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201 Intro > EXAM 1 > Flashcards

EXAM 1 Flashcards

HYGIENE/PRECAUTIONS/INF CTRL/HEARING AIDS/ VS/ ROM/TRANSFERS WEEKS 1-3

1
Q

SKIN OVERVIEW

A

Largest organ in the body- Temperature regulation, Secretions, Sensation- touch, Vit Dsynthesis, Blood storage 10%, Communication- facial expressions, overall appearance

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2
Q

what are skin and mucosal cells responsible for

A

exchange oxygen, nutrients, & fluids with underlyingblood vessels

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3
Q

why is adequate nutrition, hydration and circulation important for the skin

A

to resist injury and disease

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4
Q

what does proper hygiene techniques promote for the skin

A

normal structure and function of these tissues

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5
Q

functions of the skin

A

Protection, secretion, excretion, temperature regulation, and sensation

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6
Q

primary layers of skin

A

epidermis
dermis
subcutaneous tissue

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7
Q

epidermis

A

shields underlying tissue (water loss, injury, new cells as shedding occursnormal flora- bacteria- that prevent growth of disease-causing microorganisms)

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8
Q

dermis

A

contains bundles of collagen, nerve fibers, blood vessels, sweat glands,sebaceous glands, and hair follicles. (Sebum- lubrication, bactericidal.)

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9
Q

subcutaneous tissue

A

Lies just beneath the skin; contains blood vessels, nerves,lymph, and loose connective tissue filled with fat cells. (Cushions and anchors,insulates).

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10
Q

Factors influencing hygiene/ Assessment

A

Social practices
Personal preferences
Body image
Socioeconomic status
Health beliefs and motivation
Cultural variables
Developmental stage
Physical condition

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11
Q

hygiene assessment

A

skin
Gums & teeth, hair
Feet, nails & cuticles- circulation
Ability
Safety Concerns- patient, nurse
emotional status
Current healthcare practices/education needs

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12
Q

skin assessment

A

color, hydration, turgor-elasticity, texture, lesions (pink, dry, intact)

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13
Q

ability

A

Dexterity, gait (injuries, joint deformities, contractures)

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14
Q

what all is involved in oral health

A

Mucous membrane, tongue, gums, teeth- moist, pink, intact (no open areas)

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15
Q

glossitis

A

inflamed tongue

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16
Q

chelitis

A

cracked lips

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17
Q

xerostomia

A

dry mouth

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18
Q

stomatitis

A

inflammation of oral mucos

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19
Q

saliva

A

is the liquid medium for digestion. It also has bacterial static property. For unconscious patients, the actions of swallowing saliva does not occur regularly. A risk of pneumonia from static oral secretions occurs

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20
Q

teeth

A

are used to chew (masticate) food particles. Teeth should be white, smooth, shiny ,and fairly well aligned. Note decay or edentulous.

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21
Q

dentures and denture care

A

Keep dentures covered in water when they are not wornStore in an enclosed, labeled cup with the cup placed on patient’s bedside stand

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22
Q

sensory organs

A

eyes
ears
nose

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23
Q

eyes

hygiene

A

cleansing from inner to outer canthus to prevent secretions from entering the nasolacrimal ducts, use different part of washcloth for each eye to prevent transferring microorganisms from one eye to the other. More frequently if unconscious and not blinking- secretions will build up. Glasses, dry eyes, allergies.

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24
Q

ears

hygiene

A

washing of ear and outer canal with wash cloth, Q-tips not recommended b/c potential damage to tympanic membrane (ear drum)

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25
Q

nose

hygiene

A

smell and taste. Very vascular mucous membrane. Mucous and cilia trap foreign matter to prevent it from entering the lungs. It is blown out or sneezed away

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26
Q

considerations for older adults

A

Wrinkles (decreased collagen)
Thinning of skin layers
Degeneration of elastin fibers
Decreased sweat production
Decreased oil production, drier skin
More skin lesions
Graying hair
Increase in facial hair
Dry brittle nails

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27
Q

considerations for older adults

hygiene

A

Weakening of periodontal membrane so increased risk of infection, disease

Dentures- pain, malnutrition- Ensure never thrown away or lost!

Dry mouth due to decreased saliva, meds

Malnutrition- due to socioeconomic status, limited ability to prepare healthy foods, dental problems

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28
Q

considerations for neonates

hygiene

A

skin is loosely bound, easily damaged. Layers bind together as infant gets older.

