Foundations Weeks 1-3 Flashcards
Thanks Emily S for the deck!
Describe the 4 main links of the chain of infection (there were 6 in the book but he only listed 4)
Source (wound, water, people, object), portal of entry (sx site, catheter), portal of exit (sputum, emesis, stool, urine, blood, wound drainage, genital secretions), and susceptible host.
Name 5 modes of transmission
Contact, droplet, airborne, vehicle, vector-borne
Define asepsis
To make free from disease-producing organisms
Define sepsis
The poisoning of tissues
Name 2 infections that are contact precaution
MRSA and c-dif
Name 3 infections that are droplet precaution
Influenza, pertussis, meningitis
Name 3 airborne infections
TB, measles, coronavirus
Name 2 vehicle-borne infections
Salmonella, e. coli
Name 3 carriers in vector-born infections
Mosquitoes, contaminated needles, ticks
What precautions do you take with airborne transmission?
N-95, eye protection, negative pressure rooms
Particles last HOURS
What precautions do you take with droplet transmission?
Level-1 mask (no gown or face shield needed. Particles last only minutes)
What are the minimum precautions you take with contact transmission?
Gloves and gown
Which of these actions are ways to protect yourself from needle stick injuries: SATA :)
- Never recap a needle
- Engage safety lock feature on needles
- Make sure to recap needles in emergencies
- Use puncture-proof sharps containers
- Never recap a needle
- Engage safety lock feature on needles
- Use puncture-proof sharps containers
Name 4 strategies the CDC says will decrease infection risk
- Used of bundled practices for invasive procedure or tx
- Expedient doses and treatment (blood cultures, etc)
- Careful det’d of appropriate antimicrobial therapy
- Following appropriate precautions for specific illnesses
Name 3 ways of achieving medical asepsis
Hand hygiene, using barriers (gloves, gown, etc), sterilizing
When should you use soap and water for hand hygiene?
When physically dirty
When around c-dif, spores, etc (vomiting, diarrhea)
When you eat
After using the bathroom
When is alcohol-based hand hygiene acceptable?
In between rooms
No visible soiling of hands
Between gloves
True or false: Using lotion with gloves is bad because it can break them down and make them more permeable
True
What is the term for the chemical or physical process to remove pathogens?
Disinfection
What is a process used to destroy everythinggggg, like ….even spores?
Sterilization
Name a few ways sterilization can be achieved
Heat, gas, chemicals
When should you always wear gloves (SELECT ALL THAT APPLYYYYYY)?
- When dealing with a pt with broken skin
- While examining mucus membranes for cap refill
- When taking a BP
- When dealing with body fluids
- When dealing with a pt with broken skin
- While examining mucus membranes for cap refill
- When dealing with body fluids
What PPE should you wear if splash or drainage is anticipated
Mask + gown
What do you don for protective isolation pts (ex: immunocompromised) ? (also called NEUTROPENIC PRECAUTIONS/REVERSE ISOLATION)
Gloves, gown, mask
What are some examples of when sterile technique is used (surgical asepsis)?
- Surgery
- Any procedure that involves blood
- When skin is being broken as part of a procedure
- Some dressing changes
- When caring for immunocompromised pts
Which historical nurse was the leader of asepsis, the cleaning of wounds, and infection prevention.
Florence Nightingale
Which historical nurse was instrumental in the formation of the Army Nurse Corp?
Dorthea Dix
Which historical nurse founded the Red Cross?
Clara Barton
What does SBAR stand for?
Situation
Background
Assessment
Recommendation
Name for moving a joint toward the middle of the body?
Adduction
Name for moving a joint away from the midline of the body?
Abduction
Name for decreasing the angle between two bones?
Flexion
Name for straightening a joint?
Extension
Name for turning the body or a body part to face upward?
Supination
Name for turning the body or a body part to face downward?
Pronation
What is paraplegia?
Paralysis of the legs and lower body
What is hemiplegia?
Paralysis of one side of the body
What is tetraplegia?
Paralysis of all four limbs
What does the Nurse Practice Act govern?
What you can do legally; varies by state; developed by Board of Nursing
What are some issues coming up with antibiotics concerning drug resistance?
Over-prescribing, using wrong one, not taking as prescribed, not finishing treatment
Does sepsis cause hypo- or hypertension?
HYPOtension
What would you use for hand hygiene post C. diff client?
Nonantimicrobial soap + h2o
What kind of mask do you need for TB?
N95
When would you remove a mask in between patients?
Airborne or droplet
Soiled/wet mask
What electrolytes are most important for the musculoskeletal system?
Potassium, vitamin D, phosphorus, vitamin B
Define isotonic exercise
Dynamic w/constant tension, movement, contraction (bicep curls); tonic=constant movement
Define isometric exercise
Static exercises – tense muscle, hold stationary (holding a yoga pose)
What is another word for decreased muscle tone?
Hypotonicity
What is another word for increased or rapid muscle tone
Spasticity
What is a rhythmic/repetitive motion; can happen at rest?
