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Flashcards in Exam 1 Deck (137):
1

5 Moments for Hand Hygiene

1. Before touching a patient
2. Before a clean or aseptic procedure
3. After a body fluid exposure risk
4. After touching a patient
5. After touching patient surroundings

2

Universal precautions for all patients

"I will plan a feast"

Introduce and identify (checking DOB and name)
Wash hands
Privacy
Allergies
Falls risk

3

What is the current hand washing compliance rate?

Below 50%

4

Handwashing

Warm water and soap for at least 20 seconds

Wearing gloves NEVER eliminates the need for proper hand hygiene!

5

Use Hand Sanitizers:

- Before direct contact with patients
- After direct contact with patients
- After contact with body fluids, mucous membranes, non-intact skin, and wound dressings, if hands are not visible soiled
- After removing gloves
- After touching equipment
- Before and after gloves

6

factors affecting safety

Developmental considerations
Lifestyle
Mobility
Sensory perception
Knowledge
Ability to communicate
Physical health state
Psychosocial state

7

5 types of accidents

1. MVC
2 Falls
3 Poisonings
4 Drowning
5 Fire

8

3 focus points for safety assessment

The person
The environment
Specific risk factors

9

True or false: Among adults older than 65, fires are the leading cause of injury fatality.

False. Among adults older than 65, falls are the leading cause of injury fatality.

10

Factors that contribute to falls

Age >65
History of falls
Impaired vision or balance
Altered gait or posture, impaired mobility
Medication regimen
Postural hypotension
Slowed reaction time; weakness, frailty
Confusion or disorientation
Unfamiliar environment

11

Nursing diagnoses for falls

Risk for injury r/t impaired mobility
Risk for injury r/t visual deficit

Risk for trauma r/t weakness
Risk for trauma r/t hx of previous falls

12

patient outcomes for safety

Identify real and potential unsafe environmental situations.
Implement safety measures in the environment.
Use available resources for safety information.
Incorporate accident prevention practices into ADLs.
Remain free of injury.

13

Nursing interventions for the patient at risk for falls

Orient the patient their environment
Explain and demonstrate bed, side rails
Call bell
Telephone, TV, Bathroom
ID Bracelet
Agency routine
Fall prevention contract
Keep bed in lowest position
Keep 2 siderails up
Provide a clean uncluttered environment
Provide hydration
Have patient wear non-slip foot wear
Assist patient with ambulation
Make safety rounds
Assist patient toileting every 2 hrs and prn
Move patient closer to the nurses station
Involve the family
Use a bed check system
Facilitate the removal of tubes/catheters ASAP
Provide a companion
Use of restraints

14

Safety Precautions for Side Rail Use

Ensure they are working properly
Pad side rails as needed
Minimize the risk of the patient climbing OOB

15

5 components of a restraint order when filing?

1. Type of restraint
2. Justification for use
3. Criteria for removal
4. Intended duration of restraint
5. Orders are specific and never PRN

16

5 key components of restraint documentation

1. Date time and type of restraint applied
2. Alternatives that were tried and the results
3. Notification of the provider and family
4. Frequency of assessment, your findings, when restraint is removed and nursing interventions
5. Need to release, feed and toilet q 2hrs

17

Steps in the event of a fire (RACE)

Rescue
Alarm
Contain
Evacuate and or Extinguish

18

Nosocomial

Hospital-acquired infection

19

Iatrogenic

Due to the activity of a physician or therapy

20

CAUTI

Catheter-Associated Urinary Tract Infections

21

CLABSI

Central Line-Associated Bloodstream Infection

22

VAP

Ventilator-Associated Pneumonia

23

What are the 4 most common sites for HAI?

1. Urinary tract infections
2. Surgical site infections
3. Bloodstream infections
4. Pneumonia

24

What are the six links of the infection cycle?

1. Pathogen
2. Reservoir
3. Portal of exit
4. Means of transmission
5. Portal of entry
6. New host.

Note: Each link can be interrupted, or 'broken', through various means

25

What are the basic principles of surgical asepsis

- Only a sterile object can touch another sterile object
- Open sterile packages away from you
- Hold sterile objects above the waist
- Avoid reaching over your sterile field
- DO NOT turn your back on your sterile field
- Items in contact with broken skin or penetrate the body should be sterile
- The outer 1 inch border of a sterile field is considered clean

26

What are the 7 atypical signs and symptoms of infection in the elderly?

