Nursing Level I

invasion of body tissue by microorganisms and their growth there

detectable alteration in normal tissue function

if the infectious agent can be transmitted to an individual by direct or indirect contact or as an airborne infection

ability to produce disease

freedom from disease-causing microorgansims

state of infection and can take many forms, including septic shock

limited to the specific part of the body where the microorganisms remain

if the microorganisms spread and damage different parts of the body

bacteria in the blood

bacteremia spreads throughout systems

classified as infections that originate in the hospital

direct result of diagnostic or therapeutic procedures

• 1. etiologic agent/microorganism
• 2. reservoir/place where organism naturally resides
• 3. portal of exit from the reservoir
• 4. mode/method of transmission
• 5. portal of intry into host
• 6. susceptibility of host

immediate and direct transfer of microorganisms from person to person

• vehicle-borne
• vector-borne

involves droplets or dust

• local/nonspecific defensive response to the tissues to an injurious or infectious agent
• pain
• swelling
• redness
• heat
• impaired function of part

fragile, gelatinous tissue, appearing pink or red because of the new capillaries

consist of injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of force alone or in combination with movement

when pressure ir relieved the skin takes on a bright red flush

The enlarging of vessels to allow more blood flow more quickly

force acting parallel to the skin surface

combination of friction and pressure

reduction in the amount and control of movement a person has

tissue softened by prolonged wetting or soaking

area of loss of the superficial layers of the skin

occurs where the tissue surfaces have been approximated and there is minimal or no tissue loss

extensive and involves considerable tissue, and in which the edges cannot or should not be approximated

wounds that are left open for 3-5 days to allow edema or infection to resolve or exudate to drain and then closed with sutures, staples, or adhesive skin closures

second phase in healing, extends from days 3/4 to day 21 post injury, fibroblasts begin collagen formation

dried plasma proteins and dead cells - usually black

21days-few years fibroblasts continue to synthesize collagen, more orderly matrix, remodeled wound

hypertrophic scar, abnormal amount of collagen laid down to form healing scar

chiefly of serum, watery

thicker including pus, leukocytes, liquified dead tissue debris,  dead and living bacteria

large amounts of red blood cells indicating damage to capillaries, bleeding is a bad sign

partial or total rupturing of a sutured wound

protrusion of internal viscera through an incision

removal of the necrotic tissue

ability to moove freely, easily, rhythmically, and purposefully in the environment

of a joint is maximum movement that is possible

awareness of posture, movement, and changes in equilibrium and the knowledge of position, weight, and resistance fo objects in relation to the body

condition in which the bones become brittle and fragile due to calcium depletion

decrease in muscle size

permanent shortening of the muscle

stronger muscle dominates weaker muscle repetitively

immobility causes dilation of vessels which leads to serous fluid seeping into interstitial tissues

clot

when a thrombus comes loose and obstructs circulation elsewhere

ability to move freely, easily, rhythmically, and purposely in the environment, is an essential part of living

your awareness of position, posture, movement of body, each affecting the other

• Synostatic
• Cartilaginous
• Fibrous
• Synovial

• inability to move about freely
• Causes
• - pain
• - bed rest
• - immobiliation of limbs
• - LOC: Head injury/CVA
• - Chronic Illness
• - Psychological
• - Medications

• muscular deconditioning after 24 hours
• decreased cardiac output
• decreased size of muscle fibers
• nerve damage
• psychological
• death
• blood clot

• venous stasis-blood clotting, pooling in legs
• increased cardiac workload
• decreased fluid volume (dehydration & edema)
• Thrombus/Embolus formation
• orthostatic hypotension
• decreased autonomic response

• sudden swelling of leg
• redness or discoloration
• warmth
• pain w/ activity and constant
• low-grade fever
• increased heart rate
• Homan's sign

• SOB
• chest pain
• coughing w/ bloody mucus/sputum
• lack of circulation in hands and feet

• +40
• immobility, paralysis
• stroke, previous DVT
• Cancer and treatment
• cardiac disease
• surgery
• trauma
• obesity
• indwelling IV catheter
• infection
• hypercoagulable states (INR lab)

• early mobilization
• careful monitoring
• compression stockings

• decreased metabolic rate
• hypercalcemia
• negative nitrogen balance-d/tbreakdown of tissue
• inactivity-leading to weight loss, weakness, muscle loss

wasting syndrome, loss of weight, d/t muscle atrophy, fatigue, weakness, loss of appetite

• malnutrition -cachexia, disturbance in appetite
• constipation/impaction
• diarrhea

• urinary stasis- positioning, lack of gravity to empty bladder, decrease intake, hypercalcemia, dehydration
• renal calculi
• catheter

collapse or closure of lung d/t extremely low gas exchange

• hypostatic pneumonia- increased temp, thick copious secretions, cough, increased pulse, confusion, irritability, disorienttaion, sharp chest pain, dyspnea
• Atelectasis- cough, chest pain, SOB, low O2, increased HR, fever, no breath sounds over area, decreased chest expansion
• impaired cough
• pulmonary inflammation

• muscle atrophy
• contractures
• osteoporosis
• impaired gait
• pathological fractures
• risk for falls
• risk for injury

• behavioral changes- delirium, disorientation, agitation, altered sleep/wake pattern, depression (loss of control)
• decreased coping ability - fear and anxiety, decreased self concept (distorted), innefective individual coping

• Impaired skin integrity-immobility, incontinence, emaciation, obesity, age-related skin changes, decreased tissue circulation
• Turn every 2 hours

• bony prominence with pressure against it for long periods of time
• decreased circulation-impaired o2 to tissue
• first sign is redness that will not blanch
• bed confinement

• Friction-superficial epidermal layer
• Pressure Ulcers-pressure point sites
• Shear Injury-mechanical force
• Excoriation-scratching, burns, chemicals
• Maceration-prolonged moisture

superficial epidermal layer

pressure point sites

mechanical force

scratching/burn/chemicals

prolonged moisture

• Ischemic-artery that supplies blood blocked by a thrombi, 80% of all strokes
• Hemorrhagic-weakened artery ruptures and causes blood to leak into the brain

• 3 hour window
• Numbness or weakness in face, arm, leg especially one side of the body
• First sign=confusion/trouble speaking or understanding
• Vision impairment
• Dizziness, difficulty walking, loss of balance or coordination, limb spasticity
• Severe HA with no known cause