Fundamental Final Exam Flashcards
All powerpoints from fundamentals class combined (369 cards)
1
Q
Normal Urine Productions
A
30 ml/hr
2
Q
Urination Involuntary Control
A
1) Stretch receptors in bladder stimulate urge
2) Detrusor Muscles contracts and sphincter relaxes
3
Q
Urination Voluntary Control
A
1) Initiating
2) Stopping
3) Interrupting
4
Q
Should Urinate Every?
A
Q 3-4 Hours
5
Q
Urination Factors Decreasing with Age
A
1) Decreased ability to concentrate urine (Wake up throughout the night to pee)
2) Decreased bladder tone
3) Decreased bladder contractility
6
Q
5 Things Influencing Urination
A
1) Food and Fluid Intake
2) Activity and Muscle Tone (Less ability to contract will have urination issues)
3) Pathology
4) Age
5) Medications
7
Q
UTI
A
Urinary Tract Infection
8
Q
CKD
A
Chronic Kidney Disease
9
Q
AKD
A
Acute Kidney Disease
10
Q
What does Pyridium do to urine?
A
Turns Urine Orange
11
Q
What does Euritum do to urine?
A
Turns Urine Blue
12
Q
What does Morphine do to the bladder?
A
Makes the bladder asleep and urine wont come down
13
Q
Does Dementia affect Urination?
A
Yes, dementia can affect how someone urinates
14
Q
What should you assess with fluid intake and voiding history for a patient?
A
What their normal is
15
Q
What should you use to check post void residuals?
A
A bladder scanner (Can see how much urine is left in the bladder after normal urination)
16
Q
Urine Characteristics
A
1) Volume over 24-hour period
2) Color-Clarity-Odor
17
Q
What can a routine urinalysis see in the urine?
A
Sugar and Bacteria
18
Q
How much urine does a routine urinalysis need?
A
10 mL
19
Q
Culture and Sensitivity urine test does what?
A
Discovers the name of the bacteria, we know what antibiotics will treat that bacteria and what it is resistant to
20
Q
CCMS = ?
A
Clean Catch Urine Sample
21
Q
How to get a CCMS?
A
Clean perineal area well, let first outlet of urine go into toilet, and then start urinating again and fill cup with urine.
22
Q
Collections
A
All urine that someone produces in 24 hours
23
Q
How to collect a collections?
A
Have patient empty bladder and discard that urine and then start collecting for 24 hours after that. Ex. 7am - 7am
24
Q
BUN Normal Levels
A
8-23
25
What does BUN measure in urine?
Gross indication of protein breakdown
26
If BUN is elevated this means?
Urine is not being filtered correctly
27
Creatinine normal levels
0.6-1.2
28
Creatinine measures what in urine?
Kidney Function
29
GFR stands for?
Glomerular Filtration Rate
30
What does a level of >60 GFR indicate?
Renal Disease
31
GFR is the best test for what?
Determining renal disease and stage
32
Adequate fluid intake
2-3 L a day
33
Is Urinary Incontinence a normal part of aging?
NO
34
Types of Incontinence
1) Stress
2) Overflow
3) Functional
35
What is Overflow Incontinence?
The brain does not get the signal from the bladder to urinate and bladder overflows
36
What is Functional Incontinence?
Knowing you have to urinate but can't
37
Urinary Incontinence can be caused by what, when it pushes down on the bladder?
Bowel Impaction
38
What do we use to help with incontinence associated dermatitis?
Moisture Barriers
39
How often should we change a purwick?
Every 8 hours
40
What suction should a purwick be on?
Low
41
If applied wrong what medical condition can occur with a condom cath on the head of the penis?
Paraphimosis
42
What is an Ileal Conduit?
Take a piece of the bowl and bring to the skin and attach ureters to it
43
What is a Ureterostomy?
Bring the ureters to the surface
44
What is a Neo Bladder?
