exam Flashcards
(140 cards)
1
Q
Chain of infection
A
Infectious agent susceptible hose reservoir portal of entry portal of entrance mode of transmission
2
Q
PPE Contact
A
Gloves and Gown
3
Q
PPE Droplet
A
Gloves, Gown, Mask and goggles
4
Q
PPE Airborne
A
Gloves, Gown, N-95 Mask
5
Q
PPE Contact and Droplet
A
Gloves, Gown, Mask, Goggles
6
Q
Inflammatory Response
A
trauma, fever, swelling, redness, pain, tired
7
Q
Hand Washing
A
30-60 seconds, nails fingers palms wrists
8
Q
Integument Assessment ( body hygiene)
A
Skin
Feet
Hands
Hair
9
Q
Serous Drainage
A
watery clear plasma
10
Q
Purulent Drainage
A
thick yellow, brown or tan
11
Q
Serosanguineous drainage
A
mixture of blood and water plasma
12
Q
Sanguineous drainage
A
Active Bleeding
13
Q
Granulation Tissue
A
Red, moist tissue means healing
14
Q
Slough Tissue
A
Necrotic Tissue
Yellow, white tissue. must be removed before healing can happen
15
Q
Eschar tissue
A
Necrotic Tissue
Black or Brown necrotic tissue, which needs to be removed before healing: bUT DO NOT RIP OFF.
16
Q
Assessing a wound
A
REEDA and TACO
17
Q
REEDA
A
Redness Edema (swelling) Ecchymosis ( bruising ) Drainage Approximation (size)
18
Q
TACO
A
Type of drainage
Amount of drainage
Color and consistency
Odour of drainage.
19
Q
Acute Wound
A
Wound that heals within a specific time ( surgical wounds)
20
Q
Chronic Wound
A
Wound that does not heal in a proper time frame
21
Q
Vascular Ulcer
A
Caused by poor blood return
22
Q
Arterial Ulcer
A
caused by bad blood flow
23
Q
Primary Intention
A
Clean cut wounds
heal quicker
usually surgical wounds
24
Q
Secondary Intention
A
jagged edges
longer healing time
scar is larger and more visible
higher infection risk
25
Tertiary intention
Wound is left open because of infection or contamination
26
3 phases of wound healing
Inflammation
Proliferative
Remodeling
27
Management of pressure ulcer
Clean with Saline or warm soapy water
centre to outside
cover with sterile dressing
28
Cleaning a Wound
```
hand hygiene
wound size, location, history
patient level of comfort
review orders for dressing change
explain
ppe as needed
```
29
Blanching
pressing on skin
| turns white
30
Abrasion wound
superficial with little bleeding
31
Laceration Wound
Unintentional, jagged, bleeding depends on depth and location
32
Puncture Wound
Small
circular
edges coming together in the centre
may cause bleeding underneath skin
33
Braden Scale Measures
Sensory perception, moisture, activity, mobility and nutrition
34
First thing you do when you walk into a patients room
NOD and Assess
35
Ethical principle around restraints
Least Resort
36
Wound Cultures
Clean Wound with NON-antisceptic solution ( sterile water or normal saline)
use sterile swab from culture tube
37
Prevent Stomache wound splits
Having a patient hold a folded thin blanket or pillow while coughing
38
Prone Position
Laying on your stomach
39
Supine position
Laying on your back
40
Lateral position
Laying on your side
| Good for body alignment assessments
41
Fowlers Position
Sitting up at a 45 degree angle
42
Low Fowlers Position
Sitting up right at a 30 degree angle
43
Trendallenber position
laying on your back with your feet up and head down
44
Reversed Trendallenber position
Laying on your back with your head higher then your feet
45
Positioning Devices
```
Pillow (provides support elevates body)
Wedge ( Maintains legs in abduction)
Footboot (prevents foot drop by maintaining foot in dorsiflexion)
Trochanter Roll (prevents external rotation of hips)
Sandbags
handrolls
Splints
Trapeze bar
```
46
Assistive Devices for walking
Crutches
Canes
Walkers
47
Vector Borne
Insects or pests that contain infections
48
Vehicle
is a contaminated source
49
Direct contact
Skin to Skin
50
Indirect contact
Touching a contaminated surface
51
Droplet
Is a large particle can travel up to 2 meters
52
Nosocomial
Something that can happen in a health care setting.
53
Micro-organism
Seen only with a microscope
bacteria
viruses
fungi
54
Micro-organisms that cause disease
Pathogens
55
Our Bodies Natural Defences against Infections
Normal Flora: Natural in our bodies
| In Specific Body Systems: Lungs
56
4 Moments of hand hygiene
1) As you enter the room or new environments
2) Before an aseptic procedure (sterile)
3) After any bodily fluid exposure ( even with gloves)
4) As you exit an environment
57
Necrotic Tissue
Non-Viable dead tissue that must be removed in order for a wound to heal
Eschar and Slough are Necrotic Tissues
58
What is the principle of least restraint
- The Principle of Least restraint ensures that all other measures or interventions are attempted before moving to the use of restraints. Also that the type or form of restraint is appropriate for the patients needs and safety.
