Foundations Exam 1 - pt2 Flashcards
what are the guidelines for bathing and privacy?
Privacy
Safety
Warmth
Independence
Needs
what are the national patient safety goals?
- Identify patients correctly
- 2 identifier factor - Improve staff communication
- Teach back show back
- SBAR - Use medicines safely
- Use alarms safely
- Prevent infections
- Identify patient safety risks
- Prevent mistakes in surgery
what is wrong with this diagnosis “ineffective airway clearance”
must be related to something “related to weak cough”
what must you do when planning as a nurse?
create measurable goals and outcomes
active vs passive ROM
active - pt moves themselves
passive - pt is moved by something else
sleep apnea
airway blocked during sleep
insomnia
trouble staying or falling asleep
narcolepsy
sleep paralysis
sleep deprivation
emotional stress and environment
parasomnias
sleep walking, night terrors, nocturnal enuresis (bedwetting), nightmares
what is the #1 way to prevent infection
hand hygiene
steps in the chain of infection
- Infectious agent or pathogen
- Reservoir or source for growth (grow and multiply)
- Portal of exit (blood or skin or mucous membranes or GI tract)
- Mode of transmission
- Portal of entry - to host
- Susceptible host (age, nutritious, immunosuppressant, stress, trauma, smoking)
nosocomial
hospital-acquired infection
steps in the infection process
1 - incubation period
2 - Prodromal Stage
3 - Illness stage - SXS manifest as type of injection
4 - Convalescence - SXS start to disappear
what are the modes of transmission
1 - Direct contact: person to person
2 - Indirect contact: surface to person
3 - Droplet: up to 3ft, cough and sneeze
4 - Airborne: carried on dust, evaporated droplets
serous
clear
Sanginour
bloody
purulent
pus
what are types of healthcare acquired infections
Latrogenic - from a procedure
Exogenous - from microorganisms outside the individual
Endogenous - pts flora becomes altered and overgrowth occurs
what are the steps in wound healing
1 - Inflammatory
2 - Proliferation
3- Remodeling
what is the inflammatory phase
- Histamine and vasodilation
- Wbcs move to wound area to inject debris and promote healing
- Albumin tells you how much protein is in the body - need protein to heal
- Pain, swelling, heat
what is the proliferation phase
- New blood cells and capillaries grow
- Thin layer of granulation tissue forms
what is the remodeling phase
- Collagen is remodeled and deposited
- Scar tissue becomes thin white line
what is primary vs secondary intention
primary - surgical wound (approximated edges)
secondary - loss of tissue (burn, ulceration)
what are 3 complications of wound healing
- Hemorrhage - collection of blood under tissue
- Dehiscence - incision reopens
- Evisceration - complete opening of wound (organs start to come out)
blanchable vs non-blanchable
blanchable - skin turns white, then lift up and turns red/back to skin color
non-blanchable - does not turn back to red, it is a stage 1 pressure ulcer
what factors are included in the Braden Scale
Moisture
Friction + shear
Sensory perception
Activity
Mobility
Nutrition
what are the classifications of pressure ulcers
1 - Intact skin with non-blanchable redness
2 - Partial-thickness skin loss involving epidermis, dermis, or both
3 - Full-thickness tissue loss with visible fat
4 - Full-thickness tissue loss with exposed bone, muscle or tendon
5 - unstageable
actual loss
occurs when you can no longer hear, feel, see, or know a person
perceived loss
defined by the individual experiencing the loss
grief
an individualized response to a loss, actual or perceived
what things might be needed to document after death
time of death
autopsy needed
organ donation
2 factor identification
why is the HOB elevated after death
to reduce discoloration in the face
what common medications make your urine different colors
1 - Anticoagulants - red
2 - Diuretics - pale yellow
3 - Pyridium - orange
4 - Elavil - green, blue-green
5 - Levodopa - brown / black
dysuria
painful urination
glycosuria
glucose in urine
pyuria
pus in urine
anuria
no urine
oliguria
low urine output
nocturia
need to void at night
bacteriuria
bacteria in urine
hematuria
blood in urine
proteinuria
protein in urine
what are bladder scan measurements
<50 is adequate emptying
>150 needs catheter
dysphagia
difficulty swallowing
what is the biggest warning sign of dysphagia
cough and choking during eating
what is aspiration pneumonia (complication of dysphagia)
liquid and food gets into the lungs
what are the categories of dysphagia liquids
Thin - low viscosity
Nectar - medium viscosity
Honey - honey viscosity
Spoon - pudding viscosity
what is enteral nutrition and the reasoning for its use
nutrition through GI tube
- pt is unable to chew, swallow, digest
what are the types of enteral feeding tubes
- Nasogastric (NG)
- Nasointernal (NI
-nasojejunal
-nasoduodenal - Enterostomal
-gastronomy
-jejunostomy
what is a nasojejunal tube used for
used for pt with GERD or aspiration
- tube goes beyond stomach into intestinal area
what are short term vs long term enteral feedings
short - NG and NI
long - enterostomal
when should a nasogastric/internal tube not be used
- At risk for aspiration : HOB should be elevated to 30-45 degrees for 2 hrs after feed
- Nasal injuries (CANNOT have trauma to the face)
how do you know NGT is in the right place
must get portable xray before beginning feeding
- ph levels <5.5 in stomach and >7 in intestines
difference between levin and dobhoff tubes
levin - thick feedings
dobhoff - small, long term use
what are the Enterostomal tubes
PEQ - in LUQ - directly into the stomach
PEJ - through abdomen into small intestine
what is gastric residual
if food is being absorbed or not in the stomach (I&O must equal)
PPN vs TPN
TPN - total parenteral nutrition - central line
PPN - peripheral parenteral nutrition - peripheral line
what must be checked in a pt with parenteral nutrition
blood sugar
purpose of PPN and TPN
TPN - promotes healing, is highly concentrated
PPN - less dense, short term nutrition (supplement)
peristalsis
movement of muscles in GI tract
what are 2 types of enemas
cleansing - clean intestines
retention - lubricate the stool
Ostomy appliance in textbook*****
image of enteral tube locations**
Sigmoid colostomy
LLQ
formed stool
Transverse colostomy +
loop colostomy
RUQ
semi-formed / pasty stool
Ileostomy
RLQ
liquid to pasty
End colostomy
LLQ
almost formed
