Final review Flashcards
stages of infection (IPFC)
Incubation period
Prodromal stage
Full (acute) stage of illness
Convalescent period
incubation period (think incubate)
The incubation period is the interval between the pathogen’s invasion of the body and the appearance of symptoms of infection. During this stage, the organisms are growing and multiplying. The length of incubation may vary. For example, the common cold has an incubation period of 1 to 2 days, whereas tetanus has an incubation period ranging from 2 to 21 days.
prodromal stage
A person is most infectious during the prodromal stage. Early signs and symptoms of disease are present, but these are often vague and nonspecific, ranging from fatigue and malaise to a low-grade fever. This period lasts from several hours to several days. During this phase, the patient often is unaware of being contagious. As a result, the infection spreads to other hosts.
full stage illness
The presence of infection-specific signs and symptoms indicates the full stage of illness. The type of infection determines the length of the illness and the severity of the manifestations. Symptoms that are limited or occur in only one body area are referred to as localized symptoms, whereas symptoms manifested throughout the entire body are referred to as systemic symptoms.
convalescent period
The convalescent period involves the recovery from the infection. Convalescence may vary according to the severity of the infection and the patient’s general condition. The signs and symptoms disappear, and the person returns to a healthy state. However, depending on the type of infection, there may be a temporary or permanent change in the patient’s previous health state even after the convalescent period.
A person may continually pass through the four phases with the same infectious process, such as with herpes simplex. Although there may have been only one infectious exposure, the infection may continue to cycle through the phase
5 times to wash hands
before touching a patient, before asceptic procedure, after body fluid exposure risk, after touching a patient, and after touching a patient’s surroundings
use alcohol rub to clean hands if…
they are not visibly soiled or have not come into contact with blood or bodily fluids, if moving from a contaminated body site to a clean body site during patient care, before and after each patient contact, after contact with surfaces in a patient environment, and after removing gloves.
if patient has PVD or diabetes, only who can perform foot care?
nurse - can only perform assessment of foot care. No foot soaks for diabetics.
how often is oral care for unconscious patient?
every 2 hours. That includes oral care brushing and suctioning, and place them on their side when performing that care. Bacteria in teeth causes pneumonia
modes of transmission - think transmission
droplet and airborne. droplet (large molecules) = coughing and sneezing. airborne = droplets suspended in air or dust
modes of transmissions - vectors - types of illnesses
malaria, Zika, Lyme, Plague. and you need a susceptible host.
things to consider before bathing (what you always forget)
is there a patient order, is the patient able to take care of themselves, are they bedridden.
transient pathogen
you can pick it up, easily removed by hand hygiene or hand washing. if you don’t, then they will become resident pathogens. Could be part of your normal flora.
people who carry bacteria without evidence of infection (fever, increased wbc) are
colonized
nebulizers have what bacteria?
pseudomonas
modes of transmission - what are the most common? (not airborne, etc)
contact.
direct contact (handshake)
indirect contact - stethascope
pneumonia - droplet - what precautions?
surgical mask would be acceptable. if you’re within 6 feet of patient, wear a mask
airborne - examples of viruses (VCT - victor is airborne) (and what do you need to wear)
TB, Covid, varicella - need to wear an N95 and negative pressure room.
most common HAI
Catheter associated urinary tract infections (CAUTI)
CDC tier I and II
tier 1 - hand hygiene, ppe, don’t recap needles, etc
tier 2 - airborne, droplet, contact with MRSA
Apical pulse measurement is the preferred method of pulse assessment for what age? (2 apical)
infants and children less than 2 years of age
tachypnea (tacky at 24) (FEVER)
> 24 breaths/min; Shallow -
Fever, anxiety, exercise, respiratory disorders
Bradypnea and how many (brady is so low)
<10 breaths/min; Regular - Depression of the respiratory center by medications, brain damage
Cheyne–Stokes respirations (Cheyne is friends with alden)
Alternating periods of deep, rapid breathing followed by periods of apnea; regular. Drug overdose, heart failure, increased intracranial pressure, renal failure
Biot’s respirations (don bot is totally irregular)
Varying depth and rate of breathing, followed by periods of apnea; irregular. Meningitis, severe brain damage
phase 5 bp (tap, whisper, yell, blow, silent) bp
The last sound heard before a period of continuous silence
adult’s orthostatic blood pressure (lie, dangle, stand - 10,3,2)
adult’s orthostatic blood pressure (lie, dangle, stand - 10,3,2)
What results would indicate to the nurse the client is experiencing orthostatic hypotension (the number)
A decrease in systolic pressure >20 mm Hg
when to assess vital signs
When it is ordered (minimum requirement) - very minimum
may be pre-op and post-op, or every 30 min - you can use judgement to assess
you may need to document vital signs before giving meds. meds for heart rate, etc. you want to see how the medication is working.
