Essentials Exam 1 Flashcards
Medical diagnosis
the actual name of the condition
(ex: peripheral vascular disease)
nursing diagnosis
focus on care/symptoms rather than condition
(ex: risk for impaired skin integrity)
The way we provide care (KSA)
What does KSA stand for?
Knowledge: What we should do and why
Skill: How we do it
Attitude: What we think about what we are
doing
______ + ______ = critical thinking
(this is dumb but just in case yk)
specific knowledge + data and evidence
Clinical reasoning definition
The ability to integrate/apply
different types of knowledge and
evidence with a clinical
situation (The best action based on the
situation)
bloom’s taxonomy
thinking skills pyramid
bloom’s taxonomy (bottom to top)
remember, understand, apply, analyze, evaluate, create
ADPIE stands for
assessment/analysis diagnosis planning implementation evaluation
4 Cs of the nursing process
Consistent, Comprehensive and
Coordinated Care
infection definition
INVASION of a susceptible host by pathogens or microorganisms
- Results in disease
Colonization definition
The presence and growth of microorganisms within a
host WITHOUT INVASION or damage
Communicable disease
infectious process is transmitted from one person to another.
symptomatic definition
clinical signs and symptoms ARE present
asymptomatic
clinical signs and symptoms are NOT present
HAIs what are they
healthcare-associated infections
Exogenous plus 2 examples
from outside the individual (covid, MRSA)
endogenous
patient’s “normal” flora becomes altered = overgrowth (C. difficile)
Iatrogenic
resulting from a procedure (central line infection, surgical site infection, IUC infection)
infectious agent
bacteria, viruses, fungi, protozoa, parasite
reservoir
things/people that carry infectious agents (people, equipment, water/food, meds)
portal of exit
droplets, excretions, secretions
mode of transportation
contact, droplet, airborne, vectorborne
portal of entry
resp tract, GI tract, mucous membrane, skin
susceptible host
very young, very old, immunocompromised, people w/ chronic disease
Bacteria
single cell
named by shape
staining qualities
vary in size/shape/pattern as a means of replication
Viruses
Smallest microorganisms; not killed by antibiotics
Reproduce inside living host cells
fungi
Single-cell organisms, such as mold and yeast
parasites
live on or in other organisms
contact transmission define and examples?
Meeting of body surfaces with other bodies
or objects
-Direct: Contact with an infected person
-Indirect: Contact with contaminated
object
- examples: MRSA, VRE, C diff, drug-resistant
organisms
Airborne transmission define and examples?
Microorganisms dispersed by air, then
inhaled or deposited
examples: TB, Measles, Chicken Pox
droplet transmission define and examples?
Mucous membranes of resp tract are
exposed to secretions of infected
person
* Influenza, RSV
vectorborne transmission define and examples?
blood-feeding anthropods (insects,
ticks)
* Carry pathogens from one host to
another
* Lyme disease, West Nile Virus,
Rocky Mountain Spotted Fever
factors that lead to drug resistance
- Prescribing antibiotics for nonbacterial
infections - Use of inappropriate antibiotics
- Incomplete courses of antibiotics
Wii method
wash introduce identify
Handwashing: why we do it
-Breaks the chain of infection
-Washing hands with soap removes germs much more effectively
- Soap molecules act as a mediator between water and oil molecules and bind them
- When you rinse off the soap the germs go with it!
- Handwashing can prevent about 30% of diarrhea-related sicknesses and about 20% of respiratory infections
what to do when hands are visibly soiled
soap and water
15-30s rubbing hands
C DIFF NEEDS SOAP AND WATER
what to do when hands are not visibly soiled
alcohol-based rub
rub until dry
contact precautions
private room, handwashing, gown, gloves
airborne precautions
private room with negative airflow, handwashing, N95 respirator
droplet precautions
private room, handwashing, gown, gloves, surgical mask, goggles
Airborne disease examples
Measles, tuberculosis,
SARS, MERS, COVID-19
protective isolation
filters, masks, handwashing, no live items, positive air pressure.
transporting a patient in isolation
“yellow” gown on the patient (as a robe)
face mask if on droplet/resp precaution
an extra layer of sheets
notify personnel
medical asepsis
“clean”
REDUCE microorganisms
hand hygiene, etc.
surgical asepsis
“sterile”
ELIMINATE microorganisms
disinfection definition
REMOVAL of microorganisms
sterilization definition
DESTROY all microorganisms including spores
when can skin be sterile?
