Essentials Exam 1 Flashcards
(143 cards)
1
Q
Medical diagnosis
A
the actual name of the condition
(ex: peripheral vascular disease)
2
Q
nursing diagnosis
A
focus on care/symptoms rather than condition
(ex: risk for impaired skin integrity)
3
Q
The way we provide care (KSA)
What does KSA stand for?
A
Knowledge: What we should do and why
Skill: How we do it
Attitude: What we think about what we are
doing
4
Q
______ + ______ = critical thinking
(this is dumb but just in case yk)
A
specific knowledge + data and evidence
5
Q
Clinical reasoning definition
A
The ability to integrate/apply
different types of knowledge and
evidence with a clinical
situation (The best action based on the
situation)
6
Q
bloom’s taxonomy
A
thinking skills pyramid
7
Q
bloom’s taxonomy (bottom to top)
A
remember, understand, apply, analyze, evaluate, create
8
Q
ADPIE stands for
A
assessment/analysis diagnosis planning implementation evaluation
9
Q
4 Cs of the nursing process
A
Consistent, Comprehensive and
Coordinated Care
10
Q
infection definition
A
INVASION of a susceptible host by pathogens or microorganisms
- Results in disease
11
Q
Colonization definition
A
The presence and growth of microorganisms within a
host WITHOUT INVASION or damage
12
Q
Communicable disease
A
infectious process is transmitted from one person to another.
13
Q
symptomatic definition
A
clinical signs and symptoms ARE present
14
Q
asymptomatic
A
clinical signs and symptoms are NOT present
15
Q
HAIs what are they
A
healthcare-associated infections
16
Q
Exogenous plus 2 examples
A
from outside the individual (covid, MRSA)
17
Q
endogenous
A
patient’s “normal” flora becomes altered = overgrowth (C. difficile)
18
Q
Iatrogenic
A
resulting from a procedure (central line infection, surgical site infection, IUC infection)
19
Q
infectious agent
A
bacteria, viruses, fungi, protozoa, parasite
20
Q
reservoir
A
things/people that carry infectious agents (people, equipment, water/food, meds)
21
Q
portal of exit
A
droplets, excretions, secretions
22
Q
mode of transportation
A
contact, droplet, airborne, vectorborne
23
Q
portal of entry
A
resp tract, GI tract, mucous membrane, skin
24
Q
susceptible host
A
very young, very old, immunocompromised, people w/ chronic disease
25
Bacteria
single cell
named by shape
staining qualities
vary in size/shape/pattern as a means of replication
26
Viruses
Smallest microorganisms; not killed by antibiotics
Reproduce inside living host cells
27
fungi
Single-cell organisms, such as mold and yeast
28
parasites
live on or in other organisms
29
contact transmission define and examples?
Meeting of body surfaces with other bodies
or objects
-Direct: Contact with an infected person
-Indirect: Contact with contaminated
object
- examples: MRSA, VRE, C diff, drug-resistant
organisms
30
Airborne transmission define and examples?
Microorganisms dispersed by air, then
inhaled or deposited
examples: TB, Measles, Chicken Pox
31
droplet transmission define and examples?
Mucous membranes of resp tract are
exposed to secretions of infected
person
* Influenza, RSV
32
vectorborne transmission define and examples?
blood-feeding anthropods (insects,
ticks)
* Carry pathogens from one host to
another
* Lyme disease, West Nile Virus,
Rocky Mountain Spotted Fever
33
factors that lead to drug resistance
- Prescribing antibiotics for nonbacterial
infections
- Use of inappropriate antibiotics
- Incomplete courses of antibiotics
34
Wii method
wash introduce identify
35
Handwashing: why we do it
-Breaks the chain of infection
-Washing hands with soap removes germs much more effectively
- Soap molecules act as a mediator between water and oil molecules and bind them
- When you rinse off the soap the germs go with it!
- Handwashing can prevent about 30% of diarrhea-related sicknesses and about 20% of respiratory infections
36
what to do when hands are visibly soiled
soap and water
15-30s rubbing hands
C DIFF NEEDS SOAP AND WATER
37
what to do when hands are not visibly soiled
alcohol-based rub
rub until dry
38
contact precautions
private room, handwashing, gown, gloves
39
airborne precautions
private room with negative airflow, handwashing, N95 respirator
40
droplet precautions
private room, handwashing, gown, gloves, surgical mask, goggles
41
Airborne disease examples
Measles, tuberculosis,
SARS, MERS, COVID-19
42
protective isolation
filters, masks, handwashing, no live items, positive air pressure.
43
transporting a patient in isolation
"yellow" gown on the patient (as a robe)
face mask if on droplet/resp precaution
an extra layer of sheets
notify personnel
44
medical asepsis
"clean"
REDUCE microorganisms
hand hygiene, etc.
