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Flashcards in Foundations Weeks 1-3 Deck (124)
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1

Describe the 4 main links of the chain of infection (there were 6 in the book but he only listed 4)

Source (wound, water, people, object), portal of entry (sx site, catheter), portal of exit (sputum, emesis, stool, urine, blood, wound drainage, genital secretions), and susceptible host.

2

Name 5 modes of transmission

Contact, droplet, airborne, vehicle, vector-borne

3

Define asepsis

To make free from disease-producing organisms

4

Define sepsis

The poisoning of tissues

5

Name 2 infections that are contact precaution

MRSA and c-dif

6

Name 3 infections that are droplet precaution

Influenza, pertussis, meningitis

7

Name 3 airborne infections

TB, measles, coronavirus

8

Name 2 vehicle-borne infections

Salmonella, e. coli

9

Name 3 carriers in vector-born infections

Mosquitoes, contaminated needles, ticks

10

What precautions do you take with airborne transmission?

N-95, eye protection, negative pressure rooms
Particles last HOURS

11

What precautions do you take with droplet transmission?

Level-1 mask (no gown or face shield needed. Particles last only minutes)

12

What are the minimum precautions you take with contact transmission?

Gloves and gown

13

Which of these actions are ways to protect yourself from needle stick injuries: SATA :)
- Never recap a needle
- Engage safety lock feature on needles
- Make sure to recap needles in emergencies
- Use puncture-proof sharps containers

- Never recap a needle
- Engage safety lock feature on needles
- Use puncture-proof sharps containers

14

Name 4 strategies the CDC says will decrease infection risk

1. Used of bundled practices for invasive procedure or tx
2. Expedient doses and treatment (blood cultures, etc)
3. Careful det'd of appropriate antimicrobial therapy
4. Following appropriate precautions for specific illnesses

15

Name 3 ways of achieving medical asepsis

Hand hygiene, using barriers (gloves, gown, etc), sterilizing

16

When should you use soap and water for hand hygiene?

When physically dirty
When around c-dif, spores, etc (vomiting, diarrhea)
When you eat
After using the bathroom

17

When is alcohol-based hand hygiene acceptable?

In between rooms
No visible soiling of hands
Between gloves

18

True or false: Using lotion with gloves is bad because it can break them down and make them more permeable

True

19

What is the term for the chemical or physical process to remove pathogens?

Disinfection

20

What is a process used to destroy everythinggggg, like ....even spores?

Sterilization

21

Name a few ways sterilization can be achieved

Heat, gas, chemicals

22

When should you always wear gloves (SELECT ALL THAT APPLYYYYYY)?

- When dealing with a pt with broken skin
- While examining mucus membranes for cap refill
- When taking a BP
- When dealing with body fluids

- When dealing with a pt with broken skin
- While examining mucus membranes for cap refill
- When dealing with body fluids

23

What PPE should you wear if splash or drainage is anticipated

Mask + gown

24

What do you don for protective isolation pts (ex: immunocompromised) ? (also called NEUTROPENIC PRECAUTIONS/REVERSE ISOLATION)

Gloves, gown, mask

25

What are some examples of when sterile technique is used (surgical asepsis)?

- Surgery
- Any procedure that involves blood
- When skin is being broken as part of a procedure
- Some dressing changes
- When caring for immunocompromised pts

26

Which historical nurse was the leader of asepsis, the cleaning of wounds, and infection prevention.

Florence Nightingale

27

Which historical nurse was instrumental in the formation of the Army Nurse Corp?

Dorthea Dix

28

Which historical nurse founded the Red Cross?

Clara Barton

29

What does SBAR stand for?

Situation
Background
Assessment
Recommendation

30

Name for moving a joint toward the middle of the body?

Adduction

31

Name for moving a joint away from the midline of the body?

Abduction

32

Name for decreasing the angle between two bones?

Flexion

33

Name for straightening a joint?

Extension

34

Name for turning the body or a body part to face upward?

Supination

35

Name for turning the body or a body part to face downward?

Pronation

36

What is paraplegia?

Paralysis of the legs and lower body

37

What is hemiplegia?

Paralysis of one side of the body

38

What is tetraplegia?

Paralysis of all four limbs

39

What does the Nurse Practice Act govern?

What you can do legally; varies by state; developed by Board of Nursing

40

What are some issues coming up with antibiotics concerning drug resistance?

Over-prescribing, using wrong one, not taking as prescribed, not finishing treatment

41

Does sepsis cause hypo- or hypertension?

HYPOtension

42

What would you use for hand hygiene post C. diff client?

Nonantimicrobial soap + h2o

43

What kind of mask do you need for TB?

N95

44

When would you remove a mask in between patients?

Airborne or droplet
Soiled/wet mask

45

What electrolytes are most important for the musculoskeletal system?

Potassium, vitamin D, phosphorus, vitamin B

46

Define isotonic exercise

Dynamic w/constant tension, movement, contraction (bicep curls); tonic=constant movement

47

Define isometric exercise

Static exercises – tense muscle, hold stationary (holding a yoga pose)

48

What is another word for decreased muscle tone?

