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TF of Nursing > Chapter 14, 15, 16 > Flashcards

Chapter 14, 15, 16 Flashcards

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1
Q

What are ways in which infection can occur?

A
  1. Pathogen - microorganism that causes infection introduced into system
  2. Normal flora (Fauna)- endemic microorganisms are displaced
  3. Direct transmission (Person to person)
  4. Indirect transmission ( BP cuff, door knob)
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2
Q

Name 5 types of pathogens?

A
  1. Bacteria
  2. Viruses
  3. Protozoa
  4. Fungi
  5. Helminths
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3
Q

Give examples of bacteria and the disease they can cause.

A 
Staphylococcous aureus (MRSA)
Streptococcus (Strep Throat)
Clostridium perfringens (Gangrene)
Escherichia Coli (UTI)
Mycobacterium tuberculosis (TB)
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4
Q

What does endemic means?

A

regularly found in area

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5
Q

What is the treatment if bacteria causes the infection?

A

Antibiotics

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6
Q

Which are one celled organisms bacteria or viruses?

A

Bacteria

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7
Q

Give examples of viruses?

A

Zeka
West Nile
Influenza
Herpes Simplex

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8
Q

T or F. Most viruses are dangerous and last a long time

A

False. Most are mild and are self-limiting

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9
Q

What is the treatment for viruses?

A

Most of the time treat symptoms and wait it out.

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10
Q

What are protozoa?

A

Single celled “animals” that live in the water

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11
Q

Give an example of a disease caused by a protozoan?

A

Malaria (Plasmodium)

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12
Q

What is the treatment of diseases caused by Protozoan?

A

Anti-parasitic drugs

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13
Q

Can you give an example of a fungus?

A

Candida Abilicans

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14
Q

What disease can candida abilican cause?

A

Thrush, or Yeast infection

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15
Q

What is the shape of Staphlococcous?

A

Round grape like structure in clusters

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16
Q

What is the shape of streptococcus?

A

spherical

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17
Q

T or F Staphlococcus Aureus and Streptococus are gram negative

A

F. Both are gram positive. Meaning they have a thick cell wall and can retain dye which is purple.

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18
Q

What are helminths?

A

Parasitic worms that can inhabit the digestive tract (attach to walls)

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19
Q

Give examples of helminths?

A

Enterobius (pinworms)

Taenia (Tapeworms)

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20
Q

What is the treatment for diseases caused by helminths?

A

Anti-helminthic drugs

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21
Q

Describe the chain of infection

A

I -nfectious Agent
R- esevior
P- ortal of exit

M-ode if transmission
P-ortal of entry
S- usceptible host

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22
Q

What’s the #1 way to break the chain of infection?

A

Hand washing

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23
Q

When can hand sanitizer can be used in place of hand washing?

A

before administering medications

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24
Q

Which bacteria is hand sanitizer useless against?

A

Clostridium difficile

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25
Q

What are HAI or nosocomial infections?

A

Hospital acquired infections (Self-explainatory)

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26
Q

When caring for multiple patients, how do you prevent HAI?

A

Washing your hands(hand hygience) before and after every patient

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27
Q

What is septicemia?

A

Serious sytemic infection

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28
Q

What are the body’s primary defenses against infection?

A

Skin, mucous, GI enzymes, acid and bile

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29
Q

What are the body’s seconary defenses against infections?

A

Inflammatory process, elevated temperature (bodies way to create a hostile environment), complement cascasde: proteins attack pathogens

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30
Q

What are the body’s tertiary defenses against infection?

A

Lymphocytes

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31
Q

What is the function of lymphocytes?

A

Lymphocytes signal phagocytes to destroy unwanted microorganisms

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32
Q

What factors decrease the body’s ability to defend against pathogens?

A

Age, chemical exposure, chronic illness, lack of exercise, lack of rest, increased stress, non-intact skin, poor nutrition

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33
Q

How do you perform proper hand washing?

A

Minimum of 20 seconds, vigoursous, up to rist, dry thoroughly

34
Q

When do you use standard precautions?