Making a whole new bladder
45
Risk Factors for UTIs
1) Females (Short Urethra)
2) Older Adults
3) After Menopause (Lack of estrogen)
4) Indwelling Catheters (Not good care of catheter)
5) Diabetes (Sugar not controlled)
46
Causes of Urinary Retention
1) Diseases of the spinal cord
2) Meds
3) Enlarged Prostate
47
What meds can cause urinary retention by inhibiting internal and external sphincters?
1) Anticholinergics
2) Tricyclic Antidepressants
3) Calcium Channel Blockers
4) Narcotic Analgesics
5) Anesthetic Agents
48
Normal post void residual is?
<50 mL
49
In the elderly normal post void residual is?
50-100 mL
50
Abnormal post void residual is?
>150 mL
51
Bladder Scanning is inaccurate when?
1) Morbid Obesity
2) Inadequate Gel
3) Improper aim or moving the probe during scanning
4) Scar tissue, incisions, staples (hysterectomy scar tissue)
52
Straight Cath
In, drain urine, out
53
Indwelling Cath
Into the urethra into bladder
54
Supra Pubic Cath
Long term care facilities, into bladder from outside stomach
55
Appropriate uses of catheters
1) accurate measurements
2) perioperative
3) healing of open sacral or perineal wounds
4) prolonged immobilization
5) end of life care
6) large volume infusions of diuretics during surgery
56
How many hours after a catheter is removed should the patient void?
6 hours
57
Whats included in Foley care?
1) Clean perineal area
2) clean 6 in down the tube
3) secure to thigh
4) no dependent loops
5) never hold higher than the bladder
58
Underweight BMI
< 18.5
59
Normal Weight BMI
18.5 - 24.9
60
Overweight BMI
25 - 29.9
61
Obesity Class 1 BMI
30 - 34.9
62
Obesity Class 2 BMI
35.0 - 39.9
63
Extreme Obesity BMI
40.0 +
64
What to look for in skin and hair in a nutritional assessment?
Hair falling out, dry damaged skin
65
What vitamin absorbtion is decreased with alcohol use?
Vitamin B
66
Lab Tests for nutrition
1) Serum Albumin <3.5
2) Prealbumin
3) Transferrin
4) Anemias
67
Older adults are more prone to constipation so they need increased what in their diets?
Fiber
68
Older adults have GI reflux and are more prone to what?
Aspirate
69
NPO
Nothing by Mouth
70
Clear Liquid
Clear liquid at room temp Ex. Jello, Popsicles
71
Full Liquid
Ex. Soups
72
What should we not give renal failure patients?
Orange Juice (will have a hard time with dialysis b/c of the potassium)
73
NG Tube
Nose to Stomach
74
What does it mean if an NG tube has a dual lumen?
Has 2 tracts, can be used to suck out gastric secretions or tube feeding
75
What do we use to check placement of NG tube?
X-Ray
76
Why is a Keofeed tube used for long term?
Smaller and more comfortable for patients
77
What NG tube can be used for dual purposes?
Salem Sump Nasogastric Tube
78
Peg Tube
Right into stomach through abdominal wall
79
Do we aspirate J-tubes or GJ tubes?
NO
80
Why do we not aspirate J-tubes or GJ tubes?
Can cause pressure in the Jejunum
81
What feeding is done by a syringe held above patient level?
Bolus
82
What feeding is done by machine?
Continuous
83
Head of bed should be at what degree for feedings?
45 degrees
84
How often should feeding supplies be replaced?
Every 24 hours
85
What symptoms would tell you the patient isn't tolerating the feeding?
1) Diarrhea
2) Distended Abdomen
3) Nausea
4) Pain
86
How to check patency of the tube feeding tube?
Put water down the tube
87
When to flush a feeding tube?
1) before and after bolus feedings
2) every 4 hours
3) before and after residual is checked
4) before, between, and after meds
88
What do we use to unclog an occluded tube?
ACTIVATED pancreatic enzymes
89
What syringe should you be flushing a feeding tube with and how much sterile water should you use?
30 mL
90
How to activate pancreatic enzymes?
With sodium bicarbonate
91
What should we mix crushed meds with for a tube feeding?
Sterile Water NOT tube feeding
92
What meds should we not crush?
