Foundations Exam 1 - pt2 Flashcards by Janelle Evans

what are the guidelines for bathing and privacy?

Privacy
Safety
Warmth
Independence
Needs

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what are the national patient safety goals?

Identify patients correctly
- 2 identifier factor
Improve staff communication
- Teach back show back
- SBAR
Use medicines safely
Use alarms safely
Prevent infections
Identify patient safety risks
Prevent mistakes in surgery

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what is wrong with this diagnosis “ineffective airway clearance”

must be related to something “related to weak cough”

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what must you do when planning as a nurse?

create measurable goals and outcomes

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active vs passive ROM

active - pt moves themselves
passive - pt is moved by something else

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sleep apnea

airway blocked during sleep

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insomnia

trouble staying or falling asleep

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narcolepsy

sleep paralysis

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sleep deprivation

emotional stress and environment

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parasomnias

sleep walking, night terrors, nocturnal enuresis (bedwetting), nightmares

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what is the #1 way to prevent infection

hand hygiene

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steps in the chain of infection

Infectious agent or pathogen
Reservoir or source for growth (grow and multiply)
Portal of exit (blood or skin or mucous membranes or GI tract)
Mode of transmission
Portal of entry - to host
Susceptible host (age, nutritious, immunosuppressant, stress, trauma, smoking)

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nosocomial

hospital-acquired infection

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steps in the infection process

1 - incubation period
2 - Prodromal Stage
3 - Illness stage - SXS manifest as type of injection
4 - Convalescence - SXS start to disappear

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what are the modes of transmission

1 - Direct contact: person to person
2 - Indirect contact: surface to person
3 - Droplet: up to 3ft, cough and sneeze
4 - Airborne: carried on dust, evaporated droplets

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serous

clear

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Sanginour

bloody

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purulent

pus

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what are types of healthcare acquired infections

Latrogenic - from a procedure
Exogenous - from microorganisms outside the individual
Endogenous - pts flora becomes altered and overgrowth occurs

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what are the steps in wound healing

1 - Inflammatory
2 - Proliferation
3- Remodeling

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what is the inflammatory phase

Histamine and vasodilation
Wbcs move to wound area to inject debris and promote healing
Albumin tells you how much protein is in the body - need protein to heal
Pain, swelling, heat

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what is the proliferation phase

New blood cells and capillaries grow
Thin layer of granulation tissue forms

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what is the remodeling phase

Collagen is remodeled and deposited
Scar tissue becomes thin white line

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what is primary vs secondary intention

primary - surgical wound (approximated edges)
secondary - loss of tissue (burn, ulceration)

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what are 3 complications of wound healing

1. Hemorrhage - collection of blood under tissue 2. Dehiscence - incision reopens 3. Evisceration - complete opening of wound (organs start to come out)

blanchable vs non-blanchable

blanchable - skin turns white, then lift up and turns red/back to skin color non-blanchable - does not turn back to red, it is a stage 1 pressure ulcer

what factors are included in the Braden Scale

Moisture Friction + shear Sensory perception Activity Mobility Nutrition

what are the classifications of pressure ulcers

1 - Intact skin with non-blanchable redness 2 - Partial-thickness skin loss involving epidermis, dermis, or both 3 - Full-thickness tissue loss with visible fat 4 - Full-thickness tissue loss with exposed bone, muscle or tendon 5 - unstageable

actual loss

occurs when you can no longer hear, feel, see, or know a person

perceived loss

defined by the individual experiencing the loss

grief

an individualized response to a loss, actual or perceived

what things might be needed to document after death

time of death autopsy needed organ donation 2 factor identification

why is the HOB elevated after death

to reduce discoloration in the face

what common medications make your urine different colors

1 - Anticoagulants - red 2 - Diuretics - pale yellow 3 - Pyridium - orange 4 - Elavil - green, blue-green 5 - Levodopa - brown / black

dysuria

painful urination

glycosuria

glucose in urine

pyuria

pus in urine

anuria

no urine

oliguria

low urine output

nocturia

need to void at night

bacteriuria

bacteria in urine

hematuria

blood in urine

proteinuria

protein in urine

what are bladder scan measurements

<50 is adequate emptying >150 needs catheter

dysphagia

difficulty swallowing

what is the biggest warning sign of dysphagia

cough and choking during eating

what is aspiration pneumonia (complication of dysphagia)

liquid and food gets into the lungs

what are the categories of dysphagia liquids

Thin - low viscosity Nectar - medium viscosity Honey - honey viscosity Spoon - pudding viscosity

what is enteral nutrition and the reasoning for its use

nutrition through GI tube - pt is unable to chew, swallow, digest

what are the types of enteral feeding tubes

1. Nasogastric (NG) 2. Nasointernal (NI -nasojejunal -nasoduodenal 3. Enterostomal -gastronomy -jejunostomy

what is a nasojejunal tube used for

used for pt with GERD or aspiration - tube goes beyond stomach into intestinal area

what are short term vs long term enteral feedings

short - NG and NI long - enterostomal

when should a nasogastric/internal tube not be used

1. At risk for aspiration : HOB should be elevated to 30-45 degrees for 2 hrs after feed 2. Nasal injuries (CANNOT have trauma to the face)

how do you know NGT is in the right place

must get portable xray before beginning feeding - ph levels <5.5 in stomach and >7 in intestines

difference between levin and dobhoff tubes

levin - thick feedings dobhoff - small, long term use

what are the Enterostomal tubes

PEQ - in LUQ - directly into the stomach PEJ - through abdomen into small intestine

what is gastric residual

if food is being absorbed or not in the stomach (I&O must equal)

PPN vs TPN

TPN - total parenteral nutrition - central line PPN - peripheral parenteral nutrition - peripheral line

what must be checked in a pt with parenteral nutrition

blood sugar

purpose of PPN and TPN

TPN - promotes healing, is highly concentrated PPN - less dense, short term nutrition (supplement)

peristalsis

movement of muscles in GI tract

what are 2 types of enemas

cleansing - clean intestines retention - lubricate the stool

Ostomy appliance in textbook*****

image of enteral tube locations****

Sigmoid colostomy

LLQ formed stool

Transverse colostomy + loop colostomy

RUQ semi-formed / pasty stool

Ileostomy

RLQ liquid to pasty

End colostomy

LLQ almost formed