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1
Q

Chain of infection

A 
Infectious agent
susceptible hose
reservoir
portal of entry
portal of entrance
mode of transmission
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2
Q

PPE Contact

A

Gloves and Gown

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3
Q

PPE Droplet

A

Gloves, Gown, Mask and goggles

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4
Q

PPE Airborne

A

Gloves, Gown, N-95 Mask

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5
Q

PPE Contact and Droplet

A

Gloves, Gown, Mask, Goggles

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6
Q

Inflammatory Response

A

trauma, fever, swelling, redness, pain, tired

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7
Q

Hand Washing

A 
30-60 seconds,
nails
fingers
palms
wrists
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8
Q

Integument Assessment ( body hygiene)

A

Skin
Feet
Hands
Hair

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9
Q

Serous Drainage

A

watery clear plasma

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10
Q

Purulent Drainage

A

thick yellow, brown or tan

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11
Q

Serosanguineous drainage

A

mixture of blood and water plasma

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12
Q

Sanguineous drainage

A

Active Bleeding

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13
Q

Granulation Tissue

A

Red, moist tissue means healing

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14
Q

Slough Tissue

A

Necrotic Tissue

Yellow, white tissue. must be removed before healing can happen

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15
Q

Eschar tissue

A

Necrotic Tissue

Black or Brown necrotic tissue, which needs to be removed before healing: bUT DO NOT RIP OFF.

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16
Q

Assessing a wound

A

REEDA and TACO

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17
Q

REEDA

A 
Redness
Edema (swelling)
Ecchymosis ( bruising )
Drainage
Approximation (size)
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18
Q

TACO

A

Type of drainage
Amount of drainage
Color and consistency
Odour of drainage.

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19
Q

Acute Wound

A

Wound that heals within a specific time ( surgical wounds)

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20
Q

Chronic Wound

A

Wound that does not heal in a proper time frame

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21
Q

Vascular Ulcer

A

Caused by poor blood return

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22
Q

Arterial Ulcer

A

caused by bad blood flow

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23
Q

Primary Intention

A

Clean cut wounds
heal quicker
usually surgical wounds

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24
Q

Secondary Intention

A

jagged edges
longer healing time
scar is larger and more visible
higher infection risk

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25
Q

Tertiary intention

A

Wound is left open because of infection or contamination

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26
Q

3 phases of wound healing

A

Inflammation
Proliferative
Remodeling

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27
Q

Management of pressure ulcer

A

Clean with Saline or warm soapy water
centre to outside
cover with sterile dressing

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28
Q

Cleaning a Wound

A 
hand hygiene
wound size, location, history
patient level of comfort
review orders for dressing change
explain
ppe as needed
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29
Q

Blanching

A

pressing on skin

turns white

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30
Q

Abrasion wound

A

superficial with little bleeding

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31
Q

Laceration Wound

A

Unintentional, jagged, bleeding depends on depth and location

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32
Q

Puncture Wound

A

Small
circular
edges coming together in the centre
may cause bleeding underneath skin

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33
Q

Braden Scale Measures

A

Sensory perception, moisture, activity, mobility and nutrition

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34
Q

First thing you do when you walk into a patients room

A

NOD and Assess

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35
Q

Ethical principle around restraints

A

Least Resort

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36
Q

Wound Cultures

A

Clean Wound with NON-antisceptic solution ( sterile water or normal saline)
use sterile swab from culture tube

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37
Q

Prevent Stomache wound splits

A

Having a patient hold a folded thin blanket or pillow while coughing

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38
Q

Prone Position

A

Laying on your stomach

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39
Q

Supine position

A

Laying on your back

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40
Q

Lateral position

A

Laying on your side

Good for body alignment assessments

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41
Q

Fowlers Position

A

Sitting up at a 45 degree angle

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42
Q

Low Fowlers Position

A

Sitting up right at a 30 degree angle

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43
Q

Trendallenber position

A

laying on your back with your feet up and head down

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44
Q

Reversed Trendallenber position

A

Laying on your back with your head higher then your feet

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45
Q

Positioning Devices

A 
Pillow (provides support elevates body)
Wedge ( Maintains legs in abduction)
Footboot (prevents foot drop by maintaining foot in dorsiflexion)
Trochanter Roll (prevents external rotation of hips)
Sandbags 
handrolls
Splints
Trapeze bar
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46
Q