Hypotonicity

49

What is another word for increased or rapid muscle tone

Spasticity

50

What is a rhythmic/repetitive motion; can happen at rest?

Tremor

51

What is a spontaneous brief involuntary muscle twitch or limbs or face?

Chorea

52

What is the term for a gait characterized with wide feet and described as duck-like?

Waddling

53

What is the progressive shortening of muscle; loss of joint mobility; fibrous material?

Contracture

54

What is the largest reportable problem related to mobility?

FALLS

55

What are some types of pain that can be caused by immobility?

- Kidney stones (renal calculi – from imbalance between osteoblasts and osteoclasts-->increased blood calcium level)
- Atrophy (“use it or lose it”)
- Contractures
- Joint pain (decreased flexibility)

56

What are some cardiovascular issues that come from decreased mobility?

- Increased cardiac workload: when supine, heart must work harder to perfuse body
- Thrombus formation: due to decreased venous stasis
*immobility does NOT increase blood viscosity, but dehydration impacts this*
- When immobile, baroreceptors not used as much ---> orthostatic hypotension

57

Why does thrombus formation occur with decreased mobility?

Decreased venous stasis*

*immobility does NOT increase blood viscosity, but dehydration impacts this*

58

When immobile, __________ are not used as much so orthostatic hypotension can occur.

Baroreceptors

59

S/s of orthostatic hypotension?

Dizziness, weakness, light headed, hypotension, diaphoresis, SOB

60

What issues can immobility cause with bone?

Imbalance between osteoblasts and osteoclasts (increased blood calcium levels)

61

What is the most frequent site of pressure ulcers?

Sacrum

62

What is atelectasis?

Alveolar collapse

63

What happens to the lungs with immobility?

Decreased lung expansion

64

S/s of decreased lung expansion?

- Immobile client breathes less deeply and w/more effort
- Decreased coughing ability
- Atelectasis (alveolar collapse)
- Pneumonia risk

65

How does immobility affect nitrogen levels in the body?

Negative nitrogen balance:

- Immobility increases rate of protein breakdown (excretion > intake)
- Body doesn’t have enough nitrogen for protein synthesis (impaired wound healing)
- Slow muscle restoration when mobility resumes

66

Why is constipation a possible complication with immobility?

Atrophy of GI muscles, dehydration, rectal filling slow in supine position

67

Examples of activities or programs to recommend (SATA)

Tai chi
Group activities
Gymnastics
Membership to local health club
Strength training
PT

Tai chi
Group activities
Membership to local health club
Strength training
PT

68

What is osteoporosis?

Low bone mass, deterioration of bone tissue

69

Risk factors of osteoporosis? SELECT EM ALL FRENS

- premenopausal
- family history
- history of fractures
- alcohol
- cigarette smoking
- prolonged immobility

- premenopausal (No, it's POSTmenopausal)
- family history
- history of fractures
- alcohol
- cigarette smoking
- prolonged immobility

70

Trendelenberg position is:

Head 30-40° lower than feet

71

Semi-fowlers position is:

30-45° sitting

72

Fowlers position is:

80-90° sitting

73

Prone position is:

Face down (great for oxygenation)

74

Lithotomy position is:

Supine with hips flexed; examinations

75

When a hand roll is used as a positioning aid, what does it help prevent?

Contracture

76

Cane basics:

- Maintain ___ points of support ALWAYS
- Cane on __________ side
- Move cane forward _______
- Move weak leg _____ distance as cane
- Move strong leg forward and ____ cane/weaker leg

- 2
- stronger
- first
- same
- past

= 1st cane, 2nd weak leg, 3rd strong leg

77

What is an EHR?

Electronic Health Record

78

Disadvantages of EHR?

Expensive and difficult to implement

79

Advantages of EHR?

Legible, standardization of info, graphs for trends, access off-site

80

What are the main elements of documentation?

Privacy: HIPAA, accurate (only observations YOU observed), concise and complete, objective, organized and timely (document as you go along!)

81

There are 8 million types of documentation records. Which two of these do NOT belong?

- Admission Entry or Admission Assessment
- Flow Sheet
- Plan of Care Assessment
- Clinical Pathway
- Draw Sheet
- Atelectasis Notation
- Narrative Progress Notes
- Nursing Discharge Notes

Atelectasis Notation and Draw Sheet

LOLZ

82

What is the Admission Entry or Admission Assessment?

• Extensive background questionnaire
• ie Any cultural beliefs that affect care?

83

What do you find on a Flow Sheet? What is a benefit of a Flow Sheet?

• Vital signs
• Assessment
• Lab data

These allow trends to be easily seen

84

What do you find in a Plan of Care Assessment?

• Care plan
• Concept map

85

What is a Clinical Pathway?

Used for clients with specific and generally predictable conditions, it guides care, identifies progression of client. Is different from a care plan in that’s its more related to a specific medical procedure.

86

What is included in the Nursing Discharge Summary?

• Expectations after discharge
• Follow-up appointments
• When to reach out for assistance

THIS BEGINS AT INTAKE!