if patient is on bedrest, you may need to assess vital signs, possibly orthostatis (lying, sitting, standing)
or might want to assess after (tachycardia)
- On Admission to hospital or at office visit
- When coming on to shift
Policy Guidelines - Before during or after surgery or certain procedures
- To monitor effect of medications or interventions
Nurses Judgment - Before activity
- To monitor effect of activity
- Change in behavior or assessment
rectal temp is (and when not to use?)
core temp (appropriate choice for ppl w/ unstable temp) only if necessary. Is most reliable measurement of core temp, better than temporal. don’t use for cardiac and bleeding problems. only use for good core temp (better than temporal) - don’t use for young children
if patient has irregular rate, you must do
apical for one full minute.
orthopnea (ortho feet up)
difficultly breathing when lying flat - first thing raise head of bed
New blood pressure guidelines: YOU NEED TO KNOW THIS
Normal: Less than 120/80 mm Hg;
* Elevated: Systolic between 120-129 and diastolic less than 80;
* Stage 1: Systolic between 130-139 or diastolic between 80-89;
* Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg;
* Hypertensive crisis: Systolic over 180 and/or diastolic over 120, with patients needing prompt changes in medication if there are no other indications of problems, or immediate hospitalization if there are signs of organ damage.
P A T I E N T C O N D I T I O N S
T HA T M A Y N O T
B E A P P R O P R I A T E F O R
E L E C T R O N I C
B L O O D P R E S S U R E
M E A S U R E M E N T (IPV L) (don’t forget low…) this is just jittery, not medical.
- Peripheral vascular obstruction (e.g., clots, narrowed vessels)
- Shivering
- Seizures
- Excessive tremors
- Inability to cooperate
if someone has an irregular heart rate, or Blood pressure less than 90 mm Hg systolics, DO NOT
use electronic BP device
Isolation guidelines - just hand hygiene***add to this
CDC Guidelines (1996) Two Tiered Approach:
Tier One: Use Standard Precautions,
hand hygiene and appropriate PPE
Applies to all body fluids (except sweat),
non-intact skin, mucous membranes
prodromal (the prodrome is achy)
How you feel the day before you get sick. Achy, I’m coming down with something, low grade fever. most multiplication of disease and the most infectious stage.
incubation period of common cold (short cold)
about 24 hours
ticks - direct or indirect
indirect - vector
E. Coli - direct or indirect?
both, contaminated food or feces
Hep B - direct or indirect?
direct, indirect possible but unlikely. blood, feces, body fluid
HIV direct or indirect?
direct
TB contact precautions
airborne, sputum
salmonella - direct or indirect?
both. intestinal tract animals and humans. diarrhea (food = indirect) (human to human = direct)
staph - direct or indirect?
both. skin surface, mouth, nose
undiagnosed or transmissible respiratory infection - do this w/ ppl in the hospital
offer a surgical mask, maintain more than 3 ft of separation.
if airborne, follow what procedure?
private room w/ negative air pressure, 6 -12 air changes per hour, monitor filtration if air is recirculated. keep door closed. wear a respirator w/ TB patients.
if patient has vacirella (chicken pox) or ruebella (measles)…
wear respiratory protection unless person has immunity
droplet precaution
place patient in private room if possible. wear PPE, change gloves after contact w/ infected material. limit movement in and out of room. avoid sharing patient equipment
ex. of exogenous HAI bloodborne, cohorting w/ covid)
(bloodborne from IV therapy, or patient cohorted w/ another infected patient, Covid spread in facilities) community acquired pneumonia
Intentional Torts: (intentional torte is BAID)
- Assault
- Battery
- Defamation of Character
- Invasion of Privacy
T E L E P H O N E O R V E R B A L O R D E R S
(usually only in emergent situations)
write order as you heard it, then read it back verbatim to provider. make sure they agree with what you wrote.
* Countersigned within 24 hours
* Limit to emergent need when there is no alternative
* Document order exactly as given
* Read back order after entered to provider for confirmation
* Follow policy guidelines
* Document the order with time, date and situation necessitating order
* Text message orders? providers have secure ipads.
