Exam 1 Concepts - Vol 1 Flashcards
1
Q
normal flora
A
microorganisms beneficial/essential for human growth
ex. digestion, synthesis of vitamin K
2
Q
transient flora
A
normal flora acquire by contact which can be removed via hand-washing
3
Q
resident flora
A
microbes living in deep skin layers which are typically harmless until penetration of deep tissues occurs
ex. open wound, trauma
4
Q
4 factors of successful pathogenesis
A
- “virulence” of pathogen (ability to cause dz)
- ability of pathogen to survive in host environment
- number of pathogenic organisms (increased number–>increased likelihood of dz)
- ability of host defense to prevent infection
5
Q
reservoir
A
source of infection where pathogens survive and multiply
ex. contaminated h20, human body
6
Q
carriers
A
individuals w/o symptoms of dz, but serve as reservoirs and pass dz onto others
7
Q
portal of exit
A
method of exiting a reservoir for spread of pathogen; often via body fluids
ex. blood, mucus, saliva, breast milk, urine, feces, semen, vomit, diarrhea
8
Q
modes of infection transmission
A
contact (direct, indirect)
droplet
airborne
vector
9
Q
contact infection transmission
A
direct = touching indirect = contact with a contaminated object
10
Q
droplet infection transmission
A
pathogen travel through water droplets expelled when individual exhales, coughs, sneezes, or talks; may also contaminate objects–>indirect contact
11
Q
vector infection transmission
A
organism carries a pathogen to a susceptible host, typically by biting or stinging, which creates
a portal of entry
ex. mosquito is vector for malaria, yellow fever, west nile virus
12
Q
portal of entry
A
entry of a pathogen to the body via body openings, open wounds, surgical sites
13
Q
susceptible host
A
person at risk for an infection due to inadequate defenses against an invading pathogen
14
Q
factors which increase susceptibility
A
age (young, old) breaks in first line of defense (breaks in skin, disruption of NF) illness or injury tobacco use substance abuse increased exposure to pathogens d/t envirornment chronic dz medications invasive medical procedures
15
Q
local infection
A
infection of a particular region of the body
16
Q
systemic infection
A
infections spread throughout the body via the blood or lymph
17
Q
primary defense against infection
A
anatomical features which help limit entry of pathogens
ex. normal flora, skin, lysozyme in tears and saliva, acidity of GI tract
18
Q
secondary defense against infection
A
the immune defense activated by the presence of a pathogen in the body
ex. phagocytes, complement cascade, inflammation, fever
19
Q
tertiary defense against infection
A
immunity against infection via the presence of antibodies which neutralize/destroy toxins or dz producing organisms
20
Q
humoral immunity
A
use of antibodies to destroy pathogens by aggregating to encourage phagocytosis (via B cells or other WBC), neutralizing pathogens via direct attachment, or activating the complement system (inflammatory response)
21
Q
cellular immunity
A
direct destruction of pathogen via T cells
22
Q
B cell vs T cell
A
B cells from bone marrow create antibodies
T cell made in thymus directly attacks affected cells
23
Q
factors which promote host defenses
A
nutrition hygiene rest exercise reducing stress vaccines
24
Q
medical asepsis
A
reducing contamination by dz-causing microorganisms
ex. washing hands
25
five hand-washing factors
```
time - 15 sec
water - warm
soap - agency approved
friction
drying
```
26
maintaining a clean environment
clean spills and surfaces
disinfect
consider ALL supplies contaminated
27
times to wash hands
before entering room, after leaving room, before/after glove removal, after using bathroom, before procedure
28
personal protective equipment application
1. gown
2. mask
3. goggles
4. gloves
29
personal protective equipment removal
1. gloves
2. goggles
3. gown
4. mask
30
contact precautions
private room
clean gown and gloves EVERY time
disposal of contaminated items
double bag MARKED linen
31
droplet precautions
contact precautions PLUS:
| mask and eye protection (w/in 3 ft of pt)
32
airborne precautions
contact precautions PLUS:
specially fitted N95 mask
(-) pressure room
33
exogenous infection
pathogen acquired from healthcare environment
34