45
surgical asepsis
"sterile"
ELIMINATE microorganisms
46
disinfection definition
REMOVAL of microorganisms
47
sterilization definition
DESTROY all microorganisms including spores
48
when can skin be sterile?
no, skin is never sterile
49
7 principles of surgical asepsis
1. sterile can only touch sterile
2. only sterile objects in a sterile field
3. non-sterile = object below the waist, unattended objects, turning back on the field, DO NOT CROSS ARM OVER
4. prolonged exposure contaminates the field
5. moisture = contamination
6. fluid flow in the direction of gravity
7. 1" border around field = contaminated
50
pouring sterile fluid
- contaminated = outside bottle, bottleneck
- inside bottle top sterile = sterile
- palm the container = hold the label to
palm
- lip liquid
- pour from 1"-2" above the container
- remainder of solution = date, time, and
initial
51
examples of biohazard materials
bloody products, wound dressings, IV tubing, needles, scalpels, suction canisters, waste from patients with communicable disease
52
where to dispose of sharps
red sharps container
53
where to dispose of solid materials
red trash container lined with a red plastic liner
54
where to dispose of liquids
red "sealed" containers/bottles
55
functions of the skin
Protection, secretion, excretion, temperature regulation, and sensation
56
epidermis function
shields underlying tissues, protects from water loss, injury/integrity, and infection
57
dermis
Sweat glands, sebaceous glands, and hair
follicles
– Slows water loss, lubricates skin,
bactericidal
-Too frequent bathing or hot water can
interrupt the protective properties
58
normal oral mucose look
light pink, soft, moist, smooth
59
xerostomia
dry mouth
60
gingivitis
inflammation of the gums
61
dental caries
tooth decay and tooth loss
62
factors that can impact hair
Hormonal changes, nutrition,
emotional and/or physical stress,
aging, infection
63
how to clean sensitive sensory tissues in a way that prevents injury and discomfort
– Do not use soap to clean eyes
– Examine ears for wax accumulation
- Dry outer ear
– Wipe outside of nares with warm, moist washcloth
64
Hygiene care is routine: true or false
false: hygiene care is never routine
65
4 ways to improve hygiene care
-check room temp
-administer meds before hygiene
-assist them to preform as INDEPENDENTLY
AS POSSIBLE
-NON-RUSHED atmosphere
66
5 bath giving guidelines
privacy
safety
warmth
independence
anticipate needs
67
besides soap and water, what is used for bathing hygiene
chlorhexidine gluconate (CHG) wipes
68
3 musts for denture care
- washcloth in sink
- must be removed at night
- must be covered in water when not worn
69
When to obtain hair consent
- braiding
- cutting
- shaving facial hair
70
shaving techniques
- go in the direction of hair growth
- if a patient is on certain medications
(anticoagulants) use an electric razor
71
eye care technique
- no soap
- inner to outer canthus
72
when changing linens what not to do to maintain medical asepsis
do NOT place soiled linen on the floor or next to your body/scrubs
73
back/return demonstration
having patient repeat what you taught to show proficiency
74
when entering a room what two things do you always do
2 pt identifiers
hand hygeine
75
when bathing what direction do you clean
most clean to least clean
76
order of bathing body parts
1. face
2. trunk and upper extremities
3. legs
4. perineal (front-back)
5. back
6. butt (front-back)
77
client assessment during hygiene
- skin assessment
- ROM
- strength
- independence
- comfort/ pain lvl
78
culture of safety environment
blame-free environment
79
wellness pyramid (bottom -> top)
physiological needs
safety/security
love/belonging
self-esteem
self-actualization
80
RACE what does it stand for
fire safety: Remove Activate Contain Extinguish
81
"speak up" campaign purpose and who created it
Encourages the patient/family to take an active role in preventing errors (created by The Joint Commission)
82
Yellow wristband =
fall risk
82
Red wristband =
allergies
83
purple wristband =
DNR
84
Inappropriate use of restraints =
violates both state and federal regulations.
– Use in this manner constitutes abuse
85
medical protection devices
Temporary immobilization for the performance of or recovery from a medical procedure or surgical treatment
– Protects the patient from exacerbating underlying illness or injury
(ex: Splints, braces, casts)
86
what are restraint medications and when to use
Sedatives and anti-anxiety medications
-Control disruptive behavior
–Confusion, agitation, wandering,
combativeness
86
when are medications considered a "restraint"
– Not part of standard care for the condition
– Used intentionally or in excess to
specifically limit behavior
87
why to NOT use restraints
- convenience
- family pressure
- under-staffed
- decrease legal liability
- restraints do not reduce fall/injury
87
spiraling mobility
- Process where an older person is perceived to be at risk for
falling and is restrained to prevent falling
- Becomes unable to walk due to prolonged immobilization
88
hypoxic encephalopathy
- due to restraints
Causing increased confusion and disorientation, altered mental status, restlessness
89
psychological effects of restraints
Demoralization, humiliation, feelings of low self worth, depression, impaired social functioning, social isolation
90
alternatives to restraints
- re-evaluate medications
- hourly nursing rounds
- identify the cause
91
how often must the provider complete a face-to-face patient assessment for restraints?
