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NURS 309 Exam 1 > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

What is infection?

A

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.

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2
Q

How do germs spread?

A

Contact, Airborne, Droplet.

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3
Q

The spread of infection (What are the 6 links?)

A 
Infectious agents.
Reservoir. 
Portal of exit.
Mode of transmission.
Portal of entry.
Susceptible host.
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4
Q

Portals of exit.

A 
Bodily fluids
Coughing, sneezing, diarrhea
Seeping wounds
Tubes, IV fluids
Foleys
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5
Q

Portals of entry.

A

Eyes, nares, mouth, vagina, cuts, scrapes.
Wounds, surgical sites, IV or drainage tube sites.
Bite from a vector.

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6
Q

Mode of transmission.

A

Contact:

  • Direct
  • Indirect

Droplet
Airborne

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7
Q

Susceptible host.

A 
Person with inadequate defense. 
Four determine factors:
-Virulence
-Organism's ability to survive in the host's environment
-Number of organisms
-Host's defenses.
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8
Q

What are the 3 lines of defense?

A

Primary
Secondary
Tertiary

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9
Q

What are the primary defenses?

A

Anatomical features, limit pathogen entry:

  • Skin
  • Mucous membranes
  • Tears
  • Normal flora in GI tract
  • Normal flora in urinary tract
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10
Q

What are the secondary defenses?

A

Biochemical processes activated by chemicals released by pathogens:

  • Phagocytosis
  • Complement cascade
  • Inflammation
  • Fever
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11
Q

What are the tertiary defenses?

A

Humoral immunity:
-B-cell production of antibodies in response to an antigen

Cell-mediated immunity:
-Direct destruction of infected cells by T cells

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12
Q

What are some factors that increase infection risk?

A 
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
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13
Q

What are some factors that support host defenses?

A

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

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14
Q

What is medical asepsis? & How is it promoted?

A

A state of cleanliness that decreases the potential for spread if infections.

Maintaining ca clean environment, clean hands, & following CDC guidelines

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15
Q

How do you maintain a clean environment?

A

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.

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16
Q

When should you wash your hands?

A
  • 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
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17
Q

What are the hand washing guidelines?

A

-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

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18
Q

What are standard precautions?

A

Protects healthcare workers from exposure, decreases transmission of pathogens, & protects clients from pathogens carried b healthcare workers.

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19
Q

What are the PPE (Personal Protective Equipment)?

A 
Gloves
Gown
Mask
Face shield
Goggles
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20
Q

Contact Precautions.

A

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
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21
Q

Droplet precautions.

A

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.

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22
Q

Airborne precautions.

A

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.

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23
Q

Donning & Removing of PPE

A
  • Choose appropriate PPE for situation
  • Remove safely:
    Gloves
    Gown
    Mask
    Wash hands afterwards
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24
Q

What is hygiene?

A

Activities involved in physical grooming & cleanliness. ADLs.

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25
Q

Nurse’s roles in hygiene.

A

Asess self-care abilities
Provide assistance with ADLs & promote self-care
Delegate appropriate parts of hygiene care

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26
Q

Factors that influence hygiene & self-care practices

A 
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
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27
Q

Bathing a client facilitates:

A

Assessment of integumentary system & pt’s functional abilities & status

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28
Q

Types of baths.

A 
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
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29
Q

Oral care facilitates what?

A 
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*
30
Q

How should you bathe the areas?

A

Clean to dirty starting with eyes/face first
Change linens
Bed needs to be low, locked, rails up & call light in reach

31
Q

What is intake?

A

Every fluid taken into the body.

Oral fluids, IV fluids, feeding tube contents

32
Q

What is output?

A

Every fluid eliminated/removed from the body.

Urine, diarrhea, vomit, gastric secretions, suction, drainage output, dressing from surgical wounds, sweat.

33
Q

Measuring I&Os

A

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

34
Q

Output > Input

A

Dehydration, hypovolemia

35
Q

Output < Input

A

Fluid overload; hypervolemia

36
Q

Signs of FVD

A

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

37
Q

Signs of FVE

A

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

38
Q

Normal I&O

A

> 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

39
Q

Health care personnel are at high risk for what kind of injuries & in what settings?

A

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.

40
Q

Body mechanics.

A 
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
41
Q

What are some safety factors?

A

Developmental status
Individual
Environment (home, community, hospital).
Children & elderly are the most likely to get hurt.

42
Q

Falls

A

Number 1 cause of injuries and deaths from injury among older Americans.
Always do a fall assessment

43
Q

Fall prevention

A 
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
44
Q

Restraints

A

LAST RESORT!!
Meant to prevent harm.
Belt, Vest or jacket, Wrist or ankle, Mitt.
Mechanical device: Enclosed bed, canopy bed & all side rails up

45
Q

Restraint Safety

A
  • 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
46
Q

Semi-Fowlers

A 
HOB elevated 45 degrees
Small pillow
Support arms and hands on pillows
Small pillow under thighs
Small pillow under ankles
"Float heels"
47
Q

High Fowlers

A 
HOB elevated 90 degrees 
Small pillow
Support arms and hands on pillows
Small pillow under thighs
Small pillow under ankles
"Float heels"
48
Q

Trendelenberg

A

Bed flat with feet elevated and head down

49
Q

Reverse Trendelenberg

A

bed flat with head elevated and feet down

50
Q

Correct position is vital to what?

A

Promote comforr
Prevent injury
Provide sensation

51
Q

Supine position

A

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

52
Q

Prone

A

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

53
Q

30 degree lateral (side-lying)

A 
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 &amp; neck
Bring dependent shoulder forward
Postion arms in slightly flexed position
Support upper shoulder &amp; arm with pillow
Place pillow under semi flexed upper leg
54
Q

Sims (semiprone)

A

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

55
Q

Logrolling

A

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

56
Q

Canes

A

Hold on stronger side

Move cane simultaneously with weaker side

57
Q

Walker

A

Pick up walker to move forward as stepping forward

Dont advance to far to cause reaching

58
Q

Crutches

A 
Make triangle with crutches 6 inches ahead of body
Multiple gaits based on need
Stairs: 
-Up with the good
-Down with the bad
59
Q

Active ROM

A

Pt is doing themselves

60
Q

Passive ROM

A

Nurse is performing it or someone else

61
Q

ROM

A

Move 4-5 times
Can be delegated
At least q2 or twice a day
Used to prevent stiffness, promote circulation, & Avoid getting blood clots

62
Q

TCDB

A

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

63
Q

Incentive spirometer

A
  • Helps pt take deep breaths after surgery to prevent respiratory complications
  • Visual method to measure & encourage lung expansion
64
Q

TEDs

A

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

65
Q

SCDs

A

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

66
Q

Hypoglycemic

A

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
67
Q

Hyperglycemic

A

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
68
Q

Normal BG range

A

80mg/dl - low-mid 100s

Diagnosis of diabetes- >200 mg/dl & symptoms of hyperglycemia present

69
Q

Fasting BG

A

Normal is less than 110 mg/dl

glucose checked after a period of not eating

70
Q

Hypoglycemia symptoms

A 
headache
impaired vision
hunger
irritability
weakness/fatigue
sweating
dizziness
fast Heart beat
Shaking
Anxiety
71
Q

Hyperglycemia symptoms

A 
extreme thirst
hunger
headache
going to the bathroom a lot
blurred vision
dry skin
feeling drowsy
feeling sick to stomach
72
Q

What types of pt might require BG testing?

A

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

NURS 309 Exam 1 (1 decks)

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