endogenous infection
infection resultant of treatment
35
hygiene
activities involved in personal cleanliness and grooming
36
activities of daily living
activities promoting comfort, self-image, decrease infection and dz
ex. brushing teeth, showering, washing hair
37
factors which influence hygiene practices
```
age
personal preferences
culture and religion
economic status
knowledge and cognitive level
physical factors
```
38
sensory deficits
deficiencies in the five sense which contribute to diminished self-care ability
ex. visual deficit unable to gather supplies for self-care in hospital
39
early morning hygiene care
wash face and hands, oral care
40
AM after breakfast hygiene care
bathing, toileting, hair, skin, bed making
41
PM afternoon hygiene care
toileting, hand-washing, oral care, preparing for visitors
42
HS hygiene care
relaxation activities, preparing for sleep
43
delegating hygiene care
```
instruct assistive personnel regarding:
pt limitations
use of assistive devices
presences and care of tubes
observations to make during hygiene care
```
44
pruritis
itching of the skin which leads to scratching and possible breaks in the surface
45
maceration
softening of the skin from prolonged moisture which makes epidermis susceptible to injury
46
excoriation
loss of the superficial layers of the skin
| ex. digestive enzymes in feces cause
47
abrasion
rubbing away the epidermal layer, especially over bony prominences, d/t friction or shearing
ex. restraints cause
48
pressure ulcers
lesions caused by tissue compression and inadequate perfusion
49
acne
inflammation of sebaceous glands
50
types of baths
assist
partial
complete
51
assist bath
RN helps wash parts that are hard for pt to reach
| ex. back, feet, legs
52
partial bath
RN cleanse areas which cause odor or discomfort
| ex. axillae, perineum
53
oral care fascilitates
removal of food particles
improved appetite
assessment of clients oral status
54
periodontal dz
"pyorrhea" infection of the gums which causes recession and eventual tooth loss
55
glossitis
inflammation of the tongue
56
cheilosis
cracking and/or ulceration of the lips; often caused by vitamin B deficiencies
57
oral care for unconscious pt
turn pt to their side if suction is not available to avoid aspiration
do NOT use lemon glycerin swabs (drying)
brush twice a day
58
important notes about hygiene care
```
ASK pt's preferences
gather supplies BEFORE starting
bath "clean to dirty"
change linens DAILY
always leave pt in SAFE position
```
59
safe bed position
bed rails (all up considered restraint), bed locked, low bed position, call light in reach
60
pediculosis
head lice infestation
61
alopecia
hair loss which can be caused by autoimmune disorder, hormonal imbalance, thyroid dz, stress, medication, chemo
62
hair care
daily brushing w/brush or comb that won't damage pt's scalp, stimulate scalp circulation via massage, involve pt and/or family
WASH a pt's beard/mustache
63
semi-fowler's bed position
head at a 30 degree incline
| ex. pt w/acid reflux at risk of aspiration
64
trendelenburg bed position
feet slightly raised to promote blood flow towards head; mattress kept flat (at an angle)
65
fowler's bed position
head raised at a 45 degree angle
66
reverse trendelenburg bed position
head raised w/mattress kept flat
67
universal steps
check pt using 2 identifiers (NOT room #)
double check orders
know hospital policy
68
intake assessment
every fluid taken INTO the body accounted for:
| oral fluids, IV fluids, feeding tube contents
69
output assessment
every fluid ELIMINATED from the body:
| urine, diarrhea, vomit, suction from airway secretions, gastric secretions, drainage from wound, sweat
70
measuring intake and output
measure in mL
total at end of each shift and for 24h period
ice chips measured at 50% volume
weigh diapers and pads
71
daily weight
reliable measure of fluid volume to be taken at same time, w/same scale, and same amount of clothing
72
hypovolemia
"dehydration"
| fluid deficit d/t insufficient fluid intake, excessive fluid loss, or fluid shifts
73
hypervolemia
fluid overload d/t excessive salt intake, kidney or liver dz, or poor pumping of the heart
74
signs of fluid volume deficiency
eyes: sunken, dry
mouth: cracked lips, dry mucous membrane
neuro: decreased LOC, dizziness, confusion