Assistive Devices for walking

A

Crutches
Canes
Walkers

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47
Q

Vector Borne

A

Insects or pests that contain infections

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48
Q

Vehicle

A

is a contaminated source

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49
Q

Direct contact

A

Skin to Skin

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50
Q

Indirect contact

A

Touching a contaminated surface

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51
Q

Droplet

A

Is a large particle can travel up to 2 meters

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52
Q

Nosocomial

A

Something that can happen in a health care setting.

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53
Q

Micro-organism

A

Seen only with a microscope
bacteria
viruses
fungi

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54
Q

Micro-organisms that cause disease

A

Pathogens

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55
Q

Our Bodies Natural Defences against Infections

A

Normal Flora: Natural in our bodies

In Specific Body Systems: Lungs

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56
Q

4 Moments of hand hygiene

A

1) As you enter the room or new environments
2) Before an aseptic procedure (sterile)
3) After any bodily fluid exposure ( even with gloves)
4) As you exit an environment

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57
Q

Necrotic Tissue

A

Non-Viable dead tissue that must be removed in order for a wound to heal
Eschar and Slough are Necrotic Tissues

58
Q

What is the principle of least restraint

A
  • The Principle of Least restraint ensures that all other measures or interventions are attempted before moving to the use of restraints. Also that the type or form of restraint is appropriate for the patients needs and safety.
  • Restraints should always be a measure of last resort.
  • Restraints are purposed as part of the medical treatment and ONLY A SHORT TERM intervention
59
Q

What are the different types of restraints?

A

Physical Restraint
Chemical Restraint
Environmental Restraint

60
Q

The objectives that must be met and followed for restraints.

A
  • They reduce the risk of patient injury
  • They prevent interruptions of patients therapy, such as IV, nj, gtubes. and so on.
  • They are used to prevent the patient from removing life support
  • and reduce the risk of harm to others by the patient.
61
Q

The 7 rights of medication delivery:

A 
Right patient
Right medication
Right Route
Right Time
Right Dose
Right Reason
Right Documentation.
62
Q

Alternatives to Restraints

A
  • Remove obstacles that promote a patient leaving ( elevators not in sight, stair cases, or street clothing)
  • Promote relaxation and normal sleep patterns
  • Evaluate all medications that the patient is receiving, and ensure effective pain management.
  • Use calm simple statements and physical cues as needed.
63
Q

Autonomy

A

is ones ability to make choices by themselves, this is based on full understanding and free of controlling influence from others.

64
Q

Beneficence

A

Doing or promoting good for others.

The the patients safety and wellbeing is more important then self-interest.

65
Q

Nonmaleficence

A

The avoidance of harm or hurt

trying to balance the risks and benefits of a plan of care while trying to not to cause harm, or least harm possible

66
Q

Changes related to aging that increase risk of accidents

A
  • Musculoskeletal changes: Muscle strength and function decrease, joints become less mobile
  • Nervous System Changes: sensitivity to touch decreases, reflexes slow down
  • Sensory Changes: vision can be effected, risk of cataracts, pain and light touch threshold increases, hearing is impaired.
  • Genitourinary Changes: incontinence increases with age.
67
Q

Body’s Defences against Infection

A

Normal Flora
Inflammation
Body System Defences

68
Q

Direct Contact

A

Skin to Skine

69
Q

Indirect contact

A

Touching a contaminated surface

70
Q

Droplet

A

Large particles that can travel up to 2 meters

71
Q

Airborne

A

small particles that can stay in the air for long periods of time.

