Exam 2 Flashcards by Joseph Lopick

Prioritization falls under what step of the nursing process?

planning

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what is priority setting based on?

urgency
patient safety
patient needs

ABCs

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what to think about when establishing priorities

“if left untreated, will result in harm”
threats to life and limb (ABCs, safety, acute pain)

high priority problems are not always physiologic problems

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ABCs

airways
breathing
circulation

in this specific order

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intermediate priority

non-emergent and non-life threatening

risk of infection

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low-priority

future or long term health needs

education

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HAIs require…

source
route
susceptible host

Healthcare Associated Infections

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Tier 1

Standard Precautions

used for all patients

hand hygiene
gloves
environmental disinfection 
sharps safety
cough/respiratory etiquette

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Second Tier

for patients who are infected or colonized with specific infections

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what are the 3 most common modes of transmission?

contact
droplet
airborne

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contact

most common
direct - sharps/needle
indirect - contaminated environment, c. diff

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droplet

respiratory secretions; stay close, on surface; within 3 feet of patient; larger organisms

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airborne

respiratory secretions; smaller, can be carried on air current, beyond 3 feet

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Personal Protective Equipment (PPE)

refers to a variety of barriers and respirators used alone or in combination to protect mucous membranes, airways, skin, and clothing from contact with infectious agents

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What does PPE include?

Gloves – protect hands
Gowns/aprons – protect skin and/or clothing
Masks and respirators– protect mouth/nose
Respirators – protect respiratory tract from airborne infectious agents
Goggles – protect eyes
Face shields – protect face, mouth, nose, and eyes

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Gowns are always worn with gloves? T or F

True

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Contact precautions include what illnesses

c. diff, MRSA, herpes, scabies, varicella / shingles

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PPE for contact precautions

Gown/gloves for all direct contact

Visitors may be asked to don PPE in a health care setting

OK for patients in contact precautions to leave room “if infectious material/location is contained or covered”, clean gown/clean hands

Disposable or dedicated medical equipment if possible (BP cuff for example)

If medical equipment must be shared, disinfect per institutional protocol (disinfectants may be specific for organisms)

Environmental cleaning/disinfecting important!

check hospital policy

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droplet precautions illnesses

Diphtheria, rubella, streptococcal throat infection or pneumonia, meningoccal infections, pertussis, influenza

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droplet precautions PPE

mask/goggles

Single patient room preferred in hospitals and long term care settings (if possible); clinics – patients should be placed in a separate area.

OK for patients to leave their room but patients need to wear a mask (if tolerated); respiratory hygiene

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Airborne precaution illnesses

rubeola virus [measles], varicella virus [chickenpox], M. tuberculosis, and possibly SARS-CoV

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airborne precaution PPE

N95 mask

Airborne infection isolation room (AIIR) single patient room (negative air flow). Room door remains closed.

HCWs wear an N 95 respirator (donned prior to room entry and removed after exiting patient room) (CDC)

Pt transport off unit? If allowed (medically necessary) , pt. wears surgical mask

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what is a focused assessment?

problem based - actual or at-risk problems
individualized 
may be conducted more frequently 
can extend to related systems 
can extend to psychosocial

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when to do a focused assessment?

clues from patient/family members
unexpected findings in standard assessment
policy (after an event)
presenting problem
nursing knowledge/expertise

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OLDCARTS

``` onset location duration characteristics aggravating factors relieving factors timing severity ```

breath sounds - crackles

Fine or coarse, crackling sound, most often heard on inspiration

breath sounds - rhonchi

Coarse, snoring sound inspiration, expiration, or both (larger airways)

breath sounds - wheezes

High pitched sounds heard on inspiration, expiration, or both (smaller airways)

what are nursing interventions to promote oxygenation?

positioning ambulation incentive spirometry coughing & deep breathing

what are some reasons someone night need oxygen?

shortness of breath hyperventilating COPD fatigue

signs for assessing oxygenation

``` Respiratory rate breath sounds use of accessory muscles color patient complaints mental state, alertness pulse oximeter ```

How much oxygen is person breathing room air receiving?