XL, SR, or enteric coated meds
93
What should we mix liquid meds with before giving them in a feeding tube?
Sterile Water
94
How much air should we flush a feeding tube with before removal?
60 mL
95
Why should patients take a breath in and hold while we remove NG tube?
So no gastric secretions go down trachea
96
What is the body's first defense?
Intact Skin
97
Incision Wound
Sterile
98
Contusion
Bruise
99
Abrasion
Rugburn
100
Puncture
Stab Wound
101
Laceration
Jagged Cut
102
Wound Types
1) Closed/Open
2) Clean/Dirty
3) Pressure Injury
4) Venous Ulcers
5) Arterial Ulcers
6) Diabetic Ulcers
103
Intentional Wound
Surgical Wound
104
Unintentional Wound
Any kind of trauma
105
What does normal healing require?
Circulation, Clean environment, Nutrition
106
Primary Intention
Edges well approximated, edges brought together with staples or sutures
107
Secondary Intention
too much tissue loss, lots of scaring, leave wound open to heal together
108
Tertiary Intention
Wound left open for 3-5 days then closed with sutures
109
Bleeding stops, Clot forms, happens within hours
Hemostasis Phase
110
Leukocytes & Macrophages come in and clean up the wound
Inflammatory Phase
111
Epithelial cells are coming in and healing
Proliferation Phase
112
Scaring Occurs
Maturation or Remodeling Phase
113
Transparent Drainage
Serous
114
Pinky Drainage
Serosanguineous
115
Bloody Drainage
Sanguineous
116
Pus like, thick, gunky
Purulent Drainage
117
What causes infection and prevents healing?
Biofilms
118
Hemorrhage
Bleeding
119
Skin comes apart after surgery
Dehiscence
120
All layers come apart after surgery
Evisceration
121
Fistula
2 things are connected when they should not be
122
Factors in elderly that inhibit wound healing
1) Collagen formation impaired
2) Immune system decreased (More susceptible to infections)
3) Bad nutritional status
4) Less subcutaneous and dermal tissue
5) Decreased vasculature (blood clot issues)
123
Desiccation
Dryed out
124
Maceration
Overly Wet
125
Smoking affects wound healing how?
Causes vasocontriction
126
Obesity affects wound healing how?
Impaired mobility, more pressure, lots of fat w/ no blood supply
127
Why does aspirin affect wound healing?
Thins out blood
128
Should document what about a wound?
Length, width, depth
129
RYB color code
Red = Keep Clean, Yellow = Clean up, Black = Necrotic fissure get out
130
What does the lab value WBC tell us?
If wound is affected or not
131
How to take a wound culture
clean the wound, swipe in a z pattern from top to bottom with slight pressure
132
What lab value gives us protein status now?
Pre-Albumin
133
When are retention sutures used?
When patient obese and trying to bring edges together
134
What drain uses negative pressure to get fluid out?
Jackson-Pratt Drain
135
1 Ounce = ?
30 mL
136
Large drain that uses negative pressure to get fluids out?
Hema Vac
137
What do we use first Cold or Heat?
Cold and followed by heat
138
Cold causes ?
1) Vasoconstriction
2) Decreased edema
3) Decreased bleeding
4) Decreased muscle spasms
5) Decreased cellular metabolism (Slows bacterial growth)
6) Local anesthetic effect
139
Heat causes?
1) Increased blood flow
2) Increased O2 and nutrients
3) Increased leukocytes to area
4) Increased smooth muscle relaxation
5) Increased cellular metabolism
6) Decreased pain
140
Want to keep a wounds environment?
Clean and moist
141
What dressing should we never use for infected wounds?
Mepilex
142
Transparent, non-absorbent, protective dressing?
Tegaderm
143
What is tegaderm used for?
IVs
144
Patients get mepilex dressing when braden score is what?
18 or less
145
How does a wound vac work?
Creates a vacuum across would and brings blood cells and epithelial cells across wound
146
What is a safe liquid to use on any wound?
Normal Saline = .9NS
147
Chemical debridement, eats away necrotic tissue
Dakins
148
Silvadene Cream
Silver has healing properties
149
Keeps wound moist
Hydrogel
150
How to use wet to moist dressings?