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29
Q

considerations for adolescents

hygiene

A

sex hormones- sebaceous glands-oil, sweat glands- odor. Hygiene

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30
Q

Hygiene Nursing Diagnosis/ Problems

A

Activity intolerance
Self-care deficit: Impaired Ability to Bath
Impaired mobility
Impaired skin integrity
Impaired oral mucous membranes
Risk for infection

r/t bathing, oral care, dressing, feeding, transfers, walking, turning in bed

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31
Q

critical thinking in hygiene

A

Integrate nursing knowledge.
Consider developmental and cultural influences.
Think creatively.
Be nonjudgmental and confident.
Draw on your own experiences.
Rely on professional standards.
Use communication to promote the therapeutic relationship.

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32
Q

planning

hygiene

A

Who is involved in care? Community agencies needed? Amount of help required?

Partner with the patient and family
Measurable, achievable, individualized

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33
Q

goals and outcomes

hygiene

A

Set priorities based on assistance required, extent of problems, nature of diagnoses
Skin will be clean, dry, and intact with good turgor. No areas of inflammation will be noted
Skin will have no pressure, tear, or sheared areas
Skin will have no areas of infection
Oral mucosa will be moist, pink, and intact

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34
Q

implementation

hygiene

A

Provide privacy, professionalism, modesty, safety, warmth (water, room, bath blanket, mitt- loses less heat, prevents drag of washcloth across skin)

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35
Q

bathing daily

A

Primary reason-cleanse & reduce microbe count, remove dead skin, Secondary reasons- stimulate circulation, provide relaxation, enhance healing

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36
Q

types of baths

A

Complete, Partial (unable to tolerate), Therapeutic (soothe itchy skin)

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37
Q

technique of bathing

A

Wash with long, firm strokes from distal (away) to proximal (closest). Why? To promote venous circulation. (Light strokes if history of blood clots)

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38
Q

applying lotion

A

Apply lotion to all areas of skin- moisturizes (except in between toes- risk of skin irritation, maceration-softening)

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39
Q

Bacterial count and excess mucous in the mouth

A

increases the risk of HAI (Healthcare or Hospital Acquired Infections) (pneumonia), Oral moisturizers as needed. Tooth brushing twice daily, flossing once daily. Helps improve taste sensation & moisturizes

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40
Q

oral care technique

A

So Oral care twice a day OR Every 1-2 h for unconscious, ventilated, NPO- nothing by mouth (Toothbrushes most recommended for all oral care. Suction available for unconscious- risk of aspiration) (Check for gag reflex before care) Diabetes, artificial airways, unconscious, chemotherapy
CHG oral rinse/paste is antimicrobial effective against dental plaque biofilms, decrease HAI

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41
Q

chg use

A

Don’t use near eyes, ears, Use in basins-stops bacterial growth, Leave on for more antibacterial effects, to rinse or not

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42
Q

promote independence

A

allow the patient to do as much as they are able/willing
anticipate needs

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43
Q

considerations for the nurse in implemmenting hygiene

A

Keep dirty gown, linens away from uniform

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44
Q

Prevent fungal growth

A

Wash and dry areas breast, axillary, and abdominal folds well

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45
Q

comb/brush hair daily

A

to distribute oil. (Braid long hair to keep it from tangling.)
Combing is more effective than use of pediculicidal shampoos in the case of head lice

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46
Q

trim nails

A

in line with tip of finger as needed & cleanse dirt from nails- (short, clean nails are less likely to spread infection)

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47
Q

feet care for diabetics

A

daily- (inspection prevents unnoticed injuries from worsening)

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48
Q

backrub

A

help with sleep, relaxation (Effleurage- long, slow, gliding strokes of massage)

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49
Q

teaching/teach-back

A

relevant instruction, prevent injury/infection

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50
Q

perineal care

A

independently or with assistance, risk of infection- uncircumcised males, urinary catheters, post-rectal or genital surgery or childbirth

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51
Q

concerns of perineal care

A

burning during urination, soreness, excoriation (raw), pain, discharge- appearance, odor, amount. Risk for skin breakdown- incontinence, dressings, catheters, obesity.

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52
Q

how to perform perineal care

A

Cleanse from front to back to reduce chance of transmitting fecal organisms to urinary meatus. Use different sections of the washcloth for folds.

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53
Q

You are caring for a non–English-speaking male patient. When preparing to assist him with personal hygiene, you should:
A. use soap and water on all types of skin.
B. ensure that culture and ethnicity influence hygiene practices.
C. shave facial hair to make the patient more comfortable.
D. know that all patients need to be bathed daily.

