant-like organisms that live on other plants or animals.Protozoa are one-celled animals. Rickettsiae are found in fleas, lice, ticks, and other insects. Viruses grow in living cells.
- Requirements of microbes: Microbes need a reservoir (host) to live and grow. Microbes need water and nourishment from the reservoir. Most need oxygen to live. A warm and dark environment is needed. Most grow best at body temperature. They are destroyed by heat and light. Normal flora are microbes that live and grow in a certain area. They are non-pathogens when in or on a natural reservoir. When a non-pathogen is transmitted from its natural site to another site or host, it becomes a pathogen.
- Multidrug-resistant organisms (MDROs) are microbes that can resist the effects of antibiotics. Antibiotics are drugs that kill certain microbes that cause infections. MDROs are caused by: Prescribing antibiotics when they are not needed (over-prescribing). Not taking antibiotics for the length of time prescribed. Two common types of MDROs are resistant to many antibiotics: Methicillin-resistant Staphylococcus aureus (MRSA). Vancomycin-resistant Enterococci (VRE)
- Infection is a disease state that results from the invasion and growth of microbes in the body. A local infection is in a body part. A systemic infection involves the whole body. The chain of infection is a process that involves a: Source—a pathogen. Reservoir—where a pathogen can grow and multiply. Portal of exit—allows pathogen to leave the reservoir.Method of transmission—a vehicle transmits microbes. Portal of entry—where the pathogen enters the body. Susceptible: host—needed for the microbe to grow and multiply.
- Healthcare-associated infection (HAI). An HAI is an infection that develops in a person cared for in any setting where health care is given. HAIs also are called nosocomial infections. HAIs are caused by: Normal flora. Microbes transmitted to the person from other sources.
- Common sites for HAIs are: The urinary system. The respiratory system. Wounds. The bloodstream. HAIs are prevented by: Medical asepsis, including hand hygiene. Surgical asepsis. Standard Precautions. Transmission-Based Precautions. The Bloodborne Pathogen Standard
- Asepsis is being free of disease-producing microbes. Medical asepsis (clean technique) is used to: Remove or destroy pathogens. Prevent pathogens from spreading from one person or place to another person or place. Surgical asepsis (sterile technique) keeps items free of all microbes.
- Sterile means the absence of all microbes. Pathogens and non-pathogens. Sterilization is the process of destroying all microbes. Contamination is the process of becoming unclean. In medical asepsis, an item or area is clean when it is free of pathogens. A sterile item or area is contaminated when pathogens or non-pathogens are present. Aseptic practices break the chain of infection.
- Disinfection is the process of destroying pathogens. Spores are not destroyed. Chemical disinfectants are used to clean surfaces. Sterilizing destroys all non-pathogens and pathogens, including spores. Very high temperatures are used.
- Blood, body fluids, secretions, and excretions can transmit pathogens. Sometimes barriers are needed to keep pathogens within a certain area. The Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007 is followed. The guideline was issued by the Centers for Disease Control and Prevention (CDC). Isolation precautions prevent the spread of communicable diseases (contagious diseases).
- Isolation precautions are based on clean and dirty.Clean areas or objects are free of pathogens. Dirty areas or objects are contaminated with pathogens.Clean and dirty also depend on how the pathogen is spread. The CDC guideline has two tiers of precautions: Standard Precautions. Transmission-Based Precautions.
- Prevent the spread of infection from: Blood. All body fluids, secretions, and excretions (except sweat) even if blood is not visible. Non-intact skin (skin with open breaks).Mucous membranes.
- Protective measures. Isolation Precautions involve wearing personal protective equipment (PPE). Removing linens, trash, and equipment from the room may require double bagging. Follow agency procedures when collecting specimens and transporting persons.
- Surgical asepsis (sterile technique) is the practice that keeps equipment and supplies free of all microbes. Sterile means the absence of all microbes, including spores. Surgical asepsis (sterile technique) is required any time the skin or sterile tissues are entered. If a break occurs in sterile technique, microbes can enter the body. Infection is a risk.
