Unit 7- Microbial Defense

• Non specific body defenses
• Specific body defense

• 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.

• the Immune response.
• The body's immune system responds to foreign protein/antigens then, the body produces antibodies to defend itself.

Body produces own antibodies to natural (ie measles) or artificial exposure (Vaccine)

body receives antibodies either naturally (from mom in utero or breastfeeding) or artificially (inj of antibiodies such as gamma globulin)

age associated changes in the immune system making it more difficult for the elderly resist infections, develope immunity after vaccination

• 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

Clostridium Difficele (C-Diff)

• Vancomycin Resistant Enterococci
• Vaancomycin Resistant Staph Aureus

• Multiple Drug Resistant Organism
• Multiple Drug Resistant T.B.

• Influenza A
• Extended Spectrum Beta Lactomase

• Risk for infection
• Impaired skin integrity

most effective is Handwashing

Hospital acquired infections

result of a treatment or diagnostic procedure

limits the number and spread of microorganism

sterile technique, practices that destroy ALL microorganism including spores.

• Standard precautions (Tier One)
• Transmission- Based precautions (Tier Two)

includes universal precations and body substance isolation

• 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

• any lesion caused by unrelevied pressure resulting in damage to underlying tissue.
• Usually over bony prominence

• Immobility
• Poor sensory perception
• Poor nutrition
• Adcanced age
• Moisture/Incontinence

• Assess/screen all cl
• Braden scalefor ID of risk
• Position changes W/ Attention to pressure points
• Manange moisture & incontinence
• Increase nutrition

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.

• 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

• Partial thickness loss invloving epidermis, dermis, or both
• Superficial and presents and abraision, blister, or crater
• cl c/o pain

• 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

• 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

Purple or maroon localized area of discoloration, skin intact or blood blister due to damage of underlying soft tissue from pressure and or shear.

• 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

• Skin tears
• Venous Insufficiency
• Arterial Insuffciency
• Diabetic