- Restraints should always be a measure of last resort.
- Restraints are purposed as part of the medical treatment and ONLY A SHORT TERM intervention
59
What are the different types of restraints?
Physical Restraint
Chemical Restraint
Environmental Restraint
60
The objectives that must be met and followed for restraints.
- They reduce the risk of patient injury
- They prevent interruptions of patients therapy, such as IV, nj, gtubes. and so on.
- They are used to prevent the patient from removing life support
- and reduce the risk of harm to others by the patient.
61
The 7 rights of medication delivery:
```
Right patient
Right medication
Right Route
Right Time
Right Dose
Right Reason
Right Documentation.
```
62
Alternatives to Restraints
- Remove obstacles that promote a patient leaving ( elevators not in sight, stair cases, or street clothing)
- Promote relaxation and normal sleep patterns
- Evaluate all medications that the patient is receiving, and ensure effective pain management.
- Use calm simple statements and physical cues as needed.
63
Autonomy
is ones ability to make choices by themselves, this is based on full understanding and free of controlling influence from others.
64
Beneficence
Doing or promoting good for others.
| The the patients safety and wellbeing is more important then self-interest.
65
Nonmaleficence
The avoidance of harm or hurt
| trying to balance the risks and benefits of a plan of care while trying to not to cause harm, or least harm possible
66
Changes related to aging that increase risk of accidents
- Musculoskeletal changes: Muscle strength and function decrease, joints become less mobile
- Nervous System Changes: sensitivity to touch decreases, reflexes slow down
- Sensory Changes: vision can be effected, risk of cataracts, pain and light touch threshold increases, hearing is impaired.
- Genitourinary Changes: incontinence increases with age.
67
Body's Defences against Infection
Normal Flora
Inflammation
Body System Defences
68
Direct Contact
Skin to Skine
69
Indirect contact
Touching a contaminated surface
70
Droplet
Large particles that can travel up to 2 meters
71
Airborne
small particles that can stay in the air for long periods of time.
72
Vector Born
Transferred by bugs or insects
73
Nosocomial
Something you get in a health care setting
74
Medical Asepsis
Clean Technique : procedure used to reduce the spread of microorganisms.
Hand Hygiene, clean gloves
means the prevention of infection
75
Sterile Asepsis
Means the absence of infection
76
Factors that influence personal hygiene practices
Social Practices : the type of hygiene products
Personal preferences : when to bathe or shave and what products they want to use.
Body Image: general appearance will reflect what personal hygiene practices one may hold. This can reflect a person emotional or mental status as well.
Socioeconomic status: a persons economic status can influence a person hygiene practices used. : Lack of resources
Health Beliefs or motivation: Lack of knowledge can have a impact on how a persons personal hygiene
Cultural variables
physical condition.
77
Physiology of the urinary system
```
Kidneys
Ureters
Bladder
Urethra
Micturination
```
78
Kidneys
Remove waste from the blood to make urine
79
Ureters
Move Urine from the Kidneys to the bladder
80
Bladder
Stores urine until the need to urinate occurs
81
Urethra
Urine travels from the bladder through the urethra until it passes outside the body
82
Micturination
Urination: When the neurological responses allow the bladder to contract, release and push the urine to leave the body.
83
Psychological factors affecting urination
Anxiety or stress
this can either cause the stopping of urination or make the urge to urinate more frequent.
Privacy
84
SocioCultural factors affecting urination
Cultural Practices
Gender or religious practices
Transportation or cost
Language barriers
85
Fluid Balance affect on urination
Alcohol, caffeine and increase in fluid intake increase your urination.
balance of electrolytes also increases urination
86
Diagnostic Examinations affect on urination
Exams that cause short term incontinence. Damage to the bladder.
87
Common Alterations in urinary elimination
Incontinence
Retention
Nocturia
Urinary Diversion
88
Incontinence
Involuntary loss of urine
| Stress or urgency
89
Urine Retention
Inability to empty bladder
90
Nocturia
Urination at night
91
Urinary Diversion
Stoma that is placed to divert the flow of urine from the kidneys directly to the abdominal surface
Trauma
cancer
Chronic cystitis
92
Oliguria
Decreased production of urine
93
Anuria
No Urine production
94
Dysuria
Painful or difficult urination
95
Hematuria
Blood in urine
96
Symptoms of urinary Alterations
```
Incontinence
Urgency
Dysuria
Frequency
Polyuria
Oliguria
Nocturia
Dribbling
Hematuria
Elevated postvoid residual urine.
