FINALS Flashcards
INFECTION CONTROL
what techniques are used ? which is most important ?
medical asepsis -cleaning technique
-reduce the number of microoganisms
surgical asepsis - surgical technique
the most IMPORTANT is HANDWASHING
what are PPE ? when do we use ?
personal proctective equiptment -universal precaution
use to protect yourself from blood and bodily fluid
what is the chain of infection ?
-the infectious agent- the pathogen (disease causing microorganism )
-the resevior _ anminal or person (place where its growing )
-exit route _ blood ,urine , feces secretions
-the method of transmission _(most common HANDS) contaminated needle , food, air droplets
-portal of entry -mouth , break in skin , muscus membrane
susceptible host - another vulernable person
ISOLATION PRECAUTIOS-contact ,droplet , airborne
CONTACT - c-dif ,MRSA, VRE
use minmimum of a glove and gown
DROPLET _ Pneumonia
minimum of a MASK
AIRBORNE - N-95 MASK
negative pressure room
tuberculosis , varicella (chicken pox
Reverse / protective isolation or neutropenic
protect the patient from you
-patient has weak immune system possibley AIDS or chemo
no fresh fruits or flowers
what increase you risk of infection ?
break in the skin malnutrition low WBC acute infection very young or old people stress weak immune system auto immunity Genetic
HYGIENE , SAFETY , SRD’S
How often do you bathe patients and with what procedure ? Is it different for elderly ?
PROCEDURE - MAINTAIN PRIVACY AND PT DIGNITY allow the patient to do as much as possible to maintain independence …………EVERYDAY ! DO AND ASSESSMENT DURING BATH /SHOWER CHECK FOR CUTS AND ABRASIONS , bathe patient from head to toe start at the face with no soap
EYES -from the inner cantus to outter
MALE PATIENT -clean from the meatus outwards ,grasp shaft of the penis retract foreskin , lift the scrotum and wash
FEMALE PATIENT -dorsal recumbent postion , wash labia majora and minora , wipe front to back ….separate the labia to expose the urethra and vagina
FOR ELDERLY -NOT AS OFTEN BECAUSE IT DRYS OUT THEIR SKIN
what precautions can you take to promote safety ?
adequate lighting no throw rugs clean up spills call light in reach lower the bed rails up ( not all 4 ) thing in reach anti skid socks check if pt need assistance q2hrs appropriate use of sharps (biohazard ) orient patient frequently identify high risk patient ( fall wrist band or alarm ) keep patient close to nurses station
what do you do after a patient falls ?
assess the patient for injury
notify the charge nurse and physician
family members
write an incident report
what do you do with a confused or dilerious patient ?
monitor them orient them keep a close eye on them offer restroom q2hrs use pictures clocks , calenders put them in a familiar enviorment
what are restraint ? how do you care for someone with restraints ?
First thing put them close to nurses station , because physican order takes 24 hours
safety reminder devices -mittens , wrist , vest, hand
CARE: Get a physicans order
take off q2hrs
perform R.O.M and make sure no skin breakdown
use a slipknot
tie to a non movable place the bed not the bed rails
BEHAVIORAL RESTRAINT VIOLENT
Assess or q15 mins
GOOD REASON FOR A RESTRAINT IS TO PROTECT THE PATIENT & OTHERS FORM HARM -----DO NOT USE FOR YOU OWN PURPOSE
VITAL SINGS & SHOCK
procedure for taking B/P ?
MOST COMMON - BRACHIAL PULSE
cuff has to fit cannot be too big or small because you can get and innacurate reading
- go 30mmg up after you can no longer feel the pulse , so you do not miss the first sound for the systolic
-if B/P is abnormal check again in both arms
what is the auscultatory gap ?
the gap between the first kirtokoff and second kirtokoff sound
after the initial kortokoff sound sometimes the sound disappear temporarily and then reappear
- for acucurate reading inflate 30mmhg
systolic_ the heart is pumping
diastolic - relaxing
what are orthrostatic blood pressure checks
from lying to sitting to standing
looking for a drop in the B/P
wait 1-3 min between reading
keep the patient close to bed for in case of vertigo (dizziness) or syncope (fainting )
—–in elderly looking for orthostatic hypotention
what is the apical / radial pulse ?
What is the pulse pressure
determine by 2 nurses counting them at the same time
- if the apical is faster than the radial -WHICH IS CALLED A PULSE DEFICIT
- -CAN BE A SIGN ; dysrhythmia , circulation, vascular disease
- the difference between the systolic and diastolic
what is hypovolemia ? what are signs of it ?
low blood volume
because of hemmorage or dehydration
loss of a lot of plasma eg:burn , crash injury
weakness rapid shallow resp decrease b/p increase temp weak pulse and thready thrist poor turgor dry mucus membrane baby frontenal (soft spot sunken) dry skin urine more concentrated and dark
- mental status - confused , sedated
- skin - cool , clammy , pale
threat - with fluid , blood , oxygen if stop breathing
what is heatstroke ? what interventions to treat ?
body is overheated
106 body temperature
if too hot can cause brain damage ,seizures , death
skin: dry & red (erythema)
treatment : cool them down ( most important )
administer oxygen , maintain ABC (first priorty ) , hydrated , prevent shivering
what is anaphylactic shock ?
allergic reaction to food or bee stings ( causes vaso dialation ) distribute shock = blood vessel problem causes: swelling of the throat hives (signs of allergy ) itching low B/P difficulty breathing treatment : epinephrine
what is the treatment for cardiac arrest ?