- Principles of surgical asepsis. All items in contact with the person are kept sterile. A sterile field is needed. A sterile field is a work area free of all pathogens and non-pathogens (including spores). Sterile gloving. Before donning sterile gloves, the sterile field is set up. After sterile gloves are on, you can handle sterile items within the sterile field. Do not touch anything outside the sterile field.
Omnibus Budget Reconciliation Act (OBRA). Passed in 1987 by the U.S. Congress. Applies to all 50 states. Requires nursing centers to provide care in a manner and in a setting that maintains or improves each person’s quality of life, health, and safety. Resident rights are a major part of OBRA.
Right to Information
Access to all records about the person. Medical record. Contracts. Incident reports. Financial records. The person has the right to be fully informed of his or her health condition. The person must also have information about his or her doctor.
Taking Part in Resident Groups
The person has the right to form and take part in resident groups. They can:Discuss concerns and suggest center improvements. Support each other. Plan activities. Take part in educational activities.
Freedom From Restraint
Residents have the right not to have body movements restricted. Restraints. Drugs. Restraints may be used only if required to treat the person’s medical symptoms. Doctor’s order is needed.
The Older Americans Act (Ombudsman Program)
The Older Americans Act is a federal law. The law requires a long-term care ombudsman program in every state. Residents have the right to voice grievances and disputes. OBRA requires that nursing centers post the names, addresses, and phone numbers of local and state ombudsmen where residents can easily see them.
- Ethics is knowledge of what is right conduct and wrong conduct.Morals are involved. It deals with choices or judgments about what should or should not be done. Ethical behavior involves not being prejudiced or biased. Ethical problems involve making choices. Professional groups have codes of ethics.
- Boundaries Professional boundaries separate helpful behaviors from behaviors that are not helpful. The following can occur when you are over-involved or under-involved with the person. Boundary crossing—A brief act or behavior outside of the helpful zone. Boundary violation—An act or behavior that meets your needs, not the person’s needs. Professional sexual misconduct—An act, behavior, or comment that is sexual in nature.
- Boundary signs are acts, behaviors, or thoughts that warn of a boundary crossing or violation. Be alert to these signs. Some violations and some types of sexual misconduct also are crimes.
- Ethics - What you should or should not do. Laws - Tell you what you can and cannot do. A law is a rule of conduct made by a government body. Criminal—generally offenses against the public and society. Civil—concerned with relationships between people.
- Torts - A wrong committed against a person or the person’s property. Part of civil law. Unintentional—harm was not intended. Intentional—harm was intended. Unintentional tort. Negligence. Malpractice is negligence by a professional person. Intentional tort. Defamation—injuring a person’s name and reputation by making false statements. Libel—made in print. Slander—made orally. False imprisonment—unlawful restraint or restriction of a person’s freedom of movement. Invasion of privacy—private affairs exposed or made public without consent. Health Insurance Portability and Accountability Act of 1996 (HIPAA). Fraud—saying or doing something to trick, fool, or deceive a person. Assault and battery—may result in both civil and criminal charges
Elements of abuse: Willful infliction of injury. Unreasonable confinement. Intimidation. Punishment. Depriving the person (or the person’s caregiver) of the goods or services needed to attain or maintain well-being. Involuntary seclusion
Vital signs reflect the function of three body processes essential for life. Regulation of body temperature. Breathing. Heart function. The four vital signs of body function are: Temperature. Pulse. Respirations. Blood pressure. Some agencies consider “pain” to be a vital sign.
Measuring and Reporting Vital Signs
- A person’s vital signs vary within certain limits. Vital signs: Are measured to detect changes in normal body function. Tell about treatment response. Often signal life-threatening events. Are part of the assessment step in the nursing process.
- Vital signs are measured: During physical exams. When the person is admitted to a health care agency. As often as the person’s condition requires. Before and after surgery, complex procedures, and diagnostic tests. After some care measures, such as ambulation (walking). After a fall or other injury. When drugs affect the respiratory or circulatory system. When the person complains of pain, dizziness, light-headedness, feeling faint, shortness of breath, a rapid heart rate, or not feeling well. As stated on the care plan.
