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NURS 309 Exam 1 > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

What is infection?

A

Healthcare associated infections (HAIs): refers to infections associated with healthcare given in any setting.

Nosocomial infections: hospital-acquired infections; leading cause of death; Exogenous- pathogen acquired from healthcare environment & endogenous- normal flora multiply & cause infection as a result of treatment.

Anytime you get sick from a microorganism.

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2
Q

How do germs spread?

A

Contact, Airborne, Droplet.

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3
Q

The spread of infection (What are the 6 links?)

A 
Infectious agents.
Reservoir. 
Portal of exit.
Mode of transmission.
Portal of entry.
Susceptible host.
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4
Q

Portals of exit.

A 
Bodily fluids
Coughing, sneezing, diarrhea
Seeping wounds
Tubes, IV fluids
Foleys
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5
Q

Portals of entry.

A

Eyes, nares, mouth, vagina, cuts, scrapes.
Wounds, surgical sites, IV or drainage tube sites.
Bite from a vector.

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6
Q

Mode of transmission.

A

Contact:

  • Direct
  • Indirect

Droplet
Airborne

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7
Q

Susceptible host.

A 
Person with inadequate defense. 
Four determine factors:
-Virulence
-Organism's ability to survive in the host's environment
-Number of organisms
-Host's defenses.
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8
Q

What are the 3 lines of defense?

A

Primary
Secondary
Tertiary

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9
Q

What are the primary defenses?

A

Anatomical features, limit pathogen entry:

  • Skin
  • Mucous membranes
  • Tears
  • Normal flora in GI tract
  • Normal flora in urinary tract
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10
Q

What are the secondary defenses?

A

Biochemical processes activated by chemicals released by pathogens:

  • Phagocytosis
  • Complement cascade
  • Inflammation
  • Fever
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11
Q

What are the tertiary defenses?

A

Humoral immunity:
-B-cell production of antibodies in response to an antigen

Cell-mediated immunity:
-Direct destruction of infected cells by T cells

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12
Q

What are some factors that increase infection risk?

A 
Developmental stage
Breaks in the skin
Illness/injury, chronic disease
Smoking, substance abuse
Multiple sex partners 
Medications that inhibit/decrease immune response
Nursing/medical procedures
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13
Q

What are some factors that support host defenses?

A

Adequate nutrition
-To manufacture cells of the immune system

Balanced hygiene

  • Sufficient to decrease skin bacterial count
  • Not overzealous; causes skin cracking

Rest/exercise
Reducing stress
Immunizations

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14
Q

What is medical asepsis? & How is it promoted?

A

A state of cleanliness that decreases the potential for spread if infections.

Maintaining ca clean environment, clean hands, & following CDC guidelines

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15
Q

How do you maintain a clean environment?

A

Clean spills and dry surfaces promptly
Remove pathogens through chemical means (disinfect)
Remove clutter
Consider supplies brought to the room as contaminated
Consider items from the client’s home as contaminated.

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16
Q

When should you wash your hands?

A
  • When you enter & exit pt’s room
  • Before & after restroom use
  • Before & after client contact
  • Before & after contact with pt’s belongings
  • Before gloving & after glove removal
  • Before & after touching your face
  • Before & after eating
  • After touching something soiled & visible dirt on hands
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17
Q

What are the hand washing guidelines?

A

-Wash for at least 15 seconds in nonsurgical setting; 2-6mins in surgical setting
-Remove jewelry & clean beneath fingernails
-Use a bactericidal solution or use water if hands are visibly soiled
Use warm not hat water
Apply soap to wet hands
Use friction
Rinse soap
Towel or hand dry

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18
Q

What are standard precautions?

A

Protects healthcare workers from exposure, decreases transmission of pathogens, & protects clients from pathogens carried b healthcare workers.

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19
Q

What are the PPE (Personal Protective Equipment)?

A 
Gloves
Gown
Mask
Face shield
Goggles
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20
Q

Contact Precautions.

A

Pathogen is spread by direct contact.

Precautions include:
Possible private room
Clean gown & glove use
Disposal of contaminated items in the room
Double-bag linen & mark
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21
Q

Droplet precautions.

A

Spread via moist droplets.

Coughing, sneezing, contaminated objects

Precautions include:
Same as those for contact w/ addition of mask & eye protection w/in 3ft of client.

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22
Q

Airborne precautions.

A

Spread via air currents.

Precautions include:
Same as those for contact w/ addition of special room (negative air pressure), special mask (N95), & mask for patient when transported.

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23
Q

Donning & Removing of PPE

A
  • Choose appropriate PPE for situation
  • Remove safely:
    Gloves
    Gown
    Mask
    Wash hands afterwards
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24
Q

What is hygiene?

A

Activities involved in physical grooming & cleanliness. ADLs.