Put on wet, take off moist
151
Proper wound cleaning
Clean AWAY from the wound edges
152
RACE - R
RESCUE anyone is immediate danger
153
RACE - A
ACTIVATE the fire code and notify appropriate person
154
RACE - C
CONFINE the fire by closing doors and windows
155
RACE - E
EVACUATE patients and other people to safe area
156
Types of med errors
1) Omission
2) Communication
3) Commission
157
Omission
Something was missing: drug not prescribed, not dispensed, not administered, or not taken
158
Communication
Vague Instructions
159
Commission
Wrong drug, dose, patient, time, route, allergic reaction, drug interaction
160
Fall risk factors
1) >65 years old
2) History of falls
3) Cognitive impairment
4) Altered gait
5) Meds
6) Incontinence
7) Unsafe environment
8) Orthostatic hypotension
9) Depression
10) Assistive Devices
11) Confusion or disorientation
12) New environment
161
Fall Preventions
1) Fall assessments
2) Frequent rounding
3) Fall precautions
4) Offer assistance to the toilet Q2
5) Grippy Socks
6) Bed in low position
7) Bed alarms ON
8) Personal items in reach
9) Call light in reach/Answer call lights
162
Morse Fall Scale
Higher score = Higher risk
163
When to use restraints
1) Safety of patient, or staff is in danger
2) Interruption of therapy
3) Prevent patient from removing life support equipment
4) Unsafe attempts at mobility
164
Restraints can add?
Risk of fall-related injuries and deaths
165
Restraints do NOT?
Lower the risk of falls or falls injuries
166
Should safety event reports be put in the EMR?
NO
167
Pressure Injury
Localized damage to the skin and underlying soft tissue, usually over a bony prominence
168
Pressure on a capillary for how long can cause a pressure injury?
30 min
169
Shear
Separation of top layer and bottom layer of skin, rips the skin
170
Pressure injury risk factors
1) Immobility
2) Obesity or thinness
3) Excessive moisture or dryness
4) Poor nutrition and hydration
5) Previous pressure ulcer (not as strong as original skin)
6) Medical conditions affecting blood flow (Diabetes Mellitus, PVD)
171
What meds can be a risk for pressure injuries?
Corticosteroids (thins out skin)
172
Why is age a risk for pressure injuries?
Do not have good sub-Q tissue
173
Moist, stringy, yellow or gray, devitalized tissue
Slough
174
Slough is one step away from _____ and is why it needs to come out
Necrotic Tissue
175
Devitalized dermis, leathery or thick, black
Eschar
176
Area of the ulcer beneath the skin that extends under the edge of the wound
Undermining
177
Narrow extensions into surrounding tissue from the sides of an ulcer
Tunneling
178
Intact skin, non-blanchable redness
Stage I Pressure Injury
179
What do we want to do for Stage I Pressure Injuries?
1) Protect from moisture
2) Protect from pressure
3) Prevent further injury
180
Partial thickness loss of skin with exposed dermis, slough and eschar are NOT present
Stage II Pressure Injury
181
Looks like serum-filled blister open or closed, or abrasion
Stage II Pressure Injury
182
Full thickness tissue loss, sub-Q fat may be visible but NOT bone or tendon, rolled edges are present
Stage III Pressure Injury
183
Stage I Pressure Injury
184
Stage III Pressure Injury
185
Stage II Pressure Injury
186
Stage IV Pressure Injury
187
Unstageable
188
Deep Tissue
189
Full-thickness skin and tissue loss, exposed bone, ligament, tendon, or muscle
Stage IV Pressure Injury
190
Full thickness tissue loss with base of ulcer covered by slough or eschar
Unstageable Pressure Injury
191
Purple localized area of intact skin or blood blister
Deep Tissue
192
Turn at risk patients ?
