What are the body's non-specific defense mechanisms that protect against infection?
Intact Skin/Mucous membranes, Inflammatory Response
The process by which cell engulf microorganisms and cellular debris.
What is the Inflammatory Response?
A local and non-specifc defensive agent that occurs once the external barriers are compromised. It occurs the same way every time. It is an adaptive mechanism.
What are the three things that the Inflammatory Response does?
Destroys or dilutes the injurious agent, prevents further spread of the injury, promotes the repair of damaged tissues
What assessment findings indicate inflammation?
Pain, Swelling, Redness, Heat, Impaired function of the part if the injury is severe
What are the causes of Inflammation?
Physical Agents, Chemical Agents, Microorganisms
What is meant by physical agents as a cause for inflammation?
mechanical objects causing trauma to tissue, excessive heat or cold and radiation
What is meant by chemical agents as a cause for inflammation?
Includes internal irritants and external irritants
What is meant by microorganisms as a cause for inflammation?
Bacteria, viruses, fungi, and parasites
What are the three stages of inflammation?
Stage One: Vascular and Cellular Response, Stage Two: Exudate Production, Stage Three: Repair
Stage One: Vascular and Cellular Response
short period of vasoconstriction at the site of injury ---> rapid vasodilation ---> marked increase in blood supply (hyperemia) ---> REDNESS AND HEAT --> Increase in vascular permeability ---> Fluids, proteins, and leukocytes move into the interstitial spaces --> SWELLING & PAIN --> Leukocytosis
What observations would you find in an assessment with a person in stage on of the inflammatory response?
Redness and Heat due to vasodilation, Swelling and pain due to altered vascular permeability that causes an outpouring of fluid, proteins, and leukocytes into the interstitial spaces
What is vasoconstriction?
Constriction of blood vessels (smaller)
What is vasodilation?
Dilation of small blood vessels (bigger)
What is hyperemia?
A marked increase in blood supply
What are the concerns regarding inflammation (stage one)?
Too much fluid pouring into areas such as the pleural or pericardial cavity can seriously affect organ function
What is leukocytosis?
Blood flow slows in the dilated vessels. This altered rate of flow helps in moving more leukocytes to the injured tissues. In response to the exit of leukocytes from the blood vessels, the bone marrow produces large numbers of leukocytes and releases them into the blood stream called leukocytosis.
clear, watery plasma
consists of clear and blood tinged drainage that is commonly seen in surgical incisions
Large amounts of red blood cells, indicating damage to capillaries that is severe enough to allow escape of RBCs from plasma. Seen in open wounds
Stage Two: Exudate Production
Fluid, dead phagocytic cells, dead tissue cells --> "exudate"
Thicker than serous exudate because of the presence of pus, which consists of leukocytes, liquefied dead tissue debris, and dead and living bacteria varying in color including blue, green or yellow. Color depends on the causative organism.
Which type of exudate would you not wish to find in a clinical assessment?
Stage Three: Repair
Involved the repair of injured tissue by regeneration or replacement with fibrous tissue (scar) formation.
The replacement of destroyed tissue cells by cells that are identical or similar in structure and function
Young connective tissue with new capillaries formed during the wound healing process
What is the Immune Response?
Body's 3rd, slowest line of defense. Directed against identifiable bacteria, viruses, fungi, or other infectious agents.
What is Immunity?
The specific resistance of the body to infectious agents.
What initiates the immune response?
What are antigens?
foreign "things" to the body
What happens in response to the presence of antigens?
The body begins to produce antibodies
What do antibodies do?
Neutralize toxins and assist in destroying bacteria
What is Humoral Immunity?
Aquired Immunity. B lymphocytes. Mediated by the antibodies produced by B cells. Can be active/passive and natural/artifical
What are B Cells?
B cells are specific to one antigen. B cells produce antibodies to the antigen causing humoral immunity which protects the body against infection.
What is Active Immunity?
Antibodies are produced by the body in response to an antigen
What is Natural Active Immunity?
Lifelong. Antibodies are formed in the presence of active infection in the body.
What is Artificial ACtive Immunity?
Boosters must take place to reinforce immunity. Antibodies are administered to stimulate antibody production.
What is Passive Immunity?
Antibodies are produced by another source...animal or human.
What is Natural Passive Immunity?
Six Months- 1 year protection. Infant receives from mother.
What is Artificial Passive Immunity?
2-3 week protection. Immune serum (antibody) from an animal or other human in injected
What is another name from cell mediated defenses?
What type of cells are involved in cell mediated defenses (cellular immunity)?
What is Cell Mediated Defenses?
On exposure to an antigen, the lumph tissues release large numbers of activated T cells into the lymph system. When this immunity is lost, the individual is "defenseless" against most infections
What are the three main groups of T Cells?
Helper T Cells, Cytotoxic T cells, Suppressor T cells
What do Helper T Cells do?
Help in function of immune system
What do cytotoxic T cells do?
Attack and kill microorganisms and sometimes the body's own cells.
What do Suppressor T Cells Do?
Suppress the functions of the T cells and cytotoxic T Cells.
What do both T and B cells create?
Memory cells that remember an antigen and attack if the antigen invades again.
What are the body's non-specific defenses that protect against infection?
skin, mucous membranes, inflammation
What are the body's specific defenses that protect against infection?
What is an infection?
An invasion of body tissues by microorganisms and their growth there
What is the difference between inflammation and infection?
Inflammation is the local and nonspecific defensive tissue response to injurious or infectious agents; it is an adaptive mechanism that destroys or dilutes the injurious agent, prevents further spread of injury, and promotes the repair of damaged tissues. Infection is the invasion and growth of microorganisms on body tissues.
What are the factors that increase an individual's susceptibility to infection?