- Vital signs show even minor changes in the person’s condition. Accuracy is essential when you measure, record, and report vital signs. Take vital signs with the person at rest—lying or sitting, unless otherwise ordered. Report the following at once: Any vital sign that is changed from a prior measurement. Vital signs above the normal range. Vital signs below the normal range.
Body temperature is a balance between amount of heat produced and amount lost by the body. Thermometers measure temperature. Fahrenheit (F) and centigrade (C) scales are used. Temperature sites include: Mouth, rectum, axilla (underarm), tympanic membrane (ear), and temporal artery (forehead). Each site has a normal range. Always report temperatures that are above or below the normal range. Fever means an elevated body temperature.
- A pulse is felt every time the heart beats. The pulse is the beat of the heart felt at an artery as a wave of blood passes through the artery. Pulse sites: Temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis (pedal) pulses are on each side of the body. Radial pulse is used most often. Carotid pulse is taken during CPR and other emergencies. The apical pulse is felt over the heart. This pulse is taken with a stethoscope.
- The pulse rate is the number of heart beats or pulses felt in 1 minute. The rate varies for each age-group. The adult pulse rate is between 60 and 100 beats per minute. Report abnormal pulses to the nurse at once.Tachycardia is a heart rate of more than 100 beats per minute. Bradycardia is a heart rate of less than 60 beats per minute.
- Rhythm and force of the pulse. Pulse rhythm should be regular (felt in a pattern with the same interval between beats). An irregular pulse occurs when the beats are not evenly spaced or beats are skipped. Force relates to pulse strength. A forceful pulse is described as strong, full, or bounding. Hard-to-feel pulses are described as weak, thready, or feeble. Electronic blood pressure equipment can also count pulses. Some show if the pulse is regular or irregular. You need to feel the pulse to determine its force.
- Taking an apical-radial pulse. The apical and radial pulse rates should be the same. To see if the apical and radial pulses are equal, two staff members are needed. One takes the radial pulse. The other takes the apical pulse. Doing this at the same time is called the apical-radial pulse. The pulse deficit is the difference between the apical and radial pulse rates. To obtain the pulse deficit, subtract the radial rate from the apical rate.
- Checking pedal pulses. Pedal (dorsalis pedis) pulse is used to check circulation in the foot. Doppler ultrasound stethoscope (DUS) is used when the pedal pulse cannot be felt. Your role may include using a DUS. Make sure you: Have received the necessary training. Follow the nurse’s directions. Follow the manufacturer’s instructions.
- Respiration means breathing air into (inhalation) and out of (exhalation) the lungs. Oxygen enters the lungs during inhalation. Carbon dioxide leaves the lungs during exhalation. Each respiration involves one inhalation and one exhalation. The chest rises during inhalation. The chest falls during exhalation. The healthy adult has 12 to 20 respirations/min. Respirations are normally quiet, effortless, and regular.
- Count respirations when the person is at rest. Position the person so you can see the chest rise and fall. The person should not know that you are counting respirations. Count respirations right after taking a pulse. Keep your fingers or stethoscope over the pulse site. To count respirations, watch the chest rise and fall.
- Blood pressure (BP) is the amount of force exerted against the walls of an artery by the blood. Blood pressure is controlled by: The force of heart contractions. The amount of blood pumped with each heartbeat. How easily the blood flows through the blood vessels. Systole is the period of heart muscle contraction. Diastole is the period of heart muscle relaxation.
- Systolic pressure—the pressure in the arteries when the heart contracts. Diastolic pressure—the pressure in the arteries when the heart is at rest. Blood pressure is measured in millimeters (mm) of mercury (Hg). The systolic pressure is recorded over the diastolic pressure. Blood pressure has normal ranges. Systolic pressure—90 mm Hg or higher but lower than 120 mm Hg. Diastolic pressure—60 mm Hg or higher but lower than 80 mm Hg.