Exam 2 Flashcards
Reduces risk of transmission of microorganisms from known or unknown substances. Includes hand hygiene, gloves any other PPE for task, safe injection practices, safe handling of body fluids, and safe handling of contaminated equipment or surfaces.
Standard Precautions
Prevention of transfer of microorganisms and pathogens.
Asepsis`
MRSA, Vanomycin-Resistant Enterobacteria (VRE), Clostridium difficile (C. diff)
Gloves and gown
Client requires private room
Remove gloves and gown before leaving room
Contact Precautions
Varicella Viruses, TB
Respirator mask approved by OSHA :N95, PAPR
Negative airflow room: closed door, seal, HEPA filter
Airborne Precautions
*Particles less than 5 microns
Covid-19
Mix of multiple isolation
N95 or PAPR, gown, gloves, face shields, hair coverings
Enhanced Respiratory Precautions
Diphtheria, Rubella, Streptococcal pharyngitis, Influenza, Pneumonia/Scarlet Fever (infants), Pertussis, Mumps, Meningitis
Surgical Mask
Private room or cohort
Client needs mask if leaving room
Droplet Precautions
*Particles greater than 5 microns
For immunocompromised clients
Private room with positive airflow
Surgical mask
No fresh fruit, vegetables, flowers (anything that can harbor bacteria)
Protective Precautions
Sterile Technique
Procedures used to eliminate all microorganisms - used any time we break skin.
*Sterile objects only touch other sterile objects.
*Sterile surface should not come in contact with another surface.
*Hold sterile objects above the waist.
*Keep sterile objects in view.
*Use sterile objects in timely manner.
*Border of sterile field is contaminated.
Factors affecting urinary elimination:
*Medications
*Anesthesia and surgery
*Psychosocial and Personal Issues
Diseases that affect urinary elimination:
*Renal disease
*Diabetes
*Neuromuscular diseases: Affects nerves that innervate bladder
*Benign Prostatic Hyperplasia: due to constriction of urethra
*Cognitive disease
*Mobility-limiting diseases
Anuria
No urination (<100 mL in 24 hours)
Diuresis
Increased urine formation
Dribbling
Leakage of urine despite voluntary control
Dysuria
Painful or difficult urination
Frequency
Voiding small amounts at frequent intervals
Hesitancy
Difficulty initiating urination
Hematuria
Blood in urine
Incontinence
Involuntary loss of urine
Oliguria
Diminished urinary output
Polyuria
Large amounts of urine voided
Residual
Volume of urine remaining in the bladder after voiding
Retention
Accumulation of urine in the bladder without the ability to empty fully
Urgency
Feeling of needing to void immediately
Signs: Bladder distention, absence of urine output, pressure or tenderness, restlessness, and diaphoresis
Urinary Retention - could be caused by obstruction or medication
Hemodialysis
*Blood removed from body, goes through dialysis machine which pulls wastes and fluids from the blood, then returns filtered blood back to client
- Client must have access device that can withstand very high pressure with two sites to access - one to remove blood and one to return blood
*3 x week, 3-4 hrs per session
Arteriovenous (AV) Fistula
Hole made between an artery and vein in arm
Graft
Small tube placed between artery and vein in arm
Bruit
Whooshing or swishing sound head with stethoscope that indicates fistula or graft are functioning properly
Peritoneal Dialysis
*Peritoneal catheter placed in abdomen
*Client instills dialysate into peritoneal cavity which sits for prescribed amount of time
*Peritoneum acts as semipermeable membrane and allows for filtering of fluids and wastes - drained from abdomen
Incontinence that occurs when there’s an increase in abdominal pressure:
Stress Incontinence
A factor outside the urinary system is causing incontinence:
Functional Incontinence
Occurs when there’s a strong sense of needing to void and then almost an immediate void:
Urge Incontinence
Urinary Tract Infection
Causes: Indwelling urinary catheters, poor hygiene, women’s shorter urethra, urinary retention
Symptoms: Pain, burning with urination, frequent urination, urgency, cloudy urine, confused mental status, nausea and vomit in more severe infection, hematuria