A
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54
Q

medical devices

hygiene

A

(Oxygen tubing- check what? …….) Cleaning ear gently with washcloth. Hearing aid maintenance

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55
Q

shampoo/shaving

A

when to use electric razor

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56
Q

cleaning eyeglasses

A

$, lens or soft cloth, cool water, no paper towels

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57
Q

care for contacts

A

clean hands, contact solution

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58
Q

caring for artificial eyes

A

warm normal saline (NS) to rinse eye, NS or water on soft gauze to rinse eye socket, Store in tap water or NS- labeled container. Observe for S& S of infection.

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59
Q

diabetic foot care part 1

A

Inspect feet and between the toes daily-thoroughly (Use mirror if needed)
Lukewarm water, thorough drying- do not soak feet due to risk of infection
Lotion to feet but NOT between the toes b/c or risk of skin irritation & breakdown
If can see and reach nails on their own, they should trim nails straight across, file edges smooth (HCW file but don’t cut- HCP order in healthcare facility)

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60
Q

diabetic foot care part 2

A

Cotton socks, comfortable & sturdy shoes
Do not apply heating pad to feet
Elevate legs when sitting.
Don’t cross legs for long periods.
Avoid smoking.
Wiggle toes and move ankles up & down for 5 minutes 2-3 times daily.
Contact HCP (healthcare provider) if concerns

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61
Q

evaluation of hygiene part 1

A

Through the patient’s eyes-
Were the patient’s expectations met?
Patient outcomes

Evaluate after each hygiene intervention. Use teach back.

If outcomes were not met, revise the care plan
Bathed

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62
Q

evaluation of hygiene part 2

A

Moisturized
Teeth brushed twice a day; flossed once a day (ADA)
Eyes, ears, nose without redness or drainage
Nails clean and trimmed
Feet have no areas of breakdown

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63
Q

Safety Guidelines for Nursing Skills part 1

hygiene

A

Identify the patient with two identifiers.
Move from the cleanest to less clean areas.
Use clean gloves for contact with nonintact skin, mucous membranes, secretions, excretions, or blood.

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64
Q

Safety Guidelines for Nursing Skills part 2

hygiene

A

Test the temperature of water or solutions.
Use principles of body mechanics and safe patient handling.
Give proper direction to UAP- unlicensed assistive personnel- when delegating.

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65
Q

the chain of infection

A

A sequence of necessary pieces for an infection to occur.

Includes an infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host.

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66
Q

infectious agent

A

something that contains bacteria, fungi, virus, parasite, or prion.

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67
Q

reservoir

A

the habitat of the infectious agent and is where it lives, grows, and reproduces itself or replicates.

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68
Q

portal of entry

A

can be any body orifice (for example, ears, nose, mouth) or can even be through the skin, and it provides a place for the infectious agent to replicate or for the toxin to act.

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69
Q

portal of exit

A

is the means by which the infectious agent can leave the reservoir

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70
Q

susceptible host

A

is required for the infectious agent to take hold and become a reservoir for infection. Not everyone who is exposed to an infectious agent gets sick.

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71
Q

modes of transmission

A

contact
droplet
airborne

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72
Q

contact

modes of transmission

A

occurs when microorganisms move from an infected person to another person.

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73
Q

droplet

modes of transmission

A

occurs when airborne droplets from the respiratory tract of a client travel through the air and into the mucosa of a host

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74
Q

airborne

mode of transmission

A

occurs when small particulates move into the airspace of another person.

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75
Q

There are two types of contact transmission:

A

direct and indirect

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76
Q

direct contact transmission

A

occurs when microorganisms are directly moved from the infected person to another person without having a contaminated object or person between the two.

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77
Q

indirect contact transmission

A

occurs when microorganisms are moved from the infected person to another person with a contaminated object or person between the two.

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78
Q

Nonspecific immunity

A

Nonspecific immunity refers to neutrophils and macrophages and their work as phagocytes.

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79
Q

phagocytes

A

eat and destroy microorganisms, thereby helping to protect the body from harm

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80
Q

when are neutrophils and macrophages released

A

during the inflammatory response.

