Exam 1 Concepts - Vol 1 Flashcards
normal flora
microorganisms beneficial/essential for human growth
ex. digestion, synthesis of vitamin K
transient flora
normal flora acquire by contact which can be removed via hand-washing
resident flora
microbes living in deep skin layers which are typically harmless until penetration of deep tissues occurs
ex. open wound, trauma
4 factors of successful pathogenesis
- “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
reservoir
source of infection where pathogens survive and multiply
ex. contaminated h20, human body
carriers
individuals w/o symptoms of dz, but serve as reservoirs and pass dz onto others
portal of exit
method of exiting a reservoir for spread of pathogen; often via body fluids
ex. blood, mucus, saliva, breast milk, urine, feces, semen, vomit, diarrhea
modes of infection transmission
contact (direct, indirect)
droplet
airborne
vector
contact infection transmission
direct = touching indirect = contact with a contaminated object
droplet infection transmission
pathogen travel through water droplets expelled when individual exhales, coughs, sneezes, or talks; may also contaminate objects–>indirect contact
vector infection transmission
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
portal of entry
entry of a pathogen to the body via body openings, open wounds, surgical sites
susceptible host
person at risk for an infection due to inadequate defenses against an invading pathogen
factors which increase susceptibility
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
local infection
infection of a particular region of the body
systemic infection
infections spread throughout the body via the blood or lymph
primary defense against infection
anatomical features which help limit entry of pathogens
ex. normal flora, skin, lysozyme in tears and saliva, acidity of GI tract
secondary defense against infection
the immune defense activated by the presence of a pathogen in the body
ex. phagocytes, complement cascade, inflammation, fever
tertiary defense against infection
immunity against infection via the presence of antibodies which neutralize/destroy toxins or dz producing organisms
humoral immunity
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)
cellular immunity
direct destruction of pathogen via T cells
B cell vs T cell
B cells from bone marrow create antibodies
T cell made in thymus directly attacks affected cells
factors which promote host defenses
nutrition hygiene rest exercise reducing stress vaccines
medical asepsis
reducing contamination by dz-causing microorganisms
ex. washing hands
five hand-washing factors
time - 15 sec water - warm soap - agency approved friction drying
maintaining a clean environment
clean spills and surfaces
disinfect
consider ALL supplies contaminated
times to wash hands
before entering room, after leaving room, before/after glove removal, after using bathroom, before procedure
personal protective equipment application
- gown
- mask
- goggles
- gloves
personal protective equipment removal
- gloves
- goggles
- gown
- mask
contact precautions
private room
clean gown and gloves EVERY time
disposal of contaminated items
double bag MARKED linen
droplet precautions
contact precautions PLUS:
mask and eye protection (w/in 3 ft of pt)
airborne precautions
contact precautions PLUS:
specially fitted N95 mask
(-) pressure room
exogenous infection
pathogen acquired from healthcare environment
endogenous infection
infection resultant of treatment
hygiene
activities involved in personal cleanliness and grooming
activities of daily living
activities promoting comfort, self-image, decrease infection and dz
ex. brushing teeth, showering, washing hair
factors which influence hygiene practices
age personal preferences culture and religion economic status knowledge and cognitive level physical factors
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
early morning hygiene care
wash face and hands, oral care
AM after breakfast hygiene care
bathing, toileting, hair, skin, bed making
PM afternoon hygiene care
toileting, hand-washing, oral care, preparing for visitors
HS hygiene care
relaxation activities, preparing for sleep
delegating hygiene care
instruct assistive personnel regarding: pt limitations use of assistive devices presences and care of tubes observations to make during hygiene care
pruritis
itching of the skin which leads to scratching and possible breaks in the surface
maceration
softening of the skin from prolonged moisture which makes epidermis susceptible to injury
excoriation
loss of the superficial layers of the skin
ex. digestive enzymes in feces cause
abrasion
rubbing away the epidermal layer, especially over bony prominences, d/t friction or shearing
ex. restraints cause
pressure ulcers
