Exam 2 fundamentals Flashcards
used for hand hygiene when a pt has C-diff
soap, water
RACE
-rescue/remove pts in immediate danger
-activate the alarm
-confine the fire by closing windows/turning off O2 & electrical equipment
-extinguish fire
PASS
-Pull pin
-Aim at base of fire
-Squeeze handles
-Sweep from side to side to coat area evenly
pt w/ this condition will be placed on airborne precautions
tuberculosis
airway, breathing, circulation/cardiac, deformities, exposure
ABCDE approach to assess pts that are deteriorating or critically ill
PPE worn in room of pt w/ C-diff
gowns, gloves
side effect of Oxycodone
dizziness
pressure injury when the skin is intact w/ non-blanchable erythema?
Stage one
redness of skin
erythema
protrusion of visceral organs through a surgical wound?
Evisceration
drainage that is pale, pink, watery texture of clear & red fluid
serosanguineous
intervention by nurse after a pt is deceased
postmortem care
pressure injury with partial thickness, skin loss; the skin might be intact or appear as a ruptured serum blister
stage two
drainage that is bright red and indicates active bleeding
sanguineous
What aids in wound healing?
protein
time interval between when a pathogen enters the body and when the first symptoms appear
incubation stage
separation of the edges of a wound, revealing the underlying tissues
dehiscence
how should denture care be performed?
w/ a soft toothbrush
how to perform oral care on an unconscious pt?
turn pt on their side, use sunctioning for oral secretions, do oral care every 2-4 hours
pressure injury where slough/eschar obscures the extent of tissue loss?
unstageable
best way to prevent the spread of infection?
hand hygiene
drainage that is clear, watery plasma?
serous
what is REEDA?
-Redness
-Edema (swelling)
-Ecchymosis (discoloration of skin due to bleeding underneath aka bruising)
-Discharge/drainage
-Approximation
*tool used to assess the inflammatory process and tissue healing in the perineal trauma (ex: vaginal birth) through the evaluation of five items of healing
pressure injury where the fat tissue is exposed; can have rolled edges; undermining & tunneling might occur in this stage?
stage three
when to hold metoprolol?
if pt’s systolic bp is less than 100
pressure injury where the fascia, muscle, tendon, ligament, cartilage and/or bone are visible?
stage four
healing that occurs by filling in an open wound with scar tissue?
secondary intention
drainage that is thick, yellow, green, tan, or brown?
purulent
when is the best time to perform a skin assessment?
during a bath
this is used to prevent or reduce the amount of swelling or edema to an area of inflammation or injury?
Ice
what do you never give prior to taking a culture?
antibiotics
if pt has any changes, what do you do?
take vitals and call the provider
what is the feeling of discomfort, illness, lack of well being
malaise
how to prevent pressure injuries?
reposition pt every 2 hours
CAUTI
catheter associated urinary tract infection
CLABSI
central line associated blood stream infection
VAP
ventilator associated pneumonia
what is an avg temperature?
98.6 , fever is anything greater than 100.4
what is a fever?
any temp greater than 100.4
normal HR
60-100 bpm
normal bp
120 s / 80 d
normal O2
greater than 95%
when is our temperature the lowest?
1am - 4am
how to bathe a pt
cleanest to dirtiest
always check vitals before and after this
giving meds
if you see red on wound, what do you do?
check vitals bc could be infection
med used to treat high blood pressure
metoprolol
how to prevent edema aka swelling
cold aka ice, elevate it
type of wound healing that would be sutures from surgical wound, wound that is closed, healing by epithelialization
primary intention
type of wound healing that heals form the inside out, doing its own thing, also has scarring, healing by granulation tissue & epithelialization
secondary intention
type of wound healing that heals after a debridement of wound, left open for several days with possible drainage
tertiary intention
what is the first thing you should do if performing a dressing change on level 3 or 4 wound?
pre-medicate with pain meds!
chain of infection (stages)
- an infectious agent or pathogen (the microorganism)
- a reservoir or source for pathogen growth (place where they can survive, multiply & await transfer to host. ex: humans, animal, food/water)
- a port of exit from the reservoir (place after leaving reservoir to enter another host like blood, respiratory tract, GI etc)
- a mode of transmission (proper PPE can interrupt this)
- a port of entry to a host (organisms enter the body the same routes they use for exiting)
- a susceptible host (susceptibility to an infectious agent depends on individual’s degree of resistance to pathogens)
what are risks of hypertension related illness?
stroke, heart attack, damage to kidneys, retinas, and the peripheral nervous system
what are modifiable risk factors for hypertension?
-obesity
-cigarette smoking
-heavy alcohol consumption
-high sodium intake
-sedentary lifestyle
-continued exposure to stress
4 types of transmission based precautions
-airborne (diseases transmitted by small droplets, need negative pressure room & N95 mask for TB)
-droplet (diseases transmitted by larger droplets like the flu, mask is required)
-contact (direct & indirect, requires gloves, gown)
-protective environment precautions (pt w/ underlying conditions/treatment who are highly susceptible to infection, needs positive airflow room w/ filter) Ex: pt underwent kidney transplant, will have to wear mask when leaving his pt room
what do you do if an IV pump is not working properly?
replace it w/ properly working one, place tag on the faulty one and remove it from service and report malfunction to appropriate department
what are issues with restraints?
-immobilization such as pressure injuries, PNA, constipation, incontinence, loss of self esteem, humiliation, and agitation
-death if restricted breathing and circulation
how often to check pt with restraints
q2 hours for nonviolent or q15 minutes for violent pt
assess pt every 60 mins or sooner for violent or self destructive pt
what to check on with pts with restraints
vitals, skin integrity, nutrition, hydration, circulation, ROM, hygiene, elimination needs, cognitive functioning, psychological status, and need for restraint
what are the basic needs that have to be met before safety levels need to be addressed
oxygen, fluids, nutrition, body temperature, elimination, shelter, sex (these are physiological needs) have to be met prior to reaching safety and security, then love & belonging needs, then self-esteem, then the top self actualization.
