Foundations Exam #2 Flashcards
(38 cards)
What are the local signs of infection?
Redness, swelling, heat, pain, pus.
What are the systemic signs of infection?
Fever, chills, fatigue, elevated WBCs, malaise, increased HR/RR, confusion.
List risk factors for infection.
- Age (very young/old)
- Immunosuppression (chemo, HIV, steroids)
- Chronic disease (diabetes, COPD)
- Breaks in skin or mucosa
- Invasive devices (catheters, IVs)
- Surgery
- Poor nutrition or hygiene
- Crowded environments (hospitals, long-term care)
What subjective assessments should be made for infection?
Ask about fatigue, chills, localized pain, burning during urination, cough.
What objective assessments should be made for infection?
Inspect wounds/lines for redness, swelling, discharge; check temp trends; listen for abnormal lung sounds; labs: ↑ WBCs, positive cultures, ↑ CRP or ESR; monitor vitals.
Define medical asepsis.
Medical asepsis, or clean technique, involves procedures and practices that reduce the number and transfer of pathogens.
Define surgical asepsis.
Surgical asepsis, or sterile technique, includes practices used to render and keep objects and areas free from microorganisms.
What are the WHO’s 5 Moments of Hand Hygiene?
- Before touching a patient
- Before a clean or aseptic procedure
- After a body fluid exposure risk
- After touching a patient
- After touching patient surroundings
What is the order for donning PPE?
- Hand Hygiene
- Gown
- Mask or Respirator
- Goggles or Face Shield
- Gloves
What is the order for doffing PPE?
- Gloves
- Goggles or Face Shield
- Gown
- Mask or Respirator
- Hand Hygiene
True or False: Standard Precautions apply to all patients, regardless of diagnosis.
True.
What are Transmission-Based Precautions (Tier 2)?
- Contact
- Droplet
- Airborne
Give examples of pathogens requiring Contact Precautions.
- Multi-drug resistant organisms (MDROs)
- Clostridium difficile
- Noroviruses
- GI tract pathogens
What are the manifestations of hypoxia in the early stages?
- Tachypnea
- Tachycardia
- Restlessness, anxiety, confusion
- Pale skin and mucous membranes
- Elevated blood pressure
What are the late manifestations of hypoxia?
- Cyanotic skin, mucous membranes
- Bradypnea
- Bradycardia
- Hypotension
- Cardiac dysrhythmias
What are the types of drains used in wound care?
- Penrose Drain
- Portable Wound Bulb Suction (Jackson-Pratt JP)
- Hemovac
- Negative Pressure Wound Vacuum
What does the Braden Scale assess?
Rates a client’s risk for alterations in tissue integrity using 6 categories: sensory perception, moisture, activity, mobility, nutrition, friction and shear.
What is the purpose of enhanced barrier precautions?
To reduce the spread of multidrug-resistant organisms (MDROs) in healthcare settings.
What is the highest risk factor for developing a CAUTI?
Prolonged use of the urinary catheter.
What are the complications of wound healing?
- Infection
- Hemorrhage
- Hematoma
- Fistula
- Dehiscence
- Evisceration
What is gas exchange?
The process of oxygen entering the bloodstream and carbon dioxide exiting.
What are the early signs of respiratory distress?
- Increased work of breathing (WOB)
- Coughing
- Cyanosis
- Orthopnea
- Changes in respiratory rate or rhythm
What are the nursing interventions to promote respiratory function?
- Coughing and deep breathing
- Incentive spirometry
- Flutter valve
- Chest physiotherapy and postural drainage
- Suctioning
- Breathing techniques
What is the typical flow rate for a nasal cannula?
1-6 L/min.
