Class 1 Notes - Maria Cho PDF

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Maria Cho...

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Spiritual assessment ● Spirituality -> awareness of one’s inner self and a sense of connection to higher being, nature, or to some purpose greater than oneself ● Influence on health ● Important factor that helps individuals achieve balance needed to maintain and well being & to cope w/ illness ● (older adult) ● Association between spirituality and ability to adj. or cope w/ illness and other life stressors ● Loss ● Undesired change or removal of a valued object, person, or situation ● Grief ● Emotional response to loss, manifested in ways unique to an individual based on personal experiences ● Types ● Uncomplicated ● Complicated ● Anticipatory ● Disenfranchised ● Responses to grief ● Physiological (physical sensations) ● Psychological (feelings) ● Cognitive (thought patterns) ● Behavioral (conduct or actions) ● Stages 1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance 6. Finding meaning (6th stage?) Temperament ○ The part of our personality that we inherit ■ Refers to our sensitivity, iritibility, distractibility ○ Refers to how sensitive is the nervous system ■ If very sensitive, then you are less likely to approach new things ■ If not very sensitive, then it allows you approach new things ● Traits ○ Staple characteristics of personalities

○ Begin to stabilize around age 3 ○ Sometimes traits go together ■ Ex. shy,reserved, attention is focused inwards ■ When go together or are similar they form a type ● This would be introverted type ■ Ex. bold, outgoing, socialize easily, attention is focused outward ● This would be extroverted type ● Type (introvert/Extrovert) ○ Ex. shy,reserved, attention is focused inwards ■ This would be introverted type ○ Ex. bold, outgoing, socialize easily, attention is focused outward ■ This would be extroverted type ● Self-concept ○ Refers to all your ideas, perceptions, and feelings about who you are ● Self-esteem ○ Based on your self-concept ○ This is your perception as yourself as a worthwhile person who is confident or a insecure person who is lacking confidence ● Common traits ○ These are traits that are shared by most members of a culture ■ Ex. if most members of 70% of americans are competitive, then we could say competitiveness is a common trait in our culture ● Individual traits: ○ Central traits ■ Refers to several characteristics or traits that really describe a person ● Ex. knowing a person because they are charming and honest ○ Secondary traits ■ Superficial characteristics of a person ■ Don't describe in detail much about the person (less revealing) ○ Cardinal traits ■ Refers to if a person has one trait that really describes a person ● Ex. how abraham lincoln was known as honest abe ■ Not many people have a cardinal trait. More ppl have a central trait ● Surface traits ○ Are visible features of personality ■ Ex. if this person helps out people, talkative, or assertive

● Source traits ○ Are deeper characteristics of a person’s personality ○ 16 traits that analyze general underlying factors between different ppl’s personality ● Big 5: ○ This idea of trait theory says we have certain traits in us and that's why we act the way we act (internal traits) ○ Extroversion ■ If a person scores high on this, they are very sociable, outgoing, and bold ■ If a person scores lows on this, they are shy and focus is inward ● Means you are introverted ○ Agreeableness ■ A person who scores high on agreeableness, they are very friendly and nurturing ■ A person who scores low on agreeableness, they are more cold and more different (don’t care much) ■ Most of us will score in the middle ○ Conscientious ■ If a person who scores high on conscientious, they are selfdisciplined and responsible ■ A person who scores low on conscientious, it would just mean you are not self-disciplined (more lazy) ○ Neuroticism ■ If a person who scores high on neuroticism, they are negative,irritable, and unhappy ■ If a person who scores low on neuroticism, they are the opposite of that ○ Openness ■ If a person who scores high on openness, they are open and receptive to new ideas ■ If a person who scores low on openness, they are more rigid in their thinking (closed minded) ○ (External theory) ■ Says what really determines your personality is not so much these internal traits but the situation that you are in ■ Ex. you might be shy (introvert) at cal state east bay, but a club you are more wild ○ Psychoanalytic/psychodynamic theory -