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25
Nurse's roles in hygiene.
Asess self-care abilities Provide assistance with ADLs & promote self-care Delegate appropriate parts of hygiene care
26
Factors that influence hygiene & self-care practices
``` Psychosocial Personal preferences Culture & religion (Different cultures focus on hygiene differently) Economic Status Developmental level (child/elderly) Knowledge level (can be delayed) ``` ``` Physical: pain limited mobility sensory deficits cognitive impairments emotional disturbances ```
27
Bathing a client facilitates:
Assessment of integumentary system & pt's functional abilities & status
28
Types of baths.
``` Assist (hard to reach areas) Partial (only areas absolutely necessary, including perineum) Bed Bath: -complete -partial -Help bath Packaged bath Towel bath Show/Tub bath Therapeutic bath ```
29
Oral care facilitates what?
``` Removal of food secretions Improved appetite Assessment of client's oral status Care of dentures *if patient is unconscious & there is no suctioning available, turn pt on their side with HOB in lowered position* ```
30
How should you bathe the areas?
Clean to dirty starting with eyes/face first Change linens Bed needs to be low, locked, rails up & call light in reach
31
What is intake?
Every fluid taken into the body. Oral fluids, IV fluids, feeding tube contents
32
What is output?
Every fluid eliminated/removed from the body. Urine, diarrhea, vomit, gastric secretions, suction, drainage output, dressing from surgical wounds, sweat.
33
Measuring I&Os
Measure in mL Total at the end of each shift & for 24 hr Family can help keep up numbers Compare over several days: trends Daily weight is the most reliable method of assessing FV status
34
Output > Input
Dehydration, hypovolemia
35
Output < Input
Fluid overload; hypervolemia
36
Signs of FVD
O > I Eyes: sunken eyes, decreased or absent tearing Mouth: dry mucous membranes, shrunken tongue Neuro: Decreased LOC; dizziness; lethargic Skin: cool & clammy CV: Increased pule rate, orthostatic hypotension GI: sunken abdomen, rapid weight loss Renal: oliguria or anuria, dark concentrated urine, specific gravity increased
37
Signs of FVE
I > O Eyes: periorbital edema, blurred vision Mouth: excessive salivation Skin: edema Respiratory: increased rate, orthopnea, crackles/bronchi CV: bounding pulse rate, increased BP GI: rapid weight gain in 24 hours Renal: decreased urine specificity gravity, diuresis, dilute urine
38
Normal I&O
>1500 mL/day (2-3Ls unless restricted) Oral intake should be approx 600 mLs greater than output UOP should be >30 mL/hr, if less notify MD
39
Health care personnel are at high risk for what kind of injuries & in what settings?
Over use injuries in the hospital (2x), nursing home (3x), & ambulance (5x) due to them not having a lot of resources, more patients are less mobile and mobility issues when moving or lifting patients.
40
Body mechanics.
``` Feet spread apart. Minimize bending and twisting. Bend knees (dont bend at waist) Lift with leg muscles Keep objects close Use both hands DONT stand on tip toes IF possible, avoid lifting! Push, Slide, Pull Keep elbows bent ```
41
What are some safety factors?
Developmental status Individual Environment (home, community, hospital). Children & elderly are the most likely to get hurt.
42
Falls
Number 1 cause of injuries and deaths from injury among older Americans. Always do a fall assessment
43
Fall prevention
``` Fall education Assisting with ambulation Slip resistant footwear Fall risk identifier (fall arm band) Clear environment fo hazards Pt room near nurse's station 1:1 supervision Bed alarms: weight comes off bed, alarm goes off Padding floor around bed could help ```
44
Restraints
LAST RESORT!! Meant to prevent harm. Belt, Vest or jacket, Wrist or ankle, Mitt. Mechanical device: Enclosed bed, canopy bed & all side rails up
45
Restraint Safety
- Try less restrictive measures 1st - Must obtain MD's order (timing of order to be determined by facility protocol). - Order must be renewed t least q24 - MUST educate pt on need - REMOVE ASAP - REMOVE q2 and assess pt and sites - Test ROM, make sure they go to the bathroom, eat, drink, etc. , check for bruising, friction - Nurses decide when to take them out of restraints
46
Semi-Fowlers
``` HOB elevated 45 degrees Small pillow Support arms and hands on pillows Small pillow under thighs Small pillow under ankles "Float heels" ```
47
High Fowlers
``` HOB elevated 90 degrees Small pillow Support arms and hands on pillows Small pillow under thighs Small pillow under ankles "Float heels" ```
48
Trendelenberg
Bed flat with feet elevated and head down
49
Reverse Trendelenberg
bed flat with head elevated and feet down
50
Correct position is vital to what?
Promote comforr Prevent injury Provide sensation
51
Supine position
