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lOMoARcPSD|11253286

NS1881 Content Summary
Nursing Practice 1 (James Cook University)

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Bacteria
2
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Fungi
4
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Prions

Types of infection:
Acute

Chronic
Specific and sharp
Generalised and persistent
Appears suddenly
Appears slowly
Short lasting (coincides with the cause)
Long lasting (can extend after cause is ‘treated’)
Note: Fever, malaise, nausea, and vomiting are often signs of SYSTEMIC infection
Oedema, redness, heat, and pain are often signs of LOCALISED infection

Chain of infection:

Transmission: Direct (contact/droplet) + Indirect (airborne/transfer by inanimate object)
Host: Any immune-suppressed individual

Interventions:
1
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Reservoir
 Change dressing regularly
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Portal of Exit
Cover portals when able
PPE
Discard soiled materials

4
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Portal of entry
Cover entry
Restrict entry points (no unnecessary invasive procedures)
Do not wear jewellery that can create new portals of entry

6
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)
Note: more likely to get infection in hospital as defence mechanisms are often breached and immune systems are
lowered
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Contact (direct) (additional PPE)
2
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Airborne (indirect) (mask)
Note: these are considered when employing transmission based precautions, in addition to standard precautions
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2
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4
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6
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8
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ANNT
Dispose of sharps appropriable

Think: Having Cool Peers At Dances Can Double Eagerness

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2
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4
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Before touching patient
Before procedure
After procedure
After touching patient
After touching patient surroundings

PPE:
On

Of
1
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3
...

5
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2
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4
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Gloves
Goggles
Mask
Gown
Hand hygiene

Clinical Reasoning
Clinical Reasoning Cycle:

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Think: Cats Can Play Interesting Games And Eat Rats
1
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Collect queuesConsider subjective information to gain objective information needed to make a decision- Handover reports,
medical assessments, tests, new information from your own assessment (vital signs, visual assessment,
palpation and auscultation)
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Process infoProblem solve, deduct, identify abnormalities, create objective from subjective, draw from experience
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Identify problems/issues
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Potential and actual issues
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Establish Goals
Plans need to be SMART (specific, measurable, achievable, relevant, and timely)
6
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) or independent
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Might pick up additional queues that need treating
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Evaluate Outcomes
How successful was the intervention
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Apply findings from process to other patients
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Reflect on process and new learning
Continue, alter or discontinue plan
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Lifespan considerations: (their impact on overall health)
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Biological- age, illness etc
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Politico-economical- government, policies and economy
Sociocultural- society, culture and beliefs
Environmental- activities of living etc
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Vital Signs
Relevant and accurate information that is indicative of a patients physiological wellbeing, used to inform practice
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Blood pressure- 90/60 – 140/90
2
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Temperature- 36-37
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Heart Rate (and pulse)- Between 60-100 BPM at rest for adult
5
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Gender
Health status/weight
Activity
Environment
Lifestyle
Illness
Psychological status
Nutrition
Frank starling law
Viscosity
Blood volume
Peripheral resistance/elasticity of vessels
Haemoglobin amount
Circulation
Functionality of organs (causing compensation)

Instruments used to take vital
Blood pressure
Temperature

Oxygen saturation
Heart rate
Respiratory rate

Blood pressure cuff (sphygmomanometer) + stethoscope for auscultation of arteries
Doppler ultrasound to auscultate when difficult
Thermometer:
 Tympanic=ear
 Axilla=underarm
 Oral= mouth
 Anal= anus
Pulse oximeter
Palpitation/auscultation with stethoscope or doppler
Auscultation, visual

When to check
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On admission (record normal to catch deterioration early, to check if in healthy range etc
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Following an incident/injury (may indicate hidden issue)
Before, during and after surgery (to catch deterioration quickly, to ensure procedure was successful)

Note: an ADDS (adult deterioration detection chart) is useful to detect a decline in an individual’s health

Places where the pulse can be taken:
1
...

3
...

