301 Test 1 power points Part 2 Flashcards
All health care employees must receive training related to infection control and barrier precautions every __ years
4
equipment that enters patient’s vascular system or mucous membranes must be
sterilized
Health care professional should NOT care for patient if they have ___ lesions, etc
exudative
Mode of transmission:
Organism to ___ to portal of exit to ____ to portal of entry to ___ and back to organism
organism RESERVOIR portal of exit TRANSMISSION portal of entry VULNERABLE HOST
any person, animal, arthropods, plant, soil, or substrate in which an causative agent normally lives and multiplies
RESERVOIR
break in skin allows infectious agent to enter the body (i.e., surgical wounds, cuts, rashes, needlestick injuries, IV sties mucous membranes (i.e., mouth, nose, eyes,)
Portal of entry
mostly infect skin but opportunistic
fungi
amoebas and giardia (diarrhea) and plasmodium species (malaria)
Protozoa
Legionnaires’ disease isn’t
contagious
to reduce risk of spreading pathogens from draining wounds,
Keep draining wounds covered w dressings
Modes of transmission: sneezing, speaking, coughing
Droplet
Modes of transmission: droplets evaporate leaving behind droplet nuclei that are so small they remain suspended in air
Airborne
Modes of transmission: TB, chickenpox, measles, SARS, smallpox
Airborne
Modes of transmission: i.e. influenze, pertussis, bacterial meningitis
Droplet
One type of med that indicates someone could be a susceptible host
steroids
Hand hygiene: Wet hands, use warm water, apply soap and rub all surfaces for __ seconds, rinse, dry and turn off water w paper towel
15
hygiene products: preferred when hands are NOT visibly soiled
Alcohol based
hygiene products: For C difficile infection use
soap and water
frequent cleaning and disinfection of environment at least
daily
Droplet Precautions can include what kinds of masks
simple or surgical
Organisms needing airborne precaution T C M S S Z
TB, chickenpox, measles, Sars, smallpox, zoster
Airborne precautions Patient transport: limit movement, place a ___ mask on patient if possible.
SURGICAL
in which step of the Nursing process do you Validate data
assessment
Mdx or Ndx: ineffective breathing pattern
Ndx
Mdx or Ndx: pain
Ndx
Never events: Foreign object r/t
surgical procedure
Never events: Air __
embolism
Never events: Administering wrong type of __
blood
Never events: Stage 3 and 4 pressure __
ulcers
Never events: Falls w ___ injury
significant
Never events: CAUTI aka
Catheter-Associated Urinary Tract Infections
Never events: CLABS aka
Central Line-Associated Bloodstream infection
Never events: S&S from __ and hyperglycemia
hypo
Never events: Surgical site ___
infections
Never events: DVT / PE following ___ surgery
ortho
DVT
deep vein thrombosis
Hazards for poisoning
cosmetics, etc
Carbon Monoxide Poisoning is treated with
100% humidified oxygen
Falls are prevalent in those > __ years
65
falls can be caused by a low
toilet seat
Falls may be witnessed or
unwitnessed
Falls may be noninjurious or result in
injury
May involve patient being lowered to floor with assistance
falls
May be reported by staff, patient, family, or visitor
falls
occurs suddenly or is an acute condition that causes a fall such as dizziness
A precipitating risk
Examples are lower extremity weakness, history of a fall, and side effects of certain high risk medications.
predisposing factors
type II diabetes and depression are part of what type of assessment
falls assessment
anyone who is post surgery status is at risk for
falls
another risk for falls is co____
comorbidities
one way to decrease fall risk is regularly
toileting
Despite widespread use of alarms, there is little evidence as to their effectiveness in reducing ___ in hospitals.
falls
Because some research shows that they are ineffective, their benefit for hospital patients is uncertain. In addition, they may be bulky and cumbersome making use undesirable they may be bulky and cumbersome making use undesirable
hip protectors
Post fall assessment has 3 categories (3 time periods)
immediately after fall
next 48
remaining follow up period
Immediate Post Fall Assessment: Provide reassurance & keep __ until help arrives
warm
Immediate Post Fall Assessment: Obtain information from ___ about incident and pain when patient status permits
patient
Immediate Post Fall Assessment: Depending upon stability of patient, take measures to control ___
bleeding
Immediate Post Fall Assessment: Depending upon stability of patient, assess level of ___
consciousness
Immediate Post Fall Assessment: Depending upon stability of patient, take vital ___
signs
Immediate Post Fall Assessment: Depending upon stability of patient, assess __ status
oxygen
Immediate Post Fall Assessment: Depending upon stability of patient, determine finger stick ___
glucose
leg shortening can indicate
hip fracture
Subdural hematoma is manifested by changes in ___ status
neurologic
Preventing falls can be done by providing anticipatory nursing such as
toileting, rounds, pain control
patients requiring additional precautions against falling:
Those with impaired judgment or thinking
Those with osteoporosis who are at risk for fracture
Those with current hip fracture
Those with current head or brain injury
Those on anticoagulants or with a bleeding disorder
Precautions for orthostatic hypotension include rising slowly, ___ pumps, __ clenching, and elevating head of the bed.
ankle
hand
strategies to reduce physical restraints
use of advanced practice nurses, comprehensive interdisciplinary approaches to enhance cognitive and physical function, staff education, organizational strategies, environmental interventions.
remember the importance of adequate calcium and Vitamin __ supplementation for the prevention of fall related fractures.
D3
Which NANDA Dx? A pattern of ease, relief, and transcendence in physical, psychospiritual, environmental, and or social dimensions that can be strengthened
Readiness for enhanced comfort
Which NANDA Dx? Perceived lack of ease, relief and transcendence in physical, psychospiritual, environmental and social dimensions
Impaired comfort
possible interventions for impaired physical comfort: ac___
Acupressure
possible interventions for impaired physical comfort: aro____
Aromatherapy
possible interventions for impaired physical comfort: cutaneous ____
Cutaneous Stimulation
possible interventions for impaired physical comfort: __/__ application
Heat/Cold Application
possible interventions for impaired physical comfort: nausea m___
Nausea Management
possible interventions for impaired physical comfort: p___ management
Pain Management
possible interventions for impaired physical comfort: progressive m___ relaxation
Progressive Muscle Relaxation
possible interventions for impaired physical comfort: simple ___
Simple Massage
Oral mucosa needs special care for pts on
mechanical ventilators
when cleaning ears do not use
q tips
the skin of older adults has __ perspiration
less
is generally the cause for changes in the feet after age 55
Arthritis
major sleep center of the brain
hypothalamus
special cells that maintain alertness and wakefulness
RAS
S____ from pons and medulla may promote sleep
Serotonin
Proper ___ is as important to good health as good nutrition and adequate exercise
sleep
Nursing interventions are often effective in resolving short- and __-term sleep disturbances.
long
the amount of NOCTURNAL sleep old ppl is __ than young ppl, but total amount of sleep is usually the same
less than
Obstructive apnea causes a serious decline in arterial ___ ___ level
oxygen saturation
sleep apnea pts are at risk for
cardiac dysrhythmias, right heart failure, pulmonary hypertension, angina attacks, stroke, and hypertension
Sleep apnea contributes to high blood pressure and increased risk for ___ ___ and ___
heart attack and stroke
____ ___ __ (CSA) involves dysfunction in the brain’s respiratory control center
Central sleep apnea
During CSA, The impulse to breathe temporarily fails, and nasal airflow and ___ ___ ___ cease
chest wall movement
Produced in brain and helps control circadian rhythm
Melatonin
herb that helps with sleep
Velerian
kind of drug: hypnotic, sedative and antianxiety (Ativan)
Benzodiazepines