A

All patients, whether signs of infection process or not

35
Q

If you were caring for a patient with MRSA what type of precautions would you use?

A

Contact

36
Q

What precautions are used for airborne illnesses?

A

Negative pressure room, gown, glove, shoe covers, special isolation room, N95 mask

37
Q

How do you help elevate psychological/emotional distress in isolated patients?

A

Spend time talking and interacting with patient, distraction, contact with family, friends, clergy via skype/facetime. Allow to express feelings.

38
Q

How do you put on and put off PPE?

A

Don: 1. Gown, 2. mask, 3. googles, 4. gloves
Doff: 1. gloves, 2. googles, 3. mask, 4. gown folding gown into itself to contain contamination

39
Q

What cares are associated with AM or early morning cares?

A

Toileting, oral care, bathing, hair care, dresssing, bed change, shaving

40
Q

What cares are associated with bedtime cares?

A

Prepare for sleep, toileting, fluids (if allowed), straighten room, dim lights, urinal/bedpan/bedside commode within reach

41
Q

What are the benefits of bathing?

A

Cleanses the skin, increases circulation, sensory stimulation, comfort, relaxation, improved self-esteem

42
Q

Define self care, assisted care, total care.

A

Self: performs own AdLS
Assisted care: Requires some assistance
Total care: Do little or nothing for themselves

43
Q

When assisting a patient with a bed bath, do you leave?

A

No

44
Q

What is the nurse’s responsibility in relation to bed making?

A

Delegate, must be wrinkle free, patient is left in safe position, side rails are used appropriately, draw sheet used appropriately

45
Q

Define open, closed, and surgical in terms of bed making?

A

Open: covers folded at foot of bed, ready to receive patient

Closed: Covers are pulled up to protect bedding from organisms,

Surgical: covers are fan folded to side to in preparation to receive patient.

46
Q

What factors are considered when bathing and performing ADLS?

A

Preference, culture, timing and ability

47
Q

What does the nurse assess for when performing oral care?

A

Decaying, boken, missing teeth, damaged gums, ulcerations, coating, leukoplakia (white patches) sordes (coating on tongue and teeth)

48
Q

What position is the unconscious patient placed in for oral care?

A

Lateral positon (side lying) HOB flat, suction available. No petroleum products

49
Q

Why would you have suction available when performing oral care on the unconscious patient?

A

To prevent choking/aspiration

50
Q

Why would you not want ot use lemon glycerin swabs for oral care?

A

Increased dry out the mouth can cause micro abraisons

51
Q

What precautions would you use for the patient recieving anticoagulation therapy?

A

Electric razor (no straight razors or safety razors), monitor for bruising, signs of bleeding

52
Q

What precautions would you use for the patient with a diagnosis of diabetes related to nail care?

A

File do not clip

53
Q

What situations require removal of piercings? and do stainless steel and titanium piercing have to be removed for MRI?

A

Surgery, intubation, diagnostic testing, catheterization

54
Q

What precautions do you need to take when removing contact lenses?

A

Wash hands, glvoes, do not touch eye

55
Q

What tool is used to remove a prsthetic eye?

A

Suction cup, squeeze the suction cup and place o prothesis

56
Q

What tool is used to remove a prosthetic eye?

A

Suction cup, squeeze the suction cup and place o prothesis

57
Q

How do you prevent embolism in the immobile patient?

A

ROM, position changes, OOB, ASAP

58
Q

Why is it important to dangle a patient?

A

Prevent pooling of blood in lower extremities to allow for patient to acclimate to changes in position

59
Q

What are the signs of orthostatic hypotension?

A

Dizzy, pale, clammy, nausea, lightheadedness

60
Q

Define atelectasis? How do you prevent it?

A

Pooling of fluids in the lungs related to decreased muscle strenght and decreased expansition. Cough and deep breath, incentive spirometer, OOB ASAP

61
Q

What is peristalsis?

A

Is the downward propulsion of muscle movement of the GI tract

62
Q

How do you prevent shearing?

