Exam 2 fundamentals Flashcards by Emma Ware

used for hand hygiene when a pt has C-diff

soap, water

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RACE

-rescue/remove pts in immediate danger
-activate the alarm
-confine the fire by closing windows/turning off O2 & electrical equipment
-extinguish fire

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PASS

-Pull pin
-Aim at base of fire
-Squeeze handles
-Sweep from side to side to coat area evenly

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pt w/ this condition will be placed on airborne precautions

tuberculosis

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airway, breathing, circulation/cardiac, deformities, exposure

ABCDE approach to assess pts that are deteriorating or critically ill

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PPE worn in room of pt w/ C-diff

gowns, gloves

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side effect of Oxycodone

dizziness

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pressure injury when the skin is intact w/ non-blanchable erythema?

Stage one

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redness of skin

erythema

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protrusion of visceral organs through a surgical wound?

Evisceration

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drainage that is pale, pink, watery texture of clear & red fluid

serosanguineous

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intervention by nurse after a pt is deceased

postmortem care

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pressure injury with partial thickness, skin loss; the skin might be intact or appear as a ruptured serum blister

stage two

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drainage that is bright red and indicates active bleeding

sanguineous

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What aids in wound healing?

protein

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time interval between when a pathogen enters the body and when the first symptoms appear

incubation stage

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separation of the edges of a wound, revealing the underlying tissues

dehiscence

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how should denture care be performed?

w/ a soft toothbrush

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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

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pressure injury where slough/eschar obscures the extent of tissue loss?

unstageable

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best way to prevent the spread of infection?

hand hygiene

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drainage that is clear, watery plasma?

serous

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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

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pressure injury where the fat tissue is exposed; can have rolled edges; undermining & tunneling might occur in this stage?

stage three

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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)

1. an infectious agent or pathogen (the microorganism) 2. a reservoir or source for pathogen growth (place where they can survive, multiply & await transfer to host. ex: humans, animal, food/water) 3. a port of exit from the reservoir (place after leaving reservoir to enter another host like blood, respiratory tract, GI etc) 4. a mode of transmission (proper PPE can interrupt this) 5. a port of entry to a host (organisms enter the body the same routes they use for exiting) 6. 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.