Every 2 hours
193
Risk = Major or Minor
Depends how long you are under anesthesia
194
Diagnostic Surgery
To diagnose something
195
Ablative
To remove an organ
196
Palliative
To relieve symptoms
197
Reconstructive
To make something function properly again
198
Transplantation
Transplant organs
199
Elective Surgery
Scheduled, non urgent
200
Urgent Surgery
Needs to be done soon
201
Emergency Surgery
Needs to be done ASAP
202
When should teaching for the surgery take place?
Pre op
203
When should reinforcement of teaching points be mentioned?
Post op
204
Pre op Teaching
1) Pain management
2) Coughing and deep breathing
3) Incentive Spirometry
205
Pre op Screening
1) Risk Factors
2) Allergies
3) Results are recorded in patient records
4) Abnormal results are reported
5) Consent in signed
206
What is the nurses role with signing consent?
Only witnessing signature
207
Pre op Antibiotics
Need within one hour of the cut
208
Skin prep for surgery
Chlorhexidine bath night before, clean sheets and gown, chx bath again in the morning
209
Clear liquids up to __ hours for elective surgery?
2 hours
210
Light breakfast __ hours prior to surgery?
6 hours
211
Heavier mean allowed __ hours prior to surgery?
8 hours
212
General Anesthesia Causes?
1) Loss of consciousness
2) Analgesia
3) Relaxation
4) Loss of reflexes
5) Amnesia
213
Regional Anesthesia Causes?
1) Analgesia
2) Relaxation
214
Conscious Sedation Causes?
1) Analgesia
2) Relaxation
3) Amnesia
215
Topical/Local Anesthesia Causes?
1) Analgesia
216
What do we treat malignant hyperthermia with?
Dantrolene
217
Who changes the first dressing?
The surgeon
218
Atelectasis
Collapsed alveoli
219
What is the #1 nursing intervention to prevent evisceration?
Splinting the wound
220
What can PONV cause?
1) Pain & Anxiety
2) Delayed recovery
3) Surgical site stress
4) Dehydration
5) Aspiration Pneumonia
6) Delayed resumption of eating
7) increased healthcare costs by increased LOS
221
PONV Risk Factors
1) Female
2) History of PONV
3) History of motion sickness
4) Nonsmokers
5) Post op use of opioids
6) Surgery lasting more than 60 min
7) Obesity
8) Pain
222
What do we want to stop within 24 hours of surgery to prevent c diff?
Prophylactic Antibiotics
223
What med should we keep patients on to prevent cardiac complications in surgery?
Beta Blockers
224
What side should we clip on a suture?
Side opposite of the knot
225
What is the largest preventable death factor?
Smoking
226
What does EVALI stand for?
e-cigarette or vaping product use associated lung injury
227
Oxygenation
Properly functioning alveolar capillary membranes, removes carbon dioxide from blood, oxygenate venous blood
228
Ventilation
Ability to transport air to and from lungs
229
Warms, filters, and humidifies air?
Upper Airway
230
Conduction of air, mucociliary clearance?
Lower airway function
231
Gas Diffusion?
Alveolar capillary membrane
232
Factors affecting pulmonary function
1) Levels of health
2) Meds
3) Lifestyle
4) Environment
233
Popping of alveolar sacks
Crackles
234
Narrowing of airways
Wheezes
235
Secretions in bronchi
Rhonchi
236
What do we want a patients SpO2 to be at?
>92%
237
What is the highest you can go on a nose cannula?
6L
238
What suction level should we use for lung suction?
Medium to high
239
Activated by the patient's inspiration
Dry powder inhaler
240
Delivers controlled dose of meds with each compression of the canister
Metered dose inhalers
241
Disperse fine particles of meds into deeper passages of respiratory tract
Nebulizers
242
Why should we rinse after using a steroid metered dose inhaler?
To prevent thrush
243
How many liters is a non rebreather mask on?
15-30 L
244
Clinical judgment measurement model
1) Recognize cues
2) Analyze cues
3) Prioritize hypotheses
4) Generate solutions
5) Take actions
6) Evaluate outcomes
245
Nursing Process - ADPIE
A - Assessment
D - Diagnosis
P - Planning
I - Implementing
E - Evaluating
246
What assessment is about establishing a baseline?