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81
Q

specific immunity

A

refers to the work of antibodies (also called immunoglobulins) and lymphocytes. Antibodies bind to infectious agents and call to the white blood cells and complement to destroy them

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82
Q

The Inflammatory Response

A
  1. Pattern receptors on the surface of cells recognize harmful stimuli.
  2. Inflammatory pathways are activated.
  3. Inflammatory markers are released.
  4. Inflammatory cells are recruited.
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83
Q

stages of infection

A

incubation
prodromal
acute illness
decline
convalescence

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84
Q

incubation stage of infection

A

An infection enters host and begins to multiply

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85
Q

prodromal phase of infection

A

The client begins having symptoms.

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86
Q

acute illness stage of infection

A

Manifestations of the specific infectious disease process are obvious and may become severe.

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87
Q

decline stage of infection

A

Manifestations begin to wane as the degree of infectious disease decreases.

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88
Q

convalescence stage of infection

A

The client returns to a normal or a “new normal” state of health.

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89
Q

A nurse holds dirty linen away from the body during transport to an appropriate receptacle. The nurse is intervening to break the chain of infection for which link?
A. Etiological agent
B. Reservoir
C. Portal of entry to susceptible host
D. Susceptible host

A
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90
Q

A client complains of feeling very tired, having aching muscles, and a slight headache. The nurse recognizes the client may be experiencing which phase of the infectious process ?
A. Incubation stage
B. Prodromal stage
C. Illness stage
D. Convalescent stage

A
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91
Q

LOCAL INFECTIONS

A

are confined to one area of the body. Local infections can be treated with topical antibiotics and oral antibiotics

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92
Q

SYSTEMIC INFECTIONS

A

start as local infections and then spread to the bloodstream to infect the entire body

93
Q

SEPSIS

A

is systemic inflammatory response syndrome resulting from body’s response to a serious infection due to microorganisms (usually bacterial

94
Q

hand hygiene

A

broad term to cover any type of cleansing of hands

95
Q

what exactly is hand hygiene? how is it performed?

A

Handwashing- 15-20 sec. Soap and water for diarrheal disease (c-diff spore potential), Sanitizer >70% alcohol, lotion to prevent dermatitis- itchy, dry skin/ irritation

96
Q

when should you perform hand hygiene

A

Hands are soiled, before & after pt contact, before sterile gloving, contact with body fluids, each time gloves removed

97
Q

When should hand hygiene be performed?

A
98
Q

When can hand sanitizer be used and when should it not be used?

A
99
Q

medical asepsis

A

(clean technique) is a term used to define the elimination of and absence of disease-causing microorganisms

100
Q

surgical asepsis

A

sterile technique

101
Q

Principles of Surgical Asepsis (Sterile Field)

A

A sterile object is free of all microorganisms.

All objects on a sterile field must be sterile.

sterile items below the waist or out of the field of vision are not sterile

avoid talking, laughing, sneezing, and prolonged air over sterile field

102
Q

how to open a sterile field

A

1st open flap or side furthest away from you using, 2nd & 3rd flaps on either side using closest hand, 4th side closest to you- Why?

103
Q

what does moisture do to a sterile field

A

Moisture contaminates a sterile field. Water-proof barriers are used. Wet objects become contaminated by capillary action. Pour from sterile solution into container. Make sure cap of bottle set face up on clean surface.

104
Q

outer edges of sterile fields

A

Outer 1 inch of a sterile field is considered unsterile b/c touches surfaces and can be touched by non-sterile hands. Outer edges of containers considered contaminated.

105
Q

standard precautions

A

is a term used to describe the infection prevention practices applied to all clients, whether or not they are known to have an infectious agent

106
Q

ppe

A

It is the nurse’s responsibility to know what type(s) of Personal Protective Equipment (PPE) are needed to care for clients and to don and doff PPE appropriately.

107
Q

donning ppe

A
  1. gown
  2. mask/respirator
  3. goggle/face shield
  4. gloves
108
Q

removing ppe

A
  1. gloves
  2. goggles/face shield
  3. gown
  4. mask/respirator
  5. hand hygiene
109
Q

airborne

precautions-stopping spread

A

for diseases that transmit via the air, either as molecules less than 5 microns or by riding on dust particles that small. Molecules remain suspended in the air. N95 particulate respirator-fit-testing, Negative pressure room (HEPA filtration) (TB, chicken pox, COVID, Ebola)

110
Q

droplet

precautions-stopping spread

A

for pathogens that are transmitted by particles larger than 5 microns. And drop to the floor or fomites within 3 feet of the host (sick person). Mask required. (Influenza, pertussis)

111
Q

contact

precautions-stopping spread

A

for pathogens that are transmitted by direct or indirect contact with the host. All items and fomites (furniture) are contaminated within 24 hours of the host being place in the room. (Always gown, gloves, hand-washing, mask if risk of splashing) (MRSA)

