Final Exam Study Guide Flashcards
Oral Temp Range
96.8 - 99.5
When do you need to wash your hands with soap and water?
after bathroom
contact-enteric
when hands are visibly soiled
When do you use standard precautions?
will ALL patients
Donning PPE
applied OUTSIDE the room
gown
mask
goggles
gloves
Doffing PPE
removed INSIDE the room, close to the door
gloves
goggles
gown
mask
Contact Precautions
organisms transmitted through touch
PPE: gowns, gloves
sanitizer / soap and water
Contact Precaution Examples (5)
bed bugs
lice
wound drainage (uncontrolled)
varicella (chicken pox)
RSV (respiratory disease in children)
Contact-Enteric Precautions
transmitted via gut
PPE: gowns, gloves, mask, eyewear, shoe cover
soap and water (if poop is involved)
Contact-Enteric Precaution Examples (4)
C. diff (bacteria)
uncontrolled diarrhea
salmonella
rota virus (kids)
Droplet Precautions
transmitted via big droplets
PPE: mask (surgical)
soap and water / sanitizer
Droplet Precaution Examples (5)
RSV
influenza
mumps
microplasma pneumonia
meningitis
Airborne Precautions
transmitted via small droplets (hang in air)
PPE: N95 mask, surgical mask on patient if have to leave room)
soap and water / sanitizer
Airborne Precaution Examples (4)
COVID-19
TB
chicken pox (varicella)
shingles
Multi-Drug Resistant Precautions
resistant to drugs
PPE: gloves, gown, mask
soap and water / sanitizer
ex: MRSA
Protective / Reverse Precautions
protecting patient
immuno-compromised patient
no live plants
soap and water / sanitizer
Protective / Reverse Precaution Examples (4)
oncology patients receiving chemo
HIV (AIDS)
transplant recipients
patient with splenectomy w/in last 5 years
Standard Fall Precautions (7)
2 bed rails
anti-slip socks
call light within reach
water/kleenex/bed pan w/in reach
clear path
night light (when available)
bed in low position, wheels locked
How many indicators for Fall Risk Assessment Tool
12
12 indicators for Fall Risk
history of fall (w/in last 3 months)
poly-pharmacy
CNS/psychotic medication
cardiovascular medication
age greater than 65
altered elimination
cognitive deficit
sensory deficit
dizziness/vertigo
depression
mobility deficit/weakness
male gender
What score on fall scale indicates a high risk for falls?
4 or greater
High Risk Fall Interventions (7)
gait belt
“safe” band on patient
signage on door
turn alarm on bed
alarm for seated patient
3 bed rails
communication
Fowler’s
between 45 and 60 degrees
sitting position
Semi-Fowler’s
between 30 and 45 degrees
Orthopneic
tripod position
upright, pillow on table, lean on pillow/table
allows for lung expansion
Dorsal Recumbent
pt lies on back with legs flexed and rotated outward
Lateral
pt lays on side
Sims
pt lies on left side, left hip and leg straight, right hip and knee bent
Prone
pt lies of stomach
Supine
pt lies flat on back
Trendelenburg
head lower than feet
increase blood flow to brain
Types of Baths (6) and what they are
complete bed bath: head to toe
assist/set up: can bathe but cannot gather supplies
partial bath: face, hands, back, perineal, axilla, feet
bag bath: pre-packaged wipes
tub bath: pt takes bath in bathtub
shower: pt takes shower
Safety Considerations for Baths (5)
don’t leave pt alone
pt may slip
shower chair
call light in shower
shower bench
Arab Heritage Diet Considerations
bread is served at every meal
no pork, meats cooked well done
food is eaten with right hand
beverages are drunk after the meal not during
Jewish Heritage Diet Considerations
dietary laws govern the killing, preparation, and eating of foods
meat and animal milk are not eaten at the same time; dairy substitutes are permitted
pork is forbidden
all blood must be drained from meats
always wash hands before eating
Mexican Heritage Diet Considerations
rice, beans, and tortillas are core, essential foods
being overweight may be viewed as positive
the main meal of the day is at NOONTIME
Intake and Output
intake is everything liquid
output is everything that comes out
document in mL
Minimum Urine Output Requirement
30 mL/hr for adults
Fecal Impaction: what is it? how is it assessed? how is it relieved? special considerations?
hardened feces in rectum
digital (finger) exam
pull away at impaction until the rest begins to flow
vagus nerve may be stimulated and pt will pass out
Peri stomal and Stoma Skin
peri stomal skin should be normal
stoma should be pink/beefy and moist
How often should you change an ostomy appliance?
weekly unless signs of skin breakdown are noted
empty bag about half full
Routine Urine Specimen
no time frame around it (drug screen or pregnancy test)
Clean Catch for C & S
sterile sample, to figure out what bacteria it is, midstream, peri-care before, may do straight cath
Foley Catheter
only collect specimen right when placed in pt, use blue port to collect after bag is inserted, do NOT take sample from bag
Timed Urine
over a period of time, must collect every drop of urine within the time frame, sample collection bag is on ice to keep cold
Nasal Cannula
1-6 L/min
24-44% of oxygen
use for mild shortness of breath
also have high flow cannula
Simple Mask
4-8 L/min
40-60% of oxygen
may use for mouth breathers
may cause claustrophobic feeling
Venturi Mask
4-15 L/min
24-60% of oxygen
Most ACCURATE oxygen delivery
use for COPD patients (constriction of the airways)
Non-Rebreather Mask
10-15 L/min
100% of oxygen
use for patients in extreme respiratory distress
must have good fit
must have bag inflated with oxygen
Preventing DVT/PE
antiembolic stockings (TED hose)
Intermittent Pneumatic Compression (IPC) Devices (alternating compression between legs)
Anticoagulants (coumadin, lovenox, heparin)
S&S for DVT
leg pain, warm, swollen, red
S&S for PE
chest pain, hurt on inspiration, dyspnea, decreased O2 sat, Increased RR, HR, and BP
Contraindications to Heat Therapy
after surgery, traumatic injury for up to 24 hours, hemorrhage, skin disorders
Contraindications to Cold Therapy
allergy/hypersensitivity to cold
Contraindications for Heat and Cold Therapy
neurosensitivity impairment, impaired mental status, impaired circulation, on open wound
Types of Restraints and What they are (3)
physical: any device that limits movement of body parts
chemical: pharmacological (Haldol)
seclusion: confinement to room where pt is alone and unable to leave
Safety Concerns for Seizures
NEVER PUT ANYTHING IN PT’S MOUTH DURING SEIZURE
Interventions for Seizures
protect head
turn pt on side
oxygen if needed
suction if needed after
reassess after (vitals, A&O, neuro, etc)