■ Means they believe that your personality is greatly influenced by unconscious memories, unconscious conflicts, and unconscious feelings from childhood ● (Repression) - blocking painful memories unconsciously ● Id/Ego/Superego ○ Id - (child part of our personality) ■ Is the part of your personality that is inborn and the Id represents your biological instincts and urges ■ Part of personality that is irrational, impulsive, and operates on an unconscious level ■ Operates on the pleasure principle ■ Wants to gratify your unconscious impulses ■ 2 main unconscious impulses ● Impulse to aggressive ● Impulse to be sexual ○ Ego - (adult part of your personality) ■ Tries to find the middle ground between the Id and superego ■ Aware of external reality ■ Is that part of your personality that you can delay gratification and create a plan ○ Superego - (parent part of your personality) ■ Where your conscience or morals exist ■ Part of your personality where you might feel guilt ■ AKA the internalized parent ● Voice in your head that tells you what you should and shouldn’t do ■ The voice that says we should release these impulses in an respectable way Virulence is defined as the degree or severity of harm. Virulence can follow a range from highly virulent to avirulent. Something that is avirulent lacks harm. Bacterial virulence factors enable a host to replicate and disseminate within a host in part by subverting or eluding host defenses (Cross, 2008). We will address virulence in more detail in lecture soon, but this lab focuses on a few examples of virulence factors. Part One: Virulence factors of Staphylococcus spp. and Streptococcus spp. Staphylococcus spp., in particular S. aureus, can possess capabilities that cause harm us that other strains of S. aureus do not possess. These capabilities include antibiotic resistance and coagulase production for Staphylococcus spp. For Streptococcus spp., one notable virulence factor is hemolysin production, and factors include the production of a variety of extracellular enzymes.

A. Let’s start with Staphylococcus aureus: Recall that S. aureus is Gram positive and it’s cellular morphology and arrangement are cocci in grape-like clusters. The cells can also be present as singles.

Staphylococcus aureus is known to possess a variety of virulence factors despite doing good things for us as it resides on our skin and in our sinuses. S. aureus infections are often associated with burn victims, surgical wound infections, osteomyelitis (bone infections), endocarditis (heart), bacteremia (blood) and food poisoning. Toxin production is one factor and behind some of these pathologies; one we will address further in lecture. Two notable virulence factors that some S. aureus possess are antibiotic resistance and coagulase production and will be the focus of this lab. Methicillin is a β-lactam antibiotic that inhibits penicillin-binding proteins (PBPs) which are important in the synthesis of peptidoglycan. It has been used when common treatment using penicillin no longer worked. Today unfortunately, we are seeing Methicillin-resistant S. aureus (MRSA) which necessitates the use of another antibiotic, Vancomycin. Vancomycin is used/saved for serious infections, but we are seeing the need for its use more and more. Again, we will talk more about this in lecture. How do we know if someone has an infection caused by an MRSA? First, you need to isolate S. aureus from a wound site or sinus drainage, for example. This can be rapidly achieved by the use of Mannitol Salt Agar (MSA). MSA is selective and/or differential for Gram positive bacteria. The high salt concentration (7.5%) in the medium inhibits Gram negative bacteria. It is differential based on mannitol utilization. S. aureus uses mannitol as a food source, and other Staphylococcus spp., such as S. epidermitis cannot. Phenol red is the pH indicator in the medium. As you know, phenol red turns yellow at acidic pH (such as when mannitol is digested) and is red at alkaline pH (when protein sources are digested). If you see a result as below, it is likely S. aureus. A Gram stain be used to verify. Now, is it an MRSA? We can conduct a Kirby Bauer and/or use Chromogenic media, such as ChromMRSA (Hardy Diagnostics). The latter is meant to assist with diagnosis but

not be used solely for diagnosis of and therapy measures for the presence of an MRSA.

Now, with S. aureus (yellow plate, confirmed Gram stain), you can steak for isolation on ChromMRSA and if it is a presumptive MRSA it looks like this:

A negative result would look just like S. aureus growing on a TSA plate, and the colonies might not pigment. If you perform a Kirby Bauer, you would see either no zone or a zone whose diameter is considered resistant. Many times an MRSA infection is associated with a S. aureus that also possesses another virulence factor known as coagulase. Coagulase is an enzyme, that we actually possess, that takes the blood plasma protein fibrinogen and converts it to another protein, fibrin. Fibrin is involved in blood clotting and wound healing (scab formation). It is produced extracellularly.