Age, Heredity, Stress, Nutrition, Medical Therapies or Diseases, and Medications
How does Age play a role in an individual's susceptibility to infection?
Newborns and older adults have reduced defenses against infection
How does Heredity play a role in an individual's susceptibility to infection?
Influences the development of infection in that some people have a genetic susceptibility to certain infections
How does Stress play a role in an individual's susceptibility to infection?
Elevates blood cortisone. Prolonged elevation of blood cortisone decreases anti-inflammatory responses, depletes energy sources, leads to state of exhaustion and decreases resistance to infection
How does Nutrition play a role in an individual's susceptibility to infection?
Resistance to infection depends on adequate nutrition
Which medications play a role in an individual's susceptibility to infection?
antineoplastic, antiinflammatory, antibiotics
Open wound involving the skin. Surface scrape, either unintentional, such as a scraped knee from a fall or intentional, such as dermal abrasion to remove pockmarks.
Closed wound - skin appears ecchymotic. Caused by a blow from a blunt instrument.
Open wound - deep or shallow Caused by sharp instrument such as knife or scalpel.
Open wound; edges are often jagged. Tissues torn apart, often from accidents, such as with machinery.
Open wound. Penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional
Define Infection, Risk For
At risk for being invaded by pathogenic organisms.
Risk factors for Infection, Risk For
invasive procedures, insufficient knowledge regarding avoidance of exposure to pathogens, trauma, tissue destruction and increased environmental exposure, rupture of emniotic membranes, pharmaceutical agents, malnutrition, increased environmental exposure to pathogens, immunosuppression, inadequate acquired immunity, inadequate secondary defenses, inadequate primary defenses, chronic disease
Serum White Blood Cell Count Normal Adult
5,000-9,000 cubic millimeters
Increased Serum White Blood Cell Count
Sign of Leukocytosis & Infection. Over 9,000 cubic millimeters.
Decreased Serum White Blood Cell Count
Sign of Autoimmune Disease, Leukopenia. Below 5,000 cubic millimeters.
A reduction in the number of white blood cells in the blood, typical of various diseases.
What does the differential count consist of?
neutrophils, lymphocytes, monocytes, eosinophils, and basophils
What are Neutrophils?
The largest group, first line of defense against invading organisms. Quickly die and form exudate or pus in inflammatory response
What is the lifespan of Neutrophils?
Normal Neutrophil Findings For Adult
Increased Neutrophil Finding
Sign of Stress and/or Acute Infection
Decreased Neutrophil Finding
Sign of Viral Disease and/or Radiation Therapy
What are Lymphocytes?
Differentiate invading cells from normal cells, travel to injured site and initiate immune response
Normal Lymphocyte Findings For Adults
Increased Lymphocyte Finding
Sign of: chronic bacterial infection, mononucleosis, tuberculosis, viral infection, lymphocytic leukemia
Decreased Lymphocyte Finding
Sign of: immune suppressive medications, autoimmune diseases, severe malnutrition
What are Monocytes?
Ingest dead or defective cells, migration out of the bone marrow in response to infection or inflammation, primary cells involved in beginning stages of inflammation, initiate process that allows T cells and B cells to recognize antigens (foreign agents)
Normal Monocyte Findings For Adults
Increased Monocyte Findings
Sign of: chronic inflammatory disorders, tuberculosis, chronic ulcerative colitis, protozoan infections
Decreased Monocyte Findings
Sign of: Medication Therapy (prednisone)
What are Eosinophils?
Travel to injured site that are a result of an allergic reaction
Normal Eosinophil Findings Adult
Increased Eosinophil Findings
Sign of: Parasitic infections, Allergic infections, Leukemia
Decreased Eosinophil Findings
Sign of Corticosteroid therapy
What are Basophils?
Aid in inflammatory process by producing histamine
Normal Basophil Findings Adult
Increased Basophil Findings
Decreased Basophil Findings
Sign of: Acute allergic reaction, acute infections, corticosteroids
Where are cultures obtained from?
Why are cultures obtained from body fluids?
To isolate the source of unknown fevers and to identify the microorganism causing signs of clinical infection
Which body fluids are culture specimens obtained from?
blood, sputum, stool, throat, wound exudates, urine, spinal, joint, pleural or other body cavity fluids
What is a benefit of obtaining good culture specimens?
sensitivity testing of microorganisms
What is sensitivity testing?
After microorganisms are grown in culture media, various concentrations of antibiotics are used to test their ability to inhibit growth or kill the organism. The laboratory reports the names of the organisms present and whether they are sensitive or resistant to specific antibiotics.
Where are blood cultures obtained from?
Two separate venipuncture sites.
When is the ideal blood specimen drawn?
Just before or during the rise in temperature
What equipment do you need to obtain a blood specimen?
a set of culture bottles, a sterile syringe, two sterile needles, skin preparation equipment and a tourniquet.
Now Let Me Evaluate Blood
N: Neutrophils quickly die and form exudate L: Leukocytes initiate immune response M: Monocytes are the primary cells at the start of inflammation E: Eosinophils go to the injury site as a result of an allergic reaction B: Basophils aid inflammatory response by releasing histamine
Why would a sputum culture be obtained?
When a client has a fever and productive cough.
When should a sputum culture be obtained?
In the morning before the client eats because it should not contain saliva because it contaminates the specimen.
Why is blood not drawn from previously inserted lines?
Because indwelling catheters may be contaminated with surgace pathogens.
Why is the blood culture specimen drawn just before or during a rise in temperature?
Because the pathogens are usually circulating in high concentration at that time
How do you obtain a throat culture?
With a sterile cotton swab that is touched to the back of the throat as the client says ahhh
Why is it important to perform a throat culture procedure quickly?
it may trigger the gag reflex
What is important to due after obtaining a throat culture?
