Flashcards in Exam 1 Deck (137):
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
Universal precautions for all patients
"I will plan a feast"
Introduce and identify (checking DOB and name)
What is the current hand washing compliance rate?
Warm water and soap for at least 20 seconds
Wearing gloves NEVER eliminates the need for proper hand hygiene!
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
factors affecting safety
Ability to communicate
Physical health state
5 types of accidents
3 focus points for safety assessment
Specific risk factors
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.
Factors that contribute to falls
History of falls
Impaired vision or balance
Altered gait or posture, impaired mobility
Slowed reaction time; weakness, frailty
Confusion or disorientation
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
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.
Nursing interventions for the patient at risk for falls
Orient the patient their environment
Explain and demonstrate bed, side rails
Telephone, TV, Bathroom
Fall prevention contract
Keep bed in lowest position
Keep 2 siderails up
Provide a clean uncluttered environment
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
Safety Precautions for Side Rail Use
Ensure they are working properly
Pad side rails as needed
Minimize the risk of the patient climbing OOB
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
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
Steps in the event of a fire (RACE)
Evacuate and or Extinguish
Due to the activity of a physician or therapy
Catheter-Associated Urinary Tract Infections
Central Line-Associated Bloodstream Infection
What are the 4 most common sites for HAI?
1. Urinary tract infections
2. Surgical site infections
3. Bloodstream infections
What are the six links of the infection cycle?
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
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
What are the 7 atypical signs and symptoms of infection in the elderly?
Delayed fever response
Failure to thrive
What 6 types of patients are most at risk for skin injury?
Poorly nourished/poorly hydrated
Infant and elderly skin
5 Times for Scheduled/Routine hygiene care
Why is bathing a patient important?
Cleansing the skin
Helps relax a person
Stimulating the rate and depth of respirations
Providing sensory input
Help to improve self image
Strengthen the nurse-patient relationship
What 9 types of patients are at high risk for oral care hygiene issues?
Oral airways/ ET tubes
s/p oral surgery
Antiembolic Stockings (TEDS)
Prevention of Phlebitis, thrombi formation
Apply prior to getting OOB
good for diabetics
Intermittent Pneumatic Compression Stockings
Promote venous return
3 points of bed safety
Linens clean and dry, wrinkle free
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
Protective supine position
patient lies flat on back, could lead to skin breakdown and foot drop
Protective prone position
side-lying position, pillow under head, under arm at stomach and under calf, top knee up
Protective side-lying or lateral position
side-lying position, pillow under head, under arm at stomach and under calf
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
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
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
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.”
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.
4 phases of wound healing
4. maturation/remodeling phase
hemostasis phase of wound healing
Formation of platelet plug
Formation of stable fibrin clot
inflammatory phase of wound healing
Removal of bacteria and cellular debris
Limit amount of tissue damage
proliferation phase of wound healing
Regenerative or connective tissue phase
maturation/remodeling phase phase of wound healing
Collagen is remodeled
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.
normal respiratory rate
adult 16- 20 breaths per minute
normal Oxygen Saturation
O2 sat - >95%
What is the function of the upper airway?
To warm, filter, humidify inspired air
What are the 3 functions of the lower airway?
1. Conduction of air
2. mucous clearance
3. production of pulmonary surfactant
Bronchial breath sounds
normal breathing sound: high-pitched and longer, heard primarily over the trachea
Vesicular breath sounds
normal breathing sound: low-pitched, soft sound during expiration heard over most of the lungs
Bronchovesicular breath sounds
normal breathing sound: medium pitch and sound during expiration, heard over the upper anterior chest and intercostal area
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
How many lobes do each of the lungs have?
Right: 3, Left: 2
What is the location of the lungs?
Extend from the base of the diaphragm to the apex above the first rib
What are the 4 components of the lower airway?
2. Right and left main stem bronchi
3. Segmental bronchi
4. Terminal bronchioles
What are the 4 components of the upper airway?