Confusion
Lethargy
Anorexia
Delayed fever response
Falls
Urinary incontinence
Failure to thrive

27

What 6 types of patients are most at risk for skin injury?

Poorly nourished/poorly hydrated
Poor circulation
Infant and elderly skin
Excessive perspiration
Jaundice
Fluid loss

28

5 Times for Scheduled/Routine hygiene care

Awakening
After breakfast
After lunch
Bedtime
PRN Care

29

Why is bathing a patient important?

Cleansing the skin
Helps relax a person
Promotes circulation
Musculoskeletal exercise
Stimulating the rate and depth of respirations
Providing sensory input
Help to improve self image
Strengthen the nurse-patient relationship

30

What 9 types of patients are at high risk for oral care hygiene issues?

Seriously ill
Comatose
Dehydrated
Confused
Paralyzed
Mouth breathers
NPO
Oral airways/ ET tubes
s/p oral surgery

31

Antiembolic Stockings (TEDS)

Prevention of Phlebitis, thrombi formation
Apply prior to getting OOB
good for diabetics

32

Intermittent Pneumatic Compression Stockings

Promote venous return

33

3 points of bed safety

Lowest position
Wheels locked
Linens clean and dry, wrinkle free

34

Fowler's position

45-60 up in the bed

Semi-Fowler's position: lying in bed in a supine position with the head of the bed at approximately 30 to 45 degrees

Upright at 90 degrees is full or high Fowler's position

*remember to keep head in alignment with the spine to prevent neck flexion

35

Protective supine position

patient lies flat on back, could lead to skin breakdown and foot drop

36

Protective prone position

side-lying position, pillow under head, under arm at stomach and under calf, top knee up

37

Protective side-lying or lateral position

side-lying position, pillow under head, under arm at stomach and under calf

38

The provider's admitting orders indicate that the client is to be placed in Fowler’s position. Upon positioning this client, how much will the nurse elevate the bed?

45 to 60 degrees

39

An obstetrical nurse is preparing to help a patient up form her bed and to the bathroom three hours after the woman delivered her baby. Which of the following actions should the nurse perform first?

Explain to the patient how the nurse will assist her

40

The nurse and assistant are preparing to move a patient up in bed. Arrange the following steps in the correct order:

1. Adjust the head of the bed to a flat position.
2. Place a friction-reducing sheet under the patient.
3. Ask the patient to bend legs and place the chin on the chest.
4. Position the assistant on the side opposite you
5. Remove all pillows from under the patient
6. Grasp the sheet and move the patient on the count of 3.

1, 5, 4, 2, 3, 6

41

A nurse is placing a patient in Fowler’s position. What should the nurse teach the family about this position?

“Do not raise the knees with the knee gatch.”

42

The nurse is helping a patient walk in the hallway when the patient suddenly reaches for the handrail and states, “I feel so weak. I think I am going to pass out.” Which of the following initial actions by the nurse is appropriate?

Support the patient’s body against yours and gently slide the patient onto the floor.

43

4 phases of wound healing

1. hemostasis
2. inflammatory
3. proliferation
4. maturation/remodeling phase

44

hemostasis phase of wound healing

Formation of platelet plug
Formation of stable fibrin clot

45

inflammatory phase of wound healing

Removal of bacteria and cellular debris
Limit amount of tissue damage

46

proliferation phase of wound healing

Regenerative or connective tissue phase

47

maturation/remodeling phase phase of wound healing

Collagen is remodeled
Scar formation

48

RYB wound classification

Red: the color of healthy granulation tissue -- means that wound is healthy, and normal healing is underway. When a wound begins to heal, a layer of pale pink granulation tissue covers the wound bed. As this layer thickens, it becomes beefy red.