Maintain sterility, place the swab into a culture medium and transport to the lab.
What is the purpose of obtaining a urine culture?
To determine the presence of microorganims and the antibiotics to which the organisms are sensitive.
What are the purposes for obtaining a wound culture?
To identify the microorganisms potentially causing an infection and the antibiotics to which they are sensitive and to evaluate the effectiveness of antibiotic therapy
What is the first thing you must do when preparing to obtain a wound culture?
Assess the appearance of the wound and surrounding tissue. Check the character and amount of wound drainage.
What is the second thing you should do when preparing to obtain a wound culture?
Assess client complaints of pain or discomfort at the wound site
What is the third thing you should do when preparing to obtain a wound culture?
Assess signs of infection such as fever, chills, or elevated white blood cell count
Why must you assess the wound, client symptoms, and signs before obtaining a wound culture?
To gather data regarding the progression of wound healing and note any signs or symptoms of infection, to be documented and reported to primary care provider.
Where should you take a sample for a wound culture?
areas of granulation tissue because the microorganisms most responsible for the wound infection reside in viable tissue.
What must you determine before obtaining a specimen for a wound culture?
If the wound should be cleaned prior to obtaining specimen, whether the site from which to take the specimen has been specified
What should you not use when obtaining a specimen for a wound culture?
Pooled exudate or pus. These secretions contain a mixture of contaminants that are not the same bacteria as those causing the infection.
What equipment do you need to gather in preparing to take a specimen for a wound culture?
PPE, googles, gown, clean gloves, sterile gloves, moisture proof bag, sterile dressing set, normal saline and irrigating syringe, culture tube with swab and culture, medium and/or sterile syringe with needle for anaerobic cultures, completed labels for culture containers, completed requisition to accompany the specimens to the laboratory
Where are aerobic organisms found?
surface of the wound
Where are anaerobic organisms found?
deep in wounds, tunnels, or cavities
Why must you check the medical orders before obtaining a specimen for wound culture?
cultures need to be ordered by the PCP and a lab requisition needs to be signed by the PCP to accompany the culture to the lab
What should you administer for pain 30 minutes before a wound culture procedure?
analgesic PRN for pain during treatment
Where should you discard the old dressing after removing it in a wound culture specimen collection procedure?
In a moisture-proof bag, making sure it does not touch the outside of the bag
When should you don sterile gloves in a wound culture specimen collection procedure?
After you have opened your sterile dressing set using sterile technique and assessed the wound
What should you assess before donning sterile gloves in preparing for obtaining a specimen for wound culture?
swelling, opening at the edges, inflammation, bleeding, and drainage. Palpate along the wound edges noting any tenderness or drainage.
What solution should you use when cleaning the wound for obtaining a specimen for a wound culture?
normal saline because the use of antiseptic solution may destroy the organisms present and result in a false negative culture report
Where should you avoid touching when swabbing for a wound culture?
intact skin at wound edges
When should the specimen for a wound culture be delivered to the lab?
Within 15 minutes
What is the best way to decrease the inflammatory response?
The prevention of infection, trauma, surgery, and contact with potentially harmful agents.
What two vitamins are important for healing?
Vitamin A & C
Why are vital signs important to note with inflammation?
When an infectious process is present, T, P, & R may increase.
Why is it important to elevate an injured site?
It will reduce edema at the inflammatory site and increase venous return. Elevation helps reduce pain and improve circulation of blood which provides the oxygen and nutrients needed for healing
Why is it important to teach a client with inflammation about stress reduction techniques?
Excessive stress predisposes individuals to infections
Why is it important to monitor and document fluid intake and output every shift for those with inflammation?
Fluid intake permits fluid output that flushes out the bladder and urethra, removing microorganisms that could cause an infection.
Why is it important to assess and educate a client on the importance of rest and sleep that has inflammation?
Essential to health and renewing energy. Rest and immobilization of the inflamed area promote healing by decreasing the inflammatory process, assisting in the repair process and decreasing metabolic needs
Why is it important to assess the client's past immunizations on admission and follow recommended immunization schedule throughout the life span and obtain PCP orders to administer required immunizations with clients with inflammation?
Immunizations have dramatically decreased the incidence of infectious diseases
Why is it important to maintain supple, moist skin in those with inflammation?
Dry skin can lead to inflammation, excoriations and possible infection.
What are antibiotics?
an antimicrobial agent derived from cultures of a microorganism or produced semi synthetically, used to treat infections
What are antimicrobials?
An agent that kills or inhibits the growth or replication of microorganisms
Ampicillin TRADE NAME
Polycillin or Omnipen
Polycillin GENERIC NAME
Omnipen GENERIC NAME
What is the action of Ampicillin?
Interferes with cell wall replication of susceptible organisms. The cell wall, rendered osmotically unstable, swells and bursts from osmotic pressure.
What are the Side/Adverse effects of Amipicillin
Coma, Seizures, N, V, D, Glomerulonephritis, Bone marrow depression, Granulocytopenia, Pseudo membranous colitis, Anaphylaxis, Vaginitis, Rash
What are the nursing implications for po administration of AMPICILLIN?
administer on empty stomach for best absorption 1-2 hours before meals or 2-3 hours after meals, store in dry, tight, container, oral suspension refrigerated for two weeks or one week at room temp, tablets can be crushed, capsules may be opened and mixed with water
For best absorption, how long before meals should AMPICILLIN be administered?
For best absorption, how long after meals should AMPICILLIN be administered?
Penicillin V TRADE NAME
Pen-Vee-K GENERIC NAME
PENICILLIN V Use
resp. infection, scarlet fever, otitis media, pneumonia, skin and soft tissue infections, gonorrhea, gram + cocci, gram - cocci, gram + bacilli, gram - bacilli
gram + and - cocci, gram + and - bacilli
PENICILLIN V Action
Interferes with cell wall replication of susceptible organisms. The cell wall, rendered osmotically unstable, swells and bursts from osmotic pressure.