112
Q

contact plus

precautions-stopping spread

A

same as contact but wipe down room surfaces routinely & thoroughly to kills spores- Clostridium difficilie/c.diff)

113
Q

protective environment

precautions- stopping spread

A

private room, positive airflow, high-efficiency particulate air (HEPA) filtration, mask when out of room, no live plants or flowers due to aspergillosis mold- can cause infection (Immunosuppressed/ Neutropenic)
Limit patient movement outside of room, clean gown, mask (PPE) on patient for transport if needed, door closed
Psychological implications, bagging of trash, patient care items, specimen collection

114
Q

specifics of contact precautions

A

hand hygiene
gown and gloves
*if risk of splash/spray, wear face and eye protection

115
Q

specifics of contact plus precautions

A

hand hygiene- not foam but requires soap and water
gown
gloves
if risk of splash/spray, wear eye and face protection
*twice daily cleaning of high touch surfaces

116
Q

specifics of droplet and contact precautions

A

hand hygiene
mask
eye protection
gown
gloves

117
Q

specifics of droplet precautions

A

hand hygiene
standar precautions but add mask

118
Q

specifics of airborne precautions

A

hand hygiene
standard precautions
n95 respirator
Pt must be in negative pressure room with door closed

119
Q

specifics of protective precautions

A

no one with an infection may visit
hand hygiene
Pt wears a surgical mask when out of room
no live plants/flowers

120
Q

In addition to standard precautions, what precautions are required for a client with tuberculosis

A
121
Q

In addition to standard precautions, what precautions are required for a client with pertussis?

A
122
Q

In addition to standard precautions, what precautions are required for a client with MRSA? C-difficicile?

A
123
Q

Which commonly used household cleaner is effective against bacteria, TB, spores, fungi, and viruses?

A
124
Q

The four major HAIs are:

A

Central Line-associated Bloodstream Infections (CLABSIs)

Catheter-associated Urinary Tract Infections (CAUTIs)

Surgical Site Infections (SSIs)

Ventilator-assisted Pneumonias (VAPs)

125
Q

Health Care-Associated Infections (HAIs)

A

Morbidity, mortality, cost——Not reimbursed

126
Q

types of hai infections

A

Iatrogenic—from a procedure
Exogenous—from microorganisms outside the individual
Endogenous—when the patient’s flora becomes altered and an overgrowth results

127
Q

HAI & Antibiotic resistance-

A

Invasive procedures, altered immune defenses, older adults, antibiotic administration, multi-drug resistant organisms (mdro)

Gene mutations after surviving antibiotic therapy (mdro)

Spread to sputum, bloodstream, urinary tract

128
Q

examples of antibiotic resistant microorganisms

A

MRSA (methicillin-resistant S. aureus) colonizes is nose, skin
VRE (vancomycin-resistant Enterococcus)
C-difficile (soap & water) to kill spores

129
Q

broad spectrum antibiotis

A

to treat infection may eliminate or change normal flora, leading to a superinfection- overgrowth of harmful bacteria.

130
Q

normal flora

A

Microorganisms- found in skin, saliva, oral mucosa, and intestinal walls.
Maintain sensitive balance with other microorganisms to prevent infection. Disruption of balance increases risk for acquiring of illness/disease.

131
Q

hai/mdro prevention

A

Hand hygiene, conservative antibiotic use, universal precautions, transmission-based precautions, proper disposal of PPE, not sharing patient items, antimicrobial dressings, no artificial fingernails, limit urinary catheterizations, careful monitoring- Limit/Intervene/Break the chain of infection

132
Q

Nursing Diagnoses (Problems)——Nursing Actions

hygiene

A

Risk for Infection
Imbalanced Nutrition: Deficient Food Intake
Impaired Oral Mucous Membrane
Impaired Skin Integrity
Social Isolation
Impaired Tissue Integrity
Readiness for Enhanced Immunization Status

133
Q

patient safety

hygiene

A

Separate personal care items
Handling exudate
Wound cleaning
Cough etiquette
Dirty linen- never on floor
Maintain skin integrity
Perineal care after toileting
Urinary catheters and drainage sets
Teach back

134
Q

Occupational Safety and Health Administration (OSHA)-

A

regulations to protect employees whose jobs put them at risk for exposure to blood/infectious agents

135
Q

human body fluids

A

saliva, fluids contaminated with blood, semen, vaginal secretions, cerebrospinal fluids, synovial fluid, pericardial fluid, amniotic fluid, unfixed tissue or organs, cultures containing HIV/Hep B/Hep C, infected animals

136
Q

standard precautions

A

providing care for all persons to reduce the risk of microbial transmission from one person to another- handwashing, safe disposal of Sharps- never recap used needle, PPE

137
Q

ppe

A

Protect skin, mucous membranes, respiratory tract. Gloves, masks, gowns, shoe covers, goggles (not just eye glasses). Don’t touch face. Guidelines are to remove gloves, remove gown by only touching it on inside, remove mask, wash hands.