```
97
Urine Assessment
```
Intake and output of fluids
Colour
Odor
Clarity
Amount
```
98
Type of Urine Collection
Random Specimen ( routine urinalysis or other tests)
Clean-void ( midstream) Sterile specimen cup
Catheter specimen
Timed Urine Specimen.
99
Random Specimen
Routine Urinalysis or other tests
100
Clean-void or midstream specimen
Sterile Specimen cup is used to collect urine and a aseptic technique is used ( surgical technique)
101
Catheter Specimen
Aseptic technique through special port. Risk for CAUTI
102
CAUTI
Catheter associated Urinary Tract Infection.
103
Promoting Regular Urination
Stimulating Miturination reflex
Maintaining elimination habits
Maintaining adequate fluid intake
104
Types of catheters
Coude Catheter
Indwelling or foley catheter
Intermittent straight catheter
Triple Lamen
105
Coude Catheter
Curved tip used for male patients with large prostate
106
Indwelling or Foley Catheter
Longer periods of time in bladder
| small balloon holds it agains the bladder neck
107
Intermittent straight catheter
Used for 5-10 min to release urine from bladder but taken out after elimination.
108
Methods of measuring urine output
Urometer
| Urine hat
109
Practices to avoid catheter infections CAUTI
Hand Hygiene
Closed urinary drainage system
Monitor potency of catheter system
110
Closed urinary drainage system
A break could lead to microorganisms being introduced
111
Monitoring patency of catheter systems
Prevent urine from pooling in the tubes and allowing bacteria to form
this could possibly create an infection if it is pooled back into the body.
112
Indwelling catheter perineal care
at least done twice daily
after a bowel movement
or as needed
soap and water or skin cleansers will help reduce the amount of microorganisms at the enterance of the urethra
be careful not to push the catheter inwards as this could introduce bacteria.
113
Urinary Diversions
Ureterostomy
Nephrostomy
ill conduit
Continent pouch
114
Ureterostomy
Bringing the end of one or both ureters to the abdominal surface
115
Nephrostomy
A tube placed directly into the renal pelvis yo give urinary drainage
116
ileal conduit
Separating a loop of intestinal ileum with blood supply still intact.
117
Continent Pouch
Provides urinary storage in a leak proof pouch.
118
Factors affecting bowel elimination
```
Diet : Fibre
Fluid intake: needed to liquify intestinal contents
Physical Activity
Personal bowel elimination habits
Privacy
```
119
Common Bowel Elimination Problems
```
Constipation
Impaction
Diarrhea
Bowel Incontinece
Flatulence
Hemorrhoids
```
120
Constipation
Is a symptom not a disease
infrequent bowel movements
abdominal pain, sensation of being full
straining during defecation
121
Fecal Impaction
unrelieved constipation can cause overflow incontinence
| harden feces wedged in the rectum that can not be removed.
122
Diarrhea
increase in the number of stools a day
passage of liquid
infections
food intolerances
medications
intestinal disease
cause fluid and electrolyte imbalances
123
Bowel Incontinence
inability to control the passing of faces and gas.
diet
fluid intake
alcohol
nicotine
124
Flatulence
accumulation of gas in the intestines
| causes abdominal fullness, pain and cramping.
125
Hemorrhoids
dilated engorged veins in lining of the rectum
| external or internal
126
Stoma
Permanent or temporary opening in the abdominal wall
| The ends of the intestines are brought through the abdominal wall to create a stoma
127
Ileostomy
Surgical opening in the ileum
has the
Kock continent ileostomy
128
Colostomy
```
Surgical opening in the colon
usually has
Loop Colostomy
End Colostomy
Double Barrel Colostomy
```
129
Kock Continent ileostomy
Small intestine
| creates a pouch and the use of a catheter to drain
130
Loop Colostomy
```
Usually done in a medical emergency
Temporary and large
Made in the transverse colon
Proximal end drains stool
Distal end drains mucus
```
131
End Colostomy
One Stoma
| Distal portion of GI tract is either removed or sewn shut
132
Double-Barrel Colostomy
Bowel is surgically cut and both ends are brought out onto the abdominal wall
Proximal is functioning
Distal is nonfunctioning.
133
Transverse Colon
More solid, formed stool
134
Ascending Colon
More frequent and more liquid
135
Descending Colon
Near normal Stool
136
Documenting an Ostomy
Stoma characteristics
Peristomal Skin
Pouch system used
Amount, Colour and Odour.
137
Resperitory effects of deconditioning
Hyperventilation
Decreased lung expansion
Impaired gas exchange
138
Circulatory effects of Deconditioning
Drecreased cardiac output
| Venous pooling
139
Integumentary effects with Deconditioning
Shearing of skin during movement
| Decreased delivery of oxygen and nutrients to tissues
140
Musculoskeletal effects of Deconditioning
Reduced muscle mass
| Impaired joint mobility