5
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7
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Radial- wrist
Brachial- inner elbow
Carotid- neck
Femoral- upper thigh
Popliteal- behind knee
Pedal- top of foot
Posterior tibial- inner side of foot
Apical- chest

Note: Doppler ultrasound can be used if palpating pulse is difficult

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Press 1/3 chest depth
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ANTT (Aseptic Non-Touch Technique)
Definitions:
Asepsis
Disinfect
Antiseptic
Sterile
Clean

Free from pathogenic micro-organisms
Remove most pathogens from inanimate objects
Inhibiting or stopping growth of micro--organisms
Free from all living micro-organisms
Free from visible marks and stains

Elements of ANTT:
1
...
Key parts- equipment

Types of ANTT:
Surgical ANTT- Requires more PPE
 More than 20min
 Numerous key parts
 Invasive
 Complex

Standard ANTT –
 Less than 20 mins
 Few key parts
 Non-invasive
 Simple

Indicators of infection:
Localised
 Odour
 Exudate
 Oedema
 Redness
 Heat
 Pain

Systemic
 Fever
 Malaise
 Nausea
 Vomiting

Phases of wound healing:
Inflammation
3-6 days
Proliferation
4-21 days

Maturation
21-1/2years

Homeostasis: Vasoconstriction, retraction of vessels from site and blood clots formed
...

Phagocytosis: Dead tissue/micro-organisms cleared by macrophages
Collagen produced that adds strength to the wound
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Fills wound,
then epithelium proliferate over it
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Is
tender and fragile
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Wound fully closes and is remodelled by collagen
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Scar or keloid (raised scar) may be seen
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may be required
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Types of wound healing:
1
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This kind of closure is characterised by minimal tissue loss + scarring eg
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2
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Repair time,
scarring and risk of infection is greater eg
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3
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eg
...

Note: higher risk of injury if skin condition is poor (cancer, dryness, inelasticity, old age) and in poor overall health
...

Do not change too regularly as wound can be compromised

Classification of wounds:
Clean

Clean surgical wounds are under aseptic conditions where the viscera are not opened eg
...
colectomy
Opened viscera with spillage of gut contents or major break in aseptic technique

Clean-contaminated
Contaminated
Dirty

Dirty or infected wounds with pus and dead tissue often resulting from visceral perforation
eg
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Types of wounds
Type
Incision
Contusion/hematoma
Abrasion
Puncture
Laceration
Penetrating

Cause
Sharp instrument
Blunt force trauma
Surface scrape
Penetration by sharp instrument
Tissue torn
Penetration of skin and tissues

Example
Scalpel
Hammer
Fall on concrete
Needle
Machinery
Shrapnel

Complications
Haemorrhage
Infection
Dehiscence

Excessive bleeding (closed wound=haematoma [bruise])
Contamination by micro-organisms
Rupturing of wound
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2
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4
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6
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2
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4
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 Toning of GI tract
 Increased peristalsis
 Increased appetite
 Increased glomerular filtration (from
increased blood flow)
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Increase in mood elevating substances

Immobility
 Disuse osteoporosis
 Muscle atrophy
 Contractures (muscle shortening)
 Stiffness and joint pain
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Decreased respiratory movement
Increased risk of pneumonia (inflammation
of alveoli [fill with secretions])
Decreased functioning of lungs
Decreased metabolic rate
Constipation
Negative ion balances
Urinary retention
Increased risk of kidney stones
Increased risk of UTI’s
Decrease in mood elevating substances

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Stages of PI’s
Normal skin is blanchable (when pressure is applied, colour is lost, but returns after a few moments)
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Is non-blanchable
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Blister looking
Stage 3: Deep wound from full dermis loss
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Stage 4: Very deep wound due to full tissue loss in which tendons, muscles or bone may be exposed
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PI Prevention:
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Changing positions (approximately every 2 hrs is optimal)
Being gentle when cleaning and touching skin
Moisturising
Gentle cleaning products
Use of a reactive support surface (mould/ gel/foam)
Use of an active support surface (eg
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Active- Person is able to independently move each joint through complete ROM, maximally stretching all
muscle groups
2
...

