Exam 1 Flashcards
Asepsis
freedom from disease-producing microorganisms
Sepsis
toxic condition resulting from the presence and multiplication of pathogenic microorganisms or their products in the blood
Endogenous
microorganisms already present on the person
Exogenous
source of microorganism was from hosiptal
iatrogenic
microorganisms coming from catheters, improper iv, improper wound dressing changes, ect.
infectious agent
microbial organism with ability to cause disease; bacteria, viruses, fungi, parasites
reservoir
place where organisms can thrive and reproduce
portal of exit
place where organism can leave the reservoir
Mode of Transmission
way an organism is carried from one place to another
susceptible host
any one at risk of infection
signs and symptoms of infection
fever, increase pulse and resp rate, energy loss, anorexia, nausea, enlarged lymph nodes, elevated WBC and ESR, growth of microorganisms from urine, blood
medical asepsis
procedures that reduce number and transfer of pathogens
surgical asepsis
practices used to render and keep objects and areas free from microorganism
Tier 1 Standard precautions
used by all healthcare professionals for ALL patients: hand hygiene, ppe, safe injection practices, safe handling
Tier 2: Transmission-Based Precautions
used for patients with known or suspected infections that spread in 1 of 3 ways: airborne, droplet, or contact
Airborne Precautions
patient has private room with negative pressure. 6-13 air changes every hour, N95 respirator, use surgical mask on patient if transporting them
Droplet Precautions
private room when available, wear mask, surgical mask on patient during transport, visitors are 3 fee from patient
Contact precautions
private room when available, gloves and gown, limit patient movement outside room, delicate use of patient care equipment to this patient
Epidemiologically Important Pathogens
MRSA, VRE, C. diff, EVD
Preventing Epidemiologically Important Pathogens
clean hands, PPE, patient dedicated equipment (Standard precautions + contact precautions)
reverse isolation
for patients who are immunocompromised
private room
no people with resp infections/communicable diseases
no live plants
no fresh produce
communication process
Channel: visual, auditory, kinesthetic
receiver
source
Standards of Effective Communication
Complete
Clear
Brief
Timely
SBAR
situation
background
assessment
recommendation
Temperature
normal: 96.8-100.4
oral: under tongue, wait 30 min if patient has been eating, drinking, or smoking
rectal: most accurate, insert 1.5 inch, increased safety concerns
axillary: no clothing in the way
tympanic: adult-pull auricle up and back, children- bull auricle down and back, compares to core reading
temporal artery: middle of dry forehead,
Pulse
adult normal: 60-100
Respirations
adult normal 12-20
Blood pressure
120/80
40% circumference
dont use arm with IV, PICC line, history of mastectomy on that side, dialysis catheter in place
Pulse OX
normal 95-100%
placed on finger, ear, bridge, nose, or forehead
Nursing process
identify patients health status and actual or potential health care problems or needs
establish plans to meet identified needs
deliver specific nursing interventions to meet needs
Assessment
to establish a database about patients response to health concerns or illnesses and ability to manage healthcare needs
Diagnosing
nursing diagnosing: clinical judgment about individual, family, or community responses to actual or potential health problems/life processes that can be prevented or resolved by independent nursing interventions
nursing diagnoses vs medical
nursing: ineffective breathing pattern, activity intolerance, acute pain, body image disturbance, risk for altered body temp
medical: Chronic obstructive pulmonary disease, cerebrovascular accident, appendectomy, amputation, strep throat
nursing diagnosis format
P-problem
E-etiology
D- defining characteristics
Planning
Inital: Nursing history and assessment
Address each problem identified upon admission
Ongoing: Carried out by the nurse who is interacting with the patient, Keep plan up to date
Discharge: Sometimes carried out by case manager/care coordinator, Help family and patient maintain health and self-care after discharge
Priority Setting
prioritize nursing diagnoses
Maslow’s hierarchy of needs
patient preference
potential future problems
Consider values and beliefs, resources available, urgency of problem, and medical treatment plan
goals vs expected outcomes
goals: broad statements, “the patient will” short or long terms, realistic
expected outcomes: specific, obersvable and measurable, realistic, evaluates progress “weight gain 5lb by October 15”
nursing interventions/activities
Actions the nurse/patient perform to achieve patient outcomes
nurse intiated interventions
Activities nurses are licensed to initiate (i.e., physical care, ongoing assessment)
physician initiated interventions
Activities carried out under primary care provider’s orders or supervision, or according to specified routines
collaborative interventions
Actions nurse carries out in collaboration with other health team members
Reflect overlapping responsibilities of health care team
Implementation
carrying out specific interventions
Evaluating
is the patient making progress toward goal/expected outcome
ongoing: formative eval
eval at the end of hospitalization: summative
ex: outcome met aeb
outcome partially met aeb
outcome not met aeb
alternatives to restraints
involve the family
assist with toileting frequently
distraction
provide warm beverage, back rubs, soft lighting
determine cause of confusion
rocking chair
