Exam 1 study Flashcards
Droplet illnesses
- Flu
- Mumps
- Pertussis
Airborne illnesses
- Measles
- Chickenpox
- TB
- herpes roster
Droplet barrier protection
- private or cohort room
- surgical mask
- mask on patient while transporting and only when necessary
Airborne barrier precautions
- private room
- negative airflow pressure
- n95 mask
- ultraviolet irradation or air filter
Contact indications
MDR0’s
wound infection
skin infection
eye infection
private or cohort room
-gloves and gown
Protectice indications
- transplant
- chemotherapy
- burns
- immunocompromised
- private room
- positive airflow
- no plants or fruit
- full PPE
How can nursing care support the body’s natural primary defenses against infection?
watching for impaired skin integrity hygiene of the patient make sure patient is breathing properly eyes are protected mouth is clean no GI, GU or bowel problem
systemic infection
occur when pathogens invade the blood or lymph and spread throughout the body
latent infection
sneaky/hiding infection. might not even know you’re sick
ex. HIV, TB
exogenous infection
pathogen acquired from the healthcare environment
endogenous infection
the pathogens arise from the patient’s normal flora when some form of treatment causes the normally harmless microbe to multiply & cause infection
Infection Stages: incubation
stage between successful invasion of pathogen into the body & the first appearance of symptoms
person doesn’t suspect that they’ve been infected but may be capable of infecting others
Prodromal stage
first appearance of vague symptoms
decline stage
patients immune defenses along with any medical therapies successfully reduce the number of pathogenic microbes
convalescence stage
tissue repair and a return to health as the remaining number of microorganisms approaches 0.
Standard precautions
contact w/ blood & body fluids, non-intact skin, and mucous membranes from ALL patients
PPE: gown, gloves, mask, goggles
Under normal conditions, the kidneys produce how many ml of urine?
1500 ml/24 hr
Abnormal urine output
30 ml an hour or less for 2 hours
The first steps in urination begins when the bladder contains how many ml of urine?
need to void occurs at 200-450 ml
about 400-500 ml/voiding
Anuria
absence of urine often associated with kidney failure or congestive heart failure.
urine output is less than 100 ml in 24 hrs
Dysuria
painful or difficult urination
end stage renal disease
chronic rise in serum creatinine levels associated w/ loss of kidney function
must be treated with dialysis or transplantation
enuresis
involuntary loss of urine
nocturia
frequent urination after going to bed
oliguria
urine output less than 400 ml in 24 hrs
polyuria
excessive urination
caused by excessive hydration, diabetes, or kidney disease
proteinuria
presence of protein in urine
sign of infection or kidney disease
pyuria
pus in urine.
caused by lesions or infection in the urinary tract
Alterations in urinary eliminations
Intake and output Urine appearance (color, clarity, amount, odor) Urinalysis BUN 10-20 mg/dL creatinine 0.5-1.2 mg/dl
Normal & abnormal urine
normal- yellow, clear. no odor. sweet or fruity in diabetic patients.
abnormal- red, orange, green. ammonia smell
Urinalysis
Normal protein, glucose, & ketones= negative.
PROTEIN SHOULD NOT ESCAPE FROM URINE
glucose may show up in diabetic patient
leukocyte/bacteria present= infection. should be negative
blood in urine indicates an infection
BUN= 10-20. if higher= some type of kidney disease
creatinine= 0.5-1.2
specific gravity= 1.003-1.03
if higher= may be dehydrated. lower may be over hydrated
Post-void residual (PVR)
patient voids
within 10-15 min get a bladder scan & see how much urine left in bladder after its emptied
Stress incontinence
increased abdominal pressure
abdominal muscles not strong enough to keep it from coming out
ex. laughing, sneezing. seen in pregnancy pt’s
Mixed incontinence
some urge & some stress combined
overflow incontinence
bladder so full that a little dribbles out. can happen often
functional incontinence
nability or blockage, can’t get to bathroom
no urinary or psychosocial reason
prompted toileting
hourly rounding
remove the barrier
reflex incontinence
neurological problem– stroke, spinal cord injury, bladder being damaged
scheduled voiding
intermittent catheterization
types of urinary diversions: cutaneous ureterostomy
surgery reroutes the ureter directly to surface of abdomen forming a small stoma
limited use bc it provides a pathway for pathogens to enter the kidney drainage bag
Conventional urostomy (ileal conduit)
most common type
small piece of ileum used to make a patch into which the ureters are implanted.
urine drains continuously from stoma & is collected in a pouch (drainage bag)
Continent urinary reservoir
valve.
same as ileal conduit but instead of urine constantly flowing, the patient inserts a catheter into the stoma to drain urine through the valve no drainage bag
which diversions are incontinent?
cutaneous ureterostomy & conventional urostomy/ileal conduit (drainage bag)
Nursing process
ADPIE
- assess
- diagnose
- plan
- implement
- evaluate
How do you write a nursing diagnosis?
NANDA defintion, state related to factor, then AED
use frameworks (maslow hierarchy of needs) ABC's- airway, breathing, circulation safety/risk reduction least restrictive/less invasive prioritize acute over chronic problems
High urgency example
pain, risk for falls
Medium urgency example
imbalanced nutrition
Low urgency example
chronic low self esteem, anxiety
Each medication order must include:
the patient's name order date medication name dosage route frequency prescriber's signature
SIX rights of medication administration
right medication right dose right route right time right patient right documentation
PRN
as needed
peak and trough
peak- highest concentration
trough- lowest concentration
- peak-check 30-60 min after its completely infused*
- check trough levels 30 min before administer next dose*
Temp of otic meds
body temp or slightly warmer. DONT USE COLD MEDS
parenteral route
bypass the GI tract
intradermal, subcutaneous, intramuscular, iv
Intradermal
under skin. goes in at 15 degrees
ex. tb test allergy testing
Subcutaneous intramuscular
under the skin, but not in muscle. 45-90 degree angle
intramuscular
90 degrees into the muscle
sites: deltoid, ventral gluteal, vestas laterals
IV advantages
fast acting
establishes constant blood levels
delivers large volumes
most dangerous
Specifc gravity
Normal: 1.005-1.030
Abnormal: <1.005 Renal disease or overhydration
> 1.030 dehydration
Protein
Normal result: Negative
Abnormal: Positive- renal disease
Glucose
Normal: Negative
Abnormal: positive - abnormal glucose metabolism such as diabetes
Ketones
Normal: Negative
Abnormal: positive- poorly controlled diabetes
RBC
Normal: 0,1,2
Abnormal: 3 or more - UTI, cancer in the urinary tract, or trauma
Bilirubin
Normal: Negative
Abnormal: Positive- gallbladder or liver disease
Nitrite
Normal: Negative
Abnormal: Positive- UTI
Leukocyte esterase
Normal : Negative
Abnormal: Positive- UTI
WBC
Normal: Negative
Abnormal: Positive- UTI
Bacteria
Normal: Negative
Abnormal: Positive- UTI or contaminated specimen
BUN “blood urea nitrogen”
Normal: 10-20 mg Abnormal: >20 -Renal disease -Liver disease -Bleeding in the GI tract -Dehydration
<10mg
-Overhydration
Creatinine
Normal: 0.5-1.2 mg
Abnormal: >1.2mg
-renal disease
-dehydration
