Exam 1 Flashcards
What is infection?
Healthcare associated infections (HAIs): refers to infections associated with healthcare given in any setting.
Nosocomial infections: hospital-acquired infections; leading cause of death; Exogenous- pathogen acquired from healthcare environment & endogenous- normal flora multiply & cause infection as a result of treatment.
Anytime you get sick from a microorganism.
How do germs spread?
Contact, Airborne, Droplet.
The spread of infection (What are the 6 links?)
Infectious agents. Reservoir. Portal of exit. Mode of transmission. Portal of entry. Susceptible host.
Portals of exit.
Bodily fluids Coughing, sneezing, diarrhea Seeping wounds Tubes, IV fluids Foleys
Portals of entry.
Eyes, nares, mouth, vagina, cuts, scrapes.
Wounds, surgical sites, IV or drainage tube sites.
Bite from a vector.
Mode of transmission.
Contact:
- Direct
- Indirect
Droplet
Airborne
Susceptible host.
Person with inadequate defense. Four determine factors: -Virulence -Organism's ability to survive in the host's environment -Number of organisms -Host's defenses.
What are the 3 lines of defense?
Primary
Secondary
Tertiary
What are the primary defenses?
Anatomical features, limit pathogen entry:
- Skin
- Mucous membranes
- Tears
- Normal flora in GI tract
- Normal flora in urinary tract
What are the secondary defenses?
Biochemical processes activated by chemicals released by pathogens:
- Phagocytosis
- Complement cascade
- Inflammation
- Fever
What are the tertiary defenses?
Humoral immunity:
-B-cell production of antibodies in response to an antigen
Cell-mediated immunity:
-Direct destruction of infected cells by T cells
What are some factors that increase infection risk?
Developmental stage Breaks in the skin Illness/injury, chronic disease Smoking, substance abuse Multiple sex partners Medications that inhibit/decrease immune response Nursing/medical procedures
What are some factors that support host defenses?
Adequate nutrition
-To manufacture cells of the immune system
Balanced hygiene
- Sufficient to decrease skin bacterial count
- Not overzealous; causes skin cracking
Rest/exercise
Reducing stress
Immunizations
What is medical asepsis? & How is it promoted?
A state of cleanliness that decreases the potential for spread if infections.
Maintaining ca clean environment, clean hands, & following CDC guidelines
How do you maintain a clean environment?
Clean spills and dry surfaces promptly
Remove pathogens through chemical means (disinfect)
Remove clutter
Consider supplies brought to the room as contaminated
Consider items from the client’s home as contaminated.
When should you wash your hands?
- When you enter & exit pt’s room
- Before & after restroom use
- Before & after client contact
- Before & after contact with pt’s belongings
- Before gloving & after glove removal
- Before & after touching your face
- Before & after eating
- After touching something soiled & visible dirt on hands
What are the hand washing guidelines?
-Wash for at least 15 seconds in nonsurgical setting; 2-6mins in surgical setting
-Remove jewelry & clean beneath fingernails
-Use a bactericidal solution or use water if hands are visibly soiled
Use warm not hat water
Apply soap to wet hands
Use friction
Rinse soap
Towel or hand dry
What are standard precautions?
Protects healthcare workers from exposure, decreases transmission of pathogens, & protects clients from pathogens carried b healthcare workers.
What are the PPE (Personal Protective Equipment)?
Gloves Gown Mask Face shield Goggles
Contact Precautions.
Pathogen is spread by direct contact.
Precautions include: Possible private room Clean gown & glove use Disposal of contaminated items in the room Double-bag linen & mark
Droplet precautions.
Spread via moist droplets.
Coughing, sneezing, contaminated objects
Precautions include:
Same as those for contact w/ addition of mask & eye protection w/in 3ft of client.
Airborne precautions.
Spread via air currents.
Precautions include:
Same as those for contact w/ addition of special room (negative air pressure), special mask (N95), & mask for patient when transported.
Donning & Removing of PPE
- Choose appropriate PPE for situation
- Remove safely:
Gloves
Gown
Mask
Wash hands afterwards
What is hygiene?
Activities involved in physical grooming & cleanliness. ADLs.
Nurse’s roles in hygiene.
Asess self-care abilities
Provide assistance with ADLs & promote self-care
Delegate appropriate parts of hygiene care
Factors that influence hygiene & self-care practices
Psychosocial Personal preferences Culture & religion (Different cultures focus on hygiene differently) Economic Status Developmental level (child/elderly) Knowledge level (can be delayed)
Physical: pain limited mobility sensory deficits cognitive impairments emotional disturbances
Bathing a client facilitates:
Assessment of integumentary system & pt’s functional abilities & status
Types of baths.