ABC’s & CPR -cardiopulmonary resusitaion
what are barriers to communication ?
cliché : don’t worry be happy , brushing it off
false reassurance : everthing will be alright
nurse focus - focusing on yourself
arguing - judging , giving your opinion
acting rush : close body posture , not hearing or seeing
language barrier - translator
what are effective communication techniques ?
eye contact-brief and direct contact , listen , show interest , respect
- -6 sec to not be threating or intimidating
- culture affect how people interpret eyecontact
active listening technique
-pen ended questions - let the patient elaborate
closes questions _ yes or no answer
reflection - reflection back pt feelings to them
silence - effective and acward , has to be used carefully eg ; if someone has to gather their emotions
-
goal of therapeutic communication
building trust and meeting patients needs
procedure for peforming a nursing assessment inclluding nursing history & physical assessment
head to toe , system to system
start neuro , - PERRLA , LOC , ORIENT
chest
extremities -examine the skin
perineal area
foot
abdomen - not enough movement - hypoactive
enough movement - hyperactive
listen to all 4 quads in the abd
listen to lung in zigzag patterntechnique for physical assessment
inspection -looking
palpation -touch
auscultation -listening
percussion -tapping
what is subjective data ?
what ever the patient says about how they are feeling
naseau , pain
what is objective data ?
measurable - the nurse findings - temp b/p urine output
what dietary needs may a jewish client have ?
kosher diet no pork (no sea food , shellfish ) no mix of meat & diary utensils separate (prepackage ) meat slaughterd a certain way no activity on Saturdays rabbi to visit
how do you know a patient dietary needs
assessment #don’t assume
what should your intervention be if a patient does not speak English ?
get and interpreter - a medical interpreter
not family member
what do you do before you beginning to teach your patient ?
assessment
learning styles - kinestic
visual
auditory
---find out , what they know and what they need to knowwhat do you do following teaching ?
get sepcific feedback
information thought
let the patient explain so you know they understand
what guidelines do you use when charting ?
ball point pen -no gel black ink pen only specific terms - don't be vague do not chart your opinion every entry write - date , time and sign don't leave spaces in entry late entry if forge to chart something and sign if error - draw a line though it
what are different types of charting ?
narrative _ charing in chronological order , storyytelling
SOAP -subjective , objective , assessment , plan , intervention , evaluation ,revise
SOAPIER - problem oriented medical record (POMR)
CBE-(charting by exception ) - anything that changes
why is wound care done ?
to prevent infection
what are types of drainage
purulent - thick , yellow , green , tan and brown
serous - clear watery , plasma
sanguineous - bright red indicate active bleeding
serosanguineous - bloody and serum discharge from wound , pale , red , watery —-mixture of serous and sanguineosus
what are signs of infection ?
purulent inflammation fever tenderness swelling /edema redness(rubor )
how do you clean a wound ?
away from the incision
form the cleanes to the dirtiest for irrigation
clean each area with different swipes
from in to out
how do you prevent pressure ulcers ?
keep the patient of bony prominences turn pt q2hrs uses pillows heel protectors good hygiene nutrition skin assessment once a shift
how often should you inspect the skin ?
q2hrs
what should you do if the patient has a reddened area?
massage the surrounding area
not the direct area
what are the steps of the nursing process ?
A- ASSESSMENT - gather and analyze
D-DIAGNOSIS -nanda related to the etiology as evidenced by the symptoms
P-PLAN - goal & intervention
I-INTERVENTION -carry out the plan
E-EVALUATION - evaluate to see if the plan worked , or comparing actual outcome /desired outcome
what is the appropriate format for a nursing diagnosis ?
P.E.S - problem , etiology , symptoms
nanda r/t cause aeb defining charachteristics
how do you prioritize ?
ABC- airway , breathing , circulation
maslows heirchay _
self aculization - growth and fulfillment
esteem needs - reputation , achievement , status , responsibility
belonging & love needs : work group , family , affection , relationship
safety needs : protection , security , order , law limits , stability etc
biological and psychosocial needs : basic life needs - air, food, shelter , warmth , sex , sleep , elimination
why is evaluation done ?
to see if the plan worked out and if any changes are needed
with the care plan let the patient be involved
autonomy - imput from patient
what intervention are appropriate for a patient with difficulty voiding?