● Death ○ Uniform determination of death act (1981) ○ Individual who has: ■ Irreversible cessation of circulatory and respiratory function ■ Irreversible cessation of all functions of entire brain (including brainstem) ○ Determination of death must be made in accordance w/ accepted medical standards ○ 2 parts of dying process ■ Physiological ● 90% die after long illness ■ Psychological ○ Advance directives ■ Patient self-determination act (PSDA) - 1991 ● Patient autonomy transferred over to relative/attorney w/ informed consent ○ Living will ■ Legal document that directs treatment in accordance w/ pt’s

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wishes in event of terminal illness/conditiong Durable power of attorney (DPAHC) ■ Health care proxy ■ Legal document that designates person or person(s) to make healthcare decisions when oneself loses ability to Physician orders for life-sustaining treatment (POLST) ■ Complements advance directive → but doesn’t replace it ■ CPR = attempt or do not attempt Palliative care ■ Goal → to help pts and families achieve best quality of life ● Focuses on prevention, relief, reduction, or soothing of symptoms of disease through entirety of disease Hospice care ■ Priority to manage a pt’s pain or other symptoms, comfort, quality of life, and attention to physical, psychological, social, and spiritual needs Post-mortem care ■ Care of body after death Team communication ■ CUS ● Tool designed to clearly communicate pt is at risk for harm ○ “I am concerned” ○ “I am uncomfortable” ○ “This is a patient safety issue” ■ Hand-off ● Transfer of info (w/ authority & responsibility) during transitions in care across continuum → opportunity to ask questions, clarity, and confirmation ■ SBAR ● Technique for communicating critical info that requires immediate attention and action concerning pt’s condition ● Parts ○ Situation -> what is going on w/ pt? ○ Background -> what is the clinical background or context? ○ Assessment -> what do you think the problem is? ○ Recommendation & request -> what would I do to correct it?

Incivility ● Exchange of seemingly inconsequential inconsiderate words and deeds that violate the conventional norms of workplace conduct Workplace bullying ● Repeated harassing, offending, socially excluding someone, or negatively affecting someone’s work Horizontal bullying (originated in oppression theory) ● Unable to revolt against oppressor ● Used to explain fighting w/in nursing that represents safe way to release tension when actual aggression is meant for oppressor Stress response ● Triggered by specific event or indirectly through psychological event ● Involves autonomic nervous and endocrine system and responds immediately to stress ● Short term ● Increase HR, R, BP ● Vision more acute ● Glucose & fat released ● Non-emergency bodily functions suppressed (ie. digestion) ● Long-term ● Cognitive impairment ● Tension headaches ● Stroke ● Angina ● Cardiac arrhythmias ● Atrophy of immune system organs ● Decreases immune response ● Disables body’s natural self-repair mechanisms ● Function only when body is in relaxation Relaxation response ● Group of physiologic changes that cause decreased activity of the sympathetic nervous system and consequent relaxation after stimulation of certain regions of hypothalamus

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Counteracts stress response Arousal decreased Muscle fibers elongate Decreased neural impulses, HR, BP Sense of calm and peace

Complementary & alternative therapies ● Allopathic medicine → conventional Western medicine ● Complementary ○ Used in addition or together w/ conventional medicine ● Alternative ○ Replace allopathic medical care ● Integrative health care ○ Allopathic + CAM ○ Multidisciplinary ○ Holistic ○ Informed by evidence ● Below, you see the response by a bacterium to antibiotics. Recall that you would measure the diameter of the Zone of Inhibition for each antibiotic in millimeters (this includes the disk, and if you can’t get a good measure of a diameter, go with a radius value multiplied by 2 (d=r x 2)(see below). You MUST always measure a zone unless there is no zone, as seen below for Vancomycin, Bacitracin, Optochin and Penicillin. Those responses are clearly “Resistant”. Once you get your values, you refer to a standardized chart for interpretation of your data (remember, data are values in this case, and results are a verbalization of those data). ● Just to recap: ● You would prepare a fresh culture to match a 0.5 McFarland Standard to get a standardized cell concentration.

● Streak for Confluency: Notice the plate on the right where you see the “X,Y, & Z” streaking pattern using a sterile swab with the aim to cover the entire surface of the medium with bacteria.

● Time to put the antibiotic disks on top of the plated bacteria. The plate above shows coverage 18-24 h post-streaking. You won’t see, of course, bacterial growth when you put down the antibiotics. You DO NOT put the disks down after you see bacterial growth. You Streak for Confluency and then immediately place down the antibiotic disks. ● You can place the antibiotics down manually and aseptically, or use a dispenser. If you go the manual route, make certain to place the disks apart in an equidistant manner, and of course, both methods demand that you work aseptically.