87

What are Narrative Progress Notes?

Relevant client and nursing activities throughout shift in a narrative format; easiest to learn; allows for detail; takes time; difficult to pick out important details

88

What are 3 acronyms for types of taking Narrative Progress notes?

• SOAP
• PIE
• FOCUS

89

What is a SOAP note?

Subjective
- What patient expresses
Objective
- Vital signs, lab data
Assessment
- A “conclusion” based on the S and O
Plan
- What nursing interventions are used to address the
conclusion

90

Disadvantage of SOAP notes?

Unable to be used for general charting

91

What is a PIE note?

- Problem
- Intervention
- Evaluation

Good way to focus on nursing problem; problem is that it’s NOT interdisciplinary

92

What is a FOCUS (DAR) note?

- Data
- Action
- Response

Great for teaching pt something at discharge. Pt education. Disadvantage: Not used by other health professionals.

93

What is it called when nurses document only what is abnormal? This is the exception to "if you didn't chart it, you didn't do it."

Charting by exception

94

What documentation occurs when there is an error?

Incident report

95

T/F: Always put in your notes when you made an incident report

False. Never note this. It should not be a part of the patient's chart.
(SO SKETCH.)

96

List a few examples of things that would lead to an incidence report?

- Falls
- Medication errors
- Equipment malfunction
- Injury to client/visitor/employee

97

What does SBAR stand for?

- Situation
- Background
- Assessment
- Recommendation

98

When do you use a verbal order?

Emergencies only! Use call-out and call-back
technique.

99

If a verbal order is not an emergency, what should you do?

Request that provider put in the order, nicely :)

100

What is a handoff?

Report given whenever another person is assuming care for the patient.

101

When should you do a handoff?

Traveling to get a test, going for a procedure, changing hospitals, shift change.

102

How should report be given to the next shift?

- Given at client’s bedside
- Concise + accurate

103

What is another word for the ability to perform primary functions (feeding, toileting, bathing, dressing)?

Self care

104

What are the physical benefits of bathing (SATA)?

Remove bacteria
Allows skin assessment
Promotes circulation
Hydration
Maintain muscle tone
Maintain joint mobility

Remove bacteria
Allows skin assessment
Promotes circulation
Maintain muscle tone
Maintain joint mobility

105

What are the psychosocial benefits of bathing?
Mo SATA

- Client relaxation
- Rapport with nurse
- Promotes well-being
- Promotes circulation
- Client comfort

- Client relaxation
- Rapport with nurse
- Promotes well-being
- Client comfort

(Circulation is a physical benefit)

106

What is a sitz bath? What/who/when does it benefit?

Used to cleanse, soothe, reduce inflammation of perineal or vaginal area (post childbirth, rectal surgery, hemorrhoids/fissures)

107

Benefit of a hot water bath?

Relieve muscle spasms and soreness

108

What kind of bathing is considered general bathing?

Warm water bath.

109

When would you use a cool water bath?

Relieve muscle tension, decrease body temp when febrile

110

Why would you use a soak bath?

To soften or loosen secretions, reduce pain and swelling in inflamed skin

111

Best temp to keep general bath water?

Between 110°-115°F

112

Name some factors that affect self care.

- Environment (homelessness, safety, accessibility, wheelchair ramp)
- Motivation (mental health, cognitive abilities: confusion, delusion, doing everything for them)
- Energy (meds, disease states that impact o2 and energy levels)
- Illness, surgery
- Pain
- Neuromuscular fxn/sensory deficits (tremors)

113

Concerning levels of self care rating 0-4, the ______ the level, the more dependent the patient is rated

Higher

0: completely independent
1: use equipment or devices to perform self-care activities INDEPENDENTLY
2: requires assistance or supervision from another to complete activities
3: requires assistance or supervision AND uses equipment/devices (DEPENDENT)
4: completely depends on another person to perform self-care activities

114

What do feet with poor perfusion look like?

Cold and dusky

115

What do feet with poor perfusion possible indicate?

Decreased healing
Increased fall risk
Decreased sensation
Increased risk of infection

116

SELECT ALL THAT APPLY as important for diabetic foot care:

Inspect daily
Clean with cold water + soap
Dry carefully, esp between toes
Cut toenails straight across
No lotion between toes

Inspect daily
NOT Clean with cold water + soap -- w/WARM water
Dry carefully, esp between toes
Cut toenails straight across
No lotion between toes

117

What is a flat, thickening of skin; usually bony prominence?

Callus

118

What is a cone shaped lesion; usually 4th or 5th toe over joint?

Corn

119

What are round, irregular, flat warts; often painful?

Plantar warts

120

What are inflammation/thickening of bursa of great toe joint?

Bunions

121

What is red, scaly, cracking skin esp in between toes

Tinea pedis (athlete’s foot)

122

What is the treatment for lice (hair and clothes)?

Hair: pyrethrin and permethrin every 9-10 days
Clothing: extreme temps for 5 minutes (hot h2o + hot air)

123

What are two things you might call in a speech therapist for?

Swallow evals; appropriate diet

124

What does an OT focus on?

ADLs