PENICILLIN V Side/Adverse effects
Coma, Seizures, N, V, D, Glomerulonephritis, Bone marrow depression, Granulocytopenia, Anaphylaxis, Vaginitis, Oliguria, Proteinuria, Hematuria
What are the nursing implications for administering PENICILLIN V po?
administer on empty stomach for best absorption, storage in dry, tight container, oral suspension refrigerated for two weeks
What are the nursing responsibilities when caring for clients receiving antibiotics?
Assess for infection, I&O, assess renal function, blood studies, erythema, culture and sensitivity before med started, assess for superinfection, educate client to use medication as prescribed
How do you assess for infection?
Temperature, characteristics of sputum, wounds, urine, stools, before, during, and after every treatment
What should you report about I&O if you suspect infection?
Any hematuria or oliguria
Why are renal studies important in patients on antibiotics?
Most antibiotics are excreted slowly in poor renal function and toxicity may occur rapidly.
What blood studies should be preformed in a person receiving antibiotics?
WBC, RBC, Hct, Hgb, bleeding time
What renal studies should be preformed for a patient receiving antibiotics?
urinalysis, protein, blood
What is erythema?
A redness associated with skin rashes
When should you assess for erythema in a patient who is receiving antibiotics?
After administration of antibiotics to one weeks after discontinuing medication
What is a superinfection?
An infection occurring during antimicrobial treatment for another infection.
What factors contribute to a development of bacterial resistance to antibiotics?
over prescription of antibiotics, Use of inappropriate antibiotics for the infecting organism, Incomplete use of antibiotic prescriptions as symptoms subside, Harboring and spreading of resistant organisms by carrier who remain symptom free and unaware that they have been inflected, increased use of antibiotics in farming contaminating milk and meat
What is a resistant strain?
The ability of a microorganism to remain unaffected by an antimicrobial agent.
Four strategies in the CDC 12 Step Campaign to Prevent Antimicrobial Resistance in Healthcare Settings
Prevent Infection, Diagnose and treat infection effectively, Use antimicrobials wisely, Prevent Transmission
What is Hemostasis?
Considered part of the inflammatory phase in which the body responds by initiating a complex process to stop bleeding.
What are the phases of wound healing?
Inflammatory, Proliferation, Maturation
What does vasoconstriction do in the inflammatory phase?
Helps slow blood to any ruptured vessels, platelet aggregation, activation of the coagulation cascade and the formation of fibrinous clot to stop bleeding
What is the inflammatory process usually called in terms of phases of wound healing?
How long does the defensive phase (inflammation) usually last?
What is the main function of the defensive phase (inflammation)?
Removes bacteria and cellular debris from the wound
What do neutrophils do?
What do Macrophages do?
Destroy any remaining bacteria and clean the wound of cellular debris
Initial vasoconstriction quickly turns into what early on in the inflammatory phase?
vasodilation to facilitate an increased blood flow and release chemoattractants which include WBCs
When does proliferation take place?
3-4 days after injury
What is proliferation?
True beginning of healing
has a beefy, shiny, granular appearance and contracts to help pull the sides of the wound together
What is done during the proliferation phase in terms of granulation tissue?
Angiogenesis granulation tissue is formed to help close the defect. Within and beneath the granulation tissue, the injured blood vessels are reformed to bridge the wound
What is done in terms of collagen during the proliferation phase?
collagen is generated by fibroblasts within this tissue to give it tensile strength and structure and protein elastin to provide elasticity
What is the nurse's role during the proliferation phase?
Must assess for adequate nutritional and hydration intake, administer multivitamins, vitamin C and zinc
What must happen if wound is to heal without a scar?
Epithelial cells eventually meet to close the wound without a scar
When does the maturation phase take place?
4-24 days depending on the initial severity
What is the purpose of maturation?
To restore strength to damaged tissue by reorganizing the collagen fibers into larger bundles and a stronger mesh beneath the scar
What is the problem about scar tissue?
It only regains 80% of the tensile strength of undamaged tissue and will always be at risk for reinjury
How long does maturation last?
can occur anywhere for a few weeks up to two years
What are the three types of wound healing?
Primary intention, secondary intention, and tertiary intention
What is Primary Intention?
clean cut edges, approximated by sutures, surgical staples or other means, acute wounds secondary to surgical procedures or trauma, lower risk of infection
When does a primary intention wound heal?
What is Secondary Intention?
significant tissue loss, edges can not be brought together, healing takes place more slowly, greater risk of infection, fills with granulation tissue and epithelialization gradually takes place from the wound margins, chronic wounds caused by underlying pathologies such as diabetes and pressure ulcers
What is Tertiary Intention?
combination of primary and secondary, Surgical wound intentionally left open for several days to allow infection or edema to resolve or to drain exudates from the wound, assessed and managed as an open wound healing by secondary intention, once edema has resolved and bacteria has decreased, wound can be closed or covered with a skin graft, more rapid healing with less risk of infection
Red Wound Description
Late regeneration phase. Granulation Tissue Present
Red Wound Goal
Red Wound Interventions
cleanse gently, avoid use of dry dressing, apply a topical antimicrobial, apply a transparent or hydrocolloid dressing, change the dressing infrequently
Yellow Wound Description
Liquid to semiliquid slough often present with purulent drainage
Yellow Wound Goal
Yellow Wound Interventions
Irrigate the wound, apply wet to dry dressings, Use absorbent materials, Consult with MD about topical antimicrobial
Black Wound Description
Covered with a thick necrotic tissue or eschar
Black Wound Goal
Black Wound Interventions
Perform sharp, mechanical, chemical, or autolytic debridement, Hydrotherapy may be used
What is hydrotherapy?