Initial Assessment
247
What assessment is very detailed, asks questions, looks at skin throughly?
Admission Assessment
248
What assessment checks to see if the patient has changed throughout the shift?
Shift assessment
249
What assessment focuses on only one system?
Focused assessment
250
Subjective Data
What the patient feels or says
251
Objective Data
Measurable and Observable
252
Nursing Diagnosis
A clinical judgement about an individual's responses to actual or potential health problems
253
Cognitive Outcome
Increase in patient knowledge
254
Psychomotor Outcome
Patient's achievement of new skills
255
Affective Outcome
Changes in patient values, beliefs, and attitudes
256
Physiologic Outcome
Physical changes in the patient
257
SMART goal
S = Specific
M = Measurable
A = Attainable
R = Realistic
T = Time Bound
258
When the drug does the opposite of what it is supposed to do
Idiosyncratic
259
Highest concentration of meds in an individual
Peak
260
Lowest concentration of meds in an individual
Trough
261
Timing of measurement depends on route of med
Peak
262
Measured immediately before the next dose
Trough
263
Peak for IV meds
15-30 min
264
Peak for IM meds
30-60 min
265
Peak for po meds
60 min
266
Amount of time it takes for 50% of blood concentration of a drug to be eliminated from the body?
Half Life
267
Concentration of drug in the blood serum that produces the desired effect without causing toxicity?
Therapeutic range
268
Medication Reconciliation
What the patient is prescribed in the hospital VS what they are taking at home
269
Patient Rights
1) Patient
2) Med
3) Dose
4) Route
5) Time
270
BID
Twice a day
271
TID
Three Times a day
272
QID
Four times a day
273
AC
Before meals
274
PC
After meals
275
HS
Hours sleep
276
Intradermal Injection needle length
1/4 - 1/2 in
277
Intradermal injection gage
25, 27
278
Has to be less than 0.5 mL in this injection
Intradermal
279
Sub Q needle length
3/8 - 5/8 in
280
Sub Q needle gage
25 - 30
281
1 mL max volume for this injection
Sub Q
282
Sub Q needle degree
45-90
283
Intradermal needle degree
5-15
284
IM needle length
5/8 - 1.5 in
285
IM needle gage
20 - 25
286
Up to 3 mL in this injection
IM
287
Never recap what needles
Dirty
288
What are three things that skin needs?
1) Nutrition
2) Hydration
3) Circulation
289
Skin changes in the elderly
1) Thinning of sub q and dermal layer
2) Decrease activity of glands
3) Longer time window for cell renewal
4) Nail changes
5) Decrease in collagen fiber
290
QSEN competencies
1) Patient centered care
2) Teamwork and collaboration
3) Evidence based practice
4) Quality improvement
5) Safety
6) Informatics
291
Never use what bed position?
Trendelenburg
292
Occult Blood
Blood that can not be seen
293
Hard immovable mass of stool in the rectum or higher
Impaction
294
Stool in liquid form, passing through fast enough water is not being absorbed
Diarrhea
295
Inability to control sphincter
Incontinence
296
Gas
Flatulence
297
Veins in the rectum or out of rectum protruding
Hemorrhoids
298
Absorb more water into stool to make it pass
Stool Softeners (Colace)
299
Irritate bowel and make peristalsis happen but can cause cramping
Stimulant (Dulcolax)
300
Makes stools larger and softer to increase pressure in the intestines to get stool moving
Bulk Forming (Metamucil)
301
What side should the patient be on when dealing with the colon?
Left
302
Lubricates stool and intestinal mucosa / how many mL ?
Oil retention / 150-200 mL
303
Distends intestine, irritates intestinal mucosa, low volume enema / how many mL ?
Fleets hypertonic / 70-130 mL
304
Distends intestine, irritates intestinal mucosa, softens stool / how many mL ?
Soap suds / 500-1000 mL
305
Distends intestine, increases peristalsis, softens stool / how many mL ?
Tap water and Normal saline / 500-1000 mL
306
HAI
Health Care Associated Infections
307
CAUDI
Catheter associated urinary tract infection
308
Top HAI's in acute care settings
1) UTI
2) Surgical site infections
3) Bloodstream infections
309
Most effective protections against HAI's is?