no, skin is never sterile
7 principles of surgical asepsis
- sterile can only touch sterile
- only sterile objects in a sterile field
- non-sterile = object below the waist, unattended objects, turning back on the field, DO NOT CROSS ARM OVER
- prolonged exposure contaminates the field
- moisture = contamination
- fluid flow in the direction of gravity
- 1” border around field = contaminated
pouring sterile fluid
- contaminated = outside bottle, bottleneck
- inside bottle top sterile = sterile
- palm the container = hold the label to
palm - lip liquid
- pour from 1”-2” above the container
- remainder of solution = date, time, and
initial
examples of biohazard materials
bloody products, wound dressings, IV tubing, needles, scalpels, suction canisters, waste from patients with communicable disease
where to dispose of sharps
red sharps container
where to dispose of solid materials
red trash container lined with a red plastic liner
where to dispose of liquids
red “sealed” containers/bottles
functions of the skin
Protection, secretion, excretion, temperature regulation, and sensation
epidermis function
shields underlying tissues, protects from water loss, injury/integrity, and infection
dermis
Sweat glands, sebaceous glands, and hair
follicles
– Slows water loss, lubricates skin,
bactericidal
-Too frequent bathing or hot water can
interrupt the protective properties
normal oral mucose look
light pink, soft, moist, smooth
xerostomia
dry mouth
gingivitis
inflammation of the gums
dental caries
tooth decay and tooth loss
factors that can impact hair
Hormonal changes, nutrition,
emotional and/or physical stress,
aging, infection
how to clean sensitive sensory tissues in a way that prevents injury and discomfort
– Do not use soap to clean eyes
– Examine ears for wax accumulation
- Dry outer ear
– Wipe outside of nares with warm, moist washcloth
Hygiene care is routine: true or false
false: hygiene care is never routine
4 ways to improve hygiene care
-check room temp
-administer meds before hygiene
-assist them to preform as INDEPENDENTLY
AS POSSIBLE
-NON-RUSHED atmosphere
5 bath giving guidelines
privacy
safety
warmth
independence
anticipate needs
besides soap and water, what is used for bathing hygiene
chlorhexidine gluconate (CHG) wipes
3 musts for denture care
- washcloth in sink
- must be removed at night
- must be covered in water when not worn
When to obtain hair consent
- braiding
- cutting
- shaving facial hair
shaving techniques
- go in the direction of hair growth
- if a patient is on certain medications
(anticoagulants) use an electric razor
eye care technique
- no soap
- inner to outer canthus
when changing linens what not to do to maintain medical asepsis
do NOT place soiled linen on the floor or next to your body/scrubs
back/return demonstration
having patient repeat what you taught to show proficiency
when entering a room what two things do you always do
2 pt identifiers
hand hygeine
when bathing what direction do you clean
most clean to least clean
order of bathing body parts
- face
- trunk and upper extremities
- legs
- perineal (front-back)
- back
- butt (front-back)
client assessment during hygiene
- skin assessment
- ROM
- strength
- independence
- comfort/ pain lvl
culture of safety environment
blame-free environment
wellness pyramid (bottom -> top)
physiological needs
safety/security
love/belonging
self-esteem
self-actualization
RACE what does it stand for
fire safety: Remove Activate Contain Extinguish
“speak up” campaign purpose and who created it
Encourages the patient/family to take an active role in preventing errors (created by The Joint Commission)
Yellow wristband =
fall risk
Red wristband =
allergies
purple wristband =
DNR
Inappropriate use of restraints =
violates both state and federal regulations.
– Use in this manner constitutes abuse
medical protection devices
Temporary immobilization for the performance of or recovery from a medical procedure or surgical treatment
– Protects the patient from exacerbating underlying illness or injury
(ex: Splints, braces, casts)
what are restraint medications and when to use
Sedatives and anti-anxiety medications
-Control disruptive behavior
–Confusion, agitation, wandering,
combativeness
when are medications considered a “restraint”
– Not part of standard care for the condition
– Used intentionally or in excess to
specifically limit behavior
why to NOT use restraints
- convenience
- family pressure
- under-staffed
- decrease legal liability
- restraints do not reduce fall/injury
spiraling mobility
- Process where an older person is perceived to be at risk for
falling and is restrained to prevent falling - Becomes unable to walk due to prolonged immobilization
hypoxic encephalopathy
- due to restraints
Causing increased confusion and disorientation, altered mental status, restlessness
psychological effects of restraints
Demoralization, humiliation, feelings of low self worth, depression, impaired social functioning, social isolation
alternatives to restraints
- re-evaluate medications
- hourly nursing rounds
- identify the cause
how often must the provider complete a face-to-face patient assessment for restraints?
- RN must assess a minimum of every 2
hours - limited to 4hrs for adults; 2hrs children
- time limit for restraints 24 hrs
- know your facility policies and state laws
ongoing care when using restraints for patient
- restraint breaks
- call light within reach
- bed in lowest position, locked
- delegation (assessment cannot be
delegated)
how to tie a restraint
- quick-release knot
- 2 fingers should fit between the body
restraint - always tied to BED FRAME
what is a seizure?