Continuous tub baths, wet sheet packs or shower sprays
What are the purposes of Wound Irrigation?
Clean the area, apply heat and hasten the healing process, apply an antimicrobial solution
Hydrogen Peroxide (H2O2)
softens and removes exudate and debris
Normal Saline (0.9% NaCl or 0.9% NS or Sodium Chloride)
Irrigation of clean or noninfected wounds, safest and most appropriate solution for open wounds
Broad spectrum effectiveness against bacteria, spores, fungi, viruses when used on intact skin or small clean wounds
Lactated Ringer's (LR)
Irrigation of clean or noninfected wounds
Cleansing of clean or noninfected wounds
What are factors that inhibit wound healing in older adults?
Vascular changes, Collagen tissue is less flexible, Scar tissue is less flexible, Changes in immune system result in a decreased delivery of oxygen, Nutritional deficiencies, Diabetes or cardiovascular disease, Cell renewal is slower
Who heals the fastest?
Healthy children and adults
What are the nutrients most essential for wound healing?
Protein, Carbohydrates, Lipids, Vitamin A, Vitamin C, Iron, Zinc, Copper
Why is exercise important for wound healing?
Good circulation and because blood brings oxygen and nourishment to the wound, more likely to heal quickly
Why is smoking negative for wound healing?
Smoking reduces the amount of functional hemoglobin and limiting oxygen carrying capacity of blood and constricts arteries
What are medications that affect wound healing?
Anti-inflammatory, Anti-neoplastic, Anti-biotics (prolonged use susceptible to wound infection by resistant organisms
What is the significance of the diagnostic test used to monitor blood coagulation?
Platelets move out of capillary to seal the wounded area. It is the clotting factor
Platelet Count Normal Adult
Increased Platelet Count Finding
Malignant disorder, Polycythemia
Decreased Platelet Count Finding
Chemotherapy, Thrombocytopenic purpura, Viral Infections, AIDS, Lupus
What is Stress?
A condition in which the human being responds to changes in its normal balanced state. All people experience. A nonspecific demand requires an individual to respond or take action.
What is a Stressor?
Any event or stimulus that causes an individual to experience stress. Internal, external, developmental, or situational
Physical Manifestation of Stress
Can threaten a person's homeostasis. Activation of sympathetic nervous system and neuroendocrine system.
Verbal Manifestation of Stress
Voice changes, Voice tremors, Increased questioning, Communication may be difficult to understand
Motor Manifestation of Stress
restlessness, temors, inability to relax, sleeplessness, poor motor coordination
What is a NUR DX that comes to mind when thinking of the motor manifestations of stress?
Risk for Falls
Psychological/Emotional Manifestations of Stress
Anxiety, Fear, Anger, Depression
Cognitive/Intellectual Manifestations of Stress
Thinking responses that include problem-solving, Structuring, Self-control/self-discipline, Suppression, Fantasy
Social Manifestations of Stress
May alter a person's relationships with others
Spiritual Manifestations of Stress
Can challenge one's beliefs and values
What is Anxiety?
A state of mental uneasiness, a persistent feeling of dread, apprehension, or foreboding. It is a feeling of helplessness related to an impending or anticipated unidentified threat to self or significant relationships. A common reaction to stress.
Four points about Anxiety
The source of anxiety is usually unidentifiable, Anxiety is typically related to an anticipated event, Anxiety is vague, Anxiety results from a psychological or emotional conflict
What is Fear?
An emotion or feeling of apprehension aroused by impending or seeming danger, pain or another perceived threat. The object of fear may or may not be based in reality
Four points about Fear
The source of fear is identifiable, Fear can be past/present/future based, Fear is specific or definite, Fear results from a specific physical or psychological event/object/or phenomenon
What are the four levels of anxiety?
mild, moderate, severe, panic
Produces a slight arousal state that enhances perception, learning, and productive abilities. There is a slight increase in perceptual field and increased alertness. Ability to relate thoughts and ideas coherently is maintained. Most health people experience mild anxiety that prompts a person to seek information and ask questions
Increases the arousal state to a point where the person expresses feelings of tension, nervousness, or concern. Perceptual abilities are narrowed. Attention is focused more on a particular aspect of a situation with blocking of peripheral stimuli to a small extent. Some decrease in seeing, hearing, comprehending, but it is possible to focus attention when directed to.
Perceptual field is greatly reduced - only able to focus on a few details. Inability to think clearly, very specific and concrete directions are needed for the person to function. Behaviors are aimed at relief of anxiety-laden situation. The person, unable to focus on what is really happening, focuses on only 1 specific detail of the situation generating the anxiety. At this level the anxiety consumes most of the person's energy and intervention is required
An overpowering, frightening level of anxiety causing the person to lose control. There is severe incapacitation and poor judgement. The person can not think clearly or do things even when directed. Contact with reality is unstable, and perceptions can be altered to the point where the person distorts events. Immediate escape from the situation is sought. This level of anxiety is less frequently experienced than other levels of anxiety.
Selye's definition of Stress
The nonspecific response of the body to any kind of demand made on it
What does Selye call the nonspecific response?
General Adaption Syndrome
Describe the General Adaption Syndrome
Non-specific stress occurs --> Sympathetic Nervous System --> Hypothalamus --> Increase in CRH --> Anterior Pituitary ---> Increase in ACTH --> Adrenal Cortex OR Adrenal Medulla --> If Adrenal Cortex ---> Mineralocorticoid OR Glucocorticoids IF Adrenal Medulla --> Epinephrine OR Norepinephrine
Proinflammatory. Na+ retention protein anabolism
Anti-inflammatory. Protein catabolism. Gluconeogenesis
Peripheral Vasoconstriction. Decreases blood to kidney --> increase in renin = increase in BP
Increase myocardial contractility/output, increase in bronchial dilation/increase in oxygen, increase blood clotting, increase in metabolism and energy
What are the three stages of Selye's General Adaption Syndrome?