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
True or false: Wheezes are continuous, musical sounds, produced as air passes through airways constricted by swelling, narrowing, secretions, or tumors.
Excessive posterior thoracic curvature - hunchback
Excessive anterior lumbar curvature - swayback
an abnormally low concentration of oxygen in the blood.
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
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.
Normal pulse oximeter readings
Normal = 95-100%
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.
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
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.
4 main types of supplemental oxygen apparatuses
1. nasal canula
3. partial rebreather mask or non-rebreather mask
4. venturi mask
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)
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.
Endotracheal tube or ET
tracheal tube that is nearly always inserted through the mouth (orotracheal) or nose (nasotracheal)
an incision in the windpipe made to relieve an obstruction to breathing
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:
Speak using vocal cords
Cough out secretions (mucous) through the mouth
What is the optimal oxygenation percentage for patients with an artificial airway?
nasal canula: delivery amount/min and percentage of oxygen
mask delivery amount/min and percentage of oxygen
partial rebreather mask or non-rebreather mask delivery amount/min and percentage of oxygen
***non-rebreather mask delivers highest percentage of O2
venturi mask delivery amount/min and percentage of oxygen
What should you always do prior to disconnecting a patient from ventilator?
What's the maximum amount of time you can suction a trach, and how deep?
10-15 seconds -- only 4 inches (10cm)
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
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
Tidal Volume (TV)
the normal volume of air displaced between normal inhalation and exhalation when extra effort is not applied
Vital Capacity (VC)
the amount of air displaced by maximal exhalation
Forced Vital Capacity (FVC)
Forced vital capacity (FVC) is the total amount of air exhaled during the FEV test
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.
Total Lung capacity (TLC)
the amount of air contained within the lungs at maximum inspiration
Residual Volume (RV)
the amount of air left in the lungs at maximal expiration
Peak Expiratory Flow Rate (PEFR)
the maximum flow attained during the forced expiratory maneuver
deliver a controlled dose of medication with each compression of the canister
Dry powder inhalers
breath-activated delivery of medications
open narrowed airways
True or False? A meter-dosed inhaler delivers a controlled dose of medication with each compression of the canister.
5 steps of the nursing process
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
3 steps when writing a nursing diagnosis
1. identify the problem
3. Defining characteristics
3 types of nursing goals
1. Cognitive (patient teaching)
2. Psychomotor (change in skill)
3. Affective (change in beliefs, attitudes)
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
How often should patients be turned?
Every 2 hours
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
when a patient sits up and they feel dizzy/weak
axillary vs. lofstrand crutches
axillary are temporary, lofstrand is for longer term
lateral movement of a body part away from the midline of the body
lateral movement of a body part toward the midline of the body
2 key developmental activity milestones for 3-6 month infant
- ability to sit
- head control
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
2 key developmental activity milestones for 9-12 month infant
- progresses towards unassisted walking
- is able to pick up small objects
by 15 months, most toddlers can
by 18 months, most toddlers can
by 2 years, most toddlers can
by 3 years, most toddlers can
stack blocks, string large beads, work simple puzzles, dress themselves
by age 4, most children should be able to
negotiate stairs, walk backwards, hop on 1 foot
by age 5, most children should be able to
skip, jump rope, jump off heights of several steps
normal adult temperature range
normal adult range of pulse beats/min
normal adults range of respirations (breaths/min)
normal adult blood pressure mm/Hg
alternating periods of deep, rapid breathing followed by periods of apnea (regular)
associated with drug overdose, heart failure, increased intracranial pressure, renal failure
varying depth and rate of breathing followed by periods of apnea; irregular
associated with meningitis, severe brain damage
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
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
increased concentration of carbon dioxide in the blood
a medical emergency in which decreased ventilation (hypoventilation) increases the concentration of carbon dioxide in the blood and decreases the blood's pH
what is the last step in making an occupied bed?
lower the bed to its lowest position
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
a surgical complication in which a wound ruptures along surgical suture
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.
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
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.
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.