Help stimulate pt to voiding like running getting up
Voiding programming
Increase awareness about using the bathroom
Don’t embarrass the pt or humiliate pt about when they urinate or have and accident
Increase fluid intake
Bladder training
Offer restroom q2hrs
Use proper briefs , pads or liners
Give medication for incontinence As order (ditropan&detrol)
what is the procedure for inserting a foley catheter ?
sterile technique
place equipment between pt legs
set up
test balloon
lubricate tube
clean the female or male
female 3-5 inches male 6-8 inches insert
inflate the bbaloon
pull on it to make sure its in the bladder
female catheter size 14-18 male - 18-22 French
what do you do if resistance is felt initially ?
tell the patient to take a deep breath
if pain , deflate and insert further into the bladder
how do you care for a foley chather and prevent UTI ?
for care clean it with soap and water around the perineal area
once a shift (q8hrs )
no kinks
keep bag below the bladder
prevent with cranberry juice
water
how do you take a urine sample form a catherther ?
use a needle and take it from the aspiration port
what are signs of fluid volume excess /overload ?
weight gain
JVD (jugular vein destention )
edema /swelling
increase B/P
what are signs fo fluid volume deficit / dehydration ?
dry mucus membrane thrist decrease urine output poor turgor weight loss pale cool skin tenting of the skin
what is the procedure for and enema ?
left sims position large volume enema 12-18 inches lubricate w/water soluble lubricant insert 2-4 inches for 5 mins if cramping slow it down if bleeding stop and notify the physican
small enema 30mins
fecal impaction _ oil retention
how is a 24 hour urine collection done ?
patient void before they start (empty bladder )
Collect urine for 24hrs
Void before the 24hrs is over
If any of the urine is not collected within the 24hrs you have to start all over
Urine is kept on ice w/a preservative
How is bladder training done ?
With Kegel excersize
Frequent offering the restroom q2hrs
How is and NG tube inserted ?
Measure from the nose to earlobe to xiphoid process
Assess the patentcy first on the nose
Have patient in high fowlers position
Then chin to chest when you reach throat
Tell the patient to swallow or give a straw to sip some water
CHECK FOR PLACEMENT :
30 cc of air
X-ray most reliable
p-h strips
Acultate while inserting air
#always put content back
How is NG tube care done ?
Prone to having dry mouth
Frequent mouth care
NPO - nothing by mouth
Moisten pr mouth
How should a nasal canula be cared for ?
Check patentcy Q2hrs
Check setting and to make sure it is flowing
Humidify the oxygen so it becomes moist
Oxygen get dry
How is nasopharyngeal suction done ?
Like a trach Sterile technique Hyperoxygenate 100% Suction 10-15 secs Circular motion Intermittently If resistance don't force it
What concerns are related to elderly and nutrition
Chewing Swallowing Appetite Small frequent meal Purée ( machanical soft
What is informed concent ?
Approval by pt
Signed before any procedure
Md is responsible to give pt full info , risk , benefit or potential harm , outcome , consequence , of refuse ,
Pt cannot sign if medicated
Under 18 parent must sign
Nurses with was competency if it’s an emergency
Do whatever to save a life , can be done without a concent of can’t sign
What is durable power of attorney ?
Legal document that authorize a person to make choices for the pt when they are not able to physical injury or mental health
-the person that can make decision for you
What should your response be of a patient express interest in a new therapy ?
Ask questions abouth the therapy the patient is interested in
Be knowledgeable about the multiple CAM availed and the therapies used by your patient
Have accurate information for the doctor
Don’t discourage pt
Five information to pt
Pt teaching and only facts
What are ericksons development stages ?
Infancy - trust vs mistrust Toddler - autonomy vs shame and doubt Pre-k - initiative vs guilt School age - industry vs inferiority Adolescence - identity vs role diffusion Young adult - intimacy vs isolation Middle adult - genrativity vs stagnation Late adult - integrity vs despair
What is pain ? What is the gate theory of pain ?
Pain is subjective , whatever the patient says it is
Pain is unpleasant sensory & emotion
On a scale from 1-10
Ask when it started & what makes it better
THEORY - pain impulse does not travel to the brain
Other stimuli that can distract the brain and pain impulses are blocked
How do you perform pain assessment ?
The 5th vital sign
Numerical pain intensity scale
What are complication of opiods ?
Constipation
Respiratory prob ( decrease breathing )
Addiction
To prevent complication
Monitor very close
NARCAN - if they get too much
What are stages of sleep ? Why is sleep important ?
NREM-non rapid eye movement Decides into 4 stages Restores and rest the physical body V/s decrease / slow body function Stage 4 is the deepest , where the sleeper may sleep walk and eneurisis may occur
REM-rapid eye movement
Important for the mind - dream vividly
6-8 hrs of sleep
What are kubler-Ross stages of grieving ?
DABDA Denial Anger Bargaining Depression Acceptance
What are the patients fear related to dieing ?
Abandonment
Loneliness
Pain
-anxiety producing event
-medication help
Being in control in their own care helps
-constantly calling the nurse because of loneliness
What are nursing intervention should you do to support family members dealing with a loss ?
Give them time
Sit and wait for them to speak
-then clean the patient , tag bag ,
-therapuetic communication
How and when is pain treated ?
Deal with pain right away when the patient informs you
-it’s best to schedule pain MEDS for ongoing pain
-reassess the patient and how the patient respond to pain
Order pain MEDS
NSAIDS - steroids / codeine / / oxycodone /morphine