A

Lift when moving instead of sliding

63
Q

Define supine, prone, Sims, orthopenic, high fowlers, semi fowlers, and lateral.

A

Supine- back

Prone- stomach

sims- side with knee bent used for enema

high fowlers- 90% knee bent,

semi fowlers- 45% knee bent,

lateral- side

orthopenic- 90% leaning forward, arms up

64
Q

What is a trochanter roll?

A

A device used on the external aspect of the the hip to maintain alignment

65
Q

What s the handle with care initiative?

A

American nurses association has developed standards for lifting and moving patients in health care and have presented a bill to elminate all manual lifts in care facilities.

66
Q

Name different types of PPE

A

Gloves, gown, mask, eye protection, face shield

67
Q

How do you maintain a clean environment?

A

Use Disinfectant wipes on tables, Washing off equipment

68
Q

Primary PPE for contact based precautions

A

Gown and gloves

69
Q

Name two transmission based precautions

A

Airborne and Droplet

70
Q

What are the precautions for droplet transmisison?

A

Standard plus mask
Tissues into biohazard
Range 3 feet
Transmited via respitory when cough, sneeze or talk

71
Q

Define medical asespis

A

To prevent the spread of infection (minimize)

72
Q

Surgical asepsis

A

To prevent pathogens from entering the body (Eliminate)

73
Q

What are the effects of immobility on the Musculoskeletal?

Prevention

A

Muscle atrophy- decreased strenghth and mass
Food drop/contractures -Shortening and tightening of connective tissue

Osteoporosis- calcium depletion

Prevention- Use trochanter rolls/foot boards when needed

74
Q

What are the effects of immobility on the cardiovascular?

Prevention

A

Orthostatic hypotension- decreased cardiac output
Thrombus in legs, pulmonary embolus- polling of blood/ venous stasis

increased cardiac work load

Prevention: Encourage movement of extremities, frequent position changes, raise, lower head of bed, monitor when getting out of bed

75
Q

What are the effects of immobility on the Respiratory?

Prevention

A

Atelectasis- decreased muscle strength, decreased expansion of lungs
Hypoxemia- impaired gas exhange
Pneumonia - pooling of respiratory secretions

Prevention: Turn side to side every 2 hours
elevated HOB 45 degrees
Encourage cough and deep breathing every hour while awake
incentive spirometer 10-20 breaths every hour

76
Q

What are the effects of immobility on the Gastrointesinal?

A

Constipation- Decreased peristalis
Decreased appetite
Falatulence, distension-increased intestinal gas

Prevention: Toileting- OOB as soon as allowed or when possible

Reposition q 2 hours
ROM exercises
Sitting position for defecation on bed pan
Good nutrition fiber / water
no straws (swallow more air)
Bowel assessment
Laxatives/ stool softners if necessary and appropriate

77
Q

What are the effects of immobility on the Neurological?

Prevention

A

Compression neuropathy (decreased oxygen to nerves
Impaired LOC Decreased normal cues and activities
Ataxia- decreased balance when initally rising

Prevention
Baseline LOC
Foot board/High top tennis shoes
Assess neurological stasis
Stimulate cognitive functioning/cues if necessary
Reorient to PPT as necessary
78
Q

What are the effects of immobility on the Psychological?

Prevention

A

Depression, anxiety, insominia - decreased in normal social interactions
Decreased independence

Prevention
Minimize sensory deprivation
engage patient contact with multi sensory stimuli
Encourage self care as much as possible
allow to express feelings, concerns
be kind listen. involve other disciplines when necessary
encourgage family friends to visit

79
Q

What are 3 things you must do when repositioning a patient?

A
  1. lock wheels
  2. Bed is at appropriate height
  3. Always return to lowest postition
80
Q

How often should you reposition patient?

A

Minimum q 2 hours

81
Q

What does repositioning prevent?

A

Capillary and nerve compression

82
Q

What equipment are used to help with repositioning?

A

Pillows, hand rolls, arm boards, and foot boards, trochanter rolls, balnket roll, arm boards

TF of Nursing (8 decks)

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