Assist (hard to reach areas) Partial (only areas absolutely necessary, including perineum) Bed Bath: -complete -partial -Help bath Packaged bath Towel bath Show/Tub bath Therapeutic bath
Oral care facilitates what?
Removal of food secretions Improved appetite Assessment of client's oral status Care of dentures *if patient is unconscious & there is no suctioning available, turn pt on their side with HOB in lowered position*
How should you bathe the areas?
Clean to dirty starting with eyes/face first
Change linens
Bed needs to be low, locked, rails up & call light in reach
What is intake?
Every fluid taken into the body.
Oral fluids, IV fluids, feeding tube contents
What is output?
Every fluid eliminated/removed from the body.
Urine, diarrhea, vomit, gastric secretions, suction, drainage output, dressing from surgical wounds, sweat.
Measuring I&Os
Measure in mL
Total at the end of each shift & for 24 hr
Family can help keep up numbers
Compare over several days: trends
Daily weight is the most reliable method of assessing FV status
Output > Input
Dehydration, hypovolemia
Output < Input
Fluid overload; hypervolemia
Signs of FVD
O > I
Eyes: sunken eyes, decreased or absent tearing
Mouth: dry mucous membranes, shrunken tongue
Neuro: Decreased LOC; dizziness; lethargic
Skin: cool & clammy
CV: Increased pule rate, orthostatic hypotension
GI: sunken abdomen, rapid weight loss
Renal: oliguria or anuria, dark concentrated urine, specific gravity increased
Signs of FVE
I > O
Eyes: periorbital edema, blurred vision
Mouth: excessive salivation
Skin: edema
Respiratory: increased rate, orthopnea, crackles/bronchi
CV: bounding pulse rate, increased BP
GI: rapid weight gain in 24 hours
Renal: decreased urine specificity gravity, diuresis, dilute urine
Normal I&O
> 1500 mL/day (2-3Ls unless restricted)
Oral intake should be approx 600 mLs greater than output
UOP should be >30 mL/hr, if less notify MD
Health care personnel are at high risk for what kind of injuries & in what settings?
Over use injuries in the hospital (2x), nursing home (3x), & ambulance (5x) due to them not having a lot of resources, more patients are less mobile and mobility issues when moving or lifting patients.
Body mechanics.
Feet spread apart. Minimize bending and twisting. Bend knees (dont bend at waist) Lift with leg muscles Keep objects close Use both hands DONT stand on tip toes IF possible, avoid lifting! Push, Slide, Pull Keep elbows bent
What are some safety factors?
Developmental status
Individual
Environment (home, community, hospital).
Children & elderly are the most likely to get hurt.
Falls
Number 1 cause of injuries and deaths from injury among older Americans.
Always do a fall assessment
Fall prevention
Fall education Assisting with ambulation Slip resistant footwear Fall risk identifier (fall arm band) Clear environment fo hazards Pt room near nurse's station 1:1 supervision Bed alarms: weight comes off bed, alarm goes off Padding floor around bed could help
Restraints
LAST RESORT!!
Meant to prevent harm.
Belt, Vest or jacket, Wrist or ankle, Mitt.
Mechanical device: Enclosed bed, canopy bed & all side rails up
Restraint Safety
- Try less restrictive measures 1st
- Must obtain MD’s order (timing of order to be determined by facility protocol).
- Order must be renewed t least q24
- MUST educate pt on need
- REMOVE ASAP
- REMOVE q2 and assess pt and sites
- Test ROM, make sure they go to the bathroom, eat, drink, etc. , check for bruising, friction
- Nurses decide when to take them out of restraints
Semi-Fowlers
HOB elevated 45 degrees Small pillow Support arms and hands on pillows Small pillow under thighs Small pillow under ankles "Float heels"
High Fowlers
HOB elevated 90 degrees Small pillow Support arms and hands on pillows Small pillow under thighs Small pillow under ankles "Float heels"
Trendelenberg
Bed flat with feet elevated and head down
Reverse Trendelenberg
bed flat with head elevated and feet down
Correct position is vital to what?