HOB flat Small pillow under lumbar area, if not contraindicated Pillow under head, neck & shoulders Trochanter rolls parallel to lateral surface of thighs Float heels: pillow under ankle Use footboard or high top sneakers to prevent foot drop Pillows under forearms Hand rolls or splints
52
Prone
Roll pt to one side with arms alongside body (arm on turning side) Roll pt over arm-keep arm close to body with elbow straight & hand under hip Postion on abdomen in center of bed Turn head to one side & support with small pillow Place small pillow under ab Place arms in flexed position at shoulders Support lower legs with pillows to elevate toes
53
30 degree lateral (side-lying)
``` Lower HOB Postion pt to side of bed opposite side being turned on Flex knees and turn pt on side Pillow under back to support Pillow under head & neck Bring dependent shoulder forward Postion arms in slightly flexed position Support upper shoulder & arm with pillow Place pillow under semi flexed upper leg ```
54
Sims (semiprone)
Lower HOB Place in supine postion Roll pt on side Postion on lateral side, lying partially on abdomen Life depends shoulder & place arm at side Small pillow under head Pillow under flexed upper arm & upper leg
55
Logrolling
Requires three people -2 on one side to be turned towards -1 on turning from side Small pillow between knees Cross arms on chest Use draw sheet One nurse grabs draw sheet at lower hips & thighs Other nurse grabs draw sheet shoulders & lower back Roll as unit in one smooth, continuous motion "single nurse" places pillows along the length of pt for support or cleans pt Gently lean the pt as a unit back towards the pillows for support or back on the surface of the bed
56
Canes
Hold on stronger side | Move cane simultaneously with weaker side
57
Walker
Pick up walker to move forward as stepping forward | Dont advance to far to cause reaching
58
Crutches
``` Make triangle with crutches 6 inches ahead of body Multiple gaits based on need Stairs: -Up with the good -Down with the bad ```
59
Active ROM
Pt is doing themselves
60
Passive ROM
Nurse is performing it or someone else
61
ROM
Move 4-5 times Can be delegated At least q2 or twice a day Used to prevent stiffness, promote circulation, & Avoid getting blood clots
62
TCDB
Turn Cough Deep Breath Encourages lung expansion & mobilizes secretions Place pt in Fowler's If ab or Ches incision, provide pillow to splint & brace site Teach pt to breath with diaphragms slowly After 2-3 breaths, encourage pt to lean forward & cough
63
Incentive spirometer
- Helps pt take deep breaths after surgery to prevent respiratory complications - Visual method to measure & encourage lung expansion
64
TEDs
Thromboembolic devices. Promote venous return by maintaining pressure on superficial veins & prevent venous pooling. Prevent passive dilation of veins and tears. Find correct measurement/size Remove when out of bed to prevent injury or use slippers if up briefly Remove once a shift for 15-30minutes
65
SCDs
Sequential compression devices Air pump, connecting tubing, & sleeves that sequentially inflate & deflate Drives superficial blood into deep veins & prevents venous stasis/pooling Remove when out of bed Watch placement of tubing/pump (Always face outside of body) *Fall risk*
66
Hypoglycemic
Levels drop too low to provide enough energy BG level= Below 70 mg/dl Onset: often sudden, may pass out if untreated Causes: too little foo or skipped meal, too much insulin or diabetes meds. more active than usual Treatment: - Check BG - Administer sugar containing foods (hard candies, 4 oz juice, non-diet soft drink, 8 oz milk), SL glucose paste or dextrose 50% IV - Recheck BG in 15 mins - Follow with well balanced meal contains complex carbs if able to take PO
67
Hyperglycemic
Levels are too high, there is too much that it can't be used for fuel Causes: too much food, too little insulin, illness or stress BG levels= Above 200 mg/dl Onset:gradual; may progress to diabetic coma if untreated Treatment: - Check BG levels - Contact MD - Administer insulin as ordered (per sliding scale) - Continue to assess pt & recheck BG level
68
Normal BG range
80mg/dl - low-mid 100s | Diagnosis of diabetes- >200 mg/dl & symptoms of hyperglycemia present
69
Fasting BG
Normal is less than 110 mg/dl | glucose checked after a period of not eating
70
Hypoglycemia symptoms
``` headache impaired vision hunger irritability weakness/fatigue sweating dizziness fast Heart beat Shaking Anxiety ```
71
Hyperglycemia symptoms
``` extreme thirst hunger headache going to the bathroom a lot blurred vision dry skin feeling drowsy feeling sick to stomach ```
72
What types of pt might require BG testing?
Diabetics (insulin dependent & nondependent) Pt receding TPN Pt started on enteral feedings Pt receding corticosteroids Pt who BG may be temporarily elevated due to stress of illness

NURS 309 Exam 1 (1 decks)

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