Cystitis
Bladder infection
Pyelonephritis
UTI travels to kidneys causing more serious infection - monitor for worsening fever, flank pain, costovertebral tenderness
Non-invasive Tests for Urinary Alterations:
*X-ray
*CT scan
*Ultrasound
*Intravenous Pyelogram (IVP): X-ray used with contrast dye to highlight kidneys, ureters, and bladder
Invasive Tests for Urinary Alterations:
*Cystoscopy: Introduction of a scope into urethra to get visual of bladder
*Renal Arteriogram: Accessing the renal arteries through catheterization and use of contrast dye
Urinalysis
Most common urinary tests - screens for many issues and indicates problems in urinary system
Specific Gravity
Indicates how dilute or concentrated urine
*Lower more dilute
*Higher more concentrated
Indwelling Catheters
*Temporary or long-term - bladder is continually draining upon - upon insertion a balloons inflated to keep catheter in place in base of bladder - attached to bag the urine drains into - increased risk of infection due to continual access to urethra and bacteria can crawl in bladder
Intermittent Catheters
“Straight” catheters - place catheter, let all urine drain out then remove catheter - doesn’t stay in place - used to relieve retention, get specimen
External Catheter
Alternative to indwelling catheter - condom catheters: end attached to suction which sucks urine away to canister and keeps the client dry
PureWicks
For women - looks like banana with absorbent pad that is placed by labia - end attached to suction which sucks urine away and keeps client dry - not for ambulatory clients
CAUTI
Catheter Associated Urinary Tract Infection
CAUTI Prevention Measures
- Fluid Intake
*Frequent perineal care
*Catheter kept below bladder level
*Avoid dependent loops
*Empty bag prior to moving client
*Secure catheter to client’s leg
*Avoid prolonged cramping of tubing
Redness when there’s ischemia
Erythema
Redness that blanches when pushed on and returns to red when pressure is removed
Blanchable Erythema
When pressure is applied an area remains red - Stage 1 Pressure Ulcer
Non-blanchable Erythema
Pus that is yellow or green and thick
Exudate
Clear or yellow drainage
Serous
Pink drainage - mix of serous and sanguineous drainage
Serosanguineous
Blood drainage
Sanguineous
Gray, white, or yellow tissue that can be stringy - dead tissue
Slough
Black dead tissue in a would - indicative of infarction
Eschar
Granulation - new pink tissue that appears in wounds during healing
Vascular Tissue
Localized injury to skin and underlying tissue. Common over bony prominence
Pressure Ulcers
Pressure Ulcer Interventions
*Turning
*Positioning
*Placement of prophylactic dressings
Pressure Ulcer Risk Factors
*Decreased mobility
*Decreased sensory perceptions
*Moisture
*Incontinence
*Poor nutrition
*Altered LOC
*Shear and friction
*Age
3 Factors that Determine the Likelihood of Developing Pressure Ulcers
- Intensity
- Duration
- Tissue tolerance
Pressure Ulcer Intensity
Capillary closing pressure greater than 32 mmHg
Skin reddened and may be warm to touch and either feel firmer or softer than surrounding skin
Stage 1 Wound
Skin breaks open exposing the epidermis or dermis - lesion will be superficial and often resembles an abrasion/popped blister
Stage 2 Wound
Lesion extends into dermis and begins to enter the subcutaneous layer - lesion will form small crater and fat may begin to show in open sore
Stage 3 Wound
Subcutaneous layer and underlying fascia are breached exposing muscle and bone
Stage 4 Wound
Wounds that have so much eschar and slough that they can’t be staged - must deride wound first
Unstageable Wound
Occurs when epidermis is intact but there’s some injury deep down in tissue - will appear like severe bruise
Deep Tissue Injuries
Tool used to assess skin breakdown - was score of 23 and the lower the score the higher the risk for skin breakdown
Braden Scale
Primary intention wound
Wound that is closed (sutured or stapled)
Secondary intention wound
Wound is left open to heal from inside out