Tremor
What is a spontaneous brief involuntary muscle twitch or limbs or face?
Chorea
What is the term for a gait characterized with wide feet and described as duck-like?
Waddling
What is the progressive shortening of muscle; loss of joint mobility; fibrous material?
Contracture
What is the largest reportable problem related to mobility?
FALLS
What are some types of pain that can be caused by immobility?
- Kidney stones (renal calculi – from imbalance between osteoblasts and osteoclasts–>increased blood calcium level)
- Atrophy (“use it or lose it”)
- Contractures
- Joint pain (decreased flexibility)
What are some cardiovascular issues that come from decreased mobility?
- Increased cardiac workload: when supine, heart must work harder to perfuse body
- Thrombus formation: due to decreased venous stasis
- immobility does NOT increase blood viscosity, but dehydration impacts this*
- When immobile, baroreceptors not used as much —> orthostatic hypotension
Why does thrombus formation occur with decreased mobility?
Decreased venous stasis*
immobility does NOT increase blood viscosity, but dehydration impacts this
When immobile, __________ are not used as much so orthostatic hypotension can occur.
Baroreceptors
S/s of orthostatic hypotension?
Dizziness, weakness, light headed, hypotension, diaphoresis, SOB
What issues can immobility cause with bone?
Imbalance between osteoblasts and osteoclasts (increased blood calcium levels)
What is the most frequent site of pressure ulcers?
Sacrum
What is atelectasis?
Alveolar collapse
What happens to the lungs with immobility?
Decreased lung expansion
S/s of decreased lung expansion?
- Immobile client breathes less deeply and w/more effort
- Decreased coughing ability
- Atelectasis (alveolar collapse)
- Pneumonia risk
How does immobility affect nitrogen levels in the body?
Negative nitrogen balance:
- Immobility increases rate of protein breakdown (excretion > intake)
- Body doesn’t have enough nitrogen for protein synthesis (impaired wound healing)
- Slow muscle restoration when mobility resumes
Why is constipation a possible complication with immobility?
Atrophy of GI muscles, dehydration, rectal filling slow in supine position
Examples of activities or programs to recommend (SATA)
Tai chi Group activities Gymnastics Membership to local health club Strength training PT
Tai chi Group activities Membership to local health club Strength training PT
What is osteoporosis?
Low bone mass, deterioration of bone tissue
Risk factors of osteoporosis? SELECT EM ALL FRENS
- premenopausal
- family history
- history of fractures
- alcohol
- cigarette smoking
- prolonged immobility
- premenopausal (No, it’s POSTmenopausal)
- family history
- history of fractures
- alcohol
- cigarette smoking
- prolonged immobility
Trendelenberg position is:
Head 30-40° lower than feet
Semi-fowlers position is:
30-45° sitting
Fowlers position is:
80-90° sitting
Prone position is:
Face down (great for oxygenation)
Lithotomy position is:
Supine with hips flexed; examinations
When a hand roll is used as a positioning aid, what does it help prevent?
Contracture
Cane basics:
- Maintain \_\_\_ points of support ALWAYS - Cane on \_\_\_\_\_\_\_\_\_\_ side - Move cane forward \_\_\_\_\_\_\_ - Move weak leg \_\_\_\_\_ distance as cane - Move strong leg forward and \_\_\_\_ cane/weaker leg
- maintain 2 points of support
- cane on stronger side
- move cane forward first
- move weak leg same distance as cane
- move strong leg forward and past cane and weaker leg= 1st cane, 2nd weak leg, 3rd strong leg
What is an EHR?
Electronic Health Record
Disadvantages of EHR?
Expensive and difficult to implement
Advantages of EHR?
Legible, standardization of info, graphs for trends, access off-site
What are the main elements of documentation?
Privacy: HIPAA, accurate (only observations YOU observed), concise and complete, objective, organized and timely (document as you go along!)
There are 8 million types of documentation records. Which two of these do NOT belong?
- Admission Entry or Admission Assessment
- Flow Sheet
- Plan of Care Assessment
- Clinical Pathway
- Draw Sheet
- Atelectasis Notation
- Narrative Progress Notes
- Nursing Discharge Notes
Atelectasis Notation and Draw Sheet
LOLZ
What is the Admission Entry or Admission Assessment?
- Extensive background questionnaire
* ie Any cultural beliefs that affect care?
What do you find on a Flow Sheet? What is a benefit of a Flow Sheet?
- Vital signs
- Assessment
- Lab data
These allow trends to be easily seen
What do you find in a Plan of Care Assessment?
- Care plan
* Concept map
What is a Clinical Pathway?
Used for clients with specific and generally predictable conditions, it guides care, identifies progression of client. Is different from a care plan in that’s its more related to a specific medical procedure.
What is included in the Nursing Discharge Summary?
- Expectations after discharge
- Follow-up appointments
- When to reach out for assistance
THIS BEGINS AT INTAKE!