72
Q

Vector Born

A

Transferred by bugs or insects

73
Q

Nosocomial

A

Something you get in a health care setting

74
Q

Medical Asepsis

A

Clean Technique : procedure used to reduce the spread of microorganisms.
Hand Hygiene, clean gloves
means the prevention of infection

75
Q

Sterile Asepsis

A

Means the absence of infection

76
Q

Factors that influence personal hygiene practices

A

Social Practices : the type of hygiene products
Personal preferences : when to bathe or shave and what products they want to use.
Body Image: general appearance will reflect what personal hygiene practices one may hold. This can reflect a person emotional or mental status as well.
Socioeconomic status: a persons economic status can influence a person hygiene practices used. : Lack of resources
Health Beliefs or motivation: Lack of knowledge can have a impact on how a persons personal hygiene
Cultural variables
physical condition.

77
Q

Physiology of the urinary system

A 
Kidneys
Ureters
Bladder
Urethra
Micturination
78
Q

Kidneys

A

Remove waste from the blood to make urine

79
Q

Ureters

A

Move Urine from the Kidneys to the bladder

80
Q

Bladder

A

Stores urine until the need to urinate occurs

81
Q

Urethra

A

Urine travels from the bladder through the urethra until it passes outside the body

82
Q

Micturination

A

Urination: When the neurological responses allow the bladder to contract, release and push the urine to leave the body.

83
Q

Psychological factors affecting urination

A

Anxiety or stress
this can either cause the stopping of urination or make the urge to urinate more frequent.
Privacy

84
Q

SocioCultural factors affecting urination

A

Cultural Practices
Gender or religious practices
Transportation or cost
Language barriers

85
Q

Fluid Balance affect on urination

A

Alcohol, caffeine and increase in fluid intake increase your urination.
balance of electrolytes also increases urination

86
Q

Diagnostic Examinations affect on urination

A

Exams that cause short term incontinence. Damage to the bladder.

87
Q

Common Alterations in urinary elimination

A

Incontinence
Retention
Nocturia
Urinary Diversion

88
Q

Incontinence

A

Involuntary loss of urine

Stress or urgency

89
Q

Urine Retention

A

Inability to empty bladder

90
Q

Nocturia

A

Urination at night

91
Q

Urinary Diversion

A

Stoma that is placed to divert the flow of urine from the kidneys directly to the abdominal surface

Trauma
cancer
Chronic cystitis

92
Q

Oliguria

A

Decreased production of urine

93
Q

Anuria

A

No Urine production

94
Q

Dysuria

A

Painful or difficult urination

95
Q

Hematuria

A

Blood in urine

96
Q

Symptoms of urinary Alterations

A 
Incontinence
Urgency
Dysuria
Frequency
Polyuria
Oliguria
Nocturia
Dribbling
Hematuria
Elevated postvoid residual urine.
97
Q

Urine Assessment

A 
Intake and output of fluids
Colour
Odor
Clarity
Amount
98
Q

Type of Urine Collection

A

Random Specimen ( routine urinalysis or other tests)
Clean-void ( midstream) Sterile specimen cup
Catheter specimen
Timed Urine Specimen.

99
Q

Random Specimen

A

Routine Urinalysis or other tests

100
Q

Clean-void or midstream specimen

A

Sterile Specimen cup is used to collect urine and a aseptic technique is used ( surgical technique)

101
Q

Catheter Specimen

A

Aseptic technique through special port. Risk for CAUTI

102
Q

CAUTI

A

Catheter associated Urinary Tract Infection.

103
Q

Promoting Regular Urination

A

Stimulating Miturination reflex
Maintaining elimination habits
Maintaining adequate fluid intake

104
Q

Types of catheters

A

Coude Catheter
Indwelling or foley catheter
Intermittent straight catheter
Triple Lamen

105
Q

Coude Catheter

A

Curved tip used for male patients with large prostate

106
Q

Indwelling or Foley Catheter

A

Longer periods of time in bladder

small balloon holds it agains the bladder neck

107
Q

Intermittent straight catheter

A

Used for 5-10 min to release urine from bladder but taken out after elimination.