Alarm Reaction, Stage of Resistance, and Stage of Exhaustion
What two phases are included in the Alarm Reaction stage of Selye's General Adaption Syndrome?
Shock phase and Countershock Phase
The body's initial reaction to the stressor which alerts the body's defenses.
The stressor is perceived either consciously or unconsciously --> activation of the sympathetic nervous system which releases large amounts of epinephrine, norepinephrine and cortisone into the body --> ready for flight or flight. This response is short lived 1 minute-24 hours
During this time the changes produced in the body during the shock phase are resolved
Stage of Resistance
This is when the body's adaption occurs - the body attempts to cope with a stressor and to limit the stressor to the smallest area of the body that can deal with it. (manifestations of stress come out at this stage live hives, depression, hypertension, migraines, acne)
Stage of Exhaustion
The adaption that the body made at the second stage can not be maintained. The effects of the stress may spread to the rest of the body if the stressor has not been obliterated. At the end of this stage the body either returns to normal and rests, or death may be the ultimate end result.
Refusing to allow into awareness some aspect of reality that is somehow distressing. It allows the person to overcome weaknesses and achieve success.
Returning to earlier modes of behavior and previous interests. Allows person to return to a point in development when nurturing and dependency were needed and accepted with comfort.
Helps a person to cope with the inability to meet goals or certain standards
Effect of stress on Physiologic
altered elimination pattern, change in appetite, altered sleep pattern
Effect of stress on Safety and Security
expresses nervousness and feelings of being threatened, focuses on stressors and inattention to safety measures
Effect of stress on Love and Belonging
isolated and withdrawn, becomes overly dependent, blames others for own problems
Effects of stress on Self-Esteem
fails to socialize with others, becomes a workaholic, draws attention to self
Effects of stress on Self-Actualization
preoccupied with own problems, shows lack of control, unable to accept reality
Ways to minimize anxiety and stress
regular exercise, optimal nutrition, adequate rest and sleep, effective time management, minimize anxiety as able, mediate anger, teach/use relaxation techniques, crisis intervention
Therapeutic Nursing Interventions to Minimize Stress and Anxiety
determine situations that precipitate anxiety and identify signs of anxiety, verbalize feelings, perceptions and fears as appropriate, identify personal strengths, recognize usual coping patterns and differentiate positive from negative coping mechanisms, identify new strategies for managing stress, identify available support systems
What are things an RN needs to do in order to minimize stress and anxiety
listen attentively and try to understand the client's perspective on the situation. Provide an atmosphere of warmth and trust; convey a sense of caring and empathy. Provide factual information as needed to prepare clients for tests, treatments, and so on. Use short, clear sentences. Encourage clients to participate in the plan of care; give them choices about appropriate aspects of care. Stay with clients as needed to promote safety and feelings of security and to reduce fear. Decrease stimuli.
What can you teach clients about minimizing stress and anxiety?
The importance of exercise, a balanced diet, and rest and sleep. Support groups. Educational programs available such as time management, assertiveness training, and meditation groups.
Iorazepam TRADE NAME
Ativan GENERIC NAME
Anxiety, irritability in psychiatric or organic disorders, preoperatively, insomnia, adjunct in endoscopic procedures
Potentiates the actions of GABA, especially in system and reticular formation
Iorazepam Adverse Effects
Drowsiness. Can lead to tolerance and dependency issues.
Iorazepam Nursing Considerations
Do not drive or operate machinery while taking this medicine.
A vague, uneasy feeling of discomfort or dread accompanied by an autonomic response, (the source often nonspecific or unknown to the individual), a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with the threat.
Defining Characteristics Fear
report of alarm, apprehension, being scared, increased tension, decreased self-assurance, dread, excitement, jitteriness, panic, terror, diminished productivity, learning ability, problem solving, identifies object of fear, stimulus believed to be a threat, attack or avoidance behaviors, impulsiveness, increased alertness, narrowed focus on the source of the fear, anorexia, diarrhea, dry mouth, dyspnea, fatigue, increase in perspiration, pulse, RR, systolic BP, muscle tightness, N, V, pallor, pupil dilation
Defining Characteristics Anxiety
Diminished productivity, Expressed concerns due to change in life events, Extraneous movement, Fidgeting, Glancing About, Insomnia, Poor eye contact, restlessness, Scanning, Vigilance, Apprehensive, Anguish, Distressed, Fearful, Feelings of inadequacy, Focus on Self, Increased Irritability, Jittery, Overexcited, Painful increased helplessness, Persistent increased helplessness, Rattled, Regretful, Uncertainty, Worried, Facial tension, Hand Tremors, Increased Perspiration, Increased Tension, Shakiness, Trembling, Voice Quivering, Anorexia, Cardiovascular excitation, D, Dry mouth, Facial Flushing, Heart pounding, Increased BP, Increased P, Increased reflexes, Increased R, Pupil Dilation, Respiratory Difficulties, Superficial vasoconstriction, Twitching, Weakness, Abdominal pain, Decreased BP, Decreased P, Faintness, Fatigue, N, Sleep Disturbance, Tingling in extremities, Urinary Frequency, Urinary Hesitancy, Urinary Urgency, Awareness of physiologic symptoms, Blocking of thought, Confusion, Decreased perceptual field, Difficulty concentrating, Diminished ability to problem solve, Fear of unspecified consequences, Forgetfulness, Impaired Attention, Preoccupation, Rumination, Tendency to blame others
Related To Factors Anxiety
Change in: economic status, environment, health status, interaction patterns, role function, role status, exposure to toxins, familial association, heredity, interpersonal contagion, interpersonal transmission, maturational crises, situational crises, stress, substance abuse, threat of death, threat to: economical status, environment, health status, interaction patterns, role function, role status, self concept, unconscious conflict about essential goals of life, unconscious conflict about essential values, unmet needs
Definition of Fear
Response to perceived threat that is consciously recognized as danger
Related To Factors Fear
innate origin (sudden noise, height, pain, loss of physical support), innate releasers (neurotransmitters), language barrier, learned response (conditioning, modeling from or identification with others, phobic stimulus, sensory impairment, separation from support system in potentially stressful situation (hospitalization, hospital procedures), unfamiliarity with environmental experience
Answers the question "What brings you here today?"