What are Narrative Progress Notes?
Relevant client and nursing activities throughout shift in a narrative format; easiest to learn; allows for detail; takes time; difficult to pick out important details
What are 3 acronyms for types of taking Narrative Progress notes?
- SOAP
- PIE
- FOCUS
What is a SOAP note?
Subjective
- What patient expresses
Objective
- Vital signs, lab data
Assessment
- A “conclusion” based on the S and O
Plan
- What nursing interventions are used to address the
conclusionDisadvantage of SOAP notes?
Unable to be used for general charting
What is a PIE note?
- Problem
- Intervention
- Evaluation
Good way to focus on nursing problem; problem is that it’s NOT interdisciplinary
What is a FOCUS (DAR) note?
- Data
- Action
- Response
Great for teaching pt something at discharge. Pt education. Disadvantage: Not used by other health professionals.
What is it called when nurses document only what is abnormal? This is the exception to “if you didn’t chart it, you didn’t do it.”
Charting by exception
What documentation occurs when there is an error?
Incident report
T/F: Always put in your notes when you made an incident report
False. Never note this. It should not be a part of the patient’s chart.
(SO SKETCH.)
List a few examples of things that would lead to an incidence report?
- Falls
- Medication errors
- Equipment malfunction
- Injury to client/visitor/employee
What does SBAR stand for?
- Situation
- Background
- Assessment
- Recommendation
When do you use a verbal order?
Emergencies only! Use call-out and call-back
technique.
If a verbal order is not an emergency, what should you do?
Request that provider put in the order, nicely :)
What is a handoff?
Report given whenever another person is assuming care for the patient.
When should you do a handoff?
Traveling to get a test, going for a procedure, changing hospitals, shift change.
How should report be given to the next shift?
- Given at client’s bedside
- Concise + accurate
What is another word for the ability to perform primary functions (feeding, toileting, bathing, dressing)?
Self care
What are the physical benefits of bathing (SATA)?
Remove bacteria
Allows skin assessment
Promotes circulation
Hydration
Maintain muscle tone
Maintain joint mobility
Remove bacteria Allows skin assessment Promotes circulation Maintain muscle tone Maintain joint mobility
What are the psychosocial benefits of bathing?
Mo SATA
- Client relaxation - Rapport with nurse - Promotes well-being - Promotes circulation - Client comfort
- Client relaxation
- Rapport with nurse
- Promotes well-being
- Client comfort
(Circulation is a physical benefit)
What is a sitz bath? What/who/when does it benefit?
Used to cleanse, soothe, reduce inflammation of perineal or vaginal area (post childbirth, rectal surgery, hemorrhoids/fissures)
Benefit of a hot water bath?
Relieve muscle spasms and soreness
What kind of bathing is considered general bathing?
Warm water bath.
When would you use a cool water bath?
Relieve muscle tension, decrease body temp when febrile
Why would you use a soak bath?
To soften or loosen secretions, reduce pain and swelling in inflamed skin
Best temp to keep general bath water?
Between 110°-115°F
Name some factors that affect self care.
- Environment (homelessness, safety, accessibility, wheelchair ramp)
- Motivation (mental health, cognitive abilities: confusion, delusion, doing everything for them)
- Energy (meds, disease states that impact o2 and energy levels)
- Illness, surgery
- Pain
- Neuromuscular fxn/sensory deficits (tremors)
Concerning levels of self care rating 0-4, the ______ the level, the more dependent the patient is rated
Higher
0: completely independent 1: use equipment or devices to perform self-care activities INDEPENDENTLY 2: requires assistance or supervision from another to complete activities 3: requires assistance or supervision AND uses equipment/devices (DEPENDENT) 4: completely depends on another person to perform self-care activities
What do feet with poor perfusion look like?
Cold and dusky
What do feet with poor perfusion possibly indicate?
Decreased healing
Increased fall risk
Decreased sensation
Increased risk of infection
SELECT ALL THAT APPLY as important for diabetic foot care:
Inspect daily
Clean with cold water + soap
Dry carefully, esp between toes
Cut toenails straight across
No lotion between toes
Inspect daily
NOT Clean with cold water + soap -- w/WARM water
Dry carefully, esp between toes
Cut toenails straight across
No lotion between toesWhat is a flat, thickening of skin; usually bony prominence?
Callus
What is a cone shaped lesion; usually 4th or 5th toe over joint?
Corn
What are round, irregular, flat warts; often painful?
Plantar warts
What are inflammation/thickening of bursa of great toe joint?
Bunions
What is red, scaly, cracking skin esp in between toes
Tinea pedis (athlete’s foot)
What is the treatment for lice (hair and clothes)?
Hair: pyrethrin and permethrin every 9-10 days
Clothing: extreme temps for 5 minutes (hot h2o + hot air)
What are two things you might call in a speech therapist for?
Swallow evals; appropriate diet
What does an OT focus on?
ADLs