skin: dry, scaly, poor turgor, clammy w/hypovolemia
CV: increased HR, weak pulse, hypotension, decreased cap refill
GI: sunken abdomen, rapid weight loss
renal: oliguria, anuria, dark urine
75
signs of fluid volume excess
eyes: edema, blurred vision
mouth: excessive
skin: edema
respiratory: dyspnea, cough, crackles, rhonchi
CV: bounding pulse, increased BP, third heart sound
GI: rapid weight gain, increased abdominal girth
renal: diuresis, clear/pale urine
76
normal I and O values
Oral intake 600 mL greater than output (at least 1500 mL daily unless restricted)
UOP >30 mL/h
77
restraint
device or method used to restrict a pt's freedom of movement to protect the pt, protect a medical device, or prevent staff harm; restraints increase care needed and risk of injury
78
restraint safety
try less restrictive measures
must document why, what type, who ordered
order must be renewed q24h
remove q2h to assess pt
79
restraint prevention measures
educate pt
supervise pt w/sitter, family, or staff
distract pt
place pt close to RN station
80
hazards of restraints
pressure ulcers
contractures
loss of strength and circulation
nerve damage
81
body mechanics
```
feet spread apart
minimize bending and twisting
bend knees and use leg muscles
elbows bent
push, slide, or pull; try not to lift
```
82
fighting vector-borne pathogens
remove sources of stagnant water
| kill or repel insects
83
fall risk prevention
```
fall education
slip resistant footwear
fall risk identifier
bed alarm
clear environment of hazards
pt near RN station
```
84
position aids
trochanter roll (either side of leg to maintain neutral position)
hand roll
cradle boots (prevent foot drop)
hip abduction pillow (b/w legs)
85
ambulation
```
consider pt's gait
dangle to avoid hypotension
instruct pt to notify RN of dizziness
brace knee to knee
guide pt to floor if start to fall
```
86
antalgic gait
limp to avoid pain when bearing weight on affected side
87
propulsive gait
stooped, shuffling gait
| ex. pt w/Parkinson's
88
scissors gait
legs flexing slightly at the hips w/ knees and thighs crossing in a scissor-like move
ex. pt w/cerebal palsy, stroke
89
steppage gait
an exaggerating motion of lifting leg to avoid scraping the toes of a foot w/footdrop
ex. pt w/Guillain-Barre sydrome
90
spastic gait
stiff, foot-dragging walk caused by one-sided muscle contraction
ex. pt w/head trauma, brain tumor
91
waddling gait
rolling motion in which opposite hip drops
| ex. pt w/MS, hip dyplasia
92
lateral position
side lying position w/top hip and knee flexed and placed infront of the rest of the body (pillow under top knee)
relieves pressure from heels and sacrum
93
prone position
pt lies on abdomen w/head to one side
allows mouth secretions to drain freely, but creates curvature of the spine
94
Sims' position
"semiprone" lower arm placed behind pt, upper arm flexed, top leg flexed more than lower leg
ideal position for administering an enema or perineal procedure
95
supine position
patient lies on back w/head and shoulders elevated w/pillow
96
logrolling
special turning used when pt must have spine kept in straight alignment
97
active ROM
range of motion performed by the pt to prevent contractures and blood clots
98
passive ROM
range of motion performed by the RN/staff/family member to prevent contractures and blood clots
move joint 3-5 times and STOP at resistance
99
thromboembolytic devices
promotes venous blood return by maintaining pressure on superficial veins and venous pooling
get CORRECT size; remove when out of bed and once per shift for 15-30mins
100
sequential compression devices
air pump with tubing which inflate and deflate sleeves that drive superficial venous blood into deep veins
101
hypoglycemia
blood sugar level below 70mg/dL d/t skipped meal or too diabetic medication/insulin
provide sugary foods and re-check blood glucose in 15mins
102
hyperglycemia
blood glucose >200mg/dL
administer insulin as ordered and continue to assess pt
103
pts require blood glucose testing
```
diabetics
TPN pt
pt w/enteral feedings
pt receiving corticosteroids
pt w/elevated blood glucose d/t stress
```
104
blood glucose monitoring
follow order
don't obtain from cold, cyanotic, or bruised sites (SIDE of finger)
milk the finger
wipe away FIRST drop of blood IF alcohol used