- RN must assess a minimum of every 2
hours
- limited to 4hrs for adults; 2hrs children
- time limit for restraints 24 hrs
- know your facility policies and state laws
92
ongoing care when using restraints for patient
- restraint breaks
- call light within reach
- bed in lowest position, locked
- delegation (assessment cannot be
delegated)
93
how to tie a restraint
- quick-release knot
- 2 fingers should fit between the body
restraint
- always tied to BED FRAME
94
what is a seizure?
– Sudden, disorderly discharge of cerebral
neurons
– Characterized by sudden alteration in the
brain. function: motor, sensory and
autonomic function
95
Who is at risk for a seizure?
– Neurologic or metabolic disturbance
– Head Injury
– Brain tumor
96
generalized seizure
- tonic-clonic
- sustained involuntary muscle contractions
- 2-5 minutes, cry, loss of consciousness,
tonic-clonic movement, incontinence
– During: shallow breathing, cyanosis,
incontinence
– Postictal phase: disoriented, no recall of
event, deep sleep
97
Grand mal (or tonic-clonic)
Tonic: rigid muscles
Clonic: muscular jerking
2-5 minutes
98
Focal seizure
- Motor: muscular jerking, smacking lips,
clapping hands, blinking, chewing
- Non-motor: lack of movement, staring,
change in sensation, cognition
99
absent seizure
- Staring spells
- Last usually less than15 seconds
100
Status Epilepticus
- a seizure lasting more than 5 minutes
- 2 or more seizures within 5 minutes
101
Aura
the before of seizures
safe environment
102
During seizure
- positioning, no objects in the mouth, do
not restrain, time seizure, privacy
103
post-ictal
post seizure
- reorient
- assessment
104
seizure precautions
- padded side rails
- bed at lowest
- clutter-free environment
- access to call bell
- suction equipment at bedside
- O2 and nasal cannula at the bedside
- avoid the use of restraints
105
how to document a seizure
- the time it begins
- duration
- the time it ends
- sequence and times
- note an injuries
-not pt report of 'aura'
106
morse fall scale
simple, quick assessment tool for fall risk
high risk: 45 or higher
moderate risk: 25-44
low risk: 0-24
107
Hendrich II Fall Risk
looks at not only physical factors but medications as well
get up and go test: part of assessment
a score of 5 or greater = high risk
108
how often should fall risk be evaluated
minimum once a day
109
"if it wasn't documented it wasn't done" true or false
true (documentation)
110
who sets the standards of documentation and why?
The Joint Commission (TJC)
evaluates quality and appropriateness of client care
111
non-reimbursable events
'never' events
specific hospital-acquired/preventable conditions
112
how to begin each documentation entry
date/time and end with your signature and title
113
SOAP:
subjective, objective, assessment, plan
114
SOAPIE:
subjective, objective, assessment, plan, intervention, evaluation
115
PIE:
plan, intervention, evaluation
116
DAR:
data, action, response
117
hand-off report can be:
verbal, recorded, or written
118
SACCIA: (documentation/handoff)
Sufficiency
Accuracy
Clarity
Context
Interpersonal Adaptation
119
'Read back'
method for verification
do not 'repeat back'
120
student nurses CANNOT take phone orders. true or false
true
121
SBAR
situation background assessment recommendation
122
Paperwork cannot be given to the patient. true or false
true
123
why is immobility a critical nursing concern
increase hospital stays
increase fall risk
124
effects of immobility
metabolic changes
GI motility decreases
respiratory changes
cardiovascular changes
urinary changes
musculoskeletal changes
pressure ulcers
125
assessment of mobility
ROM
Gait
Activity Tolerance
Body alignment
body systems
126
trochanter roll
maintains hip alignment
prevents external rotation
127
supine position
laying on back
128
prone position
laying on stomach
129
semi-fowlers position
sitting at a 45-degree angle
130
lateral position
fetal position
131
sims position
fetal position with one leg up
132
Trendelenburg position
supine position head lowered feet raised
133
safe patient transfer of patient that can assist
wide base of support
lower center of gravity
134
what position to sit the pt when helping the patient walk
DANGLE the client's legs
135
how a walker should be measured
top of the walker should line with the crease of the inside of the wrist
elbows flexed 15-30 degrees
136
cane measurements
The cane length should equal the distance
between the greater trochanter and
the floor
137
how to use a cane
- Keep cane on stronger side of body
- Place cane forward 6 to 10 inches,
keeping body weight on both legs
* Weaker leg is moved forward
* Divide weight between cane and
stronger leg
* Stronger leg is advanced past cane
* Divide weight between cane and
weaker leg
137
crutches measurement
- Ensure the length of the crutch is 2-3 finger widths below the axilla
- Position the tips (bottom) about 2 inches lateral
- 4-6 inches anterior to the front of the patient’s shoes
-Handgrips: Arms should flex 20-25 degrees when upright and supporting weight on handgrips
138
Writing Learning Objectives MUST HAVE
- Condition: What teaching strategy are you going to use
- Audience: the client, the patient, the community
- Behavior: domain, level, verb, product (topic)
- Degree: 100%, correctly, consistently
139
avoid phrases:
appreciate, have faith in, know, learn, understand, believe
