Exam 2 Flashcards
Prioritization falls under what step of the nursing process?
planning
what is priority setting based on?
urgency
patient safety
patient needs
ABCs
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
ABCs
airways
breathing
circulation
in this specific order
intermediate priority
non-emergent and non-life threatening
risk of infection
low-priority
future or long term health needs
education
HAIs require…
source
route
susceptible host
Healthcare Associated Infections
Tier 1
Standard Precautions
used for all patients
hand hygiene gloves environmental disinfection sharps safety cough/respiratory etiquette
Second Tier
for patients who are infected or colonized with specific infections
what are the 3 most common modes of transmission?
contact
droplet
airborne
contact
most common
direct - sharps/needle
indirect - contaminated environment, c. diff
droplet
respiratory secretions; stay close, on surface; within 3 feet of patient; larger organisms
airborne
respiratory secretions; smaller, can be carried on air current, beyond 3 feet
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
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
Gowns are always worn with gloves? T or F
True
Contact precautions include what illnesses
c. diff, MRSA, herpes, scabies, varicella / shingles
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
droplet precautions illnesses
Diphtheria, rubella, streptococcal throat infection or pneumonia, meningoccal infections, pertussis, influenza
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
Airborne precaution illnesses
rubeola virus [measles], varicella virus [chickenpox], M. tuberculosis, and possibly SARS-CoV
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
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
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
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?
3
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