138
Q

American Nurses Association advocated for

A

federal regulations instituting needless devices to promote needlestick safety and prevention- prevent puncture wounds

139
Q

Health Promotion for Immune System

part 1

A

A diet with fresh fruits, vegetables, whole grains, nuts, & legumes; fewer processed foods; decrease allergies- early solid foods
Adequate rest and Exercise at least three times a week for 30 minutes at a moderate or strenuous level
Maintain a weight that is suitable for height so that Body Mass Index –Ideal BMI ranges from 18.5 – 24.9
Stress management and reduction by effective positive means

140
Q

Health Promotion for Immune System

part 2

A

Use of alcohol, drugs, cigarettes, and unprotected sex increase the risk of a compromised immune system (triggers, stds)
Immunizations are protective from communicable diseases by mounting an immune response (antigen-antibody) (active immunity- long-lasting)
Treating ongoing disease whether related to infection or immune system

141
Q

placement of hearing aids

A

Hearing aids are often forced into the incorrect ears. Red is for right. Blue is for left.

142
Q

batteries for hearing aids

A

Don’t keep batteries by medications!!!

-Battery doors should be open when the hearing aids are not being worn.

143
Q

when should you clean hearing aids

A

It is important that the hearing aids are cleaned as often as possible (ideally daily when removed).

144
Q

storing hearing aids

A

Labeled nighttime storage containers. May be locked in secure spot.

145
Q

trouble shooting hearing aids

A

9 times out of 10 when a patient reports hearing aids are not working, they are not clean.
Inspect for wax.
If possible, change wax guard or clean out tubing.

146
Q

squealing hearing aids

A

If the canal contains excessive cerumen, or is occluded the hearing aids will produce feedback.
Referral for cerumen management.

147
Q

realistic expectations of hearing aids

A

Just because your patient has hearing aids, does not mean they have normal hearing.
Volume VS. Clarity
Presence of background noise.
The aging brain.

148
Q

Tips for communicating with the hearing impaired

A

Get their attention!
Say their name.
Alert them if the topic has changed.
Be in an area with good lighting where they can access all visual cues
Movements of the mouth, body language
Eliminate noise sources.

149
Q

Tips for communicating with the hearing impaired.

part 2

A

Decrease your rate of speech.
Talking loudly is not the answer.
Complete your words.
Slight pause between sentences.
Rephrase.
If they did not understand you the first time, do not repeat what you said. Rephrase and say it another way.
Expand on what you are saying.
Be patient!
It can be frustrating for both parties.
If worse comes to worse, write it down!

150
Q

objective data

vital signs

A

temp
hr
rr
bp
SaO2

151
Q

subjective data

vital signs

A

pain is the 6th vs
objective with pain scale

152
Q

can nurses delegate vs

A

yes, but nurse is ultimately responsible and must follow up on values obtained

153
Q

when should a nurse not delegate vs

A

unstable/changing condition
meds given that affect vs
uncontrolled bleeding
cold/clammy/pale skin
suspected change/reaction such as shock, pe, stroke, mi, fall, injury

154
Q

nurse must be aware and is responsible for

vs

A

base line vs
pmh
normal/abnormal vs for age
factors that influence vs
appropriate interventions in collaboration with the dr
minimizing environmental factors
why, how, when, who

155
Q

when are vs taken

part 1

A

upon admission (initial assessment)
check ups with dr
with any change in status
per facility policy
as ordered by dr
if Pt reports non specific symptoms

156
Q

when are vs taken

part 2

A

before/during/and after:
surgical procedures
receiving blood products
receiving certain meds

157
Q

afebrile

A

when a fever breaks

158
Q

fever of unknown origin
fuo

A

fever from undetermined cause

159
Q

what constitutes a fever

A

100.4 F

160
Q

how to treat a fever

A

cool juices/drinks
cool room
light/no covers (sheet only)
antipyretics (tylenol, ibuprophen)
antibiotics (once cultures obtained)
cool them off