– Sudden, disorderly discharge of cerebral
neurons
– Characterized by sudden alteration in the
brain. function: motor, sensory and
autonomic function
Who is at risk for a seizure?
– Neurologic or metabolic disturbance
– Head Injury
– Brain tumor
generalized seizure
- tonic-clonic
- sustained involuntary muscle contractions
- 2-5 minutes, cry, loss of consciousness,
tonic-clonic movement, incontinence
– During: shallow breathing, cyanosis,
incontinence
– Postictal phase: disoriented, no recall of
event, deep sleep
Grand mal (or tonic-clonic)
Tonic: rigid muscles
Clonic: muscular jerking
2-5 minutes
Focal seizure
- Motor: muscular jerking, smacking lips,
clapping hands, blinking, chewing - Non-motor: lack of movement, staring,
change in sensation, cognition
absent seizure
- Staring spells
- Last usually less than15 seconds
Status Epilepticus
- a seizure lasting more than 5 minutes
- 2 or more seizures within 5 minutes
Aura
the before of seizures
safe environment
During seizure
- positioning, no objects in the mouth, do
not restrain, time seizure, privacy
post-ictal
post seizure
- reorient
- assessment
seizure precautions
- padded side rails
- bed at lowest
- clutter-free environment
- access to call bell
- suction equipment at bedside
- O2 and nasal cannula at the bedside
- avoid the use of restraints
how to document a seizure
- the time it begins
- duration
- the time it ends
- sequence and times
- note an injuries
-not pt report of ‘aura’
morse fall scale
simple, quick assessment tool for fall risk
high risk: 45 or higher
moderate risk: 25-44
low risk: 0-24
Hendrich II Fall Risk
looks at not only physical factors but medications as well
get up and go test: part of assessment
a score of 5 or greater = high risk
how often should fall risk be evaluated
minimum once a day
“if it wasn’t documented it wasn’t done” true or false
true (documentation)
who sets the standards of documentation and why?
The Joint Commission (TJC)
evaluates quality and appropriateness of client care
non-reimbursable events
‘never’ events
specific hospital-acquired/preventable conditions
how to begin each documentation entry
date/time and end with your signature and title
SOAP:
subjective, objective, assessment, plan
SOAPIE:
subjective, objective, assessment, plan, intervention, evaluation
PIE:
plan, intervention, evaluation
DAR:
data, action, response
hand-off report can be:
verbal, recorded, or written
SACCIA: (documentation/handoff)
Sufficiency
Accuracy
Clarity
Context
Interpersonal Adaptation
‘Read back’
method for verification
do not ‘repeat back’
student nurses CANNOT take phone orders. true or false
true
SBAR
situation background assessment recommendation
Paperwork cannot be given to the patient. true or false
true
why is immobility a critical nursing concern
increase hospital stays
increase fall risk
effects of immobility
metabolic changes
GI motility decreases
respiratory changes
cardiovascular changes
urinary changes
musculoskeletal changes
pressure ulcers
assessment of mobility
ROM
Gait
Activity Tolerance
Body alignment
body systems
trochanter roll
maintains hip alignment
prevents external rotation
supine position
laying on back
prone position
laying on stomach
semi-fowlers position
sitting at a 45-degree angle
lateral position
fetal position
sims position
fetal position with one leg up
Trendelenburg position
supine position head lowered feet raised
safe patient transfer of patient that can assist
wide base of support
lower center of gravity
what position to sit the pt when helping the patient walk
DANGLE the client’s legs
how a walker should be measured
top of the walker should line with the crease of the inside of the wrist
elbows flexed 15-30 degrees
cane measurements
The cane length should equal the distance
between the greater trochanter and
the floor
how to use a cane
- Keep cane on stronger side of body
- Place cane forward 6 to 10 inches,
keeping body weight on both legs - Weaker leg is moved forward
- Divide weight between cane and
stronger leg - Stronger leg is advanced past cane
- Divide weight between cane and
weaker leg
crutches measurement
- Ensure the length of the crutch is 2-3 finger widths below the axilla
- Position the tips (bottom) about 2 inches lateral
- 4-6 inches anterior to the front of the patient’s shoes
-Handgrips: Arms should flex 20-25 degrees when upright and supporting weight on handgrips
Writing Learning Objectives MUST HAVE
- Condition: What teaching strategy are you going to use
- Audience: the client, the patient, the community
- Behavior: domain, level, verb, product (topic)
- Degree: 100%, correctly, consistently
avoid phrases:
appreciate, have faith in, know, learn, understand, believe
