Test 1 Flashcards
(129 cards)
1
Q
Goal of asepsis
A
- Protect yourself
2. Protect your patient
2
Q
Bacteria
A
Most common infectious agent
3
Q
Virus
A
Cannot use “antibiotics” for treatment
4
Q
Fungi
A
Can be normal flora; problem for immunosuppressed pt’s (mold)
5
Q
Parasite types
A
- Endoparasites: in your body
2. Ectoparasites: outside of you
6
Q
Common Portals of Exit
A
- Respiratory
- Gastrointestinal
- Genitourinary tracts
- Breaks in skin
- Blood and tissue
7
Q
Modes of Transmission
A
- Contact route (direct or indirect)
- Vehicle route (food, water, blood, equipment)
- Airborne route
- Droplets (close contact or touching infected objects)
- Vectors (mosquito, tick, flea)
8
Q
Stages of Infection
A
- Incubation period
- Prodromal stage
- Full stage of illness
- Convalescent period
9
Q
Incubation period
A
Organisms growing and multiplying (no symptoms)
10
Q
Prodromal stage
A
Person is most infectious, vague and nonspecific signs of disease; most contagious
11
Q
Full stage of illness
A
Presence of specific signs and symptoms of disease
12
Q
Convalescent period
A
Recovery from the infection
13
Q
Normal Body Defenses
A
- Nasal passages
- Skin/mucous membrane
Skull/Spinal column - GU Tract
- GI Tract
14
Q
Types of normal flora
A
- Transient
2. Resident
15
Q
Transient
A
Bacteria that can be washed off, not permanent
16
Q
Resident
A
Stays in//on your body, cannot be removed easily
17
Q
Body’s Defense Against Infection
A
- Body’s normal floral
- Inflammatory response
- Immune response
18
Q
Inflammatory response
A
Localized response to injury or infection
19
Q
Immune response
A
Antibody response to specific antigen
20
Q
Natural immunization
A
After getting the virus you would be immune the next time
21
Q
Acquired immunization
A
Getting the vaccine
22
Q
Cardinal Signs of Acute Infection
A
- Redness
- Heat
- Swelling
- Pain
23
Q
Lab data indicating infection
A
- WBC (normal is 5,000-10,000/mm3
2. Positive culture (presence of pathogen in urine, blood, sputum)
24
Q
Nosocomial infection
A
Infections associated with the delivery of health care (pt’s or health care workers)
25
Common nosocomial infections
1. Urinary tract infections
2. Surgical site infections
3. Bloodstream infections
4. Pneumonia
26
Standard precautions
1. Wash hands
| 2. Wear gloves for any contact with body fluids
27
When do you use a mask
During spinal procedures, protects against meningitis specifically
28
PPE (personal protective equipment)
1. Gloves
2. Gowns
3. Masks
4. Protective eyewear
29
PPE for airborne
N-95 respirator and negative pressure room
30
Common airborne diseases
1. Tuberculosis
2. Measles
3. Chickenpox
31
PPE for droplet
Mask, no N-95 respirator, no negative pressure room, private room
32
Common droplet diseases
1. Influenza
2. Whooping cough
3. Mumps
4. Meningitis
33
PPE for contact
Gown and gloves
34
Drug resistant organisms
1. MRSA
2. VRE
3. C. diff.
35
Protective Isolation AKA
Neutropenic precautions
36
Protective Isolation precautions
1. Positive pressure room
2. No carpet
3. No flowers
4. Pt's wear N-95 respirator when transporting
37
Aseptic Technique
Includes all activities to prevent or break the chain of infection
38
Categories of aseptic technique
1. Medical asepsis (clean technique)
| 2. Surgical asepsis (sterile technique)
39
Medical asepsis
Things are assumed clean unless proven dirty
40
Surgical asepsis
Things are assumed dirty until proven clean
41
Rules for surgical asepsis
1. Don't touch anything not sterile
2. Don't reach over sterile field
3. Hands above waist
4. Do not turn back on sterile field
5. Peel open packages away from you and drop items
6. Pour liquids carefully
42
Communication
Interchange of information or thoughts
43
Levels of communication
1. Intrapersonal: Self-talk
2. Interpersonal: Two or more people
3. Group: Small group
44
Forms of communication
1. Verbal: Spoken, written
| 2. Nonverbal: Body language
45
Things that influence/effect communication
1. Developmental level
2. Gender
3. Values
4. Environment
46
Types of proxemity
1. Intimate zone (0-18 inch)
2. Personal zone (18in-4ft)
3. Social zone (4-12 ft)
4. Public zone (12-25 ft)
47
Helping relationship
1. Not spontaneous
2. Unequal sharing of info
3. Nurse is helper, pt is being helped
4. Used to establish rapport and helping-trust relationships
48
Social relationship
1. Spontaneous
2. Equal sharing of info
3. Both people's roles are equal
4. Used to establish rapport and trust
49
Phases of the helping relationship
1. Orientation phase
2. Working phase
3. Termination phase
50
Orientation phase
1. Introductions
2. Clarify roles (I am you SN...)
3. Establish agreement about the relationship
4. Orient pt to the health care system
51
Working phase
1. Work together to meet pt's needs
2. Provide assistance to meet goals
3. Provide teaching and counseling
52
Termination phase
1. Examine goals
2. Make suggestions for the future
3. Encourage pt's to express emotions about the termination
4. Help pt establish a helping relationship with another nurse
5. Assist pt in transferring
53
Therapeutic interviewing questions
1. Open-ended questions
2. Closed questions
3. Validating questions
4. Clarifying questions or comments
5. Reflective questions or comments
6. Sequencing questions or comments
7. Directing questions or comments
54
Types of nursing notes
1. Narrative
| 2. Flowsheet
55
Narrative
Uses sentences to describe the pt's progress and what just happened
56
Flowsheet
Uses checklists and is usually electronic, only charts significant findings or exceptions to the norm (charting by exception)
57
HIPPA stands for
Health Insurance Portability and Accountability Act
58
Drug/medication
Any substance that modifies the body functions when ingested
59
Examples of drug/medications that you wouldn't think of
1. Over the counter meds
2. Herbal supplements
3. Marijuana
4. Caffeine
5. OXYGEN
6. Alcohol
60
Chemical name
Identifies drug’s atomic and molecular structure
61
Generic name
Assigned by the manufacturer that first develops the drug
62
Official name
Name by which the drug is identified in official publications. (usually generic name)
63
Trade name
Brand name copyrighted by the company that sells the drug
64
Pharmacodynamics
Process by which drugs alter cell physiology and affect the body
65
Types of parenteral medication injections
1. Subcutaneous injection
2. Intramuscular injection
3. Intradermal injection
4. Intravenous injection
66
Types of medication orders
1. Standing order: Carried out until cancelled by another order
2. PRN: As needed
3. Single or one-time
4. Stat: Carried out immediately
67
Parts of the Medication Order
1. Patient’s name
2. Date and time order is written
3. Name of drug
4. Dosage of drug
5. Route of drug
6. Frequency of administration
7. Signature of person writing the order
68
MAR
Medical administration record; list of medication of a pt
69
Where do you open a unit dose
At the bedside
- So you don't mix up
- If pt refuses
70
5 rights of medication administration
Right:
1. Medication
2. Patient
3. Dosage
4. Route
5. Time
71
3 checks of medication administration
1. When nurse reaches for medication
2. After retrieval from drawer and compared with MAR/CMAR
3. Before giving medication
72
1 kilogram= ?g
1,000 g
73
1 gram= ?mg
1,000 mg
74
1 mg= ?mc
1,000 mc
75
60 mgs= ?gr
1 grain
76
1 teaspoon(tsp)= ?mL
5 mL
77
1 Tablespoon(Tbsp)= ?mL
15 mL
78
1 ounce= ?mL
30 mL
79
What is the first identifier when ID'ing a pt
Validate the pt's name
80
What is the second identifier when ID'ing a pt
Validate the pt's ID number, medical record number, or birth date
81
Adverse drug effects
1. Allergic effects (anaphylactic reaction)
2. Drug tolerance
3. Toxic effect
4. Idiosyncratic effect: Wild reaction
5. Drug interactions (antagonistic and synergistic effects)
82
Antagonistic effect
Two meds fight each other off
83
Synergistic effect
The two meds work even better together
84
Who can prescribe a narcotic
Some states say only physicians, others allow APN's (Advanced practice nurse) and PA's
85
What extra security measures are taken for narcotics
1. Must be locked
2. Record must be kept
3. Routine counts done
4. When another nurse comes, they also count and verify any meds that are discarded (if pt refuses)
86
What are the nursing responsibilities concerning meds
1. Give medication appropriately as ordered
2. Know the indication
3. Know the drug action
87
Common high alert medications
1. Insulin
| 2. Anticoagulants
88
What organs should you assess because of their function before giving meds
1. Liver (metabolize meds)
| 2. Kidneys (eliminate meds)
89
Liver function tests
1. Albumin
2. ALT
3. AST
4. Bilirubin
5. Total protein
90
Renal function tests
1. BUN
2. Creatinine
3. Creatinine clearance
4. Albumin
91
What to do when you give the wrong med
1. Check pt
2. Notify manager and PCP
3. Write description of error
4. Complete form used for reporting errors
92
When is medication reconciliation required
1. Shift report
2. Admission
3. Transfer to another hospital
4. Discharge
5. Surgery (usually)
93
Classification of pain based on duration
1. Acute
| 2. Chronic
94
Sources of pain
1. Nocieptive
| 2. Neuropathic
95
Types of nocieptive pain
1. Cutaneous (skin)
2. Somatic
3. Visceral
96
Nocieptive pain
Normal way of interpreting pain; using the pain process
97
Neuropathic pain
Nerve problem; no actual stimulus
98
Origins of pain
1. Physical
2. Psychogenic (unidentified)
3. Referred (perceived in an area distant from point of origin)
99
Pain process
1. Transduction
2. Transmission
3. Perception of pain
4. Modulation
100
Transduction
Activation of pain receptors
101
Transmission
Conduction along pathways
102
Perception of pain
Awareness of the characteristics of pain
103
Modulation
Inhibition or modification of pain
104
Gate control theory of pain
Small nerves carry pain stimuli to brain, large diameter nerve fibers inhibit pain stimuli; gating mechanism determines the impulses that reach the brain (you can distract from the pain)
105
Common responses to pain
1. Physiologic (sympathetic/parasympathetic)
2. Behavioral
3. Affective (facial expression)
106
FLACC pain scale
```
F: Faces
L: Legs
A: Activity
C: Cry
C: Consolability
- Used for infants, 0-2 points for each item
```
107
When are PO meds evaluated
Within 45-60 minutes of administration
108
When are IV meds evaluated
Within 15-30 minutes of administration
109
Analgesic drugs
1. Nonopiod analgesics
| 2. Opiod or narcotic analgesics
110
Analgesics ladder (what type of pain relief to use first)
1. Nonopiod and/or adjuvant
2. Opioid and/or nonopiod/adjuvant
3. Opiod for severe pain and/or nonopiod/adjuvant
111
Narcotic side effects
1. RESPIRATORY DEPRESSION (can kill)
2. Sedation
3. Confusion
4. Hypotension
5. Constipation
112
Nursing Process
A systematic method that directs the nurse (and patient) in planning and providing care
113
Steps of the nursing process
1. Assessing
2. Diagnosing
3. Outcome identification and planning
4. Implementing
5. Evaluating
114
Characteristics of the Nursing Process
1. Systematic
2. Dynamic
3. Interpersonal
4. Outcome oriented
5. Universally applicable
115
Types of data you gather during assessment
1. History (subjective)
| 2. Physical (objective)
116
Types of nursing assessments
1. Initial (comprehensive) assessment
2. Focused assessment
3. Emergency assessment
4. Time lapsed assessment (follow up)
117
Goal of asssessment
To identify pt needs by
1. Take all the data collected
2. Cluster it into related categories
118
Medical diagnosis
A clinical judgment identifying the illness/ disease
119
Nursing diagnosis
A clinical judgment on a client’s response to actual or potential health problems or life processes
120
NANDA stands for
North American Nursing Diagnosis Association
121
What is NANDA
- An approved standardized list of health problems treated by nurses
- Organization meets and revises the list every 2 years
122
Types of Nursing Diagnoses
1. Actual nursing diagnosis
2. Risk nursing diagnosis
3. Possible nursing diagnosis
4. Wellness nursing diagnosis
5. Syndrome nursing diagnosis
123
How do you write a nursing diagnosis
They come in 2 or 3 parts (we use 2)
- First pick best choice from NANDA list (1st part)
- Then add the phrase "related to" RT
- Add the etiology (cause/contributing factor) of the problem (2nd part) (*dont include medical diagnosis!)
- EX. Impaired gas exchange RT mucus in alveoli
124
Maslow's hierarchy of human needs (lowest to highest)
1. Physiological
2. Safety
3. Love/belonging
4. Esteem
5. Self-actualization
125
Steps in Planning (nursing process)
1. Identify overall goal
2. Id. how you will measure the goal (outcomes)
3. Id. interventions to reach goal
126
How to document goals (example)
The pt will have improved mobility AS EVIDENCED BY the ability to raise his arm above his head by discharge
- Don't use vague immeasurable sentences, has to be measured in some way
- Also state a time for this goal to be accomplished by
127
Nursing Interventions
Any treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes
128
Types of
| Nursing Interventions
1. Independent (nurse-initiated): Without physician orders
2. Dependant (Prescriber-initiated): Initiated by physician
3. Collaborative
129
How to write nursing interventions
- Be specific (who what where...)
- Start with action verb ("administer")
- Detailed instructions
- Include a time
(Ex. Assess respirations for rate, ease, and depth every shift)