Promote comforr
Prevent injury
Provide sensation
Supine position
HOB flat
Small pillow under lumbar area, if not contraindicated
Pillow under head, neck & shoulders
Trochanter rolls parallel to lateral surface of thighs
Float heels: pillow under ankle
Use footboard or high top sneakers to prevent foot drop
Pillows under forearms
Hand rolls or splints
Prone
Roll pt to one side with arms alongside body (arm on turning side)
Roll pt over arm-keep arm close to body with elbow straight & hand under hip
Postion on abdomen in center of bed
Turn head to one side & support with small pillow
Place small pillow under ab
Place arms in flexed position at shoulders
Support lower legs with pillows to elevate toes
30 degree lateral (side-lying)
Lower HOB Postion pt to side of bed opposite side being turned on Flex knees and turn pt on side Pillow under back to support Pillow under head & neck Bring dependent shoulder forward Postion arms in slightly flexed position Support upper shoulder & arm with pillow Place pillow under semi flexed upper leg
Sims (semiprone)
Lower HOB
Place in supine postion
Roll pt on side
Postion on lateral side, lying partially on abdomen
Life depends shoulder & place arm at side
Small pillow under head
Pillow under flexed upper arm & upper leg
Logrolling
Requires three people
-2 on one side to be turned towards
-1 on turning from side
Small pillow between knees
Cross arms on chest
Use draw sheet
One nurse grabs draw sheet at lower hips & thighs
Other nurse grabs draw sheet shoulders & lower back
Roll as unit in one smooth, continuous motion
“single nurse” places pillows along the length of pt for support or cleans pt
Gently lean the pt as a unit back towards the pillows for support or back on the surface of the bed
Canes
Hold on stronger side
Move cane simultaneously with weaker side
Walker
Pick up walker to move forward as stepping forward
Dont advance to far to cause reaching
Crutches
Make triangle with crutches 6 inches ahead of body Multiple gaits based on need Stairs: -Up with the good -Down with the bad
Active ROM
Pt is doing themselves
Passive ROM
Nurse is performing it or someone else
ROM
Move 4-5 times
Can be delegated
At least q2 or twice a day
Used to prevent stiffness, promote circulation, & Avoid getting blood clots
TCDB
Turn Cough Deep Breath
Encourages lung expansion & mobilizes secretions
Place pt in Fowler’s
If ab or Ches incision, provide pillow to splint & brace site
Teach pt to breath with diaphragms slowly
After 2-3 breaths, encourage pt to lean forward & cough
Incentive spirometer
- Helps pt take deep breaths after surgery to prevent respiratory complications
- Visual method to measure & encourage lung expansion
TEDs
Thromboembolic devices.
Promote venous return by maintaining pressure on superficial veins & prevent venous pooling.
Prevent passive dilation of veins and tears.
Find correct measurement/size
Remove when out of bed to prevent injury or use slippers if up briefly
Remove once a shift for 15-30minutes
SCDs
Sequential compression devices
Air pump, connecting tubing, & sleeves that sequentially inflate & deflate
Drives superficial blood into deep veins & prevents venous stasis/pooling
Remove when out of bed
Watch placement of tubing/pump (Always face outside of body) Fall risk
Hypoglycemic
Levels drop too low to provide enough energy
BG level= Below 70 mg/dl
Onset: often sudden, may pass out if untreated
Causes: too little foo or skipped meal, too much insulin or diabetes meds. more active than usual
Treatment:
- Check BG
- Administer sugar containing foods (hard candies, 4 oz juice, non-diet soft drink, 8 oz milk), SL glucose paste or dextrose 50% IV
- Recheck BG in 15 mins
- Follow with well balanced meal contains complex carbs if able to take PO
Hyperglycemic
Levels are too high, there is too much that it can’t be used for fuel
Causes: too much food, too little insulin, illness or stress
BG levels= Above 200 mg/dl
Onset:gradual; may progress to diabetic coma if untreated
Treatment:
- Check BG levels
- Contact MD
- Administer insulin as ordered (per sliding scale)
- Continue to assess pt & recheck BG level
Normal BG range
80mg/dl - low-mid 100s
Diagnosis of diabetes- >200 mg/dl & symptoms of hyperglycemia present
Fasting BG
Normal is less than 110 mg/dl
glucose checked after a period of not eating
Hypoglycemia symptoms
headache impaired vision hunger irritability weakness/fatigue sweating dizziness fast Heart beat Shaking Anxiety
Hyperglycemia symptoms
extreme thirst hunger headache going to the bathroom a lot blurred vision dry skin feeling drowsy feeling sick to stomach
What types of pt might require BG testing?
Diabetics (insulin dependent & nondependent)
Pt receding TPN
Pt started on enteral feedings
Pt receding corticosteroids
Pt who BG may be temporarily elevated due to stress of illness
