Unit 7- Microbial Defense

  1. Types normal body defenses
    • Non specific body defenses
    • Specific body defense
  2. Non specific body defenses
    • Intact skin and mucous membranes=largest organ
    • Cilia of the nose= nose hairs trap micr organism and dust
    • Phagocytes in lung= ingest foreign particles
    • Acidity of stomach= ph is low if acid is high, H. Pylori
    • Saliva in mouth
    • Tears in eyes= are healthy
    • Normal/residual flora in lower GI tract= Ecoli is important, normal ecoli living in smaill intestine.
    • Aciditiy in vagina & normal flora= anitbiotics, tampons, Yeast infections alter Normal Flora
    • Flushing action of urine=incontinence increase UTI"s. Most common in women because of shorter urethra.
    • Inflammation=the body response to injury to heal itself.
  3. Specific body defense
    • the Immune response.
    • The body's immune system responds to foreign protein/antigens then, the body produces antibodies to defend itself.
  4. Active Immunity
    Body produces own antibodies to natural (ie measles) or artificial exposure (Vaccine)
  5. Passive Immunity
    body receives antibodies either naturally (from mom in utero or breastfeeding) or artificially (inj of antibiodies such as gamma globulin)
  6. Immunosenescence
    age associated changes in the immune system making it more difficult for the elderly resist infections, develope immunity after vaccination
  7. Chain of infection
    • 1. Etiologic agent
    • 2. Portal of exit
    • 3. Portal of entry
    • 4. Reservoir
    • 5. Method of transmission
    • 6. Susceptible host
    • Hospital acquired Methicillin Resistant Staph Aureus
    • Community acquired Methicillin Resistant Staph Aureus
  9. CDI
    Clostridium Difficele (C-Diff)
  10. VRE
    • Vancomycin Resistant Enterococci
    • Vaancomycin Resistant Staph Aureus
  11. MDRO
    • Multiple Drug Resistant Organism
    • Multiple Drug Resistant T.B.
  12. H1N1 virus
    • Influenza A
    • Extended Spectrum Beta Lactomase
  13. Nursing diagnosis for microbial defense
    • Risk for infection
    • Impaired skin integrity
  14. Nursing action to prevent infection
    most effective is Handwashing
  15. nosocomial infection
    Hospital acquired infections
  16. Iatrogenic infection
    result of a treatment or diagnostic procedure
  17. Medical asepsis/aseptic technique
    limits the number and spread of microorganism
  18. Surgical asepsis/aseptic technique
    sterile technique, practices that destroy ALL microorganism including spores.
  19. Types of Isolation precautions
    • Standard precautions (Tier One)
    • Transmission- Based precautions (Tier Two)
  20. STandard precautions
    includes universal precations and body substance isolation
  21. Transmission -based precautions (Tier two)
    • Airborne precautions- neg. pressure room, T.B., MMR, Varicella
    • Droplet precautions- Flu, Pneumonia, always wear masks
    • Contact precautions- Staph, MRSA
    • Compromised client (reverse isolation/protective barrier tech)- transplant or immuno compromised cl
  22. Pressure ulcer/decubitus ulcer
    • any lesion caused by unrelevied pressure resulting in damage to underlying tissue.
    • Usually over bony prominence
  23. Risk factors for pressure ulcers
    • Immobility
    • Poor sensory perception
    • Poor nutrition
    • Adcanced age
    • Moisture/Incontinence
  24. Prevention
    • Assess/screen all cl
    • Braden scalefor ID of risk
    • Position changes W/ Attention to pressure points
    • Manange moisture & incontinence
    • Increase nutrition
  25. Etiology (cause)
    increase pressure or shear and friction (tissue caught between 2 surfaces) blood cant reach tissue, decrease oxygen and nutrition, cell dies from ischemia.

    Ischemia- lack of O2 to the tissue.
  26. Stage 1
    • skin intack with non-blanchable redness of a localized area, usually over a bony prominence.
    • Warm /cool, firm/boggy, cl can c/o pain or itching, in darkly pigmented skin color may differ from surronding area and be persistantly red, purple, blue
  27. Stage 2
    • Partial thickness loss invloving epidermis, dermis, or both
    • Superficial and presents and abraision, blister, or crater
    • cl c/o pain
  28. Stage 3
    • Full thickmess tissue loss with sub Q fat visible
    • May extend down to but not through underlying fascia
    • Undermining and tunneling may be present
    • depth varies according to the anatomical location
  29. Stage 4
    • full thickness tissue loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.
    • undermining and sinus tracts may be present
    • depth varies according to the anatomical location
  30. Suspected Deep tissue Injury (DTI)
    Purple or maroon localized area of discoloration, skin intact or blood blister due to damage of underlying soft tissue from pressure and or shear.
  31. Unstageable
    • full thickness loss with the base of the ulcer covered by >20 % slough ( yellow, tan, or gray) and /or eschar (black, hard) in the wound bed.
    • Can't determine extent/depth of wound
  32. Other types of wounds/Ulcers
    • Skin tears
    • Venous Insufficiency
    • Arterial Insuffciency
    • Diabetic
Card Set
Unit 7- Microbial Defense