4. Invasion of the body by pathogenic organisms that multiply and produce injurious effects
5. Four types of microorganisms can enter the body & cause infection
6. Harmless Organisms Resident flora -E Coli (intestine) -Staph aureus (skin) Colonization -microorganisms become resident flora Intestinal flora help synthesize vitamin K
7. Harmful Actions of Microorganisms # of organism present Ability of organism to cause disease Person’s immune system Length of contact between person & organism
8. Climate for Infection Poor nutrition Stress Humidity Poor sanitation Crowded living conditions Pollution Dust Medications
34. What might you NOTICE (subjective & objective) if the patient has inadequate protection as a result of infection or infectious disease?
35. What should you ASSESS for a patient with inadequate protection as a result of infection or infectious disease?
36. How should you INTERVENE for a patient with inadequate protection as a result of infection or infectious disease?
37. What should you EVALUATE when a patient is being treated for an infection or infectious disease
38. 2 days post-op below-the-knee amputation Reports feeling hot and sweaty VS 100-98-30 156/88 What is your best action at this time
39. Adm from nursing home H/O Stroke MRSA urine Incontinent of urine & stool No private room available Semi private bed with older pt with fractured leg
40. Immune Response recognize foreign substances neutralize, eliminate, or metabolize them with or without injury to the body's own tissues.
48. Hypofunction: Inability of the immune system to perceive and respond to mutated cells, suspected mechanism in cancer
49.
50. Inflammatory Response: Cause Physical irritants (e.g., trauma or a foreign body) Chemical irritants (e.g., strong acids or alkalis) Microorganisms (e.g., bacteria and viruses)
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52. Inflammatory Response: Local Pain Swelling Heat Redness impaired function of part *five cardinal signs of inflammation
53. Inflammatory Response: Systemic appear with moderate to severe response Fever Leukocytosis Chills sweating Anorexia weight loss general malaise
55. Test Yourself A baby is born temporarily immune to the diseases to which the mother is immune. The nurse understands that this is an example of which type of immunity?
56. Test Yourself A mother brings her children into the clinic & they are diagnosed with chicken pox The mother had chicken pox as a child and is not concerned with contracting the disease when caring for her children What type of immunity does this mother have?
72. Visual disturbancesPresent illness Prescription drugs Over the counter drugs Herbal remedies Vitamins & nutritional supplements Alternative therapies
73. Nursing History Medical history Fever Changes in elimination h/o immune disorders Menstural patterns Family history Recurrent infections Allergies Cancer
89. Allergies Allergic disorders are the result of a hypersensitivity (excessive reaction to a stimulus) of the immune system to allergens (a type of antigen commonly found in the environment).
90.
91. Allergies A pt has allergic rhinitis. If the pt does not remain compliant with the treatment regime, the patient is at risk for developing an infection Such as Sinusitis
92. Anaphylaxis A systemic reaction to allergens and the most serious type of allergic reaction. Foods, drugs, hormones, insect bites, blood, and vaccines are all associated with anaphylactic reactions.
94. Anaphylactic Reaction A patient is being given PCN via IVPB. Develops an anaphylactic reaction What would you do first? What symptom may the pt be experiencing? What is the medication of choice for anaphylaxis?
95.
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97. Transplant Rejection Even with the use of immunosuppressive medications, 10% to 15% of transplanted organs fail.
98.
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100. Latex in our lives Assess for allergies to avocados, bananas, kiwi or chestnuts for cross sensitivity to latex
106. Based on this information what would you ask Mrs. Smith
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108.
109. Components of Immune Response Located throughout the body Organs include thymus, bone marrow, lymph nodes, spleen, tonsils, appendix, Peyer's patches of small intestine.
110. Components of Immune Response Main cell types are WBCs (especially lymphocytes, plasma cells, and macrophages) all originate from the same stem cell in bone marrow, then differentiate into separate types
111. Components of Immune Response Granulocytes Eosinophils: increase with allergies and parasites Basophils: contain histamine and increase with allergy and anaphylaxis Neutrophils: involved in phagocytosis
112. Components of Immune Response Monocytes (macrophages) (e.g., histiocytes, Kupffer cells): involved in phagocytosis Lymphocytes (T cells and B cells): involved in cellular and humoral immunity
113. Immune System Response Infection WBCs released from bone marrow into blood Bone marrow increases production of additional leukocytes
151. Systemic Lupus Erythematosus (SLE) A chronic, progressive, incurable autoimmune disease affecting multiple body organs. T cells attack the skin, kidneys, and other organs Characterized by periods of remission and exacerbation.
152. Rheumatoid Arthritis A chronic, systemic autoimmune disease characterized by joint stiffness T cells attack the linings of joints
If infections are not treated or adequately treated patient can develop:SepticemiaSeptic ShockDisseminated intravascular coagulation (DIC)POOR HAND HYGIENE APPLIES TO ALL
Handwashing and alcohol based hand rubs are two methods of hand hygieneCDC bans artificial figernails for healthcare professionaal when they are caring for patients at high risk for infection