History of Present Illness
Includes aggravating and alleviating factors
Includes childhood illnesses and prior operations
List of prescription and non-prescription medications the client is currently taking
Reveals risk factor for hereditary disorders
includes work, sleep, exercise, diet, caffeine, alcohol, ADLs
Includes role of family, friends, significant others, education religion, occupation, economic factors
Review of Systems
Focuses on subjective data regarding health according to body system
Includes major stressors, usual coping patterns, communication style
The loss of underlying red tones
A bluish or ashen gray discoloration
A yellowish tinge
An abnormal redness on the skin and may appear as a bluish, purplish, or darkened discoloration in individuals with dark skin tones
Pallor in people with light skin may be evident in which body parts?
Face, conjunctiva of the eyes, and nail beds
What does pallor look like in people with dark skin?
Ashen gray or yellow
Cyanosis can be detected in dark skin how?
conjunctiva of the eyes and palms and soles
How will erythema look in a dark skin patient?
bluish, purplish, or darkened discoloration
Name all pulse sites
temporal, carotid, apical, brachial, dorsalis pedis, radial, femoral, popliteal, posterior tibial
How do you assess apical pulse?
With a stethoscope
What does a weak or thready peripheral pulse (1+) indicate?
Possible peripheral artery disease or decreased cardiac output. This would warrant notification of the PCP so further testing could be performed
What is the significance of compression of arteries?
Can cause decreased blood supply to the area, resulting in decreased or absent palpable pulses, pale, cool skin and sluggish capillary refill. It can also cause decreased circulation to muscles and nerves resulting in severe pain and lack of nerve and muscle function.
What is the significance of compression of veins?
Can cause obstruction to blood flowing from the area, resulting in cyanosis and edema. This edema can contribute to further worsening of circulation.
Transfer of heat from one molecule to another molecule of lower temperature
Dispersion of heat by air currents
Transfer of heat from the surface of one object to the surface or another without contact between the two objects
What is the significance of compression of efferent nerves?
Can cause decrease or absent messages to muscles. This would be manifested by decrease or absent motion
What is the significance of compression of afferent nerves?
Can cause decrease or absent sensation or + paresthesias. This would be manifested by lack of withdrawal from painful stimuli.
How do you prevent permanent damage to veins, arteries, and nerves?
monitor the status of CMS.
What is CMS?
circulation, motion, and sensation of extremity
What are the signs of impairment of an extremity?
edema, changes in color, complaints of abnormal sensation, decrease in sensation, decrease in strength or motion, complaints of increasing pain, changes in temperature of extremity, changes in your assessment of peripheral pulses
What is parethesia
An abnormal sensation. "Pins and needles"
What is another way to say CMS?
When is it important for the RN to assess CMS status?
anytime there is a reason to suspect the client's neurovascular status might be compromised, if it is ordered, after surgery of an extremity, application of a cast or splint, application of a compressive wrrap or tourniquet, placement of a catheter in an artery or vein
What should you do if there is a change in baseline of the client's neurovascular status
Report promptly to client's PCP
How long should ice bags be left in place?
When should heat be immediately discontinued?
With evidence of any redness which could lead to development of a burn, or complaints of pain/discomfort
What is the rebound phenomenon?
Rebound phenomenon occurs at the time maximum therapeutic effect of the heat/cold application is achieved and the opposite effect begins.
When does heat produce maximum vasodilation?
When does cold produce maximum vasoconstriction?
When involved skin reaches a temperature of 15 C or 60 F
What is critical content to be reported and documented about the application of heat and cold?
method of application, area of application, duration of treatment, client response
Client assessments to be made during application of heat
assess for edema/worsening of existing edema, assess for decrease in BP --> fainting --> falls
Client assessments to be made during the application of cold
assess for signs and symptoms of impaired circulation --> tissue death. mottled or bluish skin color, numbness, blisters, pain. Assess for increase in BP
Before initiating heat or cold application, what must the nurse assess?
condition of the equipment to be used, body part involved (some body parts are more sensitive than others), damage to body surface (open tissue or abraded skin is more sensitive to temperature variations), body surface area (an individual is less tolerant of temp changes over a large area of the body), age (infants, children, elderly more sensitive), physical condition
What are the therapeutic benefits of heat?
increase blood flow to injured body part, increase delivery oxygen and nutrients, decrease venous congestion in injured areas, increase movement of waste products and fluids away from the injured areas, increase blood flow, increase warmth, increase phagocytosis, promotes soft tissue healing, soothing and relaxing
What are the therapeutic benefits of cold?
decrease flood flow to limit swelling and bleeding, decrease movement of wastes from the injured areas, decrease in oxygen needs of the tissues, decreases bacterial growth, decreases phagocytosis, decreases nerve impulses to the brain (numbing), decreases pain
Carry blood away from the heart
at bend of elbow, medial to the biceps tendon and muscle
on the flexor surface of the wrist, laterally
on the flexor surface of the wrist, medially
on the dorsum of the foot
behind the medial malleolus of the ankle
Carry blood back to the heart
Deep Leg Veins - Femoral
just medial to the femoral artery below the inguinal ligaments
Superficial Leg Veins - Great saphenous
runs from the dorsum of the foot to the groin
Superficial Leg Veins - Small/Lesser saphenous vein
from the dorsum of the foot to the back of the knee
What are deep and superficial veins connected by?