161
Q

frost bite

A

occurs when the body is exposed to subnormal temps

162
Q

hypothermia Tx

A

warming measures

163
Q

s/s of hypothermia

A

shivering
pale/cool/puffy
decreased hr and rr
irregular hr
decreased sensation and bility to think –> confused

164
Q

malignant hyperthermia

A

hyperthermia-hereditary condition of uncontrolled heat production (likely after anesthetics). MEDICAL EMERGENCY

165
Q

hyperthermia Tx

A

cooling measures

166
Q

oral temperature procedures

A

Place thermometer to right or left of frenulum at the base of the tongue in the sublingual pocket.

167
Q

oral temperature is contraindicated if

A

Excessive talker
Hx seizures
Mouth breathers
Uncooperative
Unconscious
Infant or small children
Had oral surgery
STOP! If client has been chewing gum, smoking, or eating hot/cold food or drinks.

168
Q

why use a rectal temperature (red)

A

closer to the accurate core temp

169
Q

why not use a rectal temperature

A
  • Site can be embarrassing.
    • Can puncture GI mucosa.
      - Avoid if having diarrhea, has hemorrhoids, rectal surgery etc.
      -Avoid if patient has neutropenia or low platelet count.
170
Q

axillary temperature

A

preferred site for an infant and child
Safer for adults with seizures or if oral is unsafe

171
Q

contraindications of axillary temp

A

a recent bath, rubbing of area, and poor circulation can affect results.

172
Q

axillary temp procedure

A

Place thermometer under arm and ensure it is in contact with skin and hold in place for duration of measurement.

173
Q

pulse sites

A

temporal
carotid
brachial (antecubital space)
radial
femoral
popliteal
posterior tibialis
dorsalis pedis

174
Q

carotid

pulse site

A

Carotid- Used during CPR/MI * Do not assess both carotids at same time- cuts off blood supply to the brain.

175
Q

brachial (antecubital space)

pulse site

A

Brachial (antecubital space)- Used for B/P or to assess pulse in infants/children.

176
Q

radial

pulse site

A

most common

177
Q

radial pulse side

A

used during cpr/mi

178
Q

popliteal

pulse site

A

Popliteal- flex leg to palpate, Used if can’t use arms for B/P

179
Q

doppler D

A

Doppler (D)- is used if you can’t palpate a pulse—don’t document absent—document unable to palpate and get the doppler if available.

180
Q

normal hr for adult

A

60-100

181
Q

pulse assessment scale

A

0- Absent
1+ weak and thready
2+ normal
3+ strong/bounding

182
Q

apical heart rate
apical pulse

A

Apical heart rate (Apical pulse) most accurate and is located left of the sternum, at or below the fifth rib, and midline with the clavicle.

183
Q

how to asses apical pulse

A

Count for 1 minute. This is the point of maximum impulse. 60-100

184
Q

when to assess apical pulse

A

Used if radial pulse irregular or weak
Used if heart rate altering drugs being given (Digoxin).

185
Q

heart sounds

apical pulse

A

S1- low pitched “lubb” (when tri and bi cuspid valves slam shut)
S2-short sound-”dupp”(when pulmonary and aortic valves close)
These two sounds represent one heartbeat

186
Q

how to asses rr

A

When assessing Respirations –count at least 30 seconds—one minute if irregular—you need to determine:

187
Q

normal rr of adult

A

12-20

188
Q

rate per minute

respirations

A

Rate per minute- includes one inspiration and one expiration. Watch rise and fall of chest or abdomen. Hold arm across chest.

189
Q

depth

respirations

A

Depth –chest expansion with each breath.

190
Q

rhythm

respirations

A

Rhythm- is it a consistent pattern. Regular or irregular?

191
Q

respiratory effort

respirations

A

Respiratory effort- how hard are they working to breathe? Should be effortless.

192
Q

charting respirations

A

Always 2 parts! Ex. “Regular, Nonlabored, Rate 16”

193
Q

hypoxemia

A

ex: copd
drive to breath

194
Q

pulse ox/o2 saturation

A

noninvasive technique to monitor the o2 sat of the blood

195
Q

pulse ox procedure

A

attach to finger, earlobe, toe, nose. make sure area is clean, dry, warm, and has good circulation. they need to remain still. remove nail polish and artificial nails

196
Q

normal SaO2

A

95-100%
concern is less than 90%

197
Q

assessment of pain

A

site/location
characteristics
pain scale

198
Q

site

pain

A

Site or location- don’t assume; ALWAYS ask.

