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NUR 309 Skills > Exam 1 Concepts - Vol 1 > Flashcards

Exam 1 Concepts - Vol 1 Flashcards

1
Q

normal flora

A

microorganisms beneficial/essential for human growth

ex. digestion, synthesis of vitamin K

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2
Q

transient flora

A

normal flora acquire by contact which can be removed via hand-washing

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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

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4
Q

4 factors of successful pathogenesis

A
  1. “virulence” of pathogen (ability to cause dz)
  2. ability of pathogen to survive in host environment
  3. number of pathogenic organisms (increased number–>increased likelihood of dz)
  4. ability of host defense to prevent infection
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5
Q

reservoir

A

source of infection where pathogens survive and multiply

ex. contaminated h20, human body

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6
Q

carriers

A

individuals w/o symptoms of dz, but serve as reservoirs and pass dz onto others

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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

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8
Q

modes of infection transmission

A

contact (direct, indirect)
droplet
airborne
vector

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9
Q

contact infection transmission

A 
direct = touching
indirect = contact with a contaminated object
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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

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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

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12
Q

portal of entry

A

entry of a pathogen to the body via body openings, open wounds, surgical sites

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13
Q

susceptible host

A

person at risk for an infection due to inadequate defenses against an invading pathogen

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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
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15
Q

local infection

A

infection of a particular region of the body

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16
Q

systemic infection

A

infections spread throughout the body via the blood or lymph

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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

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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

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19
Q

tertiary defense against infection

A

immunity against infection via the presence of antibodies which neutralize/destroy toxins or dz producing organisms

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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)

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21
Q

cellular immunity

A

direct destruction of pathogen via T cells

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22
Q

B cell vs T cell

A

B cells from bone marrow create antibodies

T cell made in thymus directly attacks affected cells

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23
Q

factors which promote host defenses

A 
nutrition
hygiene
rest
exercise
reducing stress
vaccines
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24
Q

medical asepsis

A

reducing contamination by dz-causing microorganisms

ex. washing hands

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25
Q

five hand-washing factors

A 
time - 15 sec
water - warm
soap - agency approved
friction
drying
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26
Q

maintaining a clean environment

A

clean spills and surfaces
disinfect
consider ALL supplies contaminated

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27
Q

times to wash hands

A

before entering room, after leaving room, before/after glove removal, after using bathroom, before procedure

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28
Q

personal protective equipment application

A
  1. gown
  2. mask
  3. goggles
  4. gloves
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29
Q

personal protective equipment removal

A
  1. gloves
  2. goggles
  3. gown
  4. mask
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30
Q

contact precautions

A

private room
clean gown and gloves EVERY time
disposal of contaminated items
double bag MARKED linen

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31
Q

droplet precautions

A

contact precautions PLUS:

mask and eye protection (w/in 3 ft of pt)

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32
Q

airborne precautions

A

contact precautions PLUS:
specially fitted N95 mask
(-) pressure room

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33
Q

exogenous infection

A

pathogen acquired from healthcare environment

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34
Q

endogenous infection

A

infection resultant of treatment

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35
Q

hygiene

A

activities involved in personal cleanliness and grooming

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36
Q

activities of daily living

A

activities promoting comfort, self-image, decrease infection and dz
ex. brushing teeth, showering, washing hair

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37
Q

factors which influence hygiene practices

A 
age
personal preferences
culture and religion
economic status
knowledge and cognitive level
physical factors
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38
Q

sensory deficits

A

deficiencies in the five sense which contribute to diminished self-care ability
ex. visual deficit unable to gather supplies for self-care in hospital

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39
Q

early morning hygiene care

A

wash face and hands, oral care

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40
Q

AM after breakfast hygiene care

A

bathing, toileting, hair, skin, bed making

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41
Q

PM afternoon hygiene care

A

toileting, hand-washing, oral care, preparing for visitors

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42
Q

HS hygiene care

A

relaxation activities, preparing for sleep

43
Q

delegating hygiene care

A 
instruct assistive personnel regarding:
pt limitations
use of assistive devices
presences and care of tubes
observations to make during hygiene care
44
Q

pruritis

A

itching of the skin which leads to scratching and possible breaks in the surface

45
Q

maceration

A

softening of the skin from prolonged moisture which makes epidermis susceptible to injury

46
Q

excoriation

A

loss of the superficial layers of the skin

ex. digestive enzymes in feces cause

47
Q

abrasion

A

rubbing away the epidermal layer, especially over bony prominences, d/t friction or shearing
ex. restraints cause

48
Q

pressure ulcers

A

lesions caused by tissue compression and inadequate perfusion

49
Q

acne

A

inflammation of sebaceous glands

50
Q

types of baths

A

assist
partial
complete

51
Q

assist bath

A

RN helps wash parts that are hard for pt to reach

ex. back, feet, legs

52
Q

partial bath

A

RN cleanse areas which cause odor or discomfort

ex. axillae, perineum

53
Q

oral care fascilitates

A

removal of food particles
improved appetite
assessment of clients oral status

54
Q

periodontal dz

A

“pyorrhea” infection of the gums which causes recession and eventual tooth loss

55
Q

glossitis

A

inflammation of the tongue

56
Q

cheilosis

A

cracking and/or ulceration of the lips; often caused by vitamin B deficiencies

57
Q

oral care for unconscious pt

A

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
Q

important notes about hygiene care

A 
ASK pt's preferences
gather supplies BEFORE starting
bath "clean to dirty"
change linens DAILY
always leave pt in SAFE position
59
Q

safe bed position

A

bed rails (all up considered restraint), bed locked, low bed position, call light in reach

