Exam content Flashcards
Chain of Infection
- aetiological agent (micro-organism)
- reservoir (source)
- portal of exit from reservoir
- method of transmission
- portal of entry to the susceptible host
- susceptible host
Aetiological Agent - link 1
- bacteria - pneumonia, TB
- viruses - influenza, chicken pox
- fungi - thrush, athletes foot
- protozoa - malaria
- parasites - lice, scabies
Breaking the first link
kill the pathogen
* antibiotics
* antivirals
* disinfectants heat
**remove the pathogen **
* biohazard
* burning
* burial
herd immunity
the reservoir - 2nd link
- where pathogens hang out
- can be a location, an environment, population of animals
- a human or group of human
Breaking the 2nd link
- Eliminate - the reservoir e.g. food, animals, people
- isolate- the reservoir from at risk population
- treat - the reservoir - vaccine, filtration of water
Portal of exit from reservoir - link 3
how pathogen gets out of reservoir
* coughing, sneezing, bleeding, breathing, defacting, urinating etc.
* the bite of vector species
* human error e.g. spills
* mechanical failure e.g. faulty filtration; wet masks
Breaking the 3rd link
- block - the pathogen as it leaves the reservoir e.g. cough etiquette, care with body fluids
- remove access - prevent humans from accessing contents of reservoir
- eliminate outlet - from reservoir - e.g. spill prevention
Method of transmission - 4th link
how the pathogen gets to its next victim
direct transmission:
* direct contact e.g. skin to skin, soil
* droplet e.g. sneezing, coughing, talking
* vertical transmission e.g. mother to baby
Indirect Transmission:
* Air-borne
* vehicle-borne e.g. pen, stethoscope
* vector-borne e.g. mosquito, tick, flea
Breaking 4th link
- standards precautions
- transmisison precautions
- stay at home if sick
Portal of entry to susceptible host - link 5
Breaking the 5th link
the way the pathogen gets into the body
* care for your skin
* beware of sharps
* use appropriate ppe
* dont touch eyes, nose, mouth
Susceptible Host - link 6
the pathogen must reach someone that is susceptible to it in order to produce disease
* impaired immune system
* age, very young, very old
* immunosuppressed due to treatment or chronis illnesses
breaking 6th link
- employing appropriate precautions to protect those with low immunity
- vaccination - herd immunity
- use appropriate ppe
HAI - healthcare associated infections
- infections associated with the delivery of healthcare services in a health care facility
- develop during an individuals stay in a facility or after discharge
- pain, suffering
- prolonged stay
- cost to health budget
5 moments of hand hygiene
- before touching patient
- before a procedure
- after a procedure or body fluid exposure
- after touching a patient
- after touching a patient’s surroundings
Clinical reasoning cycle
- consider the patient situation
- collect cues/info
- process info
- identify problems/issues
- establish goals
- take action
- evaluate outcomes
- reflect on process & new learning
Purpose of nursing assessment
- find out about clients needs, heath problem, responses to those
- identify pateint strengths
- identify health risks such as, falling, pressure injury
- inform an individualised plan of care
- compare previous data
A-G assessment
A - airway&oxygenation
B - breathing&ventilation
C - circulation & shock management
D - disability - neurological deterioration
E - exposure&examination
F - fluids&medication infusions
G - glucose
Patient care - SOLER
S - sit squarly
O - open posture
L - lean forward
E - eye contact
R - relaxed posture
Signs of malnutrition
- protein - dull, sparse hair
- iron - spoon nails, pallor
- B2 - inflammation of corners of mouth
- B6 - inflammation of tongue
- Vitamin C - spongy bleeding gums
- vitamin D child - ricketts
Phases of Swallowing
- preparation
- swallowing
- pharyngeal
- oesophageal
Preparation for Swallowing
- mastication (chewing) - food moistened and moved around
- food mixed with saliva
Swallowing
- mouth is closed
- tongue pushes food into pharynx
iSoBAR
i - identify self and patient
S - situation
o - observations
B - background
A - assess,emt
R - recommendations/readback
*
When to assess vital signs
- on admission
- change in health status
- before and after any procedure
Respiration terms
respiration - act of breathing
inspiration - intake of air into the lungs
expiration - breathing out
costal (thoracic) breathing - observed by the movement of the abdomen
ventilation - movement of air in and out of the lungs; exchange of gases
Respiratory Rate
Adult - 12-20
Newborn - 30-60
Child - 20-30
Adolescent 16-19
Eupnoea, bradypnea, tachypnoea
Respiratory Terms pt2
dyspnoea - difficulty breathing
orthopnoea - ability to breathe only in upright position
stridor - a shrill, harsh sound heard during inspiration
wheeze - continuous, high-pitched musical squeek or whistling sound
Pulse
a wave of arterial blood created by contraction of the left ventricle of the heart.
Pulse locations
- temporal artery
- carotid artery
- radial artery
- brachial artery
- femoral artery
- popliteal artery
- posterior tibial artery
- dorsalis pedis artery
Assessing pulse
- rate
- rhythm
- strength
- equality
- elasticity
Assessing Respirations
- rate
- depth
- pattern/rhythm
- quality/sounds
- effectiveness
Assessing Consciousness
A - alert
V - verbal
P - pain
U - unresponsive
Temperature terms
Pyrexia/fever - high temp
Febrile a person who is pyrexia
Afebrile - a person who has normal temp
Hypothermia - low temp
**Recognising, responding to acute deterioration **
relies on detecting, understanding, interpreting abnormal vital signs and escalating care appropriately
Blood pressure
- measured in millimeters of mercury (mmHg)
- dependent on: cardiac output, blood volume
Systolic Blood Pressure
maximum pressure of the blood against the wall of the artery. it occurs during ventricular contraction systole.
Diastolic blood pressure
the minimum pressure of blood against the wall of the artery. it occurs during ventricular relaxation/rest.
signs of hypertension
- asymptomatic
- headache
- dizziness
- can lead to myocardial infarction, stroke, heart failure, chronic kidney disease
Signs of hypotension
- dizziness
- lightheaded
- cold, clammy skin
- fainting
DRSABCD
- Dangers
- responsive
- send for help
- airway
- breathing
- CPR
- defibrillator
ABCDE
- airway
- breathing
- circulation
- disability
- exposure
Hydration
- serves as a medium for normal cellular function/metabolic reactions
- transports nutrients, waste products and other
- helps regulate body temp
- provides lubrication & acts as a shock absorber
- makes up to 60% of the average healthy adults weight
Formation of urine
- blood, waste & water enter the kidney via the renal artery
- filtration & reabsorption takes place in the nephron
- blood without waste or excess water leaves thr kidney via renal vein
- excess water and waste, in the form of urine, leaves the kidney via ureter
signs of healthy bladder
- empties 4-8 times a day
- holds 400-600ml
- tells you when to go toilet but gives time to find a toilet
SOAPIER
S - subjective
O - objective
A - assessment
P - plan
I - intervention/implementation
E - evaluation
R - revision
Subjective
- consists of info obtained from what the person says. it describes the persons perceptions of an experience with the problem.
Objective
consists of infro that is measured or observed by use of the senses (e.g. vital signs, xray results)
assessment
the interpretation or conclusion drawn about the subjective and objective data
plan
the plan of care designed to resolve the stated problem
intervention
specific interventions that have actually been performed by the caregiver
evaluation
includes repsonses to nursing interventions and medical treatments. this is primarily reassessment data.
revision
reflects care plan modifications suggested by the evaluation.
