Chain of Infection
A resident develops a urinary tract infection caused by E. coli bacteria. In the chain of infection, the E. coli bacteria represent this link.
What is the infectious agent (pathogen)?
An 88-year-old resident has thinner, drier skin with decreased elasticity. During morning care, the nurse aide also notices several flat brown age spots that have been present for years. The resident denies discomfort, and there are no open areas.
What is normal?
Routine self-care activities are collectively known by this abbreviation.
What are ADLs (activities of daily living)?
A resident tells a nurse aide, "My stomach hurts, and I feel nauseated." This statement is an example of this type of information.
What is subjective information?
A resident drinks a cup of hot coffee immediately before the nurse aide takes an oral temperature. The reading is 100.2°F, although the resident's usual temperature is 98.1°F. Before interpreting the reading, the aide should wait 10–15 minutes and perform this action.
What is rechecking the oral temperature?
A resident has a wound infected with bacteria. The bacteria are living and multiplying inside the resident's wound. The wound serves as this link in the chain of infection.
What is the reservoir?
An 82-year-old resident has gradually lost muscle mass and walks more slowly than they did several years ago. During today's transfer, however, the aide notices that the resident suddenly cannot bear weight on their right leg and complains of hip pain.
What is abnormal?
A resident recovering from a stroke can wash their face and upper body themselves but needs assistance washing their back and legs. The nurse aide should encourage what during the bed bath.
What is independence?
A nurse aide measures a resident's temperature and obtains a reading of 101°F. The aide records the temperature and reports it to the nurse. This information is classified as this type of data.
What is objective information?
A resident's usual resting pulse is 72 beats per minute. After walking back from physical therapy, the aide measures a pulse of 104. The resident is comfortable and denies symptoms. Before determining whether the pulse remains elevated at rest, the aide should allow the resident to do this and reassess.
What is rest?
A resident with influenza coughs, releasing respiratory droplets containing the virus into the air. The virus leaves the resident's body through this link in the chain of infection.
What is the portal of exit?
A 79-year-old resident requires brighter lighting to read and has difficulty hearing high-pitched voices. The aide notices that the resident takes longer to adjust when moving from a brightly lit hallway into a darker room. These changes have developed gradually over several years.
What is normal?
While helping a resident change clothes, a nurse aide notices a persistent red area over the resident's tailbone. The aide reports the finding to the nurse because it may be this type of skin damage.
What is a pressure injury?
A nurse aide is running behind schedule and considers documenting that all residents received morning care before completing their baths. Doing so would violate this essential principle of documentation.
What is accuracy (or documenting care only after it has been provided)?
A nurse aide obtains a blood pressure of 158/92 mmHg. During the measurement, the resident was talking, the cuff was placed over a sweater, and their arm was unsupported. These conditions may have affected this property of the measurement.
What is accuracy?
A nurse aide provides perineal care for a resident with an infection. Without performing hand hygiene, the aide then assists another resident with eating. The contaminated hands demonstrate this method of transmission.
What is indirect contact transmission?
An 86-year-old resident has a history of occasional urinary leakage related to decreased bladder control. Over the past 24 hours, the resident has developed increased urinary urgency and new episodes of incontinence.
What is abnormal?
A resident who has difficulty swallowing begins coughing repeatedly while eating lunch. The nurse aide stops assisting with the meal and immediately alerts the licensed nurse. The aide is concerned about this condition.
What is aspiration?
A resident who is normally alert and oriented suddenly becomes confused and begins trying to climb out of bed. The nurse aide immediately reports the behavior rather than assuming it is part of normal aging. This is an example of the nurse aide's responsibility to identify and report this.
What is a change in the resident's condition?
A resident's blood pressure is 132/78 mmHg while lying in bed. After standing, the resident becomes dizzy, and the blood pressure decreases to 104/64 mmHg. The aide helps the resident sit safely and immediately reports the findings. This condition may explain the change.
What is orthostatic hypotension?
A nurse aide has a small open cut on their finger. While providing care without appropriate gloves, infectious drainage from a resident's wound comes into contact with the cut. The cut represents this link in the chain of infection.
What is the portal of entry?
An 86-year-old resident complains of feeling cold even when the room temperature is comfortable. During care, the nurse aide notices that the resident has less padding over bony areas and bruises more easily. The resident's skin is thin but intact.
What is normal?
A resident who normally walks independently to the bathroom suddenly requires two people to help them stand. The aide has recognized a deficet in this aspect of the resident's functioning.
What is mobility (or functional ability)?
A nurse asks a nurse aide to perform a procedure that the aide has never been trained or deemed competent to perform. The aide respectfully explains the concern and does not perform the procedure. The aide understands that assigned tasks must remain within these professional limits.
What are the nurse aide's scope of practice and demonstrated competency?
A resident's usual vital signs are BP 126/74 mmHg, pulse 78, respirations 16, and temperature 98.2°F. During morning care, the aide finds BP 92/58, pulse 118, respirations 26, and temperature 100.4°F. The resident is unusually weak and confused. Rather than treating each measurement as an isolated finding, the aide recognizes this potentially serious overall situation and immediately summons the licensed nurse.
What is an acute change in condition requiring immediate assessment?