21%

when do you use humidity for oxygen

at 3/4 liters

when do you switch from a nasal cannula to a simple mask?

5/6 liters

how much O2 does a simple face mask deliver?

40-60%

what is so special about the Venturi face mask?

you can be specific with the amount of oxygen delivered

true or false - the bag needs to be inflated for a partial rebreathing face mask

true

how much O2 does a partial rebreather deliver?

40-60%

what is the flow rate for a partial rebreather?

6-10 L

how much O2 does a non-rebreather deliver?

60-100%

what is the flow rate for a non-rebreather?

10-15 L

how much O2 does a face tent/shield deliver?

30-40%

what is the flow rate for a face tent/shield?

4-8 L

what systems are affected by nutritional status?

``` neurological gastrointestinal musculoskeletal cardiovascular HEENT integumentary ```

what are some factors influencing nutrition?

``` environment developmental cultural/religious personal preferences abilities social factors age ```

what is the typical progression for 'advance as tolerated' diet

clear liquid - fill liquid - regular diet

what is dysphagia?

difficulty swallowing

how long is the urethra in females

approx. 1.5 inches

how long is the urethra in males

approx. 7-9 inches

urinary retention

a person's inability to empty the bladder

true or false: a urinary catheter requires an order

true

reasons for an indwelling catheter

``` acute urinary retention or obstruction a need for accurate urinary measurements heal open wounds prolonged immobilization long surgery ```

what is the highest risk factor for a CAUTI

prolonged use

causes of CAUTI

``` female (shorter urethra) duration older adults bacterial colonization in the collection bag non-sterile environment diabetes ```

when using a sterile environment when would you have to start over?

sterile to non-sterile

you advance the catheter until....

you see urine

after you see urine you advance the catheter.....

1 to 2 more inches

signs of a UTI

increased temp, HR, RR blood in urine, cloudiness, sediment, odor increase in WBC count

hematuria

presence of blood in urine

dysuria

pain or discomfort when urinating

factors that contribute to skin integrity

``` age mobility continence nutrition edema sensory deficites altered mental status ```

abrasion

scrape, friction against skin, scratching

laceration

clean cut

ulceration

eroding skin, lower extremities, think when you bite the inside of your mouth

fissure

crack or small tear, cracks on the side of your mouth

incision

surgical

skin tear

caused by shearing

therapeutic diets

Nutrient Modifications (Sodium, Fiber, Fat, Cholesterol, Protein, Sugar) Texture Modifications (Mechanical Soft, Puree, Dysphagia) Allergy or Intolerance Modifications (Nut, Dairy, Gluten) Mode of Delivery (Oral, Enteral, Parenteral)

advanced as tolerated

clear liquid - full liquid - regular diet

dysphagia diet

level 1 - pureed (pudding like) level 2 - mechanically altered level 3 - advanced - nearly all textures except hard, sticky or crunchy level 4 - regular

safety measures for diet

``` position limit distractions alertness allow adequate time small bites of food foster independence ```

why do people take medications?

``` Treat, cure, manage an illness Preventative Reduce symptoms Quality of life Help diagnose an illness ```

rights of medication administration

``` medication patient dose time route documentation education assessment evaluation right to refuse ```

non-parenteral routes of administration

``` Oral (PO) Sublingual Buccal Otic Ophthalmic Nasal Vaginal Rectal Topical (transdermal) Inhalation ```

parenteral routes of administration

Intramuscular Subcutaneous Intradermal Intravenous

how many checks when administering medication?

necrotic slough

yellow, tan, white

necrotic eschar

black

granulation tissue

red, healing tissue

focused assessment wounds: objective

``` Site (wound base) Peri-wound area (around wound) Size (measure) Drainage Dressing (type, status, date) ```

focused assessment wounds: subjective

``` How did you get this wound? How often does this happen or has this ever happened before? How long as it been there? What products have you tried? Rate pain and describe it? ```

blanchable

turns white when pressed

non-blanchable

does not turn white when pressed

signs and symptoms: wound infection

``` Redness (erythema) Swelling (induration) Warmth Drainage (purulent) Pain Odor ```