60
Q

pediculosis

A

head lice infestation

61
Q

alopecia

A

hair loss which can be caused by autoimmune disorder, hormonal imbalance, thyroid dz, stress, medication, chemo

62
Q

hair care

A

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
Q

semi-fowler’s bed position

A

head at a 30 degree incline

ex. pt w/acid reflux at risk of aspiration

64
Q

trendelenburg bed position

A

feet slightly raised to promote blood flow towards head; mattress kept flat (at an angle)

65
Q

fowler’s bed position

A

head raised at a 45 degree angle

66
Q

reverse trendelenburg bed position

A

head raised w/mattress kept flat

67
Q

universal steps

A

check pt using 2 identifiers (NOT room #)
double check orders
know hospital policy

68
Q

intake assessment

A

every fluid taken INTO the body accounted for:

oral fluids, IV fluids, feeding tube contents

69
Q

output assessment

A

every fluid ELIMINATED from the body:

urine, diarrhea, vomit, suction from airway secretions, gastric secretions, drainage from wound, sweat

70
Q

measuring intake and output

A

measure in mL
total at end of each shift and for 24h period
ice chips measured at 50% volume
weigh diapers and pads

71
Q

daily weight

A

reliable measure of fluid volume to be taken at same time, w/same scale, and same amount of clothing

72
Q

hypovolemia

A

“dehydration”

fluid deficit d/t insufficient fluid intake, excessive fluid loss, or fluid shifts

73
Q

hypervolemia

A

fluid overload d/t excessive salt intake, kidney or liver dz, or poor pumping of the heart

74
Q

signs of fluid volume deficiency

A

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
Q

signs of fluid volume excess

A

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
Q

normal I and O values

A

Oral intake 600 mL greater than output (at least 1500 mL daily unless restricted)
UOP >30 mL/h

77
Q

restraint

A

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
Q

restraint safety

A

try less restrictive measures
must document why, what type, who ordered
order must be renewed q24h
remove q2h to assess pt

79
Q

restraint prevention measures

A

educate pt
supervise pt w/sitter, family, or staff
distract pt
place pt close to RN station

80
Q

hazards of restraints

A

pressure ulcers
contractures
loss of strength and circulation
nerve damage

81
Q

body mechanics

A 
feet spread apart
minimize bending and twisting
bend knees and use leg muscles
elbows bent
push, slide, or pull; try not to lift
82
Q

fighting vector-borne pathogens

A

remove sources of stagnant water

kill or repel insects

83
Q

fall risk prevention

A 
fall education
slip resistant footwear
fall risk identifier
bed alarm
clear environment of hazards
pt near RN station
84
Q

position aids

A

trochanter roll (either side of leg to maintain neutral position)
hand roll
cradle boots (prevent foot drop)
hip abduction pillow (b/w legs)

85
Q

ambulation

A 
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
Q

antalgic gait

A

limp to avoid pain when bearing weight on affected side

87
Q

propulsive gait

A

stooped, shuffling gait

ex. pt w/Parkinson’s

88
Q

scissors gait

A

legs flexing slightly at the hips w/ knees and thighs crossing in a scissor-like move
ex. pt w/cerebal palsy, stroke

89
Q

steppage gait

A

an exaggerating motion of lifting leg to avoid scraping the toes of a foot w/footdrop
ex. pt w/Guillain-Barre sydrome

90
Q

spastic gait

A

stiff, foot-dragging walk caused by one-sided muscle contraction
ex. pt w/head trauma, brain tumor

91
Q

waddling gait

A

rolling motion in which opposite hip drops

ex. pt w/MS, hip dyplasia

92
Q

lateral position

A

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
Q

prone position

A

pt lies on abdomen w/head to one side

allows mouth secretions to drain freely, but creates curvature of the spine

94
Q

Sims’ position

A

“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
Q

supine position

A

patient lies on back w/head and shoulders elevated w/pillow

96
Q

logrolling

A

special turning used when pt must have spine kept in straight alignment

97
Q

active ROM

A

range of motion performed by the pt to prevent contractures and blood clots

98
Q

passive ROM

A

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
Q

thromboembolytic devices

A

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
Q

sequential compression devices

A

air pump with tubing which inflate and deflate sleeves that drive superficial venous blood into deep veins

101
Q

hypoglycemia

A

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
Q

hyperglycemia

A

blood glucose >200mg/dL

administer insulin as ordered and continue to assess pt

103
Q

pts require blood glucose testing

A 
diabetics
TPN pt
pt w/enteral feedings
pt receiving corticosteroids
pt w/elevated blood glucose d/t stress
104
Q

blood glucose monitoring

A

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

NUR 309 Skills (9 decks)

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