lesions caused by tissue compression and inadequate perfusion
acne
inflammation of sebaceous glands
types of baths
assist
partial
complete
assist bath
RN helps wash parts that are hard for pt to reach
ex. back, feet, legs
partial bath
RN cleanse areas which cause odor or discomfort
ex. axillae, perineum
oral care fascilitates
removal of food particles
improved appetite
assessment of clients oral status
periodontal dz
“pyorrhea” infection of the gums which causes recession and eventual tooth loss
glossitis
inflammation of the tongue
cheilosis
cracking and/or ulceration of the lips; often caused by vitamin B deficiencies
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
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
safe bed position
bed rails (all up considered restraint), bed locked, low bed position, call light in reach
pediculosis
head lice infestation
alopecia
hair loss which can be caused by autoimmune disorder, hormonal imbalance, thyroid dz, stress, medication, chemo
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
semi-fowler’s bed position
head at a 30 degree incline
ex. pt w/acid reflux at risk of aspiration
trendelenburg bed position
feet slightly raised to promote blood flow towards head; mattress kept flat (at an angle)
fowler’s bed position
head raised at a 45 degree angle
reverse trendelenburg bed position
head raised w/mattress kept flat
universal steps
check pt using 2 identifiers (NOT room #)
double check orders
know hospital policy
intake assessment
every fluid taken INTO the body accounted for:
oral fluids, IV fluids, feeding tube contents
output assessment
every fluid ELIMINATED from the body:
urine, diarrhea, vomit, suction from airway secretions, gastric secretions, drainage from wound, sweat
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
daily weight
reliable measure of fluid volume to be taken at same time, w/same scale, and same amount of clothing
hypovolemia
“dehydration”
fluid deficit d/t insufficient fluid intake, excessive fluid loss, or fluid shifts
hypervolemia
fluid overload d/t excessive salt intake, kidney or liver dz, or poor pumping of the heart
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
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
normal I and O values
Oral intake 600 mL greater than output (at least 1500 mL daily unless restricted)
UOP >30 mL/h
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
restraint safety
try less restrictive measures
must document why, what type, who ordered
order must be renewed q24h
remove q2h to assess pt
restraint prevention measures
educate pt
supervise pt w/sitter, family, or staff
distract pt
place pt close to RN station
hazards of restraints
pressure ulcers
contractures
loss of strength and circulation
nerve damage
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
fighting vector-borne pathogens
remove sources of stagnant water
kill or repel insects
fall risk prevention
fall education slip resistant footwear fall risk identifier bed alarm clear environment of hazards pt near RN station
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)
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
antalgic gait
limp to avoid pain when bearing weight on affected side
propulsive gait
stooped, shuffling gait
ex. pt w/Parkinson’s
scissors gait
legs flexing slightly at the hips w/ knees and thighs crossing in a scissor-like move
ex. pt w/cerebal palsy, stroke
steppage gait
an exaggerating motion of lifting leg to avoid scraping the toes of a foot w/footdrop
ex. pt w/Guillain-Barre sydrome
spastic gait
stiff, foot-dragging walk caused by one-sided muscle contraction
ex. pt w/head trauma, brain tumor
waddling gait
rolling motion in which opposite hip drops
ex. pt w/MS, hip dyplasia
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
prone position
pt lies on abdomen w/head to one side
allows mouth secretions to drain freely, but creates curvature of the spine
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
supine position
patient lies on back w/head and shoulders elevated w/pillow
logrolling
special turning used when pt must have spine kept in straight alignment
active ROM
range of motion performed by the pt to prevent contractures and blood clots
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
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
sequential compression devices
air pump with tubing which inflate and deflate sleeves that drive superficial venous blood into deep veins
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
hyperglycemia
blood glucose >200mg/dL
administer insulin as ordered and continue to assess pt
pts require blood glucose testing
diabetics TPN pt pt w/enteral feedings pt receiving corticosteroids pt w/elevated blood glucose d/t stress
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