Handwashing
310
Most significant and most prevalent in hospital settings
Bacteria
311
Smallest of all microorganisms
Virus
312
Plant like organisms present in air, soil, and water
Fungi
313
Organisms growing and multiplying
Incubation period
314
Person is most infectious, vague and nonspecific signs of disease
Prodromal stage
315
Presence of specific signs and symptoms of disease
Full stage of illness
316
Recovery from the infection
Convalescent period
317
What is an elevated WBC
>10,000
318
immature, acute bacterial infections
Neutrophils
319
Chronic bacterial and viral infections
Lymphocytes
320
elevated in parasitic infection, fungus, allergic reaction
Eosinophil
321
What protein is non specific and indicates inflammation
C-Reactive Protien
322
MDRO
Multi drug resistant organisms
323
VAP
Ventilator associated pneumonia
324
HAP
Hospital associated pneumonia
325
CLABSI's
Central line associated bloodstream infections
326
What Hepatitis are in the blood?
b,c
327
Where is HIV located?
In the bowels
328
When do we have to wash our hands with soap and water?
1) When they are visibly soiled
2) When caring for a c diff patient
329
Donning
Putting on
330
Doffing
Taking off
331
Donning process
1) Wash hands
2) gown
3) mask
4) face shield/goggles
5) gloves
332
Doffing Process
1) gloves
2) gown
3) face shield/goggles
4) mask
5) wash hands
333
PPE Masks protect who?
Others
334
N95 masks protects who?
Yourself
335
c diff and MRSA are what precautions?
Contact
336
Influenza and pertussis are what precautions?
Droplet
337
Covid 19, TB, measles, chickenpox are what precautions?
Airborne (require a negative pressure room)
338
VRSA
Vancomycin resistant staph aureus
339
VRE
Vancomycin resistant enterococci
340
C diff
Clostridium difficile
341
What is the weight limit for patient handling tasks for one person
35 lbs
342
Can not use lower extremities
Para
343
All 4 extremities can not be used
Quad
344
One half of extremities can not be used
Hemi
345
Fowlers
45-60 degrees
346
Semi fowlers
30 degrees
347
High fowlers
90 degrees
348
Hold cane on what side
The strong side
349
Sentinel Event
Patient safety event that results in death, permanent harm, severe temporary harm
350
ISBAR
I = Introduction of yourself
S = Situation 5-10 seconds
B = Background
A = Assessment
R = Recommendations
351
Activation of pain receptors
Transduction
352
Awareness of the characteristics of pain
Perception
353
Lowest intensity of a stimulus that causes you to recognize pain
Pain threshold
354
Inhibition or modification of pain
Modulation
355
When should pain be assessed?
1) At regular intervals
2) With each new report of pain
3) after every intervention
356
Aching, deep, dull, throbbing
Somatic Pain
357
Cramping, squeezing, pressure
Visceral Pain
358
Burning, numbness, tingling
Neuropathic Pain
359
Sharp with a burning sensation
Cutaneous Pain
360
Break Through Pain
Flare-up of moderate to severe pain that occurs when the patient is taking around the clock meds
361
Physical Dependence
The body adapts to the presence of an opioid and suffers withdrawal symptoms
362
Tolerance
A larger dose of opioids are needed to maintain the same level of analgesia when the body gets used to the opioid
363
Non rapid eye movement stages
Stage 1 - Transition stage between wakefulness and sleep 5%
Stage 2 - Light sleep 50%
Stage 3 - 10%
Stage 4 - Deep sleep 10%
364
Rapid eye movement percentage of sleep
20-25 %
365
REM body reactions
Pulse, RR, BP, metabolic rate, and temp all go up
Skeletal muscle and deep tendons are depressed
366
Acceptable hours of sleep for an adult are
7-9 hours
367
Acceptable hours of sleep for older adults
6-7 hours
368
Difficulty falling asleep
Insomnia
369
Uncontrollable desire to sleep
Narcolepsy
