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