199
Q

characteristics of pain

A

Characteristics- describe: is it sharp, dull, aching, cramping, tender, constant, intermittent, stabbing, burning? Ask When does it occur, what makes worse/better ?

200
Q

pain scale

A

Pain Scale (Severity)– 0- no pain to 10 worse pain ever. Scales vary for children and nonverbal patients.

ex: numerical, faces

201
Q

acute pain

A

Acute pain is sudden onset, can be severe, lasts a short time.

202
Q

chronic pain

A

Chronic pain- hangs around with little change; may be life long; does not affect VS as much as acute pain does.

203
Q

what is bp an indication of

A

Indicator of cardiovascular health

204
Q

how to document manual bp

A

If taking manually must be documented in even numbers. If electronic can be uneven.

205
Q

bp assessment sites

A

Usually obtained on the brachial artery but can use other sites.
- Can use popliteal artery behind the knee.
- Can use lower arm and radial artery.
- Must document where B/P obtained.

206
Q

may need to choose optional bp site if pt has had

A
  • a mastectomy
    • bilateral upper extremity amputation
      - shunt/graft for dialysis
    • casts, braces, dressings, etc.
    • Vascular surgery or trauma
    • IV infusion site
207
Q

manual bp procedures

A

Sphygmomanometer bladder width must cover at least 40% of patients upper arm, and the bladder length must wrap around 80-100% of the arm circumference.
If the cuff does not fit appropriately, results will be inaccurate.

208
Q

parts of a stethoscope

A

Review parts of Stethoscope —ear tips are
positioned downward and forward towards face.
Ear pieces are cleaned with alcohol between users and the diaphragm cleaned between patients.

209
Q

positions of pt for taking bp

A

May also need to collect B/P in lying, sitting, and standing positions.

210
Q

normal adult bp

A

Less than 120/80

211
Q

Tx for HTN

A

Quit smoking, weight management, medications.

212
Q

steps to bp

A

assess- palpate brachial pulse, assess pt
place- cuff 1-2 inches above antecubital area
needle on manometer should be at 0, keep at eye level, inflate to 20 mmHg above palpated systolic pressure or up to 200
review factors affect bp

213
Q

hypotension

A

less than 90/x

214
Q

orthostatic hypotension

A

change in patient position causes bp drop- lying, sitting, standing

215
Q
  1. 0.3 g = ________________mg
A
216
Q
  1. 250 mg = ______________g
A
217
Q
  1. 0.4 mg = _______________mcg
A
218
Q
  1. 325 mcg=_______________mg
A
219
Q
  1. 2 oz = _____________mL
A
220
Q
  1. 3 tsp=_____________mL
A
221
Q
  1. 5 tbsp=____________mL
A
222
Q
  1. 30 mL=____________tbsp
A
223
Q
  1. Change to military time 9am ________
A
224
Q
  1. Change to traditional time 0050 _________
A
225
Q

a supervising/charge nurse observes a new nurse performing nursing care for several clients.

Which action requires further education?

-OR-

Which action would the charge nurse question?

(Look for wrong action)

a. Lowering the head of bed before moving a client up in bed

b. Wearing gloves when leaving a client’s room to get clean linen

c. Wearing a mask with eye protection when performing oral suctioning

d. Donning a gown and gloves before entering the room of a client on Contact Precautions

A

b

226
Q

A supervising/charge nurse discusses PPE and precautions with a novice nurse.

Which action shows that teaching was effective? (Look for correct action)

a. Removing goggles as the first step of PPE removal

b. Performing hand hygiene each time gloves are removed

c. Wearing a mask with eye protection to ask the client about their medical history

d. Sanitizing hands after providing care for a client on Contact Plus Precautions

A

b

227
Q

A supervising/charge nurse discusses PPE with a novice nurse.

Which actions show that teaching was effective? Select all that apply. (Look for correct actions as in is it True or False. Select what is True because these apply. There may be 1 or ALL correct answers for these questions)

a. Removing gloves first when removing PPE

b. Wearing gloves to quickly leave the room and grab clean linen

c. Wearing a mask with eye protection when performing oral suctioning

d. Donning a gown and gloves before entering the room of a client on Contact Precautions

e. Donning a gown and gloves before entering the room of a client on Droplet Precautions

f. Donning a surgical mask before entering the room a client on Airbourne Precautions

A

a, c, d

228
Q
A

201 Intro (9 decks)

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