● Manual placement of the antibiotic disk (above). Notice the person is using the lid to shield the plate, thus working aseptically. The forceps have been previously sterilized using an alcohol dip followed by a passing into a flame. The alcohol ignites and burns off the microbes that are present. Make sure to allow the forceps to cool for just a few seconds before you pick up an antibiotic. Also, once you put down the disk for both methods, you gently tap the disk in place. Gently! Don’t jam the disk into the medium. Use of a dispenser (below) also mandates aseptic technique.

● Twenty four hours later, you will see your responses (below, for example).

● You use a centimeter rule to measure the Zone of Inhibition in millimeters.

● You include the diameter of the disk with measuring the Zone of Inhibition, however; if there is no zone the you report the zone size as 0 mm.

● The final step involves comparing your data to those on a standardized chart. Once you have your results (S, I or R), you have completed the assay.

● Onto the follow-up exercises: ○ Below are the data for E. coli, S. aureus, and Ps. aeruginosa. Take these data and determine if the each individual antibiotic is useful (Susceptible or S) for controlling and infection, not going to be the best choice (Intermediate or I), or won’t be effective at all (Resistance or R) and thus, is not an option for therapeutic use. How do you determine S, I or R? Compare your numbers (data) to those on a

predetermined, standardized chart.

I.

Below is a MH plate, antibiotics, and Escherichia coli. Background: E. coli cells were physiologically in a state for plating on MH medium, were in a concentration that matched a 0.5 McFarland Standard, and were streaked for confluency (aseptically) on the plate. Antibiotics were placed aseptically and equidistant from one another on the surface of the bacteria, and the plate was incubated at 35°C for 18 h. Zones of Inhibition was measured in mm and were recorded in the chart below.

Antibiotic

Zone size (mm) Tetracycline 18 Gentamicin 12 Ampicillin 8 Neomycin 10 Vancomycin 0 Trimethoprim/ 22 SXZ Penicillin 0 Optochin 0 Streptomycin 8 Amoxicillin/C 10

Susceptible

Intermediate

Resistance

≥19 ≥20 ≥21 ≥15 ≥27 ≥20

15-18 12-19 12-20 12-14 12-26 19-13

≤14 ≤11 ≤11 ≤11 ≤11 ≤14

≥20 ≥25 ≥10 ≥32

19 24-16 7-9 31-18

≤18 ≤16 ≤6 ≤17

A Erythromycin Bacitracin

8 0

≥13 ≥26

12-5 15-25

≤4 ≤16

2. Below is a MH plate, antibiotics, and Staphylococcus aureus. Background: S. aureus cells were physiologically in a state for plating on MH medium, were in a concentration that matched a 0.5 McFarland Standard, and were streaked for confluency (aseptically) on the plate. Antibiotics were placed aseptically and equidistant from one another on the surface of the bacteria, and the plate was incubated at 35°C for 18 h. S. aureus are typically more sensitive to antibiotics than E. coli and Ps. aeruginosa. The zone sizes look larger than you see for E. coli and Ps. aeruginosa, but remember YOU MUST measure a zone despite the large size and compare that measurement to the chart. To save you some effort, the only antibiotic that isn’t effective, below, is the one without a zone. All others are still effective (the good news).

3. The plate below is of Ps. aeruginosa, and it looks different. That is OK. The same medium, the same procedure was employed. I showed this image so that you see variation. It doesn’t matter if you have a circular plate or a rectangular plate as long as you follow the protocol. Now let’s look at the opposite effects from S. aureus than what you see below.

As you can see below and on the next page, there are only a few Zones of Inhibition to measure given exposure to several. This strengthens the statement that “Ps. aeruginosa is known to be a multi-drug resistant bacterium and this is why we worry about this microbe in terms of infection control”. Also notice, there isn’t an Intermediate value. This is a case where it works, or it doesn’t. Determinations: The few zones presented can be assessed using the following chart: Antibiotic Cefotaxime (CAZ) Piperacillin Tazobactam (TZP) Aztreonam (ATM) Cefepim (FEP)

Zone size (mm) 9

Susceptible

Intermediate

Resistant

≥23

15-22

≤14

8 8

≥17 ≥15

---13-14

≤17 ≤12

7

≥14

15-16

≤14

7

≥21

16-20

≤15

Quiz yourself on your comprehension of Antibiotic Susceptibility testing and the Kirby Bauer Method: 1. What are the two names for the “Kirby Bauer”? 2. Why must standardization of the protocol be in place when conducting this

3. 4. 5. 6.

assay? Why is Mueller Hinton agar the only medium used when performing this test? If you see a double zone, which one do you measure? What if you see an enhanced zone between two adjacent bacterial dis...