Note: doesn’t increase strength of muscles, but does improve joint flexibility

Positions:
Fowlers:
High: 60-90
Semi: 45-60
Low: 15-45

Position
Angled sitting position and
may have knees either bent
or straight
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Orthopnoeic

Sitting upright and slightly
forward
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Allows proper
alignment
Promotes mouth drainage and
ventilation
Promotes mouth drainage, prevent
aspiration, pregnancy, relieve sacrum
pressure
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Care in which people attend to functions including bathing, toileting and grooming
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2
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4
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Face, ears and neck
Hands and arms
Chest, breasts and abdomen
Legs
Back
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Perineum

Factors affecting hygiene:
1
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3
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5
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2
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4
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Be active and eat nutritional foods
Wide variety from 5 food groups
Limit intake of salt, fat, sugar and alcohol
Breastfeed
Store and care for food appropriately

The 5 food groups:
1
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3
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5
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The macronutrients
Carbs

Lipids

Cholesterol
Proteins

A macronutrient that provides energy to cells
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Primarily found in grain products (as well as vegetables and fruits)
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↑GI=↑absorption rate and ease=empty calories
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Composed of monoglycerides, triglycerides and fatty acids
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Passive absorption
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Form of fat needed primarily for bile, steroid production and cell membranes
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Has 4 actions: anabolism (building tissue), catabolism
(breaking tissue), maintaining nitrogen balance (needed for growth and repair) and general
maintenance
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2 Types:
Complete/high quality: contains all essential amino acids
Incomplete/low quality: does not contain all essential amino acids

BMI: (body mass index)
m
Height(¿¿ 2)
Weight (kg)
¿
Underweight
≤18
...
5-24
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9

Obese

Low risk
Increased risk
Men
˂94
94-102
Women
˂80
80-88
(Risk of cardiovascular complications)
Note: Ascites (fluid accumulation in abdomen) may cause false readings

High risk
102˂
88˂

30 ≤

Waist measurements:

Feeding patients:
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Sitting
Alert
Head upright

Note: Speech pathologists may assist with this if difficulties are seen

Types of diet:
1
...

3
...

5
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7
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Selective diet- balanced meal chosen from provided options
Light diet- people unable or unwilling to eat regular meals
Clear fluid- Light beverages and broths
Fluid diet- liquids and liquidised foods at room temp (eg
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Note: Can provide all required nutrients but can lack in dietary fibre
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Normal- water, juice etc
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Moderately thick- smoothies, milkshakes etc
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Very thick- mouse, ice-cream etc
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Thick fluids travel slower
down throat and are easier to control
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5 ‘rights’:
1
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3
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5
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Involving patient in interventions (asking questions) or taking note of
the needs of the patient (in pain) allows proper caring to be ensured
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Have 1g of paracetamol
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5g) tablets
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5
=0
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Have 1000mg paracetamol bottles in 100ml
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500 100
×
=50
1000
1
∴ Need 50mls

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5ml/kg/hr
Defecation- Normal production= 100-200g/day

Physiology:
Urine
1
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3
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5
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Conscious relaxation of external sphincter allows
urination

Faeces
1
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3
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5
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Conscious relaxation of external sphincter allows
defecation
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Characteristics:
Urine- urinalysis (sample collected preferably in morning
and mid flow to decrease contaminants and influencing
factors (activity/hydration status throughout day etc
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Shape
Texture
Colour
Odour
Blood (not normal)- trauma, stones, intestinal
bleeding (produces melena=black/tarry stool)

1
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Diarrhoea- liquid stools (increased defecation)
3
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Functional
Can’t physically hold urine/faeces
2
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Stress
External pressures/ activities causing faeces/urine to escape
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Urge
Sudden urge commonly caused by overactive bladder/ rectum
5
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Think: Five Rabbits Snuggled Under One-another

Nursing interventions:
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Encourage fluid and fibre intake
Assist in toileting
Walking aids close
Provide buzzer
No harsh soaps

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