108
Q

Methods of measuring urine output

A

Urometer

Urine hat

109
Q

Practices to avoid catheter infections CAUTI

A

Hand Hygiene
Closed urinary drainage system
Monitor potency of catheter system

110
Q

Closed urinary drainage system

A

A break could lead to microorganisms being introduced

111
Q

Monitoring patency of catheter systems

A

Prevent urine from pooling in the tubes and allowing bacteria to form
this could possibly create an infection if it is pooled back into the body.

112
Q

Indwelling catheter perineal care

A

at least done twice daily
after a bowel movement
or as needed

soap and water or skin cleansers will help reduce the amount of microorganisms at the enterance of the urethra

be careful not to push the catheter inwards as this could introduce bacteria.

113
Q

Urinary Diversions

A

Ureterostomy
Nephrostomy
ill conduit
Continent pouch

114
Q

Ureterostomy

A

Bringing the end of one or both ureters to the abdominal surface

115
Q

Nephrostomy

A

A tube placed directly into the renal pelvis yo give urinary drainage

116
Q

ileal conduit

A

Separating a loop of intestinal ileum with blood supply still intact.

117
Q

Continent Pouch

A

Provides urinary storage in a leak proof pouch.

118
Q

Factors affecting bowel elimination

A 
Diet : Fibre
Fluid intake: needed to liquify intestinal contents
Physical Activity
Personal bowel elimination habits
Privacy
119
Q

Common Bowel Elimination Problems

A 
Constipation
Impaction
Diarrhea
Bowel Incontinece
Flatulence
Hemorrhoids
120
Q

Constipation

A

Is a symptom not a disease
infrequent bowel movements
abdominal pain, sensation of being full
straining during defecation

121
Q

Fecal Impaction

A

unrelieved constipation can cause overflow incontinence

harden feces wedged in the rectum that can not be removed.

122
Q

Diarrhea

A

increase in the number of stools a day
passage of liquid

infections
food intolerances
medications
intestinal disease

cause fluid and electrolyte imbalances

123
Q

Bowel Incontinence

A

inability to control the passing of faces and gas.

diet
fluid intake
alcohol
nicotine

124
Q

Flatulence

A

accumulation of gas in the intestines

causes abdominal fullness, pain and cramping.

125
Q

Hemorrhoids

A

dilated engorged veins in lining of the rectum

external or internal

126
Q

Stoma

A

Permanent or temporary opening in the abdominal wall

The ends of the intestines are brought through the abdominal wall to create a stoma

127
Q

Ileostomy

A

Surgical opening in the ileum
has the
Kock continent ileostomy

128
Q

Colostomy

A 
Surgical opening in the colon
usually has
Loop Colostomy
End Colostomy
Double Barrel Colostomy
129
Q

Kock Continent ileostomy

A

Small intestine

creates a pouch and the use of a catheter to drain

130
Q

Loop Colostomy

A 
Usually done in a medical emergency
Temporary and large
Made in the transverse colon
Proximal end drains stool
Distal end drains mucus
131
Q

End Colostomy

A

One Stoma

Distal portion of GI tract is either removed or sewn shut

132
Q

Double-Barrel Colostomy

A

Bowel is surgically cut and both ends are brought out onto the abdominal wall
Proximal is functioning
Distal is nonfunctioning.

133
Q

Transverse Colon

A

More solid, formed stool

134
Q

Ascending Colon

A

More frequent and more liquid

135
Q

Descending Colon

A

Near normal Stool

136
Q

Documenting an Ostomy

A

Stoma characteristics
Peristomal Skin
Pouch system used
Amount, Colour and Odour.

137
Q

Resperitory effects of deconditioning

A

Hyperventilation
Decreased lung expansion
Impaired gas exchange

138
Q

Circulatory effects of Deconditioning

A

Drecreased cardiac output

Venous pooling

139
Q

Integumentary effects with Deconditioning

A

Shearing of skin during movement

Decreased delivery of oxygen and nutrients to tissues

140
Q

Musculoskeletal effects of Deconditioning

A

Reduced muscle mass

Impaired joint mobility

Nursing Foundations 1 (3 decks)

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