Yellow: A yellow color in the wound bed may be a film of fibrin on the tissue. Fibrin is a sticky substance that normally acts as a glue in tissue rebuilding. However, if the wound is unhealthy or too dry, fibrin builds up into a layer that can't be rinsed off and may require debridement. Tissue that has recently died due to ischemia or infection also may be yellow and must be debrided.

Black: A black wound bed signals necrosis (tissue death). Eschar (dead, avascular tissue) covers the wound, slowing the healing process and providing microorganisms with a site in which to proliferate. When eschar covers a wound, accurate assessment of wound depth is difficult and should be deferred until eschar is removed.

49

normal respiratory rate

adult 16- 20 breaths per minute

50

normal Oxygen Saturation

O2 sat - >95%

51

What is the function of the upper airway?

To warm, filter, humidify inspired air

52

What are the 3 functions of the lower airway?

1. Conduction of air
2. mucous clearance
3. production of pulmonary surfactant

53

Bronchial breath sounds

normal breathing sound: high-pitched and longer, heard primarily over the trachea

54

Vesicular breath sounds

normal breathing sound: low-pitched, soft sound during expiration heard over most of the lungs

55

Bronchovesicular breath sounds

normal breathing sound: medium pitch and sound during expiration, heard over the upper anterior chest and intercostal area

56

Crackles (3 classifications, example patient)

Crackles are an abnormal breathing sound: they are intermittent sounds occurring when air moves through airways that contain fluid

Classified as fine, medium, or coarse

e.g. patients with pulmonary Edema/heart failure

57

How many lobes do each of the lungs have?

Right: 3, Left: 2

58

What is the location of the lungs?

Extend from the base of the diaphragm to the apex above the first rib

59

What are the 4 components of the lower airway?

1. Trachea
2. Right and left main stem bronchi
3. Segmental bronchi
4. Terminal bronchioles

60

What are the 4 components of the upper airway?

1. Nose
2. Pharynx
3. Larynx
4. Epiglottis

61

Wheezes (2 classifications, example patient)

Continuous sounds heard on expiration and sometimes on inspiration as air passes through airways constricted by swelling, secretions, or tumors

Classified as sibilant or sonorous

e.g. patient with asthma

62

True or false: Wheezes are continuous, musical sounds, produced as air passes through airways constricted by swelling, narrowing, secretions, or tumors.

True

63

Kyphosi

Excessive posterior thoracic curvature - hunchback

64

Lordosis

Excessive anterior lumbar curvature - swayback

65

Scoliosis

Lateral curvature

66

Hypoxemia

an abnormally low concentration of oxygen in the blood.

67

Hypoventilation

Also known as respiratory depression -- occurs when ventilation is inadequate (hypo meaning "below") to perform needed gas exchange

Causes an increased concentration of carbon dioxide (hypercapnia) and respiratory acidosis

68

Which statement best describes Respiration?

A. The exchange of gases and carbon dioxide in the lungs.
B. The movement of air into and out of the lungs through the act of breathing.

A

69

Normal pulse oximeter readings

Normal = 95-100%

70

Incentive spirometer

device used to help keep lungs healthy after surgery or when you have a lung illness, such as pneumonia

The patient breathes in from the device as slowly and as deeply as possible, then holds his/her breath for 2–6 seconds. This provides back pressure which pops open alveoli. It is the same maneuver as in yawning. An indicator provides a gauge of how well the patient's lung or lungs are functioning, by indicating sustained inhalation vacuum. The patient is generally asked to do many repetitions a day while measuring his or her progress by way of the gauge.

71

Chest Tube Drainage apparatus

a flexible plastic tube that is inserted through the chest wall and into the pleural space or mediastinum. It is used to remove air or fluid (pleural effusion, blood, chyle), or pus (empyema) from the intrathoracic space

72

Nebulizer

a drug delivery device used to administer medication in the form of a mist inhaled into the lungs

disperse fine particles of liquid medication into the deeper passages of the respiratory tract

commonly used for the treatment of cystic fibrosis, asthma, COPD and other respiratory diseases.

73

4 main types of supplemental oxygen apparatuses

1. nasal canula
2. mask
3. partial rebreather mask or non-rebreather mask
4. venturi mask

74

oropharyngeal airway

an airway adjunct used to maintain or open a patient's airway by preventing the tongue from covering the epiglottis (which could prevent the unconscious person from breathing)

75

nasopharyngeal airway

a tube that is inserted into the nasal passageway to secure an open airway

When a patient becomes unconscious, the muscles in the jaw commonly relax and can allow the tongue to slide back and obstruct the airway. The purpose of the flared end is to prevent the device from becoming lost inside the patient's nose.

76

Endotracheal tube or ET

tracheal tube that is nearly always inserted through the mouth (orotracheal) or nose (nasotracheal)

77

Tracheostomy

an incision in the windpipe made to relieve an obstruction to breathing

78

Fenestrated trach tube

similar to other trach tubes but has the added feature of having one or more holes in the outer cannula, which allow air to pass from your lungs up through your vocal cords and out through your mouth and nose

It lets the patient:
Breathe normally
Speak using vocal cords
Cough out secretions (mucous) through the mouth

79

What is the optimal oxygenation percentage for patients with an artificial airway?

>95%

80

nasal canula: delivery amount/min and percentage of oxygen

deliver 1-6L/min

24-44% O2

81

mask delivery amount/min and percentage of oxygen

deliver 6-10L/min

35-60% O2

82

partial rebreather mask or non-rebreather mask delivery amount/min and percentage of oxygen

deliver 6-15L/min

60-100% O2

***non-rebreather mask delivers highest percentage of O2

83

venturi mask delivery amount/min and percentage of oxygen

4-10L/min

24-55% O2

*most precise

84

What should you always do prior to disconnecting a patient from ventilator?

Hyper oxygenate

85

What's the maximum amount of time you can suction a trach, and how deep?

10-15 seconds -- only 4 inches (10cm)

86

3 aspects of airway maintenance

1. Assisting ventilation
2. Clear an obstructed airway
3. Cardiopulmonary resuscitation (CPR)
- assess the patient
- activate code team
- begin CPR

87

Which lung value is the amount of air contained within the lungs at maximum inspiration?
A. Vital capacity
B. Total lung capacity
C. Residual volume
D. Peak expiratory flow rate

B. Total lung capacity

88

Tidal Volume (TV)

the normal volume of air displaced between normal inhalation and exhalation when extra effort is not applied

89

Vital Capacity (VC)

the amount of air displaced by maximal exhalation

90

Forced Vital Capacity (FVC)

Forced vital capacity (FVC) is the total amount of air exhaled during the FEV test

91

Forced Expiratory Volume (FEV)

measures how much air a person can exhale during a forced breath. The amount of air exhaled may be measured during the first (FEV1), second (FEV2), and/or third seconds (FEV3) of the forced breath.

92

Total Lung capacity (TLC)

the amount of air contained within the lungs at maximum inspiration

93

Residual Volume (RV)

the amount of air left in the lungs at maximal expiration

94

Peak Expiratory Flow Rate (PEFR)

the maximum flow attained during the forced expiratory maneuver

95

Meter-dose inhalers

deliver a controlled dose of medication with each compression of the canister

96

Dry powder inhalers

breath-activated delivery of medications

97

Bronchodilators

open narrowed airways

98

True or False? A meter-dosed inhaler delivers a controlled dose of medication with each compression of the canister.

True

99

5 steps of the nursing process

1. Assessment
2. Diagnosis
3. Plan
4. Implement
5. Evaluation

100

medical diagnosis vs. nursing diagnosis (example of each)

MD: deals with disease or medical condition

ex: a medical diagnosis of Cerebrovascular Attack (CVA or Stroke) provides information about the patient’s pathology

ND: deals with human response to actual or potential health problems and life processes.

ex: nursing diagnoses of Impaired verbal communication, risk for falls, interrupted family processes and powerlessness provide a more holistic understanding of the impact of that stroke on this particular patient and his family – they also direct nursing interventions to obtain patient-specific outcomes

101

3 steps when writing a nursing diagnosis

1. identify the problem
2. etiology
3. Defining characteristics

102

3 types of nursing goals

1. Cognitive (patient teaching)
2. Psychomotor (change in skill)
3. Affective (change in beliefs, attitudes)

103

What is an example of a type of flora that's normal in one part of the body but that may be pathogenic in another?

Ecoli in rectum is OK; when it gets in vagina, it causes UTI

104

How often should patients be turned?

Every 2 hours

105

Log rolling

Moving a patient with two people on one side, one person on the other, and one to make sure the neck alignment is maintained with spine

counting to three and announcing movement

for suspected spinal injury

106

postural hypotension

when a patient sits up and they feel dizzy/weak

107

axillary vs. lofstrand crutches

axillary are temporary, lofstrand is for longer term

108

abduction

lateral movement of a body part away from the midline of the body

109

adduction

lateral movement of a body part toward the midline of the body

110

2 key developmental activity milestones for 3-6 month infant

- ability to sit
- head control

111

5 key developmental activity milestones for 6-9 month infant

- sits steadily
- rolls over
- creeps on all fours
- pulls to standing position
- has improved hand-eye coordination

112

2 key developmental activity milestones for 9-12 month infant

- progresses towards unassisted walking
- is able to pick up small objects

113

by 15 months, most toddlers can

walk unassisted

114

by 18 months, most toddlers can

run

115

by 2 years, most toddlers can

jump

116

by 3 years, most toddlers can

stack blocks, string large beads, work simple puzzles, dress themselves

117

by age 4, most children should be able to

negotiate stairs, walk backwards, hop on 1 foot

118

by age 5, most children should be able to

skip, jump rope, jump off heights of several steps

119

normal adult temperature range

35.8-37.5 C
96.4-99.5 F

120

normal adult range of pulse beats/min

60-100

121

normal adults range of respirations (breaths/min)

12-20

122

normal adult blood pressure mm/Hg

120/80

123

cheyne-stokes respirations

alternating periods of deep, rapid breathing followed by periods of apnea (regular)

associated with drug overdose, heart failure, increased intracranial pressure, renal failure

124

Biot's respirations

varying depth and rate of breathing followed by periods of apnea; irregular

associated with meningitis, severe brain damage

125

How to check pulse

1. place first 3 fingers over peripheral artery
2. count pulses for 30 seconds - multiply by 2 to get the rate for 1 minute

*if anything is abnormal, count the full 60 seconds

126

how to check respirations

watch the rise and fall of the patient's chest - count the number of respirations for 30 seconds and multiply by 2

*if anything is abnormal, count the full 60 seconds

127

PRN

as needed

128

hypercapnia

increased concentration of carbon dioxide in the blood

129

respiratory acidosis

a medical emergency in which decreased ventilation (hypoventilation) increases the concentration of carbon dioxide in the blood and decreases the blood's pH

130

what is the last step in making an occupied bed?

lower the bed to its lowest position

131

what is healing by primary intention?

Wound healing by primary intention is typical for noncomplicated surgical wounds. Wound edges are approximated and kept together with sutures or staples and healing occurs by wound epithelialisation and connective tissue deposition. These wounds usually heal quickly provided there is no infection.

Ex. cuts from a kitchen knife

132

wound dehiscence

a surgical complication in which a wound ruptures along surgical suture

133

what are muscle contractures?

A muscle contracture is a permanent shortening of a muscle or joint. It is usually in response to prolonged hypertonic spasticity in a concentrated muscle area, such as is seen in the tightest muscles of people with conditions like spastic cerebral palsy.

134

Stage I Pressure Ulcer

Intact skin with non-blanchable redness of a localized area usually over a bony prominence

Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area

The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue

135

Stage II Pressure Ulcer

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough

May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister

Presents as a shiny or dry shallow ulcer without slough or bruising*

This category should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation.

*Bruising indicates deep tissue injury.

136

Stage III Pressure Ulcer

Full thickness tissue loss

Subcutaneous fat may be visible but bone, tendon or muscle are not exposed

Slough may be present but does not obscure the depth of tissue loss

May include undermining and tunneling

The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers.

137

Stage IV Pressure Ulcer

Full thickness tissue loss with exposed bone, tendon or muscle

Slough or eschar may be present

Often includes undermining and tunneling

The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow

Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur