ati proctor Flashcards
Conduction
transfer of heat from the body directly to another surface (when the body is immersed in cold water).
Convection
Dispersion of heat by air currents (wind blowing across exposed skin).
Evaporation
Dispersion of heat through water vapor (perspiration)
Radiation
Transfer of heat from one object to another object without contact between them (heat lost from the body to a cold room).
Diaphoresis
Sweating
Average Temperature
98.6 F
Lowest temperature what part of the day?
Early morning
What part of the day is the highest temp
late afternoon
Fever?
100.4 or greater
Systole
MAX top number
Diastole
minimum bottom number
Cuff too small/tight?
HIGH READING
cuff large/loosely?
LOW READING
Apical pulse location?
5th ics left side midline
s1
Low lub
s2
high dub
0 pulse rate
ABSENT
+1
WEAK
+2
NORMAL
+3
STRONG
+4
bounding
Infectious Agent
ex: CDiff (virius, bacteria, fungi, parasite)
Reservoir
ex: table & bed (habitat, where it lives, grows, reproduces)
Portal of exit
ex: wound drainage, GI tract
Mode of transmission
ex: contact
portal of entry
ex: mouth, nose
susceptible host
ex: patient
Direct contact transmission
micro-organisms directly moved from infected person to another person
Indirect contact transmission
microorganisms are directly moved from the infected person to another person with having a contaminated object or person between these two.
ex. of direct contact transmission
If a nurse is caring for a client who has scabies and is not wearing gloves, the scabies mites can directly contact the nurse’s skin.
example of indirect contact transmission
drainage from a client’s wound might get on the bed rail or a bedside table, which others then touch
Airborne Transmission
Occurs when small particulates move into the airspace of another person.
Vehicle transmission
common source agent: Infection through contaminated food or water
Vector Borne transmission
infectious agents through animals: insect or rodent
Inflammatory Response
body’s natural defense that is activated when the body is injured, when foreign substances are present, or when an infectious agent attacks.
Infectious triggers
Viruses
bacteria
other microorganisms
Noninfectious triggers
Physical: burns, frostbite, injury, foreign bodies, trauma, radiation
Chemical: glucose, fatty acids, toxins, alcohol, irritants (e.g., fluoride, nickel)
Biological: damaged cells
Psychological: excitement
Manifestations of inflammation
Heat
Redness
Swelling
Pain
Loss of function
- Incubation stage
may not feel ill or have visible manifestations, however there may be lab values that are changes or changes in diagnostic tests such as x-rays or CT scans.
- Prodromal
Stage of infection when client begins having initial manifestations as the infectious agent replicates.
Acute Illness
Third stage of infection where manifestations of a specific infectious disease process are obvious. This is also the stage where it is severe.
Period of decline
Fourth stage of infection when manifestations begin to wane as the number of infectious disease decreases
Period of convalescence
Fifth and last stage of infection when client returns to a normal or a new normal state of health.
LOCAL INFECTIONS
one area of the body
SYSTEMIC INFECTIONS
start as local and then moves into blood stream and infects the whole body
Fingernails?
keep short less than 0.25 inches. Nail polish no chipped
Medical Asepsis
Clean technique & reduction of disease-causing micro-organisms. Not all micro-organisms cause disease under typical circumstances, such as when someone touches an object.
Surgical Asepsis
STERLIE. no microorganisms present
Standard precautions
apply to all pt whether or not they have an infectious agent. PPE
Contact Precautions
VRE, cdiff, noroviruses, & RSV. large wound drainage, fecal incontinence. Gown & Gloves minimum. Private room
Droplet
mask when entering the room or close contact. 3ft apart. Pt wear mask when leaving room. COVID, Rhinovirus, & Mycoplasma pneumoniae. Flu
Airborne precautions
Private room door closed
Negative pressure room
N95
protective isolation
immunocompromised
direct airflow
no plants!
CLABSI
central line associated blood stream infection
CAUTI
Catheter-associated urinary tract infections
SSI
surgical site infection
VAP
ventilator assisted pneumonias
Multidrug resistant organisms
Methicillin-resistant Staphylococcus aureus (MRSA)
Vancomycin-resistant Enterococcus (VRE)
Vancomycin-resistant Staphylococcus aureus (VRSA)
Vancomycin-intermediate Staphylococcus aureus (VISA)
Extended-spectrum beta-lactamase (ESBL)–producing organisms
Multidrug-resistant Streptococcus pneumoniae (MDRSP)
Stress incontinence
Coughing
sneezing
laughing
physical activity
that increases pressure on the bladder resulting in urine leakage
Urge incontinence
a strong need or urge to urinate, leaking occurs b/f pt gets to toliet
Reflex incontinence
urinary leakage resulting from nerve damage
Overflow incontience
Incomplete bladder emptying that results in the bladder overfilling when full, leading to urine leakage.
Functional Incontinence
Physical inability to reach the toilet in time.
Wheelchair bound, arthritis in hands, ?
Nocturnal enuresis
nighttime bedwetting
Urinary retention
incomplete emptying of bladder
Findings
diff urinating
pain
abdominal. distention
Constipation
diff. moving the bowels due to hardened stool
Hard & lumpy
older adults, no fiber, certain meds, GI disorders, & preganancy
Manifestations
abdominal pain
vomiting
weight loss
warm oil enema
Meds that affect stool prod
Constipation
Antacids
Anticholinergics and antispasmodics: medications used to treat muscle spasms
Antiseizure medications
Calcium channel blocker: medications used to primarily treat elevated blood pressure
Diuretics: which increase urine production
Iron supplements: used to treat certain forms of anemia
Anti-Parkinson disease medications
Narcotic pain medications: used to treat pain
Antidepressants
Enema position
left side with right leg pulled up to chest
Cystometric testing
measures bladder capacity, pressure of bladder during filling, & final capacity when the urge to urinate begins
Ureteral stent
allows the passage of urine when a ureter is blocked from a stone, mass, scar tissue, inflammation or infection
reagent strip
diabetes
urine concentration
Untreated uti can lead to…
PYELONEPHRITIS