Examine arms for...
edema, discoloration, rashes, scars, changes in skin texture, hair distribution, venous patterns, temperature, arterial pulse, amplitude scale, radial pulse symmetry, ulnar pulse, brachial pulse
Examine legs for....
symmetry of size, shape, color, swelling, discoloration, rashes, scars, ulcers, abnormal venous patterns, color and texture of skin and nail beds and distribution of hair of feet and toes
Palpate legs for...
temperature of feet and lower legs with backs of your fingers, palpate femoral pulse (fingers midway between anterior superior iliac spine and symphysis pubic, pressing deeply below inguinal ligament), tenderness of femoral vein (just medial to femoral pulse), popiteal pulse (flex knee, press fingertips into popliteal fossa slightly lateral to the midline), dorsalis pedis pulse (over dorsum of foot just lateral to extensor tendon of big toe. this pulse may be congenitally absent.), posterior tibialis (curve fingers behind and slightly below medial malleolus of ankle), edema, calf muscles (compress against tibia, checking for tenderness, increased firmness or tension)
An increase in the blood plasma. Increase hct and hgb can indicate this
When are high WBC counts seen?
When are low WBC counts seen?
What is hemostasis?
The cessation of bleeding resulting from vasoconstriction of the larger blood vessels in the affected area, retraction of injured blood vessels, the deposition of fibrin (connective tissue), and the formation of blood clots in the area
Which phase of wound healing does hemostasis take place?
What happens when a wound does not experience epithelialization?
Eschar (area becomes covered c dried plasma proteins and dead cells)
What do fibroblasts synthesize?
What do you assess c untreated wounds?
bleeding, infection, swelling, pain, shock
In untreated wounds, how do you control bleeding?
apply direct pressure and elevate
In untreated wounds, how do you prevent infection?
Flush with normal saline, cover wound c clear dressing, wrap to approximate wound edges
In untreated wounds, how do you control swelling and pain?
What are the signs of shock?
Low BP, pallor, rapid thready pulse, cold clammy skin
circumscribed, solid elevation of skin less than 1cm. Ex. Warts, Acne, Pimples, Elevated Moles
A circumscribed, round or oval, thin translucent mass filled with serous fluid of blood less than 0.5cm. Ex. Herpes simplex, early chicken pox, small burn blister
What is this picture an example of?
What is this picture an example of?
Skin Color Normal Findings
light-deep brown, ruddy pink-light pink, yellow overtones-olive
Abnormal Skin Color Findings
pallor, jaundice, errythema, cyanosis
Skin Color Uniformity Normal Findings
uniform except for in areas exposed to the sun and in areas of lighter pigmentation (palms, lips, nail beds) in darker skinned people
Abnormal Skin Color Uniformity Findings
hyperpigmentation of hypopigmentation
Normal Skin Lesions
freckles, some birthmarks that have no change since childhood, and some long-standing vascular birthmarks such as strawberry or port-wine hemangiomas, some glast and raised nevi, no abrasions or other lesions
Abnormal Skin Lesion Findings
various interruptions in skin integrity, irregular multipcolored or rasied nevi, some pigmented birthmakrs such as melanocystic nevi and some vascular birthmarks such as cavernous hemangiomas. deviations from normal may not be dangerous or require treatment so assessment by an advanced-level practitioner is required
Normal Findings for Hair
evently distributed hair, thick hair, silky, resistant hair, no infection or infestation
Abnormal Findings for Hair
patches of hair loss, very thin hair, brittle hair, excessively oily or dry hair, flaking, sores, lice, nites, ringworm, hirsutism in women, absent or sparse leg hair
What can naturally absent or sparse leg hair be an indication of?
Normal Nail Findings
convex curvature, angle of nail plate about 160 degrees, smooth texture, highly vascular and pink in light-skinned clients, dark-skinned clients may have brown or black pigmentation in longitudinal streaks, intact apidermis, promp return of pink or usual color in generally less than 2 seconds
Abnormal Nail Findings
spoon nail, clubbing, excessive thickness or thinness or presence of grooves or furrows, beau's lines, discolored or detached nail, bluish or purplish tint, pallor, hangnails, inflammation, delayed return of pink or usual color
What is clubbing an indication of?
long term oxygen lack
What are Beaus lines an indication of?
severe injury or illness
What is spooning an indication of?
iron deficiency anemia
Normal peripheral Vascular Findings
symmetric pulse volumes, full pulsations, presence of distention and nodular bulges at calves, when limbs elevated veins collapse and may appear tortuous or distended in older people, symmetric in size, limbs not tender, skin color pink, skin temp not excessively warm or cold, no edema, skin texture resilient and moist, immediate return of color for capillary refill test
Abnormal Peripheral Vascular System Findings
asymmetric volumes, absence of pulsation, decreased, weak, thready pulsations, increased pulse volume, distended veins in the thigh and/or lower leg or on posterolateral part of calf from knee to ankle, swelling of one calf or leg, tenderness on palpation, pain in calf muscles with forceful dosiflexion of the foot, warmth and redness over vein, cyanotic, pallor that increases with limb elevation, dusky red color when limb is lowered, brown pigmentation around ankles, skin cool, edema, skin thin and hiny or thick waxy shiny and gragile with reduced hair and ulceration, delayed return of color for capillary refill test
A solid tan, black, or skin-toned color round or oval with flat or dom-like surface that is smaller than 6mm in diameter. it has well-defined edges and in existence before age 30
